The clinical reasoning processes of extended scope physiotherapists assessing patients with low back pain

Employing allied health professionals in extended scope roles has developed relatively recently in health-care. Within physiotherapy, the extended role has provided clinicians with autonomy to use knowledge and clinical acumen to request investigations such as Magnetic Resonance Imaging (MRI) and X-ray as part of the diagnostic process, a practice beyond the traditional scope of physiotherapy. In these advancing roles, little is written about the clinical reasoning processes that clinicians use in managing patients with musculoskeletal pain and knowledge of these processes would advance training for new recruits to this arena. This qualitative study has explored the processes by which extended scope physiotherapists (ESPs) clinically reason their decisions regarding patients reporting low back pain in a musculoskeletal outpatient setting. The study used a multiple case study design informed by grounded theory methodology, using focus groups (involving ESPs and non-ESPs/musculoskeletal physiotherapists) and semi-structured interviews with a think-aloud method (ESPs only) to investigate these processes.

The themes identified include: prior thinking; patient interaction; formal testing; time; safety and accountability; external and internal factors; and gut-feeling (which challenges current physiotherapy models of reasoning). Extended scope physiotherapists reported experiencing greater stress due to higher levels of perceived accountability, safety requirements and internal drivers for competence than non-ESPs. Further research is indicated to explore the role of gut-feeling in musculoskeletal physiotherapy clinical reasoning.