Musculoskeletal Physiotherapists Research Articles

Can a training programme in motivationalinterviewing change musculoskeletalphysiotherapists’ practice?The example of low back pain

Background Low back pain (LBP) is a leading cause of disability nationally and globally, and forms between 40% and 65% of musculoskeletal physiotherapists’ caseloads in the UK. Despite professional expectations to deliver person-centred practice, a biomedical and practitioner-centred perspective continues to dominate within physiotherapy. Many physiotherapists lack the knowledge and skills to deliver psychologically informed practice, which for persistent LBP requires consideration of the needs, preferences and values of the patient. Motivational interviewing (MI) has been recommended as a psychologically informed approach for physiotherapists working with persistent LBP patients, although little research has been carried out into its use. Aim This study aims to investigate the effects of MI training on physiotherapists’ beliefs, attitudes and practice in relation to persistent LBP. Methods A convergent parallel mixed methods study was undertaken. Volunteer musculoskeletal physiotherapists (n=16) were recruited from two musculoskeletal physiotherapy departments within a Community NHS Trust in greater London and allocated to either a MI training Group A (n=10) or a comparison Group B (n=6). The MI training group received an initial two-day MI course followed up by monthly supervision sessions delivered in the workplace. Outcomes were measured pretraining (baseline) then at three and six months later for both groups. Beliefs and attitudes and to persistent low back pain were measured using the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) and the Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS). Self-reported proficiency, confidence and intention to use MI were measured using visual analogues scales (VAS). The Motivational Interviewing Training Integrity scale (MITI) generated global ratings and behaviour counts from audio-recordings of initial consultations with persistent LBP patients. The implementation and impact of MI in practice was explored through semi-structured interviews with Group A physiotherapists only at six months. Results A significant post-training decrease in biomedical orientation was demonstrated between the MI training group and the comparison group at three months (HCPAIRS) and six months (PABS-PT and HC-PAIRS) using independent t-tests. The MI training group had significantly increased proficiency, confidence and intention to use MI at three and six months (VAS); and increased MITI global ratings of Spirit (at three months), Collaboration (at three months) and Evocation (at six months). Qualitative content analysis of the semi-structured interviews revealed that the physiotherapists embraced MI as an approach. They were able to overcome initial challenges of putting MI training into practice such as time pressure and level of difficulty in changing ingrained practice and language, and found positive individual and collective ways to introduce and sustain their use of MI. Discussion The results of this study contribute new insights into the understanding of the role and impact of training musculoskeletal physiotherapists in MI, although the small sample size means that the results should be interpreted with caution. MI is acceptable to physiotherapists. Physiotherapists were able to embrace the spirit of MI and to embed MI within their practice. This allows them to development their skills as person-centred practitioners and to cope more effectively with patients perceived as difficult and those with complex presentations. However, ongoing supervision is required to develop MI proficiency, which can be expensive. Mi is acceptable to physiotherapists who seem keen to adopt this psychologically informed approach However, for MI practice to become adopted more widely across the profession, sustainable training approaches and appropriate professional support structures are required.

The meaning of manual therapy in the practice of musculoskeletal physiotherapists: a thematic analysis

The meaning of manual therapy in the practice of musculoskeletal physiotherapists: a thematic analysis

From MSK to TK2A: a musculoskeletal physiotherapists creative research capacity building journey

From MSK to TK2A: a musculoskeletal physiotherapists creative research capacity building journey

Diagnostic accuracy of upper limb neurodynamic tests for the assessment of peripheral neuropathic pain: a systematic review

Purpose: Entrapment neuropathies (EN) such as carpal tunnel syndrome (CTS) and cervical radiculopathy contribute to the socioeconomic burden of occupational related musculoskeletal complaints and the associated costs. EN are also associated with severe pain, depression and functional limitations. Clinically upper limb neurodynamic tests (ULNTs) are used by musculoskeletal physiotherapists to assess the integrity of the peripheral nervous system and for neuropathic pain. Establishing diagnostic utility of ULNTs for the presence of neuropathic pain is required to inform timely ongoing management, without the need to wait for the established, more costly approaches e.g. imaging, nerve conduction studies. The aim therefore of this study is to provide a current evidence synthesis and evaluation of the diagnostic utility of ULNTs to identify peripheral neuropathic pain in patients with arm and/or neck symptoms.

Can a training programme in motivational interviewing change musculoskeletal physiotherapists’ practice? The example of low back pain

Purpose: This study aimed to investigate the effects of MI training on physiotherapists’ beliefs, attitudes and practice in relation to persistent LBP.

Are NHS-employed musculoskeletal physiotherapists in England mis-diagnosing Cauda Equina syndrome?

Purpose: This study builds on a retrospective study presented at Physiotherapy UK conference in 2017. This study had assessed and quantified claims of alleged mis-diagnosis of Cauda Equina Syndrome (CES) by self employed physiotherapists in the UK, notified to the Chartered Society of Physiotherapy's professional liability insurance brokers. Claims of negligence against NHS employed physiotherapists in England are covered by NHS Resolution (formerly known as the NHS Litigation Authority - NHSLA). This is an arms length body of Westminster Government that manages negligence and other claims in England's health provider organisations.This retrospective study sought to quantify prevalence of mis-diagnosis claims against NHS-employed musculoskeletal physiotherapists in England, to compare with the findings from the previous study.

Australian musculoskeletal physiotherapist's perceptions, attitudes and opinions towards pre-manipulative screening of the cervical spine prior to manual therapy: Report from the focus groups

BackgroundThe Australian Physiotherapy Association 2006 VBI Guidelines are used by many of the member organisations of IFOMPT. These Guidelines are due for revision incorporating recent research findings, international guides, and member's recommendations. PurposeTo identify and consider Australian musculoskeletal physiotherapists' recommendations to inform revision of the 2006 VBI Guidelines. MethodsFocus groups were conducted in the five larger Australian state capitals by an independent qualitative researcher and a subject expert. Qualitative data were collected from 41 musculoskeletal physiotherapists who were purposefully recruited for their broad range of experience and qualifications. The five stage Framework Analysis approach was used to analyse and interpret data. ResultsParticipants recommended that the revised Guidelines have a new title reflecting a broader risk assessment and management approach, encompassing both musculoskeletal and relevant cardio-vascular risks and informed by contemporary research evidence and clinical experience. Participants requested a positively worded stepwise guide to clinical reasoning for all cervical spine manual treatment scenarios including the process of gaining and recording consent. Participants advised on individual components of the Guidelines needing to be revised or removed. The revised Guidelines, once approved, need to be disseminated in written and electronic formats to all clinicians. Training and education are required to ensure appropriate uptake within and beyond the profession. Conclusions and implicationsTo ensure their clinical acceptance and utility, the Revised Guidelines need to reflect the current use and recommendations of musculoskeletal physiotherapists. Sound knowledge translation processes are then needed to ensure that the Guidelines are incorporated into practice.

Physiotherapists implicitly evaluate bending and lifting with a round back as dangerous

BackgroundBeliefs can be assessed using explicit measures (e.g. questionnaires) that rely on information of which the person is ‘aware’ and willing to disclose. Conversely, implicit measures evaluate beliefs using computer-based tasks that allow reduced time for introspection thus reflecting ‘automatic’ associations. Thus far, physiotherapists' beliefs about back posture and safety have not been evaluated with implicit measures. Objectives(1) Evaluate implicit associations between bending lifting back posture (straight-back vs round-back) and safety (safe vs danger); (2) Explore correlations between implicit and explicit measures of beliefs towards vulnerability of the back. DesignExploratory cross-sectional quantitative study. Methods47 musculoskeletal physiotherapists completed explicit measures of fear of movement (TSK-HC), back beliefs (BackPAQDanger) and beliefs related to bending and lifting back posture and safety (BSB). An Implicit Association Test (IAT) was used to assess implicit associations between (i) images of people bending/lifting with a ‘round-back’ or with a ‘straight-back’ posture, and (ii) words representing ‘safety’ and ‘danger’. A one-sample t-test assessed the degree and direction of the sample's IAT score. Cohen's d provided an effect size of the estimated bias. Correlation between IAT and each explicit measure was assessed using Pearson's coefficient. ResultsThe sample displayed an implicit association between ‘round-back’ and ‘danger’ (μ = 0.213, 95% CI [0.075-0.350], p = .003), with an effect size magnitude of 0.45. There were fair to moderate correlations between IAT and BSB (r = 0.320, 95% CI [0.036-0.556], p = .029) and, IAT and BackPAQDanger (r = 0.413, 95%CI [0.143-0.626], p = .004). ConclusionsPhysiotherapists displayed an implicit bias towards bending and lifting with a round-back as dangerous.

Agreement between telehealth and in-person assessment of patients with chronic musculoskeletal conditions presenting to an advanced-practice physiotherapy screening clinic

ObjectiveTo determine the level of agreement between a telehealth and in-person assessment of a representative sample of patients with chronic musculoskeletal conditions referred to an advanced-practice physiotherapy screening clinic. DesignRepeated-measures study design. Participants42 patients referred to the Neurosurgical & Orthopaedic Physiotherapy Screening Clinic (Queensland, Australia) for assessment of their chronic lumbar spine, knee or shoulder condition. InterventionParticipants underwent two consecutive assessments by different physiotherapists within a single clinic session. In-person assessments were conducted as per standard clinical practice. Telehealth assessments took place remotely via videoconferencing. Six Musculoskeletal Physiotherapists were paired together to perform both assessment types. Main outcome measuresClinical management decisions including (i) recommended management pathways, (ii) referral to allied health professions, (iii) clinical diagnostics, and (iv) requirement for further investigations were compared using reliability and agreement statistics. ResultsThere was substantial agreement (83.3%; 35/42 cases) between in-person and telehealth assessments for recommended management pathways. Moderate to near perfect agreement (AC1 = 0.58–0.9) was reached for referral to individual allied health professionals. Diagnostic agreement was 83.3% between the two delivery mediums, whilst there was substantial agreement (81%; AC1 = 0.74) when requesting further investigations. Overall, participants were satisfied with the telehealth assessment. ConclusionThere is a high level of agreement between telehealth and in-person assessments with respect to clinical management decisions and diagnosis of patients with chronic musculoskeletal conditions managed in an advanced-practice physiotherapy screening clinic. Telehealth can be considered as a viable and effective medium to assess those patients who are unable to attend these services in person.

Advanced musculoskeletal physiotherapy: Barriers and enablers to multi-site implementation.

Advanced musculoskeletal physiotherapy (AMP) services are a safe, effective model of care, but without broad-scale healthcare implementation to date. The aim of the present study was to identify the barriers and enablers to implementation of 12 AMP services from the perspective of clinical staff. In a qualitative study, 12 participants (physiotherapists), from 12 different healthcare networks (seven metropolitan, three regional, two rural), were included. Their departments implemented AMP services (orthopaedic postoperative joint replacement review, n=10; general orthopaedic, n=1; emergency, n=1; and neurosurgery n=1) over a 12-month period. Participants completed a structured survey specifically designed for the study. Thematic analysis was used, with themes mapped to the validated Theoretical Domains Framework. Nine major themes emerged from the data regarding barriers and enablers to the implementation of the AMP services from the perspective of clinical staff. These were: demand/capacity; model of care; the organization; stakeholders; communication; planning and processes; evaluation; workforce; and learning and assessment framework. Important enablers included engagement and buy-in from key stakeholders and medical staff, and well-established AMP learning frameworks for training and operational frameworks. Barriers included competitive funding environment, and issues that hindered effective communication. The knowledge, skills, availability, motivation and experience of the advanced musculoskeletal physiotherapists had a large impact on the implementation. The study identified a number of factors that should be considered for successful implementation of AMP services across healthcare services or wider healthcare networks.

Effectiveness of extrinsic feedback for management of non-specific low back pain: a systematic review protocol

IntroductionLow back pain is the greatest cause of years lived with disability worldwide and is linked with high societal and economic burden. Neuromuscular control impairments are a common clinical presentation...

Exploring the job satisfaction and career progression of musculoskeletal physiotherapists working in private practice in Western Australia

BackgroundDespite increasing workforce numbers, new graduate physiotherapists are reporting short career intentions due to low job satisfaction. Job satisfaction improves retention among allied health professionals, however we have limited understanding of its influence specific to physiotherapists. ObjectivesThe aim of this study was to explore factors contributing to the job satisfaction of musculoskeletal physiotherapists working in private practice across different career stages (new graduates, graduates, postgraduates, and owners) in Western Australia. DesignMixed-methods design with an anonymous self-administered survey capturing job satisfaction and employment characteristics of Western Australian physiotherapists working in private practice. Factors including peer support and mentoring, career progression and professional development were explored. MethodPhysiotherapists were recruited through snowball sampling, with 60 practices approached to participate. Survey results were analysed using linear regression models and basic thematic analysis. ResultsTwo-hundred and five surveys were completed by physiotherapists across 52 practices. The mean job satisfaction score was 41.9 out of 50, and increased job satisfaction was associated with practice ownership, salary satisfaction, established career pathways, and access to mentoring and professional development. ConclusionsPractice owners were significantly more satisfied with their job compared to new graduate, graduate and postgraduate physiotherapists. Findings illustrated the changing needs for support across different career stages, the importance of accessible senior clinicians, and the limited recognition for the efforts made by physiotherapists to pursue ongoing education.

Clinical classification criteria for nonspecific low back pain: A Delphi-survey of clinical experts

BackgroundNonspecific low back pain (NSLBP) is a common problem. Attempts have been made to classify NSLBP patients into homogenous subgroups. Classification systems based on identifying the underlying mechanism(s) driving the disorder are clinically useful to guide specific interventions. ObjectiveTo establish consensus among experts regarding clinical criteria suggestive of a dominance of ‘articular’, ‘myofascial’, ‘neural’, ‘central’, and ‘sensorimotor control’ dysfunction patterns (DPs) in NSLBP patients. Study designA 2-phase sequential design of a focus group and Delphi-study. MethodsA focus group with 10 academic experts was organized to elaborate on the different DPs discernible in LBP patients. Consecutively, a 3-round online Delphi-survey was designed to obtain consensual symptoms and physical examination findings for the 5 DPs resulting from the focus group. ResultsFifteen musculoskeletal physical therapists from Belgium and the Netherlands experienced in assessing and treating LBP patients completed the Delphi-survey. Respectively, 34 (response rate, 100.0%), 20 (58.8%) and 15 (44.12%) respondents replied to rounds 1, 2 and 3. Twenty-two ‘articular’, 20 ‘myofascial’, 21 ‘neural’, 18 ‘central’ and 11 ‘sensorimotor control’ criteria reached a predefined ≥80% consensus level. For example, after round 2, 85.0% of the Delphi-experts agreed to identify ‘referred pain below the knee’ as a subjective examination criterion suggestive for a predominant ‘neural DP’. ConclusionThese indicators suggestive of a clinical dominance of the proposed DPs could help clinicians to assess and diagnose NSLBP patients. Future reliability and validity testing is needed to determine how these criteria may help to improve physical therapy outcome for NSLBP patients.

Inter-Rater reliability of the Functional Movement Screen (FMS) amongst NHS Physiotherapists

Objectives: The primary objective of this study was to determine the inter-rater reliability of the FMS when used by novice NHS (National Health Service) Physiotherapists. The secondary objective was to determine whether clinical specialism has any impact on the inter-rater reliability of the FMS. Design: Reliability study. Methods: Forty participants with no recent MSK injury were video recorded completing the 7 component FMS tests. Six NHS Physiotherapists with no previous experience using the FMS attended a 2 hour training programme delivered by a certified FMS practitioner. Raters then viewed and scored videos of the 40 participants completing the FMS. Results: The inter-rater reliability of the FMS composite score was excellent (ICC of 0.82 (95% CI: 0.41- 0.93)).Non-specialist rotational Physiotherapists demonstrated excellent inter-rater reliability (ICC = 0.89, 95%CI 0.78-0.94), whereas the specialist musculoskeletal Physiotherapists demonstrated good interrater reliability (ICC = 0.79, 95%CI 0.19-0.92) for FMS composite score. The seven individual movement tests of the FMS demonstrated poor to excellent inter-rater reliability. The Hurdle Step was the least reliable of the movement tests (kw = 0.15, 95% CI: -0.09-0.38), whereas Shoulder Mobility was the most reliable of the movement tests (kw= 0.85, 95%CI: 0.72-0.97).The seven individual movement tests of the FMS demonstrated moderate to excellent inter-rater reliability between non-specialist rotational Physiotherapists. In contrast, the seven individual movement tests of the FMS demonstrated poor to excellent inter-rater reliability between specialist musculoskeletal Physiotherapists. Conclusion: The FMS represents a good attempt to objectify the subjective with the FMS composite score demonstrating excellent inter-rater reliability Due to poor construct validity, it has been suggested only component scores should be utilised. The results from this study suggest that five of the seven individual movement tests do not demonstrate acceptable reliability for clinical use. With the composite score lacking construct validity and the majority of the component scores lacking both intra- and inter-rater reliability, the continued use of FMS within clinical practice is not supported.

Exploring practice & clinical evidence with pre-manipulative testing for cervical arterial dysfunction amongst musculoskeletal physiotherapists within a Welsh Health Board

Exploring practice & clinical evidence with pre-manipulative testing for cervical arterial dysfunction amongst musculoskeletal physiotherapists within a Welsh Health Board

Are self-employed musculoskeletal physiotherapists mis-diagnosing Cauda Equina syndrome? A retrospective study of clinical negligence claims in the UK

Purpose: Anecdotal evidence from annual reviews of claims against the CSP Professional Liability Insurance scheme suggested that mis-diagnosis of Cauda Equine Syndrome (CES) was being seen more frequently with potential for resultant multi-million awards for damages, defence and claimant costs. This retrospective study sought to assess and quantify all claims notified and specifically claims of alleged failure to diagnose Cauda Equina Syndrome, to inform future risk mitigation.

An evaluation of a pain education programme for physiotherapists in clinical practice.

The present study evaluated the implementation and acceptability of a pain education programme delivered to physiotherapists in clinical practice. A pre-test/post-test design with 10 physiotherapists was employed. Descriptive and inferential statistics were used for outcome measure data. Focus groups were carried out with seven physiotherapists within 1month post-intervention. These data were analysed using the framework approach. Ten musculoskeletal physiotherapists were recruited. It was possible to develop and deliver the intervention and this was found to be acceptable to physiotherapists within clinical practice. The study explored trends within outcome measures, and one was considered appropriate. The focus groups yielded three interlinked themes, which related to the impact of the programme: "providing a context for pain education", "influence on aspects of the patient-therapist encounter" and "logistics of the education programme in clinical practice". A pain education programme delivered to physiotherapists in clinical practice was both possible to deliver and acceptable to participants. A key strength of the programme was the applicability to real-life practice, which was valued by physiotherapists. While physiotherapists felt that pain neurophysiology education was important, they reported lacking confidence in implementing their pain neurophysiology knowledge with patients. Thus, more time is needed to focus on pain neurophysiology education, with the aim of increasing confidence with the application of this approach in clinical practice.

Protocol for a multi-centre randomised controlled trial comparing arthroscopic hip surgery to physiotherapy-led care for femoroacetabular impingement (FAI): the Australian FASHIoN trial

BackgroundFemoroacetabular impingement syndrome (FAI), a hip disorder affecting active young adults, is believed to be a leading cause of hip osteoarthritis (OA). Current management approaches for FAI include arthroscopic hip surgery and physiotherapy-led non-surgical care; however, there is a paucity of clinical trial evidence comparing these approaches. In particular, it is unknown whether these management approaches modify the future risk of developing hip OA. The primary objective of this randomised controlled trial is to determine if participants with FAI who undergo hip arthroscopy have greater improvements in hip cartilage health, as demonstrated by changes in delayed gadolinium-enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC) index between baseline and 12 months, compared to those who undergo physiotherapy-led non-surgical management.MethodsThis is a pragmatic, multi-centre, two-arm superiority randomised controlled trial comparing hip arthroscopy to physiotherapy-led management for FAI. A total of 140 participants with FAI will be recruited from the clinics of participating orthopaedic surgeons, and randomly allocated to receive either surgery or physiotherapy-led non-surgical care. The surgical intervention involves arthroscopic FAI surgery from one of eight orthopaedic surgeons specialising in this field, located in three different Australian cities. The physiotherapy-led non-surgical management is an individualised physiotherapy program, named Personalised Hip Therapy (PHT), developed by a panel to represent the best non-operative care for FAI. It entails at least six individual physiotherapy sessions over 12 weeks, and up to ten sessions over six months, provided by experienced musculoskeletal physiotherapists trained to deliver the PHT program. The primary outcome measure is the change in dGEMRIC score of a ROI containing both acetabular and femoral head cartilages at the chondrolabral transitional zone of the mid-sagittal plane between baseline and 12 months. Secondary outcomes include patient-reported outcomes and several structural and biomechanical measures relevant to the pathogenesis of FAI and development of hip OA. Interventions will be compared by intention-to-treat analysis.DiscussionThe findings will help determine whether hip arthroscopy or an individualised physiotherapy program is superior for the management of FAI, including for the prevention of hip OA.Trial registrationAustralia New Zealand Clinical Trials Registry reference: ACTRN12615001177549. Trial registered 2/11/2015 (retrospectively registered).

Advanced musculoskeletal physiotherapists in post arthroplasty review clinics: a state wide implementation program evaluation

ObjectiveTo evaluate outcomes following a state-wide implementation of post arthroplasty review (PAR) clinics for patients following total hip and knee arthroplasty, led by advanced musculoskeletal physiotherapists in collaboration with orthopaedic specialists. Design and settingA prospective observational study analysed data collected by 10 implementation sites (five metropolitan and five regional/rural centres) between September 2014 and June 2015. Main outcome measuresThe Victorian Innovation and Reform Impact Assessment Framework was used to assess efficiency, effectiveness (access to care, safety and quality, workforce capacity, utilisation of skill sets, patient and workforce satisfaction) and sustainability (stakeholder engagement, succession planning and availability of ongoing funding). Results2362 planned occasions of service (OOS) were provided for 2057 patients. Reduced patient wait times from referral to appointment were recorded and no adverse events occurred. Average cost savings across 10 sites was AUD$38 per OOS (Baseline $63, PAR clinic $35), representing a reduced pathway cost of 44%. Average annual predicted total value of increased orthopaedic specialist capacity was $11,950 per PAR clinic (range $6149 to $23,400). The Australian Orthopaedic Association review guidelines were met (8/10 sites, 80%) and patient-reported outcome measures were introduced as routine clinical care. High workforce and patient satisfaction were expressed. Eighteen physiotherapists were trained creating a sustainable workforce. Eight sites secured ongoing funding. ConclusionsThe PAR clinics delivered a safe, cost-efficient model of care that improved patient access and quality of care compared to traditional specialist-led workforce models.

Inter-rater and intra-rater reliability of a movement control test in shoulder

BackgroundMovement faults are commonly observed in patients with musculoskeletal pain. The Kinetic Medial Rotation Test (KMRT) is a movement control test used to identify movement faults of the scapula and gleno-humeral joints during arm movement. Objective tests such as the KMRT need to be reliable and valid for the results to be applied across different clinical settings and patient populations. The primary objective of the present study was to determine the intra-rater and inter-rater reliability of KMRT in subjects with and without shoulder pain. MethodsSixty subjects were included in this study based on specific inclusion and exclusion criteria. Two musculoskeletal physiotherapists with different levels of clinical experience performed the tests. The intra-rater reliability was tested in twenty asymptomatic subjects by a single assessor at two week intervals. An equal number of subjects with and without shoulder pain were tested by both the assessors to determine the inter-rater reliability. Both components of the KMRT, the Gleno- Humeral Anterior Translation (GHAT) and the Scapular Forward Tilt (SCFT) were tested. ResultsThe Kappa values for inter-rater reliability of the GHAT and SCFT were K = 0.68 & K = 0.65 respectively in subjects with shoulder pain. In asymptomatic subjects, the inter-rater reliability of GHAT was K = 0.61 and SCFT was K = 0.85. Intra-rater reliability ranged from K = 0.66 for GHAT to K = 0.87 for SCFT. ConclusionOur study found substantial agreement in inter-rater reliability of KMRT in subjects with shoulder pain, whereas substantial to near perfect agreement was found in intra-rater and inter-rater reliability of KMRT in subjects without shoulder pain.