The Repeated Re-referral of Chronic Pain Patients into Musculoskeletal Physiotherapy Outpatient Departments

  • Daniel Topley

Student thesis: Doctoral Thesis



Chronic musculoskeletal pain and its impact is a growing concern within the UK and Europe. Physiotherapy musculoskeletal outpatient departments are one of the main UK secondary care services to which chronic pain patients are referred. A number of patients however appear to not achieve resolution yet are repeatedly re-referred through these departments cyclically. There is little investigation of repeated re-referrals, and no standardised operating procedure for leading an enquiry. Therefore, the aim of this research was to establish a picture of re-referrals and the patients experiencing them, and, from stakeholders in the referral process, to account for the occurrence and suggest solutions whereby repeated re-referral may be addressed and resolution achieved.


Statistical output from the LCID database in the NHSCT confirmed the patient segment receiving multiple referrals (n=≥3) over a given time-period. These patients’ records (both from LCID and hardcopy notes) were perused securely using data collection forms and descriptive statistics ran to give a detailed picture of the re-referrals. Focus groups explored re-referrals from the perspectives of physiotherapists in NHSCT Msk OPD departments, and patients who had undergone multiple rereferrals, regarding their respective experiences and attempts to account for the occurrence. Finally, a semi-structured questionnaire survey was administered to GPs referring into NHSCT Msk OPD departments, regarding their approach to a hypothetical patient who had been referred to physiotherapy multiple times but not achieved resolution.


Findings from the studies suggested that repeated re-referral of patients into musculoskeletal outpatient physiotherapy are attributable to two sources; expected re-referrals from degenerative conditions, and ‘problematic’ re-referrals of ‘passive’ patients who have developed dependency through low self-efficacy, and often present with generalised pain. These are characterised by comorbidity and extended treatments, and yet are re-referred a short time after discharge.

GPs consider there to be existing alternatives to re-referring, whilst physiotherapists feel the benefits of these are difficult to replicate after discharge. Citing a lack of training opportunities or resources, physiotherapists find it difficult to apply guidelines or engage these patients with active management programmes, due to ‘yellow flags’ and psychological barriers associated with their condition. They advocate supplying an adjunct to physiotherapy, in the form of CBT from a registered psychologist. Coupled with a more efficient record system, whereby re-referral can be identified, and the ‘problem’ re-referrals addressed as they occur, provision of the education and advice necessary can assist these patients to achieve the self-efficacy they claim to be pursuing. In turn, this can prevent ongoing chronicity of their pain, and associated repeated re-referral.

Conclusions and Implications

There is evidence that repeated re-referral does occur, with a portion of those repeatedly rereferred not considered problematic, but others causing concern to therapists. Loss of self-efficacy, and resulting yellow flags and psychosocial barriers, with administrative delays, contribute to the inability of physiotherapists to engage sufferers of generalised pain in treatment. The impact upon the patient is that resolution therefore is difficult, and chronicity develops. This occurrence can be overlooked in the administrative data or electronic record systems, and the use of these to allow tracking of such occurrences is warranted. Adjuncts to physiotherapy, which the literature suggests may address these psychosocial factors, are advocated by physiotherapists to facilitate the management and self-management of chronic pain sufferers, prevent re-referral, and achieve the outcome the patient desires.
Date of AwardMay 2019
Original languageEnglish
SupervisorDaniel Kerr (Supervisor) & IM Wilson (Supervisor)


  • physiotherapy
  • musculoskeletal
  • referral
  • outpatient
  • pain

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