Background
Main text
MSK physiotherapy in the UK
A framework approach for supporting point of care ultrasound
Term | Key elements | Additional information |
---|---|---|
Scope of practice (ScoP) | Refers to the context and scope of the ultrasound imaging performed plus the interpretation/reporting of that ultrasound imaging plus the clinical decision making informed by that ultrasound imaging | ScoP allows for specifying any USI that is not going to be performed; and/or where USI is performed any interpretation/reporting not undertaken; and/or where USI is performed any clinical decision making not informed by the USI |
Education & competency | Refers to the education undertaken (both informally and formally) and subsequent assessments of competency | Transparent, purposeful and efficient education provision and competency assessments are made possible by aligning with the ScoP. Appropriate education and competency are key contributors to safety and governance |
Governance | Includes legal and professional permissions (professional and regulatory body—if different), insurance arrangements and quality assurance | These are in part informed by the ScoP; and by professional and local/national agreements; and via care pathway arrangements |
A proposed framework for point of care MSK ultrasound by physiotherapists
Scope of practice of physiotherapy in the UK
Scope of practice: clinical and sonographic
Indicative ScoPs
Indicative sonographic ScoP | ScoP 1 Observation of specific structures in the MSK system | ScoP 2 Differential (sonographic) diagnosis of specific MSK disorders and/or in specific region of the MSK system | ScoP 3 Differential (sonographic) diagnosis of any MSK disorder and/or across the MSK system |
---|---|---|---|
Further detail on sonographic ScoP | Identification of specific contractile structures (e.g., individual or group of muscles) and observation of recruitment patterns and timing | Identification of relevant tissues in MSK system (may span the full range of tissues comprising the MSK system) and subsequent differential sonographic diagnosis | |
Example tissues to be imaged | (i) Muscle bundle ± musculotendinous junction | (i) Muscle bundle (including internal architecture) and musculotendinous junction (ii) Tendon and enthesis; paratenon (iii) Cortical bone (iv) Neural tissue (v) Articular joint; synovial and joint membrane (vi) Ligaments and other connective tissue | |
Example sonographic differentials to be undertaken | None | Differentiate normal presentations (including adaptations to activity levels) from pathological processes including e.g., tendinopathy, tear (muscle, tendon, ligament, etc.), inflammation, osteophyte formation Consideration of aetiology including ageing process, trauma, overuse, surgery and pharmacology | |
Areas outside of ScoP | All; except for identification and observation of muscle bundle ± musculotendinous junction | Very few; likely exclusions: • Non-MSK elements, e.g., vascular evaluation, such as DVT • Primary exclusion of non-benign (e.g., primary or metastatic) disease in relation to scanning ‘lumps and bumps’ | |
Integration with clinical ScoP | Recruitment timing or patterns relative to pathology, kinematics, therapeutic strategies, etc. | Use of imaging findings as an adjunct to clinical assessment and reasoning to support diagnostic and monitoring processes. This may include as an outcome measure; as a therapeutic target (including via one or more of rehabilitation, surgery, pharmacological intervention, etc.) | |
Clinical context for the imaging | The MSK structures to be imaged and/or the role of ultrasound imaging is well defined a priori | The MSK structures/disorder to be imaged and/or the role of USI will be broadly defined a priori, e.g., by anatomical area or specialism’s caseload | The MSK structure /disorder to be imaged and/or the role of USI could be one or more of a wide range of presentations/indications |
Clinical examples and context | Observation of stabiliser versus prime mover muscle recruitment in a rehabilitation context | Foot and ankle imaging as part of ‘one stop’ lower limb clinic | Clinician who will have a potentially un-triaged patient population and thus potential to encounter any musculoskeletal pathology and/or in any region |
Example areas of more advanced or complex imaging | Consideration of internal muscle architecture, linear/volumetric measurements and sonographic appearance of contractile structures (including musculotendinous junction and tendon tissue) | Differential sonographic diagnosis of the shoulder complex is particularly technically challenging and requires extensive scanning experience to differentiate e.g., normal tendon variations from tendinopathic change and partial tears | The integration of imaging findings of the MSK system into assessment, management decisions, evaluation of therapeutic effect and educational strategies requires a high level of expertise For those working within the ScoP of a physiotherapist, this is arguably the most advanced role |
‘Rule in’ and ‘rule out’
Aspects outside of ScoP
Stakeholders | Utility |
---|---|
Referrer to PoCUS physiotherapist | The referring practitioner is aware of: • what the physiotherapist has the remit to scan • what can be inferred from the scan •the limitations of the scan, e.g., aspects that are out of ScoP |
Patient | In providing informed consent, the patient is aware of: • what the imaging is being performed for • what the imaging is not being performed for (as above) |
Professional body and/or regulatory body | The CSP and/or HCPC can identify that the imaging performed and the subsequent decision making is appropriate and recognisable as within scope of the profession (2, 22) |
The insurer (professional body, employer or 3rd party) | Has a reference point for what would be considered scope of practice for the physiotherapy profession Can consider the PoCUS ScoP to inform decisions around insurance coverage provision and premium |
The manager of the practitioner | Agrees and understands what the USI practitioner will be imaging and what they will be doing with that information within specific working environment Facilitates and enables the design and staffing of existing and new care pathways |
The education provider | Provides clarity regarding the requisite education content and the necessary areas for evidencing competency. This includes the clinical indication for and the clinical implementation of the sonographic information |
The practitioner | The practitioner can undertake the necessary education and competency assessment requirements; can ensure the relevant governance elements have been addressed and that practitioners upstream/downstream are aware of the remit of the scan |
Prompts for other professional groups working in MSK services in the UK; and MSK physiotherapists/physical therapists in other countries
-
What element(s) of your ScoP require defining?
-
In defining your ScoP, are there implications (education and/or governance; see next section) that will need to be aligned and communicated?
-
Is one (or more) of the indicative ScoPs aspirational? If so, consider what education and/or governance aspects (see next section) need to be addressed to ensure robust expansion of ScoP
Image-guided MSK interventions
Educational elements | Relevance to scope of practice | Teaching and assessment considerations |
---|---|---|
1. Ultrasound image generation, includes: • Fundamental physics as applied to ultrasound • Artefacts and how to manage/interpret them | MSK USI PoCUS users require an awareness of: • Sonographic representation of different MSK tissues • Limitations of sonographic image generation | Assessment strategies should evidence the application of knowledge to musculoskeletal scenarios |
2. Image optimisation, includes: • The function of ultrasound machine settings (relating back to fundamental physics principles) • ‘Knobology’ and application of image optimisations strategies in practical scenarios • Probe handling techniques | Image optimisation techniques are essential for high quality imaging practice and allows for adaptation to different ultrasound machines and clinical scenarios | Phantoms, simulators and healthy subjects may have a role in the initial teaching strategies |
3. Safety and professional considerations, includes: • Ultrasound system’s quality assurance e.g., application of ALARA (As Low As Reasonably Achievable) principles • Infection prevention and control • Use of evidence based protocols; taking and labelling of standardised views • Documentation/reporting terminology • Secure storage of images and integration with electronic patient records • Awareness of benefits and limitations of USI and role of other imaging modalities • Indications for performing a scan; includes informed patient consent | Safety considerations include those generic in ultrasound imaging and others specific to MSK scanning Standardised image taking, recording and documentation allow for consistency with other ultrasound imagers As professionals without a pre-existing foundation in imaging, awareness of the indications for, and the role of imaging modalities is essential Establishing governance procedures e.g., methods of communicating with other clinicians and optimising service provision are required | Assessment may include knowledge-based approaches e.g., written coursework but evaluation of professionalism and safety must be components of clinical competency examination |
4. Imaging of ‘normal’ anatomy, includes: • Standardised protocols to identify ‘normal’ anatomy • Implementation of patient specific adaptations in response to: o Patient habitus o Patient pain o Patient’s restricted mobility o Other clinical data e.g., patient’s functional problems, physical examination findings o Identification of tissue changes within MSK system | Awareness of the range of ‘normal’ presentations provides a reference for identifying deviations from normal Provides an opportunity to familiarise self with strategies for addressing sub-optimal imaging prior to moving onto imaging patients Incidental findings, normal variants, age appropriate MSK tissue changes must be identified | Initial learning on healthy subjects often provides opportunity to promote professional discussion e.g., the role of MSK USI can be debated when changes in MSK tissues are witnessed in peers who have no symptoms or symptoms have resolved Learning and assessment must develop to the clinical environment with symptomatic patients |
5. Integration and relevance of USI into patient’s assessment and management • Awareness of the range of sonographic presentations associated with different pathologies/clinical scenarios. Where applicable, how to perform a differential sonographic diagnosis • Clinical relevance (or otherwise) of sonographic findings, including false + ve/-ve and symptomatic versus asymptomatic structural pathology • Integration of imaging into biopsychosocial framework | An awareness of how to interpret the imaging findings, implement them into clinical decision making/treatment should be underpinned by good knowledge of musculoskeletal presentations and typical management pathways The wider impact of the imaging modality includes considering communication to patients that will facilitate understanding of their condition, prevent catastrophisation through inappropriate language whilst optimising the therapeutic alliance | Learning and assessment in clinical environment needed. Requires a range of different pathologies/clinical presentations Essential requirements include availability of suitably qualified and experienced mentor, access to an appropriate patient mix and directly supervised scanning A clinician is not competent if tissue changes have been correctly identified from USI but the clinician is unable to frame them in the overall presentation |