MSK ESPs in the Armed Forces

Army physical therapists in the US have been working in extended-practice MSK roles since the early 1970s (Worthingham, 1970a; 1970b), which predates the ESP role in the UK by 20 years. James & Stuart (1975) described a US army screening service for low back pain referrals led by physical therapists. These physical therapists took direct referrals from physicians and non-medical health- care professionals; they requested X-rays and made decisions about patient management and onward referral. They had undergone postgraduate training in joint manipulation and spinal mechanics, and they worked to a low back pain protocol when taking the medical history and performing the physical examination. Outcome measures were taken at baseline and were then repeated after the introduction of the new service. As part of the evaluation, 14 orthopaedic surgeons were asked to comment on physical therapists’ performance, and physical therapists themselves were asked about their own competency levels. Nine surgeons expressed reservations about physical therapists screening for underlying non-MSK pathology, and 13 surgeons felt that trauma cases should not be seen by a physical therapist. Only one of the eight physical therapists involved in this two-centre study felt that their basic training had been insufficient to prepare them for their extended role.

60 Benson et al. (1995) also discussed US army physical therapists working as non- physician MSK health-care practitioners in a primary-care setting. These physical therapists generally undertake specific MSK postgraduate training before taking up these posts. One such programme is the neuromuscular evaluation course at Army-Baylor University, Texas, which offers a 27-month doctoral programme in physical therapy (Army-Baylor University, 2012). It is interesting that the authors used two different terms to describe these physical therapists, ‘non-physician health-care providers’ and ‘physician extenders’; both referred to physical therapists working as first-contact clinicians, where they are seeing patients without a referral from a doctor. The two terms are presumably synonymous but by avoiding any reference to physical therapists, they could be describing any health-care role that is adjunctive to the physician role. The authors concluded that these roles were successful but they provided no supporting evidence, other than to comment on the absence of legal action against physical therapists in such roles. Greathouse, Schreck & Benson (1994) argued that army MSK physical therapists in primary care had reputedly supplanted the orthopaedic surgeon’s triage role. As previously mentioned, the Vietnam War (1954-1975) was probably responsible for this development, because army physical therapists acquired the skills to work as non-physician health-care providers as a direct result of the huge numbers of casualties and shortage of doctors; non-surgical conditions needed managing in order to release surgeons’ time to operate. The authors emphasised that non-physician health-care providers see patients without a physician’s referral. This marks quite a distinction between physiotherapy extended-practice roles in the UK and the US, because ESPs in the NHS do not take direct referrals. However, patients can self-refer to NHS physiotherapy services.

NHS physiotherapy self-referral schemes, where physiotherapists accept referrals without an initial GP medical screening, are a relatively recent development (CSP, 2011). Prior to this, NHS outpatient physiotherapists could not see patients without a consultant or GP referral. Physiotherapists accepting self-referrals sometimes harbour concerns that they may not recognize a ‘medical’ problem that is mimicking or coexisting with a MSK condition (for example, spinal metastases, an

61 apical lung tumour, or an abdominal aortic aneurysm). Physiotherapists are not expected to diagnose ‘medical’ pathology; however, they must recognize when there is a need to refer a patient to someone who can. Medical differential diagnosis is an important consideration for ESP practice. The legalities around this subject are unclear and the issues relating to ESPs’ competence, training, and vicarious liability are complex. If a physiotherapist treats a patient referred by their GP for physiotherapy and fails to recognize an underlying medical problem as the cause of the patient’s MSK symptoms, it is unlikely that the physiotherapist would be held accountable for his or her actions. However, the situation might be different for a MSK ESP who is accepting GP referrals that would normally be managed by a medical consultant and his or her team. In a legal test case, the training and competence of the ESP or physiotherapist concerned would be scrutinized. Self-referral schemes will be discussed again in section 3.5.1.

To return to the physical therapist role in the US armed forces, Ziemke, Koffman & Wood (2001) reviewed the role of physical therapists on the USS Car Vinson aircraft carrier during its six-month deployment to the Persian Gulf between 1998 and 1999. Inspection of safety and medical evacuation data revealed significant cost-savings compared with other carriers without this physical therapy input; in fact, they estimated that the physical therapy service had led to eleven fewer medical evacuations during the six-month period. One could argue that this was not solely an extended role for these physical therapists because they were also involved in providing an intensive rehabilitation service for the men and women on board the carrier.

The ESP role in the armed forces in the UK seems to be a more recent development. Minden (2002) commented that army physiotherapists represent an all-officer group and that their skills have to encompass both peacetime and operational working. A descriptive study by Heywood (2006) presented the results of a UK-based study of an ESP-led spinal triage clinic. The ESP was able to request X-rays, MRI scans and blood tests, and refer to orthopaedic surgery, rheumatology, and pain clinics. Training for the role involved observation in outpatient clinics and ward rounds, and observing spinal surgery operations. The

62 ESP managed 90% of referrals independently and the author reported that the impact of this clinic had effectively halved the waiting times for orthopaedic spinal surgery. Saeed & Parker (2006) also described the introduction of an ESP-led military orthopaedic screening clinic, which dealt with general (spine and peripheral joint) orthopaedic referrals. They described the results of their first 100 patients and reported that the ESP had managed 75% of patients independently.

There is clearly a general trend towards positive outcomes for the ESP role in the military, in both the UK and the US. However, no firm conclusions can be drawn from these studies because they are largely descriptive in nature.