Differences in the Clinical Reasoning Process of Expert and Novice Cardiorespiratory Physiotherapists

Through the process of clinical reasoning, physiotherapy practitioners critically evaluate their interventions in the management of patients. This qualitative investigation focused upon the thought processes of two groups of physiotherapists as they engaged in the consideration of a presented respiratory paper case scenario; identifying problems, possible diagnoses, and finally proposing a treatment plan. One group of 15 physiotherapists were designated ‘expert’ in their practice, whereas the second group of 15 were relatively inexperienced junior physiotherapists. The aim of the study was to investigate the differences in the clinical reasoning process of the novice versus the expert group.After considering the presented paper case scenario, each therapist completed an open questionnaire. A corroborated content thematic analysis of the presenting data was performed. Through this analysis common themes were identified across the data, and differences presenting between novice and expert practitioners were explored.A number of differences in the clinical reasoning process were identified between the novice and expert groups. It is postulated that the mechanisms for storage and retrieval of knowledge are more refined in the expert group. This in turn impacts upon practitioner problem-solving ability and hence clinical judgement. These findings support those of previous studies, which have not, however, included a consideration of the clinical reasoning process in the field of cardiorespiratory physiotherapy.Clinically the results provide information on the different thought processes of novice and expert practitioners in the field of respiratory physiotherapy. This has implications for day-to-day management of physiotherapy staff and for the continuing professional development of practitioners.     

Factors Determining the Current Use of Physiotherapy Assistants: Views on their future role in the South and West UK Region

Physiotherapy assistants form approximately 20% of the work force within physiotherapy departments and account for a large proportion of the delivery of physiotherapy care. There is great interest in developing the scope of practice of physiotherapy assistants and evidence that this is under way. Little is known about the factors determining use of physiotherapy assistants and their views on their future role. The purpose of this study was to investigate how the role of physiotherapy assistants was changing, identify the factors that affect the development of the physiotherapy assistants' role and determine the views of physiotherapy assistants and physiotherapists on the future work of physiotherapy assistants. Semi-structured interviews were carried out with a stratified random sample of 18 physiotherapy assistants from the South and West Region and separately, with their 18 physiotherapy supervisors. The physiotherapy assistants worked in a range of settings – elderly care, paediatrics, outpatients and primary care. Analysis of the interviews showed that there was variation in scope of activities of physiotherapy assistants and in the level of supervision. Supervision was reduced primarily in particular specialty areas, such as elderly and primary care. Changes were primarily locally determined. A change or shortage of qualified staff was regarded as being instrumental in the development of practice. Training, levels of responsibility and supervision, and the development of generic workers were issues of concern for this changing workforce.     

The evidence for and against 'PhysioDirect' telephone assessment and advice services

Patients have experienced inadequate access to physiotherapy since the inception of the National Health Service (NHS). Over the last 50 years, many initiatives have been introduced to address this problem, the most recent being a new patient management pathway known as ‘PhysioDirect’. Within these services, physiotherapists offer initial assessment and advice by telephone, sometimes supported by computerised algorithms, and patients are sent written self-management and exercise advice by post. For some patients, face-to-face physiotherapy care will be offered where this is considered to be more appropriate. Although several such services have been developed across the UK, there is no robust evidence about clinical and cost-effectiveness, nor the acceptability of PhysioDirect to patients, physiotherapists or primary care organisations.This debate article summarises models of PhysioDirect, the links to other healthcare developments and relevant evidence to date about this type of service. By providing a summary of the arguments for, and key concerns about, PhysioDirect, this article stresses the need for more definitive evidence from high-quality randomised controlled trials before widespread roll-out across the NHS.     

Profession and Professionalisation: Part 1: Role and identity of undergraduate physiotherapy educators

The first part of this paper addresses the issues of profession and professionalisation which affect educators in physiotherapy undergraduate studies. It introduces ‘profession’ and ‘professionalisation’ in isolation, although it is not the intention to simplify discussion, but instead to explore the concepts as they stand from a wider perspective before applying them to physiotherapy education. This is followed by a consideration of the complex issues of physiotherapy itself as an aspiring profession, based upon the elements of a profession previously identified, before introducing the role of physiotherapy education and research within the professionalisation process. Part 2 continues this theme by offering a critical analysis of the overlap between education, research and professional status.The second and concluding part of this article continues the theme of professionalisation within physiotherapy, yet more specifically addresses the issues of professionalisation within academia. It provocatively considers physiotherapy academic educators themselves as jugglers of two values – the producers of future professionals and the aspirational creators of a profession. This theme is then expanded by an analysis of the demands placed upon physiotherapy educators, from the perspective both of promoting the profession, and of identifying physiotherapy educators' values. A summary of the discussion follows, outlining emerging points for future development.This paper finally proposes how physiotherapy educators need to revisit the values that underpin their role, and how the professionalisation of future physiotherapists depends upon both a sound understanding and respect of educational philosophy and educational research. The creation and support of a ‘profession’ of physiotherapy educators is offered as a medium through which they can reflect upon and evaluate their own practice within the discipline of education.     

Views of general practitioners toward physiotherapy management of osteoarthritis—a qualitative study

ABSTRACT

Background: Osteoarthritis (OA) is a major cause of pain and physical disability, and general practitioners (GPs) are usually the first point of contact for patients. Physiotherapy has been shown as effective in the management of lower-limb OA. The aim was to explore the beliefs of GPs on the physiotherapy management of lower-limb OA in primary care. Methods: This is a qualitative study evaluating GP views about physiotherapy in Sheffield, South Yorkshire, UK. Participating GPs were recruited by systematic sampling, and invitation was given to GPs in 10 practices in the four localities in Sheffield. Semistructured interviews were completed and framework analysis was used to analyze the data. Results: Eight GPs were interviewed and six themes emerged from analysis of the data: perspective on OA, management strategy, views on patients, views on physiotherapy, working collaboratively, and suggestions for service improvements. GPs had a positive impression and knowledge of physiotherapy, but lacked understanding of the processes involved in treatment and limited awareness of clinical guidelines regarding the management of OA. Improvements in communication and collaborative working were critical issues suggested by the participants. Conclusion: This study found that GPs who were interviewed had a limited understanding on the role of physiotherapists and of clinical guidelines. Interprofessional communication was not as good as it should have been. A reconfiguration of the Sheffield musculoskeletal pathway may help achieve more effective collaborative working and a better outcome for patients.     

Physiotherapy management of low back pain in India — a survey of self‐reported practice

Background. Physiotherapy is commonly used in the management of low back pain and from previous studies appears to be eclectic and not always in line with evidence‐based practice. Most previous studies have been conducted in Western countries, and no previous studies have sought to explore physiotherapy management of low back pain in India. Purpose. The aim of this study was to explore the self‐reported management strategies employed by physiotherapists in India as it is unknown if these are in line with contemporary guidelines. Methods. Study design was a self‐completed questionnaire, which was sent to the 350 physiotherapists registered with the Indian Physiotherapy Association in the state of Maharashtra in India. To maximize response rate there was repeat e‐mailing and telephone follow‐up. Results. Thirty‐eight therapists did not treat patients with back pain and 45 were not working in India and so were excluded. Out of a sample frame of 267 physiotherapists, 186 responded to the e‐mailed questionnaire (70%). All therapists reported that they gave some kind of advice to patients, used exercises and electrotherapy, and in addition about half used manual therapy. The majority of therapists used 8–12 sessions of treatment. Conclusions. This first mapping of Indian physiotherapy management of low back pain has shown several areas of ‘good practice’ in line with contemporary guidelines. It also highlighted potential areas of concern regarding evidence‐based practice; namely, very common use of passive electrotherapy modalities and potential excessive treatment. This report has implications for physiotherapy practice and education in India. Copyright © 2010 John Wiley & Sons, Ltd.     

Re-imagining the role of the physiotherapist when managing people with long-term conditions

ABSTRACT

The rising prevalence of long-term conditions (LTCs) is placing increasing pressures on healthcare systems. With the future prospect that more individuals will experience multiple comorbidities, LTCs are becoming a growing concern. This article aims to discuss the challenges faced by and the opportunities afforded to physiotherapists when caring for people with LTCs. It highlights the complexity of managing people with LTCs and the demands faced by physiotherapists when working within a transitioning healthcare service that necessitates cost-effective yet, sustainable care. It considers ways that interventions can be optimized to not only support individuals with LTCs to improve their quality of life, but live an existence that has meaning and purpose. It also explores health promotion strategies that could be influential in changing the future healthcare landscape, by helping to prevent the occurrence of LTCs. The wider intention is to facilitate discussion of the future role of the physiotherapy profession in LTC management, in the hope that a shared vision can be created that is inspiring and transformative. A vision that imagines a physiotherapy service that is resilient to change and contemporary in approach, which continues to evolve to support the changing needs of people with LTCs.     

Managing deteriorating patients with a physiotherapy critical care outreach service: A mixed-methods study

BackgroundCritical care outreach teams support ward staff to manage patients who are seriously ill or after discharge from the intensive care unit (ICU). Respiratory deterioration is a common reason for (re)admission to the ICU. Physiotherapists are health professionals with skills to address acute respiratory concerns. Experienced respiratory physiotherapists play a role in supporting junior clinicians, particularly in managing deteriorating patients on the ward.ObjectivesThe objective of this study was to evaluate a novel respiratory physiotherapy critical care outreach–style service. The primary objective was to describe service referrals and the patient cohort. Other objectives were to compare the effects of this model of care on ICU readmission rates to a historical cohort and explore clinician perceptions of the model of care and its implementation.MethodsA new physiotherapy model of care worked alongside an existing nurse-led outreach service to support physiotherapists with the identification and management of patients at risk of respiratory deterioration or ICU (re)admission. Purpose-built and pre-existing databases were used for prospective data collection and for a historical ICU readmissions control group. Questionnaires and semistructured group interviews were utilised to evaluate clinician satisfaction and perceptions.ResultsThe service accepted referrals for 274 patients in 6 months (on average 2.25/working day; commonly after trauma [29%] and abdominal surgery [19%]). During the implementation period of the model of care, fewer preventable respiratory ICU readmissions were reported (n = 1/20) than in the historical cohort (n = 6/19: Fisher's exact test, p < 0.05). Likelihood of respiratory ICU readmission, compared to all-cause readmissions, was not affected (intervention: 31%, historical control: 41%; odds ratio: 0.63 [95% confidence interval: 0.29 to 1.4]). Postimplementation surveys and focus groups revealed clinicians highly valued the support and perceived a positive impact on patient care.ConclusionsCritical care outreach–style physiotherapy services can be successfully implemented and are positively perceived by clinicians, but any effect on ICU readmissions is unclear.     

Outcome Measurement in Physiotherapy Using the World Health Organisation's Classification of Impairment, Disability and Handicap: A Pilot Study

An approach to measuring outcome which captured the broad nature of therapeutic effort by categorising the aims of speech and language therapy, using the classification of ‘impairment, disability, handicap and distress’ was described in Health Trends (Enderby, 1992).This method has been adapted for use by physiotherapists and a pilot study has been conducted showing that the results can reflect the different natures of impact of physiotherapy on different client groups.     

Weight stigmatisation in physiotherapy: a systematic review

Background: Physiotherapists play an integral role in the provision of health care to individuals who are overweight or obese. An understanding of weight stigma is therefore important in ensuring best practice. Despite these considerations, no previous systematic reviews have investigated weight stigma in physiotherapy.

Objectives: To determine if (i) physiotherapists demonstrate weight stigma through explicit or implicit means and (ii) how weight stigma is perceived by physiotherapy patients.

Methods: Database searches were conducted to identify quantitative and qualitative studies published between January 1960 and September 2015. Two reviewers independently performed data extraction and assessments of methodological quality. Outcome measures included explicit attitudes, implicit attitudes and beliefs about obesity held by physiotherapists, as well as patient perceptions of obesity management.

Results: Seven high-quality studies were included in the review. Six studies demonstrated the existence of explicit weight stigma, with a majority of physiotherapists describing people with increased weight as ‘noncompliant’ and ‘unmotivated’. One study demonstrated the existence of implicit weight stigma, but this did not appear to influence treatment approaches. Four studies found stigmatising beliefs about weight among physiotherapists, and one study found that physiotherapy patients believed both physical environments and paternalistic communication styles propagated weight stigmatisation.

Conclusions: Explicit weight stigmatisation is common in physiotherapy and is often perceived by patients, who may feel unmotivated or ignored as a result. While implicit stigmatisation also occurs, it is unclear if this influences physiotherapy management. Future research is required to assist in the development of appropriate preventative strategies.     

Comparing rehabilitation outcomes for patients admitted to the intensive care unit with COVID-19 requiring mechanical ventilation during the first two waves of the pandemic: A service evaluation

ObjectivesTo compare rehabilitation outcomes of patients admitted to the intensive care unit with COVID-19 and mechanically ventilated during wave 1 and 2, receiving two different models of physiotherapy delivery.MethodsAdults admitted to the intensive care unit between October–March 2021 (wave 2) with a confirmed diagnosis of COVID-19 and mechanically ventilated for >24 hours were included. During wave 2, rehabilitation was provided by physiotherapists over five days, with only emergency respiratory physiotherapy delivered at weekends. Rehabilitation status was measured daily using the Manchester Mobility Score to identify time taken to first mobilise and highest level of mobility achieved at ICU discharge. Outcomes were compared to data previously published from the same ICU during ‘wave 1’ (March–April 2020) when a seven-day rehabilitation physiotherapy service was provided.ResultsA total of n = 291 patients were included in analysis; 110 from wave 1, and 181 from wave 2. Patient characteristics and medical management were similar between waves. Mean ± SD time to first mobilise was slower in wave 2 (15 ± 11 days vs 14 ± 7 days), with overall mobility scores lower at both ICU (MMS 5 (Step transferring) vs MMS 4 (standing practice) (4), p < 0.05) and hospital (MMS 7 (Mobile > 30 m MMS) vs MMS 6 (Mobile < 30 m MMS), p < 0.0001) discharge. Significantly more patients in wave 2 required ongoing rehabilitation either at home or as an inpatient compared to wave 1 (81 % vs 49 %, p = 0.003).ConclusionThe change in physiotherapy staff provision from a seven-day rehabilitation service during wave 1 to a five day rehabilitation service with emergency respiratory physio only at weekends in wave 2 was associated with delayed time to first mobilise, lower levels of mobility at both intensive care unit and hospital discharge and higher requirement for ongoing rehabilitation at the point of hospital discharge.     

Executive dysfunction post-stroke: an insight into the perspectives of physiotherapists

Abstract

Purpose: To gain an understanding of physiotherapy practice in relation to executive dysfunction (ED) post-stroke. Method: Three focus groups were conducted using semi-structured interview schedules to highlight how ED post-stroke was understood by 12 physiotherapists with greater than 1 year of experience working in the area of stroke care. The focus group data were analysed using qualitative data analysis. Results: The themes extracted from the data on physiotherapists’ self-reported knowledge of ED post-stroke were: physiotherapists’ lack of knowledge of ED post-stroke; current physiotherapy practice regarding ED post-stroke; the negative impact of ED on physiotherapy rehabilitation post-stroke and the future learning needs of physiotherapists regarding ED post-stroke. Conclusions: Current results demonstrate that ED has negative implications for physiotherapy rehabilitation post-stroke. Although further interdisciplinary research is warranted, the present results suggest that physiotherapists should be aware of the presence of ED in people post-stroke and develop strategies to minimise the impact of ED on physiotherapy rehabilitation.

• Implications for Rehabilitation

• Physiotherapists report a lack of knowledge of ED post-stroke and a requirement for future learning and training regarding the optimal management of people with ED undergoing physiotherapy rehabilitation post-stroke.

• ED has negative implications for physiotherapy rehabilitation post-stroke and physiotherapists should be aware of the presence of ED in people post-stroke and develop strategies to minimise the impact of ED on physiotherapy rehabilitation.

     

Professional roles in physiotherapy practice: Educating for self-management,relational matching,and coaching for everyday life

The patient’s active participation in treatment and rehabilitation represents a cultural change in clinical practice as well as a major change in physiotherapist and patient roles. This article presents findings from a study aimed at gaining a better understanding of how physiotherapists in actual practice understand their interactions with patients during the treatment process. This article reports on the findings from focus-group interviews with physiotherapists working in three different settings. Analyses of the interview data identified three modes of physiotherapy practice. In one, physiotherapists educate their patients to be self-managing in conducting exercise programs based on sound evidence. Educational films available on the Internet are included in these efforts to teach patients. In another, physiotherapists emphasize the importance of a close relationship to the patient. A good personal chemistry is believed to improve the treatment process. And finally, what physiotherapists learn about the living conditions and the biographies of their patients was shown to be very important. Understanding the importance of the life-world and taking this into consideration in the treatment process were factors considered to be central to good practice. The article concludes with a discussion linking these findings to those of other studies identifying those factors contributing to our knowledge of what is involved in biopsychosocial practice in physiotherapy.     

An overview of podiatric biomechanics theory and its relation to selected gait dysfunction

This paper introduces the ‘foot function’ approach used by podiatrists in the treatment of lower limb musculoskeletal dysfunction. The aim is to demonstrate how podiatric theory has evolved its own perspective of mechanisms relating to normal and abnormal locomotion. Three individual podiatric paradigms are discussed, and a further theory allowing a working simplification of theory is introduced. Finally, an example of gait abnormality is discussed in relation to podiatric and physiotherapy perspectives.An insight into podiatric theory should enable therapists working within this field to develop a more holistic and multidisciplinary approach. It is the view of the authors that a closer working relationship between physiotherapists and podiatrists with an interest in movement dysfunction provides a better quality service for appropriate patients.     

An investigation into the alignment of a South African physiotherapy curriculum and the expectations of the healthcare system

Until 1994, physiotherapy education and training were aligned with the expectations of the South African healthcare system. Subsequent to policy shifts since 1994, the professional role of physiotherapists has expanded. In the absence of guiding strategies to support this change, physiotherapy curricula have remained relatively static.

Objective

The paper examines the discrepancies between physiotherapy education and training at a South African university post apartheid and the expectations of the healthcare system.

Design

Located within critical feminist research framings and employing narrative inquiry as the selected methodology, data were produced through multiple methods to obtain multiple perspectives and orientations.

Participants

This multisectorial data production approach involving student physiotherapists, physiotherapy academics and practising physiotherapists included in-depth focus group interviews, individual interviews, life-history biographies and open-ended questionnaires. The data were analysed separately for each group of research participants (physiotherapy students, practitioners and academics), followed by a cross-sector analysis.

Results

The analysis illustrated current disciplinary trends and shortcomings of the physiotherapy undergraduate curriculum, whilst highlighting that which is considered valuable and progressive in physiotherapy and health care. The dominant themes that emerged included issues relating to physiotherapy theory and practice, and issues that influenced the construction of relationships in the curriculum.

Conclusion

The significance of this study lies in the value of student and practitioner feedback to inform curriculum and professional development in the light of sociopolitical changes and healthcare expectations.     

Animal physiotherapy

Animal physiotherapy is a field of growth in the UK due to factors including increasing client (owner) awareness and demand. Advances in veterinary diagnostic and treatment technology have lead to increasingly sophisticated and integrated veterinary management of both companion and performance animals, and overall increases in animal longevity.Using human physiotherapy techniques to manage similar problems in veterinary patients is not a new phenomenon however. Animal physiotherapy can trace its origins back to at least the early 20th century in the UK. Specific legislation citing the application of ‘Physiotherapy’ in veterinary medicine first appeared over 40 years ago (Veterinary Surgeons Exemptions Order, 1962). The Association of Chartered Physiotherapists in Animal Therapy (ACPAT) was founded as special interest group of the Chartered Society of Physiotherapists (CSP) in 1985, and has a growing membership (to date has over 150 fully qualified Category A members in the UK).In 2000, the first intake of students where enrolled on the M.Sc./Post-Graduate Diploma in Veterinary Physiotherapy at the Royal Veterinary College, London. This program of part time study was developed to provide chartered physiotherapists with the ability to apply their professional knowledge, experience and practical therapy skills to the treatment of animal patients. M.Sc. students are required to complete an original research project, contributing to the development of a much-needed scientific evidence base for veterinary physiotherapy.This article aims to provide an overview of the treatment of animals with physiotherapy from the perspective of an ACPAT physiotherapist. Some understanding of human manual therapy principles and nomenclature is assumed.