Prescribing in Physiotherapy for Pain

Aim

With changing demographics, higher expectations and an increase in long term conditions  there is an 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” 

It is important for physiotherapists to understand there scope and limitations to allow use to practise within the framework as this change we need to ensure we are still working within our practise to give te best patient centred care. 

With these new responsibilities that are becoming a part of a physiotherapist’s remit, this page looks to explore prescribing as a physiotherapist.It is important that as physiotherapists we understand our role as to who can advise or prescribe this resource aims to help build understanding around scope of practise and responsibilities for prescribing for pain and how to change your prescribing responsibilities. A brief overview of some of the drugs used for pain a physiotherapist may come across in practise either as non-prescribers or prescribers. 

Audience: The resource was produced for use by Band 5 physiotherapists to understand the role the profession plays in prescribing medicines. It may be of benefit to other health professionals seeking knowledge. A case study and questions will be included, which can be used to check understanding after each section

Learning Outcomes

1. LO1. – The learner will able to complete the case study questions to demonstrate an understanding of prescribing within physiotherapy.
2. LO2. – the learner will be able to distinguish the scope of practice for non-prescribers, supplementary prescribers and independent prescribers within physiotherapy.
3. LO3. - The learner will be able to comprehend the process of how to become an independent and supplementary prescriber.
4. LO4. – The learner will be able to describe the effects & side effects of common groups of pain medication, and the role they have to play in patient centred care. Also, they should be able to provide general advice at a band 5 level for pain.
5. LO5. - The learner will be able to evaluate the effect of prescribing on the current and future role of physiotherapists.
   

Abbreviations

Key Definitions

• Pain - 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.” 
• Extended Scope Practitioner - 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.
• Drug Classes - A drug is put into a class based on the penalty it would have if there was any offence involving the drug. 
• Non-prescribers - Physiotherapists without further training within the prescribing field, newly qualified Band 5’s fit within this areas.
• Supplementary prescriber- 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.
• Independent prescribers - Without consultation are able to either from their own diagnosis or a previous diagnosis prescribe treatment including prescribing and are fully responsible and accountable for the treatment. This should be done within the physiotherapists area of expertise.
• Non-Medical Prescriber - 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.

Background

In 2013 in England and in 2014 for the rest of the UK, physiotherapists were given the right to train to prescribe independently. Below shows a timeline of Key dates:

As the healthcare needs of the British population change, the NHS must also change and adapt to meet them. For example, the British public are living longer and acquiring more long term conditions as a result. These are estimated to occupy 50% of the GP appointments and 70% of hospital beds. Another issue is that there is also thought to be an increase in the expectations of patients who want a co-ordinated, accessible 7-day service from the NHS. It has also been felt in literature that patients may find their healthcare experience disjointed and repetitive, due to a lack of integration between healthcare professionals . Each of these puts extra pressure on a resource strapped service, with costs currently thought to be around £12.3 billion per year . To meet these challenges new approaches and changing roles are being implemented .

Due to this setting of increasing demand and reducing resources, a supported decision was made to grant physiotherapists prescribing powers. Some of the many highlighted benefits of this for the patient include;

• Making a patient’s prescribing experience an easier, quicker and more streamlined pathway within a single appointment, reducing a patient’s total number of appointments within the NHS.
• Increasing involvement and independent management of a patient’s entire healthcare journey, as a result of the increasing use of physiotherapists as first-contact practitioners
• Reducing demand on finite medical resources by preventing delays and contributing to a flexible team
• Utilising the skills of the non-medical professions expertise in their specialist area to provide patient centred care.

This was summed up by Phil Gray, chief executive of the Chartered Society of Physiotherapy, upon physiotherapists being awarded the right to independently prescribe said that:

"This is a landmark moment that will lead to patients receiving faster, more effective treatment for their condition”.

Of the 94 physiotherapists who have taken this professional leap forward, six interviewed by the magazine Frontline indicated that they felt the greatest benefit of their prescribing power was the ability to streamline patient care. They felt that it allowed them to begin treating patients immediately, without having to send them back to their GP for sufficient pain relief, and allowed them to view the bigger picture of a patient’s care .

Whilst this resource looks to educate on the drugs used by physiotherapists for pain, physiotherapists are also using the independent prescribing power to help prescribe for other conditions such as spasticity management

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 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.

  Do you think prescribing is within the scope of physiotherapy?

In a narrative review, 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 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:

Personal Scope of Practice

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. 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. As a consequence, although the scope of prescribing within in physiotherapy is very wide, it is limited to only an individual's clinical specialty. This is a major difference from medical prescribing who may prescribe for any condition.

It is important to remember that prescribing physiotherapists are not the equivalent of doctors, and their practice is restricted to their own patients, who they have performed a comprehensive assessment on.

'You may reach a point in your career where begin to feel that you have gained enough knowledge, training and experience thatprescribing is becoming within your scope of practice. Would you be able to ‘tick all these boxes’? Only then is prescribing completely within your scope:'

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Once a physiotherapist decides that prescribing would be of benefit and for their practice there are two types of prescriber they can become, based on their level of training.

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. 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. In their nursing supplementary prescriber counterparts, this leads many doctors to feel that they have the ultimate responsibility for both supplementary prescriber and patient. This can result in supplementary prescribers feeling subordinate, rather than in partnership with their medical prescriber.

Supplementary prescribing is particularly suited to the care of chronic conditions, as once a CMP is in place, 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. 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.

Independent Prescribers

Independent prescribers share many features and core skills with supplementary prescribers. However, as they prescribe completely autonomously and not in partnership with medical prescribers, they are wholly responsible for every aspect of the prescribing process. They can actually prescribe fewer medicines than a supplementary prescriber, but are fully autonomous when doing so. As a result, Creedon et al. feel that they represent a greater challenge to medical authority.

 Do you think you would rather become a supplementary or independent prescriber? What would be a more useful adjunct to your practice?

How does a physiotherapist decide what is within their scope? In a qualitative study by Dawson and Ghazi of physiotherapists working in similar roles, as extended scope practitioners in orthopaedic clinics, many participants commented that they felt many of the skills required were beyond the current scope of physiotherapy. However, all felt confident in their jobs despite this, as they were aware of their limitations and able to liaise with their medical colleagues when in need of advice. This really highlights the key question any responsible physiotherapy prescriber should ask themselves when deciding what is within their scope. Simply put, it is ‘do I feel confident practicing this, with my current level of knowledge and skill set?’ This directly relates to some of the key competencies of a good prescriber, detailed by the Single Competency Framework For All Prescribers, where prescribers, irrespective of who they are, should be self-aware, aware of their limitations, and confident in their ability.

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. 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.

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.

Kumar and Grimmer also found that most of the physiotherapists were not aware of the up to date research that has influenced best practice for NSAIDs. It would therefore be argued that this was not within the scope of these physiotherapists. It is expected in the UK that all newly qualified Band 5 physiotherapists should be sufficiently competent to advise patients on where to find appropriate advice regarding their medications, and give appropriate advice of medications that might be suitable for a patient. If they can demonstrate their competence, they can give general information on a medicine, such as widely known side-effects of a commonly accessible medicine like ibuprofen. However, they are keen to stress there is a difference between giving advice and prescribing, and therefore non-prescribing physiotherapists can not suggest alterations to a patient’s prescribed medications.

Importantly, if you notice a patient is taking a medication wrongly, you can show them the directions that have been prescribed. If you feel a medicine would be of benefit to a patient, you can suggest they speak to their doctor regarding it; and if you are concerned of the effects of a medication you may ask them to speak to their doctor, or directly contact them.
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, with instructions, in an emergency, you may administer drugs 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.

Below is a useful summary of who can prescribe and what they can prescribe:
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Case Study Questions

1. Mr Smith also mentions he is having terrible trouble with indigestion, you hear him ask your independent prescriber colleague, seeing as they are already writing him a prescription, to give him something to help. Can they?
2. At lunch your colleague discusses their patient with you. They feel that they would benefit from tramadol and are considering asking an independent prescriber colleague to prescribe it. What should you say?
3. Could you, as a non-prescriber, recommend Mr Smith also take paracetamol for his pain?

Answers

1. No. As a MSK specialist, they only have sufficient knowledge on MSK conditions to prescribe safely. Although they may know a little about the gastrointestinal system, it is out of their scope of practice to treat it as a clinician. They are a specialist clinician, not a one-stop shop! Mr Smith should see his doctor.
2. Your colleague has 2 options: either recommend the patient sees their GP and ask for tramadol on their recommendation; or they can pass this patient onto an independent prescriber under their caseload. They would really need to see the patient and complete a full assessment of them before it would be safe to prescribe tramadol. In either case, it can’t be guaranteed that the patient will receive tramadol, as it may not be suitable
3. No, this would be outside of your scope. Although this is a very widely known drug, available under a GSL, Mr Smith is on a variety of other medications. You currently don’t have the detailed knowledge of drug interactions to recommend this safely.

Accountability in Prescribing

It is not enough for a physiotherapists to feel that prescribing is within their scope of practice. There must be some way that they are held accountable for their actions, and prove their competency and appropriate scope of practice. Two of the main ways that this can be done is through audits and CPD, where physiotherapists review their practice, or seek to increase their knowledge and skills.

Physiotherapists are not only responsible for their prescribing decisions, but also every aspect of the prescribing process they are involved in. Both supplementary and independent prescribers are accountable for the decision to delegate the administration of a medicine to someone else, such as the patient or another healthcare professional, although if their decision is justified, they are not accountable for how well the individual carries out the task. This could be thought of as prescribers having to not only judge their own scope, but also the scope of practice of others.

The literature identifies that physiotherapy as a profession demonstrates internal and external accountability measures already in place, but an individual’s internal rigor of accountability has the potential to be flawed. This may be a particular risk for prescribers within physiotherapy. As this is such as emerging role, like many other advanced scope practitioners, their job description and scope of practice is often still subject to revision and alteration. This lack of definition to their role gives them less external support in deciding their role, making them rely more on their own internal accountability measures, which may be subject to disagreement between professionals.

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. 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. 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.

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. Norman et al. 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. 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. 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. Norman et al. 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 no difference to their adherence. In addition to this, a national survey of nurses and pharmacists in 2008 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. 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. In their literature review, Kersten et al. found that the vast majority of sources were supportive of physiotherapists working in extended scope roles.

In a qualitative study of physiotherapists working in extended scope roles in Scotland, all commented that they felt they have learned and changed as physiotherapists through their extended roles. They felt better and more efficient at assessments, and enjoyed being able to treat patients more comprehensively. However they noted increased anxiety and pressure which came with these roles, risking burn-out, and feeling as if they had hit a ceiling of specialisation. This was shared with nurse prescribers, who felt prescribing had increased their autonomy and effectiveness, but came with increased workload, anxiety about ability, increased personal cost and concern over effect on professional relationships. Sadly, like other non-medical prescribers, such as nurses and pharmacists, who indicated that not all of those trained were currently prescribing (86% of nurses and 71% of pharmacists) (Latter et al. 2010), one third of qualified prescriber AHPs indicated they did not prescribe. Within the same study it was commented that rates of prescribing are related to the levels of support they receive throughout their journey as a prescriber. However, due to the novel nature of non-medical prescribing, Stewart et al.note that there is a lack of substantial, longitudinal and high quality research on this group of prescribers.

Insert diagram 1 xxxx here

At the beginning of this section, you were asked to reflect whether you believed prescribing to be within the scope of physiotherapy. What are your opinions now?

Traditional Physiotherapists Treatment of Pain

As we will be talking about drugs used for pain below brief summary of the pain types is below but to understand pain in further detail please see www.physio-pedia.com/Pain_Mechanisms

Pain can be categorised as chronic or acute depending on length of problem, summarised are some normal key factors (abbreviated from Vadivelu et al.)

Pain can also be categorised by pathology into neuropathic, nociceptive and a combina

tion of both

Traditional Management method

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 there is a statistically significant impact on future function by pain catastrophising and social support . Recovery time may also be impacted by the belief the patient has on recovery time.

In Brevik et al. 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 with a more exercise, education and traditional care all being emphasised in their treatments. Currently physiotherapists use various evidence based means to support those with pain, this includes exercise therapy, cognitive behavioural therapy, acceptance and commitment therapy and will be using medication to support their patients.  A cochrane review agreed with these findings that for LBP physiotherapy treatment with physical conditioning and cognitive behaviour treatment, reduced the number of sick days for this group. Evidence has been shown that physiotherapists can improve quality of life, daily function . Marienke et al. in a systematic review to help manage chronic pain found that there was low evidence but evidence of exercise therapy, behavioural treatment and working with an MDT approach all had some evidence to support their use. Traditionally this methods are shown to be good evidence base practise by adding the ability to prescribe should allow physiotherapists even more scope to support those in pain.

Drugs and Their Impact on Physiotherapy

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.

Drug Types Used for Chronic Pain

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

Interestingly different countries place different focus on which drugs are the most effective for the treatment of pain as the below table demonstrates.

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.

NSAIDs 

Examples of NSAIDs commonly used to treat pain
•Ibuprofen
•Naproxen

Taking NSAIDs causes general inhibition of target enzymes (cyclooxygenases I and II) which in turn reduces inflammation, however, they can lead to major health issues affecting the GI tract, mucosal protection and gut motility. Side effects can lead to ulcers, renal failure, heart failure and atherosclerosis. 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” 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.

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.

Opioids 

These drugs are classed as A, B or C [hyperlink to Legislation]. All controlled drugs for injection are bracketed under Class A

Communal opioid effects

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.

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. An interesting insight to this problem was documented in a BBC programme:

INSERT VIDEO

Other conditions associated with opioid use

•Acute following surgery
•Palliative care
•Headaches/fibromyalgia
•Rheumatoid arthritis
•Cancer pain

Efficacy of using opioids: drug therapy vs alternative treatment

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. However, opioids can produce cognitive impairments, tolerance and addiction (Von Korff, 2011). All patients taking opioids are also at risk of attaining withdrawal symptoms.

A study by Reinecke et al. (2015) 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. 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.

Impact on physiotherapy treatment

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.

UK Legislation

In addition to the legislation governing the process of qualification and registration as a prescriber [hyperlink to Danny], 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)
Pharmacy medicines (P) can only be sold or supplied at registered pharmacy premises or under the supervision of a pharmacist
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.

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.(Legislation.gov.uk, 2010)