Prescribing in Physiotherapy for Pain: Difference between revisions

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<div class="editorbox"> '''Original Editor '''- [[User:Daniel Neilson|Daniel Neilson]], [[User:Darren Kripaitis|Darren Kripaitis]], [[User:David Rossiter|David Rossiter]], [[User:Mary Graham|Mary Graham]] and [[User:Rosy Cuthbert|Rosy Cuthbert]] as part of the [[Current_and_Emerging_Roles_in_Physiotherapy_Practice|Queen Margaret University's Current and Emerging Roles in Physiotherapy Practice Project]] <br>'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
<div class="editorbox"> '''Original Editor ''' - [[User:Daniel Neilson|Daniel Neilson]], [[User:Darren Kripaitis|Darren Kripaitis]], [[User:David Rossiter|David Rossiter]], [[User:Mary Graham|Mary Graham]] and [[User:Rosy Cuthbert|Rosy Cuthbert]] as part of the [[Current_and_Emerging_Roles_in_Physiotherapy_Practice|Queen Margaret University's Current and Emerging Roles in Physiotherapy Practice Project]] <br>'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>


== Introduction  ==
== Introduction  ==
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With changing demographics, higher expectations and an increase in long term conditions <ref>Department of Health. Long-term conditions compendium of information: 3rd edition. 2012; Available at: https://www.gov.uk/government/publications/long-term-conditions-compendium-of-information-third-edition. Accessed 5th November, 2015.</ref>&nbsp;there is a heightened pressure and demand on the NHS. To meet these demands the roles within the NHS have had to change and expand.  As recently as 2013, physiotherapists in England have been granted the right to independently [[Prescribing Rights in the UK|prescribe]], giving them the ability to prescribe drugs, including some controlled drugs. These prescriptions must be used “within the overarching framework of human movement, performance and function”&nbsp;<ref>NHS England Publications. Frequently Asked Questions: Independent prescribing by physiotherapists and podiatrists Publications Gateway Reference 00364 . 2013; Available at:https://www.england.nhs.uk/wp-content/uploads/2013/08/faqs-ippp1.pdf. Accessed 15th November, 2015.</ref>  
With changing demographics, higher expectations and an increase in long term conditions <ref>Department of Health. Long-term conditions compendium of information: 3rd edition. 2012; Available at: https://www.gov.uk/government/publications/long-term-conditions-compendium-of-information-third-edition. Accessed 5th November, 2015.</ref>&nbsp;there is a heightened pressure and demand on the NHS. To meet these demands the roles within the NHS have had to change and expand.  As recently as 2013, physiotherapists in England have been granted the right to independently [[Prescribing Rights in the UK|prescribe]], giving them the ability to prescribe drugs, including some controlled drugs. These prescriptions must be used “within the overarching framework of human movement, performance and function”&nbsp;<ref>NHS England Publications. Frequently Asked Questions: Independent prescribing by physiotherapists and podiatrists Publications Gateway Reference 00364 . 2013; Available at:https://www.england.nhs.uk/wp-content/uploads/2013/08/faqs-ippp1.pdf. Accessed 15th November, 2015.</ref>  


It is important for physiotherapists to understand their scope and limitations to allow them to practice within this framework, as with this change we need to ensure that we remain working within our scope of practice to give the safest and best possible&nbsp;patient centred care.&nbsp;In a narrative review, Crane and Delany<ref name="Crane and Delany 2013">Crane J, Delany C. Physiotherapists in emergency departments: responsibilities, accountability and education. Physiotherapy 2013; 99:95-100.</ref>&nbsp;comment that physiotherapists demonstrate an excellent ability to clinically reason and adapt to the changing needs of the societies they serve. The UK government has been convinced that prescribing is within physiotherapy’s scope because physiotherapists already possess the core skills that it requires.
It is important for physiotherapists to understand their scope and limitations to allow them to practice within this framework, as with this change we need to ensure that we remain working within our scope of practice to give the safest and best possible&nbsp;patient centred care.&nbsp;In a narrative review, Crane and Delany<ref name="Crane and Delany 2013">Crane J, Delany C. Physiotherapists in emergency departments: responsibilities, accountability and education. Physiotherapy 2013; 99:95-100.</ref>comment that physiotherapists demonstrate an excellent ability to clinically reason and adapt to the changing needs of the societies they serve. The UK government has been convinced that prescribing is within physiotherapy’s scope because physiotherapists already possess the core skills that it requires.


The National Prescribing Centre<ref>National Prescribing Centre., A single competency framework for all prescribers. http://www.webarchive.org.uk/wayback/archive/20140627112901/http://www.npc.nhs.uk/improving_safety/improving_quality/resources/single_comp_framework_v2.pdf (accessed 6 Nov 2015)</ref> has produced a framework that applies to all prescribers, no matter what profession they come from. Below is a comparison of this framework it to the HCPC’s Standards of Proficiency for physiotherapists<ref>Health and Care Professions Council. Standards of proficiency: Physiotherapists. http://www.hcpc-uk.co.uk/assets/documents/10000DBCStandards_of_Proficiency_Physiotherapists.pdf (accessed 11 Nov 2015).</ref>:  
The National Prescribing Centre<ref>National Prescribing Centre., A single competency framework for all prescribers. http://www.webarchive.org.uk/wayback/archive/20140627112901/http://www.npc.nhs.uk/improving_safety/improving_quality/resources/single_comp_framework_v2.pdf (accessed 6 Nov 2015)</ref> has produced a framework that applies to all prescribers, no matter what profession they come from. Below is a comparison of this framework it to the HCPC’s Standards of Proficiency for physiotherapists<ref>Health and Care Professions Council. Standards of proficiency: Physiotherapists. http://www.hcpc-uk.co.uk/assets/documents/10000DBCStandards_of_Proficiency_Physiotherapists.pdf (accessed 11 Nov 2015).</ref>:  


[[Image:Grp6 table 1.jpg|border|center|500x700px]]  
[[Image:Grp6 table 1.jpg|border|center|500x700px]]
 
== Abbreviations  ==
 
[[Image:Grp6 abbreviations.jpg|center|700x300px]]<br>
 
== Key Definitions  ==
 
*<u>Pain</u> - The ISAP define pain as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”&nbsp;<ref>Merskey H, Bogduk N. Part III: Pain terms, a current list with definitions and notes on usage. Classification of chronic pain 1994:209-214.</ref>
*<u>Extended Scope Practitioner</u> - A clinician who applies and expands their expert knowledge and skills to areas of healthcare traditionally performed by another healthcare profession, which is currently seen as outside the scope of practice of the majority of their profession.<ref>Crane J, Delany C. Physiotherapists in emergency departments: responsibilities, accountability and education. Physiotherapy 2013; 99:95-100.</ref>
*<u>Drug Classes </u>- A drug is put into a class based on the penalty it would have if there was any offence involving the drug.&nbsp;
*<u>Non-prescribers</u> - Physiotherapists without further training within the prescribing field, newly qualified Band 5’s fit within this area.<ref name="NHS FAQ 2013" />
*<u>Supplementary prescriber</u>- Those who have had some further training and have an agreed working relationship with a doctor or a dentist to implement treatment plans, any prescriptions that are written by this group must be signed off by the medical practitioner.<ref name="NHS FAQ 2013">NHS England Publications. Frequently Asked Questions: Independent prescribing by physiotherapists and podiatrists Publications Gateway Reference 00364 . 2013; Available at:https://www.england.nhs.uk/wp-content/uploads/2013/08/faqs-ippp1.pdf. Accessed 15th November, 2015.</ref>
*<u>Independent prescribers</u> - Without consultation are able to either from their own diagnosis or from a previous diagnosis prescribe medication and are fully responsible and accountable for the this. This should be done within the physiotherapist's area of expertise.<ref name="NHS FAQ 2013" />
*<u>Non-Medical Prescriber</u>&nbsp;- Any healthcare professional other than doctors or dentists who can independently prescribe medicine to a patient. This includes physiotherapists nurses, podiatrists, pharmacists, chiropodists and optometrists. <ref name="NHS FAQ 2013" />
 
== Scope of Practice ==
== Scope of Practice ==
Prescribing may appear a strange addition to a physiotherapist’s toolkit and outside the remit of the profession, which are defined by the Chartered Society of Physiotherapy<ref>Chartered Society of Physiotherapy. Medicines, prescribing and physiotherapy. file:///C:/Users/user/Downloads/csp_pd019_medicines_prescribing_physiotherapy_2013_0.pdf (accessed 25 Oct 2015)</ref> as anything within the 4 pillars of practice. These are:  
Prescribing may appear a strange addition to a physiotherapist’s toolkit and outside the remit of the profession, which are defined by the Chartered Society of Physiotherapy<ref>Chartered Society of Physiotherapy. Medicines, prescribing and physiotherapy. file:///C:/Users/user/Downloads/csp_pd019_medicines_prescribing_physiotherapy_2013_0.pdf (accessed 25 Oct 2015)</ref> as anything within the 4 pillars of practice. These are:  
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#Kindred methods of treatment
#Kindred methods of treatment


Any physiotherapist must not only work within their own personal scope of practice, but also within the scope of the profession.<ref>Chartered Society of Physiotherapy. Practice guidance for physiotherapist supplementary and/or independent prescribers in the safe use of medicines. file:///C:/Users/user/Downloads/csp_pd026_practice_guidance_prescribers_aug2013_0_0.pdf (accessed 25 Oct 2015)</ref>  Although prescribing is within the scope of the profession, like any skill, it only becomes part of an individual physiotherapist’s scope of practice when they become competent through training<ref name="CSP 1" />. This means that before prescribing is suitable addition to a physiotherapist’s skill set, they must already be an expert in the field they wish to apply it<ref name="NPC 2012" />. As a consequence, although the scope of prescribing within in physiotherapy is very wide, it is limited to only an individual's clinical specialty.<ref name="CSP 1" /> This is a major difference from medical prescribing who may prescribe for any condition.
Any physiotherapist must not only work within their own personal scope of practice, but also within the scope of the profession.<ref>Chartered Society of Physiotherapy. Practice guidance for physiotherapist supplementary and/or independent prescribers in the safe use of medicines. file:///C:/Users/user/Downloads/csp_pd026_practice_guidance_prescribers_aug2013_0_0.pdf (accessed 25 Oct 2015)</ref>  Although prescribing is within the scope of the profession, like any skill, it only becomes part of an individual physiotherapist’s scope of practice when they become competent through training<ref name="CSP 1" />. This means that before prescribing can be deemed a suitable addition to a physiotherapist’s skill set, they must already be an expert in the field they wish to apply it<ref name="NPC 2012" />. As a consequence, although the scope of prescribing within physiotherapy is very wide, it is limited to only an individual's clinical speciality.<ref name="CSP 1" /> This is a major difference from medical prescribing who may prescribe for any condition. The following pre-requisites are necessary so safely undertake the role of prescribing:
 
* Understand the legal context relevant to prescribing
<br>
* Understand pharmacodynamics, pharmacokinetics, pharmacology and therapeutics relevant to prescribing
 
* Understand different prescribing mechanisms
[[Image:Boxes.jpg|border|center]]<br>
* Able to make prescribing decisions based on relevant physical examination assessment and history taking
 
* Able to communicate information about medicines and prescriptions clearly
* Able to monitor response to medications and modify or cease treatment as appropriate within scope of practice
* Able to undertake medication calculations
* Able to identify adverse medication reactions, interactions and take appropriate action
* Able to recognise medication error and respond appropriately
Once a physiotherapist decides that prescribing would be of benefit to their practice there are two types of prescriber they can become, based on their level of training supplementary prescribers or independent subscribers.  
Once a physiotherapist decides that prescribing would be of benefit to their practice there are two types of prescriber they can become, based on their level of training supplementary prescribers or independent subscribers.  
=== Supplementary Prescribers'''<nowiki/><nowiki/>'''''<nowiki/>''  ===
=== Supplementary Prescribers ===


Supplementary prescribers can prescribe any medication, but it must be detailed in a written CMP. The CMP is created in partnership with the patient and a medical prescriber.<ref name="CSP 1" /> This means that although they are accountable for their decision to prescribe, they share accountability with the medical prescriber for the decision to put the medication in the CMP<ref name="CSP 1" />. In their nursing supplementary prescriber counterparts, this leads many doctors to feel that they have the ultimate responsibility for both the supplementary prescriber and patient. This can result in supplementary prescribers feeling subordinate, rather than in partnership with their medical prescriber.<ref>Creedon R, Byrne S, Kennedy J, McCarthy S. The impact of nurse prescribing on the clinical setting. British Journal of Nursing 2015; 24:878-885.</ref>  
Supplementary prescribers can prescribe any medication, but it must be detailed in a written CMP. The CMP is created in partnership with the patient and a medical prescriber.<ref name="CSP 1" /> This means that although they are accountable for their decision to prescribe, they share accountability with the medical prescriber for the decision to put the medication in the CMP<ref name="CSP 1" />. In their nursing supplementary prescriber counterparts, this leads many doctors to feel that they have the ultimate responsibility for both the supplementary prescriber and patient. This can result in supplementary prescribers feeling subordinate, rather than in partnership with their medical prescriber.<ref>Creedon R, Byrne S, Kennedy J, McCarthy S. The impact of nurse prescribing on the clinical setting. British Journal of Nursing 2015; 24:878-885.</ref>  
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=== Non-Prescribers ===
=== Non-Prescribers ===
The vast majority of physiotherapists globally are not prescribers and there appears to be debate regarding what their level of involvement in prescribing should be. In Australia, like in the UK, this is felt to be a legislative ‘grey’ area; different physiotherapist have different opinions on the extent of their scope regarding medicines.<ref>Morris JH, Grimmer K. Non-medical prescribing by physiotherapists: Issues reported in the current evidence. Manual Therapy 2014; 19:82-6.</ref> This is reflected in the guidance provided by professional bodies, as they feel an individual’s scope should vary depending on the depth of knowledge that they can demonstrate.<ref name="CSP 2" />  
The vast majority of physiotherapists globally are not prescribers and there appears to be debate regarding what their level of involvement in prescribing should be. In Australia, like in the UK, this is felt to be a legislative ‘grey’ area; different physiotherapists have different opinions on the extent of their scope regarding medicines.<ref>Morris JH, Grimmer K. Non-medical prescribing by physiotherapists: Issues reported in the current evidence. Manual Therapy 2014; 19:82-6.</ref> This is reflected in the guidance provided by professional bodies, as they feel an individual’s scope should vary depending on the depth of knowledge that they can demonstrate.<ref name="CSP 2" />  


Studies investigating this have found that physiotherapists are frequently asked a wide variety of questions regarding NSAIDs and often feel pressured by patients to provide advice and recommendations regarding them. Almost all felt concerned that they lacked sufficient knowledge to confidently provide this, commensurate with their duty of care to their patients.<ref name="Kumar and Grimmer 2005">Kumar S, Grimmer K. Nonsteroidal anti-inflammatory drugs (NSAIDs) and physiotherapy management of musculoskeletal conditions: a professional minefield? Therapeutics and Clinical Risk Management 2005; 1:69-76.</ref>  
Studies investigating this have found that physiotherapists are frequently asked a wide variety of questions regarding [[NSAIDs]] and often feel pressured by patients to provide advice and recommendations regarding them. Almost all felt concerned that they lacked sufficient knowledge to confidently provide this, commensurate with their duty of care to their patients.<ref name="Kumar and Grimmer 2005">Kumar S, Grimmer K. Nonsteroidal anti-inflammatory drugs (NSAIDs) and physiotherapy management of musculoskeletal conditions: a professional minefield? Therapeutics and Clinical Risk Management 2005; 1:69-76.</ref><br>There are a few very specific emergency events where a non-prescribing physiotherapist may aid the administration of drugs. If a patient brings in their medication its with instructions, in an emergency, you may administer it in accordance with these, as you are assisting them to take their prescribed medication. In an emergency, like any member of the public, a physiotherapist can also lawfully give certain life-saving POMs to someone acutely unwell without a prescription. The most important of these is adrenaline which is indicated for anaphylactic shock.<ref name="CSP 2" />  Below is a useful summary of who can prescribe and what they can prescribe<ref name="CSP 2" />:[[Image:Prescribing table.jpg|border|center]]  
 
<br>There are a few very specific emergency events where a non-prescribing physiotherapist may aid the administration of drugs. If a patient brings in their medication its with instructions, in an emergency, you may administer it in accordance with these, as you are assisting them to take their prescribed medication. In an emergency, like any member of the public, a physiotherapist can also lawfully give certain life-saving POMs to someone acutely unwell without a prescription. The most important of these is adrenaline which is indicated for anaphylactic shock.<ref name="CSP 2" />  Below is a useful summary of who can prescribe and what they can prescribe<ref name="CSP 2" />:[[Image:Prescribing table.jpg|border|center]]  
== Evidence Base For Prescribing Within Physiotherapy.  ==
== Evidence Base For Prescribing Within Physiotherapy.  ==


Overall, there is a lack of high quality evidence into the effectiveness of prescribing within physiotherapy, and this is a concern which needs to tackled by the profession.<ref>Kersten P, McPherson K, Lattimer V, George S, Breton A, Ellis B. Physiotherapy extended scope of practice - who is doing what and why? Physiotherapy 2007; 93:235-42.</ref> We speculate, however, that this may well reflect the currently low levels of qualified prescribers and the novelty of this emerging role. However, the University of Surrey is currently conducting a study to understand the impact of prescribing by physiotherapists.  Despite this, there is evidence emerging that prescribing is within the scope of physiotherapy. Effective prescribing relies on the diagnostic accuracy of the prescriber. Physiotherapists in a range of MSK advanced scope roles have be shown through randomised controlled trials and systematic reviews to have equal diagnostic skill to orthopaedic surgeons and to be more accurate than other healthcare professionals, including non-orthopaedic physicians.<ref>Desmeules F, Roy JS, MacDermid JC, Champagne F, Hinse O, Woodhouse LJ. Advance practice physiotherapy in patients with musculoskeletal disorders: A systematic review. BMC Musculoskeletal Disorders 2012; 13:1-21.</ref><ref>Daker-White G, Carr AJ, Harvey I, Wollhead G, Bannister G, Nelson I, Kammerling M. A randomised controlled trial. Shifting the boundaries of doctors and physiotherapists in orthopaedic outpatient departments. Journal of Epidemiology and Community Health 1999; 53:643-50.</ref>&nbsp;In addition to this, the UK Department of Health for the year January 2005 to January 2006 reported that of the 60,000 medication incidents, none were related to physiotherapists.<ref>Morris JH, Grimmer K. Non-medical prescribing by physiotherapists: Issues reported in the current evidence. Manual Therapy 2014; 19:82-6.</ref>
Overall, there is a lack of high-quality evidence into the effectiveness of prescribing within physiotherapy, although there are many recognised benefits.<ref>Kersten P, McPherson K, Lattimer V, George S, Breton A, Ellis B. Physiotherapy extended scope of practice - who is doing what and why? Physiotherapy 2007; 93:235-42.</ref> Effective prescribing relies on the diagnostic accuracy of the prescriber. Physiotherapists in a range of MSK advanced scope roles have been shown through randomised controlled trials and systematic reviews to have equal diagnostic skill to orthopaedic surgeons and to be more accurate than other healthcare professionals, including non-orthopaedic physicians.<ref>Desmeules F, Roy JS, MacDermid JC, Champagne F, Hinse O, Woodhouse LJ. Advance practice physiotherapy in patients with musculoskeletal disorders: A systematic review. BMC Musculoskeletal Disorders 2012; 13:1-21.</ref><ref>Daker-White G, Carr AJ, Harvey I, Wollhead G, Bannister G, Nelson I, Kammerling M. A randomised controlled trial. Shifting the boundaries of doctors and physiotherapists in orthopaedic outpatient departments. Journal of Epidemiology and Community Health 1999; 53:643-50.</ref>&nbsp;In addition to this, the UK Department of Health for the year January 2005 to January 2006 reported that of the 60,000 medication incidents, none were related to physiotherapists.<ref>Morris JH, Grimmer K. Non-medical prescribing by physiotherapists: Issues reported in the current evidence. Manual Therapy 2014; 19:82-6.</ref>[[Image:Physio prescribing evidence.jpg|border|center]]
 
From the body of evidence regarding the more established nurse prescribing, it has been found that patients have embraced this due to the ease of access, reduced waiting times, knowledge, safety and holistic nature of nurse practice.<ref name="Creedon et al 2015" /> Norman et al.<ref>Norman IJ, Coster S, McCrone P, Sibley A, Whittlesea C. A comparison of the clinical effectiveness and costs of mental health nurse supplementary prescribing and independent medical prescribing: a post-test control group study. BMC Health Services Research 2010; 10:1-9.</ref>&nbsp;have also found that non-medical prescribing made no difference to self-reported adherence to medication regimes, compared to medical prescribing in the mental health setting. We can tentatively assume that some of these may be shared features, as the role within physiotherapy expands.
 
The effect on patients should be the most important aspect for any change in role, and Gimore et al.<ref>Gimore LG, Morris JH, Murphy K, Grimmer-Somers K, Kumar S. Skills escalator in allied health: a time for reflection and refocus. Journal of Healthcare Leadership 2011; 3:53-8.</ref>&nbsp;comment that professions should only expand their scope when there is a clear patient need. Within the nursing profession, patients' opinions on nurse prescribing have become increasingly favourable as more patients experience it.<ref name="Creedon et al 2015" /> They report that patients are very satisfied and feel confident with nurse prescribing. This paper believes that key to this is the nurse-patient relationship, as patients find them easier to speak to, better at communicating and more likely to implement shared decision making than doctors.<ref name="Creedon et al 2015" /> Norman et al.<ref name="Norman et al 2010">Norman IJ, Coster S, McCrone P, Sibley A, Whittlesea C. A comparison of the clinical effectiveness and costs of mental health nurse supplementary prescribing and independent medical prescribing: a post-test control group study. BMC Health Services Research 2010; 10:1-9.</ref>&nbsp;also found the only significant difference between nurse supplementary prescribing and medical prescribing in the mental health setting was that of the higher patient satisfaction in those allocated to nurse prescribers. The general public has also expressed an opinion that they support nurse prescribing, and that non-medical versus medical prescribers would make little difference to their adherence.<ref>Berry D, Courtenay M, Bersellini E, Attitudes towards, and information needs in relation to supplementary nurse prescribing in the UK: an empirical study. Journal of Clinical Nursing 2006; 15:22-8</ref> In addition to this, a national survey of nurses and pharmacists in 2008<ref name="Cooper et al 2008">Cooper R, Anderson C, Avery T, Bissell P, Guillaume L, Hutchinson A, et al. Stakeholders' views of UK nurse and pharmacist supplementary prescribing. J Health Serv Res Policy 2008 Oct;13(4):215-221.</ref>&nbsp;suggested that their non-medical prescribing was also highly accepted by both the patient and MDT.
 
This has been reflected in the preliminary findings for physiotherapy. Physiotherapists working in an extended scope, including supplementary prescribing, in emergency departments have been shown to produce higher satisfaction rates than doctors or extended nurse practitioners. Patients felt they reduced waiting times and spent more time giving better advice and explanations, which educated and empowered them.<ref name="McClellan et al 2006">McClellan CM, Greenwood R, Benger JR. Effect of an extended scope of physiotherapy service on patient satisfaction and the outcome of soft tissue injuries in an adult emergency department. Emergency Medicine Journal 2006; 23:384-7.</ref> In a systematic review, physiotherapists have been noted to provide significantly more advice, prescribe less medication and have higher rates of patient satisfaction than doctors.<ref name="Desmeules et al 2012">Desmeules F, Roy JS, MacDermid JC, Champagne F, Hinse O, Woodhouse LJ. Advance practice physiotherapy in patients with musculoskeletal disorders: A systematic review. BMC Musculoskeletal Disorders 2012; 13:1-21</ref> In their literature review, Kersten et al.&nbsp;<ref name="Kersten et al 2007">Kersten P, McPherson K, Lattimer V, George S, Breton A, Ellis B. Physiotherapy extended scope of practice - who is doing what and why? Physiotherapy 2007; 93:235-42</ref>&nbsp;found that the vast majority of sources were supportive of physiotherapists working in extended scope roles.<br> [[Image:Physio prescribing evidence.jpg|border|center]]


== Traditional Physiotherapists Treatment of Pain ==
== Traditional Physiotherapists Treatment of Pain ==
Physiotherapists are often referred patients whose main complaint is pain.  It is therefore important to understand the nature, cause, pathology of pain and also whether it is acute or chronic. Below is a brief summary of pain, however, for a more detailed explanation of pain see <u></u><u></u>&nbsp;[[Pain Mechanisms|Pain Mechanisms]]<br><span style="line-height: 1.5em; font-size: 13.28px;">nociceptive and a combination of both. Below is a diagram summary of these:</span><span style="line-height: 1.5em; font-size: 13.28px;">&nbsp;[[Image:Grp6 pain2.jpg]]</span>
Physiotherapists are often referred patients whose main complaint is pain.  It is therefore important to understand the nature, cause, pathology of pain and also whether it is acute or chronic. Below is a brief summary of pain, however, for a more detailed explanation of pain see [[Pain Mechanisms|Pain Mechanisms]]<br>[[Image:Grp6 pain2.jpg]]
<div style="font-size: 13.28px; line-height: 19.92px;"></div><div>
== Traditional Management Method ==
== Traditional Management method  ==


<br>To manage pain physiotherapists use a biopsychosocial approach, factoring in not just the biological but the psychological and social aspects that can influence a patient's perception of pain. We do this as evidence has shown that pain, catastrophising and social support have a statistically significant impact on future function&nbsp;<ref>Jensen MP, Moore MR, Bockow TB, Ehde DM, Engel JM. Psychosocial factors and adjustment to chronic pain in persons with physical disabilities: a systematic review. 2011 Arch Phys Med Rehabil</ref>. Recovery time may also be impacted by the belief the patient has on their recovery time.<ref>Ramond A, Bouton C, Richard I, Roquelaure Y, Baufreton C, Legrand E, et al. Psychosocial risk factors for chronic low back pain in primary care--a systematic review. Fam Pract 2011 Feb;28(1):12-21.</ref>  
To manage pain physiotherapists use a biopsychosocial approach, factoring in not just the biological but the psychological and social aspects that can influence a patient's perception of pain. We do this as evidence has shown that pain, catastrophising and social support have a statistically significant impact on future function<ref>Jensen MP, Moore MR, Bockow TB, Ehde DM, Engel JM. Psychosocial factors and adjustment to chronic pain in persons with physical disabilities: a systematic review. 2011 Arch Phys Med Rehabil</ref>. Recovery time may also be impacted by the belief the patient has on their recovery time.<ref>Ramond A, Bouton C, Richard I, Roquelaure Y, Baufreton C, Legrand E, et al. Psychosocial risk factors for chronic low back pain in primary care--a systematic review. Fam Pract 2011 Feb;28(1):12-21.</ref>


<br>In Breivik et al.'s<ref name="Breivik et al 2006">Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. European journal of pain 2006;10(4):287-287</ref> study of pain in Europe it was found that 2/3rds of the population questioned were being treated either additionally or solely by non medicated means, including 30% for massage and 21% for physical therapy. Evidence suggests that GP care alone is not as effective as a combined approach of more exercise, education and traditional care<ref>Lin CC, Haas M, Maher CG, Machado LA, van Tulder MW. Cost-effectiveness of general practice care for low back pain: a systematic review. European Spine Journal 2011;20(7):1012-1023.</ref>. Currently physiotherapists use various evidence based means to support those with pain, this includes exercise therapy, cognitive behavioural therapy, acceptance and commitment therapy and potentially an increasing use medication to support their patients<ref>CSP. Physiotherapy works: Chronic pain. 15 April 2014; Available at: http://www.csp.org.uk/professional-union/practice/your-business/evidence-base/physiotherapy-works/chronic-pain. Accessed 1st November, 2015.</ref>. &nbsp;A Cochrane review agreed with these findings that for LBP physiotherapy treatment combined with physical conditioning and cognitive behaviour treatment, reduced the number of sick days for this group. Evidence has been shown that this physiotherapy treatment can improve quality of life and daily function <ref>Malmros B, Mortensen L, Jensen MB, Charles P. Positive effects of physiotherapy on chronic pain and performance in osteoporosis. Osteoporosis Int 1998;8(3):215-221.</ref>. Marienke et al.<ref>Van Middelkoop M, Rubinstein SM, Kuijpers T, Verhagen AP, Ostelo R, Koes BW, et al. A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. European Spine Journal 2011;20(1):19-39.</ref> in a systematic review of the managment of chronic pain found that there was a general low quality of evidence, but exercise therapy, behavioural treatment and working with an MDT approach all had some evidence to support their use. Traditionally these methods are shown to have a good evidence base, but by adding the ability to presribe physiotherapists should have even more tools to support those in pain.  
<br>In Breivik et al.'s<ref name="Breivik et al 2006">Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. European journal of pain 2006;10(4):287-287</ref> study of pain in Europe it was found that 2/3rds of the population questioned were being treated either additionally or solely by non medicated means, including 30% for massage and 21% for physical therapy. Evidence suggests that GP care alone is not as effective as a combined approach of more exercise, education and traditional care<ref>Lin CC, Haas M, Maher CG, Machado LA, van Tulder MW. Cost-effectiveness of general practice care for low back pain: a systematic review. European Spine Journal 2011;20(7):1012-1023.</ref>. Currently physiotherapists use various evidence based means to support those with pain, this includes exercise therapy, cognitive behavioural therapy, acceptance and commitment therapy and potentially an increasing use medication to support their patients<ref>CSP. Physiotherapy works: Chronic pain. 15 April 2014; Available at: http://www.csp.org.uk/professional-union/practice/your-business/evidence-base/physiotherapy-works/chronic-pain. Accessed 1st November, 2015.</ref>. A Cochrane review agreed with these findings that for LBP physiotherapy treatment combined with physical conditioning and cognitive behaviour treatment, reduced the number of sick days for this group. Evidence has been shown that this physiotherapy treatment can improve quality of life and daily function <ref>Malmros B, Mortensen L, Jensen MB, Charles P. Positive effects of physiotherapy on chronic pain and performance in osteoporosis. Osteoporosis Int 1998;8(3):215-221.</ref>. Marienke et al.<ref>Van Middelkoop M, Rubinstein SM, Kuijpers T, Verhagen AP, Ostelo R, Koes BW, et al. A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. European Spine Journal 2011;20(1):19-39.</ref> in a systematic review of the managment of chronic pain found that there was a general low quality of evidence, but exercise therapy, behavioural treatment and working with an MDT approach all had some evidence to support their use. Traditionally these methods are shown to have a good evidence base, but by adding the ability to presribe physiotherapists should have even more tools to support those in pain.
== The Impact of Medication in Physiotherapy  ==
Knowledge of drugs indications and side effects are important when determining whether a patient would benefit from them. If a patient has already been prescribed any of these drugs, management may vary e.g. MSK pain- a patient may be more tolerant of certain exercise because of their reduced pain, the physiotherapist would have an idea of how much to push the patient.<br>Drugs affecting mood/sleep tolerance also have an impact on rehabilitation, allowing specific treatment plans to be adjusted in a patient centred manner.


<br>
The message should also be delivered to the patient that no drug works perfectly, and knowledge of their side effects should be made known. All physiotherapists should have sufficient competence to advise patients on where to obtain appropriate medication advice, as patients perceive physiotherapists to have up to date knowledge in this area<ref name="Kumar and Grimmer 2005" />.
</div>
 
== '''Drugs and Their Impact on Physiotherapy'''  ==


== <span style="font-size: 19.92px; line-height: 1.5em; background-color: initial;">Effect of drugs on the nervous system&nbsp;</span>  ==
=== Effect of Drugs on the Nervous System  ===


Drugs interfere with the transmission of nerve impulses following noxious (harmful) stimulation, occurring at peripheral or central channels sites. The intention of administering analgesic drugs is to modulate the formation of noxious chemicals or to modulate the activation of neuronal channels transmitting noxious stimuli<ref name="Stein 2013">Stein C. Opioids, sensory systems and chronic pain. Eur J Pharmacol 2013;716(1):179-187.</ref>.  
Drugs interfere with the transmission of nerve impulses following noxious (harmful) stimulation, occurring at peripheral or central channels sites. The intention of administering analgesic drugs is to modulate the formation of noxious chemicals or to modulate the activation of neuronal channels transmitting noxious stimuli<ref name="Stein 2013">Stein C. Opioids, sensory systems and chronic pain. Eur J Pharmacol 2013;716(1):179-187.</ref>.  
=== Drug Types Used for Chronic Pain  ===


<br>
* Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
 
* Opioids
== Drug Types Used for Chronic Pain  ==
* Antidepressants
 
* Muscle relaxants
•Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)<br>•Opioids<br>•Antidepressants<br>•Muscle relaxants<br>•Serotonergic compounds,<br>•Antiepileptics
* Serotonergic compounds,
 
* Antiepileptics
Interestingly different countries place different focus on which drugs are the most effective for the treatment of pain as the table below demonstrates<ref name="Breivik et al 2006" />.
 
[[Image:Grp6_table_4.png]]<br>
 
<br>As can be seen from the above, the most common drugs used in both Europe and in the UK were opioids and NSAIDs. Both have disadvantages that physiotherapists should be aware of. For this reason, these drug types will be elaborated upon in the following section.
 
<br>
 
== NSAIDs&nbsp;  ==
 
<br>Examples of NSAIDs commonly used to treat pain:<br>•Ibuprofen<br>•Naproxen
 
Taking NSAIDs causes general inhibition of target enzymes (cyclooxygenases I and II) which reduces inflammation, however, they can lead to major health issues affecting the GI tract, mucosal protection and gut motility<ref>Wehling M. Non-steroidal anti-inflammatory drug use in chronic pain conditions with special emphasis on the elderly and patients with relevant comorbidities: management and mitigation of risks and adverse effects. Eur J Clin Pharmacol 2014;70(10):1159-1172.</ref>. Side effects can lead to ulcers, renal failure, heart failure and atherosclerosis<ref name="Wehling 2014">Wehling M. Non-steroidal anti-inflammatory drug use in chronic pain conditions with special emphasis on the elderly and patients with relevant comorbidities: management and mitigation of risks and adverse effects. Eur J Clin Pharmacol 2014;70(10):1159-1172</ref>. These health risks are known but often neglected in practice. For these reasons, NSAIDs are not recommended for long term use in chronic pain, “alternative drugs, low-dose/short-term use, but especially nonpharmacologic approaches, such as physiotherapy, exercise, neurophysiologic measures, and local therapies”<ref name="Wehling 2014" /> should be priorities in management.
 
Contraindications: patients with a history of peptic ulcer, myocardial infarction (MI), stroke or heart failure, or with impaired renal function<ref>Conaghan PG. A turbulent decade for NSAIDs: update on current concepts of classification, epidemiology, comparative efficacy, and toxicity. Rheumatol Int 2012;32(6):1491-1502.</ref>.
 
[[Image:Grp6 exclamation.jpg|border|left|40x40px]]'''Interesting fact: In the USA alone, NSAIDs accounted for approximately 98 million prescriptions in 2012. Their long-term use is a leading cause of morbidity<ref name="Conaghan 2012">Conaghan PG. A turbulent decade for NSAIDs: update on current concepts of classification, epidemiology, comparative efficacy, and toxicity. Rheumatol Int 2012;32(6):1491-1502</ref>.'''
 
<br>


== Opioids&nbsp; ==
The following table highlights how countries place different focus on which drugs are the most effective for the treatment of pain<ref name="Breivik et al 2006" />.  The most common drugs used in both Europe and in the UK were opioids and NSAIDs. Both have disadvantages that physiotherapists should be aware of.  


<br>These drugs are classed as A, B or C. All controlled drugs for injection are bracketed under Class A <ref name="HCPC 2015">HCPC.,  Medicines and prescribing.  Available from: http://www.hpc-uk.org/aboutregistration/medicinesandprescribing/ [Accessed 26th October 2015]</ref>.
[[Image:Grp6_table_4.png]]<br>


<span style="font-size: 13.28px; line-height: 1.5em;">[[Image:Opioid_Table.jpg|center]]&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Information gathered from the British National Formulary&nbsp;<br>  
==== NSAIDs ====
Taking [[NSAIDs]] causes general inhibition of target enzymes (cyclooxygenases I and II) which reduces inflammation, however, they can lead to major health issues affecting the GI tract, mucosal protection and gut motility<ref>Wehling M. Non-steroidal anti-inflammatory drug use in chronic pain conditions with special emphasis on the elderly and patients with relevant comorbidities: management and mitigation of risks and adverse effects. Eur J Clin Pharmacol 2014;70(10):1159-1172.</ref>. Side effects can lead to ulcers, renal failure, heart failure and atherosclerosis<ref name="Wehling 2014">Wehling M. Non-steroidal anti-inflammatory drug use in chronic pain conditions with special emphasis on the elderly and patients with relevant comorbidities: management and mitigation of risks and adverse effects. Eur J Clin Pharmacol 2014;70(10):1159-1172</ref>. These health risks are known but often neglected in practice. For these reasons, NSAIDs are not recommended for long term use in chronic pain, “alternative drugs, low-dose/short-term use, but especially nonpharmacologic approaches, such as physiotherapy, exercise, neurophysiologic measures, and local therapies”<ref name="Wehling 2014" /> should be priorities in management. They are contraindicated in patients with a history of peptic ulcer, myocardial infarction (MI), stroke or heart failure, or with impaired renal function<ref>Conaghan PG. A turbulent decade for NSAIDs: update on current concepts of classification, epidemiology, comparative efficacy, and toxicity. Rheumatol Int 2012;32(6):1491-1502.</ref>.Examples of NSAIDs commonly used to treat pain:
* Ibuprofen
* Naproxen


<br>
==== Opioids  ====


=== Communal opioid effects ===
These drugs are classed as A, B or C. All controlled drugs for injection are bracketed under Class A <ref name="HCPC 2015">HCPC.,  Medicines and prescribing.  Available from: http://www.hpc-uk.org/aboutregistration/medicinesandprescribing/ [Accessed 26th October 2015]</ref>.  Opioids work by attaching to proteins known as opioid receptors in the brain and spinal cord to reduce the perception of pain. However, persistent use of these drugs can produce a tolerance whereby their effects decrease with repeated use of the same dose, so that increasing doses need to be used to gain the same effect. Abrupt cessation of opioid use can then lead to hyperplasia- a heightened sensitivity to pain


<br>By attaching to proteins known as opioid receptors in the brain and spinal cord they reduce the perception of pain. However, persistent use of these drugs can produce a tolerance whereby their effects decrease with repeated use of the same dose, so that increasing doses need to be used to gain the same effect. Abrupt cessation of opioid use can then lead to hyperplasia- a heightened sensitivity to pain<ref name="Stein 2013" />.  
[[Image:Opioid_Table.jpg|center]]&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Information gathered from the British National Formulary&nbsp;<br>Opioids are often used for:
* Acute pain following surgery
* Palliative care
* Headaches
* [[Fibromyalgia]]
* [[Rheumatoid Arthritis|Rheumatoid arthritis]]
* [[Cancer Pain|Cancer pain]]
Addiction is also a problem with use of opioids, with overdoses and abuse of prescriptions becoming a health issue as people crave the relief and the feelings of euphoria associated with them<ref name="CDC 2012">Centers for Disease Control and Prevention (CDC). CDC grand rounds: prescription drug overdoses - a U.S. epidemic. MMWR Morb Mortal Wkly Rep 2012 Jan 13;61(1):10-13.</ref>.


Addiction is also a problem with use of opioids, with overdoses and abuse of prescriptions becoming a health issue as people crave the relief and the feelings of euphoria associated with them<ref name="CDC 2012">Centers for Disease Control and Prevention (CDC). CDC grand rounds: prescription drug overdoses - a U.S. epidemic. MMWR Morb Mortal Wkly Rep 2012 Jan 13;61(1):10-13.</ref>. An interesting insight to this problem was documented in a BBC programme<ref name="BBC">BBC one. Panorama, Hooked on painkillers. Documentary. Available from : http://www.bbc.co.uk/iplayer/episode/b06nzl6d/panorama-hooked-on-painkillers [Accessed 28th October 2015]</ref>:
=== Efficacy of Using Opioids: Drug Therapy vs Alternative Treatment ===
<center>{{#ev:youtube|CMvK4LGqEkM}}</center>
=== Other conditions associated with opioid use ===


<br>•Acute pain following surgery<br>•Palliative care<br>•Headaches/fibromyalgia<br>•Rheumatoid arthritis<br>•Cancer pain
Long-term pharmacological treatment of Chronic Non-Cancer Pain (CNCP) is highly disputed. Non-opioids (e.g. NSAIDs) can induce gastrointestinal ulcers, bleeding or cardiovascular complications<ref name="Trelle et al 2011">Trelle S, Reichenbach S, Wandel S, Hildebrand P, Tschannen B, Villiger PM, et al. Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis. BMJ 2011 Jan 11;342:c7086.</ref>. However, opioids can produce cognitive impairments, tolerance and addiction<ref name="Von Korff et al 2011">Von Korff M, Kolodny A, Deyo RA, Chou R. Long-term opioid therapy reconsidered. Ann Intern Med 2011;155(5):325-328</ref>. All patients taking opioids are also at risk of attaining withdrawal symptoms.  
 
<br>
 
== Efficacy of using opioids: drug therapy vs alternative treatment  ==
 
<br>Long-term pharmacological treatment of Chronic Non-Cancer Pain (CNCP) is highly disputed. Non-opioids (e.g. NSAIDs) can induce gastrointestinal ulcers, bleeding or cardiovascular complications<ref name="Trelle et al 2011">Trelle S, Reichenbach S, Wandel S, Hildebrand P, Tschannen B, Villiger PM, et al. Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis. BMJ 2011 Jan 11;342:c7086.</ref>. However, opioids can produce cognitive impairments, tolerance and addiction<ref name="Von Korff et al 2011">Von Korff M, Kolodny A, Deyo RA, Chou R. Long-term opioid therapy reconsidered. Ann Intern Med 2011;155(5):325-328</ref>. All patients taking opioids are also at risk of attaining withdrawal symptoms.  


A study by Reinecke ''et al''. <ref name="Reinecke et al 2015">Reinecke H, Weber C, Lange K, Simon M, Stein C, Sorgatz H. Analgesic efficacy of opioids in chronic pain: recent meta‐analyses. Br J Pharmacol 2015;172(2):324-333</ref> suggested that the treatment of chronic pain with opioids compared to traditional physiotherapy and psychological treatment was not significantly better in terms of pain intensity, functioning and quality of life. However, as each patient has individual benefits and side effects, efficacy of their treatment cannot be objectively predetermined. It is worth noting the study did not last longer than 3 months and there was significant dropout rates due in part to adverse side effects of the drugs.  
A study by Reinecke ''et al''. <ref name="Reinecke et al 2015">Reinecke H, Weber C, Lange K, Simon M, Stein C, Sorgatz H. Analgesic efficacy of opioids in chronic pain: recent meta‐analyses. Br J Pharmacol 2015;172(2):324-333</ref> suggested that the treatment of chronic pain with opioids compared to traditional physiotherapy and psychological treatment was not significantly better in terms of pain intensity, functioning and quality of life. However, as each patient has individual benefits and side effects, efficacy of their treatment cannot be objectively predetermined. It is worth noting the study did not last longer than 3 months and there was significant dropout rates due in part to adverse side effects of the drugs.  
Line 147: Line 110:
Randomised controlled trials with the same control e.g a placebo, and with the same outcome measure e.g. pain score, are not always directly comparable between individuals. There is also generally a lack of longitudinal studies demonstrating long-term effects of opioid usage for chronic pain patients. Guidelines therefore recommends medication should be maintained or halted based on individual monitoring over time.  
Randomised controlled trials with the same control e.g a placebo, and with the same outcome measure e.g. pain score, are not always directly comparable between individuals. There is also generally a lack of longitudinal studies demonstrating long-term effects of opioid usage for chronic pain patients. Guidelines therefore recommends medication should be maintained or halted based on individual monitoring over time.  


==  Impact on physiotherapy treatment  ==
==  Conclusion   ==
 
<br>Knowledge of drugs indications and side effects are important when determining whether a patient would benefit from them. If a patient has already been prescribed any of these drugs, management may vary e.g. MSK pain- a patient may be more tolerant of certain exercise because of their reduced pain, the physiotherapist would have an idea of how much to push the patient.<br>Drugs affecting mood/sleep tolerance also have an impact on rehabilitation, allowing specific treatment plans to be adjusted in a patient centred manner.
 
The message should also be delivered to the patient that no drug works perfectly, and knowledge of their side effects should be made known. All physiotherapists should have sufficient competence to advise patients on where to obtain appropriate medication advice, as patients perceive physiotherapists to have up to date knowledge in this area<ref name="Kumar and Grimmer 2005" />.
 
<br>
 
== UK Legislation  ==
 
In addition to the legislation governing the process of qualification and registration as a prescriber, there are a variety of laws classifying drugs that both prescribers and non-prescribers should be aware of.
 
Prescription only medicines (POMs) can only be sold and/or supplied with a prescription from an appropriate practitioner (a doctor, dentist, or other independent or supplementary prescriber)<br>Pharmacy medicines (P) can only be sold or supplied at registered pharmacy premises or under the supervision of a pharmacist<br> Medicines on the general sale list (GSL) can be sold at a wider range of outlets (such as supermarkets), provided those premises are lockable and the medicines are pre-packed<ref name="HCPC 2015" />.
 
==  Legislation and Opioids  ==
 
As previously mentioned, opioids are classed as A, B or C according to their level of penalty for possession/sale without a prescription under the Misuse of Drugs act 1971. The Misuse of Drugs Regulations 2001 further brackets drugs into schedules 1-5 with opioids falling into schedules 2 and 3.<ref>National Archives of HM. The Misuse of Drugs Regulations 2001. Available from: http://www.legislation.gov.uk/uksi/2001/3998/contents/made [Accessed 29th October 2015]</ref>
 
<br>
==  Prescribing and a changing profession  ==
 
''‘Better access, improved assessment and monitoring, more specific titration of meds up/down, a one-stop-shop with other treatment''’. A recent comment from David Baker, one of the first independent prescribers in the UK on a recent Physiotherapy led descussion on twitter <ref name="Physiotalk 2015">Physiotalk. Prescribing in Physiotherapy. http://embed.symplur.com/twitter/transcript?hashtag=PhysioTalk (accessed 25th October 2015).</ref>.
 
Essentially this is the basis of what independent prescribing in physiotherapy can achieve. As a profession physiotherapy has had a need for change for some time, with many drivers of change such as increasing prevalence of chronic disease, ageing populations, and increasing community expectations of responsiveness (eg shorter waiting times, quicker assessments)<ref name="Morris and Grimmer 2014">Morris J, Grimmer K. Non medical prescribing by physiotherapists, issues reported in the current evidence. Manual therapy 2014; 19(1):</ref>. The question is whether independent prescribing can help to bring about this change.
 
Since the introduction and increasing use of self-referrals in physiotherapy, which has benefits in itself <ref name="NHS 2014">NHS. Improving medication error incident reporting and learning. https://www.england.nhs.uk/wp-content/uploads/2014/03/psa-sup-info-med-error.pdf (accessed 25th October 2015).</ref>, physiotherapy has become very much a one stop shop for patients. However in times gone past, patients would need to make further repeated trips to GPs to gain prescriptions, something that is now no longer necessary. This should ultimately lead to more streamlined and quicker access to care, resulting in less inconvenience to patients. It also has the potential to help foster a better working relationship between physiotherapist and patient, after all would you completely trust someone telling you to take a medication that they are unable to actually prescribe themselves?
 
Of course this is all hearsay until evidence becomes available in the future, but several physiotherapists who have been independently prescribing thus far have personally seen the benefits, especially in regards to aspects such as waiting times for pain medication ().
 
In 2009, the Department of Health in the UK concluded that non-medical prescribing has the potential to; improve patient care without compromising safety, make it simpler and more efficient for patients to get the medicines they need, increase patient choice in safely accessing medications, make better use of the skills of health professionals and increase value for money, contribute to the introduction of a more flexible team working together to facilitate early discharge from hospitals. Whether all of this happens in relation to physiotherapists prescribing remains to be seen.
 
Evidence has shown however that physiotherapists in ESP roles are equal to or better than usual care in comparison to physicians in terms of diagnostic accuracy, treatment effectiveness, use of healthcare resources, economic costs and patient satisfaction<ref name="Desmeules et al 2012" />. Evidence in relation to this has improved a lot in comparison to an earlier systematic review by Kersten et al.<ref name="Kersten et al 2007" />&nbsp;Therefore as a profession physiotherapy may well be on the right track in relation to independent prescribing but there is still a significant need to increase the evidence base surrounding this, especially with many physiotherapists themselves having varying degrees of acceptance of prescribing<ref name="Kumar and Grimmer 2005" />.
 
A major study at the University of Surrey is currently researching some of these aspects:&nbsp;[http://www.surrey.ac.uk/fhms/research/healthcarepractice/evaluation_of_physiotherapy.html www.surrey.ac.uk/fhms/research/healthcarepractice/evaluation_of_physiotherapy.htm]
 
[[Image:Grp6 exclamation.jpg|border|left|40x40px]]'''Take home point: The significant need for an evidence base to back up practice and show benefits'''.<br>
 
==  'Cure' over 'Care'   ==
 
As a profession physiotherapy has always worked within its scope of four pillars of practice, but with the implementation of prescribing there is a possible issue as to whether the profession is moving towards a ‘cure’ over ‘care’ practice<ref name="Creedon et al 2015">Creedon R, Byrne S, Kennedy J, McCarthy S. The impact of nurse prescribing on the clinical setting. British Journal of Nursing2015; 24(17):</ref>. Given the biopsychosocial nature of pain, the treatment of pain as mentioned before, especially in its chronic stages should be very much focussed on a holistic ‘care’ rather than ‘cure’ treatment process.
 
[[Image:Grp6 question.jpg|border|left|40x40px]]'''Think back to a challenging chronic pain patient you have encountered, how much of your treatment comprised of reassurance and education? Would your ability to be able to independently prescribe have changed this in any way?'''
 
<br>
 
As a profession, independent prescribing should not take away from physiotherapist’s current array of skills and treatment techniques but rather it should add to it. It should not become the basis of treatment, simply prescribing a patient medication and sending them on their way in order to meet discharge goals, but instead by using prescribing as a way to enhance overall patient centred care. A survey of nurses prescribing found that 80% prescribe two or three times weekly, whilst 61% prescribe daily<ref name="Royal college of nursing 2013">Royal college of nursing. Nurse prescribing: Update 2013. http://journals.rcni.com/userimages/ContentEditor/1379936184622/Nurse-Prescribing.pdf (accessed 25th October 2015).</ref>. How these figures will relate to physiotherapists prescribing is yet to be seen but research into the patterns of independent prescribing by physiotherapists is needed in order to inform practice.
 
<br>
 
'''[[Image:Grp6 exclamation.jpg|border|left|40x40px]]'''
 
'''The importance of ‘care’ over ‘cure’ should not be underestimated.'''
 
==  Potentially inappropriate prescribing  ==
 
As this is a relatively new aspect of physiotherapy practice, there is a lack of published evidence relating to the role and effectiveness of physiotherapists when prescribing or administering medication<ref name="Morris and Grimmer 2014" />. This raises the issue of potentially inappropriate prescribing (PIP) by physiotherapists.
 
According to National Patient Safety Agency (NPSA)&nbsp;figures<ref name="NHS 2012" />, 11% of all adverse accidents involve medications within the NHS<ref name="NHS 2012">NHS. Organisation patient safety incident report. http://www.nrls.npsa.nhs.uk/news-cp/organisation-patient-safety-incident-reports-september-2012/ (accessed 25th October 2015).</ref> and a startling 525,186 medication error incidents were reported over a six year period between 2005 and 2010. Also it is worth keeping in mind that not all errors are reported/documented so this will be an under-reporting <ref name="NHS 2014" />.
 
Nurses, doctors, GPs and other AHPs have been accountable for both PIP and polypharmacy. The risk of both of these increases greatly in elderly patients, something that is to become more significant and potentially dangerous with an ever increasing elderly population<ref name="Bradley et al 2012">Bradley M, Fahey T, Cahir C, Bennett K, O’Reilly D, Parsons C, Hughes C. Potentially inappropriate prescribing and cost outcomes for older people: a cross-sectional study using the Northern Ireland Enhanced Prescribing Database. European journal of clinical pharmacology 2012; 68(10): .</ref>&nbsp;<ref name="Kovacevic et al 2014">Kovacevic S, Simisic M, Rudinski S, Culafic M, Vucicevic K, Prostran M, Milijkovic B. Potentially inappropriate prescribing in older primary care patients. Plos one 2014; 9(4):</ref>.
 
Research also shows that 47% of all serious medication errors were caused by seven drugs/ drug types consisting of methotrexate, warfarin, nonsteroidal anti-inflammatory drugs, digoxin, opiods, acetylic salicyclic acid, and beta blockers<ref name="Saedder et al 2014">Saedder E, Brock B, Nielsen L, Bonnerup D, Lisby M. . Identifying high-risk medication: A systematic literature review.European journal of clinical pharmacology 2014; 70(6)</ref>, many of which are likely to be prescribed by physiotherapists in their new role as non medical prescribers. Of course it is not yet known as to whether PIP by physiotherapists currently is or will become an issue in the future, but the risk is there as the evidence shows.
 
With physiotherapists now becoming the first point of contact for a lot of patients, with an ever increasing number of people using self-referrals, this further increases importance of getting it right, and aspects such as information are sharing becoming ever more crucial. Thus the effectiveness of physiotherapists prescribing is something that will need to be evaluated in the future and compared with other groups currently prescribing.
 
'''[[Image:Grp6 exclamation.jpg|border|left|40x40px]]'''
 
'''A patient's medication journey is more than what happens at the bedside<ref name="Edwards and Axe 2015">Edwards S, Axe S. The 10 Rs of safe multidisciplinary drug administration. Nurse prescribing 2015; 13(8):</ref>.'''<br>
 
<br>
 
== Blurring of roles  ==
 
CSP professional adviser Pip White, one of those closely involved in the campaign for independent prescribing rights for physiotherapists has said that, ‘We will evolve when clinicians, educators, researchers, managers and policy all work together to share our vision’<ref name="Physiotalk 2015" />. Physiotherapy as a profession is changing, but will this mean a change for other professions too? This is where an issue of a ‘blurring of roles’ can possibly arise. With the introduction of independent prescribing, a simple question such as which professional should a patient see, or when should the patient see them, has now become more complicated.
 
MDT working has long been a vital part in the provision of the best and most cost-effective care in the NHS<ref name="NHS 1993">NHS. New world, new opportunities, nursing in primary healthcare. London: DOH; 1993.</ref>. But in reality, the effectiveness of MDT working and interaction is not always as good as it should be, with tension, hierarchical issues, cooperation, varying education, and information sharing all issues <ref name="Dawson and Ghazi 2004" />&nbsp;<ref name="Gregory and Haigh 2008">Gregory J, Haigh C. Multi disciplinary interpretations of pain in older patients on medical units. Nurse education and practice 2008; 8(4):</ref><ref name="Webster 2002">Webster J. Teamwork: Understanding Multi-professional working. Nursing older people 2002; 14(3):</ref>. Through the introduction of independent prescribing there is the possibility to cause further issues within the MDT. Gimore et al.<ref name="Gimore et al 2011">Gimore LG, Morris JH, Murphy K, Grimmer-Somers K, Kumar S. Skills escalator in allied health: a time for reflection and refocus. Journal of Healthcare Leadership 2011; 3:53-8</ref> comment that where any profession expands it scope, it will commonly encroach on the scope of another, leading to a possible “turf war” as healthcare professionals struggle over authority and jurisdiction. In regards to nurse prescribing it has been shown that although senior doctors are quite supportive, more junior doctors are resistant, due to a possible perceived threat to their own role and scope<ref name="Creedon et al 2015" />, something that could similarly be an issue in relation to physiotherapists. Problems within the MDT could mean patient care is affected. MDT and role responsibility issues are often related to knowledge and perceived benefits of what other healthcare professionals can offer.
 
Although over 96% of GPs in Scotland said that they were confident in a physiotherapists ability to diagnose and manage MSK conditions, 77% were generally unaware of the changing scope of physiotherapy practice<ref name="Holdsworth et al 2008">Webster V, Holdsworth L, McFadyen A, Little H. Self referral, access and physiotherapy: Patients knowledge and attitudes – results of a national trial. Physiotherapy 2008; 94(2):</ref>. Research has also shown that even as students, many other health care professionals, do not understand physiotherapy, with many even feeling that it is not very effective<ref name="Varghese et al 2012">Varghese B, Kanagaraj R, Swaminathan N, Vishal K, Romer M, Cusack T. Knowledge and perception of physiotherapy by final year students of various health care professions. International Journal of Therapy. Rehabilitation 2012; 19(11):</ref><ref name="Goodwin 2014">Goodwin K. An exploratory study into student midwives understanding of the role of the physiotherapist.. British Journal of Midwifery 2014; 22(5):</ref>. Similarly, patients are often lacking a general knowledge in relation to what physiotherapy involves<ref name="Holdsworth et al 2008" />, with many recognising physiotherapists as holistic clinicians skilled in pain management, but generally only associating them with post-acute care and rehabilitation, rather than having roles in extended scope practice<ref name="Anaf and Sheppard 2010">Anaf S, Sheppard, LA. Lost in translation? How patients perceive the extended scope of physiotherapy in the emergency department. Physiotherapy 2010; 96:160-8</ref>. For example how many patients have you had say to you ‘I don’t know why I’m here or what physiotherapy is, my doctor just sent me here’. In order for physiotherapy and prescribing to move forward, there is a need to educate and inform both patients and other healthcare professionals in order to promote an overall better understanding of physiotherapy and minimise the issue of a possible blurring of roles and misunderstanding between patients and other healthcare professionals.
 
Legal issues relating to a blurring of roles may also become a potential problem. An increased blurring of roles means there is very much a legal grey area should something go wrong. This is something that those prescribing need to be aware of and information from the CSP relating to this could be beneficial. However as of yet there has not been a case against a physiotherapist independent prescriber.
 
For the benefit of both patients and the MDT, role responsibilities and a clear decision tree need to be defined.
 
==  Moving forward as independent prescribers  ==
 
Regardless of whether the pros of prescribing outweigh the cons or vice versa, the fact is that independent prescribing has been introduced and physiotherapy as a profession has taken a huge step forward. The important thing now is for the profession to continue to move forward, adapt and improve.
 
Critical reflection, and continuing to develop learning and skills are of vital importance at this point. A survey of nurse prescribing found that work based learning and training days were both effective ways at developing their prescribing knowledge, whilst 89% of the nurses surveyed felt they developed their prescribing skills since qualifying<ref name="Royal college of nursing 2013" />. Aspects such as free supplements, guides, and online learning resources however were only used by few. Physiotherapists working in extended scope roles felt the support of the medical profession is the most crucial aspect underpinning the success of their role, as they were aware of their own limited scope of practice<ref name="Dawson and Ghazi 2004" />.
 
This altogether highlights the need for the CSP to implement measures in the future in relation to CPD in prescribing and general support in the workplace in order to give the greatest benefit to both patients and the physiotherapy profession.
 
==  General issues  ==
 
Length of waiting lists:
 
*Waiting lists may get longer because more patients will be becoming directly to physiotherapy (One stop shop).
*Waiting lists may get shorter because patients will be getting better access to care and will need fewer appointments.
*Length of appointments:&nbsp;With physiotherapy appointments generally 30 minutes per patient, is there time to write prescriptions for patients and treatment plans.<br>
 
<br>
 
= Conclusion  =
 
As this resource has demonstrated, physiotherapists continue to push boundries and extend their scope of practice. Evidence shows that they strive to meet and exceed the challenge of their changing role, and have excellent diagnostic accuracy and clinical reasoning skills. In addition to joining the prescribing professions, they are also enhancing it through their holistic attitude and encorporation of non-pharmamacological treatment methods. They see prescribing as a useful adjunct to practice rather than a panacea.
 
In modern day healthcare, medicines have a key role to play in patient care, therefore as Band 5's it is important to be aware and understand the implications for treatment of the various drugs used in pain management. Band 5's should have a basic understanding of common over-the-counter medicines and should be able to signpost patients to find the most appropriate advice on their medications.&nbsp;
 
To become a prescriber physiotherapists must go through a comprehensive training programme. This includes teaching, clinical practice and rigorous assessment. It has been identified by NMP's that mentorship and clinical practice are key to establishing their competence and confidence, but feel this is often overlooked in many of the programmes.&nbsp;
 
As with any emerging role this area is not without issues and concerns, not least; a change from our holistic approach to patients, potential prescribing errors and the controversy of blurring and role sharing within the MDT.&nbsp;<br>
 
However, prescribing within physiotherapy offers a streamlined, and potentially very effective holistic intervention for patients. They, and other non-prescribers have been shown to decrease waiting times, improve patient satisfaction and offers physiotherapists a new and wider perspective on patient care.&nbsp;
 
We hope that this page has been informative and thought provoking, and allowed you to reflect on the role and effect of prescribing on physiotherapy. Should you wish to further broaden your knowledge and understanding of this rapidly emerging area of physiotherapy, there are a number of useful resources suggested.
 
<br>The [http://www.csp.org.uk/ CSP website] includes publications, support and discussions regarding the scope of practice of physiotherapists and their opinions on prescribing.&nbsp;
 
<br>Documented in our training and mentorship section, we have included links to websites detailing the courses available to train for this advanced role, and some selected universities who offer such a course.


<br>Should you ever have any queries about medicines, the best source to consult in the British National Formulary, which is available in most practice settings and from the [http://www.evidence.nhs.uk/formulary/bnf/current NICE website],&nbsp;here is the [http://www.evidence.nhs.uk/formulary/bnfc/current children’s BNF]&nbsp;
There are many pros and cons in the case for Physiotherapists prescribing medication for patients experiencing pain.  However, more research needs to take place to ensure that these extended scope roles are supported. the fact is that independent prescribing has been introduced and physiotherapy as a profession has taken a huge step forward. The important thing now is for the profession to continue to move forward, adapt and improve.  


<br>Finally, it is worthwhile to keep an eye on the news, and publications such as Frontline, to follow the changes and challenges that will inevitably affect prescribing within physiotherapy in the future. <br>
Critical reflection, and continuing to develop learning and skills are of vital importance at this point. A survey of nurse prescribing found that work based learning and training days were both effective ways at developing their prescribing knowledge, whilst 89% of the nurses surveyed felt they developed their prescribing skills since qualifying<ref name="Royal college of nursing 2013">Royal college of nursing. Nurse prescribing: Update 2013. http://journals.rcni.com/userimages/ContentEditor/1379936184622/Nurse-Prescribing.pdf (accessed 25th October 2015).</ref>. Aspects such as free supplements, guides, and online learning resources however were only used by few. Physiotherapists working in extended scope roles felt the support of the medical profession is the most crucial aspect underpinning the success of their role, as they were aware of their own limited scope of practice<ref>Dawson LJ, Ghazi F. The experience of physiotherapy extended scope practitioners in orthopaedic outpatient clinics. Physiotherapy. 2004 Dec 1;90(4):210-6.</ref>.  Nevertheless, prescribing within physiotherapy offers a streamlined, and potentially very effective holistic intervention for patients. They, and other non-prescribers have been shown to decrease waiting times, improve patient satisfaction and offers physiotherapists a new and wider perspective on patient care.


= References  =
== References  ==


<references />  
<references />  

Latest revision as of 13:23, 7 September 2023

Original Editor - Daniel Neilson, Darren Kripaitis, David Rossiter, Mary Graham and Rosy Cuthbert as part of the Queen Margaret University's Current and Emerging Roles in Physiotherapy Practice Project
Top Contributors - Rosy Cuthbert, Mary Graham, Kim Jackson, Daniel Neilson, David Rossiter, Admin, 127.0.0.1, Evan Thomas, Michelle Lee, Claire Knott, Melissa Coetsee and Ines Musabyemariya

Introduction[edit | edit source]

With changing demographics, higher expectations and an increase in long term conditions [1] there is a heightened pressure and demand on the NHS. To meet these demands the roles within the NHS have had to change and expand. As recently as 2013, physiotherapists in England have been granted the right to independently prescribe, giving them the ability to prescribe drugs, including some controlled drugs. These prescriptions must be used “within the overarching framework of human movement, performance and function” [2]

It is important for physiotherapists to understand their scope and limitations to allow them to practice within this framework, as with this change we need to ensure that we remain working within our scope of practice to give the safest and best possible patient centred care. In a narrative review, Crane and Delany[3]comment that physiotherapists demonstrate an excellent ability to clinically reason and adapt to the changing needs of the societies they serve. The UK government has been convinced that prescribing is within physiotherapy’s scope because physiotherapists already possess the core skills that it requires.

The National Prescribing Centre[4] has produced a framework that applies to all prescribers, no matter what profession they come from. Below is a comparison of this framework it to the HCPC’s Standards of Proficiency for physiotherapists[5]:

Grp6 table 1.jpg

Scope of Practice[edit | edit source]

Prescribing may appear a strange addition to a physiotherapist’s toolkit and outside the remit of the profession, which are defined by the Chartered Society of Physiotherapy[6] as anything within the 4 pillars of practice. These are:

  1. Massage
  2. Exercise and movement
  3. Electrotherapy
  4. Kindred methods of treatment

Any physiotherapist must not only work within their own personal scope of practice, but also within the scope of the profession.[7] Although prescribing is within the scope of the profession, like any skill, it only becomes part of an individual physiotherapist’s scope of practice when they become competent through training[8]. This means that before prescribing can be deemed a suitable addition to a physiotherapist’s skill set, they must already be an expert in the field they wish to apply it[9]. As a consequence, although the scope of prescribing within physiotherapy is very wide, it is limited to only an individual's clinical speciality.[8] This is a major difference from medical prescribing who may prescribe for any condition. The following pre-requisites are necessary so safely undertake the role of prescribing:

  • Understand the legal context relevant to prescribing
  • Understand pharmacodynamics, pharmacokinetics, pharmacology and therapeutics relevant to prescribing
  • Understand different prescribing mechanisms
  • Able to make prescribing decisions based on relevant physical examination assessment and history taking
  • Able to communicate information about medicines and prescriptions clearly
  • Able to monitor response to medications and modify or cease treatment as appropriate within scope of practice
  • Able to undertake medication calculations
  • Able to identify adverse medication reactions, interactions and take appropriate action
  • Able to recognise medication error and respond appropriately

Once a physiotherapist decides that prescribing would be of benefit to their practice there are two types of prescriber they can become, based on their level of training supplementary prescribers or independent subscribers.

Supplementary Prescribers[edit | edit source]

Supplementary prescribers can prescribe any medication, but it must be detailed in a written CMP. The CMP is created in partnership with the patient and a medical prescriber.[8] This means that although they are accountable for their decision to prescribe, they share accountability with the medical prescriber for the decision to put the medication in the CMP[8]. In their nursing supplementary prescriber counterparts, this leads many doctors to feel that they have the ultimate responsibility for both the supplementary prescriber and patient. This can result in supplementary prescribers feeling subordinate, rather than in partnership with their medical prescriber.[10]

Supplementary prescribing is particularly suited to the care of chronic conditions, as once a CMP is in place, a medical prescriber can pass over management of a patient to the supplementary prescriber. Supplementary prescribers have expert knowledge of medications within their specialty, and can therefore modify or prescribe any drug detailed within the CMP, but have no influence on drugs that patients receive for other co-morbidities.[11] As experts in prescribing they may also provide detailed advice on any aspect of a medication for a patient, so long as they are used in their area of clinical specialty.[11]

Independent Prescribers[edit | edit source]

Independent prescribers share many features and core skills with supplementary prescribers.[9] However, as they prescribe completely autonomously and not in partnership with medical prescribers, they are wholly responsible for every aspect of the prescribing process.[8] They can actually prescribe fewer medicines than a supplementary prescriber, for example, being able to prescribe only seven controlled drugs:[8]

  • Diazepam
  • Dihydrocodeine
  • Lorazepam
  • Morphine
  • Oxycodone
  • Temazepam
  • Fentanyl

Non-Prescribers[edit | edit source]

The vast majority of physiotherapists globally are not prescribers and there appears to be debate regarding what their level of involvement in prescribing should be. In Australia, like in the UK, this is felt to be a legislative ‘grey’ area; different physiotherapists have different opinions on the extent of their scope regarding medicines.[12] This is reflected in the guidance provided by professional bodies, as they feel an individual’s scope should vary depending on the depth of knowledge that they can demonstrate.[11]

Studies investigating this have found that physiotherapists are frequently asked a wide variety of questions regarding NSAIDs and often feel pressured by patients to provide advice and recommendations regarding them. Almost all felt concerned that they lacked sufficient knowledge to confidently provide this, commensurate with their duty of care to their patients.[13]
There are a few very specific emergency events where a non-prescribing physiotherapist may aid the administration of drugs. If a patient brings in their medication its with instructions, in an emergency, you may administer it in accordance with these, as you are assisting them to take their prescribed medication. In an emergency, like any member of the public, a physiotherapist can also lawfully give certain life-saving POMs to someone acutely unwell without a prescription. The most important of these is adrenaline which is indicated for anaphylactic shock.[11] Below is a useful summary of who can prescribe and what they can prescribe[11]:

Prescribing table.jpg

Evidence Base For Prescribing Within Physiotherapy.[edit | edit source]

Overall, there is a lack of high-quality evidence into the effectiveness of prescribing within physiotherapy, although there are many recognised benefits.[14] Effective prescribing relies on the diagnostic accuracy of the prescriber. Physiotherapists in a range of MSK advanced scope roles have been shown through randomised controlled trials and systematic reviews to have equal diagnostic skill to orthopaedic surgeons and to be more accurate than other healthcare professionals, including non-orthopaedic physicians.[15][16] In addition to this, the UK Department of Health for the year January 2005 to January 2006 reported that of the 60,000 medication incidents, none were related to physiotherapists.[17]

Physio prescribing evidence.jpg

Traditional Physiotherapists Treatment of Pain[edit | edit source]

Physiotherapists are often referred patients whose main complaint is pain. It is therefore important to understand the nature, cause, pathology of pain and also whether it is acute or chronic. Below is a brief summary of pain, however, for a more detailed explanation of pain see Pain Mechanisms
Grp6 pain2.jpg

Traditional Management Method[edit | edit source]

To manage pain physiotherapists use a biopsychosocial approach, factoring in not just the biological but the psychological and social aspects that can influence a patient's perception of pain. We do this as evidence has shown that pain, catastrophising and social support have a statistically significant impact on future function[18]. Recovery time may also be impacted by the belief the patient has on their recovery time.[19]


In Breivik et al.'s[20] study of pain in Europe it was found that 2/3rds of the population questioned were being treated either additionally or solely by non medicated means, including 30% for massage and 21% for physical therapy. Evidence suggests that GP care alone is not as effective as a combined approach of more exercise, education and traditional care[21]. Currently physiotherapists use various evidence based means to support those with pain, this includes exercise therapy, cognitive behavioural therapy, acceptance and commitment therapy and potentially an increasing use medication to support their patients[22]. A Cochrane review agreed with these findings that for LBP physiotherapy treatment combined with physical conditioning and cognitive behaviour treatment, reduced the number of sick days for this group. Evidence has been shown that this physiotherapy treatment can improve quality of life and daily function [23]. Marienke et al.[24] in a systematic review of the managment of chronic pain found that there was a general low quality of evidence, but exercise therapy, behavioural treatment and working with an MDT approach all had some evidence to support their use. Traditionally these methods are shown to have a good evidence base, but by adding the ability to presribe physiotherapists should have even more tools to support those in pain.

The Impact of Medication in Physiotherapy[edit | edit source]

Knowledge of drugs indications and side effects are important when determining whether a patient would benefit from them. If a patient has already been prescribed any of these drugs, management may vary e.g. MSK pain- a patient may be more tolerant of certain exercise because of their reduced pain, the physiotherapist would have an idea of how much to push the patient.
Drugs affecting mood/sleep tolerance also have an impact on rehabilitation, allowing specific treatment plans to be adjusted in a patient centred manner.

The message should also be delivered to the patient that no drug works perfectly, and knowledge of their side effects should be made known. All physiotherapists should have sufficient competence to advise patients on where to obtain appropriate medication advice, as patients perceive physiotherapists to have up to date knowledge in this area[13].

Effect of Drugs on the Nervous System[edit | edit source]

Drugs interfere with the transmission of nerve impulses following noxious (harmful) stimulation, occurring at peripheral or central channels sites. The intention of administering analgesic drugs is to modulate the formation of noxious chemicals or to modulate the activation of neuronal channels transmitting noxious stimuli[25].

Drug Types Used for Chronic Pain[edit | edit source]

  • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
  • Opioids
  • Antidepressants
  • Muscle relaxants
  • Serotonergic compounds,
  • Antiepileptics

The following table highlights how countries place different focus on which drugs are the most effective for the treatment of pain[20]. The most common drugs used in both Europe and in the UK were opioids and NSAIDs. Both have disadvantages that physiotherapists should be aware of.

Grp6 table 4.png

NSAIDs[edit | edit source]

Taking NSAIDs causes general inhibition of target enzymes (cyclooxygenases I and II) which reduces inflammation, however, they can lead to major health issues affecting the GI tract, mucosal protection and gut motility[26]. Side effects can lead to ulcers, renal failure, heart failure and atherosclerosis[27]. These health risks are known but often neglected in practice. For these reasons, NSAIDs are not recommended for long term use in chronic pain, “alternative drugs, low-dose/short-term use, but especially nonpharmacologic approaches, such as physiotherapy, exercise, neurophysiologic measures, and local therapies”[27] should be priorities in management. They are contraindicated in patients with a history of peptic ulcer, myocardial infarction (MI), stroke or heart failure, or with impaired renal function[28].Examples of NSAIDs commonly used to treat pain:

  • Ibuprofen
  • Naproxen

Opioids[edit | edit source]

These drugs are classed as A, B or C. All controlled drugs for injection are bracketed under Class A [29]. Opioids work by attaching to proteins known as opioid receptors in the brain and spinal cord to reduce the perception of pain. However, persistent use of these drugs can produce a tolerance whereby their effects decrease with repeated use of the same dose, so that increasing doses need to be used to gain the same effect. Abrupt cessation of opioid use can then lead to hyperplasia- a heightened sensitivity to pain

Opioid Table.jpg

                                                               Information gathered from the British National Formulary 
Opioids are often used for:

Addiction is also a problem with use of opioids, with overdoses and abuse of prescriptions becoming a health issue as people crave the relief and the feelings of euphoria associated with them[30].

Efficacy of Using Opioids: Drug Therapy vs Alternative Treatment[edit | edit source]

Long-term pharmacological treatment of Chronic Non-Cancer Pain (CNCP) is highly disputed. Non-opioids (e.g. NSAIDs) can induce gastrointestinal ulcers, bleeding or cardiovascular complications[31]. However, opioids can produce cognitive impairments, tolerance and addiction[32]. All patients taking opioids are also at risk of attaining withdrawal symptoms.

A study by Reinecke et al. [33] suggested that the treatment of chronic pain with opioids compared to traditional physiotherapy and psychological treatment was not significantly better in terms of pain intensity, functioning and quality of life. However, as each patient has individual benefits and side effects, efficacy of their treatment cannot be objectively predetermined. It is worth noting the study did not last longer than 3 months and there was significant dropout rates due in part to adverse side effects of the drugs.

It is difficult to improve chronic pain through the use of opioids, because psychological and learning variables play a large part in the diagnosis; “learning, conditioning, cognition, affect, emotions, social and cultural influences, financial aspects of the health care system, litigation and others” have major influences[25]. Opioids may inhibit nociceptive pain, but have little impact on these factors. Prescribing opioids may therefore have a major impact on the way physiotherapist’s treat chronic pain, as a psychosocial approach focussing on these factors has traditionally been a mainstay of physiotherapy treatment

Randomised controlled trials with the same control e.g a placebo, and with the same outcome measure e.g. pain score, are not always directly comparable between individuals. There is also generally a lack of longitudinal studies demonstrating long-term effects of opioid usage for chronic pain patients. Guidelines therefore recommends medication should be maintained or halted based on individual monitoring over time.

Conclusion[edit | edit source]

There are many pros and cons in the case for Physiotherapists prescribing medication for patients experiencing pain. However, more research needs to take place to ensure that these extended scope roles are supported. the fact is that independent prescribing has been introduced and physiotherapy as a profession has taken a huge step forward. The important thing now is for the profession to continue to move forward, adapt and improve.

Critical reflection, and continuing to develop learning and skills are of vital importance at this point. A survey of nurse prescribing found that work based learning and training days were both effective ways at developing their prescribing knowledge, whilst 89% of the nurses surveyed felt they developed their prescribing skills since qualifying[34]. Aspects such as free supplements, guides, and online learning resources however were only used by few. Physiotherapists working in extended scope roles felt the support of the medical profession is the most crucial aspect underpinning the success of their role, as they were aware of their own limited scope of practice[35]. Nevertheless, prescribing within physiotherapy offers a streamlined, and potentially very effective holistic intervention for patients. They, and other non-prescribers have been shown to decrease waiting times, improve patient satisfaction and offers physiotherapists a new and wider perspective on patient care.

References[edit | edit source]

  1. ↑ Department of Health. Long-term conditions compendium of information: 3rd edition. 2012; Available at: https://www.gov.uk/government/publications/long-term-conditions-compendium-of-information-third-edition. Accessed 5th November, 2015.
  2. ↑ NHS England Publications. Frequently Asked Questions: Independent prescribing by physiotherapists and podiatrists Publications Gateway Reference 00364 . 2013; Available at:https://www.england.nhs.uk/wp-content/uploads/2013/08/faqs-ippp1.pdf. Accessed 15th November, 2015.
  3. ↑ Crane J, Delany C. Physiotherapists in emergency departments: responsibilities, accountability and education. Physiotherapy 2013; 99:95-100.
  4. ↑ National Prescribing Centre., A single competency framework for all prescribers. http://www.webarchive.org.uk/wayback/archive/20140627112901/http://www.npc.nhs.uk/improving_safety/improving_quality/resources/single_comp_framework_v2.pdf (accessed 6 Nov 2015)
  5. ↑ Health and Care Professions Council. Standards of proficiency: Physiotherapists. http://www.hcpc-uk.co.uk/assets/documents/10000DBCStandards_of_Proficiency_Physiotherapists.pdf (accessed 11 Nov 2015).
  6. ↑ Chartered Society of Physiotherapy. Medicines, prescribing and physiotherapy. file:///C:/Users/user/Downloads/csp_pd019_medicines_prescribing_physiotherapy_2013_0.pdf (accessed 25 Oct 2015)
  7. ↑ Chartered Society of Physiotherapy. Practice guidance for physiotherapist supplementary and/or independent prescribers in the safe use of medicines. file:///C:/Users/user/Downloads/csp_pd026_practice_guidance_prescribers_aug2013_0_0.pdf (accessed 25 Oct 2015)
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 Chartered Society of Physiotherapy. Medicines, prescribing and physiotherapy. file:///C:/Users/user/Downloads/csp_pd019_medicines_prescribing_physiotherapy_2013_0.pdf (accessed 25 Oct 2015)
  9. ↑ 9.0 9.1 National Prescribing Centre., A single competency framework for all prescribers. http://www.webarchive.org.uk/wayback/archive/20140627112901/http://www.npc.nhs.uk/improving_safety/improving_quality/resources/single_comp_framework_v2.pdf (accessed 6 Nov 2015)
  10. ↑ Creedon R, Byrne S, Kennedy J, McCarthy S. The impact of nurse prescribing on the clinical setting. British Journal of Nursing 2015; 24:878-885.
  11. ↑ 11.0 11.1 11.2 11.3 11.4 Chartered Society of Physiotherapy. Practice guidance for physiotherapist supplementary and/or independent prescribers in the safe use of medicines. file:///C:/Users/user/Downloads/csp_pd026_practice_guidance_prescribers_aug2013_0_0.pdf (accessed 25 Oct 2015)
  12. ↑ Morris JH, Grimmer K. Non-medical prescribing by physiotherapists: Issues reported in the current evidence. Manual Therapy 2014; 19:82-6.
  13. ↑ 13.0 13.1 Kumar S, Grimmer K. Nonsteroidal anti-inflammatory drugs (NSAIDs) and physiotherapy management of musculoskeletal conditions: a professional minefield? Therapeutics and Clinical Risk Management 2005; 1:69-76.
  14. ↑ Kersten P, McPherson K, Lattimer V, George S, Breton A, Ellis B. Physiotherapy extended scope of practice - who is doing what and why? Physiotherapy 2007; 93:235-42.
  15. ↑ Desmeules F, Roy JS, MacDermid JC, Champagne F, Hinse O, Woodhouse LJ. Advance practice physiotherapy in patients with musculoskeletal disorders: A systematic review. BMC Musculoskeletal Disorders 2012; 13:1-21.
  16. ↑ Daker-White G, Carr AJ, Harvey I, Wollhead G, Bannister G, Nelson I, Kammerling M. A randomised controlled trial. Shifting the boundaries of doctors and physiotherapists in orthopaedic outpatient departments. Journal of Epidemiology and Community Health 1999; 53:643-50.
  17. ↑ Morris JH, Grimmer K. Non-medical prescribing by physiotherapists: Issues reported in the current evidence. Manual Therapy 2014; 19:82-6.
  18. ↑ Jensen MP, Moore MR, Bockow TB, Ehde DM, Engel JM. Psychosocial factors and adjustment to chronic pain in persons with physical disabilities: a systematic review. 2011 Arch Phys Med Rehabil
  19. ↑ Ramond A, Bouton C, Richard I, Roquelaure Y, Baufreton C, Legrand E, et al. Psychosocial risk factors for chronic low back pain in primary care--a systematic review. Fam Pract 2011 Feb;28(1):12-21.
  20. ↑ 20.0 20.1 Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. European journal of pain 2006;10(4):287-287
  21. ↑ Lin CC, Haas M, Maher CG, Machado LA, van Tulder MW. Cost-effectiveness of general practice care for low back pain: a systematic review. European Spine Journal 2011;20(7):1012-1023.
  22. ↑ CSP. Physiotherapy works: Chronic pain. 15 April 2014; Available at: http://www.csp.org.uk/professional-union/practice/your-business/evidence-base/physiotherapy-works/chronic-pain. Accessed 1st November, 2015.
  23. ↑ Malmros B, Mortensen L, Jensen MB, Charles P. Positive effects of physiotherapy on chronic pain and performance in osteoporosis. Osteoporosis Int 1998;8(3):215-221.
  24. ↑ Van Middelkoop M, Rubinstein SM, Kuijpers T, Verhagen AP, Ostelo R, Koes BW, et al. A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. European Spine Journal 2011;20(1):19-39.
  25. ↑ 25.0 25.1 Stein C. Opioids, sensory systems and chronic pain. Eur J Pharmacol 2013;716(1):179-187.
  26. ↑ Wehling M. Non-steroidal anti-inflammatory drug use in chronic pain conditions with special emphasis on the elderly and patients with relevant comorbidities: management and mitigation of risks and adverse effects. Eur J Clin Pharmacol 2014;70(10):1159-1172.
  27. ↑ 27.0 27.1 Wehling M. Non-steroidal anti-inflammatory drug use in chronic pain conditions with special emphasis on the elderly and patients with relevant comorbidities: management and mitigation of risks and adverse effects. Eur J Clin Pharmacol 2014;70(10):1159-1172
  28. ↑ Conaghan PG. A turbulent decade for NSAIDs: update on current concepts of classification, epidemiology, comparative efficacy, and toxicity. Rheumatol Int 2012;32(6):1491-1502.
  29. ↑ HCPC., Medicines and prescribing. Available from: http://www.hpc-uk.org/aboutregistration/medicinesandprescribing/ [Accessed 26th October 2015]
  30. ↑ Centers for Disease Control and Prevention (CDC). CDC grand rounds: prescription drug overdoses - a U.S. epidemic. MMWR Morb Mortal Wkly Rep 2012 Jan 13;61(1):10-13.
  31. ↑ Trelle S, Reichenbach S, Wandel S, Hildebrand P, Tschannen B, Villiger PM, et al. Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis. BMJ 2011 Jan 11;342:c7086.
  32. ↑ Von Korff M, Kolodny A, Deyo RA, Chou R. Long-term opioid therapy reconsidered. Ann Intern Med 2011;155(5):325-328
  33. ↑ Reinecke H, Weber C, Lange K, Simon M, Stein C, Sorgatz H. Analgesic efficacy of opioids in chronic pain: recent meta‐analyses. Br J Pharmacol 2015;172(2):324-333
  34. ↑ Royal college of nursing. Nurse prescribing: Update 2013. http://journals.rcni.com/userimages/ContentEditor/1379936184622/Nurse-Prescribing.pdf (accessed 25th October 2015).
  35. ↑ Dawson LJ, Ghazi F. The experience of physiotherapy extended scope practitioners in orthopaedic outpatient clinics. Physiotherapy. 2004 Dec 1;90(4):210-6.
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