Roles of physiotherapists in primary care teams: a scoping review

Abstract

Objectives

We aimed to provide an overview of the existing knowledge regarding the roles of physiotherapists in primary care teams.

Design

Scoping review based on the methodological framework provided by Arksey and O’Malley (2005) and updated by Levac et al (2010). 

Data sources and study selection

A search strategy was carried out across the Medline, CINAHL, Academic Search Complete and AMED databases in June 2023. Selected articles, based on qualitative or mixed design studies, had to report on the roles of physiotherapists working in team-based primary care organisations and be published in the last 10 years.

Data extraction and analysis

Data were extracted by one team member and further validated by a second team member. A mixed thematic analysis based on the Competency Profile for Physiotherapists in Canada was used to identify all the roles undertaken by physiotherapists. 

Results

The database search yielded 2324 articles. From the 13 included articles, 6 main themes emerged: conduct client assessment for musculoskeletal conditions, participate in health promotion and prevention, promote self-management support, communicate with patients, collaborate with other primary care providers and partners, and provide holistic care.

Conclusions

The review identified a wide variety of roles, primarily related to the treatment of musculoskeletal patients. In primary care settings, interprofessional collaboration can be hindered by a lack of knowledge regarding the roles of physiotherapists. Future studies should aim to develop effective strategies to ensure that all primary care team members have a comprehensive understanding of the roles of physiotherapists and to explore roles associated with non-traditional forms of physiotherapy practice.

STRENGTHS AND LIMITATIONS OF THIS STUDY .

• This paper includes articles from several databases with peer-reviewed literature expanding the pool of potentially eligible articles.

• A pragmatic approach was used, recognising that there are different ways of interpreting data and thus including perspectives from physiotherapists, other primary care providers and partners, and patients. 

• In the search strategy, only terms related to primary care were included for the physiotherapy context of practice, which may have introduced bias towards a Canadian perspective.

• The limitations of this scoping review include the possibility of missing valuable articles due to the use of only qualitative data and studies in English or French published within the last 10 years. Additionally, no protocol was published. 

Introduction

As qualified rehabilitation professionals, physiotherapists bring essential expertise to individuals of all ages by conducting assessments, providing diagnoses and prognoses, using various treatment modalities, providing education and counselling support, formulating recommendations and promoting an active lifestyle.^{1 2} They can manage musculoskeletal, respiratory or neurological conditions and treat individuals with various chronic diseases.^{1 3} Physiotherapists also contribute to addressing mental health issues,² as individuals suffering from musculoskeletal conditions have a higher risk of developing mental health conditions.⁴ An interdisciplinary approach including physiotherapists is increasingly common in primary care.³ They are most often found within a family medicine clinic, where they can see patients individually or jointly with a primary care physician, enhancing collaboration and communication.^{5 6} Within an interdisciplinary team, physiotherapists may work with nurse practitioners, occupational therapists, social workers, dieticians and other professionals.³

There is growing evidence supporting the interdisciplinary approach including physiotherapists. Studies have shown improved management of patients with chronic diseases^{5 7} and increased patient satisfaction.^{7 8} Patients with musculoskeletal conditions who consulted the physiotherapist first had better outcomes regarding disabilities and quality of life than those seeing a physician first.⁹ This led to fewer consultations with their general practitioner (GP),¹⁰ reduced healthcare costs^{9 11 12} and decreased medication and imaging use.^{13 14} This physiotherapist-led model is a concrete application of primary care, defined as the first point of contact with the healthcare system, but physiotherapists also contribute to other aspects of primary care, such as continuity of care, prevention and management of common health problems.¹⁵ Another effective strategy in primary care teams was to involve the physiotherapist and the practitioner in a co-consultation with the patient.^{8 16} When the two healthcare providers were present at the same appointment, physiotherapists provided education to physicians, helping them feel more confident in managing musculoskeletal issues. Continuity of care was also improved, as the physiotherapist could conduct follow-up consultations with the patient.⁸

Not all primary care providers are aware of physiotherapists’ expertise in managing various types of conditions.^{17 18} Knowledge of physiotherapy’s scope of practice may be limited, as interviews with mental health professionals revealed that some of them questioned the usefulness of physiotherapists and expressed concerns about their skills and clinical expertise in managing patients with mental health issues.¹⁸ This lack of awareness regarding the potential roles of physiotherapists in a primary care team may lead to communication and referral challenges among professionals.¹⁷ Understanding the roles of each professional within an interdisciplinary team has proved essential to enhancing collaboration.¹⁹ Better understanding of the potential role of physiotherapists in primary care teams is crucial to facilitating their full contribution. Thus, this scoping review aims to provide an overview of the existing knowledge regarding the roles of physiotherapists in primary care teams.

Method

Scoping review design  

A scoping review was conducted using the methodological process developed by Arksey and O’Malley,²⁰ which was later updated by Levac et al.²¹ Scoping reviews have a broad objective to identify and map the available literature while systematic reviews focus on precise research questions such as the effectiveness of a treatment or the feasibility of a specific intervention.^{22 23} Arksey and O’Malley suggested five stages: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) charting the data; and (5) collating, summarising and reporting the results.²⁰

Stage 1: identifying the research question

What roles do physiotherapists undertake within interprofessional teams in primary care settings? 

Stage 2: identifying relevant studies

To identify relevant studies, the search strategy was developed in collaboration with a librarian and carried out across Medline, CINAHL, Academic Search Complete and AMED, in June 2023. The following keywords were used: physical therapy, physiotherapist, musculoskeletal therapists, primary-care musculoskeletal specialists, musculoskeletal practitioners, primary care clinics, primary care facility, primary care center, primary care practice, primary-care, primary health care, primary healthcare centers. A specific combination of keywords was used for each database shown in online supplemental appendix A. The search was limited to the last 10 years given that primary care models are rapidly evolving across the globe. Hand-searching was also conducted using the reference lists of the excluded review articles.

Stage 3: selecting studies

To be included, studies had to fulfil the following inclusion criteria: (1) the roles of physiotherapists working in team-based primary care organisations were reported; (2) qualitative or mixed designs were used; (3) articles were published in the last 10 years. Articles were excluded when they were not in English or French, used non-empirical research, only used a quantitative design, did not describe the roles of physiotherapists in sufficient detail or did not report on primary care settings. Systematic and literature reviews were also excluded as this scoping review focused on primary research studies rather than synthesised secondary data,²³ but their references were hand-searched.

The search yielded a total of 2324 articles, of which 1534 remained after removing duplicates. Titles and abstracts were screened by the lead author (MC) to remove articles that clearly did not meet the inclusion criteria. A total of 1446 articles were excluded during the first step. The full-text paper of the remaining articles was retrieved and independently assessed by two team members (MC and AP). Of these remaining 88 articles, 76 were excluded: 2 were not in English or French, 10 used non-empirical research, 10 only used a quantitative design, 46 did not sufficiently describe the roles of physiotherapists and 8 did not report on primary care settings. Following hand-searching of the excluded reviews, one article was added. A flowchart of the study selection process is presented in figure 1. Finally, this research was situated within a pragmatic approach, where we acknowledged that there are different ways of interpreting data and that multiple realities may exist simultaneously.²⁴ Thus, the included studies present the roles of physiotherapists from the perspective of patients and other primary care providers and partners, as well as that of physiotherapists themselves.

Figure 1. Flowchart.

Stages 4 and 5: charting and summarising the data

We first gathered descriptive characteristics for each study including the author, year of publication, country of origin, study design and method, study aim, participant information, whether the primary care settings were public or private, and key findings (see online supplemental appendix B). This grid was completed by one team member (MC) and further validated by a second team member (AP). 

To summarise and report the results, we used a mixed thematic analysis²⁵ based on the Competency Profile for Physiotherapists in Canada. This framework describes seven domains of physiotherapy practice: physiotherapy expertise, communication, collaboration, management, leadership, scholarship and professionalism.²⁶ MC performed the initial data extraction and organised these data according to the seven domains of the competency profile. New themes were then developed according to emerging data. To enhance reliability, seven articles were selected for their complexity. Of these, two articles with abundant qualitative data, as well as five articles that were considered difficult for data extraction, were independently analysed by a second team member (AP). Then, both team members discussed the results of their thematic analysis and ultimately reached a consensus on the final key themes.

Patient and public involvement

Neither patients nor the public were involved in this study.

Results

(See figure 2)

Figure 2. Overview of themes.

Study characteristics

13 studies from 8 countries were included, and their characteristics are shown in online supplemental appendix B. Five studies were conducted entirely (n=4) or partially (n=1) in Canada. The others were conducted in the UK, Ireland, Brazil, Sweden, Japan, New Zealand and Australia. Participants were mainly physiotherapists, along with other primary care providers such as GPs, nurse practitioners or registered nurses, and one occupational therapist. The studies also involved various partners, including those involved in physiotherapy education, healthcare policy and quality insurance, as well as reception staff, office managers and an executive director. One study included patients with low back pain. Although some articles did not specify the source of funding of the primary care setting, most studies were conducted in public healthcare systems. 

Conduct client assessment for musculoskeletal conditions

Several authors have mentioned the role of the physiotherapists in client assessment.27,35 To ensure patient safety, physiotherapists needed to identify potential red flags to differentiate between a purely musculoskeletal clinical presentation and a condition warranting referral for an underlying serious pathology.³² Physiotherapists perceived conducting client assessments as a crucial responsibility:

We would just take in referrals, do our assessments, and then make recommendations as necessary or plan for interventions or referral to community resources… We primarily function as assessors…²⁸

In the case of physiotherapists acting as first contact providers, they conducted their assessment while screening for medical pathologies that can coexist with musculoskeletal conditions, such as neurological or metabolic conditions like diabetes.³⁰ The role of the physiotherapist could not simply be summarised as a musculoskeletal expert, but rather as one who has acquired a broad scope of knowledge leading to more complex reflections:

But you also need that slight lateral thinking of, hang on, are we dealing with a urinary tract infection here or has this got a smell of rheumatology or whatever? (T4).³⁰

During the initial assessment, physiotherapists might encounter suicidal behaviour.³⁶ Thus, physiotherapists recognised their role in identifying patients with symptoms or risk factors of mental illness, but they felt that they did not have the appropriate knowledge or the skills to perform more complex tasks such as mental health assessments.³⁶ Physiotherapists also had to conduct functional assessments of their patients to help GPs gain a better understanding of patients’ condition and work ability.³⁴

Participate in health promotion and prevention

Five articles mentioned a role related to health promotion.^{28 31 33 37 38} This role was observed mainly during group sessions once a therapeutic relationship was established between the patient and the physiotherapist.³³ However, although physiotherapists acknowledged their role in health promotion, it was not necessarily implemented in their routine. The high demand for physiotherapy services in primary care settings required the prioritisation of individuals in need of rehabilitation, at the expense of those who could have benefited from health promotion and prevention activities.^{33 37} French and Galvin also mentioned that while this health promotion role was emerging in the community, it was hindered by role conflicts with other providers.³⁸

The role of the physiotherapist in health prevention was also reported several times.27,2933 37 They contributed to the prevention of deformities and decubitus ulcers,³⁷ as well as disuse syndrome.²⁹ A physiotherapist raised the following point: 

[…] we can play a pivotal role and an influential role in providing that prevention piece because [doctors’ and nurses’] models are very reactive-medicine based.³⁹

Promote self-management support

Support for self-management was a frequently mentioned role.2728 31 33,35 To achieve this, shared responsibility in treatment was promoted,³³ as well as offering active strategies to manage pain.³⁵ For Dufour, Lucy and Brown, education was closely related to self-management, shifting the traditionally hands-on approach to an educational role with fewer passive treatments.²⁸ A physiotherapist stated that education was one of the tools used by physiotherapists to support self-management: 

I’m a big proponent of not making people reliant on us as providers, and I think that in terms of client empowerment… really educating them in terms of their own role related to their health… that is key…²⁸

By providing explanations to patients, physiotherapists helped patients feel more confident in managing their conditions.³⁴ When physiotherapists promote self-management support, they can enhance their patients’ quality of life.²⁷

Communicate with patients

Physiotherapists needed to be good communicators, especially using their listening skills, and consequently developing a good understanding of the patient’s needs and what they perceived as problems.^{30 35} This was illustrated by a participant in the McMahon et al study:

It is really important to be a good listener and communicator because the subjective history is absolutely crucial in primary care as the patient may present early in the disease process, they need to be able to impart information and give clear concise guidance.³¹

Patients appreciated when physiotherapists took the time to explain the treatment and were open to questions.³⁵

Collaborate with other primary care providers and partners 

In primary care settings, physiotherapists had to collaborate with various primary care providers. Multidisciplinary teams often included the following professionals: ‘public health nurse, physiotherapist, occupational therapist and, less commonly, psychologists, speech and language therapists, dentists and dieticians’.³⁸ In conjunction with physical trainers and nutritionists, physiotherapists developed activities for group sessions.³⁷ They also collaborated with orthotists during foot clinics as well as with occupational therapists for some patients’ treatments.³⁸ For patients with chronic conditions that required consultations with several healthcare providers, physiotherapists were useful to establish connections among teams of providers as they are trained to use a multi-system approach.²⁸ Often accompanied by other members of the family health centre team, such as the doctor, nurse, community health worker or community health agent, physiotherapists also had to conduct home visits. They visited individuals who were unable to travel to the clinic due to acute conditions and walking problems, or because they were bedridden.^{33 37} Physiotherapists played a role in prevention and provided exercise counselling.³⁷

Several authors reported the involvement of physiotherapists in primary care teams for programme development or improvement. In the Maharaj et al study, physiotherapists collaborated with health promoters, dieticians, social workers and nurses to perform this task.³⁹ For instance, they would review physical activity programmes to ensure their safety and efficacy.²⁸ In another study, primary care practitioners stated that physiotherapists would be of great help to promote prophylaxis in primary care settings, especially for development/preventive measures and information brochures.²⁹ Physiotherapists also played a role in chronic disease management, as they provided the team with knowledge on chronic pain and chronic disease programmes.^{27 28} Similarly, their musculoskeletal expertise provided valuable support to primary care physicians, namely, knowledge on specific topics such as low back pain:

It’s always nice to have a second set of eyes, somebody who’s specifically working within this component, ah where I can I do my assessment and the generalist stuff [as a family physician] and [the physiotherapist is] the specialist in this area.³⁵

Although learning can sometimes be one-sided, Moffat et al highlighted the role of physiotherapists in two-way learning with other primary care providers as nurses or GPs could learn through the written notes of physiotherapists, and vice versa.³² However, in the Maharaj et al study, some of their colleagues had limited knowledge about physiotherapists’ roles in primary care teams:

I think that definitely [other health care professionals] don’t see physio as maybe playing a preventive role in some chronic diseases, they think everything is very condition-specific. There’s definitely some… perception out there that [treating] musculoskeletal [conditions is] all we do.³⁹

This limited viewpoint on the roles of physiotherapists was also mentioned by another study.²⁸ Thus, to improve collaboration, physiotherapists had to advocate for their place within primary care teams by educating their colleagues about the physiotherapy profession.^{28 31 39} The opposite was also true; physiotherapists needed to understand the roles of other providers.³¹ Many agree that to ensure better collaboration, communication between them is essential,^{28 31} especially to address incorrect referrals³⁹ and to provide more integrated care.³⁵

Provide holistic care

One of the elements highlighted by the literature was the importance of providing holistic care.^{29 31 38} By providing individualised care, physiotherapists must be sensitive and respectful of different traditions and beliefs, while also understanding patients’ culture and communities.³¹ Although physiotherapists provide holistic care to individuals and their family, primary care physicians expected physiotherapists to understand their community well, including its environmental factors. As one of them said:

I think the rehabilitation specialist has a good eye to look at the community as a whole […].²⁹

Discussion

To our knowledge, this is the first scoping review to summarise the existing literature regarding the roles of physiotherapists in primary care teams. Only 13 articles were identified in the literature. This underlines how little research has been done on this topic. The most common roles were related to client assessment, collaboration with other primary care providers and partners such as community health workers and community health agents. Less frequently reported, but still important, were their roles in health promotion and prevention, supporting self-management, communicating with patients and providing holistic care.

The role of assessor was referenced in nearly all studies. This role is of particular significance for those who initially consult with a physiotherapist for musculoskeletal disorders. It is crucial to be able to identify serious pathologies, as failure to do so may result in significant complications for the patient, including hemiplegia.⁴⁰ The process of assessment also encompasses the identification of potential mental health risk factors, a procedure that has been characterised as underutilised in a recent scoping review.⁴¹ A number of studies recommended additional education for physiotherapists in order to improve mental health screening.42,45

Furthermore, this review underscores the necessity for physiotherapists in primary care teams to engage in interprofessional collaboration with other health professionals. The primary focus of current literature is on co-consultations and home visits, as well as activity and programme development. Physiotherapists engage in collaborative practice with a diverse range of health professionals, including occupational therapists, physical trainers, nutritionists, orthotists, social workers, nurses and, of course, physicians. The collaboration between physiotherapists and physicians can be beneficial in optimising the care provided to patients with specific conditions, such as chronic obstructive pulmonary disease.⁴⁶ Similarly, collaboration within a larger primary care team, comprising nurses, physicians and occupational therapists, ensures that rehabilitation interventions are beneficial to patients.⁴⁷ However, two studies have identified integration barriers for physiotherapists, primarily due to a misunderstanding of their roles by other primary care team members.^{47 48} A similar phenomenon has been observed in the integration of occupational therapists into primary care teams.⁴⁹

Thus, the question arises as to how knowledge of the role of physiotherapists can be fostered within the primary care team. One of the initial steps to achieve this is to clearly define the roles of physiotherapists. The Competency Profile for Physiotherapists in Canada outlines seven domains, subdivided into essential competencies, which are themselves divided into milestones expected of a physiotherapist at the start of their career.²⁶ Many of the roles identified in this paper align with this Canadian framework. First, within the physiotherapy expertise domain, the assessor role was retrieved but adapted to better suit primary care settings, with the addition of two adjacent subroles: identifying serious pathologies and screening for mental health risk factors. The roles related to promoting self-management support and providing holistic care were also extracted from the included studies, as physiotherapists had to understand their patients’ traditions, beliefs and culture, as well as the environmental factors of their communities. Finally, the physiotherapy expertise domain includes the plan, deliver and evaluate programmes competency, which, in our review, was associated with a more collaborative role within the team, rather than being perceived solely as part of physiotherapy expertise in this framework. Second, the communication domain can be directly linked to the communicator role with patients. We found that physiotherapists needed to listen closely to their patient’s history, as they may be consulted early in the disease process. They also needed to communicate with other primary care providers to address incorrect referrals. Third, the collaboration domain was extensively explored in this scoping review. In line with the share information about the physiotherapist’s role and knowledge milestone, our review reveals that physiotherapists had to advocate for their role in their interprofessional team. Conversely, physiotherapists had to also understand other primary care provider roles. Finally, within the leadership domain, this review emphasises the physiotherapists’ role in health promotion, through group sessions, and in health prevention activities.

In order to enhance interprofessional collaboration, it is necessary to move beyond the mere mapping of existing roles. Other primary care providers need to gain a more comprehensive understanding of the physiotherapists’ roles and responsibilities. Fortunately, the existing literature offers promising solutions to address this challenge. A study reported that family medicine residents demonstrated enhanced comprehension of physiotherapists’ scope of practice following the receipt of both didactic and experiential education from a physiotherapist on their primary care team.⁵⁰ Pagano et al discovered that the implementation of an integrated model, in which cardiorespiratory physiotherapists and primary care physicians managed a weekly clinic, led to a notable increase in the awareness and comprehension of physiotherapists’ involvement in diagnosis and management.⁴⁶

Despite our efforts to identify all the roles of physiotherapists, further research is required to fully explore every aspect of their broad scope of practice in primary care settings. Specifically, in the included studies, it was often challenging to ascertain whether the physiotherapist was serving as the primary point of contact for the team or as a musculoskeletal consultant. It is recommended that future studies exploring physiotherapists’ roles define the position held by the physiotherapist within the team. Given the existence of multiple models of primary care that integrate physiotherapists, it would be beneficial to conduct a comparative analysis of their efficacy in terms of the quality of care they provide. Finally, there remain numerous unanswered questions with regard to the role of the physiotherapist in the treatment of non-musculoskeletal patients. It would be beneficial to collect further data, given the paucity of existing literature on non-traditional forms of physiotherapy practice.

Limitations

It is essential to recognise the potential limitations of this scoping review. Despite the fact that our search strategy was conducted across a number of databases, it did not encompass the use of specific terms related to collaboration. The use of primary care-related terms may have introduced a bias in the scoping review towards a Canadian perspective. The restriction of included articles to qualitative or mixed-method designs enabled the acquisition of more detailed material on the roles of physiotherapists; however, this approach may have resulted in the exclusion of a few quantitative studies that might have contributed valuable data. It should be noted that language may also be considered a limitation, given that the only potential articles included were either in English or in French. The titles and abstracts of all potential articles were screened solely by the lead author. While this approach enabled consistent assessment, the absence of a second independent reviewer may have affected the reliability of the screening process. Although we adhered to scoping review methodology as closely as possible, the absence of a published protocol may have restricted the replicability of this manuscript and the ability to address potential biases. In addition, a critical appraisal of the included studies has not been conducted, as the objective was to describe the roles of physiotherapists, rather than to measure their effectiveness. Notwithstanding these limitations, we believe that this review remains relevant in enhancing primary care providers’ and health managers’ knowledge and awareness of the roles of physiotherapists.

Conclusions

The role of the physiotherapist in primary care is multifaceted, encompassing a range of responsibilities. These may include the performance of specific tasks, such as the assessment of musculoskeletal conditions, or the delivery of holistic care. Their role is that of a collaborative partner with other primary care providers. It is of the utmost importance that all members of a primary care team have a comprehensive understanding of the roles of physiotherapists in order to facilitate optimal interdisciplinary collaboration and, most importantly, to ensure the delivery of the highest standard of patient care.

Data availability statement

Data are available upon reasonable request.