Scope of practice
Noting the definitions provided in Table 3, the content (in bold) in Table 1 outlines the potential breadth of the ScoP for PoCUS by physiotherapists in PHCPs. In this regard a ‘rule in’ approach is emphasised whereby clinical assessment and reasoning formulate a priori the likely differentials—which ultrasound imaging is then used to identify (as appropriate) . This is in contrast to a ‘rule out’ approach (more typically employed by imaging services provided by imaging professionals such as radiologists and sonographers) where a range of potential sonographic findings (and subsequent clinical differentials) may be ruled out via the imaging .
As noted in Table 4, defining the ScoP provides clarity and thus confers a range of benefits for various key stakeholders. As part of this, clarification regarding the ultrasound imaging not performed and/or the interpretation/reporting not undertaken from that ultrasound imaging and/or the clinical decision making not informed by that ultrasound imaging is of equal relevance. Examples of these include:
Gestational status or foetal imaging; this includes confirmation or exclusion of current pregnancy (including ectopic pregnancy), foetal assessment, etc.
Prostate pathology, e.g. differentiation of benign prostatic hyperplasia from metastatic disease.
Primary identification of fibroids, cysts or gynaecological tumours.
Whilst the above lie outside of a physiotherapist’s ScoP, they may be identified as either incidental or concurrent imaging findings. Just as a physiotherapist has a duty of care to escalate any suspicion of red flag signs when assessing patients in the absence of ultrasound imaging, it is also necessary that they can act upon any imaging concerns . In this regard a clear protocol must be in place for the clinician to be able to discuss concerns and for the clinical assessment and/or imaging of the patient to be escalated. This could potentially include options for direct communication with those who have access to more specialist ultrasound imaging expertise, other imaging modalities and/or surgical or medical opinion. This highlights the importance of physiotherapists using PoCUS in PHCPs undertaking their ultrasound imaging as part of a wider clinical and imaging team.
Education and competency
As per Fig. 1 and Table 3, the education and competency elements must align with and should be reflective of the ScoP. Consideration of how the clinical-physiotherapy elements of Table 1 can be learnt and competency evidenced are beyond the scope of this paper but would include both informal training and formal courses, mentoring and feedback regarding pathology, clinical reasoning and clinical management .
In terms of ultrasound imaging-specific education and competency, Table 5 provides a summary of key considerations regarding post-registration education and competency; this aligns with performance, interpretation and reporting on ultrasound examinations (National Occupational Standard) . When combined with Table 1, these essentially provide a template for a potential ‘PoCUS by physiotherapists in PHCPs’ curriculum. Looking forwards, we advocate that educators map to these in creating the next generation of courses by which physiotherapists using PoCUS in PHCPs can robustly and comprehensively undertake their requisite learning and demonstrate initial competency.
In the same manner, if an individual were to undertake a pre-existing course (e.g. via ISUOG, short courses by recognised experienced clinicians skilled in pelvic health ultrasound imaging, etc.) then mapping across to the content in Tables 1 and 5 would provide a foundation for determining whether the requisite education and competency components are addressed.
Regardless of the course type, key considerations for course providers, individual learners and their managers include: whether the full range of foundation and speciality-specific elements are taught and assessed, whether the course has been externally scrutinised by a body such as the Consortium for the Accreditation of Sonographic Education (CASE) and the importance of demonstrable competency via a formal assessment route in terms of any subsequent need to defend the clinical practice of an individual . As emphasised in Table 5, availability of suitably qualified and experienced mentor(s) and access to an appropriate patient mix for directly supervised scanning are crucial components of PoCUS training. However, they are also widely acknowledged as bottlenecks in PoCUS training  and this is likely to be particularly acute where a specialism is developing PoCUS capacity. Mechanisms to potentially address this include accessing mentorship and observed practice at another unit or Trust—or via other professionals such as midwife-sonographers who may have overlapping areas of PoCUS practice. Key considerations here include the time burden involved with observing and being observed; honorary contracts and reciprocal working arrangements may need to be considered.
It is acknowledged that courses that meet the above considerations and that are specifically tailored to physiotherapists using PoCUS in PHCPs are not—at the time of writing—available in the UK. In the immediate and short term a pragmatic approach could include:
Due to the necessity for high-level clinical reasoning skills (required to appropriately choose to use ultrasound imaging and to integrate those findings into patient management), a physiotherapist using PoCUS in a PHCP requires a substantial level of PHCP clinical skills and experience. As such, training in PoCUS should occur at post-graduate level and by someone with the appropriate level of experience in PHCP care which is relevant to their subsequent PoCUS in PHCP ScoP.
The use of a medical imaging modality by clinicians without a background in career imaging inevitably raises governance questions. For physiotherapists in the UK who are members of the CSP (with the relevant level of CSP provided indemnity insurance) then the key consideration is that the scope of practice must demonstrably align with their role as a physiotherapist . In addition they must be able to evidence that they are appropriately trained and have been deemed competent to perform that activity. As such, the ScoP outlined in Table 1 aligns with the role of a physiotherapist working in PHCP. Combined with the above education and competency considerations, these provide the foundation for physiotherapists to use PoCUS in PHCPs in a robust manner.
It should be noted that if a physiotherapist were to use ultrasound imaging in a manner that is demonstrably outside of ScoP, e.g. akin to that of a career-sonographer or midwife-sonographer, then the above would not apply. Instead they would need to ensure vicarious liability coverage via their employer or private insurance coverage if working privately. Caveats around appropriate training and demonstrable competency for such roles would apply.
As noted in Table 4, clarity regarding the current ScoP for a physiotherapist using PoCUS in PHCP facilitates awareness by other care pathway members of what the scan is and is not undertaken for and also supports clinical managers in care pathway design and staffing. The use of terminology to explicitly clarify the nature of the scan is encouraged. An example of the professional context to the imaging process that could be communicated to colleagues is: “Aligning with the scope of clinical and sonographic practice outlined for physiotherapists working in pelvic health care pathways using point of care ultrasound in the UK , this ultrasound scan is undertaken for the purposes of assessing pelvic floor function and pelvic organ support as an adjunct to pelvic physiotherapy management. The identification of other anatomical or pathological elements is explicitly beyond the scope of practice of the clinician. Therefore, the scan cannot be relied upon to either confirm or exclude any such anatomical, gestational or pathological elements.”
Quality assurance considerations include data protection, storage of images, continuous professional development and access to a second opinion . As PoCUS is often undertaken in non-radiology settings, direct access to PACS (picture archiving and communication system) for secure storage and backing up of sonographic images may not be available. This poses a risk to data security as well as continuity of care and the ability to review image quality. Mechanisms for the secure storage of sonographic images will need to be addressed and this may include bespoke mechanisms to upload to PACS, use of secure cloud storage (or the use of other secure image storage capacity as advised by a data compliance officer) and reporting systems which can integrate with pre-existing patient record systems.
As part of best practice, physiotherapists using PoCUS in PHCPs should undertake ongoing audit of their practice. Double-scanning with an experienced colleague and discussion of complex cases with a more experienced imager should also be undertaken as part of continuing professional development and quality assurance activities .