Physiotherapists Offer a Safe Alternative to Usual Medical Care in Spine Clinics | Article of The Week #14

Advanced practice physiotherapists offer a good alternative to usual medical care in spinal clinics. But knowing how good depends on what question you are asking.

New models of care are evolving and becoming commonplace in modern healthcare settings. This is because of increasing resources, time and cost pressures as well as a defecit in medical staffing models. Advanced clinical practice is centre stage in several countries around the world and for physiotherapy musculoskeletal clinics are a natural specialty for us to strech our clinical capabilities and move into the gap in the medical workforce.

The most high profile example of this is the first contact practitioner role in the UK and there has been a lot of work to prove the benefit of these types of roles. The next natural step for MSK clinicians working in advanced roles could well be as an alternative to a doctor in a spinal clinic. A new systematic review published in the European Spine Journal has sought to find out if this is a viable model of care.

Deep Dive into Spinal Red Flags with Laura Finucane


Two reviewers were used to independently perform the search strategy and reach consensus on the included trials with a third being available if required. The inclusion criteria was appropriate for the research question and is readily available within the article. PRISMA was adhered to and sound data extraction and methodology was used. The Effective Public Health Practice Project Tool was used to assess risk of bias. This tool is poor at assessing bias with diagnostic agreement therefore the MacDermid tool was used when appropriate. Of the studies included 1 was of high quality, 14 moderate and 3 were of low quality.

A meta analysis was performed and as different scales were used within the included evidence a standardised mean difference was calculated. 18 studies were included (n=9405) and of these 18 2 were RCTs and 16 were observational studies. Breaking down these participants further we can see that 8900 have lumbar disorders, 200 unspecified back issues, 151 cervical spine, 146 thoracic spine disorders and a very small number having multiple spinal disorders.

The studies were from 5 different countries; 5 Irish, 4 Canadian, 4 from the UK, 2 Austrilian and 1 Swedish trials.

Clinical Significance

So the headline from this systematic review is that advanced practice physiotherapists offer an alternative to usual medical care when working in spinal clinics. The only significant difference is that waiting times are smaller when seeign a physio than a doctor. This may explain the slight preference of patients to see a physio rather than a doctor.

Self-reported patient outcomes, pain-related disability measures, ED5D, pain disability index, SF-36 and oswestry diasbility index were all the same if not very similar when seen by a physio or a doctor. If physio’s were supposed to be offering a different type of service then clearly this is not a good outcome. If the ‘different model of care’ was simply that a patient was to see a physio rather than doctor then this is a good result as no harm or difference to the patient occurred.

Unfortunately is isn’t overly clear if a different service was provided by the physiotherapists involved as education, exercise, rehab or diagnostic plans are not consistently included in any detail at all. The same can be said for education and training plans for the physiotherapists involved in these advanced practice roles. This lack of clarity in both education and treatment plans is a significant issue as services will not alter until standardisation across models of care can be reached allowing more significant assessment of care provision. Until then this type of service will always be debated.

Red Flags Deep Dive with Laura Finucane
When assessing patients in clinical practice, it is always essential to consider serious pathology as a differential diagnosis. Red flag screening questions were developed to help detect these pathologies, but there is limited evidence to support their use. So how should clinicians be using red flags and how do they know when to take action? This course aims to provide you with a critical understanding of red flags and how they can be used effectively in clinical practice.

Deep Dive into Spinal Red Flags