Musculoskeletal Physiotherapists Research Articles

Exploring personalised care planning approaches for adults with long-term conditions to inform future musculoskeletal care planning: A mixed-methods systematic scoping review protocol.

This systematic scoping review protocol outlines current research into care planning processes and highlights the need to synthesise the knowledge base available since the latest Cochrane review. Review results will underpin the formation of a future intervention designed to successfully optimise care planning consultations for musculoskeletal (MSK) physiotherapists, supporting shared decision-making processes and consequently influencing health care practices for the betterment of patient care. To systematically gather and synthesise the existing knowledge base surrounding personalised care planning approaches for long term conditions which may be informative for MSK care planning in the future. 1. Following the Cochrane review in 2015, to synthesise new evidence available to inform personalised care planning interventions for patients with long-term conditions. 2. Of the identified studies providing strong evidence, to determine what high-quality training resources are available to support clinicians in delivering personalised care planning interventions. Population - Adults with long-term health conditions.Intervention - Personalised care planning. Outcome - Any subjective or objective heath improvement. 1. Cochrane Central Register of Controlled Trials (CENTRAL). 2. MEDLINE & MEDLINE In-process (Ovid). 3. EMBASE (Ovid). 4. PsycINFO (Ovid). 5. Trial registers (clinicaltrials.gov). 6. WHO International Clinical Trials Registry Platform. Social media platforms including Twitter, Instagram, YouTube and Facebook will be used to maximise the viewership of the protocol. An abstract of the review will be submitted to present at relevant conferences. The review findings will also be presented to MSK stakeholders interested in MSK care planning approaches.

The experiences of uncertainty amongst musculoskeletal physiotherapists in first contact practitioner roles within primary care.

The aim of this research was to explore the experiences of uncertainty amongst Musculoskeletal First Contact Practitioners working in primary care. The Musculoskeletal First Contact Practitioner role involves advanced physiotherapists providing an alternative to the GP by acting as first point of contact for people presenting to primary care with musculoskeletal conditions. Limited research into the role exists but the first-contact aspect, clinical complexity and time pressures are deemed to contribute to uncertainty within the role. A qualitative research design was undertaken using a hermeneutic interpretative phenomenological approach. Data was collected using semi-structured interviews with subsequent thematic analysis of the data. Eight participants working as Musculoskeletal First Contact Practitioners across England were recruited using purposive sampling. Five themes were identified: (1) Role clarity within primary care, (2) Burden of responsibility, (3) Preparedness for the primary care environment, (4) 'I'm not really sure how long I am going to stay in this role', (5) Mitigating uncertainty. This study demonstrates the multifaceted phenomenon of uncertainty amongst Musculoskeletal First Contact Practitioners. Uncertainty appeared to be influenced by the primary care environment, preparedness for the role and perceived burden of responsibility. Diagnostic uncertainty was prevalent with concerns of missing serious pathology evident. The impact of uncertainty on wellbeing was linked to possible burnout and retention issues. Consultation approaches, access to support networks and a cultural shift in tolerating uncertainty were reported to mitigate uncertainty. Further research into possible differences in experiences related to employment models appears warranted.

Revised service metrics partially explain variation in outcomes across facilities in a state-wide advanced practice public musculoskeletal service.

Revised service metrics partially explain variation in outcomes across facilities in a state-wide advanced practice public musculoskeletal service.

A UK survey evaluation of First Contact Practitioners' and musculoskeletal physiotherapists' confidence, recognition, and referral of suspected axial spondyloarthritis.

Axial Spondyloarthritis is an inflammatory disease associated with significant diagnostic delays. Steen et al. (2021)found inadequate consideration of axial Spondyloarthritis (axSpA) in physiotherapists back pain assessments. Since the previous survey, increased professional education on axSpA has occurred and First Contact Practitioners (FCPs), now widely established in General Practice, are key in supporting earlier recognition. (1) To re-evaluate physiotherapists' and evaluate FCPs' awareness, knowledge, and confidence in screening for and recognising features of axSpA and criteria prompting referral to rheumatology. (2) To compare these results to previous research (Steen et al., 2021). As per Steen et al. (2021), an online survey was undertaken combining back pain vignettes (reflecting axSpA, non-specific low back pain [NSLBP] and radicular syndrome) and questioning on features of suspected axSpA. 165 surveys were analysed. Only 73% (n=120/165) of respondents recognised the axSpA vignette compared to NSLBP 91% (n=80/88) and radicular syndrome 88% (n=68/77). An improvement in axSpA recognition was demonstrated compared with previous data. FCPs performed slightly better with 77% (n=67/87) of respondents recognising the axSpA vignette. Adequate awareness of national referral guidance was evident in only 55% of 'clinical reasoning' and 6% of 'further subjective screening' responses. There was still misplaced confidence in recognising clinical features of axSpA compared to knowledge levels shown, including high importance given to inflammatory markers. Musculoskeletal physiotherapists demonstrate some improved knowledge and awareness of axSpA compared with previous study findings. Consideration of axSpA is still not universal in musculoskeletal physiotherapists' or FCPs' approaches to persistent back pain assessments and awareness of national referral guidance remains limited. This study highlights the continued need for professional education. Enhanced knowledge of screening and referral criteria in musculoskeletal clinical practice would support earlier diagnosis and better outcomes.

Design and development of an eHealth intervention to support self-management in people with musculoskeletal disorders - ‘eHealth: It’s TIME’: a study protocol

Background: Musculoskeletal disorders (MSDs) are a leading cause of global morbidity, with the burden expected to increase in the near future. Self-management, with the support of healthcare professionals, is recommended for many MSDs. However, frequent clinical contact is not feasible. Previous research has highlighted the need for a co-designed eHealth-mediated self-management follow-up support intervention which integrates remote monitoring and behavioural change. Thus, the current study aims to develop and design a user-centred, eHealth-mediated self-management support prototype for people with MSDs. Methods: A three-step, iterative system development cycle will be utilised to develop and design the “eHealth: It’s TIME prototype”. The three-step process will include creating website features and content using two sequential focus groups with people with MSDs (n = 6 – 8); heuristic testing using the 10 heuristic principles of Nielsen (n = 5); and usability testing through in-person 60-minute interviews with people with MSDs (n = 3 – 5) and musculoskeletal physiotherapists (n = 3 – 5). Conclusion: The eHealth: It’s TIME prototype will be a systematically developed, follow-up self-management support intervention guided by behavioural change theory and the preferences of end users.

Delegation of workload from musculoskeletal physiotherapists to physiotherapy assistants/support workers: A UK online survey

PurposeThere are approximately 9000 physiotherapy assistants/support workers in the UK. Many of them work in NHS physiotherapy outpatient services treating patients with musculoskeletal conditions, but their role(s) are relatively undefined and as such there is considerable variation in the duties and tasks they undertake. This study aimed to explore current practice of UK musculoskeletal physiotherapists in relation to delegation to physiotherapy assistants/support workers. MethodsAn online cross-sectional descriptive survey was designed and collected data on delegation practice and training in delegation. The survey was piloted with 10 physiotherapists. The final questionnaire was distributed via the interactive Chartered Society of Physiotherapy's website and the authors' professional networks via Twitter. Responses were collected over a five-week-period from October to November 2020. ResultsOf 302 survey responses, 232 were analysed (46 incomplete, 24 ineligible). The majority of respondents (66.3%, 154/232) had worked as physiotherapists for over 10 years. Most respondents indicated they had neither formal training (84%, 195/232) nor informal training (60.3%, 140/232) regarding how to delegate tasks. The clinical tasks most commonly delegated by physiotherapists were supervision of exercises (81.0%, 188/232) and walking aid provision (78.5%, 182/232) whereas the least delegated clinical task was the application of electrotherapy (19.8%, 46/232). ConclusionThese survey results provide evidence for the need to improve training in delegation for both physiotherapists and physiotherapy assistants, and to ensure clearer delegation processes to facilitate good delegation practice in the musculoskeletal setting.

‘I am the educator and the learner at the same time’: a qualitative survey of the knowledge and use of adult learning theory in UK musculoskeletal physiotherapists' patient education

Background/Aims Patient education is a core component of musculoskeletal care, yet broad definitions exist and effective delivery methods are unclear. Musculoskeletal physiotherapists' use of patient education has been described as individualised and collaborative, reflecting a person-centred model of care. However, discrepancies between perceived and actual practice, and therapist-centred approaches to education, have been observed. Little is known about the theoretical basis of musculoskeletal physiotherapists' patient education practice, yet the adult learning theory frames how adults interact with education and echoes the principles of person-centred care. The aim of this study was to analyse the use of adult learning theory to inform patient education practice among UK musculoskeletal physiotherapists. Methods This study used a novel, online questionnaire to collect quantitative and qualitative data from a self-selecting sample of UK musculoskeletal physiotherapists, using a multimodal recruitment strategy. Complete responses were provided by 66 participants. Categorical and narrative data were collected and descriptive and thematic analyses undertaken. Results Participants generally self-rated their educational competencies highly, with the exception of evaluating patient education. Participants were more familiar with reflective and self-directed learning than with other adult learning theories. Two main themes were described: implicit adult learning theory knowledge and challenges in applying adult learning theory. Conclusions The results suggest that musculoskeletal physiotherapists may have implicit knowledge of adult learning theory, yet challenges exist in applying them. This finding supports the establishment of ongoing training in educational skills for physiotherapists and could be used as a catalyst for musculoskeletal physiotherapists to reflect on their knowledge and use of adult learning theory.

Service evaluation of telehealth in a physiotherapy musculoskeletal setting: Patient outcomes and results from risk stratification.

Due to COVID-19 the ability to see all patients face-to-face (FTF) was removed. Services implemented telehealth to cater for patients requiring musculoskeletal care. A service evaluation was undertaken to assess the effectiveness of a mixed telehealth/FTF approach and identify if stratifying patients could help tailor intervention. Retrospective analysis of data collected from patients who were assessed by Musculoskeletal Physiotherapists in one Scottish health board was undertaken. Patients were divided into low, medium and high risk sub-groups through the Keele STarT MSK tool. Outcome measures for pain and musculoskeletal health were taken at baseline/discharge along with satisfaction/preference. Descriptive and Inferential statistical analysis was conducted to establish whether changes in the outcome measures within and between risk sub-groups were statistically significant. Pain level difference from baseline to discharge demonstrated clinically and statistically significant improvements across all risk groups (N=89). Musculoskeletal health demonstrated clinically significant improvements across all risk groups and statistically significant improvements in the medium/high risk groups but not the low risk. Patients with knee osteoarthritis and low back pain in the medium risk group had fewest appointments while patients with chronic shoulder pain had the most. The majority of patients were satisfied with all mediums but preferred FTF or an option between telehealth/FTF in the future. Telehealth is a promising model of care when utilised in combination with FTF for patients with musculoskeletal conditions. Through stratification, identifying specific conditions and shared decision making it may be possible to treat certain patient groups via telehealth.

Musculoskeletal physiotherapists’ perceptions using the STarT Back screening tool (SBT) during the initial physiotherapy assessment. Service evaluation using qualitative methods

Musculoskeletal physiotherapists’ perceptions using the STarT Back screening tool (SBT) during the initial physiotherapy assessment. Service evaluation using qualitative methods

What do musculoskeletal physiotherapists really think about virtual consultations?- A service evaluation

What do musculoskeletal physiotherapists really think about virtual consultations?- A service evaluation

A new development model for advanced practice musculoskeletal (MSK) physiotherapists in an NHS community outpatients service to facilitate effective learning

A new development model for advanced practice musculoskeletal (MSK) physiotherapists in an NHS community outpatients service to facilitate effective learning

Perception of massage application among clinicians and parents in spastic cerebral palsy: Qualitative study.

To explore the perceptions about traditional massage and its modified techniques among clinicians and families of the patients with spastic cerebral palsy. The qualitative, cross-sectional study was conducted from November 2019 to August 2020 in Sialkot, Pakistan, after approval from the ethics review committee of Riphah College of Rehabilitation Sciences, Islamabad, and comprised neuro paediatricians and paediatricians in Group A, parents of children with spastic cerebral palsy aged 8-15 years in Group B, and musculoskeletal physiotherapists and orthopaedic manual physical therapists in Group C. The professionals in groups A and C had a minimum of 5-year paediatric experience in government and teaching hospitals. Data was collected using a semi-structured pilot-tested questionnaire. Qualitative approach and thematic code analysis was used to analyse the collected data. Of the 26 subjects, 10(38.5%) were in Group A, 8(30.7%) in Group B and 8(30.7%) in Group C. Overall, there were 16(61.4%) males and 10(38.5%) females. Among the professionals, experience ranged 5-38 years in Group A, and 5-9 years in Group C. The identified themes were reforms in recommendations, and application of massage techniques, with the participants overwhelmingly favouring termination markers to prevent increase in hypertonicity in spastic cerebral palsy. Termination markers of massage should be considered in interventions to improve outcomes in children with spastic cerebral palsy.

Perceived barriers to evidence based practice amongst UK physiotherapists: A qualitative analysis and proposal of solutions

Purpose: Rapid developments in research, changing models of musculoskeletal care and advances in service delivery are required to ensure quality patient care. Evidence based practice (EBP) is advocated to provide safer, more consistent, cost-effective patient-centred care. Despite the evolution of clinical practice it is felt that barriers still remain limiting its implementation. The purpose of this study was to improve current understanding of perceived barriers amongst musculoskeletal physiotherapists, to propose practical solutions and utilise this information in the development of a manifesto for reform to promote best practice in evidence-based physiotherapy care in the UK.

Evaluation of the First Contact Physiotherapy (FCP) model of primary care: Patient characteristics and outcomes

Purpose: First Contact Physiotherapy (FCP) is a rapidly evolving model of primary care. Expert musculoskeletal (MSK) physiotherapists undertake the first patient consultation, to enhance and expedite MSK-patient care and free up GP capacity for other patients. A three-phased evaluation of NHS England's (NHSE) pilot of the FCP model has been undertaken (2018/2020). Here, we report the quantitative findings from Phase 3, which aimed to evaluate the FCP model of care against twelve success criteria.

Impact of an interactive workshop on specialist physiotherapists’ practice when implementing a new clinical care pathway for people with musculoskeletal conditions

BackgroundA new pathway of care proposes early comprehensive assessment and targeted management by specialist musculoskeletal clinicians for people with musculoskeletal conditions at risk of poor outcomes. Adoption of this care pathway is likely to be influenced by beliefs and behaviours of specialist musculoskeletal clinicians. ObjectiveTo evaluate the effect of an interactive educational workshop about the proposed clinical care pathway on knowledge, beliefs and practice of specialist musculoskeletal physiotherapists. DesignMixed methods. MethodsFifty specialist musculoskeletal physiotherapists participated in a 2-day interactive educational workshop. Knowledge, beliefs and clinical practice behaviours were assessed immediately before the workshop and 3 months’ later using surveys. ResultsKnowledge about key guideline messages improved and were maintained at follow-up. Most participants agreed to provide more targeted interventions to patients at risk of poor outcome (92%, 95% CI: 81%–98%) and utilise prognostic screening tools (84%, 95% CI: 71 to 93). However, only 56% (95% CI: 39%–68%) of participants believed implementing a shared care pathway was easy. At follow-up, participants’ beliefs were more aligned with the proposed care pathway (i.e., shared care: 83%, 95% CI: 68%–93%). With respect to clinical practice, there were 16% more referrals back to the primary physiotherapist at 3 months than before the workshop. Barriers (practitioner, patient and system factors) to implementation of the care pathway were discussed. ConclusionAn interactive educational workshop influenced specialist musculoskeletal physiotherapists’ knowledge, beliefs and clinical practice, but barriers need to be overcome to facilitate widespread implementation.

Evaluation of the First Contact Physiotherapy (FCP) model of primary care: a qualitative insight

ObjectiveFirst Contact Physiotherapy (FCP) is a primary care model where expert musculoskeletal (MSK) physiotherapists undertake the first patient consultation, to enhance MSK-patient care and free-up GP capacity. The authors report the qualitative findings from the FCP National Evaluation (Phase 3) which evaluated the FCP model against pre-agreed success criteria. Design and settingA mixed-methods 24-month service evaluation involving FCP sites across England. MethodsData were collected at 2 time points, year 1 and year 2. Data were collected using individual interviews and focus groups, transcribed verbatim and analysed using a hybrid inductive and deductive thematic analysis. Participants were recruited from all stakeholder groups; patients, physiotherapists, general practitioners and administration staff. ResultsA total of 6 sites were recruited over both rounds of data collection demonstrating a wide range of service models. Thirty-nine participants were recruited including fourteen patients. All six qualitative success criteria were met. GPs’ discourse reflected confidence in the FCP service and competence of the FCPs. Patient discourse reflected self-efficacy and confidence in self-management techniques and reported FCP as a positive experience. FCPs saw providing advice about work related issues as integral to their role and patient discourse reflected perceived benefit from the advice offered. Staff discourse reflected a positive experience of working with, and in, the FCP services. ConclusionAhead of the planned scale-up of the FCP primary care model across the UK, this evaluation provides useful insights and recommendations to facilitate successful FCP implementation in terms of patient outcome and experience, and staff experience.

Evaluation of the First Contact Physiotherapy (FCP) model of primary care: patient characteristics and outcomes

ObjectiveFirst Contact Physiotherapy (FCP) is a primary care model where expert musculoskeletal (MSK) physiotherapists undertake the first patient consultation, to enhance MSK-patient care and free-up GP capacity. The authors report the quantitative findings from the FCP National Evaluation (Phase 3) which evaluated the FCP model against success criteria. Design and settingA mixed-methods 24-month service evaluation involving 40 FCP sites and 240 FCPs across England. MethodsAn online platform collected patient-reported experience and outcomes following the FCP consultation and at 1, 2 and 3-months follow-up. These included the Keele STarT MSK Tool, pain intensity (0–10 NRS scale), Musculoskeletal Health Questionnaire (MSK-HQ, range 0–56), and Friends-and-Family Test. ResultsOver 13 months, 2825 patients were invited by email and 24% (n=680) completed their initial questionnaire. Their mean age was 56.2 (SD 14.9), 61% were female, ethnicity was 97% white, mean pain intensity was 6.1 (SD 2.13) and mean MSK-HQ score was 33.8 (SD 9.5). At 3-months follow-up (n=370) there was a 2.8 (CI 2.5 to 3.1) mean pain intensity reduction from baseline, a mean 7.1 (6.0 to 8.2) score improvement in MSK-HQ and 64% reporting overall improvement (much better/better) since seeing the FCP. One of the six success criteria was not met; 29% of those in employment reported receiving specific work advice from the FCP (target ≥75%). ConclusionAhead of the planned scale-up of the FCP primary care model across the UK, this evaluation provides useful data on patients who access this service, their short-term clinical outcomes and whether key success criteria are being met.

Accreditation of advanced clinical practice of musculoskeletal physiotherapy in England: a qualitative two-phase study to inform implementation

ObjectivesTo establish whether international musculoskeletal physiotherapy educational standards and associated governance framework align with advanced clinical practice (ACP) frameworks in England; and to evaluate physiotherapy stakeholders’ perceptions about potential accreditation and governance of ACP for musculoskeletal physiotherapists. DesignA qualitative two-phase study. 1] An explicit documentary mapping process of established international educational musculoskeletal standards to the ACP frameworks for England, in terms of domains, standards and competencies by two independent reviewers. Results were evaluated by a third reviewer and focus group participants. 2] Focus groups enabled maximal insight into perceptions of musculoskeletal stakeholders through the interactive process facilitated by a topic guide. Groups were recorded and transcribed verbatim; data were analysed using thematic coding. SettingThree focus groups in London, Birmingham and Manchester facilitated recruitment from all regions of England. ParticipantsPurposive sampling (n=26) ensured representation of stakeholders for ACP (e.g. Professional Networks, patients). ResultsInternational educational standards fully mapped to both ACP frameworks, with 100% saturation of defined capabilities, and agreement across reviewers and focus groups. Four themes were identified from focus groups: musculoskeletal physiotherapy specific professional factors; fit for purpose, innovative educational opportunities; advocated recognition of musculoskeletal physiotherapy ACP as a discrete professional practice field; and advocating a potential vehicle for musculoskeletal physiotherapy ACP. ConclusionsThis study identifies the importance of musculoskeletal ACP specific to the physiotherapy profession. Fit-for-purpose innovative educational opportunities for musculoskeletal physiotherapists are required at Masters level to support preparation for ACP roles. The established national and international musculoskeletal frameworks afford an opportunity.

Physiotherapists' awareness, knowledge and confidence in screening and referral of suspected axial spondyloarthritis: A survey of UK clinical practice.

Axial spondyloarthritis (axSpA) is an inflammatory disease associated with significant diagnostic delays and is commonly missed in assessments of persistent back pain. To explore musculoskeletal physiotherapists' awareness, knowledge and confidence in screening for signs, symptoms and risk factors of suspected axSpA and criteria for rheumatology referral. An online UK survey was undertaken combining back pain vignettes (reflecting axSpA, non-specific back pain and radicular syndrome) and questioning on features of suspected axSpA. Recruitment utilised online professional forums and social media. Data analysis included descriptive statistics and conceptual content analysis for free text responses. 132 survey responses were analysed. Only 67% (88/132) of respondents identified inflammatory pathologies as a possible cause of persistent back pain. Only 60% (79/132) recognised the axSpA vignette compared to non-specific low back pain (94%) and radicular syndrome (80%). Most suspecting axSpA would refer for specialist assessment (77/79; 92%). Awareness of national referral guidance was evident in only 50% of 'clinical reasoning' and 20% of 'further subjective screening' responses. There was misplaced confidence in recognising clinical features of axSpA (≥7/10) compared to knowledge levels shown, including high importance given to inflammatory markers and human leucocyte antigen B27 (median=8/10). Musculoskeletal physiotherapists may not be giving adequate consideration to axSpA in back pain assessments. Awareness of national referral guidance was also limited. Professional education on screening and referral for suspected axSpA is needed to make axSpA screening and referral criteria core knowledge in musculoskeletal clinical practice, supporting earlier diagnosis and better outcomes.

Using the diagnostic thinking inventory in musculoskeletal physiotherapy: a validity and reliability study.

Development of clinical reasoning is an essential aspect in musculoskeletal physiotherapy practice that is linked to better outcomes. The measurement of clinical reasoning has placed an emphasis on diagnostic reasoning using different types of examinations. The Diagnostic Thinking Inventory (DTI) is a self-assessment tool developed to measure two aspects of diagnostic reasoning: flexibility in thinking (FT) and structure in memory (SM). DTI is valid and reliable that has been used extensively in medical field. To investigate the validity and reliability of DTI in musculoskeletal physiotherapy practice. Two groups of musculoskeletal physiotherapists completed DTI. Expert musculoskeletal physiotherapists assessed face and content validity. Data from the second group of musculoskeletal physiotherapists were used to assess test-retest reliability. Internal consistency was calculated using Cronbach's alpha. Construct validity was assessed by comparing both groups. Data were analyzed using the IBM SPSS statistics 25.0 version. The experts agreed that DTI measures diagnostic reasoning. For test-retest reliability, average intraclass correlation coefficient was 0.91, 0.92 and 0.90 (p<0.001) for DTI, FT and SM scores, respectively. Cronbach's alpha was 0.909, 0.919 and 0.897 (p<0.001) for DTI, FT and SM, respectively. The independent samples t-test demonstrated that the experts group achieved higher and statistically significant score (p<0.001). DTI is valid and reliable in measuring diagnostic reasoning in the context of musculoskeletal physiotherapy practice. It can be used to assess the impact of continuing education on musculoskeletal physiotherapists' diagnostic reasoning.