Skip to main content

The Musculoskeletal 30-question multiple choice questionnaire (MSK-30): a new assessing tool of musculoskeletal competence in a sample of Italian physiotherapists



The prevalence and cost of musculoskeletal diseases increased dramatically over the past few decades. Therefore, several institutions have begun to re-evaluate the quality of their musculoskeletal educational paths. However, current standardized questionnaires inadequately assess musculoskeletal knowledge, and other musculoskeletal-specific exams have limitations in implementation. The musculoskeletal 30-question multiple choice questionnaire (MSK-30) was proposed as a new tool for assessing basic musculoskeletal knowledge.


To analyse basic musculoskeletal knowledge in a sample of Italian physiotherapists by administering the MSK-30 questionnaire.


After a transcultural adaptation process, the MSK-30 was developed and administered to Italian physiotherapists to assess their musculoskeletal knowledge. Participants were invited to participate in the survey via the SurveyMonkey link. Mann-Whitney test and the Kruskal-Wallis test with Bonferroni correction were used to observe the differences between groups in the MSK-30 scores.


Four hundred-fourteen (n=414) physiotherapists participated in the survey. The median MSK-30 value was higher in physiotherapists who attended the International Federation of Orthopaedic Manipulative Physical Therapists postgraduate certification than in those who attended unstructured postgraduate training in musculoskeletal condition or in those who had not completed any postgraduate training in this field (p<0.001).


This work demonstrates significant differences in the management of musculoskeletal disorders between those with specific postgraduate university education and those without. The findings can contribute to the advancement of the physiotherapy profession in Italy. Authors recommend further research with more robust methodologies to deeper understand this topic. Musculoskeletal conditions will continue to represent a significant portion of primary care visits, and future generations of physiotherapists must be prepared to address this challenge.

Peer Review reports


Musculoskeletal Conditions (MsC) are a significant contributor to global disability [1]. These disorders have a high prevalence throughout all ages, with at least one person out of five (children included) complaining of musculoskeletal pain, as seenable based on previous articles [2,3,4]. MsC contains more than 150 diagnoses affecting the musculoskeletal system [3]. The impact of these conditions is expected to increase with the global aging of the population, driven by age-related risk factors [4]. This trend will result in a rise in healthcare costs, which are already heavily influenced by MsC [5].

Taking into account all these factors, many institutions re-evaluated the significance of developing specific clinical competencies on this topic [6]. To establish if medical students were adequately experienced to face this rising problem, members of the University of Pennsylvania Orthopaedic Surgery Department developed a base competence questionnaire that could objectively evaluate the musculoskeletal knowledge of the health professional [7]. Usually known as the "Basic Competency Examination in Musculoskeletal Medicine" (BCEMM), this questionnaire has been repeatedly used in several American and European Universities to appreciate the adequacy of Medical didactic programs [8,9,10].

In 2019, the musculoskeletal 30-question multiple-choice questionnaire (MSK-30) was presented by Cummings et al. [11]. It is a helpful, multiple-choice questionnaire about the musculoskeletal competence evaluating the musculoskeletal competence of the healthcare professionals working in primary-care process. This questionnaire aimes instead to identify common and critical MsC, to choose appropriate initial management, and to know when to refer the patient to a professionalist. Furthermore, the exam format reduces the likelihood of misinterpretation compared to the short-answer format used in the BCEMM, thus allowing for more accurate statistical analysis [11]. By assessing individual musculoskeletal knowledge, this clinical evaluation tool identify weaknesses and address knowledge gaps. The accompanying answer explanation guide and included references further support this process.

Nowadays, direct access to physiotherapy care is a largely used method for managing musculoskeletal pain in many patients [12,13,14]. This trend needs advanced skills developed by the physiotherapists working in direct access to allow the best management of the patient's condition, including his referral, if necessary [15].

For these reasons, the aims of this study were to adapt the MSK-30 questionnaire into Italian language and to evaluate the basic musculoskeletal knowledge in a sample of Italian physiotherapists by administrating the Italian version of the MSK-30 questionnaire. The secondary aim of this work is to spark a deeper analysis on the necessity of carving university physiotherapy programs corporating these key topics.


Study design and ethical approval

This research project is an observational study of prevalence, conducted according to the CHERRIES Guidelines [16] and reported following the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist [17].

The Ethical Committee of the University of Molise, Campobasso, Italy, approved the study protocol (Prot. n. 03/2021).

Questionnaire development and pretesting

To adapt the questionnaire to the Italian context, a transcultural adaptation process of the Cummings' version was performed following the international guidelines [18] (the detailed steps followed for the transcultural adaptation of the MSK-30 into Italian language are shown in Appendix 1). The entire MSK-30 Italian version is reported in Appendix 2.

MSK-30 implementation

The original questionnaire comprises 30 items developed and based on most common critical arguments of musculoskeletal medicine (i.e., trauma, infection, pediatrics, overuse, injuries, osteoarthritis, rheumatologic disease, environmental injury, head injury, and low back pain) [11]. The questions aimed to correctly identify MsC and the correct initial management, including the possibility of a referral to another health professional.

MSK-30 consists of 30 multiple-choice questions; each question has four alternative answers with only one correct option. Following the procedures described in the original article, the final score count assigned one point for every correct answer and was obtained by summarising every correct question. The final score was be expressed in percentage. There was no established minimum score for the test threshold.

Socio-demographic variables were implemented from Cummings study [11] and were investigated by 12 multiple-choice questions (i.e., age, sex, education, work ages). For the clinical questions, the authors decided not to modify the original ones as they reputed them to be complete and exhaustive in the topic investigation.


The survey was administered to Italian physiotherapists working in Italy during the survey sharing period; the participation was voluntary and anonymous.

The "Associazione Italiana di Fisioterapia" (AIFI) and the "Gruppo di Terapia Manuale e Fisioterapia Muscoloscheletrica e Reumatologica" (GTM) promoted the survey. These scientific associations emailed the survey to their associates, inviting them to complete the form. The survey was also promoted on the main Italian social network of physiotherapists identified by the authors. The survey was sent together with a presentation letter to the participants explaining the aim of the study. The presentation letter contained a terms of agreement button and explained that participation without reimbursement or payment was voluntary and anonymous.

To make a competencies comparison based on the Italian university system, the physiotherapists' samples were divided into education levels: three-year Bachelor Degree (BSc), Bachelor Degree with a Postgraduate Degree in Orthopaedic Manual Physical Therapy (OMPT), and Master of Science Degree (MSc). The qualification in OMPT is a specialized area of physiotherapy for managing musculoskeletal conditions. OMPT is recognized in Italy as the academic postgraduate degree program organised as Manual Therapy course, complying with the standards set by the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT), a member organization of World.

Inclusion and exclusion criteria

Participants were included if they were physiotherapists working on the Italian territory possessed a BSc in Physiotherapy (Class L/SNT2) or equivalent degree, were regularly enrolled in the Professional Register in the year of compilation of the survey and own a valid personal email address. Participants were excluded if they knew the questionnaire, had no knowledge of the Italian language, or had pending legal cases.

Questionnaire administration

The questionnaire was spread as a survey through the "Survey Monkey" online platform (SurveyMonkey, Palo Alto, CA) [19]. The link to the survey was shared on social media platforms such as Facebook and Twitter, as well as instant messaging applications like WhatsApp and Telegram, or sent via email. Participation to the survey was voluntary and completely free of charge for the participants, and the questionnaire was completed anonymously. The first server interface consisted of an information sheet regarding the aim of the study.

All the interviewees completed a written informed consent form before participating. All study-related procedures were performed according to the principles of the statement of Helsinki [20]. The participation in the survey explicitly authorized the treatment of data and finalized the study development. The server was programmed to block access from the same IP address after receiving a complete and successful submission to prevent more than one compilation from the same user. Moreover, to prevent the same user from filling out the questionnaire using different IPs, respondents were asked to indicate own registration number with the Order of Physiotherapists they belong to. The respondent could edit every answer to the questionnaire during the compilation and navigate the survey by clicking the dedicated buttons to modify previous answers. However, after completing the survey, no further changes have been made by the user.

Data collection

The survey administration period was limited to three months, between October 1st and 31st of December 2021. After three weeks of no responses, we decided to close the survey.

To protect the anonymity of the respondents, users' data was collected with hidden IP and registration number address of respondents and secured by a password. Once the surveys were compiled, the results were anonymously sent to the authors, that provided them to the blind statistical analyst for data analysis.

Statistical analysis

Descriptive statistics were used to describe the characteristics of the sample. Moreover, to assess the groups' differences in the questionnaire score, the non-parametric Mann-Whitney test was used when the groups contained two categories (e.g., gender, IFOMPT postgraduate degree, model of care) and the Kruskal-Wallis test with Bonferroni corrections was run when the groups included more than two variables (i.e., age, origin, academic title, etc.).

All statistical analyses were performed using SPSS (version 25 for Windows; SPSS Inc., Chicago, IL; 2004), and the alpha value was set to p=0.05.


Four hundred and fourteen (n=414) Italian physiotherapists participated in this survey: 57.5% were males (n=238/414), and 42.5% were female (n=176/414). Average time for completion MSK-30 was 12 minutes. The detailed sample characteristics are reported in Table 1.

Table 1 Demographic characteristics of the sample (N=414)

The physiotherapists' samples were divided into three educational levels: three-year Bachelor Degree (BSc) (n=262), Bachelor Degree with a Postgraduate Degree in Orthopaedic Manual Physical Therapy (OMPT) (n=96), and Master of Science Degree (MSc) (n=41) aimed to make a competencies comparison based on the Italian University system. Moreover the sample were divided into who obtained an IFOMPT degree (n=96) and who did not (n=318), aimed to evaluate the quality of teaching in IFOMPT courses regarding screening for referral and red flag identification. The scores' differences between groups are shown in Table 2.

Table 2 Differences in MSK-30 score between groups

In the age subgroups, statistically significant differences in the MSK-30 scores were detected between those under-30 (n=144) and those over 45 (n=87), favouring under-30 respondents (18.0 vs. 16.0 points, p=0.046). Statistically significant differences in the MSK-30 scores were reported between those in Northern Italy (n=214) and those in Southern Italy (n=116), favouring Northern respondents (17.0 vs. 16.0 points, p=0.008). There is a statistically significant difference in the score between those who obtained a Master of Science Degree (n=41) and who received a Postgraduate Degree (n=11) (16.0 vs. 19.0 points, p<0.001) and between those who got a Bachelor Degree (n=262) and who obtained a Postgraduate Degree (n=11) (17.0 vs. 19.0 points, p<0.001).

Regarding the postgraduate specialization in MsC, statistically significant differences existed between those who obtained an IFOMPT degree (n=96) and who did not (n=318) (p<0.001).

For the clinical setting, physiotherapists working in private structure (n=215) report values with a median value of 18.0, two points higher than who works in the NHS (n= 77) (p=0.006) and who works in private structures affiliated with NHS (n=122) (p<0.001). Moreover, there was a statistically significant difference between those who practiced direct access (n=218) and who received patients sent by physicians (n=196) (p=0.033). Further detailed comparisons were resulted in Table 2.


The completed survey aligns with other surveys spread through the Italian physiotherapists to investigate their knowledge regarding different musculoskeletal topics [21,22,23]. The MSK-30 is the latest standardized exam created to evaluate the musculoskeletal knowledge of medical graduates and those involved in the primary care process [11]. Interestingly, unlike the work of Cummings et al. [11], we administered the questionnaire to physiotherapists and not to medical doctors.

The absence of a threshold for passing the examination does not allow estimating the minimum level of knowledge to ensure adequate competence in MsC. Analyzing the data in detail, some significant results can be noted. Firstly, physiotherapists with a Postgraduate Degree (19/30) scored significantly higher than those with a BSc (17/30) and MSc (16/30). The difference between postgraduate-qualified physiotherapists and those with an MSc suggests that the Postgraduate Degree may have greater clinical relevance for physiotherapists who pursue it after their Bachelor's degree.

This discrepancy may be because postgraduate training equips professionals with greater proficiency in gathering and critically analyzing the best available scientific evidence relevant to their field.

Therefore, introducing a basic approach to interpreting scientific literature during Bachelor's degree programs could be beneficial, potentially enhancing accessibility of such knowledge for physiotherapists.

Interestingly, no significant score differences were observed between physiotherapists with BSc and those with BSc and postgraduate training programs in MsC like Kaltenborn, Maitland, Mulligan, and others. This could be attributed to the predominantly practical and technical nature of these courses.

Equally interesting were the data regarding the age and working context of the sample. At the same time, there was no significant difference in the scores of physiotherapists with more experience compared to those with less working experience. However, a difference could be observed between those under 30 years of age (18/30 points) and those over 45 years of age (16/30 points). These seemingly conflicting findings could be justified by the profound legislative and academic change that began within the profession in the early 2000s and, therefore, by the profound differences that had characterized academic paths over the years, as further explained. Last but not least, it is important to consider the data relating to the working context: this result could be justified by the highly competitive nature of the private practice. Differential diagnosis skills appeared greater in physiotherapists who obtain specific training (in particular, an IFOMPT Postgraduate Degree). These results are in line with Giovannico et al. (2020) found in their study [15]: graduates and specialists in OMPT obtained higher scores than non-specialized colleagues. Additionally, manual therapy physiotherapists had higher different pass rates. They performed better than their non-specialist colleagues and even better than those specialized in Sports Physiotherapy.

Differential diagnosis is a major area of study emphasized in University Physiotherapy programs worldwide, representing a necessary skill for physiotherapists, especially in private clinical practice and direct access to primary care [24]. This work highlights how Italian physiotherapists have obtained medium-low success rates and it also points out the lack of attention given to screening for the most common MsC within Italian university programs. Considering the growing availability of direct access care for musculoskeletal patients in Italy, this necessitated the introduction of a significant amount of content pertaining to the screening of common MsC in physiotherapy degree courses. In Italy, the figure of the physiotherapist has undergone many changes in the last twenty years [25], transitioning from auxiliary figures to professional orders with ethical and judicial responsibilities [26, 27]. The legislative evolution of the figure of the physiotherapist requires greater attention on how future professional figures are being trained, especially in sensitive areas like musculoskeletal health. This field can significantly impact a state's Gross Domestic Product due to its substantial socioeconomic impact [28]. In this context, physiotherapists could play an essential role in reducing the burden on healthcare systems [29, 30]. Therefore, university courses for physiotherapy should be implemented, considering the evolving role of these professionals and equipping them to recognize pathological clinical characteristics of an extra-professional nature through appropriate screening processes [31]. The diagnostic suggestion of the physiotherapist should prioritize identifying red flags and, in the case of a positive systems analysis, guide an advisable referral to a specialist physician [32,33,34,35]. This highlights a potential inadequacy of the current duration of the physiotherapy degree. Aligning the program's content with the demands of the socio-cultural an healthcare system in which it operates and extending its duration, for instance, from the current three, to five years, could represent an evolutionary process. At the same time, Postgraduate Degrees, offered as a two-year specialization at the end of the five-years Bachelor Degree, could allows physiotherapists to acquire skills in a specific field (e.g. musculoskeletal, respiratory, cardiological). These changes in the university training of Italian physiotherapists could have an important clinical impact, as they would make treatments more appropriate and effective.

It is necessary to observe how there have already been considerable improvements regarding the differential diagnosis and the management of complex conditions by physiotherapists [36] starting from the birth of the Postgraduate OMPT programs, which have significantly increased professionals' skills in these areas. Numerous scientific articles authored by Italian physiotherapists who have undergone this training show their competence in managing a broader range of MsC [37,38,39,40,41,42,43]. This expanded skillset strengthens their ability to deliver comprehensive patient care within their scope of practice. Moreover, the MSK-30 evaluation tool could be a valuable instrument to assess the effectiveness of physiotherapy education in Italy. By applying it solely to physiotherapists trained through postgraduate OMPT programs, we could evaluate the long-term impact of this training on graduates' skills compared to those with a shorter training period. This would provide valuable insights into the quality of teaching and potential areas for curriculum development.

Strengths and limitations of the study

The heterogeneity of the population investigated associated with the first administration of the MSK-30 questionnaire in Italian allows for the broadest vision of the objective of the study. Moreover, the questions' composition is perfectly suitable for teaching purposes as it provides the tested subject to easily trace the bibliographic reference in the literature for a direct study of the topic covered within the specification question. Finally, the ideal multiple-choice response mode compared to the open response test used in BCEMM [9] is helpful because it minimizes the impact of misinterpretation by allowing for better analysis.

However, careful analysis is necessary, and several limitations must be considered. First, due to the small sample recruited, it is impossible to generalize the entire population of Italian physiotherapists. Also, the form of administration, a survey, and the lack of time limit within which to complete the examination could lead participants to use external sources (any tool of a technical or paper nature or anything that can create an advantage over the knowledge of each participant) contaminating answers and data. Moreover, the previous administrations of MSK-30 took place in the presence and the mode of examination.

Finally, to reach the final version of the test, numerous healthcare workers were involved, almost all doctors and only one physiotherapist.


This work aimed to investigate the skills of Italian physiotherapists regarding the management of musculoskeletal disorders, establishing that there are significant differences between those who hold a specific post-graduate university education and those who do not. It would be remarkable for this work to contribute to a significant improvement of the physiotherapy profession in Italy, supporting a process that has already accelerated in the past two decades.

The authors recommend further research, employing more robust methodologies, which has recently gained traction across several European countries and Universities. As MsC will continue to be a prominent concern in primary care, future generations of physiotherapists must be adequately equipped to address this growing challenge.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.


  1. Murray C, Lopez A. The global burden of disease: a comprehensive assessment of mortality and disability fromdiseases, injuries and risk factors in 1990 and projected to 2020. Boston: Harvard University Press; 1996.

    Google Scholar 

  2. Smith E, Hoy DG, Cross M, Vos T, Naghavi M, Buchbinder R, Woolf AD, March L. The global burden of other musculoskeletal disorders: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014;73:1462–9.

    Article  PubMed  Google Scholar 

  3. Moradi-Lakeh M, Forouzanfar MH, Vollset SE, El Bcheraoui C, Daoud F, Afshin A, et al. Burden of musculoskeletal disorders in the Eastern Mediterranean Region, 1990–2013: findings from the Global Burden of Disease Study 2013. Ann Rheum Dis. 2017;76(8):1365–73.

    Article  PubMed  Google Scholar 

  4. Safiri S, Kolahi AA, Cross M, Hill C, Smith E, Carson-Chahhoud K, et al. Prevalence, Deaths, and Disability-Adjusted Life Years Due to Musculoskeletal Disorders for 195 Countries and Territories 1990–2017. Arthritis Rheumatol. 2021;73(4):702–14.

    Article  CAS  PubMed  Google Scholar 

  5. Functioning and Disability Reference Group. The ICF: An Overview. World Heal. Organ. (2010). Accessed 22 August 2023.

  6. GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392:1789–858.

    Article  Google Scholar 

  7. Bone and Joint Burden Initiative The impact of musculoskeletal disorders on Americans: Opportunities for action. Accessed 22 August 2023.

  8. Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine. J Bone Joint Surg Am. 2002;84:604–8.

    Article  PubMed  Google Scholar 

  9. Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. J Bone Joint Surg Am. 1998;80:1421–7.

    Article  CAS  PubMed  Google Scholar 

  10. Broadhurst N. Measuring cognitive and clinical competency in orthopaedics. J Bone Joint Surg Am. 2002;84:683–4.

    Article  PubMed  Google Scholar 

  11. Day CS, Yeh AC, Franko O, Ramirez M, Krupat E. Musculoskeletal medicine: an assessment of the attitudes and knowledge of medical students at Harvard Medical School. Acad Med. 2007;82:452–7.

    Article  PubMed  Google Scholar 

  12. Al-Nammari SS, Pengas I, Asopa V, Jawad A, Rafferty M, Ramachandran M. The inadequacy of musculoskeletal knowledge in graduating medical students in the United Kingdom. J Bone Joint Surg Am. 2015;97:e36.

    Article  PubMed  Google Scholar 

  13. Cummings DL, Smith M, Merrigan B, Leggit J. MSK30: a validated tool to assess clinical musculoskeletal knowledge. BMJ Open Sport Exerc Med. 2019.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Moore JH, McMillian DJ, Rosenthal MD. Risk determination for patients with direct access to physical therapy in military health care facilities. J Orthop Sports Phys Ther. 2005;35:674–8.

    Article  PubMed  Google Scholar 

  15. Mintken PE, Pascoe SC, Barsch AK, Cleland JA. Direct Access to Physical Therapy Services Is Safe in a University Student Health Center Setting. J Allied Health. 2015;44:164–8.

    PubMed  Google Scholar 

  16. Maselli F, Piano L, Cecchetto S, Storari L, Rossettini G, Mourad F. Direct Access to Physical Therapy: Should Italy Move Forward? Int J Environ Res Public Health. 2022;19:555.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Giovannico G, Brindisino F, Pappaccogli M, Saltalamacchia A, Bonetti F, Tavarnelli M, Mezzetti M, Delitto A. A description of Physical Therapists’ Knowledge in Basic Competence Examination of Musculoskeletal Conditions: an Italian National Cross-Sectional Survey. Muscles, Ligaments Tendons J. 2020.

  18. Eysenbach G. Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res. 2004;6:e34.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Vandenbroucke JP, von Elm E, Altman DG, Gøtzsche PC, Mulrow CD, Pocock SJ, Poole C, Schlesselman JJ, Egger M. STROBE Initiative. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. Int J Surg. 2014;12:1500–24.

    Article  PubMed  Google Scholar 

  20. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self- report measures. Spine (Phila Pa 1976). 2000;25:3186–91.

    Article  CAS  PubMed  Google Scholar 

  21. SurveyMonkey, SurveyMonkey and IRB guidelines. Accessed 22 August 2023

  22. World Medical Association. World Medical Association Declaration of Helsinki Ethical Principles for Medical Research Involving Human Subjects. JAMA. 2013;310:2191–4.

    Article  Google Scholar 

  23. Mourad F, Lopez G, Cataldi F, Maselli F, Pellicciari L, Salomon M, Kranenburg H, Kerry R, Taylor A, Hutting N. Assessing Cranial Nerves in Physical Therapy Practice: Findings from a Cross-Sectional Survey and Implication for Clinical Practice. Healthcare. 2021;9:1262.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Rossettini G, Palese A, Geri T, Fiorio M, Colloca L, Testa M. Physical therapists’ perspectives on using contextual factors in clinical practice: Findings from an Italian national survey. PLoS One. 2018;13(11):e0208159.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Rossettini G, Geri T, Palese A, Marzaro C, Mirandola M, Colloca L, Fiorio M, Turolla A, Manoni M, Testa M. What Physiotherapists Specialized in Orthopedic Manual Therapy Know About Nocebo-Related Effects and Contextual Factors: Findings From a National SurveyFront Psychol. 2020;11:582174.

    Google Scholar 

  26. Piano L, Maselli F, Viceconti A, Gianola S, Ciuro A. Direct access to physical therapy for the patient with musculoskeletal disorders, a literature review. J PhysTher Sci. 2017;9:1463–71.

    Google Scholar 

  27. Decreto 14 settembre 1994, n. 741 Regolamento concernente l'individuazione della figura e del relativo profilo professionale del fisioterapista. (GU Serie Generale n.6 del 09-01-1995) Accessed 22 August 2023

  28. Legge 26 febbraio 1999, n. 42 Disposizioni in materia di professioni sanitarie. (GU Serie Generale n.50 del 02-03-1999. Accessed 22 August 2023

  29. Legge 1 febbraio 2006, n. 43 Disposizioni in materia di professioni sanitarie infermieristiche, ostetrica, riabilitative, tecnico-sanitarie e della prevenzione e delega al Governo per l'istituzione dei relativi ordini professionali. (GU Serie Generale n.40 del 17-02-2006). Accessed 22 August 2023

  30. Yelin E. Cost of musculoskeletal diseases: impact of work disability and functional decline. J Rheumatol Suppl. 2003;68:8–11.

    PubMed  Google Scholar 

  31. Hon S, Ritter R, Allen DD. Cost-Effectiveness and Outcomes of Direct Access to Physical Therapy for Musculoskeletal Disorders Compared to Physician-First Access in the United States: Systematic Review and Meta-Analysis. Phys Ther. 2021;101(1):pzaa201.

    Article  PubMed  Google Scholar 

  32. Samsson KS, Grimmer K, Larsson MEH, Morris J, Bernhardsson S. Effects on health and process outcomes of physiotherapist-led orthopaedic triage for patients with musculoskeletal disorders: a systematic review of comparative studies. BMC Musculoskelet Disord. 2020;10(21):673.

    Article  Google Scholar 

  33. Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL, Beneciuk JM, Leech RL, Selfe J. International Framework for Red Flags for Potential Serious Spinal Pathologies. J Man Manip Ther. 2017;25:223–6.

    Google Scholar 

  34. Demont A, Bourmaud A, Kechichian A, Desmeules F. The impact of direct access physiotherapy compared to primary care physician led usual care for patients with musculoskeletal disorders: a systematic review of the literature. Disabil Rehabil. 2021;43:1637–48.

    Article  PubMed  Google Scholar 

  35. Boissonnault WG, Goodman C. Physical therapists as diagnosticians: drawing the line on diagnosing pathology. J Orthop Sports Phys Ther. 2006;36:351–3.

    Article  PubMed  Google Scholar 

  36. Ross MD, Boissonnault WG. Red flags: to screen or not to screen? J Orthop Sports Phys Ther. 2010;40:682–4.

    Article  PubMed  Google Scholar 

  37. Jiandani MP, Mhatre BS. Physical therapy diagnosis: How is it different? J Postgrad Med. 2018;64:69–72.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Robarts S, Stratford P, Kennedy D, Malcolm B, Finkelstein J. Evaluation of an advanced-practice physiotherapist in triaging patients with lumbar spine pain: surgeon-physiotherapist level of agreement and patient satisfaction. Can J Surg. 2017;60:266–72.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Storari L, Signorini M, Barbari V, Mourad F, Bisconti M, Salomon M, Rossettini G, Maselli F. A Thoracic Outlet Syndrome That Concealed a Glioblastoma. Findings from a Case Report Medicina (Kaunas). 2021;57:908.

    PubMed  Google Scholar 

  40. Maselli F, Storari L, Barbari V, Rossettini G, Mourad F, Salomon M, Bisconti M, Brindisino F, Testa M. Can Haglund’s Syndrome Be Misdiagnosed as Low Back Pain? Findings from a Case Report in Physical Therapy Direct Access. Healthcare (Basel). 2021;9:508.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Storari L, Barbari V, Brindisino F, Testa M, Maselli F. An unusual presentation of acute myocardial infarction in physiotherapy direct access: findings from a case report. Arch Physiother. 2021;11:5.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Brindisino F, Passudetti V, Pennella D, Giovannico G, Heick JD. Recognition of pulmonary pathology in a patient presenting with shoulder pain. Physiother Theory Pract. 2022;38:597–607.

    Article  PubMed  Google Scholar 

  43. Youssef S, Brindisino F, Forno B, Giovannico G. Recognition of a Severe Pathology in a Runner Presenting With Atraumatic Neck Pain: A Case Report JOSPT Cases. 2021;1:161–5.

    Google Scholar 

Download references


The research activity of Matteo Cioeta and Gabriele Giannotta was funded by the Italian Ministry of Health (Ricerca Corrente). The funders played no role in the design, conduct, or reporting of this study. The authors report no involvement in the research by the sponsor that could have influenced the outcome of this work.

Author information

Authors and Affiliations



Concept/idea: GiG, MP. Research design: GiG, MP, FB. Writing: GiG, MP, MC, DA, GaG, FB. Data collection: MP, MC, LP, SY, DA, GaG. Data analysis: LP, FB. Project management: GiG, MC, GaG, FB. Consultation (including review of manuscript before submitting): All authors. Final approval of the Manuscript: All authors

Corresponding author

Correspondence to Matteo Cioeta.

Ethics declarations

Ethics approval and consent to participate

The Ethical Committee of the University of Molise, Campobasso, Italy, approved the study protocol (Prot. n. 03/2021). The participants signed digital informed consent before participation.

Consent for publication

Not applicable in the declarations section.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Giovannico, G., Pappaccogli, M., Cioeta, M. et al. The Musculoskeletal 30-question multiple choice questionnaire (MSK-30): a new assessing tool of musculoskeletal competence in a sample of Italian physiotherapists. BMC Musculoskelet Disord 25, 265 (2024).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: