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Background: The ability of primary care Extended Scope Physiotherapists (ESPs) to refer appropriate patients to secondary care has not been adequately examined. Also referrals for shoulder surgery from secondary care ESPs have been shown to be misdirected in comparison to other specialties. Barriers to referral have not been investigated but the literature suggests that referral criteria may improve appropriate referrals. The high prevalence of rotator cuff disease, its impact on pain and disability, and the lack of agreement between surgeons about when to operate indicate that there is a strong case for the development of surgical referral criteria for rotator cuff tear pathology. Method: The thesis has three stages of study. First a national survey of 99 primary care ESPs was undertaken to determine conversion to surgery rates, barriers to referral and the use of referral criteria. Secondly a national Delphi study with 20 shoulder surgeons was undertaken and surgical referral criteria for rotator cuff tear were developed. Thirdly after development, the criteria were tested on a convenience sample of 9 ESPs using 3 vignette case studies. Results: Primary care ESPs have a mean conversion rate of 74%. There was not enough data to show differences between subspecialist groups. Most barriers to specialist referral were associated with commissioning rather than issues pertaining to the primary care environment. 50% of ESPs reported using referral criteria which may explain why barriers to referral were relatively low. Surgical referral criteria for rotator cuff tear were developed. Key areas of consensus were: severity of pain, functional limitation, identification of fat atrophy and agreement for a trial of physiotherapy before referral. When referral criteria were piloted on a surgical candidate 33% of the ESPs changed their referral behaviour appropriately. Conclusion: ESPs in primary care have shown mean conversion rates of 74%. Surgical referral criteria to improve the appropriateness of rotator cuff tear referrals have shown promising results when piloted. Implications: In future referral criteria may have the potential to improve the appropriateness of rotator cuff referrals and may be beneficial as a benchmark against which ESPs can independently demonstrate the appropriateness and quality of the care they provide.

Background Unpredictability, time constraints and having to constantly adapt to new situations characterise modem physiotherapy practice such that everyday clinical situations can be seen to have no easy and unambiguous solutions. Physiotherapists' practice has not yet been explored in the U.K. and their voices not yet heard, as they cope with increasing workloads in the day to day realities of busy hospital departments and their continuing professional development needs. Methodology and Design An eight months in-depth investigation into a team of NHS physiotherapists' construction of their day to day practice, viewed from a social constructionist stance, was carried out. The chosen paradigm for this study was ethnography as it embraces the importance of context related to time and the person. Analysis and Findings A systematic analysis of coding, categorising and identification of themes was carried out. All observations with the participants were followed up from a reflexive stance in the quest for a co-constituted account. Four main building blocks were identified as major contributors to the construction of the team's practice: the team's relationships with their patients, their negotiation and meaning of their food activities, their use of humour and their response to the visit from the inspectors from the Commission for Health Improvement. The institutional hierarchy and the demand for leadership skills in the senior therapist were the most potent parameters of the team's practice arena. Conclusions Contrasting themes have been presented as a way to explain the everyday world of this team's practice. The senior therapists had to manage the differing requirements of training the juniors alongside their own expectation of excellence. Propositional and craft knowledge have to complement each other more and critical reflexive dialogues are a powerful vehicle to achieve this, but the bi-annual rotations put this potential at risk. Hierarchical stances within a department can 'blur' issues by deflecting the juniors' expertise.

Lateral epicondylitis (LE) is one of the most common lesions of the arm. Physiotherapy is a conservative treatment that is usually recommended for LE patients and a wide array of physiotherapy treatments is used. Two of the most common physiotherapy treatments for LE are Cyriax physiotherapy and supervised exercise programmes. More recently physiotherapists are able to use a new modality called polarised polychromatic non-coherent light (Bioptron light) for the management of LE. The clinical value of these treatments for LE is not known. The aim of this project was to investigate the clinical use and clinical effectiveness of Cyriax physiotherapy, a supervised exercise programme and polarised polychromatic non-coherent light (Bioptron light) for the treatment of LE. Systematic review (Chapter 2) found that there was strong evidence for the short-term effectiveness of acupuncture for LE. It also found that there was strong evidence that four physiotherapy modalities, low power laser light, ultrasound, extracorporeal shock wave therapy, and pulsed electromagnetic field therapy were not effective treatments for the management of LE. There was insufficient evidence available for other treatments used for LE, such as iontophoresis and home exercise programmes, to judge their effectiveness. Chapter 2 recommended that more evidence is needed for Cyriax physiotherapy, supervised exercise programmes and polarised polychromatic non-coherent light (Bioptron light). It is necessary to establish optimal protocols for these treatments before a suitable clinical trial can be designed. A critical literature review (Chapter 3) found that treatment protocols for Cyriax physiotherapy, supervised exercise programmes and polarised polychromatic non-coherent light (Bioptron light) were mainly derived from the views of advocates of these treatments, based on their personal experience. Two preliminary clinical studies were conducted to pilot the use of treatment protocols derived from the critical review in Chapter 3 on overuses injuries that were similar to LE and were regularly presented to the clinic (Chapter 4). In the first study (section 4.3) Cyriax physiotherapy did not reduce the pain in patellar tendinopathy, while the supervised exercise programme did. In the second study (section 4.4) polarised polychromatic non-coherent light (Bioptron light) reduced nocturnal pain and paraesthesia in carpal tunnel syndrome (CTS). The findings of these two pilot studies should be interpreted cautiously because the number of patients included in the patellar tendinopathy was small and in the CTS study it was not possible to attribute changes to the light per se because the study lacked a control group. Before the effectiveness of these protocols could be tested, a questionnaire survey was conducted to establish the current clinical practices of these physiotherapy treatments for LE. This survey was based on the self-reporting of chartered physiotherapists in Athens using these treatments in their clinical practice (Chapter 5). It may be confidently assumed that the results of the questionnaire present a representative view of current clinical practice of Cyriax physiotherapy, a supervised exercise programme and polarised polychromatic non-coherent light (Bioptron light) on LE at least as these treatments are applied in Athens. How much this reflects usage in the rest of the Greece, Europe, or even the world, is yet to be seen by extending the research. When the effectiveness of Cyriax physiotherapy, a supervised exercise programme and polarised polychromatic non-coherent light (Bioptron light) for LE was compared, the three treatments reduced pain and improved function at the end of the treatment and at any of the follow-up time points (Chapter 6). Whether this is due to placebo effects is not known. The supervised exercise programme produced the largest effect in the short, intermediate and long term (Chapter 6). This finding suggests that, of the three treatments, the supervised exercise programme should be used as a first treatment option when physiotherapists manage LE patients (Chapter 6; Chapter 7). If this is not possible, Cyriax physiotherapy and polarised polychromatic non-coherent light (Bioptron light) may be suitable (Chapter 6; Chapter 7). Although the three treatments are promising interventions for the management of patients with LE, further research is warranted to investigate and confirm the effectiveness of Cyriax physiotherapy, supervised exercise programmes and polarised polychromatic non-coherent light (Bioptron light) in the treatment of impairment and disability resulting from LE.

Aims: This study aims to explore the attitudes and beliefs of military physiotherapists and how these influence the management of military patients presenting with low back pain. The Armed Services require personnel who are physically fit and able to deploy operationally to inhospitable areas, including Afghanistan. Low back pain is a common condition, but within the Armed Services it can lead to medical downgrading, non-deployability and in extreme cases to medical discharge. Methods: The study was a mixed methods study undertaken in two phases. Phase 1 was a quantitative study, which utilised a valid and reliable measure of health care provider's attitudes and beliefs about functional expectations for chronic low back pain patients, the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS). Demographic data was also collected, which included; gender, rank, age range, physiotherapy experience (years), physiotherapy qualification to practice, military service (years), post registration training completed, post registration training being undertaken and self-reported number of patients seen monthly with low back pain. Statistical analysis was undertaken on the results to explore whether a statistically significant correlation existed between questionnaire score and any of the demographic factors identified. Phase 2 was a qualitative study in which semi-structured interviews were undertaken with 16 military physiotherapists. Whilst phase 1 would provide information relating to what beliefs the physiotherapists held Phase 2 would allow exploration of why these attitudes and beliefs prevailed. The transcripts were analysed using a method of thematic content analysis. Results: Results from phase 1 yielded 83 completed questionnaires, a response rate of 91 %. The military physiotherapists obtained a mean score of 50.78 (SD= 10.12) with scores ranging from 29 to 79. Higher scores on the HC-PAIRS indicate a greater acceptance of the notion that LBP is equated with disability. These results indicate the military physiotherapists were neutral to the acceptance of LBP as a legitimate cause of disability among military personnel. The results of non-parametric testing using Spearman's rho indicated a statistically significant correlation at the 0.05 level (2 tailed) between He-PAIRS score and length of military service, indicating an association between higher scores and greater length of military service. Analysis of semi-structured interviews undertaken in phase 2 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 were 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 (12/16) 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. Conclusions: The results from phase 1 indicated that military physiotherapists, with the greatest length of military service were most likely to accept disability and reduced functional expectations as a consequence of chronic low back pain. In phase 2 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. The Armed Services are a hierarchal organisation; the structure should be utilised to improve the management of low back pain in military personnel. This would benefit both patients and the Armed Services, by reducing the disability caused by low back pain, whilst increasing number of operationally deployable service personnel.

Financial constraints are constantly being put upon the rehabilitation team to prove validity of treatment and continuation of therapy (Sheldon R 2004). There are increasing demands for empirical proof of efficacy of treatment. It was thought that this device may provide a means of measurement that would help to show validity of treatment and enhance treatment method. The SmartStep™ device was 5 used to assess all incoming patients in a busy private physiotherapy clinic and the subsequent collected data was analysed. The use of the SmartSep device was compared to not using the SmartStep device and using the SmartStep device with added biofeedback. A total of 24 patients were included in the active part of the trial. Fifteen female patients with an average age of 46.7 years (range 18 - 83 years) and 9 male patients with an average age of 51.2 years (range 17 - 83 years). T tests were used to compare the controlling group with the active groups and to compare if added benefit was achieved by adding biofeedback. Though not statistically viable because of the poor confidence factor, a trend could be seen that showed greater change when the device is added and an even greater change when the biofeedback was added.

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