Injection therapy for physiotherapists

Products used in injection therapy

• Licensed medicines
  • Corticosteroids ± local anaesthetic for inflammatory/degenerative disorders.
  • Botulinum toxin for spasticity, dystonia, chronic headaches/migraine or other MSK muscle overactivity disorders.
• UK-CA licensed medical devices e.g. hyaluronic acid and other orthobiologic products.
• Other products used as a vehicle to administer the medicine or device e.g. saline.
• Products used to have a chemical irritant effect that stimulate a controlled inflammatory response (Prolotherapy) e.g. phenol, glycerol, dextrose.
• Platelet-rich Plasma (PRP) is an unlicensed medicine and may only be administered by a physiotherapist the direction of the doctor who has manufactured the product.

Training requirements

Injection therapy is a non-regulated post-registration activity.

Many UK HEI’s offer validated Level 6 (10) or Level 7 (11) modules in injection-therapy. Other providers such as The Society of Musculoskeletal Medicine offer training that meets our expectations.

Members are expected to:

• Complete appropriate initial training aligned with CSP expectations including 150 hours of training including supervised practice, and formal assessment of capabilities.
• Maintain their skills with ongoing CPD in line with HCPC expectations

Medicines frameworks

You do not need to be a prescriber.

You can 'supply and administer' the medicines used in injection therapy.

The setting and service you work in may determine what mechanisms are available for you to use.

If you want to train to be a physiotherapist-prescriber you will need to undertake separate regulated training. See our Prescribing Pages

Insurance

All UK physiotherapists must have appropriate insurance in place to cover all of their work. This may be from any combination of an employer, a professional body membership and/or a commercial insurance provider.

The CSP PLI scheme covers therapeutic injection therapy, subject to policy terms and conditions.

• To clarify: carpal / tarsal / cubital tunnel syndrome are nerve entrapment neuropathies for which the primary purpose of treatment is to reduce associated swelling and so these injection techniques are covered by the PLI scheme (subject to terms and conditions).

The CSP PLI scheme has the following exclusions relating to injection therapy, meaning these types of injection are not insured:

• General and regional anaesthesia including peripheral nerve blocks.
• Spinal and peripheral nerve blocks such as the suprascapular or genicular nerve blocks.
• Spinal injections including the sacroiliac joints.

Setting up in private practice

Offering injection-therapy services in private practice may bring benefits to members wanting to diversify their practice. However, initial training may be costly so you should think about the following factors before committing yourself:

• Read Private physiotherapy practice – the essential guide
• Business planning: Weigh-up the costs of training, equipment, ongoing supplies and any additional insurance with estimated patient demand and pricing models. Is the service viable and sustainable for you?
• Training: Consider the requirements of your preferred training course and make sure you can access the supervision you will require as part of your training.
• Facilities and equipment: Ensure you have appropriate clinical space (clean, private, infection-control compliant). Consider how you will obtain the necessary equipment required for safe and effective practice. Check out if you need any additional local authority licensing or authorised waste and sharps disposal services.
• Access to medicines:
  • Prescribers: Make contact with a local pharmacist and ensure you have mechanisms in place for the medicines you prescribe privately to be delivered to your clinic for when you need them. You can bulk order stocks of GSL and P products, but you cannot order wholesale stocks of Prescription Only Medicines such as corticosteroid and local anaesthetic.
  • Non-Prescribers: Make sure you work in a setting that is permitted to use a PGD or make contact with the appropriate practitioner who will be providing a private prescription on your recommendation.
  • Remember – the NHS prescription forms and charges are only available for NHS services and cannot be used in private practice.
• Patient pathways and record keeping: Define referral and escalation routes (e.g. GP/secondary care). Set up robust systems for clinical documentation, follow-up, and monitoring outcomes.
• Clinical governance and safety procedures: Put in place policies for clinical audit, consent, risk management, infection control, and adverse event management. Establish protocols for safe handling, storage, and disposal of medicines and sharps.  

Can I use prolotherapy?

The purpose of the injections is to have an osmotic and chemical irritant effect that stimulates a controlled inflammatory response. This produces a thickening of the fibres in the damaged tissue, which may have a therapeutic benefit. Solutions of phenol, glycerol and dextrose are commonly injected; however, these may also include lidocaine.

Regardless of whether the solutions contain lidocaine, the intention is to provoke a physiological response in order to treat the medical condition, so the products used should be treated as medicines (as they have a medicinal purpose) which must be appropriately prescribed and/or supplied and administered using a relevant medicines framework.

What about 'mixing' or unlicensed medicines?

Physiotherapist independent prescribers cannot prescribe unlicensed medicines unless the unlicensed medicine has been created by you mixing two licensed medicines together during treatment for a specific patient e.g. injection therapy corticosteroid and local anaesthetic. They cannot prescribe any other type of unlicensed medicine.

If you are not an independent prescriber and you are instead using a PGD (Patient Group Direction), you can not mix any medicines together as PGD rules do not allow any mixing of medicines or the use of unlicensed medicines.

• A more detailed explanation is given within our Practice Guidance for Prescribers – p19-20.

Can I order adrenaline in advance for emergencies? 

No – adrenaline is a prescription-only medicine and can not be ordered wholesale by physiotherapists. You may, however, use it “if it is available to you” e.g. on a crash trolley, or in a grab bag, at the time a life-threatening emergency occurs. If it is not available to you, you must call 999. 

Can I offer spinal injection therapy?

Spinal injections are within the scope of physiotherapy practice but outside the scope of CSP PLI cover. You must ensure you are educated, trained and competent in any activity you undertake. You should also only offer this service if you have an appropriate clinic environment with access to medical support to ensure patient safety.

If you undertake spinal injections outside of employed NHS settings, which are covered by the NHS indemnity schemes, you must arrange additional insurance.

Can I use Platelet-Rich Plasma (PRP) as injection therapy?

This is only possible under the direction of a doctor (registered medical practitioner) who has manufactured the PRP and who then instructs you to administer it. In all other circumstances it is illegal and not permitted.

Read our PRP page for more information.

All PRP use is excluded from the CSP PLI scheme and so is not insured.

Is my injectable a medicine or a device?

Is it in the British National Formulary (BNF)? Most medicines authorised for use in the UK will be listed in the BNF.

The product information leaflet (PIL) will tell you the legal status of a medicine. Product packaging will also clearly show POM or P for medicines or UK-CA/CE marks for devices.

The Medicines & Healthcare products Regulatory Agency (MHRA) holds the Public Access Registration Database (PARD), which lists registered device manufacturers and registered device types.

Can I use Arthrosamid and/or other injectable devices?

Yes. Arthrosamid is an injectable gel with a European market approval (“license”) for use for the “symptomatic treatment of patients with knee osteoarthritis”. The UK’s MHRA has classified Arthrosamid as a medical device, not a medicine, because it works by physically cushioning the knee joint rather than through any pharmacological, immunological or metabolic action. This classification-reasoning by the MHRA extends to other similar injectable products for joints, such as those containing hyaluronic acid.

Medical devices are regulated in the UK by the Medical Device Regulations 2002 and require a CE Mark (for the EU) or a UKCA mark (for the UK) to be placed on the market and made available for clinicians. Clinicians hold the responsibility for deciding if a device is suitable for use with a specific patient or not. The Medical Device Regulations 2002 are aimed at manufacturers, and do not set out how individual clinicians should use devices.

However clinicians should follow the manufacturer’s intended purpose when using any device, which will be set out within the device licence. This is because, as part of securing a device licence, the manufacturer will have obtained the necessary evidence to demonstrate that the product is safe and effective for use in a set of specific circumstances. Using a device within the terms of its licence is known as 'on-label' use.

If a clinician uses Arthrosamid, or any other device, for a purpose that is not set out within the terms of the device licence, this is considered “off-label” use. In this case, the clinician assumes full responsibility for using a device in an alternative way, as the manufacturer will not have the evidence that the device has been tested or approved for that alternative purpose, even though the product holds a licence for other uses.

In addition, physiotherapists must not use unlicenced devices, i.e. those without any form of market approval, as there is no assurance from the MHRA that the product is safe or effective for use with patients.

A written prescription is not required for the supply of devices. However, manufacturer guidelines often stipulate that such products can only be supplied to registered health professionals and/or used under the direction of a doctor or registered health professional. While a legal written prescription is not required, good practice dictates that appropriate written policies and records are in place when such products are used.

The use of medical devices, for both on-label and off-label use, is covered by the CSP PLI scheme, subject to the policy terms and conditions.

Can I ask a GP to prescribe a medicine for me to inject as an independent practitioner?

No. This is because a GP is a doctor who is contracted to provide primary medical services on the NHS to patients who sit within a defined NHS catchment population. GPs prescribe NHS medicines that will be dispensed at NHS expense.

If you require a prescriber to provide a prescription for a private patient, they may charge a private prescription charge. The patient will have to pay the private prescription cost, the cots of the medicine and any dispensing fee the pharmacist charges.

Can I use a patient group direction (PGD) in independent practice?

PGDs can only be used in independent clinics that are registered with the Care Quality Commission (CQC) (or the equivalent in Scotland/Northern Ireland) or have a formal contractual agreement to provide NHS services to patients in a private setting. Most physiotherapy clinics are exempt from CQC registration.

If you work in a private setting where you cannot use a PGD, and you are not an independent prescriber, you must use a patient specific direction (PSD). This means you will need to ask a private doctor to write a private prescription for the medicines needed.

A doctor may agree to do this on your remote recommendation, or they may ask to see the patient, or decline to prescribe for your patient.

Can I use a PGD if I need to mix medicines?

No. PGDs can only be used for the supply and administration of licensed medicines. Mixing two licensed products together creates a new unlicensed product. Licensed premix products are available for use under PGDs.

Mixing of medicines can only be done under an independent prescriber framework or a PSD. Controlled drugs cannot be mixed under any circumstances.