Physiotherapy explained

A physiotherapist can be a great ally to doctors and medical students. Ciaran Scott Hill tells you what physiotherapists really do and explains how we can get the most out of them

PHOTOS.COM

After five years and countless late nights, I’ve now completed my physiotherapy degree and am in my penultimate year of the graduate entry medicine programme at Bart’s and the Royal London School of Medicine. Throughout my training I’ve seen many similarities between physiotherapy and medicine and an even greater number of misconceptions on both sides. This is especially important in the current culture of multidisciplinary teamwork. Physiotherapists are the third largest group of healthcare providers after nurses and doctors, but general knowledge about them is limited and they are often stereotyped as masseuses, granny draggers, and physioterrorists. Be careful with these stereotypes as they are outdated, inaccurate, and unsurprisingly they are likely to cause offence.

What is physiotherapy?

It is difficult to summarise physiotherapy (also known as physical therapy in some countries) as a profession. The workload is split between the broad categories of musculoskeletal, cardiorespiratory, and neurology specialties. Physiotherapists analyse movement and use specific handling techniques, exercise plans, and manipulations to treat an eclectic range of conditions. They may also use adjuncts to their hands on skills, such as massage and electrotherapy. Physiotherapists are specialists in rehabilitation of all disciplines and you’d be hard pushed to find an area that physios don’t work in. There is even a large number of mental health specialists.

Physiotherapy training

Entry to the physiotherapy degree course is extremely competitive, with about 20-40 applicants per place at each university. Typically, a successful applicant will have three A levels with grades of at least BBB. Physiotherapy is a three year bachelor of science degree (BSc (Hons)) course in England and Wales, or a four year course in Scotland. Like medicine, physiotherapy courses now have a fast track graduate course of two years, which gives the applicant a master of science (MSc) degree.

Preclinical years

The first year of undergraduate training is usually spent exclusively in the classroom. Physiotherapists learn a vast amount of musculoskeletal anatomy; it’s not unusual for a first year student to learn details of every bone and muscle in the body including origins, insertions, and nerve root innervations. Teaching is functionally orientated and pathology is learnt as an integrated subject. Many schools are now using problem based learning style cases to develop clinical reasoning. The cardiorespiratory and neurological systems are also extensively covered but pharmacology, the gastrointestinal, and the urinary systems are usually areas of weakness.

Clinical years

These include a minimum of 1000 hours of clinical attachments. Unlike medical students, physio students are given their own patients to assess and treat very early on in training, often with minimal supervision. Physios are taught to practise evidence based medicine and a large number of their techniques are now the subject of clinical trials.

Qualification

Since early 2005, in order to be legally called a physiotherapist, physical therapist, or physio you must have received a physiotherapy degree from a certified university, be registered with the Health Professions Council (analogous to the General Medical Council for doctors), and fulfil all continued professional development requirements. This explains the recent emergence of a greater number of sports and rehabilitation therapists.

Types of physiotherapists

All physiotherapists in hospitals tend to wear a bright white T shirt or tunic with navy trousers or shorts, and because of this it’s likely that all physiotherapists appear the same to you (figure). In hospitals, you might come across:

Staff (junior to senior)

• Students—apart from the healthy flush of youth these can usually be identified by the lack of a dark blue trim to their T shirts or tunics and the absence of a Chartered Society of Physiotherapy badge
• Junior, basic, or staff grade—these are physios who may be newly qualified but may have been working for between two and three years. They will be on rotations between specialties, each lasting around three to four months. They are quite likely to be those you meet when you are on call
• Senior II—analogous to senior house officers, these physios are rotational and may be settled in a specialty or doing longer rotations. They are largely independent and will only occasionally need to defer clinical decisions to seniors
• Senior I—experienced practitioners who are specialised in a specific area
• Superintendents (III, II, and I)—senior band of physios who have ceded some of their clinical role in order to manage a physiotherapy department. Some may have additional titles:
• Clinical specialists—have specialist knowledge in their area but can be of senior I grade in an audit post
• Extended scope practitioners—practitioners who have taken on some roles that traditionally fall outside of the scope of the practice of physiotherapists. For example, they may assess patients at an orthopaedic clinic and help filter them for the resident medical consultant (a similar job to what is commonly done by medical registrars). They may also have taken postgraduate courses that give them special skills, for example, administering corticosteroid injections
• Consultant physiotherapists—the highest clinical post in physiotherapy. Few and far between, these practitioners mix clinical work with developing protocols and services
• Other posts include lecturer-practitioners and researchers

Assistants

• Physiotherapy assistant—support the work of a physiotherapist. Assistants can carry out documented treatment plans but cannot assess patients or make decisions about their treatment
• Technical instructor—have more responsibility, cannot assess patients but may be able to progress them.

What a physiotherapist can do for you

Physiotherapists usually work a five day week but in larger hospitals there will be a physio on call at nights and weekends for intensive care and deteriorating respiratory patients. Physios may contribute to ward rounds but will generally look at the admissions list for the ward they are covering and select at risk patients to see. Otherwise, their workload comes from specific referrals from doctors, nurses, and other allied health professionals. Usually, a physio will accept a referral from any member of the healthcare team if it can be justified. Physiotherapists are autonomous and therefore keep their own notes. Occasionally, they will summarise progress with a patient in the medical notes or nurses’ kardex if it is indicated for communication purposes. On many wards it is inappropriate to discharge a patient until they have had a physio assessment of their mobility and independence.

General wards

A physiotherapist’s role will differ depending upon their area of specialty. On surgical wards, a physio will routinely see postoperative patients who meet the at risk criteria for complications such as respiratory difficulties, bed sores, mobility problems, etc. If an elective surgery patient who may have these problems is identified, it is often better for the physio to see the patient preoperatively so that information and exercises can be given while the patient is still relatively free of pain and medication. If you have a patient you think might benefit from help with mobility or breathing then check your hospital’s referral guidelines or speak to a physio on the ward. In order for a physio to see a patient they will usually require a written referral.

Remember, physios have great functional anatomy knowledge and their assessments of deviations from normal can be very useful. For example, does that patient’s gait show a hip drop classic of osteoarthritis? Does this stroke patient’s trunk show low tone on the left or high tone on the right? Is that blood gas a compensated metabolic acidosis? Not sure? Try asking your physio; their opinion can be a great aid and ensure a really comprehensive clerking.

Respiratory care

It often comes as a surprise to doctors that physios have a key role in respiratory care during nights on call. They have a vast range of skills and techniques at their fingertips to treat a patient with respiratory difficulties or who is chronically deteriorating. These may consist of teaching the patient breathing exercises, using percussion to loosen secretions, and manual hyperinflation. Physios can teach patients effective coughing techniques that don’t put surgical wounds under stress or cause unnecessary bronchoconstriction. They have extensive knowledge of chest x rays, arterial blood gases, auscultation, oxygen therapy, and invasive and noninvasive ventilation on and off the intensive care unit. Physios are also able to perform nasopharyngeal or oropharyngeal suction and tracheostomy care. Furthermore, if you’re having trouble getting a sputum sample then ask them nicely and they will get it for you.

Referring patients

A physiotherapist will always make a personal assessment of any patient referred to them. They take full clinical histories and perform targeted examinations, and on the basis of their findings, they make problem lists and formulate treatment plans. If a patient is referred with a firm diagnosis made by a doctor, the physio is unlikely to disagree with it unless their assessment directly contradicts it. Physios are autonomous clinicians who are capable of making an independent diagnosis and exercising clinical judgment.

When referring, it is always best to give as much detail as possible while avoiding the temptation to tell the physio what treatment you think is best. It is their opinion regarding a particular problem that you should be requesting, not a treatment.

Want to know more?

If you want to know more about the role of physios on your ward then look on the Chartered Society of Physiotherapy’s website, or why not invite your local physiotherapist to give a talk to your firm? If you don’t feel you have covered a topic very well then find a friendly looking physio and ask them if they could give you a talk on the subject; you’ll probably get a lot out of it. Likewise, why not follow your patients when they go down to the physio gym? I learnt more about cerebral palsy in one hydrotherapy session than I did in several lectures, and at the very least you’ll have the novelty of wearing swimming trunks to work.

The article has been checked by several senior physiotherapists around the country, including Suzannah Jones at the Leeds Teaching Hospitals NHS Trust and Victoria Ashall at the Royal Bromtpon and Harefield NHS Trust.

Ciaran Scott Hill, chartered physiotherapist and fourth year medical student, Barts and The Royal London School of Medicine, London
Email: hillciaran@hotmail.com


studentBMJ 2006;14:1-44 January ISSN 0966-6494