Reflections and Future Directions on Extending Physical Therapist Scope of Practice to Improve Quality of Care and Preserve Health Care Resources

Health care legislation and policies in several countries have extended physical therapists’ scope of practice to include the right to order and interpret imaging (radiography, magnetic resonance imaging [MRI], ultrasound scans), electro-neurophysiological tests, and blood and urine tests, as well as to perform joint and soft tissue injections and prescribe medications. In this report, we describe the reasons physical therapists’ scope of practice has been extended in several countries. These additional competencies apply to both professional and postprofessional musculoskeletal (MSK) physical therapist education. To date, there have been evaluations of the practitioners in these new roles with respect to diagnostic accuracy, opioid usage, patient satisfaction, and the quality and cost of these new models of care. We question why legislation and implementation of these high-value models of care have been so slow within developed health care systems. The physical therapy profession should take definitive actions to address this in order to improve the MSK health of the patients we serve. In February 2017, a few colleagues met in Quebec, Canada, to discuss/design and conduct research. The group included a physical therapist trained in the United Kingdom and one from Canada. During the course of the discussions, John Pape, an Advanced Practice Practitioner (APP) physical therapist from the UK, suggested that since we had access to a cadaver laboratory, he was interested in testing the accuracy of injecting the coraco-humeral ligament in cadavers. This ligament is considered one of the main restrictors of glenohumeral joint range of motion.1,2 The initial reaction was to dismiss the idea as there was no interest in testing the accuracy of an injection technique not performed in clinical practice. However, John informed us that he performed about 15–20 injections per month in the UK, targeting various joints and soft tissue structures, with the majority directed toward the subacromial space. We were surprised and asked why physical therapists rehabilitate using management strategies that include joint injections at such a high rate. John's response that there was a “shortage of skilled practitioners performing injections in the UK” and that “physiotherapists were well educated to perform these” surprised us. Physical therapy APP roles were initially developed in the UK, Canada, Australia, and other countries to address long waits for musculoskeletal (MSK) conditions and elective surgical waits.3,4 This was done by implementing the role co-located with orthopedic surgeons. This model of care was so successful that it was scaled up and spread to a variety of settings, including other niche areas such as emergency departments, neurology, pediatric, and respiratory specialties.5,6 In some settings, the physical therapists’ scopes of practice have been expanded, out of necessity, to include the right to order and interpret investigations, such as X-rays, magnetic resonance imaging (MRI), ultrasound scans, electro-neurophysiological tests, and blood tests, and to perform joint and soft tissue injections and prescribe medications.7 Since 1995, upon completion of accredited training, physical therapists in the UK have had the right to inject corticosteroids, local anesthetics, botox, and viscosupplementation into intra- and extra-articular tissues, and joint spaces, and to perform aspiration of joint spaces to treat joint and soft tissue inflammatory and degenerative disorders.8 It is expected that physical therapist scope of practice will evolve and continue to develop as services and the profession respond to patient and population needs. Individual elements of advanced practice will be incorporated into practice or developed further at an advanced level as skills, knowledge, and competencies grow and are refined. Why should the physical therapy profession endorse such roles? Is there really a need for physical therapists to extend their scope of practice? Why not leave these skills to physicians or nurse practitioners? The reason is that physicians and nurses receive very little training in the assessment and management of MSK conditions—which is 80% of the skill set required in advanced practice MSK roles. Thus, it is far easier to add on the additional skills of ordering imaging, laboratory tests, or injecting a joint to a physical therapist's skill set than to add the MSK assessment and management to physicians’ or nurses’ skill sets. Moreover, in some provinces in Canada (eg, Alberta), 40% of family physicians are already “specializing in niche areas” at a time when not everyone has a family physician. Thus, adding on the specialized skill sets required from family physicians to manage MSK disorders is not a viable alternative and would be a costlier option for the health care system. Allowing advanced practice physical therapists in the primary and tertiary care sector to manage MSK conditions has reduced the opioid prescriptions (deemed to be expeditious, safe, and more cost effective), increases options for non-surgical management of patients, and improves triage and surgical yield when patients are referred to orthopedic surgeons.9,10 Additionally, APP physical therapists are equipped to deliver quality care11,12 in areas where qualified practitioners are sparse or the waiting lists don’t allow timely access to high-quality care. There is evidence that consulting a physical therapist first results in significant cost savings13 and a decrease in opioid prescriptions, emergency room visits, and imaging.14 There are several key issues facing health care professionals that require extensions of their scope of practice and greater collaboration between health professionals. In the global burden of disease, low back pain, neck pain, and other MSK conditions rank in the top 4 conditions of years lived with disability in 25- to 64-year-old patients in both developed and developing countries.15 Some authors have noted there is a rapidly approaching tsunami of patients suffering from chronic pain and physical disability caused by MSK conditions, and that general medical practitioners (who have traditionally been the first point of contact for patients) are currently ill prepared and inadequately trained to deal with this challenge.16,17 In many countries, medical training is lacking in MSK management, with reports of 82% of medical school graduates failing to demonstrate basic competency in MSK medicine18 and medical students receiving as little as 4 weeks of specific training in MSK conditions.16 This lack of requisite skills results in an increasing number of patients referred into the secondary sector for specialist assessments, leading to a bottleneck of orthopedic and rheumatology clinics16 rather than using highly skilled physical therapists in primary care to assess and manage these patients.11 Physical therapists already have MSK training as a core threshold to entry-to-practice in most curricula around the world.19 These entry-to-practice skills are often enhanced with further postgraduate training. Trained physical therapists and rheumatologists displayed similar accuracies in corticosteroid injection,20 resulting in time and cost savings by reducing the number of medical visits for the management of patients with frozen shoulder, for example.20 Physical therapists, through long training in the field of neuro-musculoskeletal clinical practice, have developed skills in palpation, placing them as key players in infiltration decision making for diagnostic accuracy,21 lower cost, and faster intervention.22 APP physical therapists are deemed to be cost effective, as they request fewer investigations23 and are competent in their diagnostic skills, with a high level of agreement between clinical diagnosis and MRI findings reported, indicating clinical diagnostic accuracy of 74.5% for APP physical therapists, 80.8% for orthopedic surgeons, and 35.4% for non-orthopedic providers.24 This supports the idea that APP physical therapists ordering specialized investigations will shorten and streamline the patients’ pathway of care. The waiting times to consult APP physical therapists are also generally shorter than those to see a specialist.4 Although safety, patient satisfaction,25 quality of care, and cost-effectiveness of MSK physical therapists11,13 have been demonstrated in extended roles within primary care clinics, implementation of non-physician-led primary care programs and health care policies in many countries have not been updated to reflect these high-quality cost savings measures. It is time to further define the role of physical therapists within the health care system around the world, both in developed and developing nations. The health care systems in the UK, Canada, Australia, and New Zealand are implementing cost saving measures that extend physical therapists’ role while preserving or improving quality of care.11,13,22 Time has come for health care policies in many countries to expand physical therapists’ role in the health care system, similar to what our Australian colleagues are currently pursuing related to quality of care and the economic impact of extending physical therapist scope of practice.22 While not addressed in this paper, implementation of these roles within the primary care sector will require new funding models for health care delivery that are based on quality rather than transactional visits. Concept/idea/research design: J-M. Brismée, J.L. Pape, L.J. Woodhouse, D. Reid, S. Sobczak Writing: J-M. Brismée, J.L. Pape, L.J. Woodhouse, D. Reid, N. Bellot, F. Reumont, S. Sobczak Data collection: J-M. Brismée Project management: J-M. Brismée Clerical/secretarial support: O.C. Matthijs Consultation (including review of manuscript before submitting): J-M. Brismée, L.J. Woodhouse, N. Bellot, O.C. Matthijs, F. Reumont There are no funders to report for this submission. The authors completed the ICJME Form for Disclosure of Potential Conflicts of Interest. L.J. Woodhouse reported receiving honoraria as president and member of the Board of Directors of the Canadian Physiotherapy Association, member of the Focus on Therapeutic Outcomes (FOTO) Inc Research Advisory Board, and member of APTA Physical Therapy Outcomes Research Scientific Advisory Panel. Her institution has received grants from Alberta Innovates, Alberta Health Services, and the Canadian Institutes of Health related to her work. No other potential conflicts were reported.

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