Knowledge and Care Quality of Physiotherapy Technologists in the Management of Common Shoulder Disorders: Results from a Survey in the Province of Quebec, Canada

Abstract

Purpose:

In Québec, physiotherapy technologist (Phys.T.) scope of practice allows them to complete the evaluation and treat various musculoskeletal disorders, including shoulder disorders, after an initial assessment by a referring provider. They may need to re-evaluate and refer back to the providers if a patient does not progress in a satisfactory manner. Our purpose is to evaluate knowledge and care of practicing Phys.T. in identifying and managing overall care for common shoulder disorders.

Method:

A survey presented four clinical vignettes featuring common shoulder disorders. Survey participants provided information regarding diagnosis, imaging recommendations, specialist referrals, medical and rehabilitation care, and their confidence in managing these clinical cases. Responses were compared to recommendations from selected clinical practice guidelines (CPGs).

Results:

43 Phys.T. completed the survey, with the majority accurately identifying common shoulder disorders across all vignettes (74%–94%). Compliance with CPGs was observed for rotator cuff tendinopathy (60%) and adhesive capsulitis (61%), with most Phys.T. refraining from initial imaging tests. However, a significant proportion recommended imaging for acute full-thickness rotator cuff tear (52%) and recurrent traumatic glenohumeral instability (80%), in line with CPGs. Education and exercises were prioritized in all vignettes as per CPGs, although a proportion favored passive physical modalities not endorsed by CPGs (13%–72%).

Conclusion:

Most Phys.T. demonstrated adequate identification and management of shoulder disorders, reflecting their collaborative role in patient care. However, discrepancies existed in adherence to evidence-based recommendations, suggesting the need for additional training to optimize care pathways and inter-professional collaborations for shoulder and musculoskeletal disorders.

Shoulder pain is common and frequently encountered in primary care.¹ Studies have shown that the lifetime prevalence of shoulder pain may be as high as 55%.² The most prevalent shoulder disorders among the adult population are rotator cuff (RC) tendinopathy, RC full-thickness (FT) tear, adhesive capsulitis, and glenohumeral (GH) instability.³ Shoulder pain is a significant health problem, with 50% of individuals still experiencing symptoms 6 months after initial consultation and 40% still symptomatic after 1 year following an initial consultation in primary care.⁴ Physiotherapy is commonly recommended to treat shoulder disorders⁵ and interprofessional collaboration between physiotherapists, physiotherapy technologists (Phys.T.) and physiotherapy assistants (PTA) is common to care for several musculoskeletal(MSK) disorders, including shoulder pain.⁶

In Quebec, two categories of health professionals are recognized by the system to provide rehabilitation services: physiotherapists (PT) and physiotherapy technologist (Phys. T.). They work in collaboration to manage the needs of various rehabilitation clienteles. Physiotherapy technologists represent a third of rehabilitation professionals in the province of Québec.⁷

Phys. T. undergo a 3-year college training program with a standardized curriculum granting them a broader set of roles and responsibilities than PTA elsewhere in Canada. In Quebec, the extent of their care autonomy is determined by the nature and severity of the patient's impairment and disability. Section 4 of the 94M) regulation states conditions that a Phys. T. must meet in order to be allowed to care for a patient presenting for physiotherapy management.⁸ For example, several MSK disorders such as shoulder pain will fall under Category 2 out of 4. In this category, Phys. T. must obtain from a physiotherapist, a physician, or a nurse practitioner a diagnosis that is not limited to symptoms, and this referral needs to include relevant medical information, a list of problems, and/or rehabilitation goals. After receiving a referral, they can initiate patient care independently by actively evaluating patients’ needs and establish physiotherapy treatment goals. They will also develop the intervention plans and select treatment modalities. While delivering care they are required to re-evaluate the patient condition which could include assessing new symptoms or a new health problem. Evaluating the ability and knowledge of Phys. T. in the overall care of these patients is therefore important, as they may need to be able to screen and refer these patients to the initial provider if the condition of the patient has changed but also if the initial diagnosis is erroneous, or the recommended medical treatment is not adequate or optimal. Several sources stress that the primary care of MSK disorders is plague by poor diagnosis capabilities of several provider including physicians.⁹ Moreover rapid access to the referring providers if the condition of a patient has changed is often difficult in our health care system. Therefore, ensuring that Phys. T. possesses basic competencies to evaluate, screen, and make an informal diagnosis, even if outside of their scope might be valuable to optimize inter and intra-professional collaborations care pathways for shoulder disorders or other MSK disorders. Phys. T.'s knowledge and ability to efficiently care for patients with shoulder pain remain fairly unknown. Demonstrating their expertise or identifying areas of practice in which they may need to acquire better knowledge is new area of interest. Based on findings of this nature, this could help foster better models of care to alleviate some of the burdens and responsibilities of other health care providers, ultimately improving access and care efficiency.

Using a survey design, the overall aim of this study was to describe for the first-time knowledge and confidence of Phys. T. in the province of Quebec in identifying and managing four common shoulder disorders. The study also aims to evaluate appropriateness of care by comparing the indicated management with recommendations from high-quality clinical practice guidelines (CPGs).

Methods

Study design

This descriptive study used a cross-sectional survey design that follows the guidelines for reporting survey-based research.¹⁰ The study was approved by the Health Research Ethics Committee of the CIUSSS-de-l’Est-de-l’Île de Montréal (2021–2024) in Montreal, Quebec, Canada. This survey is part of a larger project for which similar surveys were sent to family physicians and physiotherapists.¹¹ In this paper we present the results for Phys. T. respondents only.

Study population

A survey was sent to Phys. T. via the email list and social media accounts of the Ordre professionnel de la physiothérapie du Québec (OPPQ). The link of the survey was also sent via the email lists of selected physiotherapy clinics where our research team has ongoing collaborations. The survey was active from February to May 2021.

Survey development

The survey included an introduction and included questions on demographic and clinical characteristics of the respondents. Four clinical vignettes presented patients with shoulder pain secondary to the following conditions: rotator cuff (RC) tendinopathy, acute FT RC tear, adhesive capsulitis, or traumatic anterior glenohumeral instability. The vignettes were selected, translated, and adapted based on published survey-based studies on shoulder pain management conducted in the United States, Australia, and the United Kingdom.^12–14 The four vignettes are presented in Appendix 1. Each vignette was followed by close-ended questions on initial shoulder disorders identification and management. This section of the survey was developed based on previous studies evaluating family physicians and physiotherapists’ ability to manage appropriately general MSK disorders and shoulder pain management.¹²,¹³,^{15, 16, 17} We also questioned Phys. T. on their overall confidence level (not confident at all, slightly confident, somewhat confident, fairly confident, completely confident) in making an appropriate identification, selecting recommended investigations, adequately referring the patient to a MSK medical specialist, and selecting recommended treatments.

Initial shoulder pain management

For each clinical vignette, respondents had to identify (1) the associated shoulder disorder (RC tendinopathy, acute FT RC tear, chronic RC tear, GH osteoarthritis, GH instability, adhesive capsulitis, acromioclavicular disorders, shoulder pain referred from the neck or other disorders), (2) if they recommended any diagnostic imaging test (blood tests, X-ray, diagnostic ultrasound, magnetic resonance imaging [MRI], magnetic resonance arthrography [MRA], or any other test), and (3) if they would refer the patient to a medical MSK specialist such as an orthopedic surgeon, rheumatologist, physiatrist, sports physician.

Medical treatments

Phys. T. had to select, if any, which medical treatments they would recommend (oral non-steroidal anti-inflammatory drugs [NSAIDs], acetaminophen, opioid medication, corticosteroid infiltration, arthrographic distension, or other treatments).

Rehabilitation treatments

Phys. T. had to indicate rehabilitation interventions they would provide, and possible answers covered in detail specific interventions offered by physiotherapy professionals. For each proposed rehabilitation intervention (education, active mobility exercises, passive mobility exercises, strengthening exercises, motor control exercises, manual therapy, thermotherapy, electrotherapy), Phys. T. had to indicate the priority of the intervention on a scale from 0 to 5, 0 representing an intervention not to use and 5 representing an intervention that is extremely important to use.

Appropriateness of care

To determine the appropriateness of the Phys. T. offered for all shoulder vignettes, recommended management was based on previous survey studies using the same clinical vignettes¹⁰,²⁸,²⁹ as well as on the evidence-based recommendations of a recent high quality CPG developed by our team covering the initial management, medical, and rehabilitation treatments of RC disorders in the context of the province of Quebec.¹⁸ We also systematically reviewed the literature to identify CPGs covering the management of RC disorders and other common shoulder disorders such as adhesive capsulitis and glenohumeral instability.¹⁹ In the systematic review process, two reviewers assessed the methodological quality of the CPGs with the AGREE II checklist and extracted the recommendations.²⁰ We identified five high-quality CPGs covering the management of RC disorders,¹⁸,²¹–²⁴ two high-quality CPGs covering the management and indications for diagnosis imaging of adhesive capsulitis,²²,²⁵ and two high-quality CPGs including indications for diagnosis imaging of traumatic anterior glenohumeral instability.²¹,²² We also included the CPG covering the medical and rehabilitation management of glenohumeral instability with the highest overall score.¹⁰ Recommendations on shoulder pain management that were used to assess appropriateness of care are summarized in Table 1. Appropriateness of care was determined by one author (V.L.) and reviewed by a second author (F.D.).

Table 1.

Recommendations from Selected High Quality Clinical Practice Guidelines on the Management of Shoulder Disorders Used to Assess Appropriateness of Care Offered by Physiotherapy Technologists

Shoulder disorders	Initial management	Medical treatment	Rehabilitation treatment
Rotator cuff tendinopathy	X-rays are the first line examination for shoulder pain21/X-rays are not initially indicated in the initial management of RC tendinopathy18,22 (conflicting recommendations*) US or MRI are not recommended in the initial management of RC tendinopathy18 A referral to a medical specialist is not recommended in the initial management of RC tendinopathy18	Acetaminophen is recommended for pain relief.18 Oral NSAIDs may be useful for short-term pain relief.18 Corticosteroids injections are not recommended as first-line treatment to reduce pain and improve function, but may be useful to reduce pain and improve short-term function.18 Opioids are not recommended as first line pharmacological treatment to reduce pain in disability. Opioids may be useful to reduce short-term pain in adults that present severe pain and disability refractory to other analgesic modalities.18	An active and functional rehabilitation program is recommended as an initial modality to reduce pain and improve function (mobility, motor control, strengthening, endurance, education). It is recommended to prioritize active mobilization to passive modalities to reduce pain and improve function.18 Manual therapy can be useful provided alone or with other modalities such as exercises to reduce pain and improve function.18 Ultrasound, laser and extracorporeal shockwave treatment are not recommended to reduce pain and improve function.18 Insufficient evidence to formulate recommendations for taping, TENS, iontophoresis, pulsed electromagnetic field, interferential current.18
Acute full-thickness rotator cuff tear	X-ray, US, or MRI are recommended in the presence of a suspected FT RC tear. US should be prioritized, when possible, because of lower costs and diagnostic properties similar to MRI.20 A referral to a medical specialist is recommended in the suspicion of FT RC tear confirmed by an imaging test in the presence of important pain and/or muscular weakness and/or a significant activity limitation.18	Acetaminophen may be useful for short-term pain relief.18 Oral NSAIDs may be useful for short-term pain relief.18 Corticosteroids injections are not recommended as first-line treatment to reduce pain and improve function, but may be useful to reduce pain and improve short-term function.18 Opioids are not recommended as first line pharmacological treatment to reduce pain in disability. May be useful to reduce short-term pain in adults that present severe pain and disability refractory to other analgesic modalities.18	An active rehabilitation program is recommended as an initial modality. Active modalities such as exercises should be included as early as possible.18 Insufficient evidence to formulate recommendations for iontophoresis, pulsed electromagnetic field, interferential current.18
Adhesive capsulitis	X-rays are not initially indicated.22 Referral to a medical specialist for a surgical opinion: No recommendation regarding adding manipulation under anesthesia.25	No recommendation from CPGs on use of acetaminophen. NSAIDs is recommended in combination with outpatient physiotherapy (with passive mobilizations).25 An intra-articular steroid injection is recommended, preferably in combination with outpatient physiotherapy (with passive mobilizations).25 No recommendation from CPGs on opioids use.	Outpatient physiotherapy (with passive mobilizations) with home exercises is recommended.25 For stiffness-predominant frozen shoulder, probably use high grade mobilizations in preference to low grade mobilizations.25 Thermotherapy is not recommended.25
Traumatic anterior glenohumeral instability	X-rays are indicated.21,22,19 MRA is indicated if recurrent dislocation.10 Referral to a medical specialist for a surgical opinion: Arthroscopic or open surgery is recommended for acute first anterior shoulder dislocation, particularly in patient under age 27.10	Acetaminophen is recommended.24 Oral NSAIDs are recommended.24 No recommendation from CPGs on corticosteroid infiltration. Judicious short-term use of opioids is recommended for pain management for select patients with acute moderate to severe pain associated with shoulder dislocation. Opioids are not recommended for subacute or chronic pain.24	Exercises are recommended.24 Thermotherapy is recommended.24 No recommendation for manual therapy, therapeutic ultrasound, TENS, iontophoresis, laser.24 Taping, pulsed electromagnetic field and interferential current are not recommended.24

RC = rotator cuff; FT = full thickness; US = ultrasound; MRI = magnetic resonance imaging; MRA = magnetic resonance arthrography; NSAIDs = non-steroidal anti-inflammatory drugs; TENS = transcutaneous electrical nerve stimulation; CPG = clinical practice guideline.

^*One CPG recommend an X-ray in the initial management of RC tendinopathy and two CPGs do not recommend X-ray in the initial management of RC tendinopathy.

Data analysis

Raw data were exported into an Excel spreadsheet. Descriptive statistics were summarized for demographics and clinical characteristics of respondents and for shoulder pain management results. We recoded the level of priority of rehabilitation interventions selected by Phys. T. as not a priority, moderate priority, and high priority. Concordance between Phys. T. answers to medical and physiotherapy treatments were compared to evidence-based recommendations from selected CPGs.¹⁰,¹⁸,²⁰–²²,²⁴,^{26, 27, 28, 29}

Results

Socio-demographics and clinical characteristics of the participants

Of the targeted physiotherapy technologist in the province of Québec (n = 2901) respectively, 43 Phys. T. fully participated in the survey. This resulted in a 1% participation rate. The completion rate was 72% for the full survey. Table 2 presents the sociodemographic characteristics of the participants. Most participating Phys. T. (n = 43) were females (90.7%) with less than 5 years of clinical experience (53.5%). Phys. T. were mainly working in private physiotherapy clinics (65.1%).

Table 2.

Socio-demographic and Clinical Characteristics of the Participants

	Physiotherapy technologists (n = 43)
	n	(%)
Gender
Female	39	91
Male	4	9
Age (years)
18–24	15	35
25–34	9	21
35–44	14	33
45–54	4	9
55–64	1	2
Work experience (years)
0–5	23	54
6–10	3	7
11–20	13	31
21+	4	10
Highest education level
College	38	88
University (bachelor)	2	5
University (certificate)	2	5
Physiotherapy equivalence (France)	1	2
Clinical practice setting
Private	28	65
Public	9	21
Both settings	6	14
Percentage of patients treated for musculoskeletal disorders
1%–25%	1	2
26%–50%	3	7
51%–75%	6	14
76%–100%	33	77
Percentage of patients treated for shoulder pain
1%–25%	11	26
26%–50%	17	39
51%–75%	15	35
76%–100%	0	0
Continuing education training
Manual therapy	17	40
Osteopathic approach	1	2
Mckenzie approach	3	7
Chronic pain management	12	28
Postural approach	2	5
Sports physiotherapy	3	7
Motor control exercises approach	1	2
Military first respondent training	1	2
None	18	42

Shoulder pain identification and medical recommendations

Identification, indication for investigation and indication for medical MSK specialist referrals for all four vignettes are presented in Table 2.

RC tendinopathy vignette (n = 43)

In the vignette pertaining to RC tendinopathy (Appendix 1), however, given the patient's age, it is also conceivable that a chronic RC tear could be a valid diagnosis. Out of 43 participants, respectively, 67% (n = 28) of the participants correctly identified the diagnosis of the RC tendinopathy and 7% (n = 3) indicated that it was a chronic RC tear. Thus, it was considered that 74% (n = 31) of respondents identified the correct pathology. Most respondents (61%, n = 26) did not recommend any medical test or a medical specialist consultation (86%, n = 37) as recommended by CPGs.¹⁸ However, 39% (n = 12) of Phys. T. did recommend medical imaging despite the fact that CPG report that initial diagnosis can be accurately made with only a clinical examination.¹⁸

Acute full-thickness RC tear vignette (n = 39)

The second vignette described a patient suffering from an acute full-thickness RC tear, 83% (n = 33) of the Phys. T. correctly identified this condition. When an acute FT RC tear is suspected, notably in workers with important disability, imaging tests are indicated to confirm the diagnosis.¹⁸ However, 20% (n = 8) of participants did not recommend either diagnostic ultrasound or MRI. Forty-eight percent (n = 19) of respondents did not recommend referring the patient to a medical MSK specialist in the initial management of this acute FT RC tear, even though a rapid referral to a medical MSK specialist is recommended in this case.¹⁸

Adhesive capsulitis (n = 36)

In the vignette presenting a female suffering from an adhesive capsulitis, 86% (n = 31) of the 36 respondents identified the right pathology. Thirty-nine percent (n = 14) of the participants recommended medical imaging although X-rays or any other diagnostic imaging tests are not initially recommended in suspected cases of adhesive capsulitis.²² Most Phys. T. (83%, n = 30) did not recommend referring the patient to a medical MSK specialist which is concordant with recommendations from selected CPG.²⁵

Traumatic anterior glenohumeral instability (n = 33)

The last vignette depicted a young woman with a traumatic anterior glenohumeral instability and almost all of Phys. T. (94%, n = 31) made an accurate identification. Fifty-seven percent (57%, n = 19) of participants recommended either X-rays, diagnostic ultrasound or MRI as recommended by one CPG that state that clinicians should order X-rays or advanced imaging such as MRI or MRA in such cases.²² Forty-eight (48% n = 16) of Phys. T. suggested a referral to an orthopedic surgeon as recommended by another CPG.¹⁰ Indeed, a reference to an orthopedic surgeon is recommended to evaluate the appropriateness of surgery to treat first-time traumatic dislocations, especially in young active patients.¹⁰

Medical treatment recommendations

Medical treatments selected by Phys. T. in the management of shoulder pain patients are presented in Table 3.

Table 3.

Identification and Medical Recommendations for Each Shoulder Pain Vignette

	Rotator cuff tendinopathy		Full-thickness rotator cuff tear		Adhesive capsulitis		Glenohumeral anterior instability
	n	%	n	%	n	%	n	%
Adequate identification	n = 43		n = 40		n = 36		n = 33
Yes	31	74	33	83	31	86	31	94
No	12	0	7	17	5	14	2	6
Medical test recommendation *	n = 43		n = 40		n = 36		n = 33
None	26	61	8	20	22	61	14	42
X-rays	8	19	0	0	3	8	6	18
Diagnostic ultrasound	9	20	17	43	8	22	4	12
Magnetic resonance imaging	5	12	21	53	6	17	14	42
Magnetic resonance arthrography	1	2	2	5	0	0	0	0
Other	2	5	1	3	1	3	2	6
Medical specialist consultation recommendation *	n = 43		n = 40		n = 36		n = 33
None	37	86	19	48	30	83	15	46
Orthopedic surgeon	3	7	20	50	5	14	16	49
Physiatrist	2	5	0	0	0	0	1	3
Sports physician	1	2	0	0	3	8	0	0
Other specialist	2	5	1	3	0	0	1	3
Medical treatment recommendation *	n = 43		n = 39		n = 36		n = 31
None	28	66	18	46	11	31	26	84
Oral NSAIDs	3	7	17	44	11	31	3	10
Acetaminophen	9	21	8	21	6	17	3	10
Analgesic cream	8	19	7	18	5	14	2	7
Corticosteroids infiltration	2	5	1	3	6	17	0	0
Arthrographic distension	0	0	0	0	15	42	0	0
IA corticosteroid infiltration or AD	0	0	0	0	18	50	0	0
Opioid medication	0	0	0	0	0	0	1	3
Other	2	5	1	3	0	0	1	3

Note: Results in bold indicate a correct answer based on recommendations from selected CPGs.

^*Participants could choose more than one recommendation.

RC = rotator cuff; GH = glenohumeral; NSAID = non-steroidal anti-inflammatory drugs; IA = intra articular; AD = arthrographic distension.

RC tendinopathy (n = 43)

Most respondents (n = 28, 65%) did not recommend any medical treatment. Only a small proportion of Phys. T. recommended appropriate medical treatments for pain management consisting of acetaminophen (n = 9, 21%) and oral NSAIDs (n = 37%).¹⁸

Acute full-thickness RC tear (n = 39)

Recommendations for the non-surgical medical management of an acute FT RC tear are similar to medical treatments suggested for RC tendinopathy.¹⁸ For the acute FT RC tear, 46% (n = 18) of the respondents did not suggest any medical treatment. Forty-four percent (n = 17) recommended oral NSAIDs, 21% (n = 8) acetaminophen and 18% (n = 7) of respondents a topical analgesic cream.

Adhesive capsulitis (n = 36)

Recommended care for adhesive capsulitis should include an intra-articular corticosteroid or an arthrographic distension, preferably combined with physiotherapy treatments that include range of motion exercises.²⁵ Oral NSAIDs may also be prescribed in combination with range of motion exercises and passive mobilizations.²⁵ Fifty percent (n = 21) of respondents recommended an intra-articular corticosteroid or an arthrographic distension and 31% (n = 11) recommended oral NSAIDs. Thirty-one percent (n = 11) of respondents did not recommend any medical treatment, but other treatments suggested by respondents included acetaminophen (n = 6, 17%) and analgesic cream (n = 5, 14%).

Traumatic anterior glenohumeral instability (n = 33)

For the GH instability management, most of the participants did not suggest any medical treatments (n = 26, 84%). Ten percent of respondents recommended oral NSAIDs and three respondents (10%) recommended acetaminophen. Acetaminophen and oral NSAIDs may be recommended in the management of pain associated with glenohumeral instability,¹⁰ but it is not considered to be necessary with this case since this young woman was not reporting important pain.

Rehabilitation treatment recommendations

Rehabilitation treatments selected by the Phys. T. in the management of shoulder pain patients are presented in Figure 1.

Figure 1. Treatment priority level indicated by physiotherapy technologists for each shoulder pain vignette.

ROM = range of motion.

Rotator cuff tendinopathy (n = 43)

For RC tendinopathy, an active rehabilitation program including education and exercise is recommended.¹⁸ A total of 42 out of the 43 (98%) Phys. T. identified education as the most important priority. According to a high-quality CPG, active rehabilitation programs may include active mobilization exercises, strengthening exercises, and motor control exercises.¹⁸ Most Phys. T. indicated that active mobility exercises (n = 24, 56%), strengthening exercises (n = 28, 65%), and motor control exercises (n = 39, 91%) were a priority. Manual therapy can be useful to reduce pain and improve function¹⁸ and this modality was indicated to be of moderate priority by 56% (n = 24) and as a high priority by 16% (n = 7) of Phys. T.

However several Phys. T. indicated electrotherapy as a high priority (19%) or of moderate priority (37%) treatment, although therapeutic ultrasound, laser, and extracorporeal shockwave are not recommended in the treatment of RC tendinopathy.¹⁸ For thermotherapy, there is no recommendation on the use of these modalities in a recent high-quality CPG, but active modalities should be prioritized.¹⁸ Cryotherapy or thermotherapy were indicated as being of moderate priority by 37% or of high priority by 30% Phys. T. in the present survey.

Acute full-thickness rotator cuff tear vignette (n = 39)

While the need for an early referral for diagnostic imaging and to a medical MSK specialist is advocated, it is advised to promptly begin an active rehabilitation treatment including education and exercises for this condition.¹⁸ Thirty-six out of 39 (92%) Phys.T. indicated that education was a priority. The 20-height (72%) respondents indicated stretching and passive mobility exercises as a priority. However, active mobility exercises, which are recommended by a recent CPG, were given a lower priority by 18 (54%) participant.¹⁸ Despite insufficient evidence to support the use of electrotherapy, 11 (28%) of respondents considered electrotherapy modalities as a high priority and 17 (44%) considered this modality of moderate priority in acute FT RC tear management.¹⁸ While CPG do not provide any recommendation on the use of thermotherapy, it was prioritized by 18 (46%) respondents.

Adhesive capsulitis (n = 36)

Out of 36 respondents, most Phys. T. recommended appropriate rehabilitation care for adhesive capsulitis including education (n = 33, 94%), stretching and passive mobility exercises (n = 32, 89%) and manual therapy (n = 28, 78%) as supported in one CPG.²⁵ However, 16 respondents placed priority on modalities like cryotherapy and thermotherapy (44%), although thermotherapy is not recommended and there exist no recommendation for cryotherapy.²⁵ In addition, electrotherapy was also prioritized by 12 (33%) of the respondents even though there is no recommendation for its use for this condition.²³

Glenohumeral instability (n = 33)

According to CPG recommendations, appropriate rehabilitation care for glenohumeral instability may include exercises and thermotherapy.¹⁰ If patient presents a GH instability and minimal pain symptoms, thermotherapy is not required and care should focus on education and exercises. Thirty-one Phys. T. participated in this vignette and over 90% of Phys. T. prioritized education (n = 29), strengthening exercises (n = 28), and motor control exercises (n = 29) as recommended by one selected CPG.¹⁰ A significant proportion of respondents (13% highly prioritized and 32% moderately prioritized) considered thermotherapy as a treatment modality even though the patient did not report pain. Fifty-five percent of Phys. T. did not prioritize electrotherapy modalities which is in line with recommendations.¹⁰

Confidence in shoulder pain management (n = 31)

Confidence levels in the management of shoulder pain patients are presented in Figure 2.

Figure 2.

Confidence level of physiotherapy technologist in shoulder pain management (n = 31).

Over 31 respondents, only 10 (32%) Phys T. reported feeling confident in identifying shoulder disorders and only 5 (16%) were confident in selecting relevant medical investigations. In contrast, most Phys. T. (n = 18, 61%) were confident in selecting medical treatments and (n = 15, 52%) referring to a medical specialist.

Discussion

The aim of this study was to assess and describe, the confidence, knowledge, and quality of care provided by Phys. T. compared to selected CPGs in the management of common shoulder disorders using clinical vignettes. In general, a significant number of Phys. T. demonstrated strong abilities in identifying shoulder disorders and appropriate care. However, the proposed care by some respondents did not align with recommended guidelines.

Shoulder disorders identification

A high proportion of Phys. T. were able to make an appropriate identification for the four vignettes. The Phys. T. results are comparable to another survey involving Quebec physiotherapists using the same clinical vignettes. In that survey, 81% accurately identified the diagnosis of RC tendinopathy, 89% responded appropriately to acute FT RC tear, and 99% provided adequate diagnosis for adhesive capsulitis and GH instability.¹¹ Considering that most respondents had less than 5 years of experience and no significant continuing education, the results are interesting given the importance of properly identifying pathologies to guide the patient to efficient care. Even if Phys. T. are not allowed to make a formal diagnosis, their entry to practice training provides them with the competencies and skills to assess and collect patient clinical relevant information from the patient's file or throught a complementary evaluation and create a treatment plan tailored to the patient's disabilities. Furthermore, they are allowed to reevaluate the patient as needed, as they bear the responsibility for ensuring the patient's progress and outcome. It appears that several have acquired the ability to identify a shoulder disorder either from their training or their experience as a clinician with a limited level of autonomy. Several sources highlight the significant challenges of misdiagnosis in primary care for MSK disorders among various healthcare provider, including physicians. Basics competencies to screen, and make informal diagnosis from Phys. T., even if outside of their scope of practice might be valuable to improve care efficiency. However, most Phys. T. in the present study expressed a lack of confidence in making an appropriate shoulder disorders identification. The lack of confidence may be attributed to differences in identifying by considering common shoulder disorders in a clinical setting and vignettes with closed-ended question. It can be argued that identifying conditions in the clinical environment is more challenging, as patients do not always exhibit textbook symptoms. Additionally, Phys. T. tended to frequently recommend medical investigation when not indicated. A possible explanation could be that the educational training provided to Phys. T. focuses more on the management than the initial assessment of common shoulder disorders, as they rely in part on the assessment of another health care provider before initiating rehabilitation management of these conditions. Enhanced and specialized training for Phys. T. to reliably identify and manage these conditions could have the potential to enhance the overall quality of care provided without requiring change in their scope of practice. Evidence indicates that primary care physicians and nurse practitioners often lack optimal skills in accurately diagnosing shoulder disorders and providing evidence-based care.³⁰ With appropriate training, Phys. T. could potentially provide assistance in the event of a misdiagnosis or if the condition worsens or changes. They could help recommend appropriate investigations or efficiently refer patients if necessary.

Shoulder pain medical care

In the four clinical vignettes, only 20%–65% of Phys. T. indicated they would recommend oral NSAIDs and acetaminophen as advocated for short-term shoulder pain reduction.⁶,¹³–¹⁸ In one previous survey, physiotherapists also underused medical treatments.¹¹ Medical pain management and pain relief is recommended as it may facilitate rehabilitation interventions such as exercises.⁶,¹³–¹⁸ These results could be explained by the scope of practice of Phys. T. as they are not allowed to prescribe autonomously medical treatments and therefore may rely more on physiotherapy interventions and exercises to reduce pain and improve patients’ function.⁵

Rehabilitation treatments

Almost all Phys. T. indicated that they would provide education to their patients as advised by CPGs.⁶,¹³–¹⁸ A large proportion of the Phys. T. identified and prioritized active treatments for the featured vignettes as recommended. However, several other Phys. T. prioritized passive modalities such as thermotherapy and electrotherapy. It is conceivable that certain Phys. T. may not possess a full understanding of the limitation of passive modalities for common shoulder disorders. Another possible explanation is that in the province of Québec, Phys. T. commonly provides services to patients in sessions ranging from 20 to 30 minutes and are often caring for multiple patients at the same time. From this perspective, passive modalities may be a way of offering services to more patients as they do not need to supervise the patient for the entire treatment compared to education or supervised exercise programs.³¹ However, relying and overusing passive modalities can hinder patients’ self-management and reduce treatment effectiveness.³²,³³ The reduction of passive modalities could be achieved by ensuring sufficient time for Phys. T. to offer supervised recommended treatments such as exercises.

Strengths and limitations

This study has major strengths. First, this is one of the very few studies evaluating the clinical competencies of Phys. T. and, to our knowledge, the first study to evaluate the management of shoulder pain by Phys. T. in the province of Quebec. Also, the clinical vignettes were selected as they were used in previous studies and this allowed us to compare care compared to other practitioners.^12–14 Moreover, to evaluate appropriateness of care, several high-quality CPGs were selected using a systematic review process with a methodological quality assessment of their development and content.

The results of this study should be interpreted cautiously considering its limitations. Firstly, the limited sample size representing only 1% of the physiotherapy technologist population may not be entirely reflective of all Phys. T. In addition, the Phys. T. who completed the survey may not be fully representative of the general population of Phys. T. as they may have an area of interest in shoulder pain and MSK disorder management. These results may also not be entirely representative of clinical practice, as the shoulder pain history, signs, and symptoms portrayed in the clinical vignettes were relatively clear and uncomplicated.³⁴ However, the use of clinical vignettes has been reported as a valid and cost-effective alternative to evaluate health care providers knowledge, competence or practice variations.³⁵,³⁶ Another limitation in the study arises from the fact that 12 participants did not complete the entire survey, potentially introducing biases. Finally, intra- and interdisciplinary collaboration was not a specific aim of this study and survey. Given that Phys. T. are expected to report issues that may affect treatment progress to the referring professional, it would be relevant to explore this aspect in future studies. Future quantitative and qualitative research should also explore the quality of care offered by Phys. T. for other MSK disorders and these studies should explore treatment efficiency in relation to intra- and interdisciplinary collaboration with physiotherapists, physicians, or nurse practitioners.

Conclusion

The majority of Phys. T. demonstrated adequate capabilities in identifying diagnosis for common shoulder disorders, while conforming to CPGs recommendations related to imaging and indications for specialist referrals. Most physiotherapy treatments proposed by respondents aligned with evidenced-based recommendations focusing on patient education and active treatments such as exercise. However, some gaps were identified as several Phys. T. recommended passive modalities such as thermotherapy and electrotherapy. Given the challenges in accessing high-quality and efficient care for musculoskeletal disorders in public outpatient physiotherapy, providing more evidence-based training could help physiotherapy technologists contribute in an inter or intra-collaborative models of care to the overall management of common shoulder disorders more effectively, ultimately enhancing access to care and potentially improving patient outcomes.

Key Messages

What is already known on this topic

To our knowledge, this is the first study to evaluate the overall management of shoulder pain by physiotherapy technologists, although they participate in several aspects of the rehabilitation care of these patients.

What this study adds

These results offer new and original data that could help guide the development of more efficient inter or intra-collaborative models of care for the overall management of common shoulder disorders. Additional training could be beneficial to optimize care pathway and ultimately patients’ outcomes.

Biography

François Desmeules is a physiotherapist who graduated from Université Laval in 2000 and received his doctorate in epidemiology from Université Laval in 2010. Professor Desmeules worked as a clinician at Quebec university health centres for over ten years. His research interests include: Developing and evaluating new models of physiotherapy, including advanced practices. Diagnosing and evaluating rehabilitation, musculoskeletal and orthopedic interventions for shoulder and knee conditions. Developing evidence-based practices and synthesizing knowledge in the fields of rehabilitation, musculoskeletal care and orthopedics. The author of over 80 studies published in various scientific journals, he has been involved in many projects related to professional physiotherapy practice over the years and has acted as an expert, consultant and administrator for multiple organizations and institutions in Quebec and Canada.

Appendix: Vignettes for the Acute and Chronic Presentations of Shoulder Pain

Vignette 1

A 77-year-old woman, a retired bookkeeper living with her husband, presents with a 6-week history of discomfort in her right shoulder/deltoid region while sleeping, and difficulty doing her hair, putting on her coat, doing up her bra, and reaching up to high shelves. On examination there is tenderness over the lateral aspect of the shoulder and pain on shoulder abduction in the mid-range but a normal range of movement. The remainder of the findings on physical examination are normal. There is no history of trauma. She has been previously well with no history of serious illness. A previous GP prescribed a 2-week course of NSAID, which didn’t provide any relief.

Vignette 2

A 45-year-old labourer sustained a work-related injury to his non-dominant left shoulder two weeks ago. A 25 kg door he was carrying slipped from his grip and he felt a sharp pain in his shoulder as he attempted to stop the door from falling. His foreman made him go to the hospital where X-rays of his shoulder were normal. Since then he reports that his pain is still present, but has improved. However, he has been unable to return to work because he cannot raise his arm above his chest height.

Vignette 3

A 50-year-old, right-hand-dominant female executive presents with a 3-week history of pain and progressive loss of motion of her left shoulder without history of trauma. The pain has been severe and interfering with sleep. On physical exam, a global loss of active and passive range of motion is noted with forward elevation to 90 degrees, internal rotation to the sacrum and external rotation to 10 degrees.

Vignette 4

A 21-year-old student comes in with a feeling of discomfort and apprehension in the left shoulder. The patient states that 6 weeks ago, she tripped down the stairs and used her left arm to stop the fall by grabbing the railing. The pain has diminished within 2 weeks of this incident, but subsequently developed two episodes of shoulder subluxation where she felt her shoulder slipping in and out of place. On clinical examination, there is no mobility restriction. Flexion is 190 degrees bilaterally. The rotation external 90 degrees of abduction is 100 degrees bilaterally with a positive apprehension on evaluation of the left shoulder.

Funding Statement

A. Bélanger was supported by a research internship award from l’Ordre professionnel de la physiothérapie du Québec.