Jonathan

There’s an Alphabet Soup of Physiotherapy Practitioners now.

Physiotherapy has been changing fast in the last ten years. Opportunities for career progression have dramatically increased as the pressures on GPs, secondary services and budgets have grown.

Managers have realised that physiotherapists can do a great number of jobs which were previously the realm of a doctor, can do them just as well and at less cost. No longer do you have to choose a management route to get to the higher levels of the profession, there are many routes now.

This has led to a variety of approaches across the UK as new ideas are attempted, and along with that an explosion in new titles with their very own acronyms.

Extended Scope Physiotherapist – ESP

This title is the first advanced role which was developed in physiotherapy. When it was first proposed that physiotherapists take on roles normally reserved for doctors, such roles were “outside the scope of physiotherapy”.

Once these roles were developed, they were called Extended Scope Physiotherapists or ESPs.

I remember a practitioner in the hip clinics in Exeter in 1989 who was one of the first in the country, reviewing hip replacement patients at six weeks, recording their ranges and checking the X-rays.

ESPs initially worked in spinal and orthopaedic clinics, alongside consultants and registrars. They could order investigations and some could list patients for surgery.

What distinguishes ESPs is that they are mostly diagnostic replacements for doctors, and don’t “do” physiotherapy in the traditional sense. They perform a triage role and refer for physiotherapy if required.

The Alphabet Soup

Since then many new roles have been developed, affecting not just physiotherapy but occupational therapy, nursing, pharmacists and other professions. This has led to a slew of new titles just in physio – orthopaedic practitioner (OP), surgical practitioner (SP), specialist musculoskeletal practitioner (SMP), advanced practice physiotherapist (APP), clinical specialist physiotherapist (CSP), first contact physiotherapist (FCP).

So, with this confusing mass of names and initials, I thought it would be worthwhile discussing some of the recent ideas in physiotherapy roles and the opportunities they afford.

Advanced Practice Physiotherapist – APP

This is now the main name for advanced practitioners, superseding extended scope practitioners as a title. APPs can work in any area, including the Emergency Department, and can diagnose, investigate, inject and refer in many cases.

APPs can incline towards the diagnosis and triage roles (the old ESP role) or towards more of a treatment role where they assess and treat patients with the arsenal of physiotherapy modalities. They also have a significant consulting and teaching role for physiotherapy staff and others, including doctors and nurses.

First Contact Physiotherapists – FCPs

Medicine and allied professions are just as prone to fashion as any other part of human life, and the fashion for FCPs is in full swing at the moment. MSK conditions make up between 15-30% of a GP’s practice, constitute a significant burden and are the realm of expertise of a physiotherapist.

The FCP could see many of these patients instead of the doctor. Evidence shows that patients are happy with this and physiotherapists can safely manage these patients. FCPs work in GP practices, seeing patients with musculoskeletal problems, the vast majority of whom do not have a significant medical diagnosis.

Clinical Specialist Physiotherapist – CSP

CSPs are advanced “traditional” physiotherapists, with specialist skills in examination, diagnosis and treatment. They may also inject and prescribe.

The role of the CSPs, apart from treating patients with advanced skills, is also to promote best practice, support physiotherapy teams, teach and mentor more junior therapists and write and review treatment pathways and patient information.

Physiotherapy’s New World

Physiotherapists have developed several routes to increase their skills and responsibilities over the last ten years. This has included prescribing, injecting and diagnosing in orthopaedic clinics.

By a process of profession creep, physios have been chipping away at the “lower levels” of the doctors’ roles, taking on more responsibility and becoming the independent clinicians we have legally been for some years.

This provides a great opportunity for up-and-coming physiotherapists to make a strong impact in their local medical communities by becoming experts in a particular role or clinical area. This should also free up doctors’ time to make the more complex, judgement-based medical decisions that only they can make.

This process is likely to continue as capacity and cost pressures continue to rise. So if you want a career which takes you into the expert clinical realm, then physiotherapy is now a better option than ever.

Change is Occurring at the Top and at the Bottom of our Professions

The Coming Healthcare Revolution

Healthcare is changing. The technological and information revolution which has blown through retailing, taxis, hotels and music is now blowing through healthcare. Demand is always quoted as the driver for these changes, but there are other drivers which may be more important.

Medicine is at the top of our particular pyramid. They diagnose and treat us and have the ultimate responsibility for our health. As science and technology progress, they can do more and more and their specialities become narrower.

Now the medical profession has a problem. By constantly acquiring new skills and techniques at the top end of their abilities, their field is continually widening and filling up with new treatments. Profession creep for the doctors means more complexity and the cutting edge.

They can treat conditions that were previously not treatable or can treat them better with new techniques. The pool of potential patients increases and looks like it will continue to do so. This process shows no sign of stopping or slowing and will likely accelerate with our ageing populations.

Medicine has dealt with this with varying success. As there is nothing “above” the medical profession it’s interesting to note what’s happening “below” medicine. Doctors are being forced to give up some of their functions to continue on their path.

Demand means that they can’t hold on to everything they have been doing. The stresses on the system have steadily increased as patients complain they can’t get to see their doctor and waiting lists rise. And that’s not considering the stress, burn out and early retirement of many doctors, a result of impossible demands.

At medicine’s cutting edge, technology and research move inexorably forward, forcing increased specialisation. Something has to give.

Profession Creep – Advancing the Profession

Nurses and physiotherapists are taking over the lower levels of doctors’ roles. Advanced practitioners exist in many medical areas and carry out procedures that doctors would normally do, such as inserting a central line or running a spinal clinic. This process is now in full swing and will continue to accelerate.

The Rise of Physiotherapy

The greatest profession creep in physiotherapy is occurring in the musculoskeletal (MSK) field. GPs have a huge and varied caseload, and MSK diagnosis and treatment is not generally one of their fortes. 15 to 30% of the patients they see have an MSK problem and as spending on this group of patients continues to rise, results are not keeping pace.

Physiotherapists, already skilled in assessing, handling and managing MSK patients, are the natural group to take over this workload. Many have taken post-graduate qualifications and become highly-skilled diagnostic clinicians in this field.

NHS managers have realised that they can provide safe and less costly services by having non-medical personnel trained to do specific jobs. Whether this work is effective is a subject for another post, but it is likely no less effective than when performed by doctors.

Physiotherapists are now diagnosing, requesting imaging, listing for surgery, prescribing and giving injections. They are moving into the screening and treating roles for the large number of conditions which are more routine and don’t demand advanced medical judgement.

What happens to other Professions….

Profession creep is not just happening to the doctors, it’s also happening to physiotherapy. Non-physiotherapists are routinely employed (Band 3 or 4 in NHS lingo) to do the jobs that don’t demand skilled assessment or handling by a qualified therapist.

The NHS now employs large numbers of trained and skilled people who can do the more routine work of physiotherapy, such as mobilising patients after operation or injury. This leaves the physiotherapist free to assess and treat more complex cases.

These challenges will increase, particularly for medicine. The rise of machine learning and eventually AI will heavily encroach first on the interpretation of imaging and then on diagnosis. Physiotherapy, with its emphasis on direct handling of people, is more insulated from being replaced by an algorithm.

What does an MRI Scan Say about Future Back Pain?

If the MRI scan findings are important in low back pain, we could expect them to predict how our back pain is going to be in the future. That doesn’t seem to be the case.

The Study

A group of people were given MRI scans and then followed up 10 years later.

This showed the findings on MRI scans (disc bulges, high intensity zones, modic changes and spondylolisthesis – all presumed indicators of back pain) did not predict the back pain the patients had in the following ten years.

The frequency of disc degeneration increased from 50% to 85% across the ten years, which was expected. And 77% of people who had no back pain during that time also showed disc degeneration. Similar results were found for the high intensity zones, disc bulges and modic changes.

Overall, the back pain over the following ten years was not predictable by looking at the initial MRI scans. And many people had “abnormalities” on their MRI scans but had no back pain.

This questions the idea that MRI scanning gives us objective information about our backs. And that the results mean anything for our future pain or disability. And that “abnormalities” condemn us to suffer back pain or neck pain in the future. They don’t seem to.

Many of the findings seem to be incidental, perhaps indicators of how long we have been alive, rather than a pain-producing pathology.

This also makes it hard to connect MRI scan results with a person’s back pain. If disc bulges and all the other changes are present in people without back pain and don’t mean anything for future back pain, how can we be reasonably certain they are relevant?

And even if the changes are relevant to the pain, how will they alter the treatment? If they don’t change the treatment, this may be an example of spurious diagnostic accuracy, an accurate diagnosis that means little.

Reference

Tonusu, J., et al. (2017). The associations between magnetic resonance imaging findings and low back pain: A 10-year longitudinal analysis. PLoS ONE 12(11): e0188057. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0188057

Can We Rely on the Interpretation of MRI Scans?

MRI scanners are a wonderful invention and continue to advance, giving us finer and finer pictures of our anatomy. As is typical with all fast-improving technology, the human aspects, the culture, struggle to keep up.

An MRI scan means nothing without an interpreter. It’s a language most of us don’t speak. Ordering a scan presupposes that there is someone to say what it shows and crucially, what it means for the patient. Someone has to put the patient’s story, the examination and the scan together and form a conclusion about what the next step is.

The developments in machine learning mean that reading x-rays and MRI scans will soon be done by machines. The consistency of analysis this promises will still not be enough if there is no one to sit down with the patient and discuss the results.

But this post is about the consistency of analysis of MRI scans. The ‘someone’ in these cases is a radiologist. Radiologists are highly trained doctors who specialise in imaging and in various types of interventions where imaging is used.

Since radiologists are human we should expect variation in the way MRI scans are interpreted. But how much?

The Study

A 63-year old woman with a history of low back pain and right leg pain in a particular pattern was sent to 10 different imaging centres and given MRI scans for her problem. The centres were unaware that she was being scanned anywhere else.

The researchers looked at what the radiologists reported each time for the same scans and the results were very illuminating.

In the 10 reports they found 49 distinct findings reported for the scan (disc protrusion, facet joint arthritis etc). 16 of those findings only occurred once across the ten scans, in other words the other nine radiologists did not report that finding. None of the 49 findings occurred in every scan report, making us wonder about the validity of the findings.

Highly skilled and highly trained radiologists were doing the best job they could in reporting on these scans. But the results were so variable and inconsistent that it calls the process into question. How can we make important decisions about a patient’s medical intervention if the scan finding are unreliable?

The scan looks so solid, on the screen in black and grey and white. It’s hard to accept that we might all see very different things and come to very different conclusions about what to do next for a person in pain.

And that’s without even considering the matter of what the scan results mean for our future, should they be valid in the first place. That’s next.

Reference

Herzog, R., et al. (2017) Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. The Spine Journal, 17(4), 554-561.

The New Magic Lantern

The magic lantern, an early type of image projector, was developed in the 1600s and used through the 1700s to the mid-20^th century when it was replaced by the slide projector.

The horror theatre genre “phantasmagoria” used magic lanterns to project demons, ghosts and skeletons onto walls as part of their shows. An obsession with the bizarre and the supernatural characterised the romanticism of the latter decades of the 18^th century, including the popularity of the gothic novel.

The new romanticism of the 21^st century surrounds technology and its controlling sister, the computer algorithm. Exchanging the supernatural for the super-technological, we watch magic images play on screens in our homes and in our hands.

The demons we project on our screens are no longer figments of a fearful imagination but images of ourselves cut into slices. We have digitised our layers and seen what we are made of in black and white.

The MRI scanner is the new magic lantern, providing vivid and detailed pictures of what it is to be us. And we take it all at screen value, it’s there in way over fifty shades of grey so why shouldn’t we?

The MRI scanner is amazingly useful in a large number of ailments, allowing doctors to diagnose serious conditions, but when it comes to musculoskeletal problems it’s just not so reliable. And in back pain and neck pain, it can be downright misleading.