Physiotherapy post registration training and continuing

professional development related to physiotherapy treatment of the hemiplegic upper limb after stroke

Government and professional standards require that physiotherapists engage with continuing professional development (Department of Health, 2004; The CSP, 2011). Research suggests that one of the influences on physiotherapists’ clinical decisions is post - graduate training but that

therapists are more likely to value courses aimed at improving their treatment skills (McGlynn & Cott, 2007). The list of courses which respondents were asked to select from was compiled by the researcher from those advertised in the Physiotherapy Journal and Synapse magazine. Although the primary objective of these was to develop clinical skills the scope of courses

identified may also reflect one of the functions of the profession journal: to develop practice. This may have been unwittingly imported into the scope of the research questionnaire.

This limitation was compensated for in part by other areas of the

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n=27) and doctoral (3.5%: n=5) level and indicated the value derived from this level of study. In addition to further practical courses identified

(Saeboflex™ (dynamic splinting), constraint therapy), respondents also reported attendance on “neurological theory” courses and commented that reading of theory and research literature contributed to preparation for course attendance. Previous studies related to physiotherapists’ preference for experiential learning to support practice have not identified this aspect of interlinking of theory and practice learning (Iles & Davidson, 2006; Nisgärd & Lohse, 2010).

Respondents reported that attendance on a skills based course also involved the “interpretation and opportunity for peer discussion” of recent publications in relation to practice by the expert course leaders and that they considered this to be an appropriate and useful way of updating background research knowledge relevant for practice.

Physiotherapy is an action based profession and it is perhaps un-surprising that further education is directed at linking theory and physical aspects of practice. The limited access to funding and study leave for further

physiotherapy education may also contribute to the requirement to

demonstrate to budget holders that course content will be directly imported into practice development.

Further education in neurological physiotherapy is dominated by two paradigms (Davidson & Waters, 2000); neurological developmental

techniques and functional practice and many post-graduate training courses are aligned with either the Bobath concept” or the Motor Relearning Process; this was demonstrated by the course uptake of the responding therapists. Courses addressing either the Bobath concept (n=91: 63%) or motor

(re)learning (n= 34; 23.8%) accounted for the largest number of attendances reported. Data was not analysed to determine if individual respondents had adhered to a single paradigm.

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The dominance of uptake of Bobath concept courses may reflect the availability of instruction; the infra-structure supporting this concept is International and has a strong base in Europe (International Bobath Tutors Association, 2014); a large number of courses are available and the

progression is clearly defined, conversely the authors of the Motor

Relearning Process are based in Australia and there appears to be a less defined pathway of alleged expertise.

3.13.1 Influence of attendance on a neurology based post- graduate course

Most respondents indicated that attendance on a postgraduate course had influenced treatment; this was slightly more apparent for selection of

intervention than for delivery. Treatment selection is related to the needs of the client and delivery to the skills of the therapist (Shumway-Cook & Woollacott, 2007). The effect on selection may indicate that increasing knowledge about an intervention increases therapists’ ability to evaluate its suitability for a specific client; an effect on delivery that an increased ability to execute the treatment increases the likelihood that they will use it.

It is interesting that the effect was slightly greater for selection than it was for delivery; the courses included in the list provided for respondents included treatments which are commonly covered in undergraduate programmes and with which they would be familiar; this suggests that although modest the influence of the course was on delivery rather than determining applicability which is consistent with work related to the areas of effect of post graduate masters study (Petty, Scholes & Ellis, 2011b).

The influence of post graduate courses on clinical decisions was supported by the number of respondents (n=109) who made additional comments, these suggested that the greatest areas of influence were to increase skill and range of practice which is in accord with existing research (McClynn & Cott, 2007) however respondents also indicated the value of courses attendance on application of research into practice. This demonstrates that although therapists value the increase in quality and range of treatment skills

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subsequent to attendance of post graduate courses they also consider this to be in related to greater theoretical knowledge and understanding of the application of research. That is, both to an improved kinaesthetic ability within practice and to an increased ability to make theory: practice links.

3.13.2 Effect of attendance on a non-neurology based post- graduate course

Attendance on a non- neurological course was considered to have less direct effect on physiotherapy practice for clients with central nervous system dysfunction than attendance on neurological post graduate course. This appeared to relate to the content of the courses identified: greatest effect was attributed to “practice” based courses which included kinaesthetic components which are closely related to neurological theory and practice and therefore suggested that therapists found these areas of knowledge and skill easy to adapted and transfer to their own client group (musculo-skeletal practice, relief of pain, core stability, strapping, myofascial release, cognitive behavioural therapy). This suggests adaptability on the part of therapists and the need for a wide scope of knowledge from which to draw in addition to specialist skills.

A smaller number of respondents identified the value they had derived from attendance on courses related to communication (informed consent, capacity for decision making and equality and diversity) and the insight provided by managerial training courses (cost effective treatment, aspects of leadership) or those fostering effective multi-profession team working. This may reflect the seniority of the respondents and that they have responsibilities in both treatment and management.

3.13.3 Effect of published research read by respondent in the past 5 years

Responses suggested variation in the effect of published research on the selection and delivery of treatment. A third of respondents identified that their treatment selection (37.1%; n=53) and delivery (32.9%; n=47) had been

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influenced by research findings but a further group reported the opposite; that it had been of little value to selection (16.1%) and on delivery (23.1%). This suggests that attendance on courses influences practice more than published research which is consistent with the findings of existing studies (McGlynn & Cott, 2007).

However, one of the valued components of postgraduate courses is the inclusion of recent research advances in both theory and practice. This was apparent from further responses; reading research contributed to personal development, preparation for or subsequent to courses attendance, in- service training and journal clubs.

Further, respondents identified the barriers to accessing individual RCT’s afforded by time constraints consistent with Caldwell et al., (2007) and identified the value of expert peer reviews and summarised results included in Cochrane reviews and professional guidelines. This is in accord with the findings of Guyatt et al., (2000) which reviewed the behaviour of medical practitioners; the conclusion that despite increasing skills of appraisal and critical review it is difficult to keep up with the wealth of published material may be equally applicable to physiotherapists.

It was apparent from comments that therapists consider it important that their practice is based on a body of high quality clinically relevant evidence: areas which therapist used as examples which had affected practice were those for which there is considerable evidence: constraint induced movement therapy (n=18), Intense early rehabilitation (n=12), Task/function related practice (n=10), Mirror therapy(n=9), Bilateral upper limb tasks (n=7) and Splinting (n=7). This reflects research findings that in general that despite barriers afforded by time, appraisal skills and relevance of publications to practice physiotherapists have a positive attitude towards Evidence Based Practice (Jette Grover & Keck, 2003; Iles & Davidson, 2006).

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It appears that the primary objective of physiotherapist’s engagement with research is to directly support and develop practice although responding therapists consider many research projects to differ in key aspects from client groups encountered, treatment offered within the constraints of practice (Iles & Davidson, 2006; Nisgärd & Lohse, 2010).

3.14 To describe the type and frequency of occurrence of problems