The clinical reasoning processes of extended scope physiotherapists assessing patients with low back pain

Physiotherapy assessment in people with neurological conditions-Evidence for the most frequently included domains: A mixed-methods systematic review

RATIONALE

There is a lack of consensus in the literature related to what is assessed clinically by physical therapists in people with neurological disorders.

AIMS

This mixed-methods systematic review aimed to identify domains that physiotherapists routinely assess in people with neurological conditions in clinical settings and explored factors influencing assessment domains including country, clinical setting, therapist experience and neurological condition.

METHOD

Five databases were searched from 1946 to 31st January 2023. Studies with any design reporting on domains assessed by a physiotherapist, in people with neurological conditions in any clinical setting, were included. Independent reviewers assessed eligibility and risk of bias using relevant McMaster critical appraisal tools. Data were extracted and synthesised following the Joanna Briggs Institute approach for mixed systematic reviews.

RESULTS

A total of 23 (16 quantitative, 7 qualitative) studies involving 3134 participants were included. The studies were rated as high (n = 14) or medium (n = 9) quality. The domains of function (n = 14); postural alignment and symmetry (n = 11); gait (n = 11); balance (n = 9), and muscle strength (n = 8) were most frequently included in assessments. Five key themes were identified from the qualitative studies: the clinical reasoning process, clinical use of standardised measures, utilisation of the senses, clinician experience and information gathering. There was minimal data on how country, clinical setting, therapist experience and neurological condition influence inclusion of assessed domains.

CONCLUSION

Five domains were most frequently included in assessment: function; postural alignment and symmetry; gait; muscle strength; and balance. This limited number of domains is in stark contrast to the full neurological physiotherapy assessment recommended by expert textbooks. Further research is needed to understand the reasons why this might be so.

Decision-making processes in image guided radiotherapy: A think aloud study

INTRODUCTION

3D Image Guided Radiotherapy (IGRT) using Cone Beam Computer Tomography (CBCT) has been implemented for a range of treatment sites across the UK in the last decade. A paucity of evidence exists to understand how radiation therapists (RTTs) make clinical decisions during image interpretation as part of the IGRT process. The aim of this study was to investigate the decision-making processes used by RTTs during image interpretation of IGRT.

METHOD

Case study methodology was adopted utilising a think aloud observational method with follow-up interviews. 12 RTTs were observed and interviewed across three UK radiotherapy centres. Participants were observed reviewing and making clinical decisions in a simulated environment using clinical scenarios developed in partnership with each centres' Clinical Imaging Lead. Protocol analysis was used to analyse the observational data and thematic analysis was used to analyse the interview data.

RESULTS

A range of approaches to decision-making was observed which varied in length from nine phrases to 57 (mean 24) per case. Six themes emerged from the data: Set Sequence, Site Specific Clinical Priorities, Initial Gross Review, Decision to treat, Compromise and experience. In addition, three cognitive decision-making processes were identified: Simple linear, Linear repeating and Intuitive decision-making process. The findings of the study align with general principles of expert performance, whereby experience in a specific scope of practice is more beneficial in developing expertise than overall experience.

CONCLUSION

This study has provided new and original insight in the decision-making processes of RTTs. The study has highlighted three process models to explain how RTTs make decisions during IGRT: Simple linear, Linear repeating and Intuitive decision-making process. Intuitive processes are widely accepted to be error prone and linked to bias. When using this process, some RTTs followed this with a confirmation phase. This second phase of the process should be encouraged when teaching IGRT. The results of the study support the concept of expert performance, where performance and expertise are only improved by exposing individuals to specific types of experiences. RTTs, managers and Higher Education Institutions are encouraged to review these models and implement them into IGRT training. It is clear from the evidence base that understanding how we make decisions, enables us to develop expertise and reduce errors during the decision-making process.

Physiotherapists' perceptions on using a multidimensional clinical reasoning form during psychologically informed training for low back pain

PURPOSE

Building clinical reasoning skills is important to effectively implement psychologically informed practice. We developed a multidimensional clinical reasoning form (CRF) to be used by physiotherapists in a psychologically informed practice training programme for low back pain. In this paper we describe the development of the CRF, how the CRF was used in the training, and present an evaluation of physiotherapists' perceptions of the CRF.

METHODS

Qualitative semi-structured interviews were conducted with ten physiotherapists purposively sampled in primary care. Data were gathered through pre, and post training focus group interviews and a secondary analysis of individual physiotherapist interviews conducted after the training. Thematic analysis was used to analyse the data and capture the emergent themes.

RESULTS

Two main themes emerged before the training: (1) the CRF 'needs formal training' and (2) 'lacked instruction'. Three main themes emerged after the training (1) it provided 'a helpful framework for multidimensional clinical reasoning' (2) the CRF, and accompanying operational definitions, helped physiotherapists 'elicit information, with 'question prompts' helpful in facilitating patient disclosure (3) 'Utility' - although the CRF was not formally used by the physiotherapists it provided a conceptual reasoning framework to work from with more challenging patients.

CONCLUSION

The CRF was not designed to be used in isolation by clinicians without training. However, when used as a training adjunct it appears to be valued by physiotherapists to help develop their critical thinking and better characterise patients' presentations in order to personalise care from a bio-psychosocial perspective.

Do Physical Therapists Practice a Behavioral Medicine Approach? A Comparison of Perceived and Observed Practice Behaviors

OBJECTIVE

A behavioral medicine approach, incorporating a biopsychosocial view and behavior change techniques, is recommended in physical therapy for the management of musculoskeletal pain. However, little is known about physical therapists' actual practice behavior regarding the behavioral medicine approach. The aim of this study was to examine how physical therapists in primary health care judge their own practice behavior of a behavioral medicine approach in the assessment and treatment of patients with persistent musculoskeletal pain versus how they practice a behavioral medicine approach as observed by independent experts in video recordings of patient consultations.

METHODS

A prospective cohort study was conducted. Video recordings of 23 physical therapists' clinical behavior in 139 patient consultations were observed by independent experts and compared with the physical therapists' self-reported practice behavior, using a protocol including 24 clinical behaviors. The difference between observed and self-reported clinical behaviors was analyzed with a Chi-square test and a Fisher exact test.

RESULTS

The behavioral medicine approach was, in general, practiced to a small extent and half of the self-reported clinical behaviors were overestimated when compared with the observed behaviors. According to the observations, the physical perspective dominated in assessment and treatment, the functional behavioral analysis was never performed, and the mean number of behavior change techniques used was 0.7.

CONCLUSION

There was a discrepancy between how physical therapists perceived the extent to which they practiced a behavioral medicine approach in their clinical behavior compared with what the independent researchers observed in the video recordings.

IMPACT

This study demonstrates the importance of using observations instead of using self-reports when evaluating professionals' clinical behavior. The results also suggest that-to ensure that physical therapy integrates the biopsychosocial model of health-physical therapists need to increase their focus on psychosocial factors in clinical practice.

Portfolios in practice: Developing advancing practice within a musculoskeletal competency-based model

INTRODUCTION

The development of professional portfolios and the relevance of this within professional practice, competency and capability is gaining significant credibility in line with professional requirements. Nursing and medicine in terms of historical perspectives have long held the need for clinicians to maintain a portfolio for professional validation, whilst in other professional groups it is a requirement of registration. The allied health professionals, physiotherapy and ultimately musculoskeletal practice within this context are rapidly developing advancing and consultant practice. This professional development further requires appropriate verification and validation of practice, and achieving this can be through formal and non-formal routes.

PURPOSE

This paper looks to explore this and give direction to professionals developing portfolios whilst placing the requirements in context to contemporary practice in the U.K. Universities, professional bodies and special interest groups are now aligning in the need to support practice in a multi-format way, that moves away from traditional methods of evaluation into more diverse models of competency-based assessment.

IMPLICATIONS

With improvement in technology, the development of national frameworks and standards, portfolios in practice although commonly considered as standard practice will be a requirement not only of registration but as a criteria of maintaining status, career development and expansion of roles.

BACKGROUND

Musculoskeletal (MSK) physiotherapy in the U.K. has moved forward significantly in the last 20 years. Sitting within a clinical reasoned framework, the introduction of additional skills such is image requesting, injection therapies, and non-medical prescribing has further underpinned the advanced practice agenda (Langridge et al., 2015). While these advancements in practice are driving the profession forward, challenges remain in providing the workforce with a clear process of career development. Alongside developing professional pathways methods of evidencing advanced knowledge and skills acquired outside formal routes are required to support practitioners' career pathway into advancing practice.

A service evaluation of the management of patients with suspected cauda equina syndrome from an outpatient physiotherapy service in the United Kingdom

BACKGROUND

The expanding scope of physiotherapists worldwide has come with an increased responsibility to identify serious pathologies such as fracture, infection, tumour and cauda equina syndrome (CES). Guidelines recommend a low threshold for emergency MRI to avoid the potentially devastating consequences of CES, but a balanced approach is required to prevent excessive strain on emergency resources.

AIM

To evaluate the management of patients presenting to an outpatient physiotherapy service with suspected cauda equina syndrome.

DESIGN

Service evaluation with an embedded case series of patients with radiological CES.

METHOD

The records of patients who were identified by their outpatient physiotherapists as having suspected CES (n-231) over a 27-month period were included. Data was extracted from patients' medical records by a team of Advanced Clinical Practitioners (ACPs). The lead author further analysed the records of patients with clinical and radiological CES, in order to present the embedded case series.

RESULTS

In 79% of cases, it was decided that emergency referral was not required. The remaining 21% of patients were referred to the emergency department and 49% of these had an emergency MRI. In the case series of seven patients with cauda equina compression on MRI, four patients had a disc bulge and underwent emergency surgery. One patient had non-emergency surgery for a disc bulge combined with anterolisthesis and scoliosis. Two patients had stenosis and decided against surgical intervention.

CONCLUSIONS

Findings from this service evaluation suggest support for the use of safety netting and an effective communication chain to facilitate effective management of patients with suspected CES.

Recommendations on patient-facing websites regarding diagnostic imaging for low back, knee, and shoulder pain: A scoping review

Objective

To describe and synthesise the content of public-facing websites regarding the use of diagnostic imaging for adults with lower back pain, knee, and shoulder pain.

Methods

Scoping review conducted in accordance with PRISMA guidance. A Google search was performed to identify public-facing websites that were either United Kingdom-based, or National Health Service affiliated. The DISCERN tool was used to appraise website quality before information regarding the use of imaging was synthesised using thematic analysis.

Results

Eighty-six websites were included, with 48 making reference to the use of imaging. The information within the majority (n = 43) of public-facing websites aligns with best available evidence. Where there is inconsistency, this may be explained by lower website quality. Three themes were apparent regarding the use of imaging - imaging to inform diagnosis and management; imaging in context; patient experience and expectations.

Conclusion

The recommendations and rationale for use of imaging contained within public-facing websites does not appear to justify the increase in imaging rates for musculoskeletal pain in the UK.

Innovation

Publicly available information following a novel search strategy, is largely aligned with best evidence, further understanding is required to determine reasons for requesting imaging from a patient and clinician perspective.

Student Perceptions of the Use of Case-Based Cadaver Dissections in Doctorate of Physical Therapy Program

Case-based cadaver dissection offers students unique opportunities to blend traditional anatomic knowledge acquisition with clinical reasoning. Twelve physical therapy students completed surveys centered on case-based dissections. Case-based cadaver dissections were defined in this study as multiple clinical vignettes that required students to use the accessible cadavers to solve clinically based problems. The results of the study provide preliminary evidence that students perceive case-based cadaver dissections as beneficial to their anatomy education and beneficial to the development of their clinical reasoning skills.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-022-01540-x.

Barriers to Physiotherapists’ Use of Professional Development Tools for Chronic Pain: A Knowledge Translation Study

Purpose: The Pain Science Division (PSD) is a special interest group of the Canadian Physiotherapy Association that serves physiotherapists who have an interest in better understanding and managing patients’ pain. The PSD developed evidence-based resources for its members with the goal of improving patient care by supporting professional development. However, online metrics tracking access to these resources indicated that access was low. The purpose of this study was to identify the barriers PSD members encountered to the use of PSD resources and to recommend interventions to address these barriers guided by the Theory and Techniques Tool (TTT). Method: We distributed an online survey to PSD members across Canada. We used the TTT, a knowledge translation tool, to guide the design of the questionnaire and identify actionable findings. Results: Response rates from 621 non-student members and 1,470 student members were 26.9% and 1.4%, respectively. Based on the frequency of practicing physiotherapists’ ( N = 167) agreement with items in the TTT, the primary barriers to use of the PSD resources were forgetting that the resources were available and forgetting to use them. Conclusions: The TTT can be used to identify barriers to use of professional development tools.

The advanced practitioners' perspective. Exploring the decision-making process between musculoskeletal advanced practitioners and their patients: An interpretive phenomenological study

INTRODUCTION

Advanced practice roles for allied health professionals continue to expand and provide key services within pathways of care for patients with musculoskeletal conditions. Despite the extensive utilisation of these roles and previously reported high patient satisfaction, little is understood about how these practitioners interact with their patients and the factors that influence decision-making conversations.

STUDY

A qualitative study utilised Interpretive Phenomenological Analysis (IPA) to explore the decision-making process occurring between Advanced Practitioners (APs) and their patients in a musculoskeletal service. AP data were collected through focus groups and analysed using IPA methodology.

CONCLUSIONS

Advanced practice decision-making is a complex process and APs exhibit a range of styles, from paternalistic to shared decision-making. APs may have a personal preference, but exhibit the ability to flex between styles in consultations. Multiple themes emerged from the data that influenced the decision-making process, including AP staff understanding the importance of patient expectations and the complex factors that influence patient interactions. It is important that clinicians have an awareness of the multiple factors that contribute to the decision-making process.

The complex problem of identifying serious pathology in Musculoskeletal care: Managing clinical risk during the COVID pandemic and beyond

The expanding scope of physiotherapists has come with an increased level of responsibility to identify 'red flag' signs and symptoms. Red flags can indicate the presence of serious pathology but are notoriously unreliable. This leaves diagnosis heavily reliant on diagnostic investigations which are generally a finite resource within healthcare organisations. The COVID pandemic seems to have further compounded the problem and the possibility of 'missed' or 'delayed' diagnosis is ever-present. This may present a threat to patients' lives, to clinicians' careers and wellbeing, and to organisations' finances and reputations. Although clinical risk in musculoskeletal physiotherapy may never be eliminated, there are opportunities to work towards minimising it. This professional issue will explore the complex problem of identifying serious pathology in musculoskeletal care and will propose strategies to manage the associated risks during the COVID pandemic and beyond. A video abstract is included in Appendix A.

Cross-sectional UK survey of advanced practice physiotherapy: characteristics and perceptions of existing roles

Background/aims

Few studies have investigated the characteristics of advanced practice physiotherapy in the UK to evaluate current context and implementation. The aim of this study was to understand how advanced practice physiotherapy is implemented in the UK.

Methods

A cross-sectional online descriptive national questionnaire was developed, using a previous survey and literature, comprising 33 closed, Likert-scale and open questions. Data analysis was undertaken using frequencies and thematic analysis. All 646 members of the Advanced Practice Physiotherapy Network were invited to participate.

Results

A total of 142 (22% response) reported 13 job titles; 40% had experienced ≥1 title change; most (50.7%) preferred ‘advanced practice physiotherapist’. High level job satisfaction was identified but barriers prevent fulfilment of the four advanced practice physiotherapy pillars: clinical practice, leadership and management, education and research. High level clinical skills and facilitating patient pathways were key to role differentiation. Problems included lack of support, inconsistency between responsibility and reward, and no consistent framework for advanced practice physiotherapy roles.

Conclusions

Advanced practice physiotherapists are largely satisfied, but significant variation exists in titles and implementation of roles. A consistent advanced practice physiotherapy framework is required.

"How does physical examination findings influence physiotherapists' decision-making when matching treatment to patients with low back pain?"

BACKGROUND

Further clinical data how low-back pain (LBP) symptoms and signs manifests in physiotherapy clinical reasoning and treatment decision-making is needed.

OBJECTIVE

The aim was to explore and describe how symptoms and signs portrayed in three case descriptions of LBP influences physiotherapy treatment decision-making.

DESIGN

This was an exploratory interview study using inductive content analysis.

METHOD

Fifteen semi-structured individual interviews were used to collect data of physiotherapists' treatment decision-making regrading three diverse LBP case descriptions. The participants were men, women, experienced and novice, working in primary healthcare settings in one sparsely populated region and in one larger city in Sweden.

FINDINGS

Two overarching themes were identified influencing decision-making for the treatment of LBP:1) Explicit assessment features distinguish treatment approaches; with categories describing how symptoms and signs were used to target treatment (nature of pain induce reflections on plausible cause; narrative details trigger attention and establishes knowledge-enhancing foci; pain-movement-relationship is essential; diverse emphasis of pain modulation and targeted treatment approaches): and 2) Preconceived notion of treatment, with categories describing personal treatment rationales, unrelated to the presented symptoms and signs (passive treatment avoidance and motor control exercise ambiguity).

CONCLUSION

This study identifies how assessment details lead to decisions on diverse treatment approaches for LBP, but also that treatment decisions can be based on preconceived beliefs unrelated to the clinical presentation. The results underpin the mix of knowledge sources that clinicians need to balance and the necessity of self-awareness of preconceptions for informed and meaningful clinical decision-making.

Factors influencing implementation of the GLA: D Back, an educational/exercise intervention for low back pain: a mixed-methods study

Introduction and aims:

Guidelines for low back pain (LBP) management recommend patient education and exercises. GLA:D Back, a structured group-based patient-education exercise program for LBP, facilitates evidence-based care implementation. This study aimed to inform on the implementation processes, assessing clinician-related factors. Objectives were to describe profiles of implementers and nonimplementers by demographics, and responses to the tailored version of the Determinants of Implementation Behaviour Questionnaire (DIBQ-t) qualitatively explore clinician perspectives on implementation, and compare the results of the DIBQ-t with the interview data to evaluate their fit of integration for facilitators, barriers, and new insights.

Methods:

A mixed-methods parallel design study was conducted. Physiotherapists and chiropractors, educated in the GLA:D Back program, were asked to complete the DIBQ-t (measuring theoretical determinants of implementation) 6 months after their training. Implementers and nonimplementers of the program were selected for interviews. Qualitative data were used to understand clinicians’ viewpoints on implementation, providing a broader perspective on the quantitative data and exploring new aspects.

Results:

More physiotherapists than chiropractors implemented the program. Implementers responded more positively on most domains of the DIBQ-t. The interviews revealed three themes important for implementation: personal gain, practicalities, and buying-in on the program. Clinicians’ attitudes to the program appeared additionally as relevant to implementation.

Conclusion:

The profession of the clinician was associated with implementation behavior. Implementers and nonimplementers identified the same themes but perceived them as either positive or negative. Both groups reported high levels of knowledge and skills, indicating that training alone is insufficient for implementation.

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

BACKGROUND

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.

OBJECTIVE

To investigate the validity and reliability of DTI in musculoskeletal physiotherapy practice.

METHODS

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.

RESULTS

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).

CONCLUSION

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.

The professional development and career journey into musculoskeletal first contact physiotherapy: a telephone interview study

(a)Background: Musculoskeletal (MSK) first contact physiotherapy (FCP) is being rolled out in the National Health Service, but limited research exists on career pathways into MSK FCP, or on pre-and-post-registration educational preparation for the knowledge and skills that are required for musculoskeletal first contact physiotherapy. (b) Objectives: From the perspectives of existing MSK FCPs, the study sought to understand the pre-and-post-registration professional developmental journey into musculoskeletal first contact physiotherapy. (c) Methods: Semi-structured interviews over the telephone were conducted with a self-selected and snowball sample of 15 MSK FCPs from across Britain. Framework analysis was used to analyze the interview transcripts. (d) Results: Four overarching themes were identified: (1) Decision to choose a career path as a MSK FCP; (2) Relevancy of pre-registration physiotherapy (PT) education for MSK FCP; (3) Relevancy of post-registration continuing professional development for MSK FCP, and; (4) Improving pre-registration PT education for the foundational knowledge and skills required to work in musculoskeletal first contact physiotherapy. Each overarching theme generated several subthemes. (e)Conclusion: The research contributes to understanding the career pathway into the MSK FCP role and showed what relevant knowledge and skills were acquired for this role at pre-and-post registration levels. Findings will inform guidance for pre-registration PT curriculum development.

Clinician and patient beliefs about diagnostic imaging for low back pain: a systematic qualitative evidence synthesis

OBJECTIVE

Overuse of diagnostic imaging for patients with low back pain remains common. The underlying beliefs about diagnostic imaging that could drive overuse remain unclear. We synthesised qualitative research that has explored clinician, patient or general public beliefs about diagnostic imaging for low back pain.

DESIGN

A qualitative evidence synthesis using a thematic analysis.

METHODS

We searched MEDLINE, EMBASE, CINAHL, AMED and PsycINFO from inception to 17 June 2019. Qualitative studies that interviewed clinicians, patients and/or general public exploring beliefs about diagnostic imaging for low back pain were included. Four review authors independently extracted data and organised these according to themes and subthemes. We used the Critical Appraisal Skills Programme tool to critically appraise included studies. To assess confidence in review findings, we used the GRADE-Confidence in the Evidence from Reviews of Qualitative Research method.

RESULTS

We included 69 qualitative studies with 1747 participants. Key findings included: Patients and clinicians believe diagnostic imaging is an important test to locate the source of low back pain (33 studies, high confidence); patients with chronic low back pain believe pathological findings on diagnostic imaging provide evidence that pain is real (12 studies, moderate confidence); and clinicians ordered diagnostic imaging to reduce the risk of a missed diagnosis that could lead to litigation, and to manage patients' expectations (12 studies, moderate confidence).

CONCLUSION

Clinicians and patients can believe that diagnostic imaging is an important tool for locating the source of non-specific low back pain. Patients may underestimate the harms of unnecessary imaging tests. These beliefs could be important targets for intervention.

PROSPERO REGISTRATION NUMBER

CRD42017076047.

Physiotherapists' lived experiences of decision making in therapeutic encounters with persons suffering from whiplash-associated disorder: A hermeneutic phenomenological study

Conceptual discussions related to clinical reasoning and decision making have evolved over the years from biomedical to incorporating more holistic approach to reasoning. Empirical studies exploring clinical reasoning and decision making in physiotherapy practice have mostly focused on aspects of managing persons with low back pain, such as exercise prescription, education and communicating diagnosis. There is a paucity of studies exploring decision making in whiplash-associated disorder (WAD); thus, the aim of this study was to explore the physiotherapists' lived experiences of decision making related to treating persons with WAD. A qualitative research design based on hermeneutic phenomenological methodology was used in this study. Five participants (physiotherapists) were purposefully recruited, and data are collected via semistructured interviews, which were recorded and transcribed verbatim. Interpretative phenomenological analysis (IPA) was used as a method for analysing the data. Emergent, superordinate and master themes emerged from the data to illuminate the lived experiences under exploration. Three master themes were identified: (1) sense of collaboration; (2) sense of being out of control; and (3) sense of emotional engagement (subthemes: feeling of satisfaction and feelings of distress and uncertainty). A sense of collaboration revealed varied meaning related to the role of persons receiving care, suggesting a lack of conceptual clarity related to shared-decision making. A perceived loss of a sense of being in control was related to experienced emotions, such as feelings of distress and uncertainty. The findings of this study highlight the importance of providing space for reflection and mentoring in the workplace.

Musculoskeletal ultrasound imaging - An exploration of physiotherapists' interests and use in practice

BACKGROUND

Musculoskeletal ultrasound imaging (MSKUSI) has gained popularity; several professions have expressed an interest in this application but the clinical use by physiotherapists has not been fully researched.

OBJECTIVES

To explore physiotherapists' interests and use of MSKUSI in practice.

DESIGN

Sequential mixed-methods; questionnaire followed by semi-structured interviews.

METHOD

A questionnaire was developed and distributed to gain initial information, (75 responses). Analysis informed topic-guide development and enabled a purposive-sampling strategy for semi-structured interviews that explored physiotherapists' interests, education and clinical use of MSKUSI (n = 11). Interview data were analysed thematically.

RESULTS

Five themes were identified: 1. Professional skill set - physiotherapists' suitability for MSKUSI. 2. Factors that have impacted physiotherapists' ability to use MSKUSI. 3. Physiotherapists' motivation to use ultrasound - improving patient focused care. 4. Quality assurance strategies. 5. Application of biopsychosocial model. Themes revealed links between physiotherapists' core skills, knowledge and professional experiences that align with MSKUSI requirements. Some participants reported support accessing education but many described challenges finding appropriate mentorship. Participants observed education did not always reflect practice typical of physiotherapists. Application of clinical reasoning processes utilised by physiotherapists was regarded as integral to patient-focused scanning.

CONCLUSIONS

Physiotherapists' professional training and musculoskeletal practice are seen as a foundation for education in MSKUSI. Accessing education can be challenging, in particular mentorship that fully incorporates the biopsychosocial model. Proposed roles for MSKUSI for physiotherapists include verification of clinical assessment findings for diagnosis and facilitation of patient education. The potential to streamline patient pathways and optimise resource management warrants investigation.

An empirical, pragmatic approach applying reflection in interaction approach to manual therapy treatments

Background: Most literature on decision processes within physiotherapy relates to "reasoning that results in action" - decisions based on information including assessments that are gathered prior to treatment decisions. A process of "reasoning in interaction" that is often used, particularly by expert clinicians, has received less attention. Objective:  To provide a theoretical and practical approach to applying reasoning in interaction in a musculoskeletal setting. Methods: The theory is: If an impairment that can be directly targeted by treatment (i.e. pain or limitation of passive movement) is related to patient's active impairments and functional limitations, then moment-to-moment changes in the targeted impairment can be used as feedback to guide real-time treatment modification before formal reassessment of functional limitations and other impairments. Results: Applying the theory to manual therapy results in parameters of techniques such as force, speed, direction and duration no longer being pre-determined, but rather being continually adjusted in real-time according to feedback from the patient through both therapist perception (changes in movement quantity or quality) and patient verbal responses. Conclusion: A process of continuous decision-making is described that the authors believe is used by many experienced clinicians but has not previously been adequately described in the literature. .

Predictors of Clinical Reasoning Using the Reasoning 4 Change Instrument With Physical Therapist Students

BACKGROUND

Although physical therapist students must be well prepared to integrate biopsychosocial and behavioral perspectives into their clinical reasoning, there is a lack of knowledge regarding factors that influence such competence.

OBJECTIVE

This study explored the associations among the independent variables-knowledge, cognition, metacognition, psychological factors, contextual factors, and curriculum orientation vis-à-vis behavioral medicine competencies-and the dependent variables-outcomes of input from client (IC), functional behavioral analysis (FBA), and strategies for behavior change (SBC) as levels in physical therapist students' clinical reasoning processes.

DESIGN

This study used an exploratory cross-sectional design.

METHODS

The Reasoning 4 Change instrument was completed by 151 final-semester physical therapist students. Hierarchical multiple regression analyses for IC, FBA, and SBC were conducted. In the first step, curriculum orientation was inserted into the model; in the second step, self-rated knowledge, cognition, and metacognition; and in the third step, psychological factors.

RESULTS

All independent variables except contextual factors explained 37% of the variance in the outcome of IC. Curriculum orientation explained 3%, cognitive and metacognitive factors an additional 22%, and attitudes another 15%. Variance in the outcomes of FBA and SBC were explained by curriculum orientation only (FBA change in R2 = 0.04; SBC change in R2 = 0.05). Higher scores of the dependent variables were associated with a curriculum having behavioral medicine competencies.

LIMITATIONS

The limitations of this study are that it was cross-sectional.

CONCLUSIONS

Cognitive and metacognitive capabilities and skills and positive attitudes are important predictors of physical therapist students' clinical reasoning focused on behavior change at the IC level. Curricula with behavioral medicine competencies are associated with positive outcomes at all clinical reasoning levels.

The skills, knowledge and attributes needed as a first-contact physiotherapist in musculoskeletal healthcare

OBJECTIVES

The provision of musculoskeletal assessment and pathway management by physiotherapists in primary care is an expanding innovation within the UK National Health Service. This new model of care is challenging physiotherapists to work in new ways, and so an understanding of these roles is timely and wil contribute to the growing knowledge regarding these practitioners and their impact.

METHODS

This qualitative study aimed to improve the understanding of the clinical practice of first-contact clinicians in musculoskeletal healthcare. The study used a think-aloud method to explore eight clinicians' views via a stage 1 semi-structured interview process. This was followed by a stage 2 focus group involving physiotherapists and a general practitioner trainer. A thematic analysis then followed, which involved the researcher and a research colleague coding the data and subsequently developing themes.

RESULTS

The themes identified were: medical assessment and systems knowledge; speed of thought in an uncertain environment; breadth of knowledge; people and communication skills; common sense/simplify; and responsibility and experience.

CONCLUSIONS

The identified themes should help to underpin the competence, capability and training requirements for these new roles, and should be considered when developing new services utilizing first-contact primary care physiotherapy practice.

Aspects influencing clinical reasoning and decision-making when matching treatment to patients with low back pain in primary healthcare

BACKGROUND

It is unclear how physiotherapists match treatment to patients with low-back pain (LBP) in primary healthcare. A further exploration of physiotherapists' perspective of matching treatments to the individual patient in this setting is needed.

OBJECTIVE

The aim of this study was to explore and describe aspects influencing physiotherapists' clinical reasoning in the decision-making on individualized treatment of LBP in primary healthcare.

DESIGN

This was an explorative study using qualitative content analysis.

METHOD

Fifteen semi-structured individual interviews were conducted with physiotherapists, men and women, experienced and novice, working in primary healthcare settings in one sparsely populated region and in one larger city in Sweden.

FINDINGS

Two overarching themes were identified influencing decision-making for individualized treatment of LBP: 1) Matching requires differentiation and adaptation, with categories describing specific patient characteristics, assessment findings and treatment adaptations (classification of pain and bodily findings; patient physical capacity and emotions; patient awareness and motivation; treatment combinations and atypical treatment rationales): and 2) The tension between trust and barriers; with categories describing aspects of physiotherapists' convictions, constraints and working environment (confidence in treatments and oneself; physiotherapists' terms overrule patients' preferences; personal constraints and workplace approach and priorities).

CONCLUSION

This study describes aspects of the patients, the physiotherapists and their workplaces that influence decisions for individualized treatment of LBP. The findings underpin the need for clinician self-reflection, initiatives for skilled clinical competence and the weight clinician observations carry on the complex treatment selection process which need to be appreciated when implementing evidence-based recommendations in clinical practice.

Physiotherapists' experiences of managing upper limb movement impairments due to breast cancer treatment

Background: Physiotherapy is recommended for upper limb movement impairments (ULMI) following breast cancer treatment. There is limited research into the pathophysiology and management of ULMI. Care is provided in different health-care contexts by specialist and nonspecialist physiotherapists, with referrals set to increase. This study explores physiotherapists' experiences of managing ULMI. Design: Qualitative study using a hermeneutic phenomenological approach. Method: We interviewed six physiotherapists from various UK treatment settings. The data were analyzed using interpretative phenomenological analysis. Findings: Four master themes were identified: (1) lack of confidence surrounds various aspects of practice, influenced by limited evidence to guide treatment of ULMI, fear of causing harm, and working in a less-established area of physiotherapy; (2) increasing confidence in practice develops with experience, reinforcing perceptions of the benefits of physiotherapy; (3) physiotherapy is understood to empower and enable patients to regain their sense of self and quality of life; and (4) provision of care is perceived to be subject to many barriers. Conclusion: Physiotherapy for ULMI has professional challenges but is seen as beneficial, encompassing psychosocial and physical effects. Experiences in this area of practice suggest a need for increased professional support, further research to guide treatment, and better patient and health professional awareness of ULMI and the role of physiotherapy.

Physiotherapists as detectives: investigating clues and plots in the clinical encounter

This article investigates the clinical reasoning process of physiotherapists working with patients with chronic muscle pain. The article demonstrates how physiotherapists work with clues and weigh up different plots as they seek to build consistent stories about their patient's illness. The material consists of interviews with 10 Norwegian physiotherapists performed after the first clinical encounter with a patient. Using a narrative approach and Lonergan's theory of interpretation, the study highlights how, like detectives, the therapists work with clues by asking a number of interpretive questions of their data. They interrogate what they have observed and heard during the first session, they also question how the patient's story was told, including the contextual and relation aspects of clue production, and they ask why the patient's story was told to them in this particular way at this particular time. The article shows how the therapists configure clues into various plots on the basis of their experience of working with similar cases and how their detective work is pushed forward by uncertainty and persistent questioning of the data.

Pain-related fear of (re-)injury in patients with low back pain: Estimation or measurement in manual therapy primary care practice? A pilot study

BACKGROUND

Manual physical therapists (MPTs) working in primary care get limited information about patient's courses of (chronic) low back pain (LBP). Identification of kinesiophobia is mostly based on clinical perception.

OBJECTIVE

The aim of this study was to evaluate the association between the scores with which manual physical therapists in a primary care setting identify kinesiophobia in patients with low back pain, and the patients' self-reported measures of kinesiophobia.

METHODS

The cross-sectional study comprised 104 patients with LBP and 17 MPTs. Patients first independently completed the Tampa Scale for Kinesiophobia (TSK-17). The therapists, blinded to the TSK-scores, rated their perception of a patient's kinesiophobia using the Visual Analogue Scale-Estimation (VAS-est) and the accuracy of their ratings using the Visual Analogue Scale-Accuracy (VAS-ac). Kendall's tau b was used to determine the level of correlation between scores on the TSK-17 and the VAS-est.

Socio-Cultural Factors and Experience of Chronic Low Back Pain: a Spanish and Brazilian Patients' Perspective. A Qualitative Study

BACKGROUND

Low back pain (LBP) could be influenced by socio-cultural factors. Pain narratives are important to understand the influence of environment on patients with chronic LBP. There are few studies that have explored the experience of patients with chronic LBP in different socio-cultural environments. The aim of this study was to describe the experience of patients with chronic LBP in Spain and Brazil.

METHODS

A qualitative phenomenology approach was implemented. Chronic LBP patients from the University Hospital of Salamanca (Spain), and/or Federal University of São Carlos (Brazil) were included, using purposeful sampling. Data were collected from 22 Spanish and 26 Brazilian patients during in-depth interviews and using researchers' field notes and patients' personal diaries and letters. A thematic analysis was performed and the guidelines for reporting qualitative research were applied.

RESULTS

Forty-eight patients with a mean age of 50.7 years (SD: ± 13.1 years) were included in the study. The themes identified included: a) ways of perceiving and expressing pain-the participants focused constantly on their pain and anything outside it was considered secondary; b) the socio-familial environment as a modulator of pain-most participants stated that no one was able to understand the pain they were experiencing; c) religion as a modulator of pain-all Brazilian patients stated that religious belief affected the experience of pain; and d) socio-economic and educational status as a modulator of pain-the study reported that economic factors influenced the experience of pain.

CONCLUSIONS

The influences of LBP can be determined based on the how a patient defines pain. Religion can be considered as a possible mechanism for patients to manage pain and as a form of solace.