The assessment and management of breathing dysfunction in musculoskeletal conditions: A survey of current United Kingdom physiotherapy practice

Purpose: The prevalence of breathing dysfunction (BD) is estimated at 10% of the United Kingdom (UK) adult population, and higher in those with asthma (Thomas et al., 2005), while an estimated 20% of adults attend primary care each year with musculoskeletal conditions (Department of Health and Social Care, 2019). Current research indicates a possible relationship between BD and musculoskeletal conditions including alterations in thoracic mechanics, respiratory muscle strength and spirometry, however, there is a lack of evidence regarding the most appropriate BD assessment and management strategies. This study investigated physiotherapists’ use of BD assessment and management strategies for patients with musculoskeletal conditions and explored relationships between professional characteristics and current practice variation.
Methods: An observational cross-sectional online survey was utilised. UK-based musculoskeletal physiotherapists were invited to participate via social media, professional networks and email. The survey consisted of 28 closed and 16 open questions informed by similar surveys and relevant BD literature. The survey was piloted by five musculoskeletal physiotherapists and was open for eight weeks between 22/05/2020 - 17/07/2020 with a half-way reminder. Data analysis included descriptive statistics and Fishers exact test.
Results: 257 questionnaires were completed. 81% (n=208) of participants worked within the NHS and 31.1% (n=80) in private practice, with the majority working at an equivalent band 6 (23%, n=58), band 7 (33%, n=84) and band 8a (31%, n=79). 13.2% (n=34) reported a special interest in BD. 72% (n=185) of participants did not assess or manage BD, 28% (n=72) did. In this latter group 100% (n=72) assessed BD using subjective indicators and patient observation, while muscle-length testing (69%, n=50), physical assessment (68%, n=49), respiratory parameters (26%, n=19) and BD specific questionnaires (14%, n=10) were less commonly reported. BD management consistently included breathing retraining (94%, n=68), general exercise and BD education (89%, n=64). The inclusion of BD assessment and management in musculoskeletal conditions was statistically significantly associated with BD special interest (pConclusion(s): This is the first survey of physiotherapy BD assessment and management in musculoskeletal conditions and indicates infrequent assessment and management of BD. For physiotherapists who do assess and manage BD, subjective indicators and observation were the most commonly assessed, while breathing retraining was the most frequent management strategy. BD special interest, relevant post-graduate training and NHS equivalent banding were statistically significantly associated with use of BD assessment and management.
Implications: Findings could inform future survey design including international surveys comparing findings across a more diverse sample. Qualitative work or use of vignettes could explore rationales regarding the inclusion of BD assessment and management in musculoskeletal practice. Due to the potentially detrimental clinically important reduced respiratory muscle function associated with mechanical ventilation (Lu et al., 2016; Nassar et al., 2018) and COVID-19 illness (Brosnahan et al., 2020), future quantitative research could investigate whether there is an association between COVID-19 and BD or the effect of long COVID on breathing mechanics and musculoskeletal dysfunction.
Funding acknowledgements: Project was unfunded.
Ethical approval: Ethical approval was granted by the Health and Human Sciences Ethics Committee, University of Hertfordshire on 19/05/2020 (no. HSK/PGT/UH/04121(1)).