When presenting cases, consistently include essential information while excluding what is extraneous Write referral letters that are concise, accurate and contain all required information to accepted practice standards and are appropriate to the audience With the patient’s consent, consistently provide concise and accurate reports back to referrer and community services that contain assessment findings, working diagnosis and plan 4.2 When acting to obtain their involvement, present all relevant information to expert colleagues Provision and coordination of care 5. Evaluate referrals 5.1 Discern patients appropriate for advanced physiotherapy management in accordance with individual strengths or limitations, any legal or organisational restrictions on practice, the environment, the patient profile/needs and within defined work roles Consistently discern patients appropriate for advanced musculoskeletal physiotherapy management Consistently discern patients not appropriate for advanced musculoskeletal physiotherapy management and act to redirect the patient down the appropriate referral pathway Engage in timely discussion and referral to expert colleagues for appropriate cases Appropriately and immediately identify red flags from initial referrals Appropriately acknowledge yellow flags identified from initial referral and consider the relevance and potential influence of these Complete all necessary arrangements to facilitate triaged management plans Ensure triage decisions are documented according to organisational procedure When prioritising work, consistently apply local organisational requirements regarding patient flow 5.2 Discern patients appropriate for management in a shared-care arrangement in accordance with individual strengths or limitations, any or organisational restrictions on practice, the environment, the patient profile/needs and within defined work roles 5.3 Defer patient referrals to relevant health professionals, including other physiotherapists, when limitations of skill or job role prevent the patient’s needs from being adequately addressed or when indicated by local triage procedure
supervision of a consultant) capillary blood collection (blood glucose) collection Follow the organisation’s policies and procedures regarding the referral and requesting of pathology (consult with medical team or nurse practitioner) Convey accurate and relevant patient assessment findings to the consultant to ensure the pathology request form conveys full and accurate information, including: the right test is conducted for the right indication for the right patient clinical details are accurate details of drug therapy that may affect test or interpretation ● Describe procedures and tests to the patient accurately and in a manner they can understand and consented to ● Ensure suitable location and positions for procedural access ● Interpret a range of pathology tests relevant to the practice context in consultation with pain consultant such as blood glucose testing and full blood count 8.3 Identify the appropriate test(s) consistently and act to gain authorisation as required 8.4 Convey all required information to appropriate personnel when initiating pathology tests 8.5 Interpret routine pathology test results for patients with common and/or complex conditions, as relevant to the practice context and in consultation with expert colleagues 8.6 Meet threshold credentials and/or external learning and assessment processes set by the organisation, governing body, or legislation
Provide written information for health professionals involved in patient care regarding any changes to patient’s medication regimen initiated while being managed in the pain clinic, which is relevant to the practice context 10. Apply advanced clinical decision making 10.1 Synthesise and interpret findings from clinical assessment and diagnostic tests to confirm the diagnosis Identify relevant evidence from subjective or objective examination to support or refute differential diagnoses, with a particular focus on those that indicate pathology Display an awareness of the diagnostic accuracy of physical tests performed and discuss the effect of a positive or negative test finding on pre/post-test probabilities Demonstrate flexible thinking and revisit subjective or objective examination findings when presented with new information, either from the patient or as a result of diagnostic investigations Link radiological findings to the presenting complaint, demonstrating awareness of aberrant pathology, incidental findings, anatomical variants and normal images Consider other physiological measures and their impact on differential diagnosis Interpret the relevance of findings of pathology results and decide on further assessment or management in conjunction with appropriate medical staff Involve staff to determine appropriate management when necessary – for example, doctor, psychologist, occupational therapist Incorporate the patient/caregiver in formulating a management plan Identify the appropriate management plan for soft tissue injuries and acute and persistent spinal and peripheral 10.2 Demonstrate well-developed judgement in implementing and coordinating a patient management plan that synthesises all relevant factors
4. Communicate with colleagues 4.1 Use concise, systematic communication at the appropriate level when conversing with a range of colleagues in the practice context 4.2 Present all relevant information to expert colleagues when acting to obtain their involvement PROVISION AND COORDINATION OF CARE 5. Evaluate referrals 5.1 Discern patients who are appropriate for advanced physiotherapy management in accordance with individual strengths or limitations, any or organisational restrictions on practice, the environment, the patient profile/needs and within defined work roles 5.2 Discern patients who are appropriate for management in a shared care arrangement in accordance with individual strengths or limitations, any legal or organisational restrictions on practice, the environment, the patient profile/needs and within defined work roles 5.3 patient referrals to relevant professionals (including other physiotherapists) when limitations of skill or job role prevent the client’s needs from being adequately addressed, or when indicated by local triage procedure 5.4 Prioritise referrals based on patient profile/need, organisational procedure or targets and any local factors Communicate action taken on referrals using established organisational processes 6. Perform health assessment/examination 6.1 Design and perform an individualised, culturally appropriate and effective patient interview with common and/or complex conditions/presentations 6.2 Formulate a preliminary hypothesis and differential diagnoses for a patient with common and/or complex conditions, as relevant to the practice context 6.3 Perform complex modifications to routine musculoskeletal assessment in recognition of factors that may impact on the process such as the patient profile/needs and the practice context 6.4 Design and conduct an individualised, culturally appropriate and effective clinical assessment that: is includes relevant clinical selects and measures relevant health indicators
To perform an accurate clinical assessment of patients, the AMP describes accurately, and includes the following: The AMP is capable of describing and performing additional tests as appropriate and relevant to the practice context, for example: Dystonia Neglect like symptoms or symptoms of disturbed body perception of the affected extremity Sympathetically maintained pain may occur; there may be an evolution of signs and symptoms of variable durations Observation of posture and any associated spinal problem, muscle wasting, skin integrity, absence or presence of deformity or swelling, or protective posturing Conducts a baseline assessment Conducts a neurovascular assessment where indicated – inclusive of peripheral nerve assessment and/or thorough neurological assessment Examination techniques as appropriate, for example: Palpation Functional tests Range of motion tests Muscle strength tests Special tests as indicated Shoulder Hawkins-Kennedy impingement test Neer’s sign and test Yocum’s test Jobe’s test O’Brien’s test
The AMP is aware of the, role, indications, risks and clinical decision pathways to investigations for the diagnosis and management of the above disorders: Blood tests Biochemistry – urine analysis and joint aspirations X-rays MRI CT Nerve conduction studies (NCS) Ultrasound Common peripheral nerve blocks Common spinal nerve blocks Common infusions such as ketamine Sympathetic blocks such as cervical and lumbar The AMP is also capable of interpreting investigations (plain films, blood tests and urine tests) in order to assist in the diagnosis and/or management of the disorders stated above. The AMP is also able to identify the point at which referral for a secondary care opinion is appropriate, if applicable. Differential Diagnosis The AMP shows awareness of and can identify the following differential diagnoses: Referred pain from visceral organs inclusive of cardiac presentations Infection Malignancy and tumour Osteomyelitis Rheumatological conditions DVT, thrombosis Herpes zoster and post-herpetic neuralgia Fibromyalgia Complex regional pain syndrome
The AMP demonstrates awareness of the: The AMP is able to discuss the common neuromuscular and systemic signs and symptoms associated with endocrine dysfunction, for example: Interrelation between ‘neuromuscular’ problems such as carpal tunnel, adhesive capsulitis, peripheral diabetic neuropathy and endocrine problems The interrelation of other factors such as alcoholism and obesity with endocrine problems Chondrocalcinosis Hypothyroidism Diabetes mellitus Metabolic alkalosis/acidosis Osteoporosis Osteomalacia Paget’s disease Oncology The AMP demonstrates awareness of the possible red associated with oncological conditions The AMP is able to discuss signs and symptoms commonly associated with cancer of the: Musculoskeletal system Neurological system and demonstrate knowledge of referred pain patterns from oncological conditions Visceral/vascular The AMP demonstrates knowledge of referred pain patterns from visceral organs, for example: Heart (and vessels) Lung Kidney Stomach Intestines
Fractures Degeneration Spondylolisthesis The AMP has the ability to identify abnormal findings on film of cause that require a medical review and may be diagnosed by the medical team such as: Acute osteomyelitis Bony metastases Multiple myeloma Foreign bodies Soft tissue mass Psychology The AMP demonstrates awareness of and can briefly describe common psychological techniques and interventions for acute and persistent pain The AMP is able to recognise signs of increased risk of suicide Biopsychosocial assessment Case formulation Motivational interviewing Psycho-education Goal setting Relaxation training Biofeedback Graded exposure therapy Cognitive behavioural therapy Mindfulness Acceptance and commitment therapy Self-hypnosis Distraction Current predicament, stressors, social situation Current thoughts of suicide Previous suicide attempts or threats Drug or alcohol use Impulsiveness
Cumulative assessment tool – pain clinics Candidate’s name: Assessment timeframe: Name(s) of assessor(s) and designation: Practice context area: Pain clinic ELEMENTS AND PERFORMANCE CRITERIA Did the candidate provide evidence of the following? * The candidate must be rated as independent in all performance criteria to achieve competency. ROLE RELEVANCE (RR)(indicate) work role Performance Rating Scale Recommended Assessment (Ax) Indicate Methods Of Assessment Used Dependent (D) Marginal (M) Assisted (A) Supervised (S) Independent (I) Self-assessment (SA) Written responses (WR) Oral appraisal (OA) Documentary evidence (DE) Workplace observation (WO) Case-based presentation (CBP) Qualification/training record (Q/T) Portfolio (PF) Performance appraisal (PA) PROFESSIONAL BEHAVIOURS 1. Operate within scope of practice 1.1 Identify and act within own knowledge base and of practice OA, WO 1.2 Work towards the full extent of the role PF, PA 2. Display accountability 2.1 Demonstrate responsibility for own actions as it applies to the practice context SA, PA LIFELONG LEARNING 3. Demonstrate a commitment to lifelong learning 3.1 Engage in lifelong learning practices to maintain and extend professional competence PF, SA 3.2 Identify own professional development needs and implement strategies for achieving them PF, SA 3.3 Engage in both self-directed and practice-based learning PF, PA 3.4 Reflect on clinical practice to identify strengths and areas requiring further development CBP, SA, PA COMMUNICATION
9.5 Identify when input is required from expert colleagues and act to obtain their involvement WO, CBP, PA 9.6 Apply relevant knowledge of the medicine involved when recommending and informing patients of the risks and benefits of use WO, CBP 9.7 Exercise due care, including assessing properly the implications for individual patients receiving therapeutic medicine, as relevant to the practice context 9.8 Maintain proper clinical records as they relate to therapeutic medicine DE 9.9 Meet threshold credentials and/or external learning and assessment processes set by the organisation, governing body and national and state/territory legislation Q/T, WO, CBP, WR Q/T = University of Melbourne pharmacology subject 10. Advanced clinical decision making 10.1 Synthesise and interpret findings from clinical assessment and diagnostic tests to confirm the diagnosis WO, CBP 10.2 Demonstrate well-developed judgement in implementing and coordinating a patient management plan that synthesises all relevant factors 10.3 Use finite healthcare resources wisely to achieve best outcomes PA, WO, CBP 11. Formulate and implement a management/intervention plan 11.1 In collaboration with the patient formulate complex, evidence-based management plans/interventions as determined by patient diagnosis that are relevant to the practice context WO, CBP 11.2 Identify when guidance is required from expert colleagues and act to obtain their involvement 11.3 Facilitate all prerequisite investigations/procedures prior to consultation, referral or follow-up, as relevant to the practice context 11.4 Assess the need for referral or follow-up and arrange if necessary 11.5 Identify when input to complement care is required from other health professionals and act to obtain their involvement WO, CBP, PA 11.6 Provide appropriate education and advice to patients with common and/or complex conditions, as relevant to the practice context 11.7 Conduct a thorough handover to ensure patient care is maintained 12. Monitoring and escalation 12.1 Monitor the patient response and progress throughout the intervention using appropriate visual, verbal and physiological observations WO, CBP 12.2 Identify and respond to atypical situations that arise when implementing the management plan/intervention 13. Obtain patient consent 13.1 Explain own activity to the patient as it specifically relates to the practice context and check that the patient agrees before proceeding WO
Monitor the patient response and progress throughout the intervention appropriately 12.1, 12.2 13. Obtain patient consent Explain own activity as it specifically relates to the practice context and check that the patient agrees before proceeding 13.1 Consider the patient’s capacity for decision-making and consent 13.2 Inform of risks and confirm understanding 13.3 OPTIONAL FOLLOW-UP QUESTIONS FOR THE ASSESSOR TO CONSIDER What are the risks associated with ordering plain x-rays? What are the key principles to to minimise risk associated with plain x-rays? 7.1 What are the indications for imaging the following regions: peripheral joints (UL and LL)? spinal? What are three examples of clinical decision making rules for imaging? 7.2 What are the risks associated with pathology tests and what do clinicians requesting pathology tests need to do to minimise these risks? 8.1 Provide an example of what and when pathology tests may be indicated. What tests can be initiated by a physiotherapist? 8.2 What is the process when pathology tests are indicated but can’t be initiated by a physiotherapist? 8.3 In what situations should expert colleagues be consulted in relation to medicines and what important information needs to be conveyed? 9.5 12.2 When is over-the-counter analgesia indicated and what is the relevant information to inform patients of when recommending over-the-counter analgesia? 9.6, 9.7 When is over-the-counter analgesia not indicated? 9.7 Explain your clinical decision making. 10.1 -2 Provide an example of a situation you have faced an atypical situation and discuss how you managed the situation. 12.2 Provide an example of when input is required from expert colleagues in the care of a patient with spinal pain. Provide an example of when input is required from expert colleagues in the care of a patient with limb pain.
Subjective assessment Allergies HOPC Special questions – red flags, yellow flags, population-specific questions assessed Past medical and surgical history Current health status Medications taken on the day and usual regimen Social history Smoker/alcohol/drugs Objective assessment Neurovascular status Skin integrity Other observations Vital signs if indicated Palpation findings Functional status Range of movement Special / neuro Investigations – referral information adequate, outcome documented Reviewed by consultant? Working diagnosis/impression
Advanced musculoskeletal physiotherapist – performance appraisal Physiotherapist’s name: Date: Performance criteria: 1.2, 2.1, 3.3–4, 4.1–2, 6.1–7, 7.6, 8.4, 9.5–7, 10.3, 11.5–7, 19.7, 20.9 Please circle: Designs and performs an individualised, culturally appropriate and effective patient interview Yes No 6.1 Acts to ensure all ‘red flags’ and ‘yellow flags’ are identified in the assessment process and takes appropriate action in a timely manner Yes No 6.6 6.7 Performs complex modifications to routine musculoskeletal assessment in recognition of factors that may impact on the process such as the patient Yes No 6.3 Designs and conducts an individualised, culturally appropriate and effective clinical assessment that: is systems-based includes relevant clinical tests selects and measures relevant health indicators substantiates the provisional diagnosis Yes No 6.4 Formulates a preliminary hypothesis and differential diagnoses for a patient with common and/or complex conditions Yes No 6.2 Identifies when input is required from expert colleagues and acts to obtain their involvement Yes No 6.5 7.6 9.5 Uses concise, systematic communication at the appropriate level when conversing with colleagues Yes No 4.1 Presents all relevant information to expert colleagues, when acting to obtain their involvement Yes No 4.2 8.4 Identifies when to complement care is required from other health professionals and act to obtain their involvement Yes No 11.5 Uses finite healthcare resources wisely to achieve best outcomes Yes No 10.3 Provides appropriate education and advice to patients with common and/or complex conditions Yes No 11.6 Conducts a thorough handover, to ensure patient care is maintained Yes No 11.7 towards the full extent of their role Yes No 1.2 Takes responsibility for own actions and functions accordance with legislation, health standards and organisational policies and procedures Yes No 2.1, 19.7, 20.9 Comments: Consultant’s name: Consultant’s signature:
Example of a curriculum timeline (full-time physiotherapist who has met the selection criteria working as an advanced musculoskeletal physiotherapist in the pain clinics) ORIENTATION 1 2 Block 3 Block 4 Orientation program Workplace observation (skills checklist) with consultant LEARNING MODULES (not all modules may be required**) Radiology Radiation safety Complete quiz (80% pass rate) Communication Complete Learning analysis Part A and B and discuss in collaboration with clinical lead to develop individualised Learning and assessment plan SELF-DIRECTED LEARNING MODULES Pain conditions Cervical spine Thoracic Lumbar spine Radiology Indications for imaging Requesting imaging IN-SERVICE: Orthopaedic surgeon what makes a good surgical candidate? SELF-DIRECTED LEARNING MODULES Pain conditions limb limb Radiology Interpreting imaging IN-SERVICE: Hand surgeon: What makes a good surgical candidate for secondary wrist surgery SELF-DIRECTED LEARNING MODULES Pain conditions Visceral, head and face Pharmacology IN-SERVICE: Pharmacy or anaesthetics – analgesia SELF-DIRECTED LEARNING MODULES Pain conditions Fibromyalgia Rheumatological Differential diagnosis of conditions IN-SERVICE: Rheumatology: inflammatory conditions MEET WITH MENTOR Discuss Learning needs analysis Part A and B OBSERVE/SHADOW CLINIC ONE (1) CLINIC REDUCED CLINICAL LOAD WITH ACCESS TO CLINICAL LEAD TWO (2) CLINICS MEET WITH MENTOR Formative assessment CASE-BASED PRESENTATION 1
Block 5 Block 6 Block 7 Block 8 9 WORK-BASED COMPETENCY ASSESSMENT SELF-DIRECTED LEARNING MODULES Pathology IN-SERVICE Pathology Routine bloods SELF-DIRECTED LEARNING MODULES Psychology: Understanding common psychological conditions IN-SERVICE Psychologist: How anxiety and depression affect the experience of pain SELF-DIRECTED LEARNING MODULES Psychology: motivational interviewing IN-SERVICE Psychologist: An introduction to motivational interviewing SELF-DIRECTED LEARNING MODULES Diabetes APA modules 1, 2 IN-SERVICE: Diabetes educator REVISION Diabetes APA modules 3, 4 IN-SERVICE: Physical educator / EP: enhancing physical activity levels in people with chronic illness Present clinical log and professional practice portfolio Oral appraisal Direct workplace observation x 1–2 Written test/quiz Performance appraisal Further case-based presentations as required Skills assessment (consultant) Record-keeping audit MEET WITH MENTOR Formative assessment CASE-BASED PRESENTATION 2 MEET WITH MENTOR Formative assessment CASE-BASED PRESENTATION 3 MEET WITH MENTOR Prepare for work-based competency assessment Repeat Competency standard tool