A few weeks ago I wrote a post about the level of clinical competency required at specialist levels of physiotherapy practice which generated a bit of interest. I mentioned that my experience of working at this level (compared with other levels of practice) is the expectation that the specialist physiotherapist will have a solution we are others have failed. Often we are ‘expected to know’. 

In the previous post I discussed some of the factors that contribute to ‘complexity’. So how do I approach and interpret my assessment and make decisions about appropriate treatment given that many people I see have already had many investigations and treatment, often from very competent professionals?

In my practice, people tend to fall into one of two groups:

1. Missed diagnosis (e.g frozen shoulder) or treatable impairment such as loss of ROM, muscle function or cognitive/psychosocial modifiers such as patient beliefs and expectations.
2. Complex rehabilitation presentations. These are less common conditions (e.g symptomatic os acromiale) or those with persistent pain or sensorimotor deficits. This group requires a higher level of clinical reasoning including diagnostic reasoning and rehabilitation expertise.

With these two groups in mind, I’ve put together some of the common processes I have found helpful for guiding my decision-making when seeing specialist patients.

1. Assume nothing.
2. Find out what the patient and referrer want (sometimes not the same thing).
3. Do the basics extremely well:
   • Diagnosis: exclude significant conditions that need onward referral.
   • Treatment: Assess for specific physical impairments (e.g ROM, muscle function) that might influence symptoms or function.
4. Identify persistent pain mechanisms (e.g neuropathic or nociplastic pain) and other health or psychosocial “modifiers” that may be influencing response to treatment.
5. Understand the clinical pathways for specific conditions and the role of physiotherapy in the context of non-surgical and surgical treatment.
6. If not improving, get another opinion. Build a local, multi-disciplinary referral network that you can refer to for advice or further assessment and/or management.

​I’d love to hear whether other Specialist Physiotherapists have any other tips, or whether this helps other physiotherapists out there to organise your thinking and develop a framework for troubleshooting challenging clinical presentations.
If you’re interested in hearing more about how to reason through challenging clinical situations you may be interested in this recorded webinar hosted by Physio Academy.
Problem Solving the Problem Shoulder: 3 Reasons They’re Not Improving

Shoulder pain, disability and psychosocial dimensions: Profile of patients attending shoulder physiotherapy clinics.
 
White, R. J., Olds, M., Cadogan, A., Betteridge, S., & Sole, G. (2022). Shoulder pain, disability and psychosocial dimensions across diagnostic categories: Profile of patients attending shoulder physiotherapy clinics. New Zealand Journal of Physiotherapy, 50(1), 6–20. https://doi.org/10.15619/NZJP/50.1.02

Full text link: https://pnz.org.nz/Attachment?Action=Download&Attachment_id=2436

Congratulations to Roger on this publication. This was a great project to be involved in and an example of what can be achieved with academic and clinician collaboration.

For me the most fulfilling part of any publication is the discussion and clinical applications where the rubber hits the road. There were so many interesting findings from this study. We've summarised a few of the key findings in this infographic. I've provided a few other reflections on the practicalities of collecting the data in the clinical setting here:

1️⃣  Be aware of 'questionnaire burden'. The reality of collecting this information in the clinical setting is that patients have varying tolerance for completing forms that they perceive 'don't apply to me', or where 'questions are repetitive'. Choose a small number of pre-appointment questionnaires that cover key dimensions in the majority of your clinical population (I include a health screen in mine), and use others as indicated for specific patients. As an example, I now only use the CSI score after I have assessed the patient if I suspect central sensitivity based on other clinical findings as the yield of high scores in this population is low (<10%).

2️⃣  Individual question responses can be helpful. Pre-appointment questionnaires are a good way of collecting baseline data, but the total scores often don't tell the full story. Responses to individual questions can provide good direction for follow-up questioning in specific patients.

3️⃣  Literacy. Some patients failed to return the electronic questionnaires before the appointment, and when asked to complete the 'hard copies' on arrival a few became agitated. On questioning, some reluctantly disclosed they have dyslexia, or can't read and we helped them complete the forms within the session. Be sensitive and ask if people need help if they appear reluctant to complete questionnaires.

4️⃣ Use questionnaires validated in your clinical population. Some questionnaires may not adequately capture pain and disability (or other measures) in certain clinical populations. Some pain and function scores ask only about ADLs (e.g 'brushing your hair', or 'reaching a shelf'). Where pain and function are being measured, consider the patient. If pain is not a major factor (sometimes instabilty is the primary symptom) and their activity demands are high choose a questionnaire that specifically addresses their symptoms and activities e.g 'instability' questionnaires (WOSI, Oxford) may be more appropriate for these patients.

Click here for links to shoulder outcome questionnaires.

#collaboration #psychosocial #physiotherapyspecialist #screening #pain #disability #shoulderpain #shoulderinstability

This infographic give a summary of a case I saw in 2021. This highlights the importance of red flag screening in physiotherapy. Click here for more information about red flag screening in physiotherapy.