What’s Next? A Guide for Recently Graduated UK Physiotherapy Students

Authors: Ben Burslem, Heather Dimond, Dermot Duffy, Kelly Giroux, Aldo Matassa and Satu Reivonen

Introduction

Graduation from any university programme can be an exciting but also daunting time of life. This educational resource is intended for recently graduated UK BSc or MSc physiotherapy students to provide a decision-making guide for important career considerations after graduation. While parts of this resource may benefit recent physiotherapy graduates from other countries, the focus will be on graduates from the UK to ensure clarity and focus throughout. So, let us get started!

Upon graduation, you are faced with many decisions regarding your career that can seem overwhelming. You have gone from a structured university programme, to an open world of choice. You might identify with some of these areas of uncertainty seen below.

It is now time to decide how you will carve out your unique career path as a young physiotherapist. There are many options available to a physiotherapist for both destination and settings. You may want to stick to traditional physiotherapy roles, settings and destinations, or you may want to take a less traditional route. However, you do not know where to begin or what options are available. This educational resource will help guide your decision-making with an emphasis on highlighting the non-traditional options. The authors do not claim for this resource to be a comprehensive guide covering all countries to work in or all career options, but instead to highlight examples of non-traditional destinations and unique and emerging settings.

What's the Purpose?

The purpose of this educational resource is to navigate a variety of career directions through:

Importance of this Resource

Physiotherapy is a rapidly changing and developing profession that has to adapt to keep up with the changes in society, populations and lifestyles. As a student, it may be that studying the underlying theory takes up most of the time resulting in reduced awareness of what lies ahead in terms of a career. The time to find out about new developments in physiotherapy might be limited and you might not know where to look. Additionally, usually students core placements are in an NHS setting within the country of study, which may not be exposing students to emerging settings and opportunities that they may not be aware of. Physiotherapists are having an increasing role in areas you might not have thought of and in addition the role of physiotherapists regardless of the setting is constantly moulding and developing to meet the needs of a fast-changing society. This resource may prove to be a motivational tool giving students an exciting insight into many options within their chosen career. The aim of this resource is help you as a fresh graduate to navigate around some of these changes and develop your understanding of the broadening opportunities out there for you as a physiotherapist.

Outline and Learning Outcomes

This resource is divided into three main sections which answer three common questions upon graduation:

Each of the three sections has corresponding learning outcomes as seen below. This resource will enable you to...

As you work through this resource there will be reflection questions, ultimately leading to a career plan activity aimed at consolidating this resource. By the end of this resource you will be one step closer to embarking on a focused career!

Physiotherapy is an ever-evolving practice around the world. Having recently graduated with a degree in physiotherapy from an institution here in the UK, you are equipped with the knowledge and skills to get yourself started in your future careers. But where will you choose to pursue this career? This is one of the many questions recent graduates ask themselves as they begin their search for a job in the field. Perhaps you know exactly where you want to work, or maybe you want to go abroad and have new experiences. Nevertheless, it is important to know what your options are and how to pursue them. Navigating the various choices and considering what influences them can appear to be a daunting task. By highlighting some important factors regarding which country to work within, the process will hopefully be clearer and will assist you in making these choices after graduation.

What This Chapter Will Cover

This chapter covers various aspects of establishing a career in physiotherapy in both current and emerging countries, including:

• Comparing the salary, education and any other specific requirements of physiotherapy in the UK to the most popular overseas practise destinations: Canada, USA, Australia, New Zealand and South Africa. Relevant resources are also provided to aid the accreditation process within these countries.
• Highlighting and comparing emerging countries for physiotherapy, including UAE, China, India and Nepal, and providing access to necessary steps to working in these countries.
• Categorising and discussing the emerging countries based on your current values and goals as a recent graduate.

Common Physiotherapy Countries Across the World

The Chartered Society of Physiotherapy (CSP) is a well-established, professional body for physiotherapists in the United Kingdom. Their mission is “to transform the health and wellbeing of individuals and communities by empowering our members and exerting our influence”. The CSP has become the largest physiotherapy membership-based organisation with over 53,000 members and interest has been established in working outside of the UK. As such, the CSP considers Australia, Canada, New Zealand, South Africa and the USA as the “Big Five” English-speaking countries, as they are the most common overseas destinations among UK physiotherapists.

Some general questions to ask yourself when working outside of the UK include:

• Am I planning a temporary (less than six months) or a permanent move?
• Am I seeking paid employment, or looking for volunteer work?
• If I have a choice, might it be better to consider working in a different country?
• Is my UK physiotherapy qualification recognised in that country?
• Do I need to register with a national or regional health authority?

Below is a comparison of the most common countries for established physiotherapy practice.

A Comparison of UK and "The Big Five" Countries
Country (click for accreditation website)	Salary (GBP Equivalent)	Minimum Level of Education Required	Equivalent Regulating Body	Specific Requirements
UK	£26,302 - £35,225	BSc	Chartered Society of Physiotherapy (CSP)	---
Canada	$65,000 - $75,000 (CAD) (£36,267 - £41,846)	MSc	Canadian Physiotherapy Association (CPA)	1025 clinical placement hours Eligibility for work visa based on definite job offer
USA	$81,030 (USD) (£56,895)	Doctorate	American Physical Therapy Association (APTA)	Permission to work in U.S. (granted by USCIS) Laws/requirements for obtaining a PT license may vary by state – useful to know which state you intend to work in
Australia	$89,103 (AUD) (£48,599)	BSc	Australian Physiotherapy Association (APA)	Varying permissions to work in Australia (eg. Visa, EOI) If registration granted in New Zealand, the individual can apply for registration in Australia via a streamlined process (under terms of TTMR – Trans-Tasman Mutual Recognition)
New Zealand	$68,000 (NZD) (£35,144)	BSc	Physiotherapy New Zealand (PNZ)	Visa required (various types depending on purpose); note – Australian resident visa holders do not need a visa to work in NZ If a 3-year degree course has been obtained and no post-graduate studies taken, a min. of 1-year work experience is needed If registration granted in Australia, the individual can apply for registration in New Zealand via a streamlined process (under terms of TTMR)
South Africa	R 250,224 (ZAR) (£14,536)	BSc	South African Society of Physiotherapy (SASP)	Appropriate visa/work permits required Foreign-educated PTs can work in South Africa under a non-renewable contract for a max. of 3 years Foreign-educated PTs can only work in the public sector within under-served or rural areas
Legend: Great British Pounds (GBP); Canadian Dollars (CAD); United States Dollar (USD); Australian Dollar (AUD); New Zealand Dollar (NZD); South African Rand (R)

Click the relevant CSP links are provided below for further country-specific information, including registration processes, accreditation, work permits/visas, and other relevant references and materials (note: must be logged into CSP account to access the full PDF document at the bottom of the page).

• Canada
• United States of America
• Australia
• New Zealand
• South Africa

Outwidth the ”Big Five”, there are still many opportunities for UK physiotherapists throughout the world and your decision will depend on your goals and values as a physiotherapist.  

Emerging Destinations Across the World

If working within the ‘Big Five’ countries does not interest you then there are more options out there for you to explore. Working in an emerging country provides adventure, the opportunity to contribute to developing projects and broaden your scope of physiotherapy practise. The decision to work within a less-resourced country can be difficult and this section will help to navigate this decision based on your values and/or goals as a physiotherapist.

The World Confederation for Physical Therapy (WCPT) is the sole international voice for physiotherapy worldwide and it is based in the UK. It encompasses over 108 countries across the world and aims to maintain high standards of physiotherapy rehabilitation, research and education across the globe (WCPT 2018). For a comprehensive list of these countries and their accreditations please click here.

Take a Break:

Click here to read six reasons why living abroad will make you smarter!

Of these emerging destinations, some of these countries may be developing the profession of physiotherapy, such as the United Arab Emirates (UAE). The Emirates Physiotherapy Society (EPS) was established in 2002 and was accepted into the WCPT in 2007 – quite recently in comparison to other, well-established physiotherapy associations amongst other countries. The EPS aims to engage as many physiotherapists as possible to continually enrich and improve the profession. While the concept of physiotherapy in India is itself not new, the implementation of community physiotherapy is an emerging idea here. Its persistently-growing population places a burden upon its healthcare system and community-based rehabilitation has been implemented to assist in reducing this. However, certain aspects of physiotherapy, such as preventative care, need further development.

On the other hand, there are other non-traditional countries you may not have considered outside the “Big Five” where physiotherapy exists but are in need of more physiotherapists. Examples of these countries include China and Nepal. Chinese government places value on the importance of rehabilitation, especially since its evolution in 2008 after hosting the Olympic Games . However, in comparison to Westernised-countries, the number of available physiotherapists is currently lacking. Additionally, an increase in natural disasters in Nepal has triggered a rise in the number of residents in need of physiotherapy to cope with growing disability levels. Nepal is also struggling to produce qualified bachelor level physiotherapists due to their underdeveloped education system. More physiotherapists to respond to this need would help to address these changing demographics as well as to strengthen the healthcare system in Nepal. The table below provides examples of countries where there is a need for physiotherapists.

Emerging Physiotherapy Destinations
Country (Click for Link to Accreditation Website)	Salary (GBP Equivalent)	Minimum Level of Education Required	Equivalent Regulating Body
China	¥ 144,607 (CNY) (£16,170)	BSc	N/A as physiotherapy is not a recognised profession yet
India	₹ 247,765 (Rs) (£2,663)	BSc	The Indian Association of Physiotherapists (IAP)
UAE	118,740 (AED) (£22,683)	BSc	Emirates Physiotherapy Society (EPS)
Nepal	180,000 (NPR) (£1,209)	BSc	Nepal Physiotherapy Association (NEPTA)
Legend: Great British Pounds (GBP); Chinese Yuan; Indian Rupee (Rs); United Arab Emirates Dirham (AED); Nepalese Rupee (NPR)

Each physiotherapy graduate is unique and will have different goals and values. Common goals and values of recently graduated physiotherapists can include:

Below you will find a guide to help navigate the decision to work in an emerging country based on your values and/or goals as a physiotherapist.

Assist Others

In emerging physiotherapy destinations, the role of a physiotherapist is rarely limited to one setting. Physiotherapists can be involved in any overlap of settings such as clinical, teaching and training, emergency relief from disasters, disease outbreaks or volunteer. The variety of settings also means there is a variety of contexts to assist others as a physiotherapist. However, you will have to be prepared to undertake roles non-traditional roles.

Healthcare:

Recently healthcare amongst these countries has shifted from saving lives to improving health and wellbeing throughout the life course. Extreme poverty globally has decreased from 47% in 1990 to 14% in 2015. Therefore, with a globally aging population, more individuals are living with long-term conditions and require rehabilitation. The World Health Organization (WHO) estimates that between 7-10% of the population worldwide lives with a disability and the incidence increases with natural disasters.

Emergency:

Emergency settings result from natural disasters, conflict, trauma or disease outbreaks. There is a growing need to incorporate physiotherapists into emergency medical teams for rehabilitation because disasters such as earthquakes and tsunamis are increasing, such as Nepal however the mortality rate from these disasters is decreasing. Therefore more individuals are surviving with long term complications which require rehabilitation. One way physiotherapists can help during disaster relief is through humanitarianism.

Humanitarianism is defined as active assistance during emergencies without prejudice and with an aim to promote human welfare. Examples could include distributing the basic necessities of food, water, clothing and medical supplies during an emergency. It should be noted that while humanitarians have good intentions, they also battle the hardships of disease, violence, severe weather or death threats. However, since the aftermath of an emergency can last for years, health professionals play a vital role in disaster relief because individuals of these communities may endure long term physical and emotional effects which warrant treatment. Watch the video below to understand the public's view and importance of humanitarians.

Activity:

• After watching the above video, take some time to think about what you consider to be a humanitarian.
• Does this role interest you?

Humanitarian positions are often volunteer-based, however if your primary aim is to help others and make a difference in the lives of those in need in a unique way these positions may be for you. Missions are normally conducted through agencies such as VSO because they often manage the logistics such as visas and physiotherapy registration for their volunteers.

If your goal is to make a large income but still work amongst emerging countries, then you will want to consider countries with a more established physiotherapy network. Continue reading to find out more!

Make a Large Income

It is no surprise that a main aim of any new graduate from any professional programme is to make ample income; physiotherapy graduates are no exception (Ohman et al 2002). Whether it is for the purpose of paying student debt, to travel the world or to afford a comfortable lifestyle, making money is an objective in both the short and long-term. Some of the emerging countries previously mentioned are surprisingly on par with the UK for this opportunity. The average salary in the UK is £26,302-35,225 and the salaries in UAE and China are AED 118,740 and CNY 144,607, respectively. However, exceptions to this are Nepal with a salary of 180,000 NPR and India with a salary of Rs 247,765 These yearly salaries are the equivalent of approx. £1220.00 and £2,663.00, respectively. Possible reasons for this equivalency is the extreme poverty of Nepal resulting in a low health expenditure per capita and a shortage of healthcare resources. Despite a growing economy in India, the country’s poverty rate is high due to having an extremely large population and its struggle to accommodate for its “growing pains”. However, poverty has begun to and is expected to decrease, albeit slowly, which will prove beneficial to its health-related economy and the potential for improved rehabilitation opportunities.

Overall, the salaries of these emerging countries are diverse: some are equivalent to the UK whereas others are much lower. As such, it may be worthwhile to consider these countries’ respective cultures in order to help with decision-making. Cultural differences will play a large role in everyday life if you choose to move abroad which will impact your experience with working as physiotherapist in these countries. The next section is dedicated to discussing the differences further.

Expand your Cultural Awareness

One of your goals as a physiotherapist could be to expand your cultural awareness outside the UK and the ‘Big Five’ countries. A complete resource on working within less-resourced countries can be found here. However this subsection will provide an overview of how working in less resourced countries can expand your cultural awareness.

Are you already uncertain about working in a less-resourced country? Before we get started, click here to briefly read why culture shock can be good for you. You might be surprised!

Culture is defined as shared sets of values, attitudes, beliefs, and behaviours that are learned and transmitted amongst a particular group. Culture guides our decision making and actions to define us as individuals .  Culture includes our language, religion and traditions, and is dynamic and constantly evolving. Our culture shapes how we view the world and as a physiotherapist it is important to avoid assuming others have the same views as yourself, and judging those who do not. This is called ethnocentrism and leads to discrimination and poor practise. In keeping with person centred care, physiotherapists need to become culturally responsive and consider social and cultural factors that could underpin the illness experience . Working in a less resourced country is an opportunity to expand your cultural awareness and therefore build your cultural competency. Developing cultural competence is a valuable transferable skill to have for any physiotherapy position in the future.

“Who brings ‘expertise’, and who gains most from our involvement. When we offer our services in low and middle-income settings, we have a responsibility to strive to ensure that local people are the principal beneficiaries. However, we often find that the same people have at least as much to teach us as we have to offer them.” 

Developing cultural competence is important to ensure you provide effective healthcare as a physiotherapist. Cultural competency is defined as, “the capacity to provide effective healthcare by taking into consideration people’s cultural beliefs, behaviours and needs” and it begins by understanding your own values and beliefs . In addition to culture, cultural competency also considers religion, gender, language and ethnicity. As seen below in the Papadopoulous, Tilki and Taylor Model for Developing Cultural Competence, there are 4 stages to developing cultural competency.

Being culturally competent implies having the skills and capacity to work effectively with culturally diverse clients. The achievement of cultural competence requires the synthesis of previously gained awareness, knowledge and sensitivity, and its application in the assessment of clients’ needs, clinical diagnosis and other caring skills.

Using the examples of emerging destinations mentioned above, all of them will have a different culture to the UK. They will differ by food, religion, transportation, language, values etc. For example, in Nepal and India the prominent religion is Hinduism where it is also disrespectful for a woman to wear shorts or sleeveless tops. Transportation is also an adjustment compared to the UK because in Nepal the road conditions are especially poor due to the 2015 earthquakes, buses are often overcrowded and generally driving standards are low because many drivers are not properly licensed. In India the air pollution and mosquito-borne diseases such as Dengue Fever, are hazards to public health that must be considered. All of these factors are important to consider when embracing a new cultural as a physiotherapist and beginning to develop cultural competency.

Some challenges with attaining cultural competence include:

• Working amongst areas with a limited understanding of rehabilitation.
• Working amongst areas where you are the first physiotherapist in the community.
• Working amongst other therapists who had a different level of training to yourself and therefore have different reasoning and ways of practise.
• Having limited materials available for your treatments.
• Language barrier between you and your patients / other. co-workers / the interpreters comprehension of technical physiotherapy language.

Despite these challenges, it is your responsibility as a physiotherapist to ensure your practise is patient centred, non-discriminatory, accessible to all and legally compliant. It is also important to remember that culture is specific to each individual depending on their previous experiences and to embrace diversity . Culture is dynamic and responds to changing environments and circumstances. Therefore, through becoming culturally competent, you will be able to adapt your physiotherapy practise accordingly.

Activity:

• What are your initial thoughts regarding travelling abroad outside of the “Big Five”?
• Do you have an initial preference for a destination to practice?
• What are your personal values, beliefs and other cultural aspects that you consider to define you?
• How comfortable are you to incorporate other cultures into your physiotherapy practice?

Now that you have learned about what different geographical locations you can consider working in, let’s zoom into more specific settings, where physiotherapists are becoming increasingly important, but of which you may not have thought of before.

People of all ages, genders and situations may need the assistance of a physiotherapist at some stage of a life span. The settings that one may receive treatment are also highly variable. With a wide range of possible work settings a physiotherapist could work within, it may be important to highlight these settings from an early stage to open up your mind to the future possibilities. As a student physiotherapist you may not be aware of the many different settings you could possibly work within. Throughout your studies, thoughts and preferences of settings that you may wish to work within develop and become more significant as you come towards the end of your studies. Highlighting these emerging settings may prove valuable to you as a recent graduate through enhancing job perspectives, developing thoughts on practices used within these settings and overall the significance of the emergence of these settings for physiotherapy

What This Chapter Will Cover

• A brief overview of core physiotherapy settings.
• Niche physiotherapy settings including prisons and armed forces and the roles of a physiotherapist within these settings.
• Considerations and challenges within physiotherapy in emerging settings including disability sport, social media and primary care.

Core Physiotherapy Settings

As students, the majority of placements are based in National Health Service (NHS) settings including hospitals, clinics or the community. It is important to highlight different settings to give recent physiotherapy graduates an insight into other opportunities they may have never considered to develop their career. Within these areas, there are various opportunities with unique settings which are beginning to become more popular. The following will identify these reasons and settings whilst outlining roles of a physiotherapist, considerations and challenges within each.

First, a quick reminder: physiotherapy is a wide field of study which can be classified into three main areas of Musculoskeletal, Cardio-respiratory and Neurology. The figure below provides you with an overview of these main areas and it is important to keep these areas in mind whilst reading through this section as these areas may overlap within the upcoming niche and emerging settings.

These core settings can also be applied to niche and emerging settings that physiotherapists may work within. Niche and emerging settings will be described in the following two sections.

Niche Settings

The term niche is defined as ‘a specialised segment of the market for a particular kind of product or service’ . The following section will focus on two niche areas of physiotherapy, prisons and UK armed forces, which you may not have known about as an option after graduation. The aim of this section is not to be comprehensive, but rather to focus on a couple of niche areas that you may find interesting.

Prisons

Regardless of a person’s background, access to healthcare is a human right. In Scotland there are over seven thousand individuals in prison and all should have access to physiotherapy as required.

Role of a Physiotherapist:

A physiotherapist's role in prisons is similar to the well known settings of hospital wards, outpatient clinics, private clinics etc. Physiotherapists can work in a range of settings within the prison from small hospital wards to MSK clinics. Physiotherapists need to treat prisoners with a range of injuries and diseases such as acute or chronic musculoskeletal injuries, respiratory diseases and encourage physical activity within the prison.

Working in prisons has its own unique considerations and challenges. For example:

• A high proportion of prisoners have mental health and addiction issues.
• Limited equipment accessibility such as tendon hammers, Therabands and walking aids.
• Without appropriate security training healthcare workers must be accompanied by a guard at all times.
• All of the above considerations and challenges can affect time management.

To find out more about working in prisons click here. To read about the personal experience of a physiotherapist working within a prison in England, click here. Now it is time for another activity.

Activity:

The considerations and challenges to rehabilitation mentioned above can impact the quality of treatment sessions with prisoners.  A creative, confident and organised physiotherapist is needed to fulfil this role.

• Are you interested in pursing your physiotherapy career in a prison setting? Why or why not?
• Identify another barrier to working within a prison and how how it might be overcome.
• Continue reading to consider working within the UK armed forces.

UK Armed Forces

In addition to prisons, another area you may not have heard about as an option after graduation is working with the armed forces. Working as a physiotherapist in the UK armed forces is unique, as not only will you be required to carry out the role of a physiotherapist, but also to work as an army officer and soldier. Therefore the application process to work in this particular setting is different to others. There is the option to become a reservist (part-time) or a regular (full-time). Due to the varied roles, you are required to have additional skills and qualities compared to typical physiotherapy roles. These additional standards may not be for everybody. Below is a brief video which illustrates what working as a member of the army medical corps entails:

Role of a Physiotherapist:

Working as an armed forces physiotherapist has a number if different roles. A few to note are:

• Rehabilitate both soldiers and civilians in rehabilitation centres, defence medial group and field hospitals.
• Work amongst overseas operations treating and rehabilitating soldiers, prisoners of war and civilians.
• Work alongside other medical professionals to treat acute injuries, trauma, amputees, neurological conditions and critical care conditions.
• Rehabilitate soldiers to a high level of fitness, similar to that of high level athletes.
• Delegate with commanders regarding injuries and return to training.
• Take part in military operations.

A sample of a physiotherapist's role in an overseas operation in Afghanistan where the armed forces were fighting the Taliban in 2011 is illustrated in the video below.

Unique Considerations

If you are considering a career in the armed forces as an option after graduation there are some unique considerations you will need to make. This job poses challenging and sometimes dangerous working conditions which require a number of unique skills and qualities not associated with typical physiotherapy positions. Additionally, the process to become an army physiotherapist is different to other physiotherapist jobs and requires a number of steps including and a military training components. Details of the skills required and the process to become an army physiotherapist are listed below.

Skills and Qualities Required to Become a Combat Physiotherapist:

• High level of physical fitness and conditioning.
• Basic military skills (including weapon and handling tactics).
• Survival skills.
• Ability to work under pressure.
• Courage and motivation.
• Problem solving skills.
• Leadership skills.
• Competence managing MSK conditions and injuries.

Process to Become a Regular Full-Time Army Physiotherapist

The steps to becoming a regular full-time army physiotherapist are described in the figure below.

Process to Become a Reserve Part-Time Physiotherapist

1. Complete two weeks of basic military training.
2. Specific army physiotherapy training depending on experience.

For more information on how to apply, entry requirements, rank progression, and becoming an army reservist physiotherapist visit the British Army website here, and for more information on salary, benefits, work conditions and other progressions click here.

Emerging Settings

The term emerging is used to describe something that is ‘becoming apparent or prominent’ . In this section we will discuss three emerging settings within physiotherapy practice which you may find interesting; social media, disability sport and primary care. Being informed about these emerging areas may potentially have implications for you in your career planning, and provide you with more options for what direction you decide to go in. Again, the purpose of this section is not to give you a comprehensive list of all emerging settings, but just to highlight some of the settings that are currently emerging.

Social Media

The use of social media has increased dramatically in recent years. In 2007 only 22% of internet users had a social media profile while in 2016 that rose to 76% of all internet users (96% of internet users aged 16-24). With the prominent use of social media the opportunity for physiotherapists has expanded.

The emerging opportunities for physiotherapists take many forms and use many platforms. Social media is unique in its ability to connect people across the globe from something as simple as a smartphone.Although there is the possibility for some of the content to have a subscription fee to generate income, most platforms provide free content. However, many use this platform to promote and advertise their services and businesses. Creating high quality material for social media may require you to learn new technical skills such as photography, computer animation and video editing which are not typical physiotherapist.

There are many roles for a physiotherapist within the social media setting. A few to note are:

• Education: Increasing the understanding of disease and injury as well as possible treatment
• Communication: Collaborative working worldwide with other physiotherapist and those involved in health promotion.
• Promotion and advertising: Using social media to bring attention to physiotherapy treatments, health issues and your services.

There are many platforms within social media. Find out about some popular platforms below that all allow physiotherapists to educate, communicate, promote and advertise. Below you will find an example of each.

YouTube

Through the use of video hosting communities some physiotherapists have begun creating educational videos on rehabilitation for common injuries. One Youtube channel called ‘physiotherapyvideo’ has over 550,000 subscribers with over 60 million views. Bob and Brad who host the channel, demonstrate and promote health information on physiotherapy treatments and reviewing products which may benefit recovery from injury and disease. They claim ‘Our videos offer the best "get fit , stay healthy, and pain-free" information directed toward people 0 to 101 years old’. A video is posted every day on a range of topics from ‘simple stretches for plantar fasciitis,’ to ‘How to properly adjust and safely use crutches.’ These short and often humorous videos are engaging and easy to understand. Watch the video below for an example of how physiotherapists such as Bob and Brad can promote their business and educate viewers.

Podcasts

Another great way to develop and communicate ideas as a physiotherapist is through the use of podcasts. Podcasts give the opportunity for in-depth discussion of a range of topics with a far reaching audience.

Clinical edge is a podcast just for physiotherapy. It discusses real life assessment and treatment techniques and interviews with inspiring and expert physiotherapists. It aims to give you the knowledge and resources to improve your practice and skills. Listen here to the latest content on anterior shoulder pain, long head of biceps tendon pathology and SLAP tears with Jo Gibson.

Activity:

• If you were to make a physiotherapy podcast what would it be about?
• How often would you produce a podcast?
• Who would your target audience be?
• Now let us consider another social media platform.

Twitter

Twitter allows those across the globe to communicate and share ideas. Tweet chats on physiotherapy practice allows those from across the world to discuss and network within the physiotherapy area. Connecting through Twitter allows you the opportunity to learn from others as well as spread your knowledge and experiences of physiotherapy.

Sign up to Twitter and join a tweet chat now!

See the results of a recent tweet chat herefrom #physiotalk.

Instagram

Instagram is a popular photo sharing application that allows users to post photos, short videos and stream live events. Through this platform some physiotherapists use the app to advertise their business and share information regarding musculoskeletal problems and common causes of injuries.@Mikereinold is a physiotherapist and strength coach. He runs Champion Physical Therapy and Performance in Boston. He shares useful photos and videos daily to share his knowledge of physiotherapy to his followers.

Sign up now and start posting pictures to share your knowledge and advertise your skills and business!

Blog Posts

The Manual Therapist blog is run by Dr. Erson Religioso who teaches orthopaedic manual physical therapy in Buffalo, New York. The Manual Therapist posts daily blog updates on subjects that are clinical focused such as ‘Dealing with Pelvic girdle Pain’ and ‘Top 5 ACL motor control progressions and research reviews within physiotherapy.’

Why not check out his blog post here on improving knee extension in physical therapy post total knee arthroplasty.

Activity:

• If you were to make your first blog post what would it be about? Consider a topic that creates confusion amongst the public to provide an avenue for clarification.
• Continue to read about the final social media platform, viral videos.

Viral Videos

Creating videos that have the possibility to go viral could have a large effect on raising awareness and educating many people. Sharing information through viral videos could benefit the health of people from all over the world.

DocMikeEvans posted a nine minute animated video on the effects of completing 30 minutes of exercise a day and its hugely positive effects on people’s health and prevention of disease. It went viral and has been seen over five million times. You may have heard people talk about or already seen it. If not, watch it below!

Activity:

After reading about the various social media platforms available for you to use as a physiotherapist, consider the following questions:

• Can you think of any other social media platforms not mentioned above?
• What platform do you think you could use to optimise your ability to learn, educate and advertise your physiotherapy skills?

Disability Sport

With the start of the Invictus Games in 2014 by its founder Prince Harry, the coverage of the Rio paralympics watched by over 28 million in the UK and the Glasgow Commonwealth Games 2014 staging the most para-sports in the event’s history, disability sport has never been so publicised. With the emergence of para-sport, physiotherapists have been essential to its development and its continued expansion. The video below gives an introduction into disability sport from the perspective of the athlete using the campaign #EndTheAwkward. As a physiotherapist it is important to remember to treat the person and not just their impairment.

Role of a Physiotherapist

When supporting athletes at an elite level in para sports physiotherapists' roles include:

• Focusing on performance and not on an athletes disability.
• Working alongside strength and conditioning specialists and coaches.
• Injury prevention as well as reactive injury treatment.

To find out more of the role of physiotherapists supporting athletes at the Glasgow 2014 Commonwealth Games click here.

Unique Considerations

To work with elite para-athletes unique skills and considerations are needed, for example:

• A broad knowledge of a range of conditions that athletes present with.
• Sport specific knowledge and experience in sports medicine.
• Working with athletes and their desire to win in a high pressured and competitive environment.
• Ability to travel and work unsociable hours.
• Exciting opportunities at the Paralympics and Commonwealth games.

Additional roles within elite para sport also include the assessment of para-athletes into classifications for their sport. Physiotherapists have played a vital role in developing this system of classification for sports participation for athletes with disabilities.

Case Study:

Rosie Mew was the lead physiotherapist for the Paralympics GB team at the London 2012 Paralympics. She describes what the ideal candidate should be below .

To work as a physiotherapist in future paralympics it is recommended that skills include:

• Five years of physiotherapy experience.
• Three years of elite sports injury experience.
• Registration with the Association of Chartered Physiotherapists in Sports Medicine (ACPSM).

Other useful skills to have:

• Trauma training which includes detailed knowledge of concussion injury analysis, spinal cord injury, stabilisation splintering and how to evacuate an athlete safely from an event.
• Knowledge of the application of acupuncture, massage and taping is also beneficial to treat athletes.

Working with para-athletes is an exciting opportunity and takes a knowledgeable and driven individual who can handle the stress of competition. Do you think you would be interested?

To read more about working as a physiotherapist at the paralympics and elite para-sports click here. Also, an interesting take on how physiotherapists prepare for the lead up to the paralympic games can be found here.

Promotion of Disability Sport

Not all physiotherapists work with elite level para-athletes but still have a role in disability sport. Disability sports can be played at any level and can be promoted by all physiotherapists.“English Federation of Disability Sport believes that physiotherapists can play an important role in encouraging some disabled people to take part in sport and physical activity”.

Sport can be used in a number of settings and is already prominently used by physiotherapists in practice. 99% of physiotherapists surveyed are already using sport to promote rehabilitation in at least some, if not all of their young disabled patients. One physiotherapist in North Wales is leading a programme to develop and encourage disabled people to increase their physical activity. Working as the Health disability officer for The Health Disability Sport Pathway in Wales, she is educating and training healthcare professionals to  promote sport to those with disabilities.

Read more about her work and the results click here.

Activity:

After reading the above section on a physiotherapist's role within disability sport consider the following questions:

• Does working as a physiotherapist within para-sport interest you?
• What skills will you need to learn or develop to become a proficient physiotherapist in this area?
• What barriers will you expect to face and how can these be overcome?

Primary Care

Another emerging setting physiotherapists can work within is acting as a first contact practitioner in primary care. Currently 1 in 5 GP referrals are MSK related and MSK problems are the second leading cause of sickness leave from work in the UK The UK government is beginning to incorporate more physiotherapists into primary care and act as a first contact practitioner with an aim to reduce secondary referrals, save money, and reduce the pressure on GPs. The short animated video below provides an introduction to primary care as an emerging setting for physiotherapists, while describing the current MSK patient referral pathway pathway in conjunction with the direction the NHS is moving toward.

A new contract agreed in January 2018 has set out a three year transformation plan for the primary care services in Scotland. This will see a significant increase in the number of physiotherapists working in primary care as first contact practitioners. To find out more about these plans click on the link here.

First-contact physiotherapists will also increase the clinical capacity within the primary care team. As a result, patients with MSK conditions can be managed sooner by preventing a secondary referral with the traditional system. Early intervention is beneficial to prevent further deterioration. These benefits combined have triggered the service restructure  and the increased funding to incorporate more physiotherapists in primary care.

Role of a Physiotherapist in Primary Care

There are many roles of a physiotherapist within primary care and a few to note are:

• Initial point of contact for selected patients with MSK issues.
• Establish diagnosis when possible.
• Making decision on most suitable treatment pathway for patient.
• Refer for further investigations/scans when necessary.
• Interpret results to facilitate diagnosis and treatment plan.
• Design self-management focused treatment plans.
• Encourage positive behavioral change and minimise need for pharmacological intervention.

Unique Considerations

This role will be for physiotherapist with advanced practice skills. Although it may not be relevant to you immediately after graduation, this is a role that recent graduates can consider in their career planning. The next section will discuss specialising in physiotherapy in greater depth. The physiotherapists recruited for these new roles will be those with experience  working in either MSK outpatients or triage/interface services.

Advanced level skills required:

• Advanced assessment and clinical reasoning skills.
• Complex case management skills.
• High level of autonomy.
• Risk evaluation skills.
• Ability to collaborate effectively with MDT.
• Ability to inject and prescribe.
• Ability to make referrals for further investigations.
• Ability to interpret results.
• Leadership skills.

Pros and Cons

There are a number of cons and pros working in this particular setting. Some of these include:

Cons:

• High level of responsibility.
• Failing to identify a red flag in the triage process could cause an adverse outcome for the patient

Pros:

• Opportunity for further development of skills to a high level of expertise.
• Opportunity to work in leadership roles.

Activity: After learning about the various niche and emerging settings outside of the traditional MSK, cardiorespiratory, and neurological settings, consider the following questions to consolidate your learning:

• How interested are you on a scale of 0 to 10, 0 being not interested at all and 10 being very interested, are you at pursuing a career in a niche or emerging setting?
• What skills do you need to develop further to work within your preferred setting? If a niche or emerging setting does not interest you, consider why not.

Recap

So far you have learned various factors regarding choosing the destination to start your career as a physiotherapist. You were introduced to the "Big 5" countries for physiotherapy, with a main focus on emerging countries where physiotherapy was either beginning as a new profession or in need of more physiotherapists. Depending on your main goals as a physiotherapist such as to assist others, make a large income or to broaden your cultural awareness, different countries will be best to meet these aims. The next section which you just finished, gave an overview of different niche and emerging settings beyond the traditional physiotherapy settings. You considered a physiotherapist's role in each and any applicable unique considerations. The final section will now describe how to progress the profession of physiotherapy and your own skills and knowledge.

You have now found out about some less conventional settings you can potentially be working in as a physiotherapist, but what are some broader responsibilities of physiotherapists regardless of the setting and where do you see yourself in the future?

Firstly, this section will introduce two fields that can be seen to be a part of your professional role as a physiotherapist regardless of the setting you are working in. Involvement in research and public health roles have probably been mentioned during your studies, but they may not have been given much emphasis due to time limits. The first part of this section will hence provide an overview of physiotherapy in research and public health, highlight some new developments and provide a broader picture of a physiotherapists role.

Secondly, we will plant the seed for you to slowly start thinking about finding your specific passion within physiotherapy. On placements you will have hear of specialist physiotherapists but as it may not feel relevant for fresh graduates, you don’t necessarily develop an understanding of how to become a specialist, if that is something that indeed interests you. This is not to say your only option for progressing your career is specialising, but it is perhaps something you will all do to an extent regardless of the setting and context you will be working in.

What This Chapter Will Cover

• 
  Provide an overview of two aspects of physiotherapy that may not have been the primary focus of your physiotherapy course but are crucial aspects of shaping the future of the profession: involvement in research and public health that will be relevant to you regardless of the setting/country you will be working in.
• Give you guidance on something that you might already have thought about but still feels distant: specialising. The section will provide an overview with practical ideas of how to go about specialising and some challenges you might face along the way.

Research and Physiotherapy

Research can be defined as “a systematic process of collecting, analysing and synthesising information to generate new knowledge and understanding about a specific issue” . Research is inevitably related to Physiotherapy and while Physiotherapists are expected to utilise research evidence in their clinical practice, many physiotherapists may not be involved in the research process itself . A New Zealand study found that while most Physiotherapists saw the value of research, many felt to be lacking confidence in their research skills and felt there was limited time to take part in research activities .

What reasons might there be for you to get into research? Here are some possible answers:

There are three different types of research you can get involved in, each one explained below:

1. Research project – attempts to create new generalizable knowledge
2. Service evaluation – measures how well a current service is achieving its aims without reference to a standard
3. Clinical Audit – measures practice against a predetermined standard with the aim of producing information to inform delivery of best care

Being involved in research doesn’t necessarily mean that you need to become a full-time academic. The HCPC Standards of Proficiency, which apply to all registered physiotherapists, state that you should be able to assure the quality of your practice (HCPC 2013). Here are a few specific examples of what the HCPC standards of proficiency state about quality of practice

“Recognise the need to monitor and evaluate the quality of practice and the value of contributing to the generation of data for quality assurance and improvement programmes”

“Be able to engage in evidence-based practice, evaluate practice systematically and participate in audit procedures”

“Be able to engage in evidence-based practice, evaluate practice systematically and participate in audit procedures”

* Please note that the HCPC standards of proficiency are under continual review and may be subject to change

These suggest that whether you need to be able to engage in systematic evaluation of the quality of your practice and services provided. In some form or another, research is for all physiotherapists. In the last example, there is mention of ‘evidence-based practice’ which you are likely to have come across during your studies. Let us look at evidence-based practice in a little bit more detail.

Evidence Based Practice

The term Evidence-based practice (EBP) is something you as a Physiotherapy graduate are aware of to some extent. EBP has been around since the 1990s and is something physiotherapists are taught to utilise. The image below explains what EBP covers, and importantly highlights that it is not only a matter of external research evidence but involves a process of retrieving, critically appraising and, when relevant, integrating the evidence to inform clinical decision making.

Activity: Think of a situation where you used a specific intervention.

• Were you aware of the evidence base?
• Do you feel it is relevant to be aware of it?
• Did you carry out the intervention despite poor evidence? Why or why not?

Another description of EBP is: “Evidence-based practice (EBP) requires that decisions about health care are based on the best available, current, valid and relevant evidence. These decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of available resources”.

Activity:

There is ongoing and increasing debate about EBP, its meaning and purpose.  Can you think of some arguments for and against, based on the definition above?

Here are some critiques of EBP:

• The definition of EBP does not address ethical principles around beneficence, non-maleficence, autonomy or justice.
• As much of the evidence is based on interventions for single diseases or conditions, EBP does not adequately meet the challenges brought with increasing multimorbidity.
• EBP in considering Randomised Controlled Trials as gold standard may discourage the use of other methodologies and present a challenge for many evidence around many physiotherapy interventions where randomisation is not fully possible.

This is not a comprehensive review of the debate around EBP. The aim here is to highlight that there is a debate and give you a taster of some critiques of EBP in its current form and hopefully motivate you to read further.

A good place to start is watching this debate around EBP from the CSP Physiotherapy conference in 2015.

One of the key criticisms of EBP is that the research often fails to translate into real life contexts and complexity around people and practice. This discrepancy between much of the research evidence and real life situations is becoming increasingly acknowledged.

Research and Practice - Bridging the Gap

Research and practice shouldn’t be considered separate. Instead they should be viewed as dynamically shaping each other. For research to be relevant to practice, it should be guided by questions emerging from practice. On the other hand, for practice to develop and change, it must be able to apply the new knowledge created by research.

As mentioned, research and practice are constantly developing and shaping each other. If practice must adapt to meet the changing demands, then, to an extent, research should adjust accordingly. Here are some examples of current and growing challenges to Physiotherapy practice:

1. Multi-morbidity
2. Ageing population
3. Limited resources in healthcare

Activity:

Now think of some ways that research is currently performed and how it will have to adapt accordingly to keep up with the above-mentioned changes.

Below are a few examples of key developments that are aiming to bridge the research practice gap:

References

see adding references tutorial.