Disease-specific knowledge and clinical skills required by community-based physiotherapists to...

Disease-Specific Knowledge and Clinical SkillsRequired by Community-Based Physiotherapists toCo-Manage Patients With Rheumatoid ArthritisANDREW M. BRIGGS,1 ROBYN E. FARY,2 HELEN SLATER,2 PETER BRAGGE,3 JASON CHUA,2

HELEN I. KEEN,4 AND MADELYNN CHAN4

Objective. While strong evidence supports the role of physiotherapy in the co-management of patients with rheumatoidarthritis (RA), it remains unclear what constitutes the essential disease-specific knowledge and clinical skills required bycommunity-based physiotherapists to effectively and safely deliver recommended care. This study aimed to identifyessential disease-specific knowledge and skills, link these with evidence from clinical guidelines, and broadly determinethe professional development (PD) needs and confidence related to the management of RA among physiotherapists.Methods. An international Delphi panel of rheumatologists, physiotherapists, and consumers (n � 27) identified essentialdisease-specific knowledge and clinical skills over 3 rounds. Physiotherapy-relevant recommendations from high-quality,contemporary clinical guidelines were linked to Delphi responses. Finally, an e-survey of PD needs among registeredphysiotherapists (n � 285) was undertaken.Results. Overarching themes identified by the Delphi panel across the RA disease stages included the need for excellentcommunication, the importance of a multidisciplinary team and early referral, adoption of chronic disease managementprinciples, and disease monitoring. Of the essential Delphi themes, 86.7% aligned with clinical guideline recommenda-tions. Up to 77.5% of physiotherapists reported not being confident in managing patients with RA. Across the range ofessential knowledge and skills themes, 45.1–93.5% and 71.1–95.2% of respondents, respectively, indicated they wouldbenefit from or definitely need PD.Conclusion. To effectively manage RA, community-based physiotherapists require excellent communication skills anddisease-specific knowledge, including understanding the role of the multidisciplinary team and the principles of earlyreferral, chronic disease management, and monitoring. Physiotherapists identified a need for PD to develop these skills.

INTRODUCTION

Rheumatoid arthritis (RA) is associated with a significantpersonal and societal burden, affecting 0.2–1.1% of theadult population worldwide (1,2). Data from the 2007–2008 Australian National Health Survey indicate that2.1% of Australians self-reported a diagnosis of RA (3).Recent projections point to the increasing incidence of RAamong women (4), while the prevalence is expected to

double in Australia by 2050 (5). These data highlight theneed to implement contemporary, evidence-based healthpolicy and clinical practice frameworks to facilitate opti-mal management of RA, now and in the future.

In Australia, physiotherapy services for patients withRA are predominantly provided through the public hospi-tal system. Although this service model facilitates inter-professional management, significant service access issuesexist for patients due to long waiting lists and difficultyaccessing public hospitals (6–8). In addressing these is-sues, governments recognize the importance of improvingSupported by project grants from the Australian Physio-

therapy Research Foundation (T10-PRB001) and the De-partment of Health, Government of Western Australia. Dr.Briggs’s work was supported by a fellowship from the Aus-tralian National Health and Medical Research Council.

1Andrew M. Briggs, BSc(Phty)Hons, PhD: Curtin Univer-sity and Government of Western Australia, Perth, WesternAustralia, Australia; 2Robyn E. Fary, BAppSc(Phty), Grad-DipManipTherapy, PhD, Helen Slater, BAppSc(Phty), Grad-DipAdvManipTherapy, MAppSc(Phty), PhD, FACP, JasonChua, BSc(Sport Ex Sci): Curtin University, Perth, WesternAustralia, Australia; 3Peter Bragge, BPhysio(Hons), PhD:National Trauma Research Institute and Monash Univer-

sity, Melbourne, Victoria, Australia; 4Helen I. Keen, MBBS,FRACP, PhD, Madelynn Chan, MBBS, FRACP: Royal PerthHospital and University of Western Australia, Perth, West-ern Australia, Australia.

Address correspondence to Andrew M. Briggs, BSc(Phty)Hons, PhD, Curtin Health Innovation Research Institute,Curtin University, GPO Box U1987, Perth, Western Austra-lia, 6845, Australia. E-mail: [email protected].

Submitted for publication November 17, 2011; accepted inrevised form April 20, 2012.

Arthritis Care & ResearchVol. 64, No. 10, October 2012, pp 1514–1526DOI 10.1002/acr.21727© 2012, American College of Rheumatology

ORIGINAL ARTICLE

1514

and expanding community-based primary care services forindividuals with chronic health conditions (9,10). Becausethe role of physiotherapy in managing RA is substantiatedby a strong evidence base (11–21), engaging community-based physiotherapists in management of patients with RAis warranted (8,22). However, whether the current commu-nity-based physiotherapy workforce is capable of meetingthe likely growing demand for RA-specific physiotherapyservices is unknown.

Patients with RA often present with complex clinicalpresentations, typically involving diverse and significantcomorbidities (23). In many cases, effective managementfor patients with RA requires a detailed understanding ofthe complex interactions between associated disease pro-cesses, comorbidities, and disability, and the translation ofthat knowledge to clinical practice. However, what consti-tutes the essential physiotherapy-specific disease-relatedknowledge and clinical skills required by community-based physiotherapists to effectively and safely delivercare to patients with RA is unclear. Clinical practice guide-lines (CPGs) contain care recommendations; however,their development is time consuming and resource inten-sive (24), leading to a risk that by the time of CPG publi-cation, it may be out of date due to emergence of recentevidence (25,26). One way of addressing this limitationis to convene a panel of cross-discipline experts in RAto independently identify the essential disease-relatedknowledge and the core requisite clinical skills. Combin-ing a review of CPGs with expert consultation harnessesboth the comprehensiveness of the CPG process and theup-to-date knowledge of clinical and research leaders inthe field. Such information could facilitate the delivery oftargeted professional development (PD) to the current andfuture workforce. The aims of this study were to: 1) estab-lish the essential disease-specific knowledge and clinicalskills required by community-based physiotherapists toeffectively and safely co-manage patients with RA, 2) iden-tify CPGs underpinning the identified knowledge and

skills, and 3) undertake a PD needs assessment among thecurrent physiotherapy workforce in Western Australia(WA) to broadly ascertain their confidence, knowledge,and skills in relation to co-managing patients with RA.

MATERIALS AND METHODS

This study used a 4-stage process to address the aims(Figure 1). Institutional human research ethics committeeapproval was granted for this study.

Stage 1: Delphi study. A Delphi panel consisting of 11rheumatologists, 11 physiotherapists, and 5 consumerswas convened to establish consensus regarding the essen-tial disease-specific knowledge and clinical skills requiredby community-based physiotherapists to safely and effec-tively co-manage patients with RA. The number of panel-ists and the method of selection were determined follow-ing accepted methods (27,28). To be included on thepanel, rheumatologists and physiotherapists were re-quired to meet �3 of the following 4 criteria: 1) experiencein research and/or a record of publication in the area ofRA, focusing on either health service delivery, primarycare, nonpharmacologic management, or multidisci-plinary management; 2) research, teaching, or student/trainee supervision in clinical rheumatology; 3) participa-tion in RA-related extracurricular activities such ascommittee membership and involvement with the devel-opment of clinical guidelines or PD resources; and/or4) experience of �2 years managing patients with RA(minimum 25% case load). Inclusion criteria for consum-ers were having a diagnosis of RA and having received orcurrently receiving physiotherapy services for their RA.The Delphi process comprised 3 rounds.

In round 1, all of the panelists provided demographic,work, and/or disease history information. They respondedto open questions regarding what disease knowledge andclinical skills are required by community-based physio-therapists to safely and effectively co-manage patientswith RA during 3 predetermined phases of the disease:prediagnosis, the first few years after diagnosis, and thechronic course (with the chronic course phase dividedinto knowledge and skills for RA itself and for the comor-bid conditions associated with RA). Rheumatologists andphysiotherapists were also asked to identify relevant CPGsor resources that supported their responses. Data from thisfirst round were condensed into broad themes for “knowl-edge” and “skills” across the 3 disease phases. More de-tailed and specific information provided by the panel sup-porting each theme was referred to as elements.

The second round refined the first round responses bypresenting the synthesized data back to the panel as acomposite table of themes and elements for knowledgeand skills across each phase of the disease. Panelists werethen asked to agree or disagree with, and comment furtheron, the synthesized data.

In the third round, the panelists were presented with afinal synthesis of themes and elements and asked to iden-tify which themes they considered essential diseaseknowledge and skills requirements for community-basedphysiotherapists, and to rank the importance of each ele-

Significance & Innovations● An international Delphi panel identified the essen-

tial disease-specific knowledge and clinical skillsrequired by community-based physiotherapists tosafely and effectively manage patients with rheu-matoid arthritis (RA).

● Delphi responses aligned well with recommenda-tions in RA clinical guidelines.

● Physiotherapists clearly indicate that they requireprofessional development in order to confidentlydeliver evidence-based interventions to patientswith RA.

● This study provides a clinically-oriented and con-sumer-oriented evidence-based framework to en-hance the skills of community-based physiothera-pists in the safe and effective co-management ofRA and represents a direct translation of healthpolicy into practice.

Physiotherapy in Rheumatoid Arthritis 1515

ment within each theme using a 5-point Likert scale (range1–5, where 1 � not needed and 5 � essential). Consistentwith an earlier established framework (29), consensus onessential themes was defined as �80% of the panelistsrating a theme as essential. Consensus on elements withineach essential theme was defined as �80% of the panelistsranking an element with a score of 4 or 5 on the Likertscale. During the data analysis, clusters of themes emergedrepresenting broad topics across knowledge and skills andacross disease phases. These collective themes are referredto as concepts.

Stage 2: appraisal of CPGs and extraction of physiother-apy-specific recommendations. CPGs identified by theDelphi panel and a literature review were appraised forquality using the Appraisal of Guidelines for Research andEvaluation (AGREE) instrument (30). This instrument con-sists of 23 items rated on a 4-point Likert scale from which6 domain scores are derived, each expressed as a percent-age. The validity and reliability of the instrument havebeen established previously (31,32). Four reviewers (AMB,REF, HS, PB) appraised 8 guidelines (13–20), whereas

domain scores for a further 7 guidelines (21,33–38) wereadopted from an earlier appraisal (19). Recommendationsrelevant to the Australian physiotherapy scope of practicewere extracted verbatim by the same 4 reviewers from6 guidelines (16–21), classified as “recommended” or“strongly recommended” based on domain score thresh-olds described by the AGREE instrument manual (�4 do-main scores of �30%) and published during 2006–2011.

Stage 3: linking Delphi responses with CPG recommen-dations. To examine the alignment between the Delphipanelists’ responses and evidence from the RA CPGs, eachtheme and element derived from the Delphi data wasreviewed by the 4 reviewers as a group to reach consensusand, where possible, link with a CPG recommendation(s)by manually comparing Delphi responses with the list ofextracted physiotherapy-relevant CPG recommendations.

Stage 4: PD needs assessment survey. A web-basedsurvey was developed using Qualtrics software (www.qualtrics.com). The survey targeted Australian-registeredphysiotherapists residing in WA and collected demo-

Figure 1. Schematic of the 4 stages of the project. RA � rheumatoid arthritis; AGREE � Appraisal of Guidelines for Research andEvaluation; RACGP � Royal Australian College of General Practitioners; PD � professional development; WA � Western Australia.

1516 Briggs et al

graphic, educational, and professional history data. Self-reported confidence in early detection of RA, knowledgeof its typical course, managing RA during its phases, andknowledge of evidence-based treatments were assessedusing dichotomous (yes/no) questions. PD needs in thearea of RA were assessed for those knowledge and skillsthemes that �80% of Delphi panelists nominated as es-sential for physiotherapists using nominal response cate-gories (definitely require PD, may benefit from PD, and PDnot required). These responses were later collapsed todichotomous outcomes (PD required and PD not required).There were 12 knowledge themes and 13 skills themes.The participants were also asked to indicate their interestin undertaking PD in RA. The survey was pilot testedamong 4 physiotherapists prior to dissemination.

The survey was disseminated by the WA AustralianPhysiotherapy Association (APA) and the Alumni Officeof Curtin University (the main educator of physiothera-pists in WA). In 2011, there were 2,600 physiotherapistsregistered in WA, of which 1,621 (62.3%) were members ofthe APA; the Alumni Office had contact details for 680physiotherapy graduates.

Statistical analysis. Qualitative data from the first andsecond Delphi rounds were analyzed using an inductivecontent analysis approach (39) to identify themes thatwere supported by elements. Inductive content analysis

uses detailed text statements to develop broader categories(themes). Open coding was performed while reviewing thepanelists’ responses to open questions in order to developa large number of knowledge and skills categories acrossthe predetermined disease phases. After open coding, thenumber of categories was reduced by collapsing similarcategories. Finally, each category was assigned a descrip-tor to create the theme. Primary data analysis was under-taken by one author (REF), while a second author (AMB)independently reviewed the qualitative responses to en-sure accuracy of derived categories and abstraction. Ele-ments have been included in presentation of the data toprovide transparency and validity in the creation ofthemes and to provide sufficient detail for readers to ulti-mately develop education modules. Responses from Del-phi round 3 were interpreted using frequencies. Descrip-tive statistics were used to analyze responses from thee-survey using PASW Statistics 18.

RESULTS

Delphi study. Characteristics of the Delphi panel areshown in Table 1. Across the 3 Delphi rounds, the re-sponse rate was 93–100% (Figure 1). A set of 4 overarchingconcepts emerged across the 3 RA disease phases andacross the knowledge and skills areas, including the need

Table 1. Characteristics of the Delphi panel and the PD survey respondents*

Delphi panel membersPD survey

respondents(n � 285)

Rheumatologists(n � 11)

Physiotherapists(n � 11)

Consumers(n � 5)

Women, no. (%) 7 (64) 10 (91) 5 (100) 200 (70.2)Age, mean � SD years 44 � 8.4 47 � 6.6 50 � 17.2 36.9 � 11.8Primary place of employment, no. (%)

Public hospital (tertiary) 8 (73) 4 (36) 45 (15.8)Public hospital (nontertiary) 0 (0) 0 (0) 31 (10.9)Private practice 1 (9) 1 (9) 127 (44.6)University 2 (18) 4 (36) 22 (7.7)Community-based health center 0 (0) 1 (9) 28 (9.8)Other 0 (0) 1 (9) 32 (11.2)

Secondary place of employment, no. (%)†Public hospital (tertiary) 2 (18) 1 (9) 9 (12.0)Public hospital (nontertiary) 1 (9) 1 (9) 3 (4.0)Private practice 3 (27) 2 (18) 21 (28.0)University 2 (18) 0 (0) 21 (28.0)Community-based health center 0 (0) 1 (9) 2 (2.7)Private hospital (tertiary) 0 (0) 1 (9) 0 (0)Other 0 (0) 0 (0) 19 (25.3)

Overall clinical practice experience, mean � SD years 16 � 7.1 26 � 7.1 12.6 � 11.1Rheumatology practice experience, mean � SD years 15 � 7.3 14 � 8.4Currently involved in RA research, no. (%) 9 (82) 5 (46)Currently involved in RA clinical practice, no. (%) 11 (100) 7 (64) 140 (54.9)‡Current caseload managing patients with RA, mean � SD % 59 � 23.4 20 � 18.3 4.4 � 5.9Currently working, no. (%) 11 (100) 11 (100) 2 (40) 285 (100)Years since diagnosis with RA, mean � SD 22 � 12.9Years receiving physiotherapy services, mean � SD 12 � 10.9

* PD � professional development; RA � rheumatoid arthritis.† Rheumatologists: n � 8 (72.7%), physiotherapists: n � 6 (54.5%), and PD respondents: n � 75 (26.3%).‡ Based on the proportion of respondents who are currently involved in clinical practice (n � 255).


for excellent communication, the importance of utilizinga multidisciplinary team (including early referral to rheu-matologist), a commitment to chronic disease manage-ment, and disease monitoring.

Essential knowledge and skills themes. Thirty-nineknowledge themes were identified. General physiothera-peutic principles of treatment for patients with RA (forexample, managing inflamed joints, pain relief, joint pro-tection, exercise prescription) was considered an essentialknowledge theme (�80% agreement by the Delphi panel)across all 3 disease phases (Table 2). Being alert to apresentation that may suggest RA and the importance ofearly referral to a rheumatologist were the only themesconsidered essential by 100% of the panelists.

Thirty skills themes were identified. Excellent commu-nication skills and monitoring disease activity were con-sidered essential skills themes (�80% agreement by theDelphi panel) across all 3 disease phases (Table 3).

Essential themes by the Delphi panel group. Analysisby the panelist group revealed different trends in both thenumber of themes achieving 100% consensus (consumers:n � 17, physiotherapists: n � 13, rheumatologists: n � 4)and the content of those themes. Consumers consistentlyreached 100% agreement on themes associated with com-munication, the impact of comorbidities, and involvementof a multidisciplinary team. Physiotherapists identifiedessential themes associated with physiotherapy manage-ment, ongoing disease monitoring, and their referral obli-gations as essential. Rheumatologists reached 100% con-sensus on essential themes associated with early diagnosisand referral, red flag identification, and musculoskeletalexamination skills. Two knowledge themes, general phys-iotherapeutic principles of treating inflamed joints andcontradictions to some physiotherapy treatment tech-niques, and 1 skill theme, ongoing monitoring of diseaseactivity and severity, achieved 100% agreement across theconsumer and physiotherapy groups.

Essential knowledge and skills elements. One hundredninety-five elements were identified supporting thethemes. Across the entire Delphi panel, 100% consensuswas not achieved in any element. The highest agreement,for which 24 (96%) of the 25 panelists gave a score of 5(essential to know), was achieved in 4 of the 195 elements:importance of identifying features such as repeated flaresand ruptured tendons requiring referral for medical re-view, understanding the importance of early RA diagnosis,recognition of joint instability (especially within the cer-vical spine), and being alert to the presence of inflamedjoints.

Essential elements by the Delphi panel group. Whenanalyzing element consensus by group, differences wereevident between consumers, physiotherapists, and rheu-matologists. Consumers reached 100% agreement withscores of 5 on 21 elements, physiotherapists on 12 ele-ments, and rheumatologists on 3 elements. Physiothera-pists and consumers together achieved 100% agreementon 5 elements as being essential to know, including un-derstanding the importance of early diagnosis; recognizingrepeated flares, ruptured tendon, acute joint effusion, andserious medication side effects; recognizing joint instabil-ity, especially in the cervical spine; having confidence in

referring people to more appropriate health professionalsor resources; and being particularly alert to matters ofonset and duration, pain presentation and behavior, jointinvolvement, and risk factors that may indicate RA. Phys-iotherapists and rheumatologists achieved 100% agree-ment on 1 element, being particularly alert to inflamedjoints (swelling, limited range of movement, redness,warmth). By contrast, there were no elements agreed on asessential to know by 100% of consumers and rheumatolo-gists.

Appraisal of CPGs and extraction of physiotherapy-specific recommendations. Table 4 shows scores for eachof the AGREE instrument domains derived from the ap-praisal of the 8 CPGs and the additional scores of 7 CPGstaken from the Royal Australian College of General Prac-titioners guidelines (19). The 6 CPGs selected for extrac-tion of physiotherapy-relevant recommendations are indi-cated.

Linking Delphi responses with CPG recommendations.Comparison between the 30 knowledge and skills themes(supported by their element components) identified as be-ing essential by �80% of the Delphi panelists and therecommendations from the RA CPGs demonstrated that 26(86.7%) of the 30 themes aligned with selected guidelinerecommendations (Tables 2 and 3).

PD needs assessment survey. Three hundred forty-eighte-surveys were started online, of which 285 (81.9%) metthe selection criteria, representing 10.8% of the registeredphysiotherapists in WA. Table 1 shows the demographicand work history characteristics of the respondents. Ofthose physiotherapists who were currently involved inclinical practice (n � 255 [89.5%]), 54.9% currentlytreated patients with RA. These patients represented amean � SD of 4.4% � 5.9% of their current clinical case-loads. When asked about confidence in managing patientswith RA, 41.7% were not confident in their ability torecognize an early presentation of RA, 52.5% were notconfident in their knowledge of the typical clinical courseof RA, 77.5% were not confident in their knowledge ofevidence-based physiotherapy interventions for RA, and65.6% indicated they had insufficient knowledge to safelyand effectively co-manage a patient with RA throughoutthe disease course. Across the range of essential knowl-edge and skills themes, 45.1–93.5% and 71.1–95.2% ofrespondents, respectively, indicated they would benefitfrom or definitely need PD (Tables 2 and 3). Approxi-mately 70% of respondents reported they would be inter-ested or very interested in accessing PD related to RA.

DISCUSSION

Knowledge and skills relevant to physiotherapy manage-ment of RA were identified and aligned with contempo-rary, evidence-based CPGs. Physiotherapists clearly indi-cated their PD needs in order to facilitate their evidence-based delivery of services for patients with RA. Significantworkforce development may be needed before the transi-

1518 Briggs et al

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1522 Briggs et al

tion from hospital-based to community-based services canbe realized.

The essential knowledge and skills themes identified inthis study consistently align with the core general rheu-matology topics proposed by Hewlett et al (29) for UK-based undergraduate health students. Surprisingly, theonly themes we identified that did not align with thetopics proposed by Hewlett et al (29) were those related toexcellent communication. This difference likely reflectsthe involvement of consumers in our study, but may alsoreflect a greater emphasis on the importance of communi-cation integral to Australian undergraduate physiotherapycurricula; this may also explain why communication skillswas an area of least perceived PD need. Consistent withHurkmans et al (40), all of the panelists identified the needfor promoting physical activity in patients with RA.

The themes considered essential by all of the panelists

related exclusively to the prediagnosis phase. These 2knowledge themes, being alert to a presentation that maysuggest RA and the importance of early referral to a rheu-matologist, reflect the current medical management of RA,where a narrow window of opportunity exists in the earlydisease phase to slow or halt joint damage (41). Conse-quently, it is vital that a community-based physiotherapistis cognizant about the clinical features of early RA, inorder to facilitate timely referral to a rheumatologist. At aclinical skills level, physiotherapists need to be proficientin undertaking a clinically-reasoned approach to the mus-culoskeletal examination of patients with RA, be able tomonitor disease activity, and engage in RA-appropriateself-management support. While it might reasonably beexpected that practicing physiotherapists would possessgeneral musculoskeletal skills and understand the con-cepts of self-management support, RA-specific compo-

Table 4. Domain scores for each clinical guideline appraised using the AGREE tool*

Clinical guideline,year (ref.) Scope of guideline

AGREE scores, %

Domain1

Domain2

Domain3

Domain4

Domain5

Domain6

BSR/BHPR, 2006 (21)† Management during the first 2 years ofonset of RA in adults

72 67 52 75 83 92

BSR/BHPR, 2009 (17)‡ Management after the first 2 years ofonset of RA in adults

78 50 24 71 67 50

Forestier et al, 2009 (16)‡ Nondrug management of RA 39 42 69 83 44 0RACGP, 2009 (19)‡ Early diagnosis and management (�2

years) in people with RA ages �16years

83 69 80 94 3 33

RCP/NICE, 2009 (18)‡ Diagnosis and management of RA inadults

89 63 52 83 33 83

SIGN 123, 2011 (20)‡ Disease duration of �5 years fromonset of symptoms

83 50 55 75 50 58

ACR, 2002 (34)§ Management of people with adiagnosis of RA

8 0 4 0 22 33

Emery and Suarez-Almazor,2003 (36)§

Pharmaceutical management of RA 64 8 86 58 33 66

EULAR, 2007 (38)§ Management of early arthritis 72 25 52 71 0 0Hennell and Luqmani,

2008 (15)Multidisciplinary management of RA

in the first 2 years83 63 29 83 28 0

Indian guidelines, 2002 (35)§ Diagnosis and management of peoplewith RA

11 0 4 33 0 0

Ottawa Panel evidence-basedclinical practice, 2004 (13)

Therapeutic exercises in adult patients(ages �18 years) with a diagnosis ofRA

72 71 69 38 0 25

Ottawa Panel evidence-basedclinical practice, 2004 (14)

Electrotherapy and thermotherapytreatment in adult patients (ages�18 years) with a diagnosis of RA

78 75 71 67 0 25

SIGN 48, 2000 (33)§ Early diagnosis and management (�5years from onset of symptoms) inpeople with RA

61 58 40 75 17 8

South African guidelines,2003 (37)§

Management of RA 44 58 24 17 0 67

* Domains include: 1) scope and purpose, 2) stakeholder involvement, 3) rigor of development, 4) clarity and presentation, 5) applicability, and 6)editorial independence. AGREE � Appraisal of Guidelines for Research and Evaluation; BSR/BHPR � British Society of Rheumatology/British HealthProfessionals in Rheumatology; RA � rheumatoid arthritis; RACGP � Royal Australian College of General Practitioners; RCP/NICE � Royal Collegeof Physicians/National Institute for Health and Clinical Excellence; SIGN � Scottish Intercollegiate Guidelines Network; ACR � American College ofRheumatology; EULAR � European Union League Against Rheumatism.† AGREE scores extracted from the RACGP clinical guidelines (19). Selected for extraction of physiotherapy-relevant recommendations.‡ Selected for extraction of physiotherapy-relevant recommendations.§ AGREE scores extracted from the RACGP clinical guidelines (19).


nents are likely to require further education for 2 reasons.First, at the undergraduate level, knowledge and skills aregenerally taught by principle, rather than by specific dis-ease. This aligns with a study of Canadian physiothera-pists who identified their undergraduate training in RA tobe inadequate (42). Second, the tertiary-oriented servicedelivery model likely results in depletion of knowledgeand skills among those clinicians who practice outsidethis setting. Findings from the PD survey support this,where a large proportion of respondents indicated a lack ofconfidence and the need for PD in RA-specific diseaseknowledge and clinical skills.

Delphi themes relating primarily to the scope of practicefor professions other than physiotherapy, such as knowl-edge of pharmaceutical treatments and skill in identifyingpsychosocial consequences of RA, did not reach consen-sus level for “essential” across the different groups. None-theless, these themes reinforce the importance of deliver-ing education to both practicing clinicians and trainees inan interprofessional framework. Here, generic knowledgeand skills across professions can be complementary whilealso maintaining domain-specific knowledge and skills.While the concept of Treatment to Target (T2T) is embed-ded in many areas of clinical medicine, its application toRA is relatively new (43), particularly around nonpharma-cologic management. Possibly for this reason, and the factthat the Delphi panelists were not asked specifically aboutmanagement frameworks, the T2T approach was not iden-tified as an essential knowledge or skill. Nonetheless, withthe increased emphasis on T2T, it may be important toembed this management framework within PD initiatives.

Differences were observed in knowledge and skillsthemes identified as being essential by the 3 panelistgroups. Consumers highlighted a greater number of essen-tial themes than either the physiotherapists or rheumatolo-gists, consistent with a consumer expectation for a holisticapproach to management and highlighting the need forgeneric knowledge and skills to enable an integrated teamapproach to co-care, as emphasized by Woolf (44). Further-more, consumers’ specific theme trends were differentfrom the clinician panel members. Consumers placedgreater importance on the effective use of communicationstrategies to build rapport with patients, educate patientsabout their disease, and advocate for appropriate care.These findings likely reflect consumers’ right and desire toco-manage their RA, consistent with contemporary man-agement approaches for chronic conditions (45,46). Con-sumers also emphasized the impact of comorbidities ontheir general well-being and ongoing management. Therewas a tendency for physiotherapists to place greater im-portance on practical skills and for rheumatologists tohighlight the need for medical review in the presence ofred flags, reflecting the domain-specific orientation of eachprofession.

The majority of the disease-specific knowledge and clin-ical skills themes identified as essential by the Delphipanelists were supported by evidence-based, high-quality,contemporary CPGs. Although there were some themesidentified by the Delphi panel that did not align withguidelines, these did not reflect recent developments orresearch evidence that contradict or otherwise alter inter-

pretation of the identified guideline recommendations.Due to CPG variability in the evidence hierarchies, assign-ing a single level of evidence for each guideline recom-mendation was impractical. However, aligning these rec-ommendations with the findings of the Delphi process hasprovided an important link between current expert opin-ion and evidence. Those themes identified by the paneliststhat did not link to recommendations in CPGs likely reflecta number of factors, including the medical orientation ofthe CPGs, an assumption that basic competencies are al-ready held by those professionals to whom the guidelinesapply, and that knowledge pertaining to particular skillsis assumed. Furthermore, we did not anticipate that all ofthe CPGs reviewed would encompass all physiotherapy-specific assessment skills. Additionally, CPGs may implic-itly assume that health professionals managing peoplewith RA have the necessary skills to identify potentialphysical complications and red flags associated with RA.

The majority of survey respondents worked in primarycare, the workforce group of interest. It is precisely thesephysiotherapists who could feasibly contribute to theco-management of patients with RA in Australia, sincepolicies and operational aspects of health service deliverypromote community-based management for consumerswith chronic health conditions, rather than managementdelivered from tertiary hospitals. The survey data suggestthat clinicians in primary care currently lack the confi-dence to initiate safe and effective management for pa-tients with RA, highlighting the need for PD to ensure thatworkforce capacity can meet the needs of consumers andhealth policy directives.

A particular strength of this study lies in the linkage ofexpert clinical and consumer consensus (Delphi stage)with relevant evidence from high-quality CPGs. Further-more, the study represents a direct implementation of WAstate health policy recommendations surrounding work-force development needs in this clinical area (6). Theinclusion of consumer data in the Delphi process presentsa unique perspective and emphasizes the need for physio-therapy education to be consumer oriented. A furtherstrength was the use of an international Delphi panel,enabling generalization of findings beyond the Australianhealth care setting. A potential limitation of the Delphiprocess was the size of the panel; although smaller than asimilar study (29), it met Delphi method recommendations(27,28).

Although we linked the Delphi responses with evi-dence-based CPGs, we did not undertake a full systematicguidelines search. Some relevant guidelines therefore maynot be identified, although this factor was mitigated byusing the Delphi panel to identify key guidelines. A sys-tematic appraisal of CPGs on physiotherapy in RA waspublished after this study was completed (32). Of the 8guidelines included in that study, we also appraised 7.Hurkmans et al (32) appraised guidelines published onlyin scientific journals during 1998–2009; consequently, 8guidelines we identified were not included. We recom-mended similar high-quality guidelines to Hurkmans et al(32) within our inclusion criteria (16,21); however, weappraised 2 as being of lower quality (15,38).

The majority of participants in this study were women,

1524 Briggs et al

and a sex bias is therefore possible. We are unable tocalculate the exact response rate for the e-survey, sincethe number of unique survey invitations was unknown.Although the absolute number of e-survey responses re-ceived was comparable to a similar study (42), the re-sponse rate is likely to be low and represents a limitationto the generalizability of the findings. In order to maintainanonymity of the responses and comply with privacy pol-icies imposed by the APA, Alumni Office, and local ethicscommittee, we did not have access to responder identities.Therefore, physiotherapists may have received more than1 invitation to complete the survey. The risk for duplicateresponses was minimized by asking the respondents tocomplete only 1 survey. Furthermore, the Qualtrics plat-form used browser cookies to block multiple submissionsfrom the same computer.

ACKNOWLEDGMENTSThe authors gratefully acknowledge the participationof the Delphi panel members (Ms Susan Archbold,Dr. Sydney Brooks, Dr. Lucie Brousseau, Dr. GraemeCarroll, Dr. Chris Deighton, Mr. Lindsay Dutton, Ms SuzieEdward May, Ms Rebecca Endacott, Ms Maryann Fabling,Ms Camilla Fongen, Dr. Samantha Hider, Dr. MauraDaly Iversen, Dr. Anita Lee, Ms Margaret Lewington,Ms Kerry Mace, Dr. Norma MacIntyre, Ms Maree Munday,Dr. Andrew Ostor, Dr. Zoe Paskins, Ms Kathryn Pickering,Ms Louise Preston, Dr. Susanna Proudman, Dr. Mark Quinn,Dr. Janet Roddy, Dr. Edith Villeneuve, and Ms AlisonWigg) and Dr. Joanne Jordan for qualitative analysis exper-tise. The Curtin University Alumni Office and the APA(WA office) are acknowledged for their support in dissem-inating the clinician survey.

AUTHOR CONTRIBUTIONS

All authors were involved in drafting the article or revising itcritically for important intellectual content, and all authors ap-proved the final version to be published. Dr. Briggs had full accessto all of the data in the study and takes responsibility for theintegrity of the data and the accuracy of the data analysis.Study conception and design. Briggs, Slater, Bragge, Keen, Chan.Acquisition of data. Briggs, Fary, Slater, Bragge, Chua.Analysis and interpretation of data. Briggs, Fary, Slater, Bragge.

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