Stakeholder perspectives on musculoskeletal pain assessment and management in the UK: a qualitative study

Abstract

Background:

Musculoskeletal (MSK) conditions, including rheumatic musculoskeletal diseases (RMDs), are leading causes of persistent pain, disability, reduced quality of life, impaired work participation and increased healthcare utilisation. Despite therapeutic advances, pain remains challenging to assess and manage because unidimensional measures may miss multidimensional impact, and person-centred, mechanism-informed, equitable approaches are inconsistently implemented.

Objectives:

This study explored stakeholder perspectives on (1) gaps and limitations in current MSK pain assessment; (2) priorities for improving MSK pain management across pharmacological, non-pharmacological, digital and procedural/surgical approaches and (3) service and research priorities needed to deliver equitable, person-centred, mechanism-informed care.

Design:

We conducted an anonymised online survey (Google Forms) between July and September 2025 across UK Musculoskeletal Translational Research Collaboration (TRC) networks.

Methods:

Adults (⩾18 years) able to read English were invited via TRC mailing lists, partner newsletters and professional networks. Open-ended questions explored experiences of pain assessment and management, perceived gaps and priorities for improvement and research. Free-text responses were exported, cleaned and analysed in NVivo using inductive reflexive thematic analysis (Braun and Clarke), supported by peer debriefing and an audit trail. Descriptive statistics summarised participant roles.

Results:

Thirty-five participants responded, with 54.3% patients, 40% healthcare providers and 5.7% researchers. Five overarching themes were identified: (1) appreciation of pain mechanisms to guide management, (2) holistic and person-centred care, (3) need for individualised treatment plans, (4) limitations of current pain assessment methods and (5) underestimation of pain’s broader impact. Subthemes highlighted complementary therapies, digital resources and telehealth, self-management education, equitable access, multidomain assessments and clinician capacity to deliver comprehensive biopsychosocial care.

Conclusion:

Stakeholders in this TRC-network sample prioritised individualised, holistic and mechanism-informed MSK pain management integrating pharmacological, non-pharmacological and digital strategies while addressing equity and access. Findings support moving beyond single-item intensity measures, strengthening self-management, and adopt biopsychosocial approaches. These hypothesis-generating insights should be validated in broader, more diverse samples.

Plain language summary

Patients and healthcare professionals views on pain management services

We conducted a survey of pain management services across the UK. We asked healthcare professionals, patients and researchers their views on pain management and services. We found that patients and their healthcare professionals are keen for a more joined up approach to pain management and care. Patients advocated for a broader pain assessment that includes their lifestyle, work considerations, tools for self-management and care. The insights provided by our national survey help inform a foundation for service improvements and a patient-centred research agenda in care for rheumatic and musculoskeletal diseases.

Keywords

biopsychosocial approach digital health interventions equity and access individualised treatment plans musculoskeletal pain pain assessment person-centred care reflexive thematic analysis rheumatic musculoskeletal diseases self-management

Introduction

Musculoskeletal (MSK) conditions represent one of the most significant contributors to global pain and disability, responsible for nearly 17% of all years lived with disability (YLDs) equivalent to approximately 149 million YLDs worldwide.¹ Among these, low back pain remains the single leading cause of disability, consistently ranking first in global YLDs across decades.² Within the MSK category, rheumatic musculoskeletal diseases (RMDs) add further complexity, most notably osteoarthritis (OA), which affects approximately 595 million people globally.³ In the UK, more than 20 million people live with an MSK condition and over 10 million have arthritis, with substantial impacts on quality of life, work participation and healthcare use.⁴ Together, these figures underscore the need for renewed focus on the investigations and management of MSK conditions especially RMDs.

Despite advances in diagnosis and therapeutics across RMDs, pain remains the symptom patients most want addressed and the symptom that clinicians often find most difficult to evaluate and manage well.⁵ Modern concepts of pain perception recognise that MSK pain commonly reflects interactions between nociceptive, neuropathic and nociplastic mechanisms, shaped by psychological, social and contextual factors.⁶ The International Association for the Study of Pain (IASP) recognises that the biopsychosocial model of pain impacts patients’ pain experiences, with a more recent acceptance of the influence of nociplastic pain in addition to nociceptive, inflammatory and neuropathic elements in RMDs, defining nociplastic pain as ‘pain that arises from altered nociception’ not fully explained by tissue or nerve damage, which often co-exist with other mechanisms in RMD.⁷

Given these observations, UK initiatives such as the Musculoskeletal Translational Research Collaboration (TRC), which is a joint effort between National Institute for Health and Care Research (NIHR) and Arthritis UK, explicitly prioritise mechanistically informed care and co-production with people living with pain.⁸ Yet to focus research investment meaningfully, we require granular stakeholder insight into where assessment and management are failing, and what changes would have the greatest impact in real clinics.

This study aimed to synthesise perspectives from patients, healthcare professionals, researchers, and charity/NIHR stakeholders in the TRC network. Using reflexive thematic analysis of open-text survey data, we aimed to: (1) highlight perceived gaps in current MSK pain assessment; (2) identify priorities for improving management across medication, physiotherapy or exercise, psychological therapies and surgery and (3) articulate a research agenda that is patient-centred, equitable, and mechanism-informed. In doing so, this paper contributes hypothesis-generating, agenda-informing insights from stakeholders engaged through the TRC network to support future patient-centred, equitable and mechanistically informed research and service improvement efforts.

Methods

Study design

This qualitative descriptive study used a reflexive thematic analysis, as outlined by Braun and Clarke (2006), to explore perspectives on MSK pain assessment and management. The analysis was primarily inductive, with themes generated from the data rather than predetermined, while recognising that data collection was guided by a questionnaire with predefined open-ended questions. Reflexive thematic analysis was chosen for its flexibility and its emphasis on the active role of the researcher in evaluating responses. The analysis followed the six phases described by Braun and Clarke (2006): familiarisation with the data, generation of initial codes, searching for themes, reviewing themes, defining and naming themes and producing the report. Participant responses were read repeatedly to ensure immersion in the data. Initial coding was conducted using both in vivo codes (participants’ own words) and interpretive analytic codes to capture underlying meaning. Codes were then grouped into subthemes and subsequently refined into overarching themes that represented patterned responses across the dataset (Supplemental Figure 1).

Throughout the process, a reflexive approach was maintained, with ongoing consideration of how the researcher’s perspectives and assumptions may have influenced data interpretation. The qualitative component formed part of the NIHR TRC Pain Survey conducted within the UK MSK TRC. The broader initiative aimed to inform the national research agenda for pain management in RMDs, aligning with NIHR and Arthritis UK priorities for patient-centred and mechanistically informed care. The qualitative design enabled a detailed exploration of lived experiences and professional reflections, allowing for the capture of nuanced views that are not easily expressed through structured or quantitative survey formats. Our analytical stance was interpretivist/constructivist, recognising multiple, contextually situated meanings. Reporting followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidance (Supplemental Table 1).⁹

Data collection, preparation and management

An online, voluntary survey through Google Forms was distributed in July to September 2025 via the MSK TRC mailing lists, partner organisations’ newsletters and professional networks for those who are adults that are above 18 years old and able to read English. The questionnaire that we developed and used was pilot-tested within the working group of five members in the TRC but was not validated. This includes patients, carers, clinicians, therapists, surgeons, academics/researchers, charities and NIHR-affiliated groups. The survey landing page stated the study purpose as to map current approaches to pain assessment, management and research priorities and stated that responses would be used to inform a review article.

The questionnaire contained open-ended questions inviting reflections on: (1) their experiences of pain assessment and management; (2) areas for improvement across medication, physiotherapy or exercise, talking therapies, and surgery and (3) priorities for future research (Table 1). Two multiselected items captured preferences for service improvements and research priorities to enable descriptive context for the qualitative findings. Google Forms does not record start times; therefore, completion time was not available.

Table 1.

Survey items and response formats for the musculoskeletal pain questionnaire.

S/N	Survey question	Response type/options
1	What best describes you?	Single choice (Patient/Healthcare Provider/Researcher)
2	Do you feel that current pain assessment methods used in clinics capture and give a full picture of the pain experienced by patients?	Single choice (Yes/No/Unsure)
3	Please share any thoughts on your previous response	Open-ended (free text)
4	In your opinion, which areas of pain management could be improved?	Multiple choice (Medication, Physiotherapy and exercise, Talking therapies, Surgery, Other)
5	Medication: What improvements would you suggest?	Open-ended (free text)
6	Physiotherapy and exercise: What improvements would you suggest?	Open-ended (free text)
7	Talking therapies: What improvements would you suggest?	Open-ended (free text)
8	Surgery: What improvements would you suggest?	Open-ended (free text)
9	Other:	Open-ended (free text)
10	What should future research in pain focus on?	Multiple choice (e.g. better ways to assess and monitor pain, developing new treatments, understanding patient experiences, Improving access to care)
11	Is there anything else you’d like to share about your experience or views on pain management?	Open-ended (free text)

The online survey comprised 11 mixed-format items (closed and open-ended) administered to UK Musculoskeletal TRC participants between July and September 2025 to capture views on current MSK pain assessment, priorities for improving care and key areas for future research.

We intentionally collected role only patient, healthcare professional and researcher identifiers, with no other personal characteristics for qualitative analysis. All responses were anonymised at collection, and any potentially identifying references in free text were redacted prior to analysis. Verbatim free-text responses were exported to Microsoft Word for initial data cleaning such as removing empty or duplicate entries and imported into NVivo (QSR International; NVivo R1/v1.7.1, 2020) for organisation, coding and audit-trail management. The full raw free-text dataset is not publicly shared to protect anonymity.

Data analysis

Following Braun and Clarke’s six-phase framework, we: (1) familiarised ourselves with the corpus; (2) generated inductive line-by-line codes; (3) searched for candidate themes; (4) reviewed; (5) defined and named themes and (6) produced the analytic comparing reflexive thematic analysis and other pattern-based qualitative analytic approaches.^10,11 Coding was conducted at the level of meaning units (phrases to short paragraphs), and extracts could be coded to more than one code where relevant. NVivo records each coded extract as a ‘coding reference’; across the dataset, coding generated 405 coding references (i.e. coded extracts) distributed across the developing code structure. Reference counts were used descriptively to support audit-trail documentation and to indicate which issues were commonly raised within this sample, rather than to quantify theme ‘importance’ or infer effect sizes. Reflexive memoing was employed throughout analysis to document thoughts, assumptions and evolving interpretations. These memos captured initial impressions, coding decisions and reflections on potential biases, facilitating transparency and reflexivity. Regular team debriefing sessions were conducted to discuss coding strategies, emerging themes and differing interpretations. These discussions provided critical peer review, helping to challenge assumptions and maintain analytical rigour. Memoing and debriefing together supported iterative refinement of codes and themes while keeping the analysis grounded in participants’ accounts, consistent with an interpretivist approach. SM (programme manager, NIHR MSK TRC) coordinated the online qualitative survey and developed the initial coding along with TK (Master’s student). Theme development and interpretation were refined through peer debriefing with co-authors (SM, RH (Master’s graduate pursuing medical degree), NS (clinician with expertise in rheumatology pain care and co-lead for NIHR TRC). An audit trail was maintained throughout to document analytic decisions made during coding, theme development and refinement, thereby supporting traceability from raw text to themes.

Methodological considerations: Reflexivity and rigour

Methodological rigour was supported through reflexive memoing and team discussions throughout analysis to surface assumptions and positionality and to challenge emerging interpretations, helping to keep findings closely tied to participant’s account. Dependability was supported through detailed audit trail (versioned coding logs, memos and theme-development records), documenting how codes and themes evolved. Confirmability was enhanced through transparent data management and traceability in NVivo. Transferability was supported by describing the study context and presenting illustrative quotations in the results, enabling readers to judge relevance to their settings. Member checking was not undertaken due to the anonymous, cross-sectional design.

Ethical considerations

This project was an anonymised stakeholder survey within the MSK TRC programme. No identifiable personal data were collected beyond role category, and no clinical intervention occurred. Participation was voluntary with implied consent via submission. In line with UK guidance, National Health Service (NHS) Research Ethics Committee review was not required for anonymised consultation or patient and public involvement-style activities and was determined by the Health Research Authority guidance/decision tool. All responses were treated confidentially and stored securely in accordance with UK data protection and privacy regulations, including the General Data Protection Regulation (GDPR).

Results

A total of 35 participants completed the survey, including 19 patients (54.3%), 14 healthcare providers (40%), and 2 researchers (5.7%). Open-ended responses were analysed using reflexive thematic analysis, identifying five overarching themes and seven subthemes (Figures 1 and 2). These themes reflected distinct but interconnected aspects of MSK pain assessment and management and are described in Table 2. The most frequently referenced areas were the use of alternative and complementary therapies and the need to improve equity and access to care, highlighting participants’ desire for more integrative, inclusive and accessible models of pain management.

Figure 1.

Thematic representation of pain management findings. Visual summary of five interrelated themes generated from reflexive thematic analysis, arranged in an interconnected circular model to illustrate how participants’ views on pain assessment and management interconnect to each other.

Figure 2.

Conceptual map of qualitative themes and subthemes in pain management. Schematic showing five overarching themes (blue) and seven associated subthemes (green) derived from reflexive thematic analysis of free-text survey responses, created in NVivo to illustrate how individual codes clustered into higher-order categories.

Table 2.

Summary of qualitative themes and subthemes with interpretive descriptions.

S/N	Themes/subthemes	Description
1	Appreciation of pain mechanisms to inform pain management	Comments highlighted the need to consider biological, psychological and social factors influencing pain, with critique of heavy reliance on medication.
1.1	Alternative and complementary therapies	Treatments used in addition to (complementary) or instead of (alternative) conventional medical treatments. They may include practices such as acupuncture, massage, herbal medicine, meditation, yoga.
1.2	Over-reliance on pain medications for pain management	This refers to relying too heavily on medicines to manage pain instead of using a combination of approaches. Overreliance can lead to side effects, tolerance, addiction and reduced effectiveness over time. Effective pain management should include non-drug methods as well as medications when needed.
2	Holistic and person-centred care	This is an approach to healthcare that focuses on the whole person, not just their illness or symptoms. It considers a person’s physical, emotional, social, cultural, and spiritual needs. Person-centred care also involves respecting individual preferences, values and involving them in decisions about their own care.
2.1	Equity and access to care	Inequitable access to MSK pain services was described as a ‘postcode lottery,’ shaped by long waiting times, regional variation, and practical barriers such as travel, disability access and cost. Participants noted that private care could sometimes bypass delays, but this was not accessible to all, reinforcing inequity.
3	Need for individualised treatment plans	Participants emphasised the importance of tailoring pain management to the individual and providing timely access to relevant services and resources.
3.1	Access to resources (including digital) at appropriate time of need	Digital resources were valued as timely adjuncts to face-to-face care, helping maintain continuity, provide feedback and support tailored self-management between appointments, particularly during flares or long waits.
3.2	Self-management and education	Self-management is when individuals are given the knowledge, skills and confidence to manage their own health or condition. Education supports this by providing clear information about symptoms, treatments, lifestyle choices.
4	Pain assessment too crude and simplistic	Participants noted that current pain assessment tools are overly simplistic and fail to capture the complex, multidimensional nature of pain.
4.1	Deeper exploration of options for pain assessment	This means going beyond simple or standard pain rating scales (like 1–10) and using a range of methods to understand a person’s pain. This could include physical assessments, emotional factors, cultural context, the person’s description of their pain, and how it affects daily life. The goal is to gain a fuller and more accurate picture of a person’s pain experience.
5	Perceived underestimation of pain impact	Respondents expressed concern that clinicians often underestimate the severity and impact of pain, leading to inadequate management and patient frustration.
5.1	Clinicians frustrated about not providing full assessment and plan	This describes the situation where healthcare providers feel unable to give complete care because of limits such as time pressures, lack of resources or complexity of cases. Clinicians may feel dissatisfied or stressed when they cannot fully assess a patient’s needs or develop a detailed treatment plan.

Brief definitions outline how each analytic category, developed from free-text survey responses using reflexive thematic analysis, captures participants’ experiences of musculoskeletal pain management, including expectations of care, treatment options and perceived gaps in current practice.

Responses to questions regarding treatment improvements (questions 4–9) contributed most to the thematic content, while questions on pain assessment (questions 2 and 3) informed themes related to the limitations of current methods and the broader impact of pain. NVivo visualisation functions were used to create a thematic map, illustrating how patient and professional perspectives converge around key challenges and opportunities in MSK pain management (Figure 1). Illustrative quotations supporting each theme are presented below.

Theme 1: Appreciation of pain mechanisms to inform pain management

Participants emphasised the need for pain management to be guided by a clearer understanding of underlying mechanisms rather than by a uniform, symptom-based approach. Many respondents felt that current prescribing and treatment pathways often overlook whether pain is nociceptive, neuropathic or nociplastic, resulting in ‘trial-and-error’ care that fails to meet individual needs. Both patients and healthcare providers called for a shift toward mechanism-informed, person-centred management that combines pharmacological and non-pharmacological strategies.

Subtheme 1.1: Alternative and complementary therapies

Participants expressed a desire for greater access to holistic and non-drug approaches such as acupuncture, yoga, hydrotherapy, massage, mindfulness and osteopathy. These were viewed as valuable adjuncts to conventional medical care, supporting both physical and emotional well-being. Several respondents noted that such options are often unavailable through the NHS, leading many to seek private treatment or self-manage. They wanted healthcare providers to acknowledge and, where appropriate, integrate these modalities into care plans.

Advice on complementary therapies such as acupuncture and on treatments such as osteopathy for certain conditions where relevant. – Patient 4

I can’t cope without yoga, breathwork, meditation and mindfulness. It really has changed my life. – Patient 3

Subtheme 1.2: Over-reliance on pain medications for pain management

Both patients and healthcare providers raised concerns about the healthcare system’s heavy reliance on medications, especially opioids, non-steroidal anti-inflammatory drugs (NSAIDs) and antidepressants to manage chronic pain. Participants felt prescriptions were often used as a ‘default’ response rather than part of a broader, mechanism-based plan. Many described limited discussion about side effects, long-term consequences or non-drug alternatives. They wanted more open conversations about when medications are and are not helpful, and greater emphasis on lifestyle, self-management and psychological strategies.

More information provided about using medications sensibly and not becoming over-reliant on them as side-effects can occur. More information about lifestyle and self-management would benefit patients. – Healthcare Provider 1

Too quick to move to daily long-term Naproxen and opioid-based prescribing in my experience. – Patient 1

Theme 2: Holistic and person-centred care

Participants consistently emphasised the importance of care that is tailored to each person’s unique goals, health conditions, preferences and life circumstances. Rather than standardised approaches, they advocated for flexible treatment plans that combine multiple modalities such as medication, exercise, psychological support and procedures and evolve over time as needs change. Timing was also critical: participants stressed the value of receiving the right resources at the right moment, rather than months later.

Subtheme 2.1: Equity and access to care

Participants described substantial inequities in access to MSK pain support, characterised by long waits, regional variability and practical barriers that limit engagement with services. Respondents framed care as a ‘postcode lottery,’ with availability and quality of physiotherapy, pain services and timely follow-up varying across areas and often depending on a patient’s ability to advocate for themselves. Structural barriers such as travel, parking, disability access needs and affordability were repeatedly raised, with some participants describing how private care was used to bypass delays, while others highlighted that this option is not feasible for many, reinforcing inequity and widening gaps in outcomes.

It currently feels like a postcode lottery and very dependent on the patient being able to articulate themselves exceptionally well to get the attention they request. – Patient 18

Reduction of waiting lists is an obvious issue. In my case I was able to afford to go privately to cut down my waiting time, but again this is not affordable for everyone. – Patient 4

Theme 3: Need for individualised treatment plans

Participants consistently called for care that is tailored to each person’s goals, comorbidities, preferences and life context, rather than ‘one-size-fits-all’ prescriptions. Patient respondents reported wanting flexible plans that blend modalities (medication, exercise, psychological support and procedures) and adapt over time. Timelines also mattered, people asked for the right resource at the right moment, not months later. Two subthemes captured what would make individualisation feasible in real services.

Subtheme 3.1: Access to digital resources at the appropriate time of need

Respondents viewed digital options as crucial adjuncts, not replacements, for face-to-face care. Particularly when it enables timely input between appointments, maintains momentum and supports tailored pacing (e.g. during flares, early after diagnosis or when waiting lists are long). Suggested approaches included video check-ins, structured digital follow-up and targeted online resources that can provide feedback, reinforce education and reduce loss of continuity. Digital options were repeatedly framed as most valuable when used to influence immediate next steps (adjusting exercises, troubleshooting barriers, reinforcing self-management), rather than as a wholesale substitute for in-person assessment and therapeutic relationships.

More online resources for patients to be referred as often there are long waits for talking therapies and patient’s anxieties may rise. – Healthcare Provider 1

More 1–1 session for patients with their therapists. Patients should be able to video chat with their therapists at least every 2–3 weeks to have a catch-up session [. . .] so they can get feedback [. . .] Digital physio would help. – Patient 9

Subtheme 3.2: Self-management and education

Participants asked for clear, consistent education that explains why recommendations fit their pain, links mechanisms to options and build confidence in day-to-day management. They emphasised skills (pacing, graded activity or strength, sleep, mood, flare planning) over generic leaflets and wanted clinicians to be candid about the limits of medicines while actively offering non-drug strategies that match personal goals.

More information provided about using medications sensibly and not becoming over-reliant. . . More information about lifestyle and self-management would benefit patients. – Healthcare Provider 1

I think patients should have better access to self-pain management programmes, as they really help provide patients with tools and techniques on how they can better manage their chronic pain on a daily basis. – Patient 3

Theme 4: Pain assessment too crude and simplistic

Stakeholders described routine assessment as overly focused on single-item intensity scores (Numerical Rating Scale/Visual Analogue Scale) that miss function, sleep, mood, beliefs, trauma and social context. This narrowness can invalidate lived experience and leads to plans that do not meaningfully change outcomes.

Subtheme 4.1: Deeper exploration of options for pain assessment

Participants called for multidomain, treatment-informing assessments that profile likely mechanisms (nociceptive or neuropathic or nociplastic traits), track day-to-day variation and incorporate patient-reported outcome/experience measures (PROMs/PREMs) that matter to patients (sleep, function and participation). They wanted assessments to guide decisions, not just document a number.

I think we often focus on capturing easily measured pain information and not qualitative e.g. the full patient experience. – Healthcare Provider 5

There is no standardisation. . . effect of pain on function and mood is covered but not wider contributing factors, such as pain beliefs/understanding, social circumstances, trauma/ACEs/PTSD, lifestyle (diet, stress management). – Healthcare Provider 6

Theme 5: Perceived underestimation of pain impact

Many participants felt their pain and its consequences (sleep loss, emotional toll, work and family limitations) were under-acknowledged in clinical encounters, especially when tests were normal or structural pathology was subtle. This perceived minimisation undermined trust and willingness to re-engage.

Subtheme 5.1: Clinicians frustrated about not providing a full assessment and plan

Clinicians in the sample echoed the problem from the system side. Short appointments, long waits for physiotherapy or pain psychology and commissioning variability left them unable to deliver the comprehensive biopsychosocial assessments and personalised plans they believe patients need, producing moral distress and a drift toward short-term ‘quick fixes’

I am not aware of anyone [. . .] being asked or supported with pain issues resulting from their health conditions [. . .] and no clinician has ever asked me about pain. – Patient 4

With the time we have for consultations in the NHS it is very difficult to provide a full pain assessment and provide patients with a comprehensive plan. Pain clinics are also heavily pushed, with many patients in chronic pain waiting for months to be seen. – Healthcare Provider 7

Discussion

Our findings, drawn from stakeholders responding via the MSK TRC network, suggest a perceived gap between contemporary pain science and routine MSK pain assessment and management as experienced by this sample. The NIHR TRC is a carefully vetted network, with membership verified by an administrator, ensuring that survey respondents were legitimate and engaged stakeholders. The survey was conducted as part of broader focus group discussions with patients, carers and healthcare professionals, allowing responses to be informed by prior dialogue and reflection and providing richer contextual insights. Participants described everyday practice that remains anchored to unidimensional intensity ratings, despite growing recognition that pain outcomes are shaped by fluctuation, functional interference, sleep and mood disturbance, trauma history, beliefs and social context.¹² This critique is consistent with reviews showing that single-item scales quantify severity but are insufficient to inform mechanism-aligned care or capture outcomes that matter to people.^13
–15 Pragmatically, selecting brief multidomain measures aligned with core outcome recommendations could make routine assessment feasible, but evidence shows that core outcome set uptake across health areas, specifically in low back pain trials, remains variable and often suboptimal.^16,17 In contrast, respondents called for multidomain, mechanism-informed assessment that profiles nociceptive, neuropathic and nociplastic features and then translates into personalised plans blending pharmacological and non-pharmacological strategies, an approach aligned with modern classifications and pain neuroscience.^18,19

These accounts map closely to current guidance that emphasises person-centred assessment and care planning with priority for education, exercise or physical activity and psychologically informed approaches, particularly for chronic primary pain.^20,21 Where PROMS are used, Valderas et al., (2021) indicated that routinely feeding back PROM results can improve some care processes and patient-clinician communication, although effects on patient health outcomes are typically small, underscoring the need to pair measurement with responsive, mechanism-informed care.²²

Additionally, participants described delayed access, limited psychology or community exercise options and short appointments. These accounts align with published evidence on implementation challenges in MSK care, but should be interpreted as perceptions from this exploratory TRC-network sample rather than as a national evaluation.²³ Respondents emphasised the potential value of multidomain, mechanism-informed assessment, including nociceptive, neuropathic and nociplastic features, to guide personalised treatment plans. Notably, references to mechanism-informed care were primarily articulated by healthcare professional respondents, reflecting their clinical knowledge and experience with contemporary pain science. Patient responses tended to focus on lived experience, functional impact and coping strategies, suggesting that while patients may not use mechanistic terminology, their descriptions implicitly reflect underlying pain mechanisms and priorities for person-centred management.

This perspective is reinforced by accounts of clinician frustration when providing care. Short appointments, limited service availability and systemic constraints were described as barriers to delivering comprehensive, biopsychosocial assessments and personalised plans, producing moral distress and a reliance on short-term ‘quick fixes.’ These accounts highlight the tension between contemporary understanding of pain mechanisms and the practical limitations of routine care, which may partially explain why mechanism-informed approaches are not consistently observed in patient-facing practice.

Overall, while our study is exploratory and limited by sample size, the data suggest a persistent mismatch between scientific understanding of MSK pain mechanisms and the realities of clinical practice. Patients emphasise functional impact and holistic support, whereas clinicians are constrained in delivering mechanism-informed, personalised care, underscoring the need for system-level changes, service redesign and ongoing education to bridge this gap.

Consistent with this, recent systematic reviews in primary care suggest that clinician-education-only strategies rarely shift practice meaningfully, while multifaceted implementation packages show mixed and context-dependent effects.^24,25 This highlights the importance of commissioning, pathway redesign and sustained facilitation rather than guidance alone. The need for validation, explanation and relational support also resonates with qualitative and quantitative syntheses showing that people with chronic MSK pain frequently feel unheard of invalidated when symptoms do not map neatly to visible pathology, undermining trust, adherence and confidence in self-management.^26,27

It is widely accepted that drivers of pain chronicity include factors such as age, genetics, high body mass index, sleep disturbance, fear avoidance, catastrophising, job dissatisfaction and financial difficulties.²⁸ Tanguay-Sabourin et al., (2023) have proposed prognostic risk scores for pain chronicity based on UK Biobank data. However, such prognostic risk scores for pain are currently not widely used in clinical practice. Resources such as NHS Inform are also available for patients to use to self-manage pain and are free to use.²⁹ Evidence have also shown that digital health interventions for MSK conditions yield small but consistent improvements in pain, disability and self-management, which is useful especially when access to in-person services are constrained.³⁰ Nevertheless, there is currently a disconnect between our scientific understanding of chronic pain, potential resources for patient self-management and lack of access of information and resources for patients and clinicians. The set-up of broader engagement beyond the TRC network, including under-represented patient groups and diverse service contexts, will be important to test and extend these priorities and to support implementation work.

Strengths

This study offers several strengths, including the integration of diverse stakeholder perspectives from patients, healthcare providers and researchers across the UK via the MSK TRC network, offering a broad view of real-world barriers and facilitators in MSK pain care. The anonymous, open-ended online format likely reduced social desirability pressures and encouraged frank accounts of gaps in care, including criticisms of current pathways and services. Analytic rigour was also supported by an interpretivist, reflexive thematic analysis, a documented audit trail, reflexive memoing and peer debriefing. The findings align with NIHR/TRC priorities, enhancing their practical relevance for mechanism-informed, person-centred service design.

Limitations

The study limitations include a relatively small sample (n = 35) recruited through network-based, non-probability sampling, with potential self-selection and volunteer bias and may over-represent stakeholders already engaged with MSK services or research. Recruitment via TRC mailing lists and partner/professional networks may over-represent individuals already engaged with MSK research and contemporary approaches (e.g. biopsychosocial, mechanism-informed and/or digital models of care), which may have shaped the thematic emphasis toward topics aligned with institutional or policy priorities. In addition, the distribution of respondent roles was uneven (patients 54.3%, healthcare providers 40%, researchers 5.7%), and the small number of researcher respondents limits the depth and balance of the ‘researcher perspective’ relative to patient and clinician accounts; therefore, we avoid making role-comparative claims. The cross-sectional design also provides a snapshot rather than trajectories over time, and we did not observe clinical encounters directly. The questionnaire used was not validated but was pilot-tested within the working group of the NIHR TRC.

To preserve anonymity, we intentionally collected role only, causing the absence of demographic and condition-specific data which precluded subgroup analyses by age, sex, ethnicity, socioeconomic status, diagnosis or multimorbidity, which limited insight into equity and differential experiences. This is a core limitation, particularly given our focus on equity and access, because it prevents assessment of whether and how perspectives differ across key social and clinical strata, and limits our ability to comment on underserved populations or inequities between groups. Consequently, equity-related findings should be interpreted as priorities raised by respondents in this sample rather than as evidence of differential experiences across UK subgroups.

Conclusion

In this exploratory qualitative survey of stakeholders engaged through the UK MSK TRC network, respondents described perceived gaps in MSK pain assessment and management and prioritised multidomain, mechanism-informed assessment and co-produced plans that blend education, exercise and psychologically informed therapies with judicious medicines, supported by timely digital touchpoints. Equitable access, continuity and validation of lived experience emerged as prerequisites for meaningful outcomes. Closing the evidence-practice gap will require commissioning and pathway redesign, implementation support and consistent use of core outcomes and PROM feedback to ensure measurement informs action. Taken together, these priorities outline a patient-centred, equitable and mechanism-informed agenda to strengthen engagement, trust and health outcomes in MSK pain care. Future studies should validate and refine these priorities in larger, purposively sampled and more diverse stakeholder groups across UK settings.

Supplemental Material

sj-docx-1-tab-10.1177_1759720X261447164 – Supplemental material for Stakeholder perspectives on musculoskeletal pain assessment and management in the UK: a qualitative study

Supplemental material, sj-docx-1-tab-10.1177_1759720X261447164 for Stakeholder perspectives on musculoskeletal pain assessment and management in the UK: a qualitative study by Thasmiya Khaja Israr Ahmed, Richard Hadyanto, Sheela Medahunsi and Nidhi Sofat in Therapeutic Advances in Musculoskeletal Disease

Footnotes

Acknowledgements

We thank all participants who took part in the anonymous survey and generously shared their experiences and perspectives on musculoskeletal pain assessment and management. We are grateful to members of the UK Musculoskeletal TRC, partner organisations, and professional networks who supported survey dissemination through mailing lists and newsletters. We also acknowledge the wider MSK TRC pain programme discussions and stakeholder engagement activities that helped shape the context and aims of this work. The content reported in this manuscript does not represent the official views of the NHS or NIHR.

Declarations

ORCID iD

Nidhi Sofat

Supplemental material

Supplemental material for this article is available online.

References

World Health Organization. Musculoskeletal health. Geneva: WHO, https://www.who.int/news-room/fact-sheets/detail/musculoskeletal-conditions (2022, accessed 18 November 2025).

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