From information to action: a co-created evaluation of digital resources for musculoskeletal disorders

Abstract

Background

Digital self-management plays a key role in musculoskeletal care, yet the quality and accessibility of online resources vary. This study used a co-production approach to evaluate digital resources for chronic musculoskeletal disorders, ensuring they reflected patient priorities and practical needs.

Methods

A systematic search identified 91 digital resources, reviewed by a Patient and Public Involvement and Engagement group using a structured rating framework. They assessed visual appeal, adaptability, practicality, clarity, and interactivity. Individual evaluations and group discussions refined the rankings, while focus groups explored themes on usability, accessibility, and gaps in current resources.

Results

The top 50 resources offered exercise progressions, interactive tools, and adaptable content, while lower-rated ones relied on static information with little personalisation. Discussions highlighted the value of integrated platforms combining education, guided exercise, and symptom-tracking features. Gaps included limited psychological support and workplace-specific advice. High-quality resources were often harder to find than commercially optimised but lower-quality websites.

Discussion

These findings highlight several critical directions for future research and development. Firstly, improving the discoverability of high-quality self-management resources remains essential. Search engine optimisation techniques, the use of patient-friendly language, and clinician-led resource recommendations could significantly increase patient access and engagement. Secondly, there is a pressing need to better integrate mental health support into CMSD resources, reflecting the biopsychosocial nature of chronic pain. Lastly, tailored workplace adaptations-including pacing strategies, ergonomic advice, and communication tools-must be embedded within digital tools, particularly for supporting older employees. These priorities will ensure that digital self-management resources are not only clinically relevant, but also practical, inclusive, and widely accessible.

Conclusions

Future development should focus on making evidence-based resources easier to find, integrating mental health support, and embedding workplace adaptations such as pacing, ergonomic advice, and communication tools. These priorities will help ensure digital self-management resources are clinically relevant, practical, and inclusive.

Trial registration

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-025-09222-6.

Background

Chronic musculoskeletal disorders (CMSDs) remain the leading cause of disability worldwide, affecting approximately 1.71 billion people [1]. These conditions encompass a wide range of inflammatory and degenerative syndromes, including low back pain, osteoarthritis, and rheumatoid arthritis, and are characterised by persistent pain, stiffness, and reduced mobility [2]. Beyond physical symptoms, CMSDs can impact mental wellbeing and quality of life, often leading to fatigue, social withdrawal, and distress [3]. Their prevalence is rising due to ageing populations, sedentary lifestyles, and occupational hazards [4, 5]. Musculoskeletal disorders not only impose physical and mental burdens on individuals but also lead to substantial economic costs due to increased healthcare utilisation, absenteeism, and reduced productivity. In the UK, musculoskeletal disorders affect over 20 million people and account for approximately 30 million lost working days annually, making them a leading cause of disability and workplace absenteeism [6].

Given the chronic nature of CMSDs, self-management (SM) strategies play a critical role in controlling symptoms and maintaining function. SM emphasises patient empowerment, helping individuals adopt long-term behaviour changes that improve pain management, physical function, and psychological well-being [7, 8]. As healthcare systems face increasing pressure, supporting patients in managing their conditions outside of clinical settings is essential for reducing their dependence on medical interventions while maintaining quality of life.

A variety of SM resources exist for people with CMSDs, offering exercise programmes, educational materials, coping strategies, and psychological support tools [9–11]. With the increasing use of the internet for health-related information, many patients now turn to digital SM resources to access guidance and support. However, the quality, reliability, and usability of these resources vary considerably. Misinformation, inconsistent formatting, and a lack of expert validation can make it difficult for patients to discern effective, evidence-based interventions from unverified advice [12]. This is particularly concerning for older workers, who may struggle with digital literacy or navigate complex health information. Without reliable methods to assess digital SM resources, patients may struggle to identify trustworthy information, increasing the risk of relying on misleading or suboptimal content that could hinder their ability to manage their condition effectively [13].

In 2023, the National Institute for Health and Care Research (NIHR) funded the JOINTWORKS network [14] to empower older workers with CMSDs. JOINTWORKS addresses the unique workplace challenges facing people living with CMSDs, enhancing employability and training to ensure a healthier, more productive workforce. A key goal of the JOINTWORKS network was to gather and quality-assess accessible SM resources for people living with CMSDs. This initiative was co-produced and powered by collaboration with a Patient and Public Involvement and Engagement (PPIE) group, whose invaluable insights and experiences shaped the evaluation process to meet real-world patient needs. For example, feedback from PPIE members on usability, accessibility, and effectiveness helped to refine digital SM resources and ensure the study’s relevance and alignment with best practices in musculoskeletal SM.

In this study, digital SM resources are defined primarily as web-based tools accessed via internet browsers, including websites and downloadable materials. Although some resources also offered companion mobile applications, the focus remained on online platforms, reflecting the preferences of the PPIE group. Most members reported greater comfort accessing information through computers or tablets rather than smartphones. This real-world behaviour informed the resource identification strategy and ensured alignment with how older workers typically seek and use self-management support. By embedding co-production principles throughout the process, the study aimed to create a comprehensive, patient-centred collection of relevant, accessible, and practical self-management resources.

Methods

Design and objectives

Co-production in healthcare research is a collaborative approach where researchers, practitioners, and the public share power and responsibility throughout the research process, ensuring that outputs are grounded in real-world patient experiences [15]. In line with this, a PPIE group was embedded from the outset as active co-evaluators rather than external consultants. Their lived experience with CMSDs shaped the evaluation criteria and resource selection, ensuring the process remained patient-centred and grounded in real-world needs. By embedding patient and public perspectives through the NIHR co-production framework the specific objectives of this study were as follows:

• Stage 1: Build a comprehensive collection of SM digital resources: Identify and compile a diverse array of digital SM resources for CMSDs, ensuring that they align with evidence-based practices.

• Stage 2: Conduct a Rigorous, Patient-Led Evaluation: Assess the quality, readability, and suitability of these resources through a structured, patient-led review process.

• Stage 3: Ensure Accessibility and Practical Application: Ensure that the final selection of resources addresses the real-world needs of individuals managing CMSDs.

Stage 1: build a comprehensive collection of digital SM resources

A structured systematic search strategy was used to identify relevant SM resources. The search strategy was designed by GS (lead author) and AS (research assistant), both with prior experience in systematic reviews. The final strategy was peer-reviewed by A.St. (co-author). Search strategies were developed for five electronic databases: AMED, EMBASE, CINAHL, Scopus, and the Web of Science Core Collection. The search strategies combined index terms (MeSH or database-specific subject headings) and free-text terms to capture relevant concepts related to SM digital resources. In addition, structured Google searches were conducted to reflect typical patient search behaviour. Google searches used the incognito mode on the Google Chrome browser to mitigate algorithmic bias associated with previous search history. Searches were conducted via a clean browser (cache, cookies, and history cleared prior) to replicate unbiased patient searches. While the majority (59%) of Google users visit only the first page during their search session [16], we reviewed the first six pages to capture the behaviour of the small percentage of users who explore beyond the initial page. This approach ensured a broader dataset while remaining reflective of typical search habits.

Keyword development and search strategy

The search strategy included both electronic databases and Google searches to ensure comprehensiveness. To simulate typical patient searches the keywords used were identified from an analysis of patient-reported narratives. A total of 100 patient narratives were collected from publicly available online platforms, including health forums, social media groups, and patient surveys (Tables 1 and 2). All patient-reported narratives collected during the search phase were reviewed by the PPIE group. The collected narratives (e.g., “self-help for back pain,” “managing stiff joints,” and “CMSD pain exercises”) were processed via Python (v3.9) and the Natural Language Toolkit (NLTK) library. Word frequency analysis identified the most commonly occurring terms related to CMSDs. Clinically relevant terms, such as “pain,” “back,” “joints,” “knees,” “stiff,” and “sore,” were manually filtered and validated based on clinical knowledge and relevance to musculoskeletal conditions.

Table 1.

Examples of online patient forums for the CMSD narratives

Platform/Forum	URL	Description
HealthUnlocked	https://healthunlocked.com	A popular UK-based platform for discussions on health-related topics, including CMSDs and chronic pain.
Versus Arthritis Online Community	https://community.versusarthritis.org/	A dedicated forum for individuals managing arthritis and musculoskeletal pain, run by a UK charity.
Patient.info Forums	https://patient.info/forums	A UK-based platform with discussion boards on musculoskeletal disorders and chronic pain management.
Subreddit/ChronicPain	https://www.reddit.com/r/ChronicPain	A global Reddit community discussing chronic pain, including contributions from UK-based individuals.
Subreddit//Arthritis	https://www.reddit.com/r/Arthritis	A global Reddit forum where individuals, including those in the UK, discuss arthritis-related issues.
Subreddit//Fibromyalgia	https://www.reddit.com/r/Fibromyalgia	A Reddit community focused on fibromyalgia, including musculoskeletal pain discussions.
NHS Patient Voices	https://www.nationalvoices.org.uk/	A platform featuring patient stories and narratives collected by the NHS and National Voices charity.
The Health Foundation - Patient Stories	https://www.health.org.uk/patient-stories	A repository of patient stories addressing chronic conditions, including musculoskeletal pain.
Pain Concern Forums	https://healthunlocked.com/painconcern	Pain Concern’s dedicated forum for discussing chronic pain management.

Table 2.

Illustrative examples of patient narratives

“I have constant lower back pain.”

“My knees ache every time I walk.”

“I experience stiffness in my neck every morning.”

“My hip hurts when I sit for too long.”

“Wrist pain from typing all day.”

“Chronic pain in my joints.”

“Muscle spasms in my back.”

“Back pain worsens with lifting.”

“Painful swelling in my joints.”

“I feel a constant ache in my hips.”

“My back hurts when I stand for too long.”

Inclusion and exclusion criteria for digital resources

Digital resources were eligible for inclusion if they were written in English, freely accessible, and focused on the SM of at least one CMSD. To be considered, resources needed to provide actionable and practical content, such as exercise instructions, educational advice, videos, or self-monitoring techniques that users could implement independently. To maintain clarity and manageability, the review prioritised UK-based resources, aligning with the National Health Service (NHS) and affiliated professional bodies. Additionally, only resources created or updated after 2010 were included to ensure contemporary relevance and adherence to current evidence-based practices.

We excluded purely promotional resources (e.g., advertisements or marketing materials), lacked actionable SM strategies, or focused on paediatric populations or rare musculoskeletal disorders. Furthermore, anecdotal or non-evidence-based content-such as personal blogs, private clinic websites, or health magazine articles that lacked input from qualified healthcare professionals or did not reference recognised clinical standards-was excluded. Systematic reviews and meta-analyses summarising SM strategies were excluded, as were materials designed exclusively for healthcare providers, policymakers, or organisations, as the primary focus was on patient-facing resources.

Data extraction

The screening and data extraction process followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines for systematic scoping reviews [17]. The PRISMA flowchart (Fig. 1) illustrates the stages of resource identification, screening, and inclusion. All identified resources were first screened independently by two reviewers (AS and GS) using Covidence, a software platform designed for systematic review management. Discrepancies between reviewers were resolved through discussion and consensus. Data from the included resources were extracted by the research team and rated by the PPIE group using a structured 0–5 scale across five predefined domains: appeal and visual design, progression and adaptability, practicality and ease of use, clarity and understanding, and interactivity and engagement. A score of 0 indicated that the resource completely failed to meet the criteria for that domain (e.g., no interactivity, confusing layout), while a score of 5 indicated that the resource fully met the criteria (e.g., highly interactive, clear and accessible language, adaptable content). Each PPIE member independently scored the resources, followed by facilitated group discussions to refine assessments and reach consensus.

Fig. 1.

PRISMA flowchart of the selection process for digital self-management resources for CMSDs

Stage 2: conducting a rigorous, patient-led evaluation

From the project’s inception, a PPIE group was integrated, ensuring patients were actively involved in evaluating SM resources. Unlike traditional research approaches, this study empowered the PPIE group as key decision-makers, prioritising patient-led evaluation over researcher-defined criteria. The PPIE lead, both a patient representative and a research team member, played a crucial role in bridging communication between the PPIE group and researchers, ensuring equal voice in discussions and decision-making. Throughout the project, the PPIE lead moderated discussions to ensure patients’ lived experiences shaped the final evaluations and rankings, minimising undue researcher influence.

The PPIE group (N = 7), composed of workers aged over 50 with CMSD experience, was recruited through patient organisations, support networks, and online communities to ensure diverse perspectives. The PPIE group originally consisted of 10 participants, though 3 withdrew before the project began due to personal reasons. The remaining 7 participants provided a balance of perspectives while allowing in-depth engagement. Priority was given to individuals actively self-managing their CMSDs while remaining in the workforce, ensuring participants had current, lived experience of managing symptoms during work-related activities. The PPIE group comprised five women and two men, aged 52–68 years. Four participants were of White British ethnicity, one South Asian, and two Black Caribbean. Educational backgrounds ranged from secondary-level qualifications to postgraduate degrees. Employment status included three participants in part-time work, one retired, and three in full-time employment with workplace adaptations due to CMSDs. Four participants had prior experience in PPIE activities. This diversity enabled reflection across varying levels of health literacy, socio-economic status, and lived experience. A patient-informed rating framework (Table 3) was developed based on early input from the PPIE group and aligned with principles in established tools for evaluating digital health information, such as clarity, personalisation, and user engagement [18, 19].

Table 3.

Criteria for assessing self-management resource quality

Domain	Description	Scoring
1. Appeal and Visual Design	Is the resource visually appealing, well-structured, and easy to navigate?	0 = visually unappealing or confusing layout; 3 = adequate but could be clearer; 5 = highly engaging, intuitive design
2. Progression and Adaptability	Does the resource support use at different stages of the condition and allow personalisation?	0 = completely generic or rigid; 3 = some ability to adjust or progress; 5 = fully adaptable, supports progression
3. Practicality and SM Guidance	Are there clear, actionable self-management strategies that are feasible to implement?	0 = vague or unhelpful; 3 = some practical steps; 5 = detailed, relevant, and clearly applicable guidance
4. Clarity and Understanding	Is the language clear, jargon-free, and easy to understand?	0 = complex or unclear; 3 = mostly understandable; 5 = very clear, concise, and accessible to most users
5. Interactivity and Engagement	Does the resource encourage ongoing use through interactivity, reminders, or feedback features?	0 = static content only; 3 = some interactive features; 5 = highly engaging, interactive, encourages repeat use

Each domain was scored independently by PPIE participants using a 0–5 Likert-type scale, where 0 = Poor and 5 = Excellent. Ratings were then discussed collectively to reach consensus on final scores

Participants initially assessed the resources independently using the five pre-defined criteria. Each resource was provided to the PPIE members as a link via a Microsoft Forms survey, where they rated it on a 0 (= poor) to 5 (= excellent) scale for each domain. The same PPIE group (N = 7) participated in all meetings (two 90-minute Zoom sessions and interim email consultations), with ongoing opportunities to provide feedback. The first session reviewed initial ratings, discussing strengths and limitations based on personal experiences. Between sessions, participants reflected on the discussions. Beyond structured evaluation, PPIE members co-designed the keyword list and piloted the rating framework. The second session refined the evaluations and worked towards consensus. This process ensures collective judgment, with open dialogue to resolve disagreements and achieve a shared understanding of each resource’s quality and usability.

Stage 3: ensuring accessibility and practical application

To ensure that the final selection of resources was both accessible and practically useful for individuals with CMSDs, the group prioritised resources that featured structured progression pathways, user-friendly navigation, and interactive elements. Resources that allowed users to gradually increase their engagement with SM strategies, adapted content to different levels of symptom severity, and provided easy-to-follow instructions were seen as particularly valuable. The PPIE group collectively agreed that any resource receiving a score of one or zero in any category would not be included in the final list, ensuring that only the most useful and effective resources were recommended.

A final ranking list was compiled and made available in an open-access digital repository, with accompanying descriptions outlining the strengths and limitations of each resource. The inclusion of detailed qualitative feedback ensured that patients seeking SM resources could make informed decisions based on real user experiences.

Results

Overall, 91 online SM resources were identified from initial searches. From these, 50 were selected through a structured evaluation by the PPIE group. The selected resources included a wide range of SM strategies, categorised into two primary groups: general and condition-specific (Tables 4 and 5). Generic resources provided guidance applicable across multiple musculoskeletal conditions, offering structured information on symptom management, exercise, and lifestyle modifications. Condition-specific resources were tailored to particular diagnoses, anatomical regions, or symptoms, addressing conditions such as knee osteoarthritis, back pain, or rheumatoid arthritis. Detailed descriptions of each resource, including PPIE feedback and scores, are available in Additional file 1.

Table 4.

Detailed resource ratings table for the generic digital resources

Resource Name	Appeal & Visual Design	Progression & Adaptability	Practicality & Ease of Use	Clarity & Understanding	Interactivity & Engagement	Overall Rating (Mean, SD)
Arthritis Action	★★★★☆	★★★☆☆	★★★★☆	★★★★☆	★★★☆☆	★★★★ (4.0)
Arthritis Foundation	★★★★☆	★★☆☆☆	★★★☆☆	★★★★☆	★★★☆☆	★★★ (3.6)
Backcare UK - Exercises for Office Workers	★★★☆☆	★★☆☆☆	★★★★☆	★★★★☆	★☆☆☆☆	★★ (2.6/5)
Birmingham University - Managing CMSDs at Work (Employee Guide)	★★★☆☆	★★☆☆☆	★★★☆☆	★★★★☆	★★★☆☆	★★★ (3/5)
CBT Self-Help (Get Self Help UK)	★★★☆☆	★★★★☆	★★★★☆	★★★★☆	★★★☆☆	★★★★ (4.0)
CSP- Managing Your Bone, Joint, or Muscle Pain	★★★★☆	★★★☆☆	★★★★☆	★★★★☆	★★★☆☆	★★★★ (4.0)
ESCAPE-pain Programme	★★★★☆	★★★★☆	★★★★☆	★★★★★	★★★★☆	★★★★ (4.5)
Flippin’ Pain	★★★★☆	★★★★☆	★★★★☆	★★★★★	★★★★☆	★★★★ (4.5)
JIGSAW-E (Keele University)	★★★★☆	★★★☆☆	★★★★☆	★★★★☆	★★★☆☆	★★★★ (4.3)
Live Well With Pain	★★★★☆	★★★★☆	★★★★★	★★★★★	★★★★☆	★★★★ (4.5)
NASS - Back to Action	★★★★☆	★★★★☆	★★★★☆	★★★★☆	★★★☆☆	★★★★ (4.2)
NHS Fitness Studio	★★★★☆	★★☆☆☆	★★★☆☆	★★★★☆	★★☆☆☆	★★★ (3.4)
NHS Inform	★★★★☆	★★★☆☆	★★★★☆	★★★★☆	★★★☆☆	★★★★ (4.0)
NHS – 10 ways to reduce pain	★★★☆☆	★☆☆☆☆	★★★☆☆	★★★★☆	★★☆☆☆	★★ (2.6/5)
NHS Lanarkshire Physiotherapy MSK	★★★★☆	★★★★☆	★★★★☆	★★★★★	★★★★☆	★★★★ (4.5)
Sussex MSK Partnership	★★★☆☆	★★★☆☆	★★★☆☆	★★★★☆	★★★☆☆	★★★ (3.2)
Tyneside Integrated Musculoskeletal Services (TIMS)	★★★★☆	★★★★☆	★★★★★	★★★★★	★★★★☆	★★★★ (4.4)
Versus Arthritis	★★★★☆	★★★☆☆	★★★☆☆	★★★★☆	★★★☆☆	★★★★ (4.0)
Wrightington, Wigan and Leigh NHS	★★★★☆	★★★★☆	★★★★☆	★★★★☆	★★★☆☆	★★★★ (4.2)

Key: MSK Musculoskeletal, CBT Cognitive Behavioural Therapy, CSP Chartered Society of Physiotherapy, NASS National Axial Spondyloarthritis Society, NHS National Health Service, TIMS Tyneside Integrated Musculoskeletal Services, WWL Wrightington, Wigan and Leigh Teaching Hospitals NHS Trust

Table 5.

Evaluation of condition/joint specific musculoskeletal self-management resources based on key criteria

Resource Name	Link	Appeal & Visual Design	Progression & Adaptability	Practicality & Ease of use	Clarity & Understanding	Interactivity & Engagement	Overall Rating (Mean, SD)	Comments
Hip Joint
Arthritis Foundation - Hip & Buttock Exercises	Link	★★★★☆	★★★☆	★★★★★	★★★★☆	★★★★☆	★★★★ (4.2/5)	Engaging videos with clear instructions. Would benefit from guidance on exercise dosage, progression over time, and precautions for different levels of hip pain.
NHS Inform - Exercises for Hip Problems	Link	★★★☆☆	★★☆☆☆	★★★☆☆	★★★★☆	★★★☆☆	★★★ (3/5)	Informative, but raises concerns about whether these exercises alone can address hip joint problems at all levels.
Sussex MSK Partnership – Managing your diagnosed condition	Link	★★★★☆	★★★☆☆	★★★☆☆	★★★☆☆	★★★★☆☆	★★★ (3/5)	Great resources, but self-management relies mostly on lengthy, wordy leaflets, making it less engaging.
Tyneside Integrated Musculoskeletal Services (NHS) -Self-care advice	Link	★★★☆☆	★★★☆☆	★★★★☆	★★★★☆	★★★★☆	★★★ (3.6/5)	Good primary and secondary resources. Quite wordy and boring layout.
Versus Arthritis - Hip Pain Information Booklet	Link	★★★★★	★★★☆☆	★★★★★	★★★★☆	★★★☆	★★★★ (4/5)	Comprehensive and well-structured resource but could benefit from more interactive elements and exercise progressions.
Wrightington, Wigan and Leigh Teaching Hospitals NHS - Hip Exercises leaflets and videos	Link 1 Link 2	★★★☆☆	★★★★☆	★★★★★	★★★★★	★★★★☆	★★★★ (4.2/5)	Well-structured with clear progression, images, and videos. Needs guidance on choosing a starting level and when to progress.
Knee joint
NHS Inform - Exercises for Knee Problems	Link	★★★☆☆	★★☆☆☆	★★★★☆	★★★★☆	★★☆☆☆	★★★ (3/5)	Well-structured but lacks engagement and multimedia.
Royal Orthopaedic Hospital - Exercises for Osteoarthritis of the Knee	Link	★★☆☆☆	★★★☆☆	★★★★☆	★★★★☆	★★★★☆	★★★ (3.6/5)	Offers practical exercises specifically for osteoarthritis of the knee. The webpage is somehow informative but could benefit from videos.
Torbay & South Devon NHS - Knee Exercise Programme	Link	★★★★☆	★★★★★	★★★★★	★★★★★	★★★★☆	★★★★ (4.6/5)	Engaging videos with good clarity and progression levels.
Versus Arthritis - Knee Pain Exercise Sheet	Link	★★★☆☆	★★☆☆☆	★★★★☆	★★★★☆	★★☆☆☆	★★★ (3/5)	Informative but static format.
Ankle joint
Arthritis Foundation - Feet & Ankle Movements	Link	★★★★☆	★★☆☆☆	★★★★★	★★★★☆	★★☆☆☆	★★★ (3.2/5)	Clear but lacks structured guidance on how to progress difficulty over time. Not a lot to engage with.
CSP - Video Exercises for Ankle Pain	Link	★★★★☆	★★★☆☆	★★★★★	★★★★☆	★★★☆☆	★★★ (3.8/5)	Great video guide but lacks progression advice or dosage information. Declares it is for foot pain but unclear if it’s good for everyone.
NHS Inform - Exercises for Ankle Pain	Link	★★★☆☆	★★☆☆☆	★★★☆☆	★★★★☆	★★★☆☆	★★★ (3/5)	Good educational value but limited in the variety of exercises for different conditions.
Versus Arthritis - Foot & Ankle Pain Information	Link	★★★★★	★★★☆☆	★★★★★	★★★★☆	★★★☆☆	★★★★ (4/5)	Comprehensive and well-structured resource but could benefit from more interactive elements and exercise progressions.
Versus Arthritis - Exercises for the Toes, Feet & Ankles	Link	★★★★★	★★★☆☆	★★★★★	★★★★☆	★★★☆☆	★★★★ (4/5)	Comprehensive and well-structured resource but could benefit from more interactive elements and exercise progressions.
Versus Arthritis - Osteoarthritis of the Foot & Ankle Booklet	Link	★★★★★	★★★☆☆	★★★★★	★★★★☆	★★★☆☆	★★★★ (4/5)	Comprehensive and well-structured resource but could benefit from more interactive elements and exercise progressions.
Versus Arthritis - Plantar Fasciitis Exercise Sheet	Link	★★★★★	★★★☆☆	★★★★★	★★★★☆	★★★☆☆	★★★★ (4/5)	Useful exercise sheet, but needs progression details and video demonstrations.
Wrist joint
NHS Inform - Exercises for Wrist, Hand & Fingers	Link	★★★☆☆	★☆☆☆☆	★★★★☆	★★★★☆	★★☆☆☆	★★ (2.8/5)	Reliable but lacks video demonstrations.
Versus Arthritis - Exercises for Hands, Wrists & Fingers	Link	★★★★★	★★★☆☆	★★★★★	★★★★☆	★★★☆	★★★★ (4/5)	Informative with clear guidance but lacks interactive elements.
Versus Arthritis - Hand & Wrist Pain Information	Link	★★★★☆	★★☆☆☆	★★★★☆	★★★★★	★★★☆☆	★★★ (3.8/5)	Very useful but it’s quite wordy and loses visual engagement.
Elbow joint
CSP - Elbow Pain Information & Advice	Link	★★★☆☆	★★★☆☆	★★★★☆	★★☆☆☆	★★★★ ☆	★★★ (3.4/5)	Reliable but lacks interactive elements e.g. video demonstrations.
Versus Arthritis - Elbow Pain Booklet	Link	★★★★★	★★★☆☆	★★★★★	★★★★☆	★★★☆☆	★★★★ (4/5)	Good information but lacks structured self-management guidance.
Wrightington, Wigan and Leigh Teaching Hospitals NHS Elbow Exercises	Link	★★★☆☆	★★★☆☆	★★★★☆	★★★★★	★★★☆☆	★★★ (3.6/5)	Good, structured plan with visuals. Creates some engagement but maybe not a follow-up result.
Shoulder joint
CSP - Shoulder Pain Exercises & Advice	Link	★★★☆☆	★★★☆☆	★★★★☆	★★★★☆	★★☆☆☆	★★★ (3.2/5)	Reliable but lacks progressive demonstrations. Educational information quite basic and small within the many tabs.
BESS - Exercises for Shoulder Pain	Link	★★★★☆	★★★☆☆	★★★★☆	★★★★☆	★★★☆☆	★★★★ (3.8/5)	Well-structured, engaging, and accessible but lacks further interactive tools.
NHS Inform - Exercises for Shoulder Problems	Link	★★★☆☆	★★★☆☆	★★★★☆	★★★★☆	★★★☆☆	★★★ (3.4/5)	Well-structured, engaging, and accessible but lacks interactive tools to support coming back to this page.
Stretching Series: Shoulder Exercises (YouTube)	Link	★★★★☆	★★★☆☆	★★★★☆	★★★★★	★★★★☆	★★★★ (4/5)	Good video explanation, but no structured progression/advice. More videos would be desirable.
Versus Arthritis - Shoulder Pain Booklet	Link	★★★★★	★★★☆☆	★★★★★	★★★★☆	★★★☆☆	★★★★ (4/5)	Good information but lacks progressions on self-management guidance-especially exercises.
Spine
Backcare - Workplace Back Pain Guide	Link	★★☆☆☆	★★☆☆☆	★★★☆☆	★★☆☆☆	★★☆☆☆	★★ (2.4/5)	Provides ergonomic advice but lacks interactive elements.
CSP - Neck Pain Exercises & Advice	Link	★★★☆☆	★★★☆☆	★★★★☆	★★★★☆	★★☆☆☆	★★★ (3.2/5)	Reliable but lacks progressive demonstrations. Educational information quite basic and small within the many tabs.
CSP - Back Pain Exercises & Advice	Link	★★★★☆	★★★☆☆	★★★★☆	★★★★☆	★★★☆☆	★★★ (3.4/5)	Well-structured, engaging, and accessible but lacks engagement tools.
Escape Pain for Backs (You tube)	Link	★★★★☆	★★★★☆	★★★★☆	★★★★★	★★★☆☆	★★★★ (4.2/5)	Well-structured with practical exercises but lacks tracking features.
Keele University - StartBack Leaflet	Link	★★★☆☆	★★☆☆☆	★★★☆☆	★★★★☆	★★★☆☆	★★★ (3/5)	Well-researched but more suited for healthcare professionals than lay users.
Versus Arthritis - Neck Pain Exercise Sheet	Link	★★★☆☆	★★★☆☆	★★★☆☆	★★★★☆	★★☆☆☆	★★★ (3/5)	Informative but static format. Repetitive on website as it can be found in booklets too.
Versus Arthritis - Neck Pain Information Booklet	Link	★★★★★	★★★☆☆	★★★★★	★★★★☆	★★★☆☆	★★★★ (4/5)	Good information but lacks progressive self-management guidance on exercises.
Versus Arthritis - Back Pain Booklet	Link	★★★☆☆	★★★☆☆	★★★☆☆	★★★★☆	★★☆☆☆	★★★ (3.2/5)	Good information but lacks engaging visuals.
Versus Arthritis - Back Pain Exercises	Link	★★★★☆	★★★☆☆	★★★☆☆	★★★★☆	★★☆☆☆	★★★ (3.2/5)	Lacks personalisation for different stages of pain. Same information provided on booklets and leaflets.
Inflammatory conditions
Arthritis Action - Gout Information Page	Link	★★★☆☆	★★☆☆☆	★★★☆☆	★★★★☆	★★☆☆☆	★★★ (3.4/5)	Informative but could be more engaging with visuals and videos.
NASS - Back to Action Exercise Guide	Link	★★★★☆	★★★★☆	★★★★★	★★★★★	★★★☆☆	★★★★ (4.2/5)	Well-structured with good guidance but lacks interactive tracking.
Versus Arthritis - Ankylosing Spondylitis Exercise Section	Link	★★★☆☆	★★★☆☆	★★★☆☆	★★★★☆	★★☆☆☆	★★★ (3.4/5)	Informative but lacks engaging visuals and structured progression.

The formats of these resources varied and included online platforms with instructional videos, structured digital programmes, downloadable educational materials, and, in some cases, companion mobile applications. Some platforms offered fully integrated SM, incorporating guided exercise modules and progress tracking, whereas others serve as static information repositories without interactive elements. User engagement and adaptability varied significantly, affecting their perceived usefulness and accessibility.

The PPIE evaluation revealed disparities in usability, engagement, and effectiveness. Highly rated resources were distinguished by structured progression and adaptability, enabling users to tailor SM strategies to symptom fluctuations and functional capacity, thereby enhancing long-term engagement. Resources such as “ESCAPE-pain” and “Flippin’ pain” were well-received for their clear guidance on exercise progression, symptom modification strategies, and structured pathways tailored to different CMSD stages. Websites with multimedia elements, such as video demonstrations, interactive tracking tools, and patient-centred learning materials, were rated more favourably for engagement and accessibility. Resources such as the “NHS Inform” and “TIMS NHS”, with well-structured navigation and clear visual aids, were seen as user-friendly and effective for self-management.

Conversely, resources relying heavily on static content, such as text-heavy Portable Document Format (PDF) files, non-interactive webpages, or downloadable information leaflets, were rated lower. The PPIE group noted that many of these resources lacked interactivity, exercise progression pathways, or personalisation options, limiting their support for users with varying symptom severities. Generic SM advice without clear mechanisms for tracking progress or adapting to individual needs was less effective for long-term engagement. Additionally, some platforms involved complex navigation or required high digital literacy, posing accessibility challenges for older adults and those less familiar with digital health tools. For instance, one resource required users to register and navigate multiple submenus before accessing any content, which the PPIE group found confusing and time-consuming.

The evaluation further revealed the limited availability of workplace-specific and psychological support within SM resources. Most focused primarily on physical symptom management, with minimal emphasis on psychological strategies for coping with chronic pain, stress, or mental health concerns associated with CMSDs. Given the established relationship between chronic musculoskeletal pain and psychological distress, the lack of integrated mental health components presents a significant limitation in current digital SM resources. Similarly, few resources offered workplace adaptations, despite CMSDs being a major cause of absenteeism.

Discussion

The role of co-production in evaluating self-management resources

Co-production is increasingly recognised as crucial in healthcare research for enhancing patient-centredness and intervention relevance. In musculoskeletal research, incorporating patient perspectives in intervention design and evaluation improves adherence, satisfaction, and usability of self-management tools [20]. However, while much literature focuses on co-production in the development of interventions, fewer studies have examined its role in evaluating existing resources, which this study addresses.

Although this approach ensured patient-driven evaluation, challenges were observed regarding variability in individual contributions and consensus-building within the focus groups. The literature highlights inconsistencies in co-production methods and definitions, complicating standardisation [21, 22]. Our methodology, incorporating structured evaluation criteria, iterative feedback loops, and a dedicated PPIE lead, aimed to mitigate power imbalances and support equitable participation. For example, Baines et al., [23] revealed that co-production often suffers from imbalanced power dynamics, limiting authentic patient perspectives. While our study addressed this through structured facilitation and transparency, future research should explore more scalable and equitable models of PPIE involvement in digital evaluation contexts.

Design variability in self-management resources

Our findings suggest that digital SM resources for CMSDs vary widely in terms of format, usability, and effectiveness. Structured, interactive, and adaptable SM resources with stepwise exercise progression and tailored difficulty levels demonstrate superior symptom control compared to static, generic resources [24–26]. For instance, Gohir et al., (2021) evaluated an internet-delivered exercise programme for knee osteoarthritis that included progressively tailored exercise levels. The study reported that this structured progression resulted in a greater reduction in pain (Δ=–1.5, 95% CI − 2.2 to − 0.8, p < 0.001). These findings support personalised, stepwise approaches that allow users to modify their engagement based on symptom fluctuations, a crucial factor in chronic condition management.

In addition, user engagement and adherence were significantly greater when digital resources incorporated multimedia elements, tracking tools, and gamification. For example, an RCT of an AI-driven SM application showed that tailored exercise plans, video-guided strength exercises, and daily educational messages improved adherence and disability scores [27]. However, it is important to recognise that simply adding videos or interactive elements does not guarantee engagement. A recent systematic review [28] found that many musculoskeletal SM resources fail to optimise multimedia content for learning, with issues such as content overload, poor coherence, and lack of instructional clarity. Future development of CMSD resources should prioritise evidence-based multimedia design principles, ensuring that interactivity enhances rather than overwhelms users.

The gap in personalisation and tailored support

Despite the proliferation of digital SM tools, a key limitation was the lack of tailored guidance. Resources often failed to provide mechanisms for personalising content to reflect user needs, goals, or changing symptoms. As highlighted by Krukowski et al. (2024), adaptive, personalised feedback significantly improves engagement and behavioural outcomes compared to standardised interventions. Our review found few CMSD resources offering dynamic personalisation.

While artificial intelligence (AI) holds promise for transforming personalisation in digital health, its application within CMSD resources remains limited and inconsistent. Adaptive user interfaces-which adjust content in response to symptom tracking and usage patterns-may offer more effective long-term engagement. For example, Wang et al. (2024) found that such interfaces were more successful in supporting sustained use and adherence in digital interventions [29]. This underscores the need for future self-management tools to adapt not only to clinical parameters but also to users’ evolving behavioural and contextual needs in real time.

Missing components in CMSD self-management resources

A significant gap in the current digital landscape is the limited integration of psychological strategies. Chronic pain is widely recognised as a biopsychosocial condition, where psychological factors such as fear-avoidance, anxiety, and low mood contribute significantly to disability and reduced self-efficacy [3]. However, our findings indicated that few resources addressed these aspects. Psychological education and coping tools were rarely embedded within SM resources, limiting their comprehensiveness.

This gap is especially problematic as patients may not actively search for psychological resources due to stigma or low awareness of their relevance. Blending psychological and physical strategies into one integrated experience may better address this barrier. Future interventions should explore the use of embedded cognitive-behavioural techniques, such as goal-setting, graded exposure, and stress management, to enhance impact.

Similarly, workplace-specific content was notably absent from most resources despite CMSDs being a leading cause of absenteeism and reduced productivity. Workplace-delivered SM interventions are limited and typically focus only on physical activity, rather than offering comprehensive, job-tailored SM strategies. Blake et al., [30] found workplace-delivered SM interventions focus mainly on physical activity. Our PPIE participants emphasised the need for broader workplace-relevant tools including ergonomic guidance, pacing advice, and support for negotiating workplace accommodations. This is particularly important for older workers or those in physically demanding roles. Future tools should incorporate adaptive features that reflect occupational contexts and facilitate sustainable SM within professional environments.

Discoverability of high-quality self-management resources

Another major issue was that high-quality SM resources were often difficult for users to find. Algorithms favour commercial content based on popularity rather than rigor, meaning that evidence-based tools may appear lower in search rankings [31]. This aligns with feedback from our PPIE members, who reported encountering anecdotal, promotional, or low-value content before accessing credible sources. To address this, stakeholders involved in creating and disseminating evidence-based SM resources-including universities, the NHS, charities, and research collaborations-should adopt search engine optimisation (SEO) strategies. These include aligning resource titles with common patient search terms, improving metadata tagging, and establishing backlinks from high-authority domains. Furthermore, clinician endorsement has been shown to enhance trust and uptake. Clinical services should consider compiling and recommending curated resource lists as part of standard care. Finally, public-private collaboration may be needed to elevate trustworthy resources through digital platforms.

To translate our findings into a practical resource for clinicians and stakeholders, we developed an infographic summarising the key features of high-quality CMSD self-management tools, based on PPIE feedback and evaluation outcomes (Fig. 2). This visual aid aims to support the development and selection of patient-centred digital tools in clinical and occupational settings.

Fig. 2.

Summary Infographic of Effective Design for CMSD Self-Management Resources

Strengths, limitations, and future directions

This study’s strengths lie in its rigorous co-produced methodology, use of structured evaluation tools, and the inclusion of real-world patient perspectives through a diverse PPIE group. However, limitations include its UK-centric scope and exclusive focus on digital materials. The exclusion of printed or in-person interventions may underrepresent the needs of digitally excluded populations. Future research should test co-production models in other settings, evaluate cross-country differences in online (and more broadly, overall digital) SM content, and explore interventions that integrate psychological and workplace adaptations.

Conclusion

This study highlights the value of co-produced evaluations in digital health research. It underscores the need for patient-centred digital SM resources with structured, interactive, and adaptive features. Future research should prioritise discoverability, blended physical-psychological content, and workplace integration to maximise relevance and impact for users living with CMSDs.

Abbreviations

AI

Artificial Intelligence

CBT

Cognitive Behavioural Therapy

CMSDs

Chronic Musculoskeletal Disorders

CSP

Chartered Society of Physiotherapy

HSE

Health and Safety Executive

NIHR

National Institute for Health and Care Research

NHS

National Health Service

NASS

National Axial Spondyloarthritis Society

PPIE

Patient and Public Involvement and Engagement

PDF

Portable Document Format

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

RCT

Randomised Controlled Trial

SM

Self-Management

SEO

Search Engine Optimisation

SD

Standard Deviation

TIMS

Tyneside Integrated Musculoskeletal Services

WWL

Wrightington, Wigan and Leigh Teaching Hospitals NHS Trust

Authors’ contributions

G.S. was the lead author and responsible for all sections of the manuscript, including conceptualisation, methodology, analysis, and drafting. A.St. contributed as a key author, supporting all sections of the manuscript and assisting with the literature search. C.G. provided general supervision throughout the study, S.F. offered expert guidance on PPIE and A.S. supported the literature search and data extraction. All authors reviewed and approved the final manuscript.

Funding

This research was funded by the National Institute for Health Research (NIHR) [NIHR206293]. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Data availability

Not applicable.

Declarations

Ethics approval and consent to participate

The review was granted approval by the University of Birmingham Ethics Review Committee (ERN_1400-Oct2023). Consent to participate is not applicable for this review.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.