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

© 2021 The Authors. Musculoskeletal Care published by John Wiley & Sons Ltd. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. https://creativecommons.org/licenses/by/4.0/Background: Axial spondyloarthritis (axSpA) is an inflammatory disease associated with significant diagnostic delays and is commonly missed in assessments of persistent back pain. Objective: To explore musculoskeletal physiotherapists' awareness, knowledge and confidence in screening for signs, symptoms and risk factors of suspected axSpA and criteria for rheumatology referral. Design: An online UK survey was undertaken combining back pain vignettes (reflecting axSpA, non-specific back pain and radicular syndrome) and questioning on features of suspected axSpA. Recruitment utilised online professional forums and social media. Data analysis included descriptive statistics and conceptual content analysis for free text responses. Results: 132 survey responses were analysed. Only 67% (88/132) of respondents identified inflammatory pathologies as a possible cause of persistent back pain. Only 60% (79/132) recognised the axSpA vignette compared to non-specific low back pain (94%) and radicular syndrome (80%). Most suspecting axSpA would refer for specialist assessment (77/79; 92%). Awareness of national referral guidance was evident in only 50% of ‘clinical reasoning’ and 20% of ‘further subjective screening’ responses. There was misplaced confidence in recognising clinical features of axSpA (≥7/10) compared to knowledge levels shown, including high importance given to inflammatory markers and human leucocyte antigen B27 (median = 8/10). Conclusions: Musculoskeletal physiotherapists may not be giving adequate consideration to axSpA in back pain assessments. Awareness of national referral guidance was also limited. Professional education on screening and referral for suspected axSpA is needed to make axSpA screening and referral criteria core knowledge in musculoskeletal clinical practice, supporting earlier diagnosis and better outcomes.Peer reviewe

Our pathway to a successful non-medical research strategy – a cultural shift five years on

Background: There is increasing evidence that research-active healthcare provider organisations provide better quality care, increased treatment options and improved clinical outcomes. Purpose: Delivering excellent evidence based clinical care and a high academic profile was identified as a key strategic objective at a tertiary orthopaedic hospital in the UK. This paper outlines the development and early impact of a research strategy for allied health professionals employed at the organisation. Methods: In 2013 the organisation appointed a Director of Therapies and a Consultant physiotherapist with protected time to develop a therapies research strategy. Focus groups were held across the directorate (140 staff including all therapists, orthotists, dieticians across all pay bands and grades including non-professional staff) as part of a 'listening exercise' to identify current levels of research activity, barriers and enablers to developing a research active department. Data were analysed thematically and findings used to inform a five year action plan to implement a research strategy, begin the necessary cultural shift and organisational development. Results: Five key actions were identified: 1) Identifying research programmes/themes in clinical teams. 2) Research as a key pillar in team's objectives 3) Provide appropriate research training and education 4) Identify talent and research champions 5) Develop external collaborations with appropriate academic and commercial partners. In 2014, through a commercial partnership, a grant was successful and a therapies research co-ordinator was appointed to support staff training around research methods and processes. In 2016 an internal 2 year grant received from the hospital charity supported this ongoing role along-side matched funding with a higher education institute to support a senior academic (Researcher in Residence) to provide extensive methodological support, writing skills and grant applications. To date this has resulted in six peer reviewed articles and further funding e.g. digital health technology monies. Novice researchers have been supported resulting in a NIHR PhD fellowship and two NIHR internships making staff feel valued and motivated, act as role models and build capability. Clinical teams have identified research programs to allow greater focus and prioritisation maximising resources and time. There has been greater engagement with patients regarding acceptability and relevance of research ideas. 41% of registered projects with the research and development department were submitted to national/international scientific conferences compared to only 16% in 2014. Conclusion(s): The key to success in implementation of a research strategy in a clinical setting requires clear strategic support and prioritisation, leadership, spotting the talent and investment in training. However dedicated resources and investment is required for delivery of projects to publications gained through external funding and or collaborations with academic institutions e.g. co-supervision of clinically based post graduate research projects. Implications: Research active staff identify relevant projects which impact on patient care and support improvements in healthcare. Policy makers and healthcare leaders should identify and develop a clear research strategy when developing services to ensure high quality healthcare and improved patient outcomes. Key-Words: Research, Strategy, Culture Funding acknowledgements: Royal National Orthopaedic Hospital Charity TSB Grant - Digital Health in a connected hospital competition Ethics approval: Did this work require ethics approval?:No Institution: Not Applicable Ethics Committee: Not Applicable Please state the reasons why ethics approval was not required: Unique development of a quality improvement program and strategy in clinical practicePeer reviewe

Corticosteroid Injections For Frozen Shoulder: A Global Online Survey Of Health Professionals’ Current Practice And Opinion

© 2023 World Physiotherapy.Background: Frozen shoulder is a disabling condition characterised by persistent and severe pain and loss of shoulder movement. Corticosteroid injections are targeted at reducing pain in the earlier painful phase (Ahn et al., 2018; Sun, Liu, Chen, & Chen, 2018). Currently, there are no clear guidelines regarding medicines and dose to inject and if this should be under ultrasound or landmark guidance or if an injection should even be considered. This uncertainty results in a range of methods of injections for frozen shoulder. Purpose: To investigate the current practice and opinion of global healthcare providers on injections for frozen shoulder. Methods: Methods An online questionnaire survey was used to investigate current practice and opinions on injections for frozen shoulder. The survey used JISC https://www.onlinesurveys.ac.uk/ and was disseminated via the social media platform Twitter™. It was available for 5 weeks in spring 2022. Further recruitment involved sharing the link once completed creating a ‘snowball’ effect. Results: The total number of respondents was 235 from 33 different countries across 6 continents of which (n=213, 90.6%) were Physical Therapists/Physiotherapists. Other professions were Orthopaedic Consultant (n=10, 4.3%), Sports and Medicine Doctor (n=4, 1.7%), Osteopath (n=3, 1.3%), Physiatrist (n=2, 0.9%), myotherapist (n=1, 0.4%), Radiologist (n=1, 0.4%), Sonographer (n=1, 0.4%). Most people (n=154, 65.5%) reported seeing between one and two cases of FS a week. Only (n=35, 14.9%) respondents neither injected nor referred for injection. The majority (n =155, 66%) reported injections have an important role in the management of frozen shoulder and 191 (81.3%) reported that corticosteroid injections are best administered only during the pain greater than stiffness phase. The glenohumeral joint (GHJ) was most frequently reported as the site to inject (n=136, 57.9%). Triamcinolone Acetonide (TA) was the most frequently reported (n=66, 28.1%) corticosteroid to inject the GHJ and of these, the most frequently reported dose was 40 mg/ml (n= 52, 78.8%). Doses ranged from 10mg/ml to 40mg/ml. Triamcinolone Acetonide was the most frequently reported (n=44, 18.7%) substance to inject for the subacromial space and of these, the most frequently reported dose was 40mg/ml (n=27, 61.4%). Doses ranged from 10mg/ml to 40mg/ml. Lidocaine was the most frequently reported anaesthetic: GHJ (n= 109, 46.4%). Of those who expressed an opinion (n=96, 40.7%) reported the injection should be performed under ultrasound guidance. Conclusion(s): There was overall consensus for the use of corticosteroid injections in frozen shoulder. However, the wide variety of doses and lack on convincing consensus on method of delivery, mirrors the uncertainty in the literature. In some respects, the delivery of injection therapy is probably based on personal preference or local guidance in the absence of universally agreed guidance. Further research should investigate medicine, dose, and method of delivery of corticosteroid injection. Other treatments such as hydrodistension or suprascapular nerve blocks were reported by respondents, and it would be of value to investigate current practice and opinion for both interventions. Implications: This survey highlights the need for injectors to ensure they are benchmarking their practice against current best evidence whilst acknowledging there are gaps in the literature. Keyword 1: Online survey Keyword 2: Corticosteroid injections Keyword 3: Frozen shoulder Funding acknowledgements: No funding was received for this project. Did this work require ethics approval?: Yes Institution: University of Hertfordshire Ethics committee: University of Hertfordshire ECDA Ethical approval number: Ethical approval was granted by Ref: HSK PRG UH 04693 Has any of this material been/due to be published or presented at another national or international conference prior to the World Physiotherapy Congress 2023?: No Consent: Yes Consent: Ye

Diagnostic Accuracy of Subjective Features and Physical Examination Tests for Morton’s Neuroma: A Systematic Review.

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Management of atraumatic shoulder instability in physiotherapy (MASIP): a survey of physiotherapy practice

© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License.Background: The impact of atraumatic shoulder instability (ASI) on patients can be extensive, its management complex, with a biopsychosocial approach recommended. Currently how physiotherapists manage ASI is unknown or the extent to which current clinical practice aligns with existing evidence. At the time of this study no national guidelines or consensus to direct practice existed.  Methods: A cross-sectional electronic survey was distributed between July-September 2018, targeting UK-based physiotherapists managing shoulder pathology. Respondents were invited to describe their management of ASI, and rate their awareness and utilisation of various treatment techniques on a Likert-scale; median and interquartile ranges were calculated. Free text survey items were analysed using quantitative content analysis (QCA) to identify codes and categories. Means and percentages were calculated to summarise QCA and descriptive data.  Results: Valid survey responses were analysed (n = 135). Respondents had between 2 and 39 years of physiotherapy experience (mean = 13.9 years); the majority (71.1 %) reported that ASI made up 90 % citing the Stanmore Classification. Physiotherapists adapted their management according to clinical presentation, responding to differing biopsychosocial needs of the patient scenario. Most respondents (> 80 %) did not use a protocol to guide their management. Exercise was the most utilised management approach for ASI, followed by education; novel treatment strategies, including cortical rehabilitation, were also reported.  Conclusion: Findings indicate physiotherapists utilise a wide range of treatment strategies and respond to biopsychosocial cues when managing patients with ASI. The majority reported not being very confident in managing this condition, however only a minority use rehabilitation protocols to support their management. Some interventions that respondents reported using lacked evidence to support their use in ASI management and further research regarding effectiveness is required. Guidelines have been published since this survey; the impact of these will need evaluating to determine their effectiveness in the future.Peer reviewedFinal Published versio

Analysing the experiences of undergraduate physiotherapy students transitioning from conventional to e-learning: A phenomenological study

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Exercise Beliefs and Behaviours of Individuals with Joint Hypermobility Syndrome/ Ehlers Danlos Syndrome-Hypermobility Type

This is an Accepted Manuscript of an article published by Taylor & Francis Group in Disability & Rehabilitation on 10 November 2017, available online at: https://doi.org/10.1080/09638288.2017.1398278. © 2017 Informa UK Limited, trading as Taylor & Francis GroupPurpose: To explore exercise beliefs and behaviours of individuals with Joint Hypermobility syndrome/Ehlers–Danlos syndrome – hypermobility type and to explore patient experiences of physiotherapy.Methods: A cross sectional questionnaire survey design was used to collect quantitative and qualitative data from adult members of the Hypermobility Syndromes Association and Ehlers–Danlos Syndrome Support UK. Descriptive and inferential statistics were used to analyse the data. Qualitative data was analysed thematically.Results: 946 questionnaires were returned and analysed. Participants who received exercise advice from a physiotherapist were 1.75 more likely to report high volumes of weekly exercise (odds ratio [OR] = 1.75, 95% confidence interval [CI] = 1.30–2.36, p < 0.001) than those with no advice. Participants who believed that exercise is important for long-term management were 2.76 times more likely to report a high volume of weekly exercise compared to the participants who did not hold this belief (OR = 2.76, 95% CI = 1.38–5.50, p = 0.004). Three themes emerged regarding experience of physiotherapy; physiotherapist as a partner, communication – knowledge, experience and safety.Conclusion: Pain, fatigue and fear are common barriers to exercise. Advice from a physiotherapist and beliefs about the benefits of exercise influenced the reported exercise behaviours of individuals with Ehlers–Danlos syndrome – hypermobility type in this survey.Peer reviewe

Corticosteroid injections for non-spinal musculoskeletal conditions. Consideration of local and systemic adverse drug reactions and side effects

© New Zealand Journal of Physiotherapy. This is an open access article under the Creative Commons Attribution-NonCommercial-NoDerivatives CC BY-NC-ND licence, https://creativecommons.org/licenses/by-nc-nd/4.0/Following specialist training, physiotherapists in some countries, such as the United Kingdom and Norway perform landmark, and ultrasound guided, soft tissue and joint injections for a wide range of musculoskeletal conditions. Whether they inject or not, physiotherapists may wish to recommend injections, and people requiring care commonly seek physiotherapist’s opinions on injection therapy. Globally, there has been a substantial increase in the use of corticosteroid injections to treat musculoskeletal conditions. Those performing injections or providing advice need be cognisant of the possible harms of the procedures and communicate this information sensitively to those considering the procedures. This review synthesises evidence for local and systemic adverse reactions and side effects related to corticosteroid injections in the treatment of non-spinal musculoskeletal conditions. Multiple databases including PubMed, Medline, PEDro, Cinahl were searched, and all levels of evidence were included if they added to the review. Serious adverse events appear to be rare, possibly in part, due to under-reporting of side effects. Where available, suggestions for minimising risk and aftercare have been made. As substantial gaps in the evidence were found, areas for further research are suggested and a decision-making tool is included to facilitate whether to proceed to injection, proceed with precaution or no injection.Peer reviewe

Rare coding variants in PLCG2, ABI3, and TREM2 implicate microglial-mediated innate immunity in Alzheimer's disease

We identified rare coding variants associated with Alzheimer’s disease (AD) in a 3-stage case-control study of 85,133 subjects. In stage 1, 34,174 samples were genotyped using a whole-exome microarray. In stage 2, we tested associated variants (P<1×10-4) in 35,962 independent samples using de novo genotyping and imputed genotypes. In stage 3, an additional 14,997 samples were used to test the most significant stage 2 associations (P<5×10-8) using imputed genotypes. We observed 3 novel genome-wide significant (GWS) AD associated non-synonymous variants; a protective variant in PLCG2 (rs72824905/p.P522R, P=5.38×10-10, OR=0.68, MAFcases=0.0059, MAFcontrols=0.0093), a risk variant in ABI3 (rs616338/p.S209F, P=4.56×10-10, OR=1.43, MAFcases=0.011, MAFcontrols=0.008), and a novel GWS variant in TREM2 (rs143332484/p.R62H, P=1.55×10-14, OR=1.67, MAFcases=0.0143, MAFcontrols=0.0089), a known AD susceptibility gene. These protein-coding changes are in genes highly expressed in microglia and highlight an immune-related protein-protein interaction network enriched for previously identified AD risk genes. These genetic findings provide additional evidence that the microglia-mediated innate immune response contributes directly to AD development

The scope of practice of First Contact Practitioners, and their management of persistent Rotator Cuff Related Shoulder Pain

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