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Physiotherapists and general practitioners

views of self-referral and physiotherapy
scope of practice: results from a national trial
Lesley K. Holdsworth

, a,

, Valerie S. Webstera, Angus K. McFadyena and The Scottish Physiother

NHS Quality Improvement Scotland, Delta House, 50 West Nile Street, Glasgow G1 2NP, UK

Available online 21 April 2008.

Abstract
Aim
To establish the views of physiotherapists and general practitioners (GPs) on self-referral and
physiotherapy scope of practice.
Design
Survey questionnaire design utilising both qualitative and quantitative questioning.
Setting
Twenty-six general practices throughout Scotland.
Participants
Sixty-four physiotherapists and 97 GPs with direct experience of implementing systems of selfreferral to physiotherapy in primary care in Scotland.
Method
Questionnaires containing a mix of open and closed questions were distributed at the end of a
year-long data collection period of a national trial (20032005). Responses were analysed by
clinician group: GPs and physiotherapists.
Results
An overall response rate of 73% (117/161) was achieved. High levels of comfort with, and
confidence in, physiotherapists acting as first point of contact practitioners were reported by 96%
(67/70) of GPs, and just 6% (3/47) of physiotherapists reported not being comfortable. More than
78% (91/117) of all clinicians indicated that there could be possible and definite benefits for
musculoskeletal patients if physiotherapists were involved in monitoring and prescribing non-

steroidal anti-inflammatory drugs, issuing sickness certificates and requesting X-rays, although
this was more strongly supported by physiotherapists (>88% vs >63%; P < 0.001). Seventy-eight
percent (35/47) of physiotherapist respondents felt that physiotherapists could accept selfreferrals very ably, 47% (21/47) felt that not all physiotherapists were sufficiently experienced,
and 16% (7/47) reported the need for additional training before physiotherapists could undertake
this role. Only 34% (16/47) of physiotherapists felt that the public understood what
physiotherapy is and what it can offer.
Conclusion
The concept of physiotherapists working as first point of contact practitioners is strongly
supported by the majority of GPs and physiotherapists. Potential benefits for patients were
identified if physiotherapists undertook extended roles with regard to other aspects of
musculoskeletal management. There is a need to address both professional and public awareness
of physiotherapy and self-referral specifically.
Keywords: Self referral; Physiotherapy ; GP's physiotherapists views

Are patients who refer themselves to

physiotherapy different from those referred
by GPs? Results of a national trial

Lesley K. Holdsworth

, Valerie S. Webster, Angus K. McFadyen and The Scottish Physiotherapy

NHS Forth Valley, Royal Scottish National Hospital, Old Denny Road, Larbert FK5 4SD, UK
Available online 24 January 2006.

Abstract
Objectives
To establish if there are differences in the profile of patients who refer themselves to
physiotherapy compared with patients referred by or at the suggestion of their general
practitioner (GP) in a range of primary care settings.

Design of study
Quasi-experimental.
Setting
Twenty-nine general practices throughout Scotland.
Participants
Three thousand and ten patients (>16 years of age) and 100 physiotherapists.
Method
Self-referral was introduced in each site. The demographic and clinical data relating to all
referrals collated over a full year were compared by referral group (self-referrals, GP-suggested
referrals and GP referrals).
Results
There was no relationship between gender or age group and referral group, but other differences
in the profile were found. The groups differed in terms of their presenting condition and its
severity (P = 0.027). Greater proportions of patients who referred at the suggestion of their GP
and patients who self-referred presented with low back and neck conditions (54% versus 43%,
P < 0.001). Self-referrers reported having their symptoms for less than 14 days to a greater extent
than the other groups (14% versus 9% and 10%, P = 0.011). Non-preferential treatment waiting
time to physiotherapy also differed, with 44% of patients who self-referred being seen within 2
weeks of referral compared with 36% of patients who referred at the suggestion of their GP
(P < 0.001). Self-referrers were absent from work in lower proportions (20% versus 28% and
28%, P = 0.048) and were absent for half the mean time (2.5 days versus 6 days). They also
completed their treatment in greater proportions (76% versus 69% and 72%, P = 0.002).
Although all groups experienced the same mean number of physiotherapy contacts (n = 4),
patients who referred at the suggestion of their GP had a proportionally lower contact rate with
65% having four or less contacts compared with 55% of patients who self-referred and 51% of
patients referred by their GP (P < 0.001). There was no difference in the outcome determined by
physiotherapists or patients.
Conclusions
Patients who refer to physiotherapy at the suggestion of their GP and patients who self-refer
appear to have a different profile from patients who are referred by their GP.
Keywords: Self-referral; Patient profile; Physiotherapy ; National trial

Article Outline
Background and purpose
Aims
Method
Referral type categories
Diagnosis and presenting severity
Patient employment
Outcome measures
Discharge data
Means of data collection
Statistical analyses
Results
Discussion
Limitations
Conclusions
Acknowledgements
References

Student Perceptions of Cardio-respiratory

Physiotherapy

Carolyn Roskell1, 3,

and Vinette Cross2

Received 18 January 2002;

accepted 30 July 2002.
Available online 11 October 2005.

Background and purpose

Government ambitions for the National Health Service support expansion of roles and skills for
physiotherapists alongside increased capacity of the workforce. Concerns about recruitment and
retention of physiotherapists pose a threat to these ambitions. Cardio-respiratory physiotherapy
is experiencing difficulties with recruitment and retention as well as concerns over competency
of students and new graduates. Supply of enough suitably skilled individuals is required if
service provision within this specialty is to be maintained. This study sought to explore student
perceptions of cardio-respiratory physiotherapy as a specialty in order to establish the
recruitment potential from new graduates. Evidence of this was required to generate a rationale
for further developmental work in the specialty.

Methods
Fifteen final-year students from 22 schools of physiotherapy were selected by course leaders
(N = 330). Each was asked to complete a questionnaire in the form of a descriptive survey.
Results
222 forms were returned (73%). 80% of respondents were positive about the value of cardiorespiratory physiotherapy but only 6% stated an intention to specialise. However, 45% stated
they would consider specialising, which suggested an open-mindedness about career
development. 30% said they felt less competent in cardio-respiratory than other specialties.
Clinical factors influenced students' attitudes the most and these influences were positive.
Universities influenced the least. Students' knowledge of other aspects of the world of work was
low.
Conclusions
Although students valued cardio-respiratory physiotherapy, only a small number intended to
specialise in this area. However, a potential pool existed of those who, if the conditions of work
were favourable, might consider entering the specialty. This justifies further work to advance the
specialty which may lay the foundations for a continuous professional development pathway in
cardio-respiratory skills.
Key Words: Cardio-respiratory physiotherapy ; student perceptions; competence; career
intentions; value of physiotherapy

Article Outline
Introduction
Cardio-respiratory Physiotherapy
Objective of Study
Methodology
Questionnaire
Sampling Procedures
Participants
Analysis
Results
Responses
Discussion
Limitations of the Study
Conclusions
Appendix
References

A cohort study of 7 day a week physiotherapy

on an acute orthopaedic ward

Anne-marie Boxall B.AppSc. ( Physiotherapy) , MPH (Hons.)

, Allyn Sayers and Gideon A. Cap

Post Acute Care Services, Prince of Wales Hospital, Ground Floor, McNevin Dickson Building, Avoca Stre
Editor's comment while this study did not demonstrate dramatic improvement in outcomes by
implementing a weekend and holiday physiotherapy service it did show that attempting to
improve one aspect of care delivery exposes other areas. In this case, it seems that although
patients may have been ready for discharge earlier because of the increased physiotherapy, the
problems of organising their discharge still meant their discharge was delayed.
Available online 14 May 2004.

Abstract
Physiotherapy is vital in managing orthopaedic conditions, but in many public hospitals it is
not routinely provided on weekends and holidays. This cohort study examines the impact of a 7
day a week physiotherapy programme on an acute orthopaedic ward using additional staffing
to supplement weekday services. One hundred and twenty patients with a broad range of
diagnoses were included in each group. For the total patient cohort, no statistically significant
differences were detected between groups for average length of stay (ALOS) or time to achieve
independent transfers and mobility. However, intervention patients with a fractured ankle had a
significantly shorter ALOS (p=0.05) and achieved independent mobility sooner than the control
group (p=0.03). Intervention patients admitted for a total knee replacement achieved independent
transfers significantly sooner that control patients (p=0.04). Clinically significant improvements
were demonstrated in a number of other diagnostic subgroups. A large number of patients in both
groups experienced a delayed discharge for organisational reasons, but the proportion was
significantly higher in the intervention group (p<0.001). This study provides some evidence of
the effectiveness of 7 day a week physiotherapy in reducing average length of stay and
attaining functional goals sooner for certain diagnostic subgroups. With a larger study, benefits
may be demonstrated for a wider range of patients. To maximise the benefits of 7 day a week
physiotherapy, organisational delays to discharge need to be minimised.
Author Keywords: Physiotherapy ; Weekend; Orthopaedic; Length of stay

Satisfaction Trends in Undergraduate

Physiotherapy Education
Walid El Ansari

, 1,

Received 12 April 2002;

accepted 20 August 2002.
Available online 13 October 2005.

Summary
The present study explores the effects of physiotherapy student characteristics on satisfaction
with their learning and teaching and performance in assessment. It examines the influences on
students' performance and contentment of their sex, disability, ethnicity, age, academic level and
term, mode of study and entry qualification. It also investigates the relationship between student
satisfaction and performance in terms of module grades.
Survey data from 300 questionnaires completed by students attending nine physiotherapy
modules and undertaking the BSc in physiotherapy at a British university were analysed. The
research tool was reliable and student satisfaction levels were generally high with most of the
nine physiotherapy modules examined.
The study found no significant differences in performance in relation to disability, ethnicity,
academic term, or full-time and part-time study modes. However, women performed
significantly better than men, and there was a stepwise age gradient in accomplishments, with
older people achieving better grades than younger students. Similarly, level 3 students scored
higher than level 1 participants, and those with a prior degree entry qualification achieved higher
grades than those with A-level or equivalent entries.
For some of the demographic and educational-related parameters under study, there was a
positive and parallel relation between total student satisfaction score and their module grades,
and a similar one between the percentage of satisfied students attending a module and the mean
overall grade achieved in the module. However, these relations were of small magnitude. On the
basis of the findings and their probable explanations, it seems that age, sex and education are
important predictors of achievement, since mature women with a prior degree performed better
than traditionally aged males with A-level entries.
The findings also highlight the importance of undertaking further research on developing and
measuring satisfaction markers, where such indicators could act as advanced radars', alerting
educators to areas and programmes requiring attention.

Key Words: Physiotherapy ; higher; education; student; satisfaction; attributes; demographic;

and; academic; influences

Randomized Comparison of Two

Physiotherapy Regimens for Correcting
Atelectasis in Ventilated Pre-term Neonates

Ivor Wong MPhil, PDPTb,

and Tai Fai Fok MD, FRCP(Edin)a

Neonatal Unit, Department of Paediatrics, Prince of Wales Hospital, Shatin, Hong Kong

Department of Physiotherapy and Department of Paediatrics, Prince of Wales Hospital, Shatin, Hong Ko

Received 11 August 2003;

accepted 30 October 2003.
Available online 13 July 2009.

Abstract
Chest therapy using manual physiotherapy techniques is an integral part of treating atelectasis
in pre-term ventilated neonates. The lung squeezing technique (LST) is used to restore
homogeneous inflation of the lungs by means of small amplitude oscillatory chest wall
compressions. We compared the effectiveness and safety of using LST with the conventional
percussion and vibration (PDPV) protocol for correcting atelectasis in ventilated neonates. Fiftysix pre-term neonates were randomized into an experimental group (n = 26) treated with the lung
squeezing protocol and a control group (n = 30) treated with the conventional percussion and
vibration protocol. The groups were pre-stratified according to the mode of ventilation: high
frequency oscillatory ventilation (HFOV) or conventional mechanical ventilation (CMV).
Results showed that LST was more effective for correcting lung atelectasis in pre-term neonates
than PDPV. After the first therapy session, full lung re-expansion occurred in 81% of the LST
group and in only 23% of the PDPV group (p < 0.001). Subgroup analysis showed the
superiority of LST in both the CMV (p = 0.006) and HFOV subgroups (p = 0.006). There was no
significant difference in haemodynamic disturbances when the LST group was compared to the
PDPV group. LST was more effective than conventional PDPV for re-expansion of lung
atelectases among the ventilated pre-term neonates in our study.

Key words: physiotherapy ; lung squeezing technique; neonate; ventilation; atelectasis

Teaching and learning communication skills in

physiotherapy: What is done and how should
it be done?

Ruth H. Parrya,

and Kay Brownb

Collaboration for Leadership in Applied Health Research and Care, Business School and School of Comm

Rotherham Community Health Centre, NHS Rotherham PCT, Greasbrough Rd, Rotherham, S60 1RY, UK

Available online 29 July 2009.

Abstract
Objectives
To survey practice and opinion regarding school-based teaching of communication skills, to
summarise relevant research evidence from physiotherapy and beyond, to reflect on practice in
light of evidence, and to propose associated recommendations.
Design
Survey using customised questionnaires. Basic descriptive statistical analysis and thematic
content analysis were used. The results were compared with evidence from systematic reviews to
derive recommendations.
Survey participants and setting
Educators in all UK centres delivering physiotherapy qualifying programmes in 2006.
Results
A response rate of 69% was achieved. The majority of respondents reported delivering
communication-specific modules. Lecturing was common, and more experiential methods were
also used. Assessment was mainly by written work. Educators commented on challenges and
strategies involved in student engagement, provision of authentic experiences, availability of

teaching time and expertise, and physiotherapy -specific teaching resources. Evidence from
allied health profession, medical and nursing education research emphasises the importance of
experiential teaching, formative feedback, observational assessment and a substantial evidence
base on which to ground course content. In physiotherapy, the latter is emerging but
incomplete. There are also gaps in direct evidence about advantages or otherwise of stand-alone
modules and benefits of pre-qualification communication training. Evidence suggests that
effective training requires substantial teaching time, expertise and a body of empirical research
on specific communication practices and their effects.
Conclusion
Curriculum designers and educators should endeavour to maximise the degree to which training
in this area is experiential, provide training when students have already had some contact with
patients, and assess students by observation if at all possible. Due to gaps in the evidence, some
important questions about optimal practice remain unanswered.
Keywords: Physiotherapy ; Survey; UK; Communication skills teaching; Communication
skills assessment; Communication skills research

Article Outline

Core Journals of Physiotherapy

Richard W Bohannon1,
Received 3 September 1998;
accepted 6 February 1999.
Available online 20 October 2005.

Summary
This retrospective document analysis was carried out to generate a current list of core journals of
physiotherapy, to compare the list with previously published lists, and to determine how well
the journals of the current list were covered by three major biomedical bibliographic databases.
Through citation analysis 47 core journals of physiotherapy were identified. With notable
exceptions, most of the journals on the current core list were on three previously published lists

of core journals. The majority of core journals on the current list were included in every
database; Embase was most comprehensive in its coverage (95.7%). The list of core journals
provided in this study is a good starting point for obtaining information for evidence-based
practice. Physiotherapists who use databases to find information in the core journals will need to
use either Embase or both Medline and CINAHL if they are to identify most of the relevant
literature.
Author Keywords: Physiotherapy ; citation analysis; evidence-based practice; libraries;
databases

Entwinement of Theory and Practice in

Physiotherapy : A comparative analysis of two
approaches to hemiplegia in physiotherapy

Ant T Lettinga1,

, Petra C Siemonsma2 and Marjan van Veen3

Available online 9 November 2005.

Summary
In physiotherapy in general, and in neurological therapy in particular, there is growing
awareness that the importance of theory and its use in treatment programmes must be made
explicit. The often implicit and poor scientific state of theories underlying their programmes
impedes therapists in making informed choices in their clinical and scientific work. Efforts have
been made to uncover theories that implicitly guide programmes in common use. Some theorists
propose to replace approaches based on out-dated principles in favour of new ones supported by
up-to-date scientific material. Others are less radical and suggest revising them by adding the
latest scientific knowledge. This raises the question as to which strategy is the most appropriate
for developing optimal programme configurations.
For the purpose of this article we have explored the different ways in which scientific principles
find a place in, and give shape to, the content of two approaches in common use for the
rehabilitation of stroke patients: neuro developmental treatment (NDT) and a motor relearning
programme (MRP). This analysis shows that both approaches incorporate principles of neural

plasticity to support the assumption that it makes sense to train integration of the hemiplegic side
in functional tasks. This clinical assumption is further specified into different critical treatable
factors and accompanying techniques with the help of patho-neurophysiological principles in
NDT and muscle physiological and biomechanical principles in MRP. Both tangles of principles
and practices are, in turn, entwined with diverging learning theories and related strategies.
Our analysis illustrates that the relationship between scientific principles and therapy practices is
complex. Therefore the question of whether programme development should be achieved
through the process of substitution or addition of new principles reflects an overly simplistic
evaluation of the influence of theory on practice.
Key Words: Theory; content analysis; neurogical physiotherapy ; neuro development
treatment; motor relearning programme; stroke patients; programme development

Article Outline

Developing a Curriculum Module to Prepare

Students for Community-Based Physiotherapy
Rehabilitation in South Africa

MJ Futter1,
Received 30 October 2001;
accepted 17 October 2002.
Available online 11 October 2005.

Summary
Background and purpose
With the rapid turnover and consequent demand for hospital beds and the inadequate number of
physiotherapists, increasing numbers will need to work in community settings in South Africa in
the future. Education of students at the University of Cape Town was required to move away
from a disease-centred, hospital-based curriculum to a community-based programme in order to
meet the rehabilitation needs of the majority of the disabled population in the country. The aim of
this study was to identify the gaps in the undergraduate curriculum and to make the required

curricular changes to ensure that, on graduation, the students would be competent and confident
to work in community settings.
Methods
A module on community physiotherapy preceded a four-week placement in an historically
disadvantaged community with no access to rehabilitation facilities. Seventy-five students
provided severely disabled persons and their caregivers with rehabilitation and education
programmes in their homes. The students were provided with two sessions of clinical supervision
weekly. At the end of the placement they were examined on their ability to treat patients in a
home environment and were also scored on their block performance over the month. Students
evaluated the placement as a learning experience and the clinical supervisors kept records
throughout the two years on gaps in the content of the community physiotherapy module.
Findings
The majority of students found the placement a valuable learning experience and suggested that
it should be developed into a multi-disciplinary student rotation. The clinical supervisors
identified several topics that were essential to include in the community physiotherapy module
to help the students in moving from a medical model to a bio-psychosocial model in the
management of their clients.
Conclusion
The study achieved its aim of identifying the gaps in the existing undergraduate programme that
needed to be addressed in order to prepare students to be competent and confident to practise in
community settings on graduation. Changes to the curriculum were done incrementally during
the year and also at the beginning of each of two years. These have been in operation for the past
five years.
Key Words: Physiotherapy curriculum; South Africa; developing country; education; delivery
of healthcare

Article Outline

Current Issues of Accountability in

Physiotherapy and Higher Education:
Implications for physiotherapy educators

Jenny Morris1,
Received 20 April 2001;
accepted 10 January 2002.
Available online 11 October 2005.

Summary
Despite the ongoing trend towards professionalisation of occupations, those already regarded as
such have been experiencing widespread scrutiny and criticism. The main area of concern relates
to perceived lack of public accountability which, it is argued, has led to abuse of professional
status, autonomy and power, to the detriment of society.
Professions in the public sector, including physiotherapy and higher education, have
increasingly been required to fulfil often externally imposed accountability requirements. As
members of both professions, physiotherapy educators have two sets of such requirements to
meet. This situation could make the expectations seem daunting and possibly unachievable in
light of educators' high workloads. However, these demands, although challenging, are largely
complementary and physiotherapy educators are in a position to make a valuable contribution
to the development of both professions.
Key Words: Professional accountability; physiotherapy ; higher education; physiotherapy
education

Article Outline

University Education and the Physiotherapy

Professional

Adrienne Hunt1,

, Barbara Adamson2, Joy Higgs and Lynne Harris

Available online 15 October 2005.

Summary
The growth and development of physiotherapy is influenced significantly by the professional
abilities and potential of its new graduates. Physiotherapy graduates need to have skills and
attributes relevant to their day-to-day practice to enable them to be confident and competent.
They also need skills and attributes that will enable them to adapt to changes and develop
professionally.
It could be assumed that physiotherapists are well equipped for their future role, because, as well
as gaining discipline-specific technical competence, as university graduates they are expected to
have generic skills and attributes in such areas as communication, thinking, learning, teamwork,
research, evaluation and problem solving.
However, possession of these generic university-education skills does not, alone, provide a
guarantee of competence in the workplace. The education process must equip graduate
physiotherapists for professional survival in a health care environment in which the funding and
organisation of health care are changing.
This paper examines the need for the profession and its educators to review current teaching in
physiotherapy. It explores curriculum and teaching strategies that could be implemented to
foster required skills and attributes in its newest graduates to ensure that they meet the needs of
the community, thereby facilitating the ongoing development of the profession.

Role of physiotherapy in the treatment of

subacromial impingement syndrome: a
prospective study

Victoria A. Dickens

, James L. Williams and Manjit S. Bhamra

Department of Orthopaedic Surgery, Rotherham General Hospital NHS Trust, Moorgate Road, Rotherham
Available online 3 February 2005.

Abstract
Objective
To investigate the effectiveness of a physiotherapy programme in patients with subacromial
impingement syndrome.
Design
Prospective randomised study.
Setting
Orthopaedic department in a district general hospital.
Participants
Eighty-five patients who had been listed for surgery for subacromial impingement syndrome.
Interventions
Patients were allocated at random into one of two groups. One group containing 45 patients
received physiotherapy while the other group containing 40 patients acted as controls.
Outcome measures
All patients entering the study underwent Constant score evaluation prior to being allocated to a
group. This was repeated at 6 months, prior to surgical intervention.
Results

Seventy-three patients were able to complete the study. In the physiotherapy group, 11 patients
no longer required surgery (26%). In this group, all patients improved their Constant score by a
mean of 20 (range 445). In the control group, all patients required surgery. The mean
improvement in the Constant score for the 31 control patients available for review was 0.65
(range 16 to 14).
Conclusion
All patients in this study improved with physiotherapy. Physiotherapy should be thought of as
a first-line management for patients with subacromial impingement syndrome.
Keywords: Impingement; Physiotherapy ; Subacromial injection

Article Outline
Introduction
Materials and methods
Recruitment
Randomisation
Physiotherapy group
Data analysis
Results
Discussion
References

The value of intermittent cervical traction in

recent cervical radiculopathy

A. Jellada,

, Z. Ben Salaha, S. Boudokhanea, H. Migaoua, I. Bahria and N. Rejebb

Service de mdecine physique et radaptation, CHU F. Bourguiba, 1753 Monastir, Tunisia

Service de mdecine physique et radaptation, CHU Sahloul, Sousse, Tunisia

Received 8 January 2009;

accepted 20 July 2009.
Available online 8 October 2009.

Abstract
Objective
Our objective is to assess the effect of mechanical and manual intermittent cervical traction on
pain, use of analgesics and disability during the recent cervical radiculopathy (CR).
Methods
We made a prospective randomized study including patients sent for rehabilitation between
April 2005 and October 2006. Thirty-nine patients were divided into three groups of 13 patients
each. A group (A) treated by conventional rehabilitation with manual traction, a group (B) treated
with conventional rehabilitation with intermittent mechanical traction and a third group (C)
treated with conventional rehabilitation alone. We evaluated cervical pain, radicular pain,
disability and the use of analgesics at baseline, at the end and at 1, 3 and 6 months after
treatment.
Results
At the end of treatment improving of cervical pain, radicular pain and disability is significantly
better in groups A and B compared to group C. The decrease in consumption of analgesics is
comparable in the three groups. At 6 months improving of cervical and radicular pain and
disability is still significant compared to baseline in both groups A and B. The gain in
consumption of analgesics is significant in the three groups: A, B and C.
Conclusion

Manual or mechanical cervical traction appears to be a major contribution in the rehabilitation

of CR particularly if it is included in a multimodal approach of rehabilitation.