Intermediate Care pathways for musculoskeletal conditions – are they working?


The last two decades has seen the emergence of clinical specialisation with Allied Health Professionals (AHPs) working in new roles using skills previously out with their scope of practice to provide a more efficient Health Service utilising the talents of all staff.

One innovation has been the development of the Musculoskeletal Clinical Assessment Treatment Service (MSK CATS) model. These services interface between primary (G.P.) and secondary (hospital) care to manage the growing demand of musculoskeletal (MSK) patients on orthopaedic services. The aim of this paper was to provide an evidence summary of the effectiveness of MSK CATS.

Here’s what they did

The authors searched PubMed, Web of Science, EMBASE, Ovid MEDLINE, PEDro and Google Scholar for studies evaluating MSK CATS or similar services assessing musculoskeletal (MSK) conditions. They included any studies describing primary care based triage led by AHPs, G.P.s and musculoskeletal physicians, or those evaluating referral pathways.  Outcomes of interest were: effect on waiting times, patient satisfaction, and effectiveness and referral outcomes of these services.

Here’s what they found

Twenty three studies were identified and after quality assessment using a modified Downs and Black Checklist all were included in the review. These included one randomised controlled trial, 19 observational studies (14 retrospective, 5 prospective), one prospective quasi-experimental study and two audits.

The majority of studies assessed the service during its first year of implementation over varying timescales. Quality assessment of studies varied with 11 studies deemed low, 8 medium and 4 high quality. Main findings reported were:

  • 72%-97% of patients could be managed entirely within Intermediate Care resulting in a 20%- 60% reduction in orthopaedic referral rate.
  • Knee conditions were most commonly referred onto secondary care (35%-56%) with plain film X-ray (5%-23%) and MRI (10%-18%) the most common investigations requested
  • Physiotherapists’ clinical decision making and referral accuracy were comparable to medical doctors in 68% – 96% of cases
  • Patient Reported Outcomes Measures typically showed significant symptom improvements

In 46% of services patients were assessed and triaged by physiotherapists. However, only 11% of the services had a clear evaluation strategy such as pre and post implementation data, numbers treated, discharge profiles and scoring systems for triage, making critique of the services difficult. A large proportion of patients suffered with depression (47%) and anxiety (37%) due to chronic pain. The most common referral pathway was to physiotherapy (23%), the most common intervention was steroid injections (13%). Interestingly one audit showed that a referrals via a multi-professional triage team increased waiting times with 22% of those referred onto secondary care deemed to have an incorrect diagnosis and 33% no diagnosis.

The authors concluded

MSK CATS and physiotherapy triage appropriately manage and suitably refer patients to Intermediate Care.

The Musculoskeletal Clinical Assessment Treatment Service and physiotherapy triage appropriately manage and suitably refer patients to Intermediate Care.

The Musculoskeletal Clinical Assessment Treatment Service and physiotherapy triage appropriately manage and suitably refer patients to Intermediate Care.

The Musculoskeletal Elf’s view

The Musculoskeletal Elf

Pressures on Health Services and the growing problem of an aging population has led to development of new roles and ways of working to cope with the demand for MSK assessment and management. To ease the burden on overstretched primary care services in Wales, several pilot sites are using Physiotherapists rather than G.P.s to provide consultations for people presenting with MSK conditions. The findings of this review suggest that suitably qualified and experienced Physiotherapists can appropriately manage MSK conditions independently, but highlights an urgent need for robust data collection and high quality studies to evaluate effectiveness and impact on other services, including Physiotherapy itself. Other questions such as: whether the shift of experienced staff into MSK CATS services adversely affects skill mix within Physiotherapy departments, and, what skills, training and governance is required to support such posts remain unanswered.

What do you think?

  • What has been your experience of MSK CATs or similar services?
  • Where do you think research into this area should be focussed?

Send us your views on this blog and become part of the ever expanding Musculoskeletal Elf community. Post your comment below, or get in touch via social media (FacebookTwitterLinkedInGoogle+).


Hussenbux, A., Morrissey, D., Joseph, C. & McClellan, C.M. 2015, “Intermediate care pathways for musculoskeletal conditions–are they working? A systematic review”, Physiotherapy, Vol. 101, no.1, pp.13-24 [Abstract]

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