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Physiotherapy is both clinically and cost effective in the management and treatment of musculoskeletal disorders.

Introduction

Musculoskeletal disorders (MSDs) are a group of painful disorders in muscles, tendons and nerves, such as carpal tunnel syndrome, epicondylitis (tennis elbow), neck or back pain, and strains or sprains.

Patients with MSDs are the largest patient population group treated by physiotherapists in Alberta.

Rapid access to musculoskeletal physiotherapists can reduce the amount of time people are off sick and is vital in preventing a new acute problem from becoming chronic and long-lasting.6 A recent study conducted in Saskatchewan found that a spinal triage service delivered by physiotherapists was very satisfactory to both patients and referring health-care providers.7

Physiotherapists have pioneered innovative ways of providing fast and appropriate access within existing services.8, 9

Self referral

In Alberta, physiotherapists are direct-access practitioners, which means a patient can consult a physiotherapist directly (self-referral) without a physician referral. There is evidence that patients who consult a physiotherapist directly for an MSD miss less work, use less prescription drugs, have fewer x-rays, and require fewer visits to their physician.10, 11 Health-care costs for self-referred patients are significantly lower per episode of physiotherapy care than for patients referred by their physician.9

Size of the problem

  • There are over 200 types of MSDs.
  • 11 million Canadians over the age of 12 have experienced the effects of a musculoskeletal disorder. As the population ages, this number is projected to grow to 15 million by 2031.1
  • Repetitive strain injuries affect about 15% of Canadians (4.5 million people), according to Statistics Canada.2
  • Low back pain is reported by 80% of people at some time in their life.3
  • MSDs are the most common reason for repeated general practitioner consultation.4
  • Chronic low back pain ranks as one of the leading reasons for physician consultations among people under 60 years of age in Canada.5

Risk stratification

Back pain can range from a simple ache which will correct itself to a long-standing pain. Risk stratification, where patients are screened to identify the risks which may affect their treatment outcome, allows patients to be directed to the treatment pathway they need rather than applying a one size fits all approach.

The UK’s Keele University demonstrated that risk stratification using the STarT Back Tool12 for neck and back patients was clinically and cost effective. Significantly improved outcomes at four months and £34.39 saving per patient was shown when comparing the STarT Back intervention group with those who received usual care.

The STarT Back method asks patients to fill out a questionnaire with the generally practitioner or physiotherapist. This identifies whether the risks that may affect the treatment outcome are low, medium or high. The questionnaire takes into account the patient’s symptoms, and their perception of their pain as well as how it is affecting their life. Patients can then be directed to an appropriate treatment pathway based on this assessment. The pathway may include greater emphasis on self management for low risk patients or greater management of psychological distress for high risk patients.

Promoting self management

Musculoskeletal physiotherapists support self management. They integrate education about the specific MSD with interventions or treatments that ensure the patient has the knowledge and understanding to manage their condition after discharge. This includes a home program of exercises tailored to the individual patient’s needs.

Physiotherapy Alberta - College + Association provides information for the public about evidence-based care for a range of topics, including ergonomics, low back pain, and other musculoskeletal conditions that physiotherapists treat.

Providing self-management resources at an early stage can help avoid the need for referral to secondary care with its associated higher costs.13

Case Study

A common barrier to accessing physiotherapy services is wait times. In some cases, the wait to access care can be months long. To address the problem, physiotherapists at Medicine Hat Regional Hospital and Chinook Regional Hospital undertook a comprehensive service improvement plan to increase program efficiency, improve access to care, and reduce wait times.

The hospital increased the number of appointment slots per hour and instituted a walk-in assessment program for non-surgical musculoskeletal and neurological patient populations.

In the vast majority of cases, the patient can be seen on the same day that they come to the clinic, improving patient, physician, and staff satisfaction with access to care.

No-show rates for initial assessments and follow-up appointments dropped significantly, and physiotherapist productivity improved to 90%.

Increased efficiencies meant that one full-time physiotherapist could be reallocated to a newly developed home rehabilitation team for frail elderly patients based out of the same hospital, improving health system efficiencies.

Conclusion

Fast access to physiotherapy for people with MSDs is clinically and cost effective for the health service, for employers and society. It can reduce the incidence of unnecessary visits to general practitioners and secondary care appointments, as well as improving patients’ quality of life.

References

  1. Canadian Orthopedic Care Strategy Group. Backgrounder Report: Building a Collective Policy Agenda for Musculoskeletal Health and Mobility. 2010; http://www.cihr-irsc.gc.ca/e/48830.html
  2. Statistics Canada. Canadian Community Health Survey: Combined data 2013/2014. http://www.statcan.gc.ca/daily-quotidien/150624/dq150624b-eng.htm
  3. Bone and Joint Canada. Low back pain 2014. http://boneandjointcanada.com/low-back-pain/
  4. Petrella RJ, Davis P. Improving management of musculoskeletal disorders in primary care: the joint adventures program. Clin Rheumatol. 2007;26:1061-1066. Doi 10.1007/s10067-006-0446-4
  5. Rapoport J, Jacobs P, Bell NR et al. Refining the measurement of the economic burden of chronic diseases in Canada. Chronic Dis Can. 2004;25:13–21.
  6. Ludvigsson ML, Enthoven P. Evaluation of physiotherapists as primary assessors of patients with musculoskeletal disorders seeking primary health care. Physiotherapy 2012 Jun;98 (2):131-137. doi: 10.1016/j.physio.2011.04.354. Epub 2011 Jun 30 .
  7. Bath B, Janzen B. Patient and referring health care provider satisfaction with a physiotherapy spinal triage assessment service. Journal of Multidisciplinary Health Care. 2011;2012(5):1-­15.
  8. Desjardins-Charbonneau A, Roy J-S, Thibault J, Ciccone VT, Desmeules F. Acceptability of physiotherapists as primary care practitioners and advanced practice physiotherapists for care of patients with musculoskeletal disorders: a survey of a university community within the province of Quebec. BMC Musculoskeletal Disorders. 2016;17:400. doi:10.1186/s12891-016-1256-8.
  9. Fleming-­McDonnell D, Czuppon S, Deusinger S, Deusinger R. Physical therapy in the emergency department: Development of a novel practice venue. Phys Ther. 2010;90(3):420-­26.
  10. Pendergast J, Kliethemes SA, Freburger JK, Duffy PA. A comparison on health care use for physician referral and self-referred episodes of out-patient physical therapy. Health Serv Res. 2012 Apr;47(2):633-54; doi: 10.1111/j.1475-6773.2011.01324.x 7. PMC Free Text
  11. Deyle GD. Direct access physical therapy and diagnostic responsibility: the risk-benefits ratio. Journal Orthop Sports Phys Ther. 2006 Sep; 36(9):632-634.
  12. Keele University. STarT Back; https://www.keele.ac.uk/sbst/startbacktool/
  13. Décary S, Fallaha M, Pelletier B, Frémont P, Martel-Pelletier J, Pelletier JP et al. Diagnostic validity and triage concordance of a physiotherapist compared to physicians’ diagnoses for common knee disorders. BMC Musculoskelet Disord. 2017 Nov 14;18(1):445. doi: 10.1186/s12891-017-1799-3 PMC Free Text

Acknowledgement

Adapted and used with permission of the Chartered Society of Physiotherapy.