Progressive joint disorders (PJDs) are a group of chronic musculoskeletal conditions characterised by the gradual deterioration of joint structures because of degenerative, inflammatory or metabolic processes.¹ These conditions include osteoarthritis, rheumatoid arthritis, gout, chronic low back pain, spondylitis and psoriatic arthritis, among others.^2,3 Progressive joint diseases impair mobility, limit daily functioning, reduce quality of life and impose a significant economic burden on healthcare systems because of prolonged treatment and hospitalisation, loss of productivity and the necessity for complex interventions such as arthroplasty.³

Early identification and management of these conditions are crucial for slowing disease progression and preventing irreversible joint damage.⁴ Timely intervention can improve pain control, maintain joint function and significantly enhance patient outcomes.⁴ However, despite the availability of effective non-pharmacological strategies, early intervention is often delayed or overlooked in clinical settings.^4,5 Research shows that physicians frequently prioritise pharmacological management, with 52.3% of rheumatologists indicating a preference for medication as a stand-alone over referring patients to physiotherapy.⁵ In conditions such as osteoarthritis, referrals to non-physician healthcare providers are often delayed until late-stage disease, resulting in missed opportunities for early intervention, which could delay the need for surgery by 5 years to 7 years.⁶

Effective management of PJDs relies on a combination of pharmacological and non-pharmacological approaches.² Pharmacological strategies can alleviate symptoms and slow disease progression; however, they are often insufficient as standalone therapies.^2,4 Non-pharmacological interventions, delivered by non-physician healthcare providers, address critical aspects of patient care, including pain reduction, functional restoration and improved quality of life.⁷ Non-physician healthcare providers such as physiotherapists tailor mobility programmes, podiatrists manage rheumatoid arthritis-related foot issues, occupational therapists provide ergonomic solutions, biokineticists focus on exercise-based rehabilitation, and dieticians support disease management through nutritional interventions aimed at weight management, inflammation reduction and metabolic control.^8,9,10,11 Given the chronic, complex nature of PJDs, with varying management strategies depending on disease stage, and other patient-related factors, a multidisciplinary, patient-centred approach is essential; yet non-physician healthcare providers remain underutilised or are engaged too late in the disease trajectory.^2,6,11

Pharmacists are highly accessible healthcare providers with expertise in medication management and are well-positioned to contribute proactively to musculoskeletal care by identifying clinical red flags such as persistent joint pain, gait abnormalities, unresponsive symptoms or inadequate response to pharmacological therapies and initiating timely referrals and supporting early intervention.^12,13 Despite this potential, pharmacists remain underutilised in musculoskeletal care because of barriers including limited interprofessional communication, unclear referral protocols, insufficient role clarity, gaps in training and confidence, and structural constraints such as inadequate institutional support, remuneration models and shared health information systems.^14,15,16

Addressing these gaps is particularly important within the context of South Africa’s National Health Insurance (NHI), where coordinated referral systems and integrated care pathways are ‘being mooted as’ central to improving equitable access, reducing the burden of chronic conditions, such as PJDs, and enhancing continuity of care across the healthcare system.¹⁷

The purpose of this study was to identify which PJDs are managed by which healthcare providers in South Africa, with the aim of informing the future development of referral guidelines for pharmacists. By mapping provider-specific involvement in conditions such as osteoarthritis, rheumatoid arthritis, gout, ankylosing spondylitis and psoriatic arthritis, the study aims to support more effective interprofessional collaboration, which includes pharmacists, ensuring timely and appropriate referrals, and ultimately improving patient outcomes through integrated musculoskeletal care.

A total of 266 participants completed the survey (Table 1-A3 Appendix 3), and 192 participants (73.3%) were female. The participants were predominantly white people, with 190 (71.4%) participants, while other racial groups were less represented. Ninety-five participants (35.7%) were aged between 30 years and 39 years, while participants over 60 years constituted the smallest proportion (7.1%).

The healthcare providers who participated in the study are shown in Figure 1, where 69 (25.9%) were chiropractors, who constituted the majority. The least represented were osteopaths, with six (2.3%) participants. Other healthcare providers accounted for 13.9%, including homeopaths, sports massage therapists, phytotherapists, reflexologists and aromatherapists.

Figure 2 illustrates the most commonly managed PJDs, with osteoarthritis reported by 244 participants (91.7%). In contrast, psoriatic arthritis was the least frequently reported, with only 133 participants (50.0%) indicating its management. ‘Other’ PJDs were mentioned by 44 participants (16.5%), citing conditions such as spondylolisthesis, various muscle, ligament, tendon, and joint pathologies, sports injuries, spine or back and neck-related disorders, fibromyalgia and scoliosis, among others. A complete list of ‘other’ PJDs is available in Table 1-A3 Appendix 3. The reliability analysis showed a Cronbach’s alpha of 0.85 for the top five conditions, indicating a high level of internal consistency among the items.

Details on which healthcare provider manages which PJDs were reported (Table 1-A3 Appendix 3). Osteoarthritis was the most commonly managed condition, reported by 32 biokineticists (100.0%), 10 acupuncturists (100.0%), 6 osteopaths (100.0%), 67 chiropractors (97.1%) and 26 podiatrists (96.3%). Across all providers, the percentages of those managing osteoarthritis yielded a mean of 93.8% and a standard deviation (s.d.) of 9.7%. The median percentage was 96.7%. The interquartile range (IQR) was 6.1%, with the first quartile (Q1) at 93.9% and the third quartile (Q3) at 100.0%. The highest reported management of rheumatoid arthritis was among podiatrists and osteopaths, both at 100.0% (27 and 6 participants, respectively), with the statistical mean across all providers being 87.9% (s.d. = 9.7%). Psoriatic arthritis was reported to be managed by only 10 physiotherapists (27.0%), 12 occupational therapists (25.0%) and 3 acupuncturists (30.0%). Similarly, gout had lower reporting rates among occupational therapists, with 13 participants (27.1%) and 10 biokineticists (31.3%) reporting managing it. In contrast, ankylosing spondylitis was relatively less reported among occupational therapists, with 15 participants (31.3%), and podiatrists, where only 11 participants (40.7%) indicated managing this condition.

Figure 3 illustrates the referrals and medicinal recommendations by healthcare providers. All (100%) physiotherapists, osteopaths, biokineticists, podiatrists and other healthcare professionals reported that they refer patients to other providers. Occupational therapists reported the lowest rate of medicinal recommendations, with only six participants (12.5%) indicating they do so. Additionally, all six osteopaths stated that they receive their patients through referrals.

The patterns of collaboration among healthcare providers were further explored (Figure 4). Of the participants, 62 chiropractors (89.9%) and 19 podiatrists (70.4%) reported collaborating predominantly with biokineticists. Overall, 190 participants (71.4%) indicated collaboration with physiotherapists, whereas 62 participants (23.3%) reported collaborating with pharmacists. Collaboration with pharmacists was notably limited, with only one occupational therapist (2.1%), one acupuncturist (10.0%), one osteopath (16.7%) and one biokineticist (3.1%) reporting such interaction. The nine-item binary scale demonstrated acceptable internal consistency, with a Cronbach’s alpha of 0.78, indicating that the items reliably captured patterns of collaboration between different healthcare providers and pharmacists.

Figure 5 illustrates the percentage of healthcare providers who reported collaboration with pharmacists. A total of 232 healthcare providers (87.2%) indicated that pharmacists should collaborate with physiotherapists. The average collaboration rate across all healthcare provider categories was approximately 51.1%. Seventeen healthcare providers (6.4%) stated that pharmacists should collaborate exclusively with medical doctors, while only one participant (0.4%) reported that pharmacists should not collaborate with any healthcare provider. The seven-item binary scale (coded as 1 = yes, 0 = no) demonstrated good internal consistency, with a Cronbach’s alpha of 0.82, indicating strong reliability in capturing healthcare providers’ views on pharmacist collaboration with various healthcare providers.

In an open-ended question, participants were asked to describe the type of patients whom pharmacists should refer to them. The content analysis revealed several recurring categories related to referral needs, as shown in Table 1. The most frequently reported theme was pain-related conditions, particularly joint pain, chronic musculoskeletal discomfort and symptoms unresponsive to medication, as reported by 115 participants.

Lastly, 203 participants (76.3%) reported that they do not require a referral letter from patients. In contrast, 30 occupational therapists (60.4%) indicated that they do require a referral letter, as reported in Table 1-A3 Appendix 3.

The predominance of female healthcare providers in the study reflects well-documented workforce trends within South Africa and globally, where allied healthcare professions are largely female-dominated.^18,19,20 The racial distribution aligns with previous findings that historical inequalities have continued to influence the racial composition of many professional groups.²⁰ The relatively young and early-career profile of participants is consistent with international studies and national workforce planning priorities emphasising the development of younger healthcare cadres.²¹

The study participants were non-physician healthcare professionals who provide diagnostic, therapeutic and preventive services distinct from those provided by medical doctors, nurses or pharmacists.^22,23 The study reveals a notable dominance of chiropractors, who constituted 25.9% of the participants. This aligns with statistics from the AHPCSA, which show that the number of chiropractors was the highest (n = 993) compared to other healthcare providers in this study: homeopaths (n = 600), acupuncturists (including Chinese Medicine and Acupuncture) (n = 232), phytotherapists (n = 50) and osteopaths (n = 28) registered with AHPCSA as of 02 May 2025.²² This finding further suggests that chiropractors may be more actively engaged in multidisciplinary research or healthcare networks than other physical therapy-related professions in South Africa. The osteopaths represented the smallest participant group, comprising six individuals (2.3%). This finding aligns with expectations, provided that, within the context of this research study, osteopaths constitute the least populous category within the AHPCSA registers, with only 28 registered practitioners documented as of 02 May 2025.²²

According to the HPCSA registers, when examining the healthcare providers for this study, physiotherapists had the largest number of registered practitioners at 8783 as of 31 October 2024, followed by occupational therapists with 6233.²³ However, this was not reflected in our study, as physiotherapists accounted for 13.9% of participants, ranking third, while occupational therapists ranked second with 18.1%. Although physiotherapists make up a large proportion of the national registry, they were underrepresented in this study. This may reflect differences in availability, workload or the perceived relevance of the study in daily practice. Similar disparities have been reported in other research, where survey participation did not align with registry data.²¹ This often relates to practice-setting differences, as practitioners in independent or community-based settings may have less oversight or encouragement to participate in research than those in hospital environments.²¹ Additional factors, such as a lack of incentives or the recruitment methods used, may also have influenced participation.²¹ It is therefore essential to interpret the study’s findings within the context of these potential limitations and to acknowledge that registry data alone may not accurately predict trends in healthcare research participation.

Healthcare providers’ management of PJDs demonstrated strong internal consistency (Cronbach’s α = 0.85). Osteoarthritis (91.7%) and rheumatoid arthritis (84.6%) were the most commonly managed conditions, reflecting global epidemiological trends that identify osteoarthritis as the most common form of arthritis worldwide, driven by an ageing population, obesity and the widespread exposure to joint injuries and biomechanical stresses.²⁴ Nearly all providers reported involvement in the management of osteoarthritis, although occupational therapists were less involved (70.8%), highlighting a contrast between high condition prevalence and persistently low interprofessional collaboration reported in literature (30.0%), largely attributed to role ambiguity.²⁵ Rheumatoid arthritis was managed by most providers (mean = 87.9%; s.d. = 9.7%), with podiatrists and osteopaths universally involved, consistent with evidence supporting podiatric management of foot complications and the use of osteopathic manipulative medicine as a supportive, non-pharmacological adjunct to conventional care.^26,27

Ankylosing spondylitis (58.3%) and gout (53.0%) demonstrated a greater variation in provider involvement. Physiotherapists, acupuncturists, chiropractors and osteopaths were most involved in the management of ankylosing spondylitis, consistent with physiotherapy’s central role in maintaining spinal mobility and the use of adjunct modalities for symptom relief, despite limited long-term evidence and standardised protocols.^28,29 Chiropractic and osteopathic involvement was higher than reported in some international studies, although literature emphasises cautious application of manual therapies in advanced disease because of structural spinal risks.^30,31 Gout management was most frequently reported by podiatrists, osteopaths, acupuncturists and other complementary healthcare providers, aligning with evidence highlighting these providers’ role in managing foot-related manifestations.^8,32 Conversely, the lower involvement of occupational therapists and biokineticists may reflect both limited referral pathways and scope-of-practice restrictions, suggesting underutilisation despite potential benefits in chronic disease management.^33,34

Exactly half of the surveyed healthcare providers reported management of psoriatic arthritis, with the highest engagement observed among podiatrists, osteopaths, chiropractors and other complementary healthcare providers, reflecting the condition’s musculoskeletal burden in the hands, feet and spine.³⁵ Lower involvement was observed among biokineticists, occupational therapists and physiotherapists, which may reflect limited exposure to inflammatory arthropathies in these roles or inconsistent referral practices.³⁶ Despite the high burden of functional impairment associated with psoriatic arthritis, other healthcare providers remain underutilised in its management, underscoring the need for greater interdisciplinary collaboration and targeted training.³⁷

More than half (53.4%) of healthcare providers reported recommending medicinal items. The highest rates of recommendation were observed among chiropractors, acupuncturists and those in the ‘other’ category, reflecting the increasing integration of pharmacological and complementary products within these practices.^38,39 Conversely, occupational therapists and biokineticists exhibited the lowest frequency of medicinal item use, likely attributable to scope-of-practice restrictions and a principal focus on functional and physical rehabilitation.^34,40 Physiotherapists and podiatrists presented moderate levels of medicinal item recommendations, aligning with their responsibilities in managing musculoskeletal and foot-related conditions, where adjunct medicinal support may be deemed necessary.^41,42

The diverse patterns emphasised herein illustrate the critical necessity for interdisciplinary collaboration, particularly involving pharmacists, to ensure safe, evidence-based guidance in the use of medicinal products. Pharmacists possess specialised expertise in pharmacotherapy, drug interactions and patient education, rendering them essential collaborators in optimising therapeutic outcomes and facilitating informed prescribing or recommendation practices among non-physician healthcare providers.^43,44 Emerging strategies, including the implementation of artificial intelligence-powered pharmacovigilance systems for detecting herb–drug interactions, may support safer practice, but require robust collaboration between pharmacists and non-physician healthcare providers.⁴⁵

The majority of healthcare providers surveyed reported both referring to (97.7%) and receiving referrals from (89.1%) other healthcare providers, indicating a high degree of interprofessional collaboration. Osteopaths, podiatrists and chiropractors received the most referrals, and this aligns with findings from other studies, while occupational therapists and providers in the ‘other’ category received fewer referrals, reflecting under-recognition of their roles.^46,47,48 These patterns align with prior evidence of persistent gaps in interdisciplinary communication and structural barriers to team-based care in certain healthcare settings.⁴⁹ These findings emphasise the need to strengthen bidirectional referral pathways and promote broader awareness of each provider’s scope and contribution to patient care.

Collaboration was most frequently noted with physiotherapists, followed by biokineticists and chiropractors, reinforcing physiotherapists’ recognised central role in multidisciplinary musculoskeletal care.^42,50 Lower collaboration with osteopaths and acupuncturists may reflect limited formal integration within conventional healthcare systems.²⁷ Notably, occupational therapists reported the highest collaboration with physiotherapists, while podiatrists demonstrated the highest collaboration with biokineticists and chiropractors. These findings align with the literature recognising physiotherapists as central figures in multidisciplinary teams, particularly in musculoskeletal and rehabilitation settings. Conversely, the lower collaboration rates with osteopaths and acupuncturists may reflect a lack of integration or formal referral pathways in conventional healthcare systems. Only 7.1% of respondents indicated no collaboration, and the collaboration scale demonstrated acceptable reliability (Cronbach’s α = 0.78).

Despite the overall collaboration, interaction with pharmacists was limited (23.3%), echoing previous findings that unclear referral pathways and role ambiguity hinder pharmacist integration.^16,51 This is concerning given the vital role pharmacists play in medication management, patient education and reducing adverse drug reactions and interactions.⁵² This is particularly important as many patients with joint diseases may be prescribed medicines whose side effects can directly impact therapy outcomes; for example, long-term corticosteroid use (e.g. cortisone) can weaken bones, impair cartilage integrity and increase fracture risk, while certain antiepileptic drugs may cause muscle weakness, reduce bone mineral density and impair balance, thereby raising the likelihood of falls and further injury.^53,54 Chiropractors and physiotherapists reported the highest pharmacist collaboration, while occupational therapists and biokineticists reported the lowest, highlighting missed opportunities for integrated pharmacological and non-pharmacological care.^44,52

Most providers supported pharmacist involvement in multidisciplinary care, particularly collaboration with physiotherapists, occupational therapists, chiropractors and biokineticists, and recommended that pharmacists refer patients with joint pain, musculoskeletal discomfort and symptoms unresponsive to medication. Broad acceptance of interdisciplinary collaboration was evident, with minimal support for pharmacist-only collaboration with medical doctors and strong internal consistency of this construct (Cronbach’s α = 0.82). Support for pharmacist collaboration was lowest with acupuncturists and osteopaths, likely reflecting philosophies and evidence bases; however, given patients’ frequent use of multiple care modalities, pharmacist awareness of complementary therapies remains essential for medication safety and coordinated care.^51,55

Lastly, more than three-quarters of healthcare providers surveyed indicated that they do not require a referral letter for patient consultations, highlighting a high degree of accessibility across professions. Chiropractors, osteopaths, podiatrists and providers in the ‘other’ category reported the highest levels of openness to direct patient access. Increasing recognition of direct and pharmacist-initiated referrals highlights a shift towards more accessible, patient-centred care models, although improved standardisation and communication remain necessary to support integrated musculoskeletal care.⁵⁶

This study highlights that, while non-physician healthcare providers play a central role in the management of PJDs in South Africa, referral pathways remain inconsistent, and pharmacist involvement is limited despite their importance in medication management and early ‘red flag’ identification. Care is predominantly delivered by physiotherapists, biokineticists and chiropractors, with other providers underutilised, pointing to missed opportunities for coordinated multidisciplinary care. Strengthening pharmacist integration, clarifying referral roles and addressing collaboration gaps through targeted training and system-level reforms are essential to improve early intervention, patient outcomes and the delivery of integrated, patient-centred musculoskeletal care, particularly within the context of South Africa’s NHI framework.