O'Brien AV1,2, Liddle J3, Muller S1, Thomas MJ1,4, Mallen CD1
1University of Keele, Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele, Staffordshire, United Kingdom, 2University of Keele, School of Health and Rehabilitation, Keele, Staffordshire, United Kingdom, 3Newcastle University, Institute of Health & Society, Newcastle, United Kingdom, 4Haywood Academic Rheumatology Centre, Midlands Partnership NHS Foundation Trust, Physiotherapy Department, Burslem, Staffordshire, United Kingdom
Background: Despite Polymyalgia Rheumatica (PMR) being one of the most common rheumatic conditions affecting older people, physiotherapists have no evidence base to guide their clinical practice, even though international guidelines advocate their involvement.
Purpose: This qualitative study investigated UK physiotherapists' experiences of working with people with PMR, exploring their rationale for management and the challenges that they perceived were associated with this role.
Methods: Following ethical approval, participants were recruited from previously consenting survey respondents and sampled purposively, based upon their work setting and experience with PMR patients. Semi-structured telephone interviews (with open-ended and in-depth probing questions) explored referral patterns, perceived treatment priorities, and management strategies. Interviews with 17 physiotherapists, 13 female, aged 25-57 years, mean (SD) 20.2 (10.4) years post-qualification) lasted between 44-87 minutes. Eleven (65%) participants worked in more than one employment setting. Physiotherapists' experience of treating PMR in the previous year ranged from 0 to >10 patients. Interviews were recorded, transcribed verbatim and analysed using a thematic analysis.
Results: Most participants expressed their belief in a unique role for physiotherapists working with patients with PMR, while five were ambivalent about such a role. Providing bespoke activity modification and progression education via therapeutic exercise prescription was considered by physiotherapists to be their unique role within the PMR multidisciplinary team.
Three overarching themes were identified relating to the difficulties experienced managing people with PMR: physiotherapist uncertainty; complexity of presentations; and inconsistencies of practice.
The lack of evidence base, together with relatively infrequent exposure to patients with PMR, often resulted in physiotherapist uncertainty about how to provide optimal treatment. Due to infrequent referrals, PMR was not generally considered a priority and few participants had received any PMR-specific pre- or post-registration education. Participants therefore,by necessity, modified treatment approaches from other musculoskeletal conditions, leading to further professional dissatisfaction.
PMR as a rheumatic condition was perceived to be somewhat complex by some (although not all) participants. Initial differentiation between PMR-related symptoms and other MSK comorbidity, demanded advanced clinical reasoning skills in order to effectively treat and progress patients. Physiotherapists felt compelled to consider the psychological impact of PMR, before being able to progress physical therapy programmes. Managing patient fears of easily exacerbated symptoms and subsequent reluctance to engage with therapeutic exercise, was considered challenging, especially with patients taking glucocorticoids.
Various inconsistencies of practice were identified: timing and reason for patient referrals; duration of physiotherapy follow-up; and discharge criteria. Inconsistencies and differing treatment expectations/ opportunities were reported, based on work location (community, private practice or hospital settings).
Conclusion(s): Physiotherapy for PMR is under-researched, but potentially important. Participants lacked, but appeared to want PMR-specific education, most believing physiotherapy plays a valuable role in patient care. Considered challenging to successfully treat by some, there is a clear need for PMR best practice physiotherapy guidance to reduce inconsistencies, improve both patient experience and treatment outcomes.
Implications: The physiotherapy research community needs to develop an evidence-base for the management of PMR. Subsequent future clinical guidelines will then support improved physiotherapy management of patients with PMR.
Keywords: Polymyalgia Rheumatica, Physiotherapy, Qualitative
Funding acknowledgements: AO'B is supported by Christian D Mallen's NIHR Research Professorship (NIHR-RP-2014-04-026). Funders did not influence the study design.
Purpose: This qualitative study investigated UK physiotherapists' experiences of working with people with PMR, exploring their rationale for management and the challenges that they perceived were associated with this role.
Methods: Following ethical approval, participants were recruited from previously consenting survey respondents and sampled purposively, based upon their work setting and experience with PMR patients. Semi-structured telephone interviews (with open-ended and in-depth probing questions) explored referral patterns, perceived treatment priorities, and management strategies. Interviews with 17 physiotherapists, 13 female, aged 25-57 years, mean (SD) 20.2 (10.4) years post-qualification) lasted between 44-87 minutes. Eleven (65%) participants worked in more than one employment setting. Physiotherapists' experience of treating PMR in the previous year ranged from 0 to >10 patients. Interviews were recorded, transcribed verbatim and analysed using a thematic analysis.
Results: Most participants expressed their belief in a unique role for physiotherapists working with patients with PMR, while five were ambivalent about such a role. Providing bespoke activity modification and progression education via therapeutic exercise prescription was considered by physiotherapists to be their unique role within the PMR multidisciplinary team.
Three overarching themes were identified relating to the difficulties experienced managing people with PMR: physiotherapist uncertainty; complexity of presentations; and inconsistencies of practice.
The lack of evidence base, together with relatively infrequent exposure to patients with PMR, often resulted in physiotherapist uncertainty about how to provide optimal treatment. Due to infrequent referrals, PMR was not generally considered a priority and few participants had received any PMR-specific pre- or post-registration education. Participants therefore,by necessity, modified treatment approaches from other musculoskeletal conditions, leading to further professional dissatisfaction.
PMR as a rheumatic condition was perceived to be somewhat complex by some (although not all) participants. Initial differentiation between PMR-related symptoms and other MSK comorbidity, demanded advanced clinical reasoning skills in order to effectively treat and progress patients. Physiotherapists felt compelled to consider the psychological impact of PMR, before being able to progress physical therapy programmes. Managing patient fears of easily exacerbated symptoms and subsequent reluctance to engage with therapeutic exercise, was considered challenging, especially with patients taking glucocorticoids.
Various inconsistencies of practice were identified: timing and reason for patient referrals; duration of physiotherapy follow-up; and discharge criteria. Inconsistencies and differing treatment expectations/ opportunities were reported, based on work location (community, private practice or hospital settings).
Conclusion(s): Physiotherapy for PMR is under-researched, but potentially important. Participants lacked, but appeared to want PMR-specific education, most believing physiotherapy plays a valuable role in patient care. Considered challenging to successfully treat by some, there is a clear need for PMR best practice physiotherapy guidance to reduce inconsistencies, improve both patient experience and treatment outcomes.
Implications: The physiotherapy research community needs to develop an evidence-base for the management of PMR. Subsequent future clinical guidelines will then support improved physiotherapy management of patients with PMR.
Keywords: Polymyalgia Rheumatica, Physiotherapy, Qualitative
Funding acknowledgements: AO'B is supported by Christian D Mallen's NIHR Research Professorship (NIHR-RP-2014-04-026). Funders did not influence the study design.
Topic: Rheumatology; Musculoskeletal; Older people
Ethics approval required: Yes
Institution: Keele University
Ethics committee: Ethical Review Panel 3
Ethics number: Approval Ref: ERP381 (3rd February 2017).
All authors, affiliations and abstracts have been published as submitted.
