application precautions and warnings aftercare management and patient education referrals and follow-up removal of musculoskeletal support 16. Implement care of musculoskeletal conditions in patients with diabetes 16.1 Modify routine musculoskeletal assessment in recognition of a patient’s diabetic condition, as relevant to the practice context the – and Be for Be 16.2 Modify routine musculoskeletal interventions in recognition of a patient’s diabetic condition, as relevant to the practice context 16.3 Provide patients with diabetic conditions with information relevant to altering their health behaviours and improving their health status 16.4 Identify when input is required from expert colleagues to assess and manage musculoskeletal conditions in patients with diabetes and act to obtain their involvement
and functional abilities as appropriate, to further confirm or refute differential diagnoses Identify patients presenting with non-mechanical symptoms requiring the review of another medical specialty, such as neurology or rheumatology Demonstrate advanced clinical reasoning in analysing findings Use a problem list to construct a goal-orientated management plan that the patient understands and consents to Clearly identify and prioritise patients presenting with urgent surgical requirements and/or pain management requirements, and engage the consultant to expedite further evaluation and management Perform a neurological examination with appropriate testing of reflexes, sensation, power, tone and neuro-dynamics Demonstrate ability to synthesise findings and document what is the likely underlying pathology Consistently document all areas tested, including positive and negative findings Demonstrate an advanced understanding of the evidence base for other conservative therapies, such as spinal injections and possible risks and contraindications List the types of spinal injections and what types of drugs are administered Demonstrate an awareness of anticoagulant medications and list possible complications following a spinal injection, including being on anticoagulant Document how risk is minimised when patient is scheduled to have a spinal injection motor neurone and peripheral nerve examinations with consistency in documentation standard 17.4 Identify which patients may respond to injections and have an understanding of the different types of injections, their associated risks and efficacy, and be aware when a patient is on anticoagulant medication 18. Develop and implement a management 18.1 Perform appropriate peripheral assessment with appropriate subjective examination,
Candidate’s name: Date of self-assessment: INDICATE YOUR OF CONFIDENCE AGAINST THE FOLLOWING PERFORMANCE CRITERIA 1. I require training and development in most or all of this area 2. I require further training in some aspects of this area 3. I am confident I already do this competently Underpinning skills and knowledge ROLE RELEVANCE Confidence rating scale Learning strategies 1 2 3 1. Musculoskeletal presentations Background knowledge The advanced musculoskeletal physiotherapist (AMP) has advanced knowledge in: Anatomy of the neuromusculoskeletal systems Surface anatomy Neurovascular supply Functional anatomy Physiology of the neuromusculoskeletal systems Biomechanics of the neuromusculoskeletal systems Pain mechanisms History taking The AMP is able to obtain an accurate clinical history from patient’s presenting with signs and symptoms Presenting complaint Chronological relevant sequence of events and symptoms Mechanism of injury and associated questions relating to this – for example, HS, gait aids, protective posturing Severity, irritability and nature of problem Current and past medications Past history of condition
The AMP demonstrates awareness of the: The AMP is able to discuss the 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 flags associated with oncological conditions The AMP is able to discuss signs and symptoms commonly associated with cancer of the: Musculoskeletal system Neurological system The AMP demonstrates knowledge of referred pain patterns from oncological conditions Visceral/vascular The AMP demonstrates knowledge of referred pain patterns from visceral organs, for example: (and vessels) Lung Kidney Liver Stomach Intestines
The AMP demonstrates knowledge regarding factors affecting: non-union joint stiffness AVN neurological fat embolism Sudeck’s atrophy visceral complications shortening/deformity epiphyseal arrest implant complications Plastering (ED soft tissue review clinic only) The AMP is able to describe the following: Indications for plastering Principles of plastering positioning for the pathologies listed: wrist, hand and finger fractures scaphoid fractures ankle and foot fractures Achilles ruptures Precautions and warnings relating to plastering Aftercare management The AMP can safely and effectively remove a plaster Precautions when removing synthetic casts 5. Pharmacology The AMP demonstrates knowledge of relevant state/territory legislation regarding use of medicines The AMP demonstrates an awareness of pharmacology relevant to managing Clinical pharmacology Pharmacotherapeutics Pharmacokinetics and pharmacodynamics Special considerations for certain populations (for example, paediatrics, older adults)
musculoskeletal conditions including: The AMP demonstrates knowledge about mode of action, indications, precautions and contraindications, drug interactions, adverse reactions and side effects and dosage of the following drug classes: International, national and organisational clinical guidelines in relation to medicine use Analgesics Antibiotics Anti-inflammatories Local anaesthetics Nitrous oxide Disease-modifying antirheumatic drugs (DMARDs) Neuropathic medications Corticosteroids Opioids Diabetic medications Androgen deprivation therapy (ADT) 6. Pathology The AMP demonstrates a basic understanding of three main areas relating to haematology and problems associated with these areas: The AMP can interpret simple haematological results and identifies when medical involvement is required The AMP demonstrates a basic understanding of the key areas of biochemistry The red blood cell The white blood cell Coagulation Anaemia Infection/neoplasia Thrombosis/haemorrhage and electrolyte balance Sodium and potassium The kidney Liver function tests and plasma protein Calcium Thyroid function Dehydration Renal and liver failure Diabetes
What are the risks associated with ordering plain x-rays? What are the key principles to apply to minimise risk associated with plain x-rays? 7.1 What are the indications for imaging the following regions: joints (UL and LL) and 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 may be indicated. What 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 to be conveyed? 9.5 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. Provide an example of a situation you have faced an atypical situation and discuss how you managed the situation. What are the principles of fracture management and joint reductions that indicate when input from expert colleagues are required? 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. OVERALL COMPETENCY / RESULT PERFORMANCE LEVEL Dependent Marginal Assisted Supervised Independent Date: Signature of assessor(s): Signature of candidate: 5
SPECIAL QUESTIONS / COMMENTS / FURTHER ACTION ORGANISATIONAL RECORDING PROCESSES COMPLETED Yes No Author: Last review date: Version: Next review date: BONDY RATING SCALE Scale label Standard of procedure Quality of performance of assistance required Independent (I) Safe Accurate Achieved intended outcome Behaviour is appropriate to context Proficient Confident Expedient No supporting cues required Supervised (S) Safe Accurate Achieved intended outcome Behaviour is appropriate to context Proficient Confident Reasonably expedient Occasional supportive cues Assisted (A) Safe Accurate Achieved most objectives for intended outcome Behaviour generally appropriate to context Proficient throughout most of the performance when assisted Frequent verbal and occasional physical directives in addition to supportive cues Marginal (M) Safe only with guidance Not completely accurate Incomplete achievement of intended outcome Unskilled Inefficient Continuous verbal and frequent physical directive cues Dependent (D) Unsafe Unable to demonstrate behaviour Lack of insight into behaviour appropriate to context Unskilled Unable to demonstrate behaviour/procedure Continuous verbal and physical directive cues X Not observed Reference: K N 1983, ‘Criterion-referenced definitions for rating scales and clinical evaluation’, Journal of Nursing Education, 22(9):376–381.
17.4 18.1–4 Referral and follow-up arranged appropriately 11.4 Provided appropriate education and advice to patient 11.6 Thorough handover conducted 11.7 Monitor and escalate care The patient response and progress monitored throughout the intervention appropriately 12.1–2 Obtain patient consent Own activity as it specifically relates to the practice context explained and checked that the patient agreed before proceeding 13.1 The patient’s capacity for decision making and consent considered 13.2 Patient informed of and confirmed understanding 13.3 OPTIONAL FOLLOW-UP QUESTIONS FOR THE ASSESSOR TO CONSIDER What are the associated with ordering plain x-rays? What are the key principles to apply to minimise risk associated with plain x-rays? 7.1 What are the indications for imaging the following regions: peripheral joints (UL and LL) and 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? 9.6-7 When is over-the-counter analgesia not indicated? 9.7 Explain your clinical decision making. 10.1-2 Provide an example of a situation where you have faced an atypical situation and discuss how you managed the situation. 12.2 SPECIAL QUESTIONS / COMMENTS / FURTHER ACTION OVERALL COMPETENCY/RESULT PERFORMANCE LEVEL Dependent Marginal Assisted Supervised Independent Date: Signature of assessor(s): Signature of candidate: ORGANISATIONAL RECORDING PROCESSES COMPLETED Yes No
Direct workplace observation (WO) (screening clinics): skills assessment checklist Candidate’s name: Date: Assessment linkage to competency standard: 6.3-4, 15.1–5 (ED review), 17.1, 17.3 (spinal), 18.1–3 (limb) Within each workplace observation not all performance criteria may be appropriate to be assessed. Three clinical tests per peripheral region may be chosen to be demonstrated. Once all performance criteria has been assessed as independent no further workplace observations will be required. Assessor’s name and designation: BONDY RATING SCALE label Standard of procedure Quality of performance Level of assistance required Independent (I) Safe Accurate Achieved intended outcome Behaviour is appropriate to context Proficient Confident Expedient No supporting cues required Supervised (S) Safe Accurate Achieved intended outcome Behaviour is appropriate to context Proficient Confident Reasonably expedient Occasional supportive cues Assisted (A) Safe Accurate Achieved most objectives for intended outcome Behaviour generally appropriate to context Proficient throughout most of the performance when assisted Frequent verbal and occasional physical directives in addition to supportive cues Marginal (M) Safe only with guidance Not completely accurate Incomplete achievement of intended outcome Unskilled Inefficient Continuous verbal and frequent physical directive cues Dependent (D) Unsafe Unable to demonstrate behaviour Lack of insight into behaviour appropriate to context Unskilled Unable to demonstrate behaviour/procedure Continuous verbal and physical directive cues X Not observed Reference: K N 1983, ‘Criterion-referenced definitions for rating scales and clinical evaluation’, Journal of Nursing Education, 22(9):376–381. Performance rating scale
Management/intervention plan Plan is and appropriate to diagnosis 11.1 Plan is made in collaboration with patient/family 11.1, 20.3 Input on plan is sought from colleagues appropriately and handover is adequate when indicated 11.2, 15.2–4, 16.4, Complex modifications to routine musculoskeletal intervention, evident (for example: 15 fractures, 16 diabetes, 17 spinal, 18 limb pain, 19 pain, 20 persistent pain) and includes providing appropriate patient and carer education 11.6, 15.1-4, 16.2, 17.2, 17.4, 19.4, 20.1 Referral and follow-up appointments/investigations arranged appropriately and resources used wisely 10.3, 11.3, 11.4, 11.5 Monitoring and escalation Monitor and escalate when atypical situations arise and implement the management plan/intervention appropriately 12.1, 12.2 Lifelong learning Reflection on clinical practice to identify strengths and areas requiring further development is evident 3.4 OVERALL PERFORMANCE (circle to indicate) Satisfactory Not satisfactory Signature of assessor(s): Signature of candidate: SPECIAL QUESTIONS / COMMENTS / FURTHER ACTION ASSESSMENT TASK ADDED TO ASSESSMENT RECORD Yes No N/A
Advanced musculoskeletal physiotherapist – performance appraisal Physiotherapist’s name: Date: Please Circle: Designs and performs an individualised, culturally appropriate and effective patient interview. Yes No 6.1 Acts to ensure all ‘red 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 profile/needs. 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 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 input to complement care is required from other health professionals and acts 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 Works towards the full extent of their role. Yes No 1.2 Takes responsibility for own actions. Yes No 2.1 Comments: Consultant’s name: Consultant’s signature:
Can you prioritise from attached list of referrals who should be seen in the orthopaedic or neurosurgery clinics or the ED review clinic? (this will be different for each advanced musculoskeletal physiotherapy service) 5.4 9. Apply the use of therapeutic medicines in advanced musculoskeletal physiotherapy What legislation and registration requirements relating to medicines apply to the physiotherapist working in advanced physiotherapy roles? What responsibilities apply to the physiotherapist in relation to the recommending the use of medicines to patients? 9.3, 9.4 13. Obtain patient consent What is the process if a patient refuses to be seen by a physiotherapist and requests to be seen by a doctor? 13.4 OVERALL COMPETENCE RESULT Satisfactory / unsatisfactory Date: Signature of assessor(s): Date: Signature of candidate: SPECIAL QUESTIONS / COMMENTS / FURTHER ACTION ORGANISATIONAL RECORDING PROCESSES COMPLETED Yes No Author: Last review date: Version: Next review date: Radiological interpretation of a plain-film case series: assessment tool (for the candidate)
Example of a curriculum timeline (full time physiotherapist who has met the selection criteria working as an advanced musculoskeletal physiotherapist in the orthopaedic or neurosurgery screening clinics) ORIENTATION Block 1 Block 2 Block 3 Block 4 Orientation program Workplace observation (skills checklist) with consultant SELF-DIRECTED LEARNING MODULES (not all modules may be required**) Radiology Radiation safety Complete quiz (80% pass rate) Communication Complete Learning needs analysis Part A and B and discuss in collaboration with clinical lead to develop individualised Learning and assessment plan SELF-DIRECTED LEARNING MODULES Musculoskeletal conditions Cervical spine Lumbar spine Radiology Indications for imaging Requesting imaging In-service: Orthopaedic surgeon What makes a good surgical candidate? SELF-DIRECTED LEARNING MODULES Musculoskeletal conditions Shoulder Knee Radiology Interpreting imaging In-service: Radiology Interpreting plain film? SELF-DIRECTED LEARNING MODULES Musculoskeletal conditions Hip Foot Pharmacology In-service: Pharmacy or anaesthetics – analgesia SELF-DIRECTED LEARNING MODULES Musculoskeletal Elbow Wrist Hand Thoracic spine Differential diagnosis of conditions In-service: Neurosurgery Spinal surgery 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
5 Block 6 Block 7 Block 8 Block 9 WORKPLACE COMPETENCY ASSESSMENT SELF-DIRECTED LEARNING MODULES Pathology In-service: Pathology Routine bloods SELF-DIRECTED LEARNING MODULES Diabetes APA modules 1, 2 or in-house equivalent In-service: Diabetes educator SELF-DIRECTED LEARNING MODULES Diabetes APA modules 3, 4 or in-house equivalent SELF-DIRECTED LEARNING MODULES REVISION 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