Musculoskeletal problems and access to physiotherapy

Musculoskeletal (MSK) pain problems are one of the most common causes of disability. Over one-quarter of all patients registered in general practice will consult at least once for a MSK problem each year.^1,2 Women consult with MSK problems more often than men, irrespective of age group.^1–3 The high prevalence and persistent nature of many MSK problems makes MSK pain a major health problem.⁴ The most common types of chronic MSK pain are back pain and joint pain related to osteoarthritis,⁵ including knee pain and hand pain. For example, lifetime prevalence rates for low back pain as high as 84% have been reported.⁶

This high prevalence of MSK problems results in large direct and indirect health-care costs.⁷ In 1998 alone, treatment for low back pain in the UK cost in the region of £10,668M,⁸ and recent reports suggest that these costs are likely to have risen by a further third in the last decade.⁹ In the UK, low back pain is the fourth most common reason for consulting a general practitioner (GP) and is the most common MSK reason for consultation. Estimates suggest that between 6% and 9% of people registered with a GP consult annually with low back pain,^10,11 which equates to approximately 5 million people each year in the UK.⁸ In total, MSK pain accounts for around 15% of all GP consultations.¹² Most patients are managed with advice and analgesia, but many of these patients are also referred to physiotherapists, with 4.4 million new referrals to physiotherapy being made each year, of which 1.23 million are made by GPs.¹³ The number of referrals to NHS physiotherapy increased by 37% in the 15 years between 1990 and 2005.¹³ Guidelines for practice for common MSK conditions are increasingly recommending physical therapies, with recent guidelines for persistent low back pain recommending key treatments of exercise, manual therapy and acupuncture,⁹ and core treatments for the management of osteoarthritis of the knee including advice, education, exercise and weight loss.¹⁴

Ensuring timely access to physiotherapy has long been an issue within the NHS, with waiting times of > 4 months in some areas. This is a problem for patients, because MSK conditions cause pain and disability, and for the economy, because these conditions are second only to mental health problems as a cause of days lost from work. In particular, back pain accounts for some 120 million days of certified absence from work each year and half of all patients with back pain who are off work for more than 6 months never return to employment.⁸ Delayed access to physiotherapy is also a problem for the NHS because when patients are finally offered a physiotherapy appointment many fail to attend, and in other cases patients wait a long time for a physiotherapy consultation when it is unlikely that this will offer benefit, so it could be argued that much of the current physiotherapy resource is used inefficiently and ineffectively. While patients are waiting for physiotherapy they may repeatedly visit their GP and request medication, and the delay in access to physiotherapy may lead to unnecessary referrals to MSK interface services and outpatient orthopaedic specialists.

New service models: physiotherapy-led telephone assessment and advice services for musculoskeletal pain

In response to the problems described above, new service models have been developed that involve physiotherapy-led telephone assessment and advice as a way of managing patient demand and providing early access to physiotherapy advice. Physiotherapists in two areas of England, Huntingdon and Cheltenham, developed the concept and coined the term PhysioDirect at about the same time. The Huntingdon system was devised with the primary care lead for the primary care trust (PCT) and two local GP practices in 2001. By 2004, the whole of the population covered by Huntingdonshire PCT had access to the service, covering 155,000 people. A number of other PCTs have also since developed PhysioDirect services. Further details of the current service in Huntingdonshire are summarised in Box 1.

BOX 1

Summary of the Huntingdon PhysioDirect service A computer program with templates containing dropdown boxes and free text designed for each region of the body records clinical data to assist the physiotherapist in making a diagnosis.

Although there are several variations of PhysioDirect services, they all tend to involve patients being invited to telephone a physiotherapist for initial assessment and advice, following which many patients are posted information on self-management and exercise. Physiotherapists determine the priority of need, or ‘triage’, and provide rapid advice to the patient so that recommended self-management activities, such as postural improvements and exercise, can commence. Patients are advised to ring back if their condition does not improve and a time frame for the repeat call may be recommended. Some patients are invited for a face-to-face consultation if the initial telephone assessment establishes that this is necessary. Alternatively, they may be referred back to the GP or other health professional if that is appropriate. Within integrated services, patients may be referred to an interface service (where these exist) or on to secondary care following agreed local pathways. Thus PhysioDirect can form part of a streamlined patient management system that aims to ensure patient needs are met by the most appropriate clinician in a timely fashion. Some services are predominantly operated as call-back services, in which telephone assessments are pre-booked into physiotherapists’ diaries, and they make the call at a time of convenience for the patient. Additionally, patient assessments within PhysioDirect may be supported by computerised or paper-based templates.

Some services offer PhysioDirect in conjunction with self-referral to physiotherapy as a way of managing direct contacts from patients. Increasingly, the boundaries between telephone assessment and advice and self-referral services are blurring, given the impetus from recent Department of Health reports on MSK services,¹⁵ community services¹⁶ and the evidence about self-referral.^17,18

Summary of evidence about physiotherapy-led telephone assessment and advice services for musculoskeletal pain

The available evidence about physiotherapy-led telephone assessment and advice schemes for MSK pain, or PhysioDirect, was identified using searches on MEDLINE, EMBASE, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Current Controlled Trials (CCT) database and the internet. These searches used terms and/or text words for ‘triage’, ‘PhysioDirect’, ‘telephone’ or ‘advice’ in combination with terms relating to physiotherapy [‘Physical Therapy Modalities’, ‘Exercise Therapy’, ‘Physical Therapy (Specialty)’, ‘physiotherapy.mp’]. We also specifically sought randomised trials of physiotherapy interventions using the Cochrane highly sensitive search strategy in combination with terms for physiotherapy. The search was originally conducted in August 2007 but the saved search in MEDLINE was conducted regularly throughout the research periods (2007–11) to identify any relevant new publications. A further comprehensive search to identify relevant literature since the protocol was written has been conducted in the following databases: NHS Evidence, Health Information Resources [Bandolier; UK Database of Uncertainties about the Effects of Treatments (DUETS); National Library of Guidelines, including National Institute for Health and Clinical Excellence (NICE) guidance, International Guidelines, Clinical Knowledge Summaries, NHS Evidence Specialist Collections (Musculoskeletal)]; TRIP database; Centre for Reviews and Dissemination [Database of Abstracts of Reviews of Effects (DARE), NHS Economic Evaluation Database (NHS EED) and Health Technology Assessment (HTA)]; Cochrane Database of Systematic Reviews (CDSR); EMBASE; MEDLINE; Physiotherapy Evidence Database (PEDro); Allied and Complementary Medicine Database (AMED); Cumulative Index to Nursing and Allied Health Literature (CINAHL); OTseeker; ISRCTN (International Standard Randomised Controlled Trial Number) Register; Medical Research Centre: Clinical Trials Unit; UK Clinical Research Network Study Portfolio; NIH records on ClinicalTrials.gov; Nederlands Trial Register; German Clinical Trials Register; and the Australian New Zealand Clinical Trials Registry. Citation tracking was also used to locate relevant articles.

We did not identify any published randomised trial that directly addressed the effectiveness or cost-effectiveness of PhysioDirect or similar schemes. There was, however, literature pertaining to the effectiveness of physiotherapy interventions for MSK problems, and about the benefits of early treatment with physiotherapy for MSK problems, which is relevant to the argument in favour of developing new services to provide earlier access to a physiotherapist. In addition, there have been several local audits and evaluations of physiotherapy-led telephone assessment and advice services, as well as studies and trials of telephone care by other health professionals for other conditions, which are relevant to this trial.

Physiotherapy interventions for patients with musculoskeletal problems

The most common problems leading to physiotherapy referral relate to the back, shoulder, neck or knee. With regard to back pain, most studies have concluded that manual therapy provided by physiotherapists offers little benefit over simple advice for acute low back pain.^19,20 The UK Beam Trial included patients with pain of variable duration and suggested that manual therapy has a modest effect,²¹ and some studies have suggested that it is possible to identify subgroups of patients more likely to benefit from this type of treatment,^22,23 but a recent review concludes that manual therapy is no more effective than other common therapeutic approaches.²⁴ Although systematic reviews about the effectiveness of manual therapy have reached inconsistent conclusions, in subacute and chronic back pain there is evidence for the effectiveness of physiotherapy interventions based on promoting exercise.^25–28 Importantly, recent trials have shown that a single session of advice from a physiotherapist is as effective as a course of routine physiotherapy for patients with mild to moderate back problems.^29,30 With regard to neck pain, there is evidence from two Cochrane reviews that combined exercise and manual therapy is effective.^31,32 For shoulder pain, a review found evidence of benefit from a range of physiotherapy interventions. Exercise advice appears to be of benefit in rotator cuff disease and manual therapy provided additional benefit in one trial.³³ Exercise has been shown to be effective for knee pain related to osteoarthritis, with recent trials showing the effectiveness of physiotherapy-led advice and exercise.^34–36

In summary, there is evidence that patients with MSK pain problems can benefit from interventions offered by physiotherapists, while for some patients it is more cost-effective to provide brief advice, and for others, treatments from physiotherapists have little to offer. Therefore, a service that provides assessment, triage and advice initially and reserves more intensive (and expensive) treatments for those who do not improve may be the most cost-effective strategy. This is analogous to the ‘stepped-care’ approach, which is increasingly advocated in a range of conditions, for example mental health, where there is a high level of demand and a need to target resources.³⁷ In the context of physiotherapy, this approach should reduce costs for patients and for the NHS, provide earlier advice for all patients and effective treatments more quickly for those who may benefit from them (by screening out those unlikely to benefit), and be more convenient and accessible for patients as a whole.

Earlier compared with delayed physiotherapy treatment

Providing prompt and convenient access to health care is one of the major aims of the policy drive to make the NHS more responsive to patients' needs, with fast access for health care being seen as a benefit in itself, irrespective of the effects in terms of clinical outcomes. However there is evidence from several studies that early physiotherapy intervention provides faster symptom relief, improves quality of life, reduces absenteeism, leads to a reduction in physician consultations, and is more cost-effective.^38–42 This approach is supported by the guidance from the Clinical Standards Advisory Group (CSAG) on the management of back pain. Following a review of evidence and expert advice, the CSAG advised that patients with new episodes of back pain should have prompt access to physical therapy, with the aim of reducing the risk of symptoms and disability becoming entrenched.⁴³ More recently, specific guidelines for the management of patients with back pain persisting for > 6 weeks recommend early referral to a range of physical therapies.⁹

Telephone advice services in health care generally, and in physiotherapy

PhysioDirect is based on a practitioner supported by computerised templates to assess the patient in a structured way, and to offer tailored, personalised advice. This reflects a wider trend to explore the use of this type of new technology in health care, for example in NHS Direct. Research in relation to the use of similar telephone triage systems in clinical settings other than physiotherapy has shown that it is safe, clinically accurate, cost-effective, acceptable to patients, and reduces the workload of clinicians,^44–47 although some health practitioners have some concerns in using telephone triage in patients presenting with acute health problems.⁴⁸

Within physiotherapy, local evaluations and small studies suggest that services based on telephone advice given by physiotherapists are likely to be popular with patients,^49–51 although there is no evidence about costs or outcomes, or the important issue of safety. Audits in the pioneering physiotherapy services in Cheltenham and Huntingdonshire in England suggest that 40–60% of patients referred by GPs to physiotherapy can be managed by telephone alone without a face-to-face consultation, telephone consultations take approximately half as long as face-to-face consultations, waiting times for a face-to-face appointment have been reduced from 4 weeks to 10 days and did-not-attend (DNA) appointment rates have been reduced from 15% to 1%. Patients appear to be very satisfied with the service, with 80% rating it as good or excellent.⁵²

Diagnoses made by physiotherapists or MSK triage services have been shown to be comparable with diagnoses made in face-to-face assessments and are not influenced by experience of the therapist.^53–55 In addition, therapists from different allied health professions agree on the prioritisation of patient care using telephone assessment systems.⁵⁶ There are some suggestions, however, that management of patients with MSK conditions over the telephone compares less favourably when conducted by less experienced physiotherapists in comparison with more experienced colleagues.^53,57

Related new developments in access to physiotherapy services

The Department of Health has recently published a report of the evaluation of self-referral to physiotherapy pilot sites.¹⁷ Although the evaluation was not based on a randomised trial, the report is broadly supportive of the concept of self-referral, as are other non-randomised evaluations.^18,58–60 A small number of studies evaluating self-referral to physiotherapy services highlight potential patient benefits of direct access.^61–63 Many physiotherapy service leads will consider using PhysioDirect telephone systems to help them manage self-referral, which increases the salience of our study.

Rationale for a randomised trial of PhysioDirect for patients with musculoskeletal problems

PhysioDirect services have been established in a number of areas, notably in Huntingdonshire and Cheltenham in England. These have been commended by the Commission for Health Improvement and the NHS Working in Partnership Programme as examples of good practice and have won awards for innovation. Several other areas have established, or considered, similar services. The NHS White Paper ‘Our Health, Our Care, Our Say’¹⁶ highlighted the need to test new models of physiotherapy to overcome current deficiencies. Without a high-quality randomised trial testing the clinical effectiveness and cost-effectiveness of PhysioDirect, it is unclear whether or not such services should be more widely implemented.

This study is a RCT of PhysioDirect, an approach to improving access to physiotherapy services based on initial telephone assessment and written advice sent by post, followed by face-to-face care only when appropriate. This type of service is being introduced in different parts of the UK, but there is currently no evidence about the effectiveness or cost-effectiveness of PhysioDirect compared with usual care (based on a waiting list and eventual face-to-face care).

Summary of rationale for PhysioDirect

In summary, the rationale for PhysioDirect is to:

• Provide equivalent outcomes for patients compared with usual care based on a waiting list for face-to-face treatment.
• Provide faster access to advice, which would result in more rapid improvement in symptoms and may allow patients to return more quickly to work and usual activities.
• Provide equivalent outcomes at lower cost, meaning that the PhysioDirect service is more cost-effective from an NHS perspective. The lower cost of PhysioDirect would be achieved by better tailoring the use of physiotherapy time in relation to need and capacity to benefit, using telephone consultations which were presumed to be less costly than face-to-face consultations, and by better use of resources through lower DNA rates.
• Increase patient satisfaction because of easier access to advice from a physiotherapist.