A proposed framework for point of care musculoskeletal ultrasound and ultrasound image-guided interventions by physiotherapists: scope of practice, education and governance.

BACKGROUND: The use of point of care ultrasound (PoCUS) in the management of musculoskeletal (MSK) disorders is a diverse area of PoCUS practice. Its use by clinicians, such as physiotherapists, can occur across a wide range of roles and care pathway configurations; however, professional, educational and regulatory uncertainties can leave clinicians, managers and patients at risk. MAIN BODY: A PoCUS framework approach (previously applied to support PoCUS consolidation and expansion) is used to frame these proposals. Central to this is the defining of (clinical and sonographic) scope of practice (ScoP). A number of indicative ScoPs are described to both (i) illustrate application of the principles and (ii) provide templates for ScoP derivations for individual services or clinicians. Image-guided MSK interventions are increasingly an aspect of MSK physiotherapy PoCUS. Given the utility of physiotherapists drawing upon their imaging to fully inform the selection (and performance) of such techniques, we present a rationale for competency in undertaking sonographic differentials as a pre-cursor to performing ultrasound image-guided MSK interventions. Alignment of ScoP with the relevant education and formal competency assessments are a cornerstone of the PoCUS framework approach; as such, key aspects of MSK PoCUS education and competency assessment are outlined. Strategies for addressing such requirements in healthcare settings where formal provision is not accessible, are also presented. Governance considerations are aligned with the regulatory environment, including those pertaining to professional guidance and insurance considerations. In addition, generic quality assurance elements are emphasised, as core aspects of high-quality service provision. Whilst the paper clarifies the situation for MSK physiotherapists using PoCUS in the UK, prompts are provided to support other professional groups working in MSK services in the United Kingdom (UK) and MSK physiotherapists/physical therapists in other countries-to facilitate their application of the principles. CONCLUSION: Acknowledging the breadth of MSK physiotherapy PoCUS practice, this paper draws upon a framework approach to provide integrated ScoP, education/competency and governance solutions, along with mechanisms for other professions working with MSK PoCUS-and physiotherapists/physical therapists outside of the UK-to consolidate and expand their practice.

A proposed framework for point of care lung ultrasound by respiratory physiotherapists: scope of practice, education and governance.

BACKGROUND: Point of care ultrasound (PoCUS) has the potential to provide a step change in the management of patients across a range of healthcare settings. Increasingly, healthcare practitioners who are not medical doctors are incorporating PoCUS into their clinical practice. However, the professional, educational and regulatory environment in which this occurs is poorly developed, leaving clinicians, managers and patients at risk. MAIN BODY: Drawing upon existing medical and non-medical literature, the authors present a proposed framework for the use of PoCUS. Throughout, mechanisms for applying the principles to other professionals and healthcare settings are signposted. Application of the framework is illustrated via one such group of healthcare practitioners and in a particular healthcare setting: respiratory physiotherapists in the UK. In defining the point of care LUS scope of practice we detail what structures are imaged, differentials reported upon and clinical decisions informed by their imaging. This is used to outline the educational and competency requirements for respiratory physiotherapists to safely and effectively use the modality. Together, these are aligned with the regulatory (professional, legal and insurance) arrangements for this professional group in the UK. In so doing, a comprehensive approach for respiratory physiotherapists to consolidate and expand their use of point of care LUS is presented. This provides clarity for clinicians as to the boundaries of their practice and how to train in the modality; it supports educators with the design of courses and alignment of competency assessments; it supports managers with the staffing of existing and new care pathways. Ultimately it provides greater accessibility for patients to safe and effective point of care lung ultrasound. For clinicians who are not respiratory physiotherapists and/or are not based in the UK, the framework can be adapted to other professional groups using point of care LUS as well as other point of care ultrasound (PoCUS) applications, thereby providing a comprehensive and sustainable foundation for PoCUS consolidation and expansion. CONCLUSION: This paper presents a comprehensive framework to support the use of point of care LUS by respiratory physiotherapists in the UK. Mechanisms to adapt the model to support a wide range of other PoCUS users are outlined.

Point of care ultrasound in pelvic health: scope of practice, education and governance for physiotherapists.

Pelvic health and pelvic floor dysfunction have wide-reaching implications across a range of patient groups. Placing ultrasound imaging into the hands of assessing and treating clinicians (i.e. point of care ultrasound, PoCUS) can provide a step change in clinical effectiveness and efficiency. Pelvic floor dysfunction is managed by one or more members of a multi-disciplinary team that includes physiotherapists. Physiotherapists' involvement includes diagnosis, patient education, identifying shared treatment goals, using rehabilitative strategies and empowering patients through self-management. Drawing upon existing publications in this area and applying framework principles, the authors propose a clinical and sonographic scope of practice for physiotherapists as part of supporting the consolidation and expansion of pelvic health PoCUS. Education and governance considerations are detailed to ensure the robust and safe use of this modality. Alongside empowering the use of ultrasound imaging by clinicians such as physiotherapists in the UK and internationally, we provide clarity to other members of the care pathway and ultrasound imaging professionals.

Challenges and opportunities in point-of-care ultrasound: A qualitative exploration of respiratory physiotherapists' experiences of lung ultrasound training and its adoption in critical care.

Introduction: Diagnostic lung ultrasound (LUS) is gaining popularity among respiratory physiotherapists as an imaging modality to aid pulmonary assessments, guide intervention selection, and monitor the efficacy of chosen interventions. The ability of respiratory physiotherapists to incorporate LUS into their clinical practice is influenced by multiple factors to adoption and implementation. The aim of this study was to explore the experiences of senior respiratory physiotherapists who have attempted to adopt and implement LUS into their clinical practice in critical care. It is hoped these experiences will inform the development of educational and adoption strategies for the future implementation of LUS. Methods: Following a national call out, eight senior critical care respiratory physiotherapists were purposively selected to be interviewed using semi-structured questions exploring their varied experiences of LUS adoption into clinical practice in critical care. The transcribed data were thematically analysed. Results: Five main themes emerged from the participants' responses: (i) support for physiotherapists using LUS, (ii) knowledge and understanding of LUS evidence, (iii) governance, (iv) physiotherapists' motivation to use LUS, and (v) resources. Quotes for each of the five themes are given as exemplars. Conclusion: Participants reported a range of factors that influenced their ability to adopt and implement LUS into practice several were enabling, and others were barriers to progress. Online Appendix 1 contains recommendations from the authors to help guide managers and clinicians wishing to adopt LUS into respiratory physiotherapy services and patient pathways.

Role of the halo sign in the assessment of giant cell arteritis: a systematic review and meta-analysis.

OBJECTIVES: This systematic review and meta-analysis aimed to evaluate the diagnostic value of the halo sign in the assessment of GCA. METHODS: A systematic literature review was performed using MEDLINE, EMBASE and Cochrane central register databases up to August 2020. Studies informing on the sensitivity and specificity of the US halo sign for GCA (index test) were selected. Studies with a minimum of five participants were included. Study articles using clinical criteria, imaging such as PET-CT and/or temporal artery biopsy (TAB) as the reference standards were selected. Meta-analysis was conducted with a bivariate model. RESULTS: The initial search yielded 4023 studies. Twenty-three studies (patients n = 2711) met the inclusion criteria. Prospective (11 studies) and retrospective (12 studies) studies in academic and non-academic centres were included. Using clinical diagnosis as the standard (18 studies) yielded a pooled sensitivity of 67% (95% CI: 51, 80) and a specificity of 95% (95% CI: 89, 98%). This gave a positive and negative likelihood ratio for the diagnosis of GCA of 14.2 (95% CI: 5.7, 35.5) and 0.375 (95% CI: 0.22, 0.54), respectively. Using TAB as the standard (15 studies) yielded a pooled sensitivity of 63% (95% CI: 50, 75) and a specificity of 90% (95% CI: 81, 95). CONCLUSION: The US halo sign is a sensitive and specific approach for GCA assessment and plays a pivotal role in diagnosis of GCA in routine clinical practice. REGISTRATION: PROSPERO 2020 CRD42020202179.

Halo score (temporal artery, its branches and axillary artery) as a diagnostic, prognostic and disease monitoring tool for Giant Cell Arteritis (GCA).

BACKGROUND: Giant cell arteritis (GCA) is a common large vessel vasculitis of the elderly, often associated with sight loss. Glucocorticoids (GC remain the mainstay of treatment, although biologic treatments have been approved. Biomarkers predicting disease severity, relapse rates and damage are lacking in GCA.EULAR recommends ultrasound (US) as the first investigation for suspected GCA. The cardinal US finding, a non-compressible halo, is currently categorised as either negative or positive. However, the extent and severity of this finding may vary.In this study, we hypothesise whether the extent and severity of the halo sign [calculated as a single composite Halo score (HS)] of temporal and axillary arteries may be of diagnostic, prognostic and monitoring importance; whether baseline HS is linked to disease outcomes, relapses and damage; whether HS can stratify GCA patients for individual treatment needs; whether HS can function as an objective monitoring tool during follow up. METHODS: This is a prospective, observational study. Suspected GCA Participants will be selected from the GCA FTC at the participating centres in the UK. Informed consent will be obtained, and patients managed as part of standard care. Patients with GCA will have HS (temporal and axillary arteries) measured at baseline and months 1,3,6 and 12 long with routine clinical assessments, blood sampling and patient-reported outcomes (EQ5D). Non-GCA patients will be discharged back to the referral team and will have a telephone interview in 6 months.We aim to recruit 272 suspected GCA referrals which should yield 68 patients (25% of referrals) with confirmed GCA. The recruitment will be completed in 1 year with an estimated total study period of 24 months. DISCUSSION: The identification of prognostic factors in GCA is both timely and needed. A prognostic marker, such as the HS, could help to stratify GCA patients for an appropriate treatment regimen. Tocilizumab, an IL-6R blocking agent, switches off the acute phase response (C-Reactive Protein), making it difficult to measure the disease activity. Therefore, an independent HS, and changes in that score during treatment and follow-up, maybe a more objective measure of response compare to patient-reported symptoms and clinical assessment alone.

Diagnostic thoracic ultrasound imaging - An exploration of respiratory physiotherapists' interest and use in clinical practice: A national survey.

INTRODUCTION: Physiotherapists are learning to perform diagnostic thoracic ultrasound but it is currently unknown how they are learning, how they are using thoracic ultrasound in their practice, or any factors affecting the implementation of thoracic ultrasound into practice. The aim of this survey was to explore the use of thoracic ultrasound by physiotherapists. This information could be used to aid training and implementation strategies to assist physiotherapists to integrate thoracic ultrasound safely into their practice. METHODS: A questionnaire comprising of open/closed questions was distributed to respiratory physiotherapist. Distribution was at three national study days and via a specialist newsletter containing a link to a SurveyMonkey™ questionnaire. RESULTS: A total of 133 questionnaires were returned with 31 reported that they used thoracic ultrasound imaging and 101 reporting they did not. The most common roles of thoracic ultrasound in practice were to: enhance the ability to differentially diagnose respiratory pathologies, aid respiratory assessment and support clinical reasoning. Of the 133 respondents, 58 reported that they had undertaken training in thoracic ultrasound imaging and 75 had not. The most common factors identified regarding thoracic ultrasound implementation were team support, ultrasound machine availability/cost, time pressures and mentor availability. DISCUSSION: This survey has provided an understanding of thoracic ultrasound practice amongst respiratory physiotherapists in the UK. The survey results demonstrated the barriers that inhibit current practice and highlighted the importance of mentor support. There was a good understanding by all respondents regarding the clinical application of thoracic ultrasound. These findings are being used to develop professional guidance and ensure safe practice of thoracic ultrasound.

Musculoskeletal ultrasound imaging - An exploration of physiotherapists' interests and use in practice.

BACKGROUND: Musculoskeletal ultrasound imaging (MSKUSI) has gained popularity; several professions have expressed an interest in this application but the clinical use by physiotherapists has not been fully researched. OBJECTIVES: To explore physiotherapists' interests and use of MSKUSI in practice. DESIGN: Sequential mixed-methods; questionnaire followed by semi-structured interviews. METHOD: A questionnaire was developed and distributed to gain initial information, (75 responses). Analysis informed topic-guide development and enabled a purposive-sampling strategy for semi-structured interviews that explored physiotherapists' interests, education and clinical use of MSKUSI (n = 11). Interview data were analysed thematically. RESULTS: Five themes were identified: 1. Professional skill set - physiotherapists' suitability for MSKUSI. 2. Factors that have impacted physiotherapists' ability to use MSKUSI. 3. Physiotherapists' motivation to use ultrasound - improving patient focused care. 4. Quality assurance strategies. 5. Application of biopsychosocial model. Themes revealed links between physiotherapists' core skills, knowledge and professional experiences that align with MSKUSI requirements. Some participants reported support accessing education but many described challenges finding appropriate mentorship. Participants observed education did not always reflect practice typical of physiotherapists. Application of clinical reasoning processes utilised by physiotherapists was regarded as integral to patient-focused scanning. CONCLUSIONS: Physiotherapists' professional training and musculoskeletal practice are seen as a foundation for education in MSKUSI. Accessing education can be challenging, in particular mentorship that fully incorporates the biopsychosocial model. Proposed roles for MSKUSI for physiotherapists include verification of clinical assessment findings for diagnosis and facilitation of patient education. The potential to streamline patient pathways and optimise resource management warrants investigation.

Musculoskeletal ultrasound imaging - Integration with the biopsychosocial model.

BACKGROUND AND METHOD: Musculoskeletal ultrasound imaging, (MSKUSI) has become a popular imaging modality in recent years and is being utilised by a variety of professions in clinical environments beyond radiology departments. A previously published study exploring physiotherapists' interests and use of MSKUSI in practice included in-depth interviews of participants, (n = 11). The data from this qualitative study were analysed thematically and five themes were identified; one was 'Application of the biopsychosocial model', the basis of this paper. RESULT: The theme, 'Application of the biopsychosocial model' drew together three categories of analysed data: clinical reasoning, professional variance and communication opportunity. 'Clinical reasoning' reflected the participants' value on subjective assessment information and the integration of ultrasound imaging with physical examination findings. 'Professional variance' observed the scanning processes undertaken by physiotherapists tended to vary from other professionals, the physiotherapists perceived their use of dynamic imaging was greater, in particular scanning in symptom provoking positions. Another variance observed was the style of communication that physiotherapists used when scanning, this was categorised as a 'communication opportunity' as it represented an event that could be utilised to promote patient understanding of their presentation, link imaging findings to proposed management and enhance compliance with rehabilitation strategies. Participants emphasised their responsibility when communicating with patients to avoid language that could promote unhelpful behaviour, e.g. catastrophisation. CONCLUSION: Participants placed value on integrating musculoskeletal ultrasound imaging into the biopsychosocial model, further research to explore the impact of this approach on patients' clinical outcomes and reported experiences is required.