CLINICAL REVIEW: Imaging with ultrasound in physical therapy: What is the PTs scope of practice?

Imaging with ultrasound in Physical therapy: what is the PT’s scope of practice? A competency-based educational model and training recommendations. Jackie L Whittaker, 1 Richard Ellis, 2 Paul William Hodeges, 3 Cliona O’Sullivan, 4 Julie Hides, 5 Samuel Fernandez-Carnero, 6 Jose Luis Arias-Buria, 7 Deydre S Teyhen, 8 Maria J Stokes 9

Br J Sports Med 2019;53:1447-1453.doi:10.1136/bjsports-2018-100193

By Pip Sail

Abstract

There remains considerable confusion and inconsistencies in terminology associated with physical therapist use of ultrasound (US), due in part to the manner in which US is used across the profession and in part that previously identified gaps related to scope of practice and specialised training is growing. There are limited continuing education opportunities for physical therapists to become proficient in using US within their professional scope of practice.

There are 4 broad categories of physical therapy US application.

• Rehabilitative US imaging: defined as a procedure used by physical therapists to evaluate muscle and related soft tissue morphology and function during exercises and physical tasks and to assist in the application of therapeutic interventions aimed at improving neuromuscular function. 9

• Diagnostic US imaging: a procedure examining the effects of injury, lesion or disease on joint surfaces, muscle, tendon, ligament, bursa, vessels, nerves and solid visceral organs. 35 This application may be the most controversial given that traditionally these applications have been under the scope of a consulting imaging specialist. interventions. Interventional US has been utilised by physical therapists as a safety adjunct for acupuncture, 43 trigger point release, 44 and percutaneous electrolysis. 45,46

• Research US imaging: a procedure used in basic, applied, and clinical research that aims to inform physical therapy practice.

It is important to note that within each of the four categories of physical therapy US applications, a variety of US-based imaging techniques can be used depending on the clinical or research goal

In addition to a lack of regulatory oversight, surveys conducted in the UK, 67 Australia, 68 and New Zealand 41 demonstrate that there is no internationally accepted criteria for physical therapists training in US, with continuing education or mentoring opportunities varying widely across countries and no minimal competency required for US for patient care. With the rapid growth of US use by physical therapists, the profession needs clear and consistent guidelines from regulatory and professional associations to mitigate confusion about the scope of practice for physical therapists.

Each category of physical therapy US is associated with unique knowledge, skill sets and potential for perceived infringement with the scope of other healthcare practitioners. Although there are some overlapping concepts, the issues and barriers associated with specialised training, competent use and reporting differ. In the fields of diagnostic and interventional US there are established criteria for training, competent use and regulation 69 however in some countries this may not be available and it is important to consider that physical therapists gaining their US training through courses established for

other healthcare professionals may lead to physicals therapists operating outside their scope of practice.

In contrast to diagnostic and interventional US, the field of Rehabilitative Ultrasound Imaging (RUSI) lacks professional oversight, standard curriculum and regulation for training. This has resulted in a paucity of high-quality, evidence-based training opportunities; a lack of standardisation in the performance and reporting of RUSI applications; and a potential for insufficiently trained operators. 41 67 68 Entry to practice education programme, access to postgraduate education to support safe competent practice is needed.

A competency-based education model of training is suggested, driven by ‘product’ rather than process, 71 72 where learning outcomes are identified and the curriculum is built in blocks to ensure that students achieve the competencies described in the learning outcomes.

Future efforts should focus on developing international standards for self-governance of US use by physical therapists and ensuring that the training and practice standards are identified, reached and maintained. Greater interprofessional exposure to the use of US is needed to avoid inaccurate assumptions about professional infringement and the appropriate scope of practice for physical therapists. It is imperative that physical therapists continue to provide evidence that US enhances the quality, effectiveness and efficacy of physical therapy management.

A full set of references is available on request

Key note speakers Bill Vicenzino and Michael Nitschke will be presenting in miniconference format followed by a Panel Discussion with a local guest speaker in each location. Guest speakers will be announced next week. Workshops from Bill and Michael will be held before the miniconference. Spaces are limited, get in quick!

https://event.sportsmedicine.co.nz/shop/

Bill Vicenzino BPhty, GDSportsPhty, MSc, PhD (@Bill_Vicenzino)

Chair in Sports Physiotherapy University of Queensland

Bill enthusiastically pursues an understanding of the best approach to managing musculoskeletal conditions, and to its dissemination. He focuses his scholarship in the areas of injuries related to physical activity and sports participation. He achieves this as the Chair in Sports Physiotherapy, Director of the Master of Physiotherapy (Musculoskeletal, Sport) and Sports Injuries Rehabilitation and Prevention for Health (SIRPH) research unit at the University of Queensland (Australia). His clinical research has focused on such conditions as tennis elbow, gluteal tendinopathy, chronic ankle instability and patellofemoral pain, with a number of randomized clinical trials attracting NHMRC funding and being published in high impact medical journals (BMJ, Lancet, JAMA). Bill has over 200 peer reviewed publications, 2 books, 26 book chapters and over 300 invited presentations.

Michael Nitschke

BPod (2006), MAPodA, AAPSM

(@Nittaz) Sports & Arthritis Clinic, Adelaide

Michael is a Certified Sports Podiatrist (APodA) and partner in Adelaide’s Sports & Arthritis Clinic (SPARC). Hel is also a nationally competitive long distance runner and Level II advanced middle/long distance running coach (AA), and an assistance coach at Adelaide Harriers AC.

With a decade of clinical experience in private practice and exceptional anatomy and biomechanics knowledge, Michael now specialises in the diagnosis and treatment of running injuries. He is currently in the process of his post graduate research studies looking at the training characteristics of recreational runners and the relationship between performance and injury risk.

As an accomplished track athlete Michael is well versed in working with amateur, junior and elite athletes. However Michael’s passion for the sport has grown beyond that of just the competitive side. Michael is committed to growing the entire running community in South Australia by providing an innovative running service accessible to all runners, recreational and elite.

Bill Vicenzino Keynote: Persistent ankle problems: evidence based solutions.

Sideline Management

AUT North 28 th & 29 th of March 2020

This course is for registered physiotherapists who work with individual athletes, or on the sideline at sports games or events who want to upskill in the areas of pregame preparation, first aid, acute injury assessment and management, and postevent recovery strategies. By the end of the course you will have all the tools you By the end of the course you will have all the tools you need to manage pre-event preparation, postevent recovery and to confidently assess, manage and refer common sporting injuries and wounds. Register here: https://pnz.org.nz/Event?Action=View&Event_id=2874

Proposed courses for 2020 (Not limited to) Lower Limb in Sport Venue and dates TBC

This course is for registered physiotherapists who work with individual athletes or teams in which lower limb injury is common. The focus of the course is on pathomechanics and kinetic chain deficits as they relate to injury prevention and performance, diagnosis and advanced rehabilitation of lower limb conditions. By the end of the course you will understand the pathoaetiology of common lower limb injuries, be able to perform key clinical and functional tests, rehabilitate lower limb injury in a number of sporting contexts including football, running and contact sports, and develop individualised return-to-sport programmes.

Injury Prevention & Performance Enhancement.

Venue and Dates TBC

This course will provide you with the key skills used in the enhancement of sporting performance and prevention of injury. It covers the analysis of physical, biomechanical and technical needs of sport, identifying key factors affecting performance and injury prevention.

You will learn how to assess athletes and implement an individualised programme designed to optimise movement efficiency, performance and minimise injury risk. You will learn how to develop a sport–specific screening assessment, how to monitor injury rates and target injury prevention strategies within different sporting contexts.