Musculoskeletal (Physiotherapy)

Information

What is Musculoskeletal (MSK)?

MSK conditions are those which affect bones, joints, ligaments, muscles, tendons and nerves

What does MSK Physiotherapy provide?

MSK Physiotherapists are specialists in providing rehabilitation for all MSK conditions. They are able to assess and manage those with specific (i.e. osteoarthritis, tendinopathy, post operative) and non specific (i.e. non specific back pain, non specific neck pain) MSK conditions.

MSK Physiotherapists focus on the individual using a biopsychosocial framework. They work with the individual to understand their needs, goals and lifestyle. MSK Physiotherapists enable people to help resolve the problems where possible, prevent recurrence and support those with long term conditions to live life to the full in the way they wish to. MSK Physiotherapy services across Lothian have a wide range of other highly skilled staff including physiotherapy assistants and exercise specialists.

MSK Physiotherapists work within both primary/ community care and acute settings each with their individual line management structure. For further information regarding each specific service please click on the link above “MSK services”.

Where indicated MSK Physiotherapists are able to escalate patients for opinion with the team of MSK Advanced Practice Physiotherapists (APPs) (Spinal & Peripheral) within integrated MSK services (iMSK). These clinicians work closely with Orthopaedic Consultants, Consultant Neurosurgeons, Neurologists and radiologists and hold regular joint virtual clinics. They are able to arrange investigations, interventional radiology and if necessary onward referral to secondary care.

The primary care workforce is expanding. Primary care clinicians include advanced practice physiotherapists and advanced nurse practitioners. These clinicians work in a similar way to GPs and will refer patients to MSK Physiotherapy for rehabilitation and use this ref help guidance to support the process. Please consider your local practice arrangements. These primary care clinicians based within GP practices do not provide ongoing rehabilitation or management which, if required, happens within the MSK physiotherapy service.

M.A & P.A (NHS Lothian MSK Subgroup) – 2-9-26

Who can refer:

Primary care clinicians i.e. GPs, Primary care advanced practice physiotherapists, advanced nurse practitioners
Patients- self referral (resident of East Lothian HSCP, Edinburgh HCSP and West Lothian HSCP) Where To Find Us – Musculoskeletal Physiotherapy)
Secondary care consultants and associated teams

Who to refer

Urgent

Severe radicular pain – spinal pathways criteria- for additional info see Lumbar Spine – RefHelp
Armed forces and veterans (CEL 8 (2008) – Access to health services for armed forces veterans: extension of priority treatment: obtaining the medical history of armed forces personnel on their release from HM forces)
Post op/ Post fracture
Potential for significant soft tissue injury (MOI, force and trauma)
Following interventional radiology procedure – referral and appointment typically arranged at time of procedure

Patients with 3 or more of the following criteria:
- Appropriate clinically reasoned healing times considered
- Pain medication optimised
- Off work/ study (<12/52’s) due to the current MSK episode
- Sleep disturbance due to the current MSK episode
- Main carer where current MSK episode impacting significantly on ability to provide care)
- Living alone where current MSK episode severely limits ADLs and additional support required from others

Routine

Non specific MSK conditions i.e. non specific back pain
Specific MSK conditions i.e. tendinopathies, osteoarthritis
Soft tissue injuries
Undifferentiated MSK complaints
Chronic MSK pain disorders without significant psychological/ psychiatric/ drug addiction element (see specific service for further detail)
via MSK pathways and iMSK services- people requiring diagnostics/ interventional radiology / neurosurgical/ orthopaedic opinion (see iMSK/ relevant body area for further detail- Lumbar Spine – RefHelp; Shoulder and Elbow – RefHelp)
Pelvic health i.e. continence (Edinburgh & Mid Lothian- see specific services for detail as services vary across Lothian)
Mobility assessment
Walking aid assessment

Who not to refer

Patients who have the presence of significant red flags/ suspicion of serious pathology. Serious pathology as a cause of MSK conditions is considered rare but needs to be managed either as an emergency or urgent referral to the relevant secondary care service. Consider below & also see relevant body area tab for further specific information and guidance
- Emergency conditions
  - Cauda equina syndrome- suspected (see Serious lumbar spine conditions (Red Flags) – RefHelp)
  - Metastatic spinal cord compression- (see Serious lumbar spine conditions (Red Flags) – RefHelp)
  - Spinal infection – suspected (see Serious lumbar spine conditions (Red Flags) – RefHelp)
  - Acute foot drop – (see Serious lumbar spine conditions (Red Flags) – RefHelp)
  - Septic arthritis
  - Deep vein thrombosis- suspected
- Urgent conditions
  - Cervical spondylitic myelopathy (see Serious cervical spine conditions (Red Flags) – RefHelp)
  - Major spinal related neurological deficit/ worsening neurological deficit- suspected
  - Insufficiency fracture
  - Primary and secondary cancers- suspected
  - New inflammatory arthritis/ myositis – suspected
  - Inflammatory spinal pain- suspected Axial Spondyloarthritis – RefHelp)
- Consider serious pathology as a differential diagnosis if person presents with;
  - Escalating pain and progressively worsening symptoms that do not respond to conservative management or medication as expected; systemically unwell (fever, wight loss); night pain that prevents sleep due to excavating pain and/ or difficulty lying flat

Who not to refer – other

Age under 16 yo (Under 16 Physiotherapy (MSK) Paediatrics – RefHelp)
Non-MSK complaint – chronic fatigue, weight management, SMART centre, respiratory
Provision of splints/ orthotics etc
Referral for a specific intervention – acupuncture/ ultrasound/ massage etc
People who do not wish to engage with physiotherapy
Chronic MSK pain with significant psychological/ psychiatric/ drug addiction element- Chronic Pain – RefHelp
Vestibular rehabilitation (ML, WL, ECPS, WGH)
Symptoms present <6 weeks – conditions where the natural history is typically favourable within the timeframe and improvement is likely with supported self management
Symptoms without appropriate analgesia review
Absence of self-management advice provided regarding timescales for natural healing.
Referral for the same issue within 12 months unless there’s a clear reason, such as changed symptoms, different function, or new motivation to take part in treatment. Unnecessary repeat referrals put extra pressure on services and slow access for others.
Supported exercise/ personal training in the absence of a MSK Problem – direct to local leisure/ exercise pathways

Advice Only

This service is intended to offer Primary care clinicians, MSK Physiotherapy advice on clinical problems, which may not require a formal referral/ assessment if simple advice or tips would suffice- accessed via SCI referral
The MSK Physiotherapist has the option to put the patient on to the relevant waiting list if it is felt an appointment is necessary
Please do not use the advice service for appointment queries- please contact the relevant MSK Physiotherapy service via tel 0131 536 1060

How to refer

Adults (Aged 16 or over at the date of referral)
SCI Gateway – see below for detail
For children <16 see guidance Physiotherapy (MSK) Paediatrics – RefHelp)

East Lothian Health & Social Care Partnership

AHP Physiotherapy East Lothian- East Lothian Community Hospital LI Physiotherapy

Edinburgh Health & Social Care Partnership

AHP Physiotherapy Edinburgh-Community MSK Hub (Slateford) LI Physiotherapy

Midlothian Health & Social Care Partnership

AHP Physiotherapy Mid Lothian – Bonnyrigg Health Centre LI Physiotherapy

Western General Hospital

AHP Physiotherapy Edinburgh- Western General Hospital LI Physiotherapy

West Lothian Health & Social Care Partnership

AHP Physiotherapy West Lothian- St Johns Hospital LI Physiotherapy WL

Please consider the detail provided within the specific body region to help support initial primary care management and referral process. Clinicians are asked to follow the Primary Care Management guidance on RefHelp whenever possible prior to making any referral.

Refer to each body area tab for specific guidance to support primary care management

Consider guidance on how to make a good referral How to make a good referral – RefHelp

NHS Inform – Scotland’s National health information service- contains a range of self management information, tools and exercises for supporting people to make informed decisions about their health and MSK problems www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints

Information for patients regarding MSK Physiotherapy services within NHS Lothian and MSK conditions found here Musculoskeletal Physiotherapy – NHS Lothian | Our Services

Self referral information found here: