Purpose and background

A review of secondary healthcare provision for civilians suffering persistent pain and living in the British Forces Germany (BFG) community was carried out in order to better inform referral from primary care. This population consists mostly of British nationals each with differing linguistic skills and cultural backgrounds. Patients may be referred to Evangelisches Krankenhaus Bielefeld (EvKB) in Germany or to Guys and St Thomas' NHS Foundation Trust (GSTT) in the UK. It was considered important to identify potential language or cultural-related barriers to improve decision making when considering where best to refer for a pain management programme (PMP).

The study used a qualitative methodology to explore the attitudes and beliefs of military physiotherapists and how these influenced the management of military patients presenting with chronic low back pain. Semi-structured interviews were undertaken with a sample of 16 military physiotherapists; the transcripts were analysed using a method of thematic content analysis.

Analysis of semi-structured interviews undertaken resulted in the identification of six themes. These were: military culture, occupational issues, continuing professional development, clinical reasoning, need for cure and labelling the patient. The importance of understanding the occupational demands on their patients was considered highly significant by all of the military physiotherapists interviewed. However, there appeared generally poor knowledge of the biopsychosocial model in the management of low back pain and over-reliance on the medical model. Three-quarters of the military physiotherapists interviewed expressed frustration in their management of patients with low back pain. Similarly, the military physiotherapists displayed a poor awareness of current evidence-based clinical guidelines for the management of low back pain.

The themes military culture and occupational issues were significant in influencing the military physiotherapist's clinical management. The highly physical and arduous nature of military occupations resulted in investigative procedures being requested at an earlier stage than is recommended in the current evidence-based guidelines. Justification for early investigations was provided on the basis of the unique occupational factors combined with requirement to optimise the number of military personnel able to deploy operationally.

It was concluded that the management of low back pain in military personnel could be improved by increasing awareness of the current evidence-based guidelines. This would benefit both patients and the Armed Services, by reducing the disability caused by low back pain and increasing the number of operationally deployable service personnel.

Background

Low back pain is a common condition amongst Armed Services personnel and can have significant impact upon their ability to undertake military duties, including being deployed into austere environments.

The aim of the study was to investigate the attitudes and beliefs of military physiotherapists utilising the ‘Health care providers beliefs attitudes and impairments scale’ devised by Rainville et al (1994). The scale is a valid and reliable tool which indicates the likelihood of advice given to patients with a low back pain is either pro active or fear avoidant. The scale has been utilised amongst health care professionals and has shown a high degree of correlation with patient vignettes. A high score on the HC- PAIRS, is indicative of that advice given to patients is generally fear avoidant and cautious. Conversely, a low score supports current research and indicates that pro-active advice is more likely to be given to the patient.

The HC PAIRS questionnaire was distributed to all 90 military physiotherapists currently serving in a clinical role. The questionnaire was accompanied by a letter explaining that the nature of the study and requesting the questionnaire be completed and that the biographical information of gender, rank, age range, years military service, years physiotherapy experience, qualification to practice as a physiotherapist and highest academic qualification obtained be recorded.

A total of 83 returns were received. Statistical analysis was undertaken using the SPSS (version 14) statistical package. Results indicated a mean score of 50.86(SD 10.189). Military service equated to a mean of 8.86 years (SD 9.153), whilst physiotherapy experience gave a mean of 8.87 years (SD 6.327). Further statistical analysis was undertaken to establish whether there was a correlation between any of the biographical data collected and of the HC-PAIRS score. No correlation of statistical significance was identified in any of the categories.

The results obtained from the military physiotherapists are very similar to those obtained in similar studies utilising civilian physiotherapists, moderately fear avoidant. Attitudes and beliefs would appear to be developed very early in the physiotherapist’s career, exposure to both clinical experience and military culture would appear to have minimal impact on these beliefs. This has important implications when changes to traditional management strategies are being considered and implemented.

Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.

Background Changes in professional boundaries have allowed many of the tasks traditionally undertaken by doctors to be delegated to Nurses and Allied Health professionals. The employment of an appropriately experienced specialist physiotherapist in orthopaedic clinics in the NHS to triage patients is well established. This paper examines the background, establishment and outcomes of the use of a Physiotherapist Extended Scope Practitioner (ESP) in the Orthopaedic Department at the Royal Hospital Haslar, Gosport.

Method The post at RH Haslar has evolved in the five years since its implementation. All military patients referred to RH Haslar Orthopaedic Department with spinal, predominantly low back, pain are assessed in the Military Spinal Triage Clinic. The Physiotherapist ESP case-manages patients with access to radiological and haematological investigations and onward referral to other specialities as appropriate.

Results In eighteen months 235 new patients have been assessed. Only 25 patients required review by the consultant spinal surgeon, while 5 were referred to non-spinal orthopaedic consultants with shoulder/hip pathology. A total of 18 patients were referred to Pain Clinic and 3 patients to rheumatology.

The results indicate that nearly 90% (n=210) of patients who would previously been reviewed by a consultant spinal surgeon could be managed by a Physiotherapist ESP. The waiting time to spinal surgery has reduced from approximately 8 months to between 6 and 16 weeks.

Conclusions It is concluded that an appropriately trained specialist physiotherapist is clinically and economically appropriate to manage patients in an Orthopaedic Department. This has important implications for optimising patient management and additionally supports the wider clinical employment of senior military physiotherapists.