Dr A. A. Aluko
With over 35 years clinical experience as a Chartered Physiotherapist, I remain baffled at the perception of what Physiotherapy is as a profession and the misunderstanding of the various specialisms that exist within it. There appears to be a distinct unawareness of an understanding of how we think, what underpins our different choices of intervention and our varying scope of practice as clinical practitioners. This is no truer when it specifically concerns Musculoskeletal (MSK) Physiotherapy and its scope. In the United Kingdom our training ensures that we have experience in all areas of medicine and healthcare, however, we begin to identify to areas of interest to hone our skills. This is usually after a period of 4-5 years. MSK Physiotherapy is just one part of the various specialisms that includes the likes of Paediatrics, Neurology and Orthopaedics to name but a few. There is an overlap between Orthopaedics and MSK Physiotherapy, but the distinctive difference is that the former mainly involves for example inpatient stay and post-operative recovery.
An understanding of the various scope of practice can be beneficial for instructing solicitors as it can save the time spent in the initial exploratory contact with a potential instruction to an MSK Specialist for assistance or an opinion only for it to be declined on the basis that it lies outside their remit and scope of expertise. It must be said that although any Chartered Physiotherapist should be able to offer an opinion, but I doubt that the Physiotherapist will be able to offer a robust report capable of withstanding intense scrutiny and put the case on shaky foundations even before it goes before the court. I suggest that a few minutes taking time to understand the Specialism of the proposed Expert is worth its weight in gold.
As an MSK Specialist I will confine myself to this area of expertise and hope that I can make our scope and methods clearer. The success of MSK Physiotherapy is dependent on a foundation of an ability to extract relevant information from clients and be able to decipher it to create a credible narrative to explain the symptoms reported. During my teaching career I used to equate this process to that used by a detective searching for clues when trying to solve a crime. The credibility of this process ensures that there is a clear plausible causal relationship between symptoms described by the client and the physical dysfunction, or abnormality identified from an appropriate physical clinical examination. I have lost count of the times I have been at a function and on discovering what I do for a living someone will ask ‘’I have a pain in the shoulder, I don’t think I did anything, and I go to the gym regularly to keep fit. What do you think it is?’’ I usually counter with a question, ‘’Does a mechanic know what is wrong with your car just because you hear a noise coming from the engine?’’. I no longer confess to what I do for a living when I am away from work.
During the investigative stage a story is being told within which lies the answers to all questions, such as cause, mechanism of onset and possible methods of intervention to clear the reported symptoms. Symptoms don’t lie and there is always a causal relationship with an event. The event can either be a response to an underlying pathology or an activity that creates trauma. However, the client may misrepresent the symptoms and events and it will be up to the clinician to make sense of it all with the understanding that there will, in most cases be differential diagnoses which must be acknowledged and accounted for. This is usually done by using ‘special tests’. These are scientifically proven and robust enough to support a working hypothesis for a chosen intervention and which if checked afterwards can demonstrate the effectiveness of that intervention. It is this phase of inquiry that can make or break successful intervention. The thoughts of the clinician can be understood through the clinical reasoning process employed and should be visible to a peer within the clinic notes. If a client is economical with information, deliberate or otherwise, there is a risk of inadvertent breach of duty implying that the clinician failed to spot inconsistencies and did not seek clarification or explore differential diagnoses. It is not unreasonable to expect that it is a requirement of good practice to provide a clinical reasoning trail to show that all attempts are made to maintain the principles of beneficence and maleficence and to be prepared to be made accountable for the decision-making process. It is probably arguable to say that the more experienced the clinician is better intervention outcomes are possible, I say that it is the ability to ‘hear what a client says’, ‘see what is going wrong ’and identify a causal relationship that trumps all; this is embedded within experience.
A typical characteristic of clients is an inability to precisely remember the chronology of events involving the injury or problem. This characteristic has been evaluated and defined as recall bias (Chouinard and Walter, 1995). This is particularly pertinent where pain or discomfort is involved. Especially when the pain is characterised by high levels of intensity, frequency and sensitivity that is also be associated with anxiety and depression (Standaert et al., 2008). This does make it harder but not impossible, for a clinician to navigate the history, but this again gives validity for the need of experience and not just knowledge of an MSK problem. A history can be further complicated by symptom exaggeration or catastrophising (Johnstone et al., 2004) makes deciphering verbal accounts of events hazardous but not impossible. I do not for one moment suggest that clients will deliberately be economical with the truth about their symptoms, they are of course living with them, however, a good clinician will be able to is to sift the wheat from the chaff and determine a robust working hypothesis that can be peer reviewed and understood through the clinical notes within which a clear causal relationship can be surmised. ‘To see what is going wrong’, means an ability to identify a tangible functional movement abnormality with a problem structure (muscle, bone/joint or nerve etc). This is usually done by performing a detailed MSK assessment with or without special tests that are taught through formal training (Petty, 2006). The key to understanding the importance of this is that it is not just how to perform those special tests but also the importance of correct interpretation of those results. I have seen tests performed in both Physiotherapy and GP Surgeries and winced at the inferences made because the test was either performed inadequately or the result was recorded as being relevant even though it was a false positive or false negative test. A classic example is that of a Straight Leg Raise test (SLR), raising of the leg to see if it invokes pain down the leg when evaluating sciatica, when it is said to be positive because the pain invoked is only in the middle of the back when in fact it is negative because the invoked pain should be down the distribution of the nerve down the affected leg. It is for this reason I am exasperated by terms such as ‘slipped disc’ and ‘sciatica’ which are used to describe most back pain, the inappropriate use of which facilitates catastrophisation and poor management compliance. Another example would be to say the SLR is positive because pain can be invoked in the back of the thigh of the leg being raised even though the test was done with the knee bent and not straight as it ought to be. I could go on for ages with similar examples that I have seen but it is sufficient to say I trust that you can see the picture, but I will add that it is not uncommon to see such misinterpretation within medico-legal bundles. In any case the wrong interpretation of a test can lead to the use of inappropriate treatment or management and advice and thus potential accusations of clinical negligence.
The whole process of clinical reasoning embedded with the history taking approach forms a ‘holy grail’ intervention pathway for MSK Physiotherapy for the overall management of a clinical problem. Navigation of the history taking and representation in clinical notes depends on the experience of the clinician. The more experienced colleagues recognise ‘patterns’ of the behaviour of symptoms whilst the less experienced use a more rigid process of several layers of interpretation learnt during formal education to arrive at a conclusion (Doody and McAteer, 2002) which may or may not be similar. I labour the above point because my experience so far as an Expert Witness suggests that the test for causation, breach of duty and negligence seems to hinder on the Bolam test that I interpret as that, by law, evaluates if a medical professional provide a reasonable standard of care while going about their duties (as would normally be expected by a peer). It this that intrigues me because I struggle to see how in general terms at least, treatment administered by an inexperienced clinician can be equated to that of an experienced colleague because as I pointed out above the clinical reasoning process differs and may not produce the same kind of outcome. However, if we are, as an Expert Witness required to hypothetically compare like for like, are we then inadvertently scrutinising not just the individual but also the system under which the treatment was carried out? By this I mean if the level of skill provided matches the client’s expectations, and if not, whether appropriate supervision is available to ensure that the client is not inadvertently deprived of what they should reasonably expect. This question raises further questions, particularly the level of experience that is reasonably appropriate before a clinician can safely operate independently in the private sector; we know that there is supervision within the NHS but is it credible? The whole argument however does not particularly hold true if the question is asked, if another clinician of the same level of experience would adopt the same clinical reasoning process, use the same treatment techniques and work towards the same outcome as that under question. I’m not particularly sure that this would be possible.
It might seem that I digress a bit from the objective of this article, but I raise the issue because it draws us all to the perception that all Physiotherapist are the same, having the same skill sets and no matter what the level of educational attainment or skill sets acquired through experience, a ‘physio is a physio’. I contend that this is a dangerous perception that puts clients at risk and exposes clinicians to litigation. Consideration for the bigger picture may therefore be required when formulating an opinion. Either way, I think it would be pertinent to consider the need to explain to the court any caveats that may have influenced the decision-making process. This is, in my view, as important whether working for the Prosecution or Defence as underpinned by both Part 35 of the Civil Procedure Rule and Part 19 of the Criminal Procedure Rule.
For as long as I can remember, it has been thought that exercise is the answer to everything that the Medics can’t either put a label on as a diagnosis or offer any long-term fix, as such all patients that fall within these cohorts are routinely referred to Physiotherapy. I am yet to be fully convinced that this view has entirely disappeared from healthcare delivery. I point out there is a distinct difference between acute setting treatment for an acute problem which may be provided over several sessions and rehabilitation provided for either a chronic or long-term problem, neurological problems usually fall within the latter. It is still common to see referrals to MSK providers from GPs requesting assistance to improve muscle strength in patients who have had a stroke even though we know that a stroke is a paralysis of movement and not a muscle problem. Paralysis of movement infers a deficit in communication to the muscles rather than a structural deficit of the muscle itself, therefore only an improvement in the line of communication between the brain and the muscle will make any difference. My Neurology colleagues are particularly skilled in improving this deficit. A point of contemplation is, could this be considered a breach of duty because the referral was not sent to the right Clinical Specialist? Could this be compounded if a relatively inexperienced MSK Clinician decided to provide treatment even though we know that an outcome is highly unlikely, and the referral should have been sent to my Neurology Specialist colleagues?
As an MSK Physiotherapy Specialist, one of the hardest things to do is recognising when to refuse intervention making a case to allow the natural course of recovery or admitting that there is no plausible outcome. This is particularly hard when there is an embedded unrealistic expectation of the outcome of treatment. Such situations are more common that is believed and is usually linked to client pressure or (in)direct pressure from primary referrers. Chartered Physiotherapists have autonomy of practice, and the title is protected. This can be burdensome as I have just mentioned but does mean that we must be accountable for making such a decision. This may not sit well with the inexperienced Clinician who graduates with the view that all patients referred with whatever condition must be treated, failure to which could result in censure. My personal view is that both personal and professional reputations are at risk. Treating a condition without the possibility of an outcome will only spawn client frustration with possible loss of the clinician-client relationship and the perception that Physiotherapy as an intervention is not worth it and generally ineffective. We read and hear about clients referred for treatment of ‘sciatica’ which has not helped by Physiotherapy and possibly has been made worse after intervention, the underlying reasons I have previously mentioned. If this is quantified, this could suggest a breach of duty of care and/or clinical negligence after all we are in the business of making people better not making them worse. It therefore be argued that if we are not sure we can improve a client’s condition we should not be trying to treat it.
1. CHOUINARD, E. and WALTER, S., 1995. Recall bias in case-control studies: An empirical analysis and theoretical framework. Journal of clinical epidemiology, 48(2), pp. 245-254.
2. DOODY, C. and MCATEER, M., 2002. Clinical reasoning of expert and novice Physiotherapists in an outpatient orthopaedic setting. Physiotherapy, 88(5), pp. 258.
3. JOHNSTONE, R., DONAGHY, M. and MARTIN, D., 2004. A pilot study of a cognitive-behavioural therapy approach to physiotherapy, for acute low back pain patients, who show signs of developing chronic pain. Advances in Physiotherapy, 4(4), pp. 182-188.
4. PETTY, N.J., 2006. Neuromusculoskeletal Examination and Assessment: A handbook for Therapists. 3rd edn. London: Churchill Livingstone.
5. STANDAERT, C.J., WEINSTEIN, S.M. and RUMPELTES, J., 2008. Evidence-informed management of chronic low back pain with lumbar stabilisation exercises. The Spine Journal, 8, pp. 114.