Extended roles for allied health professionals: an updated systematic review of the evidence

Figures & data

Figure 1 Stages of search strategy results.

Table 1 Summary of findings of articles selected for data extraction

Reference	Study design	Level of evidence	Findings
Aiken et al^Citation20	Cohort (n=76)	III-2	Comparison of clinical impressions of orthopedic surgeons versus those of physiotherapists regarding future care in a postoperative outpatient setting using a standard scoring measure. Agreement was 78%–90%. Patient satisfaction scores did not differ significantly between the surgeon and physiotherapist.
Aiken et al^Citation21	Cohort (n=107)	III-2	Comparison of treatment by APP and three orthopedic surgeons, preoperatively, postoperatively, and by telephone over period of 1 year. Thirty-four percent of participants were non-surgical. Only one surgeon allowed the APP to triage and perform preoperative screening – his waitlist dropped from an average of 140 days to 40 days; surgery times changed from a minimum of 3 months for urgent to maximum of 6 months for all surgeries; his waitlist dropped from 200 to 59, and 16 additional days were available to spend in the operating theater (48 additional joint replacements).
Aiken et al^Citation27	Cohort (n=38)	III-2	Comparison between orthopedic surgeons and physiotherapists: rating as candidate for surgery, urgency, and recommendations for treatment. Patient perception of disability and satisfaction were reported, showing 100% agreement on surgery versus no surgery. Physiotherapists rated with a higher surgical priority than the orthopedic surgeons. Surgeons had a higher agreement level with patients regarding their disability level (78%) than the physiotherapists (52%). The physiotherapist recommended education or conservative treatment (97%) more than the surgeons (16%). Patients were satisfied or very satisfied with both professions.
Anaf and Sheppard^Citation47	Qualitative (n=80)	III-3	Survey of emergency room patients regarding the role of physiotherapy in emergency departments. NVivo software and manual techniques were used to analyze themes. Six key domains emerged, ie, sports injury management, musculoskeletal care, rehabilitation and mobility, pain management, respiratory care, and elderly patient management. Patients tended to perceive more traumatic or musculoskeletal skills as key roles for physiotherapists in the emergency room.
Boissonnault et al^Citation22	Cohort (n=81)	III-3	Comparison of patient care decisions by physical therapists and physician; 100% deemed appropriate by a physician chart reviewer. Only 10% of patients were referred for X-ray, and 4%–16% referred to physician for pain management or medical consultation.
Braund and Abbott^Citation37	Survey (n=278)	III-3	Survey of physiotherapists regarding their medicine recommendations to patients (out of scope); 81% sometimes or often recommend NSAIDs and 82% recommend paracetamol, 85% report they routinely provide information on possible side effects, and 65% on potential risks.
Davis et al^Citation48	Case example	IV	Report of observations on a 5-month deployment regarding the workload division between physical therapists and orthopedic surgeons. More than 97% of musculoskeletal presentations were treated and returned to duty by the physical therapist alone.
Green et al^Citation36	Survey (n=48, representation from each year over a 10-year period)	III-2	Aimed to identify influence of postgraduate clinical master’s qualification on role extension. All respondents still working, with 83% having a clinical component to their role. Mean time from undergraduate to master’s qualification was 10.48 years; career pathway differed, with consultants achieving their post 8.7 years post qualification, 2.38 for lecturers; extended scope practitioners had their post on completion with clinical specialists 1 year prior.
Holdsworth et al^Citation12	Survey (n=117)	III-2	Survey regarding GP and physiotherapist perceptions of physiotherapy as first point of contact. High levels of confidence reported by GPs (96%) and physiotherapists (94%). Musculoskeletal referral patterns showed that 55% of physiotherapists reported an increase in referrals and 77% of GPs reported no change; 78% of all respondents reported definite benefits for musculoskeletal patients if physiotherapy involved in prescribing NSAIDs, issuing sick certificates, and requesting X-rays; 47% of physiotherapists felt that not all physiotherapists were experienced enough to be first point of contact.
Humphreys et al^Citation49	Semistructured interviews (n=6)	III-3	Collation of activities relevant to the consultant role. Five nurse consultants and one physiotherapy consultant participated in guided discussions to create an activity diary, which was then filled out for a period of 1 week. Activities grouped and hours totaled into expert practice (45.7%), leadership (28.8%), research (5.8%), and education (19.7%).
Kennedy et al^Citation31	Cohort (n=123)	III-2	Survey of patients post orthopedic surgery, comparing satisfaction with advanced practice physiotherapist and surgeon. Patient satisfaction (nine items) showed no significant difference in mean satisfaction scores between the orthopedic surgeon-led clinic versus the physiotherapy-led clinic.
Kilner and Sheppard^Citation42	Survey (n=28)	IV	Survey of emergency department physiotherapists to determine roles, including ESP. The majority reported working in the ED for 1–2 years, did not hold additional qualifications, but had undertaken further training (ie, radiology education and plastering courses). Any additional qualifications were in the musculoskeletal area. Roles included assessment and treatment, education of other ED professionals, discharge planning, and organizational and role development. Opinions divided whether performing ESP tasks (ordering X-rays, plastering) or role not different from traditional role.
Li et al^Citation35	Survey (n=258)	III-2	Survey to understand physiotherapist’s practice in arthritis care, education needs, and views on emerging professional roles. The majority of participants reported adequate coverage in undergraduate training in history-taking, pathophysiology, and exercise prescription, care pre-post surgery, and prescription of mobility aids. Almost half of the respondents (41%–56%) indicated they were not interested in being a certified, specialized practitioner in arthritis.
Lineker et al^Citation29	Retrospective cohort (n=58)	III-3	Comparison of practice for extended role practitioners (physiotherapists, occupational therapists) and experienced therapists without extended role training in arthritis care. Random charts were retrospectively reviewed. Extended role therapists saw more moderate cases, were more likely to receive referrals for assessment (52% versus 14%), treat patients who did not have a confirmed diagnosis, record comorbidities, recommend physical activity, advocate with family, provide longer length of treatment in days than experienced but non-extended role trained therapists.
Lundon et al^Citation43	Mixed methods, prospective (n=10)	III-3	Comparison to evaluate participants’ learning and competency post completion of an academic program for arthritis care. Pre– points using a theory and practical skills assessment plus a structured interview found significant changes from baseline scores.
MacKay et al^Citation50	Cohort (n=62)	III-2	Comparison of recommendations of orthopedic surgeons versus physiotherapists for future treatment using a standardized form. Agreement was 91.8%.
McClellan et al^Citation38	Survey (n=780)	III-3	Survey of patient satisfaction seen by extended scope physiotherapy in ED (with soft tissue injury). Higher satisfaction with ESP (55%) compared with emergency nurse practitioners (39%) and doctors (36%). Improved posttreatment outcomes at 4 weeks trend observed.
Passalent et al^Citation32	Survey (n=30)	III-2	Longitudinal survey over a 2-year period surveys (every 3 months) to evaluate the extended role practitioner in arthritis care. Most respondents (89%) working in an extended role worked under a medical directive (75%), and ordered X-rays (82%), laboratory tests (64%), diagnostic ultrasounds (40%), recommending medication dosage changes (70%) and joint injections (90%). A small minority made medication changes independently (4%) or performed joint injections (5%). Longest median wait for service was 22 days.
Pearse et al^Citation51	Cohort (n=150)	III-3	Retrospective cohort audit of extended scope physiotherapist activity in an outpatient orthopedic clinic. ESP managed 66% independently, and 77% of patients were satisfied with clinic visit. A higher proportion of dissatisfied patients was found in the ESP only group when compared with the group seen by surgeons.
Rhon et al^Citation52	Survey (n=107)	IV	Surveys to assess the perceptions of the impact of physiotherapists on the mission provided to physicians, physician assistants, nurse practitioners, and one dentist; 97% reported physiotherapists made a significant impact on the overall mission and 83% on patient prognosis, 92% regarded physiotherapists as experts in musculoskeletal problems, 74% felt a significant number of soldiers were able to remain in their on-site combat theater due to the presence of a physiotherapist rather than be sent home for conservative care.
Williamson et al^Citation45	Focus group interviews (n=16)	III-3	Focus group interviews of master’s program students for advanced practice roles to determine issues and concerns. Two main themes emerged, ie, opportunities for development and time pressure. Long-term benefits perceived from temporary hardship.

Abbreviations: APP, advanced practice physiotherapist; ESP, extended scope practice; ED, emergency department; NSAIDs, nonsteroidal anti-inflammatory drugs; GP, general practitioner.

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