Overweight and obesity management in musculo-skeletal primary care: a survey of Australian health practitioners exploring ‘the elephant in the room’

Keywords: Australian practitioners, electronic survey, musculoskeletal management, obesity, overweight, pain management, primary care, weight control.

Overweight and obesity has a bi-directional association with the growing burden of musculoskeletal (MSk) dysfunction and pain as well as presentations, across all ages, to a range of clinicians (Wills 2004; Kotowski and Davis 2010; Shiri et al. 2010; Butterworth et al. 2012; Richmond et al. 2013; Plow et al. 2014; Smith et al. 2014; The Royal Australian College of General Practitioners 2019; Australian Institute of Health and Welfare 2020, 2021). Although there are some studies showing that MSk health practitioners believe they do have a role in weight management (Pollentier and Langworthy 2007; You et al. 2012; Ard 2015), in most cases, however, that role is poorly defined, and the focussed knowledge and skills to support weight loss beyond a superficial level was reported to be lacking (Pollentier and Langworthy 2007; Shiri et al. 2010; Butterworth et al. 2012; You et al. 2012).

There are a number of studies indicating that MSk health practitioners stigmatise overweight and obese patients (Holtzman and Burke 2007; Awotidebe and Phillips 2009; Puhl and Heuer 2009; You et al. 2012; Setchell et al. 2014; Cavaleri et al. 2016), and often fail to address this factor as part of the MSk presentation. This is despite the literature showing improved MSk outcomes for people with lower body mass index (BMI), which can result in reduced biomechanical stress and pain on load-bearing joints and greater compliance so that interventions are often more effective (Kotowski and Davis 2010; Shiri et al. 2010; Butterworth et al. 2012; Cuesta-Vargas and González-Sánchez 2013; Richmond et al. 2013; Smith et al. 2014; Yang and Haldeman 2018; Australian Institute of Health and Welfare 2020).

In Australia, there are a number of health professions usually charged with managing MSk conditions in primary care. This includes: medical practitioners with a MSk interest or specialisation; Allied Health practitioners such as physiotherapists, chiropractors, osteopaths, occupational therapists and exercise physiologists; some registered nurses and massage therapists.

According to a systematic review (Cavaleri et al. 2016) and supported by our own analysis of the literature, there is little quality evidence describing the engagement of patients and their MSk health practitioner in weight management as an adjunct or direct component of their intervention or therapy. This study aimed, therefore, to survey MSk health practitioners, exploring their engagement of weight management with their patients.

The study was designed to be a self-administered electronic survey. The electronic survey aimed to collect data from health practitioners who have a focus on musculo-skeletal management (see Appendix 1). A suitable validated or non-validated questionnaire could not be found in the literature; therefore, one was constructed for this project. To enhance internal validity, the items and instructions were developed using an iterative process that included: item and instruction development; item and instructions testing with a small focus group of health practitioners; and utilising their responses and evaluations to inform the construction of the final version of the 13 items and instructions used in this survey (Gajda and Kowalska 2016). The electronic questionnaire was managed by a social media survey platform, Survey Monkey (Momentive, Inc.).

The electronic survey presented questions to collect data on participants’ profession and the location in Australia in which they practised. The participants were asked to quantify the number of patients they formally engaged with in the week prior to taking the survey. They were also asked to estimate the number of those patients seen who they measured or perceived to be, overweight or obese (OWO) according to normative BMI data cut-off points (which were supplied in the survey). Participants were also asked to estimate the number of patients for whom overweight and or obesity was the primary or adjunct determinant for their MSk-related presentation. Additionally, participants were asked: on how many clients had they focused some or all of their treatment on weight management?

The remaining questions focussed on the respondents’ perceived level of confidence in providing weight management as part of their practice and, if they were not confident, whether increased lifestyle-related knowledge and skills in weight management would encourage them to include weight management as part of their practice. Participants were also offered an open, qualitative item to share comments on their perceived role in helping their patients address issues with weight (Green and Thorogood 2018).

The target group were opportunistically selected using a membership database from a multidisciplinary, MSk practitioner network and community of learners (the Australian Musculo Skeletal Network – AMSN, www.amsn.com.au). The Network was active between 2013 and 2020 and had a multidisciplinary membership of practitioners from health professions who practice in the MSk/manipulative therapy domain. At the time the survey was opened, there were 350 registered members. All of these members were identified and verified by AMSN administration as AHPRA-registered clinicians or other identifiable health professionals such as Exercise Physiologists, Massage Therapists and Naturopaths at the time of registration.

The survey was launched through the Network’s subscription to SurveyMonkey, inviting all 350 registered users to undertake the survey. A direct link was provided in an email (and in subsequent reminders) to the questionnaire and it remained accessible to participants for 2 weeks from the date of the launch.

Instructions to participants included ethics approval information and a link provided to find more detail on ethics if it was required. Privacy and confidentiality statements were included and an assurance that their data would be de-identified. Instructions were also provided informing the participants that by pushing the submit link at the end of the questionnaire, that it would be considered to be their vicarious consent to participate.

The quantitative data were analysed with SPSS ver. 25 for descriptive statistics (SPSS Inc.). The qualitative data were thematically analysed independently by two researchers and, following consensus, only those themes that both researchers agreed on were included in the results (Braun and Clarke 2006; Green and Thorogood 2018).

The study was part of a series of investigations approved by the Home University Human Research Ethics Committee (ECN 18-181).

In total, 206 surveys were returned, representing a return rate of 59%, of which 204 were complete with all items attempted and included in the analysis.

Table 1 shows that >83% of respondents were from the seven recognised health professions in Australia that engage in MSk care: Chiropractors 24%, Physiotherapists 21%, General Practitioners (GPs) 16.7%, Osteopaths 10.3%, Occupational Therapists 6.9% and Exercise Physiologists 5.4%. The remaining responders (n = 33, 16.7%), though likely to be engaged in MSk care, were in numbers <5% of the total and were therefore, categorised as Others. The Others included: registered nurses, podiatrists, psychologists, naturopaths and massage therapists (there were no Dietitians or Chinese Medicine practitioners in the AMSN membership at the time of this survey).

Table 1.  Clinician self-perceptions of overweight and obesity management in musculoskeletal primary care survey results.

Table 1 also shows the mean (s.d. and range) number of clients for each profession estimated to have been seen by participants in the week prior to undertaking the survey.

The mean number of clients seen by the entire cohort was ∼54 patients per week and ranged, for the seven main professions, from a mean of 30 patients per week for Osteopaths and ∼70 for GPs.

The total percentage of clients estimated to be overweight was 70%. With the exception of the Exercise Physiology (EP) profession indicating an overweight clientele of 20%, all other individual MSk clinician groups estimate that >50% of their clients were overweight, with GPs estimated that to be 80%.

Table 1 also shows that the respondents estimated an average 40% of clients were not only overweight, but obese according to their BMI. With the exception of EPs who estimated that only 5% of their clients were obese, the remaining estimates were relatively evenly distributed throughout the MSk clinical professional groups.

Overweight and obesity (OWO) was estimated overall to be the primary reason/determinant for presentation for <15% of all presentations. Chiropractors, Osteopaths and EPs reported that none of their clients had presented to them directly with OWO as their primary reason/determinant. The other professions showed that <15% of presentations were directly related to OWO, with the exception of GPs, who estimated it as the main reason for presentation in 25% of their patients.

In total, the participants estimated that even though OWO was not often the direct reason for a presentation/appointment, it was a factor in >60% of their clients’ presentations. GPs and OTs estimated that it was a factor in 80% of their clients’ presentations.

Forty percent of participants said that their practice included a systematic approach to weight management. This result, however, was distributed unevenly across the professions. High percentages of EPs (100%) and GPs (79%) reported having a systematic approach to weight management in their practice, whereas relatively low percentages were reported by Occupational Therapists (23%), Physiotherapists (22%), Chiropractors (21%), and Osteopaths (14%). Adjusting for EPs, GPs and Other, 81% of the remaining professions reported not having a systematic approach to weight management.

The participants were asked: ‘Estimate how many patient/clients last week did you focus some or all your treatment on weight management?’. In total, <26% of consultations with OWO clients included a focus on weight management. EPs were the exception as they estimated that it was included in approximately 75% of their consultations. When the results are readjusted by removing EPs from the analysis of this question, the total percentage of consultations that included weight management drops to 17.5%.

The participants were asked if they felt confident in providing weight management to their patients in the form of either advice or specifically designed programs. Approximately 55% (n = 113) of the total group indicated yes. Table 1 shows that this result was not evenly distributed. EPs (100%) and GPs (94%) reported high levels of confidence, Chiropractors (55%) and Physiotherapists (49%) reported less confidence and Osteopaths (19%) and Occupational Therapists (14%) reported relatively low levels of confidence in providing weight management as part of their practice.

Forty-five percent of the participants who responded that that they were not confident in providing weight management in their practice (n = 91) were offered an opportunity to explain the main reason why. Eighty-nine of these 91 participants provided a response. These were thematically analysed and categorised under six headings, as shown in Table 2 (NB as per results shown in Table 1 there are no EP and very few GP responses to this item).

Table 2.  Reasons for lack of confidence with including weight loss in MSk practice.

More than 34% of ‘not confident’ responders believed that weight management was not in their scope of practice. Approximately 38% claimed that they lacked the knowledge and/or time to engage patients and 19% suggested that they were uncomfortable discussing weight with overweight patients.

Finally, the participants were asked if they had any general comments that they wished to share involving their role in managing weight. Sixty-nine respondents provided a response and all were included in the analysis.

These responses were thematically analysed and arranged under five main themes. The category titles were developed from quotes found in the participants’ responses. These data are presented in Table 3.

Table 3.  Thematic analysis of health practitioner comments.

This study shows that the MSk practitioners who were surveyed estimated that 70% of their clients were overweight and 40% obese, which is slightly higher than in the general Australian community; 68% and 28% respectively (Australian Institute of Health and Welfare 2021). It is not surprising that OWO is over-represented in the MSk client cohort, as the literature discussed previously that many MSk clients suffer pain and immobility that contributes to higher body mass and/or that higher body mass is a determinant in the MSk pathology leading to pain and immobility.

The participants of this survey estimated that in 60% of their clients’ presentations, OWO was a determinant and yet collectively, they reported that <18% of patients received weight management as part of their overall MSk intervention. This was unevenly distributed across the professions, with Chiropractors and Osteopaths reporting that none of their clients received weight management assistance and all of the Exercise Physiologists’ clients received weight management support.

Even though it was considered that OWO was a factor in many clients’ presentations, collectively, 60% of the clinicians suggested they did not have a systematic approach to patient weight management. EPs and GPs suggested in strong numbers that they did have a systematic approach. The EP finding in this small sample may reflect that EPs tend to see people aiming for greater fitness, and weight loss is more of an adjunct rather than the primary goal, but still considered, although this is speculative and requires further research. When these two professions and the Other category were removed from the analysis, the remaining professionals (Chiropractors, Physiotherapists, Osteopaths and Occupational Therapists) reported that >80% did not have a systematic approach to weight management in their practice.

Approximately 41% of the respondents who explained why they did not have a systematic approach to weight management suggested that this was because they did not see it as their role or in their scope of practice. The majority (51%) suggested that they lacked the skill, confidence and method to raise the issue with their clients and then do something about it. This finding appears to support that of another study, suggesting that MSk practitioners lack confidence and seldom discuss the connection between weight and the presenting issue with their clients (You et al. 2012). Indeed, 45% of the collective responses from this survey reported not being confident to offer weight management if asked or if the opportunity arose.

These data support the literature, suggesting that overall, the majority of MSk patients are OWO. Despite research showing the benefits of weight management in the outcomes of MSk therapy for the prevention of chronicity and future problems, with the exception of Exercise Physiologists and General Practitioners, most of the respondents from the Other MSk professions indicated that they are not offering a systematic approach to weight management as part of their practice. The respondents indicated that they would be more confident in offering weight management if they were able to develop more skills and knowledge in this area.

The literature suggests that sustained weight management and reduction is a difficult project for the clinician–patient relationship within current health structures and systems, and that current success rates are low (Elfhag and Rössner 2005; LeBlanc et al. 2011; Ard 2015). Addressing weight issues through lifestyle education, referral, and activity prescription could be a component of patient treatment plans, especially in the early stages of MSk pathology where OWO is so often a determinant and/or an outcome (Ard 2015).

There is a large number of primary healthcare MSk practitioners available in the community to engage with this OWO epidemic. Many would welcome the opportunity to improve their business and practice outcomes. It is timely for the MSk professions to acknowledge the ‘elephant in the room’ and the opportunity it offers to improve outcomes and incomes in practice.

The results have limited generalisability because of the size of the sample (N = 204), and smaller still, the samples of the various professions described in the analysis. Also, the respondents were drawn from a single network, which is not necessarily a representative sample of the national population of MSk primary care practitioners cohort. There were no Dietitians or Chinese Medicine practitioners included, which further limited the representativeness of the sample.

In addition, the examination of the literature about MSk therapists and weight management found limited contemporary sources. A large portion of the literature reviewed and included in this study is >10 years since publication. The size of the trends in the data, however, are large enough to, at least, stimulate the discussion that has been presented in this paper, and more rigorous research into the role of MSk practitioners in managing overweight and obesity in practice is required.

This paper set out to explore weight management in the practice of MSk practitioners. Sixty percent of the respondents in this survey indicated that they do not include weight management as part of their practice despite 70% of their patients/clients being overweight and or obese either as a determinant in, or as an outcome of, their MSk presentation. With the exception of General Practitioners and Exercise Physiologists, in this survey, the manipulative therapists including Chiropractors, Osteopaths, Physiotherapists and Occupational Therapists, indicated that they lacked confidence, knowledge and methods to engage a systematic approach to weight management with their patients/clients.

Data is unavailable due to privacy concerns.

The authors declare no conflicts of interest.

This research did not receive any specific funding.

All authors contributed to the analysis of the data and writing of the manuscript.