Task shifting for musculoskeletal disorders in Norwegian primary care: a qualitative interview study of general practitioners and specialist musculoskeletal physiotherapists.

OBJECTIVE: To explore the views of general practitioners and physiotherapists on the current model of care for patients with musculoskeletal disorders in Norwegian primary care, and if the English First Contact Practitioner model, where patients have access to multiple professional groups with musculoskeletal health expertise, could inform service development. DESIGN, SETTING, AND SUBJECTS: We analysed interviews with five GPs and 11 physiotherapists and used Lipsky's theories about street-level bureaucracy and Foucault's theories of mechanisms of power and institutional structures to explore task shifting and cooperation between different professions. RESULTS AND INTERPRETATION: The empirical material reflected a multi-faceted discourse about skill-mix in primary care, where financial factors, perceptions about competence, and task preferences moderated attitudes to task shifting. Competition and cooperation coexist between the professions, and the seemingly gradual blurring between historical hegemony and new models of care creates both alliances and rivalries. Examples of deviations from the Choosing Wisely principles and evidence-based practice indicate that both general practitioners and physiotherapists balance the roles of patient advocate, gatekeeper, and homo economicus, in a context where task shifting is challenged by established practice. It appears that the management of patients with musculoskeletal disorders is fragmented and to some extent reflects a supply-driven system.

The demand on primary care is placing increasing pressure on general practitioners.Multidisciplinary teamwork has potential to improve primary care, for both healthcare professionals and for patients.In this study, it appeared that both competition and cooperation exist between general practitioners and physiotherapists around the management of patients with musculoskeletal disorders in primary care.There is a case for change in service delivery for patients with musculoskeletal disorders in Norwegian primary care.

Collaborative healthcare education programmes for continuing professional education in low and middle-income countries: A Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 65.

BACKGROUND: Large discrepancies exist between standards of healthcare provision in high-income (HICs) and low and middle-income countries (LMICs). The root cause is often financial, resulting in poor infrastructure and under-resourced education and healthcare systems. Continuing professional education (CPE) programmes improve staff knowledge, skills, retention, and practice, but remain costly and rare in low-resource settings. One potential solution involves healthcare education collaborations between institutions in HICs and LMICs to provide culturally appropriate CPE in LMICs. To be effective, educational partnerships must address the challenges arising from differences in cultural norms, language, available technology and organisational structures within collaborating countries. METHODS: Seven databases and other sources were systematically searched on 7 July 2020 for relevant studies. Citations, abstracts, and studies were screened and consensus was reached on which to include within the review. 54 studies were assessed regarding the type of educational programme involved, the nature of HIC/LMIC collaboration and quality of the study design. RESULTS: Studies varied greatly regarding the types and numbers of healthcare professionals involved, pedagogical and delivery methods, and the ways in which collaboration was undertaken. Barriers and enablers of collaboration were identified and discussed. The key findings were: 1. The methodological quality of reporting in the studies was generally poor. 2. The way in which HIC/LMIC healthcare education collaboration is undertaken varies according to many factors, including what is to be delivered, the learner group, the context, and the resources available. 3. Western bias was a major barrier. 4. The key to developing successful collaborations was the quality, nature, and duration of the relationships between those involved. CONCLUSION: This review provides insights into factors that underpin successful HIC/LMIC healthcare CPE collaborations and outlines inequities and quality issues in reporting.

The use of an e-learning module on return to work advice for physiotherapists - A prospective cohort study.

Background: Nonspecific low back pain (LBP) can progress to chronic disability and prolonged absence from work. Despite clinical and professional guidelines, physiotherapists often fail to address return to work outcomes. Aims: The aim of this exploratory study was to determine whether an e-learning resource tailored to physiotherapy practice could affect physiotherapists' attitudes and beliefs regarding return to work advice for their patients. Design: A prospective interventional cohort study (pilot). Methods: Participants were recruited via the Chartered Society of Physiotherapy website. Responses on a clinical vignette, the Health Care Providers' Pain and Impairment Scale (HC-Pairs), and the Behavioral Constructs Questionnaire (BCQ) were collected online at baseline (Q1) and 2-months post-intervention (Q2). Results: Fifty-four physiotherapists completed Q1 and the response rate for Q2 was 44/54 (81%). Changes in the degree of agreement with guidelines indicated that the intervention made an impact on respondents (kappa 0.345; p = 0.003). HC-Pairs and BCQ results showed a nonstatistically significant trend toward the target behavior. Conclusions: There is a need for interventions to improve adherence with advice for return to work following nonspecific LBP. An e-learning tool for physiotherapists on advising patients regarding return to work has potential to positively affect self-reported clinical behavior.

Exploring what patients with musculoskeletal conditions want from first point-of-contact health practitioners.

OBJECTIVES: This research was conducted to support the development of the Musculoskeletal (MSK) Health Capabilities Framework to ensure that the framework reflected patients' priorities. The aim of this study was to explore what patients with MSK problems want from their initial consultation with a first contact health practitioner and, from the patient perspective, what characterizes a good first contact health practitioner. METHODS: Focus groups were held in four locations across England. Sixteen participants, aged 19-75 years and with a self-declared MSK condition, took part (11 female, five male). Participants discussed the questions they want answered when first going to see a health professional about an MSK problem and how they would describe a good first contact health provider. RESULTS: Participants wanted answers to questions about the nature of the problem, the management of the problem, where to get information and support to help themselves, what activities they can do and what the future holds. Values and behaviours they expect and value from first contact health practitioners include good communication skills, appreciation of impact, a willingness to discuss alternative and complementary therapies, shared decision-making and an awareness of their own limitations and when to refer. CONCLUSION: The MSK core capabilities framework for first contact health practitioners aims to ensure a person-centred approach in the first stages of managing any MSK problem with which a person may present. The focus groups enabled the developers of the framework to achieve a greater understanding of patient priorities, expectations and needs and allowed the patient perspective to be included in this national framework.

Developing a national musculoskeletal core capabilities framework for first point of contact practitioners.

OBJECTIVE: We aimed to support service transformation by developing a core capabilities framework for first contact practitioners working with people who have musculoskeletal conditions. METHODS: We conducted a modified three-round Delphi study with a multi-professional panel of 41 experts nominated through 18 national professional and patient organizations. Qualitative data from an open-ended question in round one were analysed using a thematic approach and combined with existing literature to shape a draft framework. Participants rated their agreement with each of the proposed 142 outcomes within 14 capabilities on a 10-point Likert scale in round two. The final round combined round two results with a wider online survey. RESULTS: Rounds two and three of the Delphi survey were completed by 37 and 27 participants, respectively. Ninety practitioners responded to the wider online survey. The final framework contains 105 outcomes within 14 capabilities, separated into four domains (person-centred approaches; assessment, investigation and diagnosis; condition management, intervention and prevention; and service and professional development). The median agreement for all 105 outcomes was at least nine on the 10-point Likert scale in the final round. CONCLUSION: The framework outlines the core capabilities required for practitioners working as the first point of contact for people with musculoskeletal conditions. It provides a standard structure and language across professions, with greater consistency and portability of musculoskeletal core capabilities. Agreement on each of the 105 outcomes was universally high amongst the expert panel, and the framework is now being disseminated by Health Education England, NHS England and Skills for Health.

Prone hip extension with lower abdominal hollowing improves the relative timing of gluteus maximus activation in relation to biceps femoris.

Hamstring injuries are common. The hamstrings and gluteus maximus (GM) work as synergists during hip extension. When contraction of GM is delayed relative to Biceps Femoris (BF) the hamstrings may be predisposed to injury due to increased demand. This study investigated whether specific training affected neuromuscular control of BF and GM during Prone Hip Extension (PHE). Twenty healthy volunteers were randomly allocated to the intervention or the control group. Mean onset times for BF and GM during PHE were recorded via surface electromyography (sEMG). The intervention group performed a 10min exercise with focus on proximal to distal muscle activation involving abdominal hollowing and active GM contraction prior to PHE. The control group undertook an exercise which included only PHE. Post exercise descriptive analysis indicated that the intervention exercise reduced the delay of GM firing relative to BF, however, when baseline differences between the two groups are taken into account as a covariant, the difference attributable to the intervention is not statistically significant (P=0.166). The results suggest that a short duration exercise intervention has the potential to alter the timing of activation of GM relative to BF during PHE but this needs validation through future research.