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Manual therapy to address neuromusculoskeletal function

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Manual therapy to address neuromusculoskeletal function

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Please note: The research and literature reviews collated by our TAB Research Team are not to be shared external to the Branch. These are for internal TAB use only and are intended to assist our advisors with their reasonable and necessary decision-making. Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on access or planning matters, they are to call the TAPS line for advice. The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters

Research questions:

Is manual therapy delivered by AHPRA recognised professionals effective in improving functional outcomes for people presenting with neuromusculoskeletal symptoms? How do other Australian insurance schemes and funding bodies approach the funding of on-going and time-limited manual therapies? Date: 08/08/2023 Requestor: Karyn redacted Endorsed by: Researcher: Aaron redacted Cleared by: Stephanie redacted

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Contents

Manual therapy to address neuromusculoskeletal function……………………………………………….. 1 1. Contents ……………………………………………………………………………………………………….. 2 2. Summary ………………………………………………………………………………………………………. 2 2.1 Efficacy and clinical practice ………………………………………………………………………….. 3 2.2 Funding approaches …………………………………………………………………………………….. 3 2.3 Other TAB research ……………………………………………………………………………………… 4 3. Scope and terminology ……………………………………………………………………………………. 4 4. Efficacy …………………………………………………………………………………………………………. 7 4.1 Pain …………………………………………………………………………………………………………… 7 4.2 Functional outcomes…………………………………………………………………………………….. 8 5. Clinical practice guidelines ……………………………………………………………………………….. 8 6. Australian government funding bodies ……………………………………………………………… 10 6.1 Practice restrictions and funding conditions……………………………………………………. 10 6.2 Funding limits ……………………………………………………………………………………………. 13 7. Features of Australian government funding bodies …………………………………………….. 14 7.1 List of Australian government funding bodies …………………………………………………. 14 7.2 Conditions for manual therapy funding in some Australian funding bodies………….. 15 7.3 Manual therapy fee schedules for some Australian funding bodies ……………………. 18 8. References ………………………………………………………………………………………………….. 21

Summary

This paper addresses the efficacy of manual therapy delivered by physiotherapists, chiropractors and osteopaths on functional outcomes for people experiencing neuromusculoskeletal symptoms and how this intervention is approached by Australian public funding schemes. Manual therapy comprises a variety of hands-on techniques primarily aimed to reduce pain and discomfort or improve range of motion in people with musculoskeletal disorders. It can be delivered by a variety of medical and allied health professionals or associated providers (3.1.2 Intervention). Manual therapy may also address functional difficulties including impairment, activity limitation or participation restrictions (3.1.4 Outcomes) for people experiencing neuromusculoskeletal symptoms. Neuromusculoskeletal symptoms are associated with

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diseases, conditions or disorders of the neuromuscular system or the musculoskeletal system and can include discomfort, pain, paralysis or other loss of function (3.1.1 Population).

2.1 Efficacy and clinical practice

There is evidence suggesting manual therapy can be effective at managing pain and discomfort and improving physical functioning for people with musculoskeletal-related pain conditions, especially low back pain and neck pain. Minimal evidence exists related to improvements in function for people with non-pain related conditions. While some evidence points to improvements in quality of life, most functional outcomes relate to improving range of motion or mobility. No evidence was found that manual therapy leads to a reduction in other activity limitations or participation restrictions.

Due the wide scope of practice of manual therapy, research papers pooling results can make it difficult to identify individual trends. Many therapeutic techniques utilise mixed modalities, so it is difficult to determine whether one or all of the modalities taken together are producing an effect. In addition, the current literature is largely of low or very low quality with significant risk of bias. Refer to 4. Efficacy for further details.

Despite the number of existing studies, the quality of the literature has prevented many clinical practice guidelines from offering strong endorsement of manual therapy techniques. Clinical practice guidelines generally offer conditional acceptance of manual therapy. Stronger evidence exists for the benefits of short term manual therapy, with less evidence that it is efficacious as a long-term management strategy. Further, evidence suggests manual therapy is most optimally delivered alongside active exercise treatment. However, there is also some suggestion that manual therapy, as a form of passive exercise, may be offered as an alternative to patients who are unable to engage in an active exercise program. Refer to 5. Clinical practice guidelines for further details.

2.2 Funding approaches

Funding for manual therapy in Australian public or insurance schemes varies based on funding limits and other conditions.

Funding limits can relate to cost or length of treatment. Policy and practice of service systems can vary by proportion of the therapy that is funded, the standard rate of pay per session, total funding allowed, or total number of sessions permitted. None of the service systems reviewed describe limits on number of sessions or duration of treatment that are particular to manual therapy providers. That is, while some insurance scheme clients may be funded for a set length of time (e.g., 2 years, 5 years), this limitation applies to all health or medical expenses and not just manual therapy funding. Only Medicare prescribes strict limits on the number of allowable sessions. Other service systems address will address the request on a case-by-case basis. Refer to 6.2 Funding limits for further details.

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Other funding conditions relate to the provider and the provider’s practice. All the service systems reviewed permit manual therapy in the form of physiotherapy, chiropractic or osteopathy in some form. Some also fund massage delivered by providers not eligible for registration with the Australian Health Practitioner Regulation Agency (AHPRA). Some service systems do not allow simultaneous funding of multiple manual therapy interventions (e.g., from a physiotherapist, chiropractor and osteopath). Generally, service systems do not explicitly state policy related to specific manual therapy techniques. However, different rules may apply to funding of massage depending on who provides the therapy and how it is integrated into a broader treatment program. Refer to 6.1 Practice restrictions and funding conditions for further details.

Policy and practice is generally guided by evidence-based practice and most service systems endorse the Clinical Framework for the Delivery of Health Services (Clinical Framework). The Department of Veteran Affairs explicitly states that funding is not provided to osteopaths or chiropractors for non-musculoskeletal conditions. Other service systems may impose practice restrictions in line with how their service interprets evidence-based practice guidelines. Refer to 6.1.1 The Clinical Framework for the Delivery of Health Services for a discussion of how the Clinical Framework is applied.

Other TAB research

For further examination of the evidence-base for chiropractic, refer to RES 264 Efficacy of chiropractic treatment. RES 276 Sensory based therapy contains some evidence that massage may target behaviours of concern. RES 191 Massage Therapy as a Treatment for Multiple Sclerosis provides a literature review of massage therapy for use in that cohort. General information on physiotherapy interventions for various conditions can be found in RES 203 Therapy Best Practice.

Acupuncture is sometimes referred to as a manual therapy. For a consideration of acupuncture refer to:

  • RES 190 Acupuncture as a treatment for Mitochondrial Encephalopathy Lactic Acidosis Stroke-like Episodes
  • RES 175 Treatment of Chronic Migraine
  • RES 211 Therapy Programs for Lupus.

Scope and terminology

The efficacy of manual therapy delivered by physiotherapists, chiropractors and osteopaths on functional outcomes for people experiencing neuromusculoskeletal symptoms is primarily explored through discussion of clinical practice guidelines and systematic reviews of manual therapy interventions.

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Population – people experiencing neuromusculoskeletal symptoms

Neuromusculoskeletal symptoms are associated with diseases, conditions or disorders of the neuromuscular system or the musculoskeletal system and can include discomfort, pain, paralysis or other loss of function. Conditions leading to neuromusculoskeletal symptoms can include:

  • pain conditions such as chronic back or neck pain, arthritis, fibromyalgia or headache disorders
  • significant injury such as spinal cord injury, stroke or traumatic brain injury
  • neurological conditions such as Parkinson’s disease, cerebral palsy, or multiple sclerosis (World Health Organisation, 2023a; Wang et al, 2022; Briggs et al, 2018).

Intervention – manual therapy

Manual therapy refers to a variety of hands-on physical therapy techniques. The aim is usually to reduce pain, swelling and inflammation, induce relaxation or improve joint range of motion and muscle flexibility. Manual therapy can involve soft tissue techniques, manipulation or mobilisation (NICE, 2021; Young and Argaez, 2020), though the distinctions between these practices may break down in some cases (NICE, 2021b). Soft tissue techniques target muscles, tendons, or ligaments. This can include massage, muscle energy technique, strain/counterstrain and myofascial/trigger point release (NICE, 2021; Locher & Beyer, 2021; Franke et al, 2015). Manipulation and mobilisation target joints. Manipulation is the application of force to affect short, quick movements near the end of or beyond the normal range of a joint (LaPelusa & Bordoni, 2023; NICE, 2021). In contrast, mobilisation is often defined as application of force leading to longer, slower movements of target joints (NICE, 2021; Gross et al, 2015). Mobilisation is also sometimes used to refer to the movement of joints regardless of amplitude or velocity (Krøll et al, 2021). These are often thought of as passive techniques because the therapist or practitioner moves the tissue, joint or limb while client is relaxed. They are distinguished from active techniques such as exercise programs (Ganderton & King, 2020; Canadian Agency for Drugs and Technologies in Health (CADTH), 2016). However, this distinction is challenged by researchers and clinicians who point out that some manual therapy techniques require the client’s active participation, such as pushing back or tensing in response to the practitioner’s movements (Physio Network, 2021). Manual therapy techniques are commonly used by physiotherapists, chiropractors, osteopaths and massage therapists (NICE, 2021; Franke et al, 2015; Gross et al, 2015) but may also be used by:

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  • other allied health professionals such as occupational therapists or exercise physiologists
  • medical professionals such as general practitioners, physiatrists, osteopathic doctors (in the USA)
  • traditional or alternative medicine practices such as myotherapy, Chinese medicine, acupuncture/acupressure, or the Melillo Method
  • others such as personal trainers and coaches (Locher & Beyer, 2021; Canadian Agency for Drugs and Technologies in Health, 2016).

This paper will focus on manual therapy as it is employed by allied health professionals regulated by AHPRA including physiotherapists, chiropractors, and osteopaths.

Comparison – active exercise

Where possible, this paper will compare the efficacy of manual therapy with active exercise including therapist-lead or supervised training and home- or gym-based exercise programs. However all comparisons will be considered.

Outcomes – functional improvement

A functional outcome generally contrasts with a clinical outcome. This distinction aims to highlight the differences between an intervention having some observable effect on bodily systems and an intervention improving a person’s functioning. However, the distinction is not often clearly drawn and may be used differently in different contexts. For example, reduction in pain is a common clinical outcome though it may have significant functional implications. Pain may even count as an impairment in cases of chronic or neuropathic pain (Health Direct, 2022; Young and Argaez, 2020; Franke et al, 2015; Gross et al, 2015). The World Health Organisation’s (WHO) International Classification of Functioning, Disability and Health (ICF) distinguishes three levels of functioning: of bodily systems and structures; of the whole person; of the whole person in their social context. Interruptions to functioning can occur at either level and are referred to as impairments, activity limitations and participation restrictions respectively (WHO, 2023b). National Disability Insurance Scheme (Supports for Participants) Rules 2013 signals the NDIA’s focus on activity limitations and participation restrictions (s.4.1-4.6). Where possible, this paper will focus on whether an intervention is able to achieve functional outcomes as measured by a reduction in activity limitations or participation restrictions in domains including communication, social interaction, learning, mobility, self-care, self-management (NDIS Act, s24.1(c)). However, where this information is not available, this paper will examine pain or functional outcomes in reducing impairment of bodily systems or structures.

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Efficacy

Most evidence regarding the efficacy of manual therapies relates to the treatment of pain conditions. Generally, where evidence of improvement in function exists, it is also for pain conditions. However, according to a recent systematic review, the evidence is equivocal:

In most cases, treatment with manual therapy did not result in statistically significant differences when compared to sham therapy or no treatment in adults with persistent or chronic non-cancer back and neck pain; however, there was some evidence that suggested treatment with manual therapies improved pain, functional status, and health-related quality of life (Young and Argaez et al, 2020, p.4).

An evidence review informing the NICE guideline for osteoarthritis (2022a) notes:

while there were some benefits due to manual therapy this was often in outcomes that were imprecise or heterogenous with inconsistency that could not be resolved by subgroup analysis. … [There] was insufficient evidence to indicate a benefit from manual therapy alone. However, there was evidence of benefit for manual therapy when combined with exercise.

Evidence suggests manual therapy is most effective if performed as an adjunct to active exercise treatment (Runge et al, 2022; Ganderton & King, 2020).

Pain

Comparing mixed modality manual therapy with standard treatment, an evidence review informing the NICE guideline for chronic pain found low quality evidence showing no reduction in pain up to 3 months, but some reduction in pain after 3 months (NICE, 2021a). This contrasts with other reviews which find little evidence of benefit in the long term (Runge et al, 2022; Ganderton & King, 2020).

Franke et al (2015) found low quality evidence suggesting muscle energy techniques are not effective in the treatment of low back pain. Chen et al (2020) did not find evidence that myofascial release therapy reduces pain for people with lower back pain. There is some evidence that massage is an effective pain relief for people with multiple sclerosis. However, the evidence showing efficacy is consistently low or critically low quality with serious risk of bias (NICE, 2022c).

Rubenstein et al (2012) found low quality evidence that spinal manipulation treatment is no more effective than sham control, and no more effective than any other therapy in the treatment of lower back pain. Gross et al (2015) found conditional support for the use of manipulation and mobilisation in the treatment of neck pain. NICE’s review of chronic pain management (2021a) found low quality evidence of reduction in pain for soft tissue techniques compared with usual care and manipulation / mobilisation compared with usual care up to 3 months. A recent narrative review (Licciardone et al, 2021) argues there is sufficient evidence for the effectiveness of osteopathic manipulative treatment (OMT) for lower back pain, citing

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large effect sizes comparable to some pain medications. However, the authors do not report the quality of these studies. They also note insufficient evidence for the effectiveness of OMT for any other condition. A recent review of systematic reviews of OMT found evidence of possible reduction in lower back and neck pain (Bagagiolo et al, 2022). However, all systematic reviews included in Bagagiolo et al were rated as low or critically low quality.

Functional outcomes

Some evidence exists that manual therapy can improve the physical functioning of people experiencing acute or chronic pain conditions. Low or very low quality evidence shows mixed modality manual therapy can improve physical functioning (as measured by either 5 minute walk, sit to stand, Roland Morris Disability Questionnaire, Oswestry Disability Index, Canadian Occupational Performance Measure) compared to usual care for people with chronic pain (NICE, 2021a). Multiple sessions utilising manipulation of the cervical spine may lead to improvement in function and quality of life for people with neck pain, and may be more effective than some analgesics (Gross et al, 2015). Bagagiolo et al (2022) report promising evidence that OMT improves functional status in patients with lower back pain and neck pain. There was notable heterogeneity between outcome measures preventing making firm conclusions. Runge et al (2022) determined there is evidence for improvement on some measures of physical function after manual therapy to people with hip and knee arthritis, but not for performance-based measures of function. Very little research was found to show improvements in function after manual therapy for conditions not associated with pain. Some studies show improvements in mobility and range of motion for people with Parkinson’s disease after OMT, though the studies generally have small sample sizes and show inconsistent effects (Li et al, 2021).

Clinical practice guidelines

No guidelines were found that recommended manual therapy should not be offered in any circumstance. Some guidelines withhold a recommendation for or against due to lack of evidence (NICE, 2022c; 2021b; 2019a; CADTH, 2016). Most guidelines offer conditional recommendations for manual therapy, with some indicating circumstances in which manual therapy should not be offered (Lin et al, 2020; Hawk et al, 2020; Oliveira et al, 2018; CADTH, 2016). Recommendations concerning manual therapy can vary depending on:

  • technique (spinal manipulation, massage, traction etc.)
  • condition (chronic pain, Parkinson’s disease, cerebral palsy etc.)
  • target outcome (pain, spasticity, mobility etc.)
  • chronicity (e.g., acute or chronic pain)
  • intended duration (short- or long-term pain management)

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  • effectiveness of other treatments
  • simultaneous treatments (with or without active exercise) (Lin et al, 2020; Hawk et al, 2020; Oliveira et al, 2018; CADTH, 2016).

Some clinical guidelines recommend against manual therapy in the treatment of pain in some circumstances. NICE (2020) recommend against offering traction for people with lower back pain or sciatica. Other guidelines may recommend manual therapy for acute pain but not chronic pain (Oliveira et al, 2018) or against its long-term use (CADTH, 2016).

Simultaneous active exercise

Many guidelines recommend offering manual therapy with simultaneous active exercise intervention for the management of pain. Lin et al (2020) note a consensus strongly in favour of simultaneous active exercise to treat musculoskeletal pain. This is also the NICE approach to manual therapy for lower back pain (2020) and for osteoarthritis (2022a) but not for chronic pain in general (2021b). Their guideline for people with spondyloarthritis over 16 years recommends an exercise program delivered by a specialist physiotherapist. The guideline does not clarify whether the exercises should include active, passive or a combination of modalities (NICE, 2017c). The American Academy of Orthopaedic Surgeons (AAOS) offers a limited recommendation in favour of manual therapy with simultaneous exercise for knee arthritis (AAOS, 2021).

Hawk et al (2020) report on a Delphi consensus statement of 58 Doctors of Chiropractic regarding best practice treatment for musculoskeletal pain. They recommend clinicians emphasise the importance of active exercise alongside passive manual therapy for their clients. However, Hawk et al assume manual therapy will be prescribed and suggest active exercise is also prescribed where possible. This contrasts with the consensus described in Lin et al (2020), who suggest manual therapy should only be prescribed if active exercise is also prescribed.

Recommendations in favour of simultaneous active exercise treatment should be considered in the context of clear consensus on the benefits of active exercise and maintaining physical activity for most populations (NICE, 2022a; 2022b; 2022c; 2021; 2020; 2019b; 2017a; 2017b; 2017c; 2016). For instance, the NICE guideline for osteoarthritis provides a rationale for their recommendation:

The committee acknowledged recent evidence that showed some clinical benefits of manual therapy for hip and knee osteoarthritis, with no evidence being identified for other joint sites. However, the benefits were stronger if manual therapy was combined with exercise. Clinical and economic evidence showed that exercise alone was more effective than both manual therapy alone and the combination of manual therapy and exercise. So, the committee concluded that manual therapy should only be considered alongside therapeutic exercise (NICE, 2022a, p.42).

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Functional outcomes

Few guidelines offer recommendations for outcomes other than pain management. NICE guidelines for treatment of spasticity (2016) and management of cerebral palsy (2017b; 2019a) do not make recommendations around manual therapy due to lack of evidence. The NICE guideline for Parkinson’s disease (2017a) suggests clinicians can consider the Alexander technique to address balance and motor function problems.

The NICE guideline for people with motor neurone disease (2019b) suggests clinicians can consider a tailored exercise program to address range of movement, contractures, stiffness and discomfort, function and quality of life. The programme can include passive exercises depending on the client’s needs and abilities. The guideline does not refer to any evidence that passive exercise programme can address any of the outcomes cited.

For people recovering after a traumatic injury, NICE (2022b) suggests that clinicians:

  • offer a gait training program that includes passive stretches
  • consider both passive and active exercises to maintain or improve range of movement
  • offer massage for management of scar tissue.

Passive stretching after traumatic injury is described in the context of controlled motion devices or continuous passive motion machines. It is not clear whether the recommendations cover manual therapy without such devices.

Australian government funding bodies

This section describes the approach that different Australian government funding bodies or public insurance schemes take in the funding of manual therapy. This section surveys the available information but will not cover every scheme or funding source available. Refer to 6.1 List of Australian government funding bodies for a more comprehensive list of public insurance schemes and funding bodies. More detail is provided in 6. Features of Australian government funding bodies.

Practice restrictions and funding conditions

Funding bodies may specify what therapies are covered, who can offer the treatment and how it should be delivered. Refer to 6.2 Conditions for manual therapy funding in some Australian funding bodies for further details. Most funding bodies reviewed can fund manual therapy when provided by AHPRA registered allied health professionals such as physiotherapists, osteopaths and chiropractors. One exception is Medicare’s subsidy for health services for young people with neurodevelopmental conditions. Under this scheme, physiotherapy is eligible for subsidy but not chiropractic or osteopathy (Department of Health and Aged Care, 2023). DVA specifies that chiropractors and

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osteopaths must only treat disorders of the musculo-skeletal system (DVA, 2021b-c) but this restriction is not noted for physiotherapists (DVA, 2021d). Some schemes fund non-AHPRA registered providers. Comcare, WorkSafe Victoria and icare will consider funding massage that is delivered by non-AHPRA eligible provider such as massage therapists, myotherapists, traditional medicine practitioners and others (SIRA, 2023b; Comcare, 2023a; WorkSafe Victoria, 2022b). DVA, WorkSafe Queensland and TAC will not consider manual therapies delivered by massage therapists, masseurs, myotherapists or other non-approved providers (TAC, 2023a-c; WorkSafe Queensland, 2021; DVA, 2021a). For the most part, funding bodies do not exclude particular manual therapy techniques or strategies provided by qualified and registered therapists (e.g., adjustment, manipulation, mobilisation, massage etc.). WorkSafe Queensland further specify that they will fund massage as a part of a course of treatment, but not as a stand-alone treatment (WorkSafe Queensland, 2021a). Several schemes mention the use of concurrent therapy, that is, similar modalities offered at the same time for the same condition such physiotherapy, chiropractic and osteopathy. DVA and WorkSafe Victoria note that they will not fund concurrent treatment (DVA, 2022b; WorkSafe Victoria, 2023d-f). TAC and icare note that concurrent treatment is discouraged, though might be funded if clinically necessary (TAC, 2023a-c; SIRA, 2021b; Insurance and care, 2021). For NSW’s Lifetime Care, concurrent treatment may be approved if there is:

  • reasonable clinical justification
  • an overall coordinated plan
  • close communication between treatment providers
  • closely aligned goals between treatment providers
  • written information outlining the context of request
  • evidence that providers are treating different conditions to achieve different treatment goals (Insurance and care, 2021, p.61).

The Clinical Framework for the Delivery of Health Services

The Clinical Framework for the Delivery of Health Services (Clinical Framework) is a publication from Victoria’s Transport Accident Commission (TAC) and WorkSafe Victoria. It is a principle-based framework setting out expectations for health care providers serving clients in workers’ compensation or transport accident schemes (Health Services Group, 2013). The principles of the Clinical Framework are:

  1. Measure and demonstrate the effectiveness of treatment
  2. Adopt a biopsychosocial approach
  3. Empower the injured person to manage their injury

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  1. Implement goals focused on optimising function, participation and return to work
  2. Base treatment on the best available research evidence (Health Services Group, 2013).

The Clinical Framework has been endorsed by all Australian state and federal governments and most injury insurance and general health schemes. There are two exceptions for which the relationship to the Clinical Framework is more ambiguous:

  • Queensland’s National Injury Insurance Scheme (NIISQ) is a transport accident scheme created in 2016 after the Clinical Framework was published. NIISQ treatment guidelines endorse the Clinical Framework. However, the guidelines are still in draft form undergoing a period of consultation and so it is assumed the official endorsement depends on the guidelines being finalised (NIISQ, 2023).
  • Department of Veterans’ Affairs is mentioned on the list of federal government organisations supporting the Clinical Framework (Health Services Group, 2013; TAC, 2012). However, DVA does not mention the Clinical Framework or its implementation on their website or in their publications. It is therefore not clear how DVA implements the Clinical Framework or whether they continue to support it.

While the Clinical Framework is widely endorsed there are implementation differences across workers’ compensation or transport accident schemes. Most schemes at least encourage manual therapy providers to incorporate the principles of the Clinical Framework in their practice (WorkSafe Queensland, 2020b; WorkCover WA, 2016). Some go further and specify that providers must adopt the Clinical Framework in their practice (WorkSafe Victoria, 2023d-f; Comcare, 2023a; TAC, 2020).

Most scheme legislation restricts funding to supports that are reasonable and necessary (or reasonable, necessary and reasonable, reasonably necessary, reasonable and appropriate, appropriate etc.) (WorkSafe Queensland, 2023b; 2022a; WorkSafe Victoria, 2022; WorkCover WA, 2021b; TAC, 2020; Comcare, 2017a-b; Motor Accident Insurance Commission, 2013; Safety, Rehabilitation and Compensation (Defence-related Claims) Act 1988; Military Rehabilitation and Compensation Act 2004). Both Comcare and icare explicitly use the Clinical Framework to elaborate their definition of reasonableness (Insurance & care NSW, 2021; Comcare, 2017a). WorkSafe Victoria (2023g) and TAC (2020) also incorporate the Clinical Framework in their funding approval process.

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Funding limits

For the majority of schemes, funding is limited by liability decisions made by the administering organisation. Funding for manual therapy may also be limited by caps on number of sessions, duration of coverage, cost of each session or total funding.

Limit on duration of treatment

Of the service systems reviewed, only Medicare places a strong limit on the number of allowable sessions. The Chronic Disease Management scheme subsidises up to 5 sessions of allied health therapy per year. The Complex Neurodevelopmental Disability scheme subsidises up to 20 sessions of allied health therapy in a person’s lifetime. Some schemes impose a limit on the number of sessions funded before formal approval is required. This limit does not impose a limit on the total number of sessions which might be deemed reasonable and necessary. Workers Care in NSW allows 8 visits with a physiotherapist, chiropractor or osteopath before pre-approval is required (SIRA, 2023; SIRA, 2021). DVA funds allied therapy in treatment cycles of 12 sessions or 1 year, whichever finishes first (DVA, 2022c), at which point a new treatment plan is required. Comcare allows 5 initial sessions of physiotherapy before a treatment plan is required (Comcare, 2023c). NSW’s Workers’ Care scheme limits funding based on percentage of assessed impairment. Participants in the scheme with no permanent impairment or an assessed permanent impairment under 10% are eligible for support for up to 2 years. Participants in the scheme with an assessed permanent impairment of 11-20% are eligible for support for up to 5 years. If assessed permanent impairment is over 20%, participants are entitled to support for their lifetime (Insurance and care, 2023).

Limit on cost of treatment

A number of schemes impose an upper limit on the cost of each treatment session. DVA and icare’s Workers’ Care do not permit providers to charge more than the established fee (SIRA, 2023a; DVA, 2023a; 2022a-b). Participants are likely to pay a gap with other services (Department of Health and Aged Care, 2023; WorkSafe Queensland 2023a; 2022b-c; WorkCover WA, 2022a-c; TAC, 2023a; WorkSafe Victoria, 2023a-c). Refer to 6.3 Manual therapy fee schedules for some Australian funding bodies for further details. WorkCover WA lists a total funding cap that participants in the scheme cannot exceed. In addition, WA’s Workers’ Compensation and Injury Management Act 1981 prescribes a percentage limit of the total funding cap that can be used for medical expenses. Currently the cap for health services is $73,197, which is 30% of the total funding cap. Although participants with an impairment level over 15% may be entitled to an increase funding cap for medical expenses by $250,000 (WorkCover WA, 2021a). As of July 2023, new legislation is being debated in WA’s Legislative Council which will raise the medical expenses cap from 30% to 60% of the total funding cap, increasing it to $146,395 (WorkCover WA, 2023a; Parliament of Western Australia, 2023).

Features of Australian government funding bodies

List of Australian government funding bodies

Jurisdiction Transport Accident Workers’ Compensation General health
National Comcare, Seacare, Department of Veterans Affairs Medicare, Department of Veterans Affairs, MyAgedCare
ACT Lifetime Care and Support Scheme WorkSafe ACT
NSW icare Lifetime Care, icare CTP Care Icare Workers’ Care
NT Motor Accidents Compensation Commission WorkSafeNT
QLD National Injury Insurance Scheme Queensland, Motor Accident Insurance Scheme WorkSafe Queensland
SA Lifetime Support Scheme ReturnToWorkSA
Tas Motor Accidents Insurance Board Worksafe Tasmania

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Jurisdiction Transport Accident Workers’ Compensation General health
Vic Transport Accident Commission WorkSafe Victoria
WA Catastrophic Injuries Support Scheme WorkCover WA

Conditions for manual therapy funding in some Australian funding bodies

Funding body Manual therapy can be provided by Practice conditions Other conditions
Medicare – Chronic Disease Management - AHPRA registered physiotherapists, chiropractors, osteopaths - User must have chronic condition likely to be present for 6 months
- User must have GP Management Plan with Team Care Arrangement
Medicare – Complex Neurodevelopmental Disability - AHRPA registered physiotherapists - User must be under 25 years old with a complex neurodevelopmental disorder or another eligible disability
Department of Veterans’ Affairs - AHPRA registered physiotherapists, chiropractors, osteopaths - Chiropractors and osteopaths must only treat disorders of the musculoskeletal system
- Will not fund concurrent treatment
- Osteopaths, chiropractors and physiotherapists cannot

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Manual therapy can be provided by

Funding body Practice conditions Other conditions
Comcare - AHPRA registered physiotherapists, chiropractors, osteopaths
- Massage therapists, masseurs		 - Treatment must be delivered in line with the Clinical Framework
- Treatment request must be reasonable
- Treatment request must be consistent with The Clinical Framework

| WorkCover Western Australia | - AHPRA registered physiotherapists, chiropractors, osteopaths
- Massage therapists | - Providers are encouraged to deliver treatment in line with the Clinical Framework
- Treatment request must be reasonable |

| WorkSafe Queensland | - AHPRA registered physiotherapists, chiropractors, osteopaths | - Providers are encouraged to deliver treatment in line with the Clinical Framework
- Treatment request must be reasonable and necessary and of a reasonable cost |

| WorkSafe Victoria (2022b) | - AHPRA registered physiotherapists, chiropractors, osteopaths
- Massage therapists, myotherapists, traditional medicine practitioners who are registered with the appropriate professional organisation | - Treatment must be delivered in line with the Clinical Framework
- Massage may only be used to treat musculoskeletal dysfunction
- Will not fund concurrent treatment
- Treatment request must be either consistent with the Clinical Framework or endorsed by recognised body (e.g. Medicare) |

Funding body Manual therapy can be provided by Practice conditions Other conditions
icare – Workers’ Care - AHPRA registered physiotherapists, chiropractors, osteopaths
- Massage therapists		 - Treatment must be delivered in line with the Clinical Framework
- Massage may only be used to treat musculoskeletal dysfunction
- Concurrent treatment is not recommended, though might be funded if it is clinically necessary		 - Treatment request must be reasonably necessary
- Treatment request must be consistent with the Clinical Framework
icare – Lifetime Support - AHPRA registered physiotherapists, chiropractors, osteopaths
- Massage therapists		 - Treatment must be delivered in line with the Clinical Framework
- Concurrent treatment is not recommended, though might be possible if it is clinically necessary		 - Treatment request must be reasonable and necessary
Transport Accident Commission - AHPRA registered physiotherapists, chiropractors, osteopaths - Treatment must be delivered in line with the Clinical Framework
- Concurrent treatment is not recommended, though might be possible if it is clinically necessary		 - Treatment request must be reasonable, outcome focussed and consistent with the Clinical Framework

Manual therapy fee schedules for some Australian funding bodies

The following describes recommended or mandated fees in a selection of Australian funding bodies and insurance schemes. Amounts listed are fees per session.

Funding body Gap payment Physiotherapy Chiropractic Osteopathy Notes
Medicare – Chronic Disease Management (Department of Health and Aged Care, 2023) Yes $58 $58 $58
Medicare – Complex Neurodevelopmental Disability (Department of Health and Aged Care, 2023) Yes $81.90 nil nil Only physiotherapy subsidised
Department of Veterans’ Affairs (2023b-d) No $70.40 – $88.40 $70.40 –$73.30 $70.40 –$73.30 Upper limit varies by type, location and length of service

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Funding body Gap payment Physiotherapy Chiropractic Osteopathy Notes
Comcare (2023b; 2017b) Not known $66.74 — $245.24 (varies by state and complexity) $55.03-$146.78 $135.74-—175.64 Fee schedule based on Australian Medical Association suggested fees.
Suggested upper limit varies by state and complexity.
Upper limits are not mandated and costs for individual claims are decided on a case-by-case basis.
WorkCover Western Australia (2022a-c) Yes $74.60 -—$94.75 $61.20-—$71.35 $88.40 Upper limit varies by type of service and complexity
WorkSafe Queensland (2023a; 2022b-c) Yes $97 — $124 $88 — $117 $88 — $117 Upper limit varies by type and length of service

Research paper

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Funding body Gap payment Physiotherapy Chiropractic Osteopathy Notes
WorkSafe Victoria (2023a-c) Yes $64.09 – $128.21 $55.03 – $94.29 $75.25 – $112.51 Upper limit varies by type of service and complexity
icare – Workers’ Care (SIRA, 2023a) No $62.10 – $188.30 $62.10 – $188.30 $62.10 – $188.30 Upper limit varies by type of service and complexity
icare – Lifetime Support (SIRA, n.d b; Motor Accidents (Lifetime Care and Support) Act 2006) No No set fee No set fee No set fee Fee determined on case-by-case basis
Transport Accident Commission (2023a-c) Yes $63.64 – $139.90 $54.17 – $94.33 $61.68 – $76.69 Upper limit varies by type of service and complexity

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