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RESEARCH ARTICLE
Recommending NSAIDs and Paracetamol: A Survey of New Zealand Physiotherapists’ Knowledge and Behaviours Rhiannon Braund1 & J. Haxby Abbott2* 1
School of Pharmacy, University of Otago, Dunedin, New Zealand
2
Centre for Physiotherapy Research, University of Otago, Dunedin, New Zealand
Abstract Background. Clinical guidelines recommend medications as first line treatment for many musculoskeletal injuries. As first line health professionals for musculoskeletal conditions, including sprains and strains, physiotherapists may be asked to recommend suitable medications. Currently recommending medications is outside of the physiotherapists scope of practice. However there is evidence that physiotherapists often do recommend medications, mostly simple analgesics and non-steroidal anti-inflammatory drugs (NSAIDs). Purpose. The aim of this study was to investigate the current knowledge and behaviour of New Zealand musculoskeletal physiotherapists regarding recommendation of non-prescription medications for the treatment of musculoskeletal sprains and strains. Method. 2438 New Zealand physiotherapists were surveyed, of whom approximately 948 work in musculoskeletal physiotherapy. Results. Of 278 respondents (29.3% response rate), 213 (81.0%) sometimes or often recommend oral NSAIDs to patients, and 216 (82.1%) recommend oral paracetamol. Most respondents (225, 85.5%) report that they routinely provide information on potential side effects, 181 (68.8%) on potential risks. Many refer to a pharmacist, however 146 (55.5%) make recommendations on dose, and 119 (45.2%) recommend specific brand names. When asked what the risks associated with NSAIDs were, most respondents (>70%) were able to name at least gastrointestinal upset, ulcers or bleeding, while the proportion able to name respiratory, renal or allergic risks was lower (250), and falls within the range expected for mail surveys (Portney and Watkins, 1993). Care must be taken in interpreting the results with regard to physiotherapists’ knowledge of risks associated with medications, as physiotherapists who do not recommend medications may be less likely to know or report risks associated with medications they do not commonly recommend to patients. Our results do indicate that those physiotherapists who recommended medications more often were able to name a greater number of risks and adverse effects. Nonetheless, we consider that knowledge of risks and patient-related risk factors within the sample population of physiotherapists’ is insufficient with respect to their reported medication-recommending behaviour. Although only a small proportion of practitioners report routinely recommending patients purchase medications without further professional advice, they are potentially placing their patients at risk of harm, themselves at risk of legal liability and their profession at risk of reputation damage, should an adverse event occur. Regardless of whether or not they actively recommend the drugs to patients, physiotherapists are (in many jurisdictions) primary care practitioners who will consult with patients who are concomitantly taking OTC medications. In the event that signs or symptoms of adverse effects evolve, a primary care practitioner must have the skills and knowledge to link potential cause and effect, and intervene appropriately, whether that involves counselling the patient or referring to another practitioner. This essential knowledge for a safe, first-line, autonomous practitioner is aided by knowledge of which groups of patients are more susceptible to such adverse effects. Recommending medications to patients is an area fraught with risk, as on the one hand physiotherapists’ scopes of practice do not include prescribing medications; however, on the other hand many best-practice clinical guidelines state that paracetamol or NSAIDs are recommended interventions. Thus, it could be argued 47
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that, as primary care practitioners, physiotherapists would be remiss in not relaying that knowledge to patients (Braund and Abbott, 2007; Abbott, 2008; Hancock et al., 2008). It is unclear where to draw the line between responsible recommending and prescribing. One proposed solution is the evolution of advanced practitioners (specialists) with enhanced knowledge and competence in the field, and extended scope practitioners who have undergone specific training and been granted special authority under revised physiotherapy scope of practice legislation to prescribe medicines. Further discussion of these measures can be found elsewhere (CSP 2001; CSP, 2002a; CSP, 2002b, CSP, 2003; Stevenson, 2003; WCPT, 2007). Another proposed solution is for physiotherapists — irrespective of advanced, extended or general scope status — to formally refer the patient to a clinical pharmacist (or community pharmacist) (Braund and Abbott, 2007). This allows the physiotherapist to convey to the patient that simple analgesics or NSAIDs are recommended interventions, yet an appropriately worded referral avoids any perception that the physiotherapist is making an individual recommendation or prescription (Braund and Abbott, 2007).
Conclusion A high proportion of New Zealand physiotherapists practicing in the musculoskeletal field, report they recommend medications to patients, despite such practice being outside of physiotherapists’ legal scope of practice. Knowledge of potential risks and of patient-related factors associated with elevated risk, was inadequate. Educational level was not associated with knowledge or behaviours regarding the potential risks and patientrelated risk factors associated with paracetamol or NSAIDs. We recommend that musculoskeletal physiotherapists in primary care develop and maintain knowledge of the risks and patient-related risk factors associated with common medications used by patients presenting with musculoskeletal disorders, regardless of whether it is the practice of the physiotherapist to make recommendations about drugs to patients.
Acknowledgements Thanks to the New Zealand Society of Physiotherapists Scholarship Trust for funding of this project. Also to Vicky Mcleod for the data entry. 48
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