We report a substantial increase in CDM referrals to physiotherapists, chiropractors, and osteopaths for Australians over 65 years of age between 2009 and 2018. These increases were more than double the rate of population growth for the same age group during this period (population growth: 1.38 times between June 2009 and June 2018) [14].
While CDM data is not condition specific, it is reasonable to assume that a significant proportion of these referrals were for management of chronic MSK conditions, given the large increase in back problems and arthritis as causes for exiting the workforce for both men and women over 55 years of age during this period [5, 6]. The increase in demand therefore falls disproportionally on professions who deal with managing MSK conditions. Our data reflect this trend for physiotherapy, chiropractic and osteopathy with the trend likely to continue. The increase in interdisciplinary management between GPs and allied health professionals reflected in this data suggests a need for each of the professions to be educated about their respective roles and approaches to the management of the older patient.
Accompanying this trend has been an increasing number of calls for a review of the education of health workers involved in aged care. This has been in response to attempts to meet the demands of this population group [15–19]. These calls are supported by findings from two Australian government inquiries. The first, a review into the future of the aged care sector workforce, identified skill shortages that could be best addressed through better use of allied health professionals and the establishment of nationally consistent minimum standards for training and accreditation (recommendations 7 & 15) [15]. The second, the ‘Royal Commission into Aged Care’, recommended reforms in training and professional development frameworks for all aged care occupational groups including undergraduate and postgraduate courses for allied health professionals “to broaden their knowledge and capability to support those in aged care” (p227 – interim report) [17]. These two inquiries clearly outline the need to improve the capabilities of allied health graduates and practitioners in the area of aged care. The question then arises: what additional skills and capabilities are needed to achieve this?
In Australia, physiotherapy, chiropractic and osteopathy are nationally registered professions with established capabilities and competencies for practice. Interestingly, there are no specific capabilities relating to care of the older patient or within aged care facilities across the three professions [20–22]. Capabilities documents indirectly refer to the care of older patients under the category of managing people “across the life span”. However, there are no governing or educational bodies that specialise in aged care or gerontology for allied health in Australia, although Allied Health Australia, the peak national body for allied health professions, does have a web page that provides links to allied health services for older people (https://ahpa.com.au/key-areas/aged-care/). The Australian Association of Gerontology, which includes allied health professionals among its members, also publishes links to ongoing education in the field (https://www.aag.asn.au/).
Other professions have begun to address the issue by creating best practice and/or competency documents related to aged care. Chiropractic researchers published a consensus document for older adults, which focuses on issues such as cognition when obtaining a clinical history and informed consent, managing multi-morbidities, red flags, assessment strategies, care with manual techniques in the frail patient and specific social and psychological factors [23]. They concluded that there was a need for further development of both undergraduate and postgraduate training specific to the management of older adults.
Osteopathic educators in the US, where practitioners are registered full-scope medical practitioners, produced a set of competencies for training osteopaths in geriatrics that were specific to osteopathic manipulative medicine and in addition to the standard medical competencies [24]. These included a focus on gait and posture, contraindications and limitations for manipulative techniques in the older adult, and treating somatic dysfunction to improve activities of daily living.
The British Geriatrics Society published a ‘Comprehensive Geriatric Assessment Toolkit’ for all primary care practitioners [25]. It included issues such as mobility and balance, bone health, falls, depression, confusion/delirium, mental capacity, urinary incontinence, weight loss, nutrition and end of life care. While not all of these are directly relevant to practitioners who focus on treating MSK conditions, they do provide guidance to educators when designing curricula.
In Europe, medical educators produced a consensus document of core competencies for treating the older patient that was designed for use in undergraduate medical training [26]. These competencies included respect and specialised communication, knowledge of common diseases of the elderly, advanced pharmacological knowledge, ethical and legal issues of end of life care, inter-professional respect and understanding, social care and the ability to care for the individual in diverse settings
The data we have reported demonstrate increasing interdisciplinary relationships between GPs and the three professions. Furthermore, best practice in aged care is reported as requiring these inter-professional partnerships. The American Geriatrics Advisory Group emphasised that this was due to the complexity of care required, and that the burden of cost can be alleviated using this approach to healthcare [27]. Goldberg et al [28] investigated inter-professional core competencies and agreed that, due to the complex nature of conditions and the multi-morbidities inherent in older patients, best practice in aged care required inter-professional partnerships.
While there are currently no evidence-based clinical guidelines addressing the use of manual therapy interventions for MSK conditions in the elderly, there are guidelines covering other conditions common in the elderly that may overlap this field. These include guidelines on osteoporosis and falls prevention [29]. The absence of guidelines relating to manual therapy highlights the challenge facing physiotherapy, chiropractic and osteopathic educators on how to integrate best practice recommendations into pre- and post-professional curricula.
While there are no aged care specialty pathways for allied health professionals in Australia, such pathways exist in the US where the physical therapy (PT) profession has established a specialty college in gerontology, with key competencies for practice in both the pre- and post-professional arenas [30]. These documents include six domains of practice and competency in the care of aged individuals that could provide a framework for curriculum developers in Australia. They are:
- Health promotion and safety: Identifies the advocacy role that PTs may play, and points to clinical issues such as risk of falls, polypharmacy abuse, and the use of physical and chemical restraints;
- Evaluation and assessment: Outlines the importance of comprehensive interdisciplinary assessment based on a bio-psychosocial model, the use of geriatric specific tools such as the Geriatric Depression Scale, and inclusion of advanced communication strategies in the assessment of cognition and sensory deficits;
- Care Planning and Coordination: Deals with ensuring person-centred evidence-based care including advanced care (end-of-life) planning and the need for continuity of care between locations;
- Interdisciplinary and team care: Focuses on the importance of communication between members of the team and the social relationships of the person at the centre of care;
- Care-giver support: Assesses the needs of care-givers, advocate on their behalf, and provide access to resources and services; and
- Healthcare systems and benefits: Be cognisant of and communicate the support mechanisms available to the aged person and their caregivers in the healthcare system.
Despite a degree of variability between the professions, it is clear there are a number of areas common to all three disciplines that require improvements in knowledge and skill. Suggestions for these are summarised in box below.
In order to increase proficiency in the three professions, we recommend the inclusion of all of the above in any review of pre- and post-professional curricula that is related to aged care management of MSK conditions.