# Gatekeepers in primary care - a qualitative study on manual therapists’ role in triaging patients with back and neck pain

## TL;DR

This study explores how manual therapists could help manage back and neck pain patients in Swedish primary care to reduce unnecessary treatments and waiting times.

## Contribution

The study introduces the potential role of manual therapists in triaging musculoskeletal patients within primary healthcare teams.

## Key findings

- Current management of back and neck pain patients involves long waiting times and overreliance on physicians.
- Manual therapists could reduce low-value care and physician workload if integrated into primary healthcare teams.
- Staff concerns include professional identity boundaries and limited knowledge about manual therapists' competence.

## Abstract

In Sweden, almost 60% of patients seeking care at primary healthcare centers do so due to musculoskeletal disorders. These patients constitute a strain on the healthcare system. Manual therapists are experts in diagnosing patients with these conditions but are usually not part of healthcare centers in Sweden. Further, there is a significant societal problem with overuse of medications, injections, medical imaging, and unnecessary surgeries, so-called low-value care, for back and neck pain. We aimed to explore the current management of patients with back and neck pain in primary healthcare centers, staff’s perceptions regarding the need for improvement, and incentives and concerns about having licensed chiropractors and naprapaths (manual therapists) triage these patients as part of the primary healthcare center team.

In this qualitative study, we conducted semi-structured focus group interviews with 20 participants employed at three primary healthcare centers in the Stockholm region, chosen based on location, organization, and exposure to manual therapists. Participants were purposefully selected from different professions. Data were analyzed using inductive qualitative manifest and latent content analysis.

The current management of patients with back and neck pain was described in terms of long waiting times and patients’ expectations of seeing a medical doctor and receiving imaging. Thus, there was room for improvement by reducing low-value care. Participants had limited knowledge about the competence of chiropractors and naprapaths and were concerned about the boundaries of professional identity. Decreased physician workload and more choices for patients were mentioned as incentives for manual therapists to take on a triaging role.

Staff at three primary healthcare centers in the Stockholm area described the current management of patients with back and neck pain as navigating the expectations of patients and their overreliance on seeing their physician, not other caregivers, resulting in long waiting times. Alongside patients expecting imaging, these were incentives for chiropractors and naprapaths triaging these patients as an opportunity to improve care. A lack of knowledge about the competence of manual therapists was a concern, and assigning manual therapists to the primary healthcare team would necessitate a reconfiguration of the care process, potentially challenging the boundaries of professional identity.

The online version contains supplementary material available at 10.1186/s12913-025-13593-w.