- Email: [email protected]
Shoulder pain, prognostic factors for the outcome of physiotherapy treatment. Results from a prospective multicentre cohort study
Abstracts / Manual Therapy 25 (2016) e33ee56
patient reported outcome measures (PROMs) that assess different aspects of physical, emotional and social functioning. However the extent that shoulder or upper extremity region-specific PROMs reflect the outcomes that patients with a musculoskeletal shoulder problem (MSP) consider important is not known. Purpose: The purpose of this mixed methods study was to identify which PROMs should be used in the self-assessment of outcome for MSP, from the patient's perspective. Methods: A qualitative approach was used to gain patients' perspectives. A purposive maximum variation sampling strategy was used to capture a breadth of relevant experiences of MSP, and in-depth individual interviews were conducted with fifteen patients at the outset of treatment. Transcribed, anonymised interview data were analysed using a four-stage analytical framework. Meaningful comparisons were made within and across individual accounts to identify important outcomes for patients. To facilitate comparison of the content of PROMs and the views of patients the outcomes assessed in twelve shoulder or upper extremity region-specific PROMs with acceptable psychometric properties identified through a systematic literature review were collated and linked to relevant categories of the International Classification of Functioning, Disability and Health (ICF). The unifying language and conceptual framework of the ICF was then used to compare the outcomes that patients identified as important and the content of PROMs to determine how adequately individual PROMs capture patients' perspectives. Results: Patients with a range of sociodemographic characteristics that typify a shoulder problem articulated personally relevant and important outcomes. Everyone expected to be symptom free, regain their former level of upper limb use, resume usual daily activities, regain a sense of emotional well-being, resume former family relationships and social interactions, and most expected to independently manage their own shoulder problem. Of the PROMs that have been most extensively investigated in validation studies there is accumulating evidence for the psychometric properties of validity, reliability, responsiveness, and practicality across a range of shoulder problems. The Disabilities of the Arm, Shoulder and Hand (DASH) reflected all ICF-based outcomes that patients identified as important. Of the remainder five PROMs included three-quarters, four one half and two one quarter of important outcomes for patients. Conclusion: Patients expect relief of symptoms to enable them to resume activities of daily living, work and recreation and get back to some sort of normality. Overall PROMs satisfactorily capture patients’ perspectives. The DASH should be used as the primary outcome measure for the assessment of shoulder symptoms and physical functioning, and the Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons assessment form (ASES), or the Shoulder Pain and Disability Index (SPADI) should be considered as secondary outcome measures, with the SPADI being recommended for the assessment of pain. Implications: Future research should seek to gain a widely accepted expert consensus on a ‘core set’ of PROMs that should be adopted for use either at the end point in effectiveness trials, or on a case-by-case basis in clinical practice. Use of the same PROMs in published studies may facilitate the pooling of data in future meta-analyses, and in turn the development of best practice guidelines that are integral to the implementation of evidence-based practice. Research findings therefore have the potential to enable patients to participate in evaluating and improving the quality of their own future healthcare. Funding acknowledgements: The principal investigator (CP) received an Action Arthritis Trust Award (Reference: R15387). Ethics approval: Ethical approval was gained from the Norfolk Research Ethics Committee prior to commencement of the study (Reference 07/ Q010/58). Disclosure of Interest: None declared. Keywords: Outcome measure, Patients' perspectives, Shoulder
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Intergrating Research into practice OR-SH-050 SHOULDER PAIN, PROGNOSTIC FACTORS FOR THE OUTCOME OF PHYSIOTHERAPY TREATMENT. RESULTS FROM A PROSPECTIVE MULTICENTRE COHORT STUDY R. Chester 1, 2, 3,*, C. Jerosch Herold 1, L. Shepstone 2, J. Lewis 3. 1 School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, United Kingdom; 2 School of Medicine, Faculty of Medicine and Health Sciences, Norwich, United Kingdom; 3 Department of Allied Health Professions, School of Health and Social Work, University of Hertfordshire, Hatfield, United Kingdom * Corresponding author. School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, United Kingdom.
Background: The most effective treatment for musculoskeletal shoulder pain is unknown. Physiotherapy is often the first point of referral. However, there is uncertainty as to which patients will benefit. Purpose: To identify which patient and clinical characteristics, commonly assessed at the first physiotherapy appointment, are associated with better or worse patient rated shoulder pain & function six weeks and six months later. Methods: This prospective multicentre cohort study recruited patients referred to physiotherapy for the management of musculoskeletal shoulder pain. It took place within 11 NHS trusts and social enterprises in the East of England, including primary and secondary care, between November 2011 and October 2013. Seventy one potential prognostic factors were collected prior to and during the patient's first physiotherapy appointment and included individual and lifestyle characteristics, psychosocial factors, shoulder symptoms, general health, clinical examination findings, activity limitations and participation restrictions. Physiotherapy treatment was unaffected. Outcome measures included two self-report postal questionnaires; the Shoulder Pain and Disability Index (SPADI) (MacDermid et al, 2006; Roach et al, 1991) and the Quick Disability of the Arm, Shoulder and Hand (QuickDASH) (Beaton 2005). Multivariable linear regression was used to analyse prognostic factors associated with outcome. The protocol has been published previously (Chester et al, 2013). Results: 1030 participants were recruited and provided baseline data, 82% (n ¼ 840) provided outcome data at 6 weeks, 79% (n ¼ 811) at 6 months. Ten prognostic factors were consistently associated with the SPADI and QuickDASH at one or both time points. Five factors were associated with better outcomes at both time points: lower baseline disability, patient expectation of “complete recovery” compared to “slight recovery” as “a result of physiotherapy treatment,” higher pain self-efficacy, lower pain severity at rest, and for patients who were not retired, being in employment or education. Only three clinical examination findings were associated with outcome and each at one time point only. For the SPADI in particular, a greater range of shoulder abduction was associated with a better outcome at six weeks follow up, and a smaller difference between active and passive abduction was associated with a better outcome at six months follow up. For both the SPADI and QuickDASH, at six months follow up only, a reduction in pain or increase in range of shoulder elevation with manual facilitation of the scapula during elevation of the arm, was associated with a better outcome. Conclusion: A wide range of biopsychosocial factors were associated with patient rated outcome. Psychological factors were consistently associated with outcome at both time points. Clinical examination findings associated with a specific structural diagnosis were not. Clinical examination findings associated with symptom modification during manual facilitation of the scapula during elevation of the arm was consistently associated with both outcomes at six months. Implications: When assessing people with musculoskeletal shoulder pain psychological in addition to medical information should be considered.
e54
Abstracts / Manual Therapy 25 (2016) e33ee56
Funding acknowledgements: Rachel Chester was funded by a NIHR CAT Fellowship during the duration of this study. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health. Ethics approval: Obtained July 2011 from National Research Ethics Service (NRES), East of England, Norfolk (ref 11/EE/0212).
static stability accurately and determine the effectiveness of rehabilitation interventions. Funding acknowledgements: With thanks to the Musculoskeletal Association of Chartered Physiotherapists (MACP) for supportive funding towards this research. Ethics approval: Ethical approval for this research was granted by Bournemouth University Ethics Committee.
Disclosure of interest: None declared. Disclosure of interest: None declared. Keywords: Physical Therapy, Prognosis, Shoulder Keywords: Accelerometer, Shoulder, Stability Intergrating Research into practice OR-SH-051 QUANTIFYING STATIC SHOULDER STABILITY USING ACCELEROMETERS R. Bewes 1, *, A. Callaway 2, J. Williams 1. 1 Physiotherapy, Bournemouth University, Bournemouth, United Kingdom; 2 Sports and Physical Activity, Bournemouth University, Bournemouth, United Kingdom * Corresponding author.
Background: Sensory Motor Control (SMC) describes the integration of sensory, motor and central processing to control and coordinate movement and is known to be impaired secondary to pain or following injury. There is a lack of supporting evidence for the role of SMC in shoulder rehabilitation. This may be due to the lack of viable measurement method and no normative database available for performance comparison. Subsequently, evidence is lacking for the effectiveness of interventions designed to alter SMC in the shoulder. Purpose: To investigate using accelerometers for quantifying static shoulder stability, as a measure of SMC. Methods: Thirty participants with non-painful shoulders completed the Static Shoulder Stability Test (SSST) in supine. Participants held one arm in a 90o flexed position for one minute with eyes closed. There were rests between each of three repetitions. Measurements of limb accelerations (corrected for tilt) were taken using accelerometers (THETAmetrix) placed immediately superior to the styloid process at the wrist. Participants were instructed to maintain full elbow extension. Accelerations were used to determine three measures of performance based on the sway trace of the sensor; Mean Path Length (MPL), Sum Path Length (SPL) and Resultant Acceleration (RA). Reliability and consistency of the three measurements were determined using intra-class correlation coefficient (ICC) and Cronbach's alpha from which Standard Error of Measurement (SEM) and Minimal Detectable Change (MDC) values were calculated. Pearson's correlations between the performance metrics were explored to determine if similar constructs were being measured. Results: ICCs identified excellent consistency for MPL (0.96: CI (0.93e0.97)) and SPL (0.96: CI (0.93e0.96)) but only modest consistency for RA (0.67: CI (0.50e0.79)) indicating errors between repeated measures. Cronbach's alpha was high for MPL (0.96) and SPL (0.96) reinforcing a close relationship between repeated measures. SEM and MDC values were excellent for MPL (SEM 0.005: CI (0.022e0.034): MDC 0.001 (3.8%)) and good for SPL (SEM 17.4: CI (68e103): MDC 4.2 (5.3%)) indicating high levels of accuracy. A strong correlation between MPL and SPL (Pearson's ¼ 1.0) indicates measurement of the same construct. Significant differences between dominant and non-dominant arms were found suggesting the test is sensitive enough to detect differences in limb dominance (MPL and SPL p ¼ 0.01). Conclusion: Accelerometers are a reliable measure of the static shoulder stability test using either description of path length. RA did not provide a consistent measure. MPL and SPL appear to measure the same construct and are sensitive enough to identify differences between the dominant and non-dominant limb. This study suggests accelerometers may be a viable measure of static shoulder stability and future studies can utilise such test for quantifying static shoulder stability an indicator of SMC. Implications: Encouraging results indicate accelerometers may be clinically useful in assessing static shoulder stability, an indicator of SMC. A valid and reliable outcome measure allows therapists in practice to assess
Teaching, Learning and Professional Development OR-ED-007 CREATING A LEARNING CULTURE FOR DEVELOPING CLINICAL REASONING THROUGH POSTGRADUATE MANIPULATIVE PHYSIOTHERAPY EDUCATION M. Madi*, M. Griffiths, A. Rushton, N. Heneghan. School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom * Corresponding author.
Background: Studies that evaluated health care and medical postgraduate (PG) education have only focused on identifying programme outcomes and impact. There is a little evidence describing how PG programme curriculum and teaching methods bring about changes. In the context of PG manipulative physiotherapy (MPT) education, there is no evidence regarding the learning culture through which these PG programmes facilitate the advancement of clinical reasoning (CR) skills. In line with identified international research priority within MPT education, this innovative study looked at how the learning culture of PG programmes advance CR skills. Purpose: To explore how PG MPT education advances CR skills. The study aimed to understand how the culture of the participants, their background, and their biography fit with the culture of the programme. Methods: A qualitative case study approach was utilised drawing on a PG MPT programme. Staff members (n ¼ 6) involved in the delivery of an approved IFOMPT route participated in semi-structured interviews. Semistructured interviews and focus groups were also conducted with students (n ¼ 6) at different stages of their MPT programme. A critical review of existing literature around constructivist learning environment and adult learning theory informed the topic guide for the interviews. Inductive data analyse data using constructivist version of Grounded Theory was then used to identify the educational activities, features and context of the programme that facilitated change. Results: Four themes were constructed that illustrated how the programme facilitated the advancement of CR. Themes illustrated how learning was an outcome of students' critical social interactions with specific programme practices. 1. Creating collaborative and interactive learning environment; 2. Challenging learners' biography; 3. Ensuring relevance and authenticity; 4. The context in which the above themes works in. Conclusion: CR skills can be advanced in a critical collaborative learning culture. Professional socialisation encouraged students to critically reflect on their programme experiences and on their professional biography. Interactive sharing of experiences and reflective conversations during challenging clinically relevant problem solving activities facilitated depth of analysis. This collaborative working environment facilitated identifying areas of application and relevance to practice. Implications: The study provided evidence that would support planning and delivery of PG MPT education aiming to advance CR skills. - In terms of curriculum planning, the programme should be creating social spaces that: Allow critical collaborative problem solving, reflection and peer review; Challenge students' identity and professional experience; Are relevant to participants' practice. - Educators who aim to advance CR should have pedagogical skills to facilitate such environment instead of only delivering content.
patient reported outcome measures (PROMs) that assess different aspects of physical, emotional and social functioning. However the extent that shoulder or upper extremity region-specific PROMs reflect the outcomes that patients with a musculoskeletal shoulder problem (MSP) consider important is not known. Purpose: The purpose of this mixed methods study was to identify which PROMs should be used in the self-assessment of outcome for MSP, from the patient's perspective. Methods: A qualitative approach was used to gain patients' perspectives. A purposive maximum variation sampling strategy was used to capture a breadth of relevant experiences of MSP, and in-depth individual interviews were conducted with fifteen patients at the outset of treatment. Transcribed, anonymised interview data were analysed using a four-stage analytical framework. Meaningful comparisons were made within and across individual accounts to identify important outcomes for patients. To facilitate comparison of the content of PROMs and the views of patients the outcomes assessed in twelve shoulder or upper extremity region-specific PROMs with acceptable psychometric properties identified through a systematic literature review were collated and linked to relevant categories of the International Classification of Functioning, Disability and Health (ICF). The unifying language and conceptual framework of the ICF was then used to compare the outcomes that patients identified as important and the content of PROMs to determine how adequately individual PROMs capture patients' perspectives. Results: Patients with a range of sociodemographic characteristics that typify a shoulder problem articulated personally relevant and important outcomes. Everyone expected to be symptom free, regain their former level of upper limb use, resume usual daily activities, regain a sense of emotional well-being, resume former family relationships and social interactions, and most expected to independently manage their own shoulder problem. Of the PROMs that have been most extensively investigated in validation studies there is accumulating evidence for the psychometric properties of validity, reliability, responsiveness, and practicality across a range of shoulder problems. The Disabilities of the Arm, Shoulder and Hand (DASH) reflected all ICF-based outcomes that patients identified as important. Of the remainder five PROMs included three-quarters, four one half and two one quarter of important outcomes for patients. Conclusion: Patients expect relief of symptoms to enable them to resume activities of daily living, work and recreation and get back to some sort of normality. Overall PROMs satisfactorily capture patients’ perspectives. The DASH should be used as the primary outcome measure for the assessment of shoulder symptoms and physical functioning, and the Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons assessment form (ASES), or the Shoulder Pain and Disability Index (SPADI) should be considered as secondary outcome measures, with the SPADI being recommended for the assessment of pain. Implications: Future research should seek to gain a widely accepted expert consensus on a ‘core set’ of PROMs that should be adopted for use either at the end point in effectiveness trials, or on a case-by-case basis in clinical practice. Use of the same PROMs in published studies may facilitate the pooling of data in future meta-analyses, and in turn the development of best practice guidelines that are integral to the implementation of evidence-based practice. Research findings therefore have the potential to enable patients to participate in evaluating and improving the quality of their own future healthcare. Funding acknowledgements: The principal investigator (CP) received an Action Arthritis Trust Award (Reference: R15387). Ethics approval: Ethical approval was gained from the Norfolk Research Ethics Committee prior to commencement of the study (Reference 07/ Q010/58). Disclosure of Interest: None declared. Keywords: Outcome measure, Patients' perspectives, Shoulder
e53
Intergrating Research into practice OR-SH-050 SHOULDER PAIN, PROGNOSTIC FACTORS FOR THE OUTCOME OF PHYSIOTHERAPY TREATMENT. RESULTS FROM A PROSPECTIVE MULTICENTRE COHORT STUDY R. Chester 1, 2, 3,*, C. Jerosch Herold 1, L. Shepstone 2, J. Lewis 3. 1 School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, United Kingdom; 2 School of Medicine, Faculty of Medicine and Health Sciences, Norwich, United Kingdom; 3 Department of Allied Health Professions, School of Health and Social Work, University of Hertfordshire, Hatfield, United Kingdom * Corresponding author. School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, United Kingdom.
Background: The most effective treatment for musculoskeletal shoulder pain is unknown. Physiotherapy is often the first point of referral. However, there is uncertainty as to which patients will benefit. Purpose: To identify which patient and clinical characteristics, commonly assessed at the first physiotherapy appointment, are associated with better or worse patient rated shoulder pain & function six weeks and six months later. Methods: This prospective multicentre cohort study recruited patients referred to physiotherapy for the management of musculoskeletal shoulder pain. It took place within 11 NHS trusts and social enterprises in the East of England, including primary and secondary care, between November 2011 and October 2013. Seventy one potential prognostic factors were collected prior to and during the patient's first physiotherapy appointment and included individual and lifestyle characteristics, psychosocial factors, shoulder symptoms, general health, clinical examination findings, activity limitations and participation restrictions. Physiotherapy treatment was unaffected. Outcome measures included two self-report postal questionnaires; the Shoulder Pain and Disability Index (SPADI) (MacDermid et al, 2006; Roach et al, 1991) and the Quick Disability of the Arm, Shoulder and Hand (QuickDASH) (Beaton 2005). Multivariable linear regression was used to analyse prognostic factors associated with outcome. The protocol has been published previously (Chester et al, 2013). Results: 1030 participants were recruited and provided baseline data, 82% (n ¼ 840) provided outcome data at 6 weeks, 79% (n ¼ 811) at 6 months. Ten prognostic factors were consistently associated with the SPADI and QuickDASH at one or both time points. Five factors were associated with better outcomes at both time points: lower baseline disability, patient expectation of “complete recovery” compared to “slight recovery” as “a result of physiotherapy treatment,” higher pain self-efficacy, lower pain severity at rest, and for patients who were not retired, being in employment or education. Only three clinical examination findings were associated with outcome and each at one time point only. For the SPADI in particular, a greater range of shoulder abduction was associated with a better outcome at six weeks follow up, and a smaller difference between active and passive abduction was associated with a better outcome at six months follow up. For both the SPADI and QuickDASH, at six months follow up only, a reduction in pain or increase in range of shoulder elevation with manual facilitation of the scapula during elevation of the arm, was associated with a better outcome. Conclusion: A wide range of biopsychosocial factors were associated with patient rated outcome. Psychological factors were consistently associated with outcome at both time points. Clinical examination findings associated with a specific structural diagnosis were not. Clinical examination findings associated with symptom modification during manual facilitation of the scapula during elevation of the arm was consistently associated with both outcomes at six months. Implications: When assessing people with musculoskeletal shoulder pain psychological in addition to medical information should be considered.
e54
Abstracts / Manual Therapy 25 (2016) e33ee56
Funding acknowledgements: Rachel Chester was funded by a NIHR CAT Fellowship during the duration of this study. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health. Ethics approval: Obtained July 2011 from National Research Ethics Service (NRES), East of England, Norfolk (ref 11/EE/0212).
static stability accurately and determine the effectiveness of rehabilitation interventions. Funding acknowledgements: With thanks to the Musculoskeletal Association of Chartered Physiotherapists (MACP) for supportive funding towards this research. Ethics approval: Ethical approval for this research was granted by Bournemouth University Ethics Committee.
Disclosure of interest: None declared. Disclosure of interest: None declared. Keywords: Physical Therapy, Prognosis, Shoulder Keywords: Accelerometer, Shoulder, Stability Intergrating Research into practice OR-SH-051 QUANTIFYING STATIC SHOULDER STABILITY USING ACCELEROMETERS R. Bewes 1, *, A. Callaway 2, J. Williams 1. 1 Physiotherapy, Bournemouth University, Bournemouth, United Kingdom; 2 Sports and Physical Activity, Bournemouth University, Bournemouth, United Kingdom * Corresponding author.
Background: Sensory Motor Control (SMC) describes the integration of sensory, motor and central processing to control and coordinate movement and is known to be impaired secondary to pain or following injury. There is a lack of supporting evidence for the role of SMC in shoulder rehabilitation. This may be due to the lack of viable measurement method and no normative database available for performance comparison. Subsequently, evidence is lacking for the effectiveness of interventions designed to alter SMC in the shoulder. Purpose: To investigate using accelerometers for quantifying static shoulder stability, as a measure of SMC. Methods: Thirty participants with non-painful shoulders completed the Static Shoulder Stability Test (SSST) in supine. Participants held one arm in a 90o flexed position for one minute with eyes closed. There were rests between each of three repetitions. Measurements of limb accelerations (corrected for tilt) were taken using accelerometers (THETAmetrix) placed immediately superior to the styloid process at the wrist. Participants were instructed to maintain full elbow extension. Accelerations were used to determine three measures of performance based on the sway trace of the sensor; Mean Path Length (MPL), Sum Path Length (SPL) and Resultant Acceleration (RA). Reliability and consistency of the three measurements were determined using intra-class correlation coefficient (ICC) and Cronbach's alpha from which Standard Error of Measurement (SEM) and Minimal Detectable Change (MDC) values were calculated. Pearson's correlations between the performance metrics were explored to determine if similar constructs were being measured. Results: ICCs identified excellent consistency for MPL (0.96: CI (0.93e0.97)) and SPL (0.96: CI (0.93e0.96)) but only modest consistency for RA (0.67: CI (0.50e0.79)) indicating errors between repeated measures. Cronbach's alpha was high for MPL (0.96) and SPL (0.96) reinforcing a close relationship between repeated measures. SEM and MDC values were excellent for MPL (SEM 0.005: CI (0.022e0.034): MDC 0.001 (3.8%)) and good for SPL (SEM 17.4: CI (68e103): MDC 4.2 (5.3%)) indicating high levels of accuracy. A strong correlation between MPL and SPL (Pearson's ¼ 1.0) indicates measurement of the same construct. Significant differences between dominant and non-dominant arms were found suggesting the test is sensitive enough to detect differences in limb dominance (MPL and SPL p ¼ 0.01). Conclusion: Accelerometers are a reliable measure of the static shoulder stability test using either description of path length. RA did not provide a consistent measure. MPL and SPL appear to measure the same construct and are sensitive enough to identify differences between the dominant and non-dominant limb. This study suggests accelerometers may be a viable measure of static shoulder stability and future studies can utilise such test for quantifying static shoulder stability an indicator of SMC. Implications: Encouraging results indicate accelerometers may be clinically useful in assessing static shoulder stability, an indicator of SMC. A valid and reliable outcome measure allows therapists in practice to assess
Teaching, Learning and Professional Development OR-ED-007 CREATING A LEARNING CULTURE FOR DEVELOPING CLINICAL REASONING THROUGH POSTGRADUATE MANIPULATIVE PHYSIOTHERAPY EDUCATION M. Madi*, M. Griffiths, A. Rushton, N. Heneghan. School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom * Corresponding author.
Background: Studies that evaluated health care and medical postgraduate (PG) education have only focused on identifying programme outcomes and impact. There is a little evidence describing how PG programme curriculum and teaching methods bring about changes. In the context of PG manipulative physiotherapy (MPT) education, there is no evidence regarding the learning culture through which these PG programmes facilitate the advancement of clinical reasoning (CR) skills. In line with identified international research priority within MPT education, this innovative study looked at how the learning culture of PG programmes advance CR skills. Purpose: To explore how PG MPT education advances CR skills. The study aimed to understand how the culture of the participants, their background, and their biography fit with the culture of the programme. Methods: A qualitative case study approach was utilised drawing on a PG MPT programme. Staff members (n ¼ 6) involved in the delivery of an approved IFOMPT route participated in semi-structured interviews. Semistructured interviews and focus groups were also conducted with students (n ¼ 6) at different stages of their MPT programme. A critical review of existing literature around constructivist learning environment and adult learning theory informed the topic guide for the interviews. Inductive data analyse data using constructivist version of Grounded Theory was then used to identify the educational activities, features and context of the programme that facilitated change. Results: Four themes were constructed that illustrated how the programme facilitated the advancement of CR. Themes illustrated how learning was an outcome of students' critical social interactions with specific programme practices. 1. Creating collaborative and interactive learning environment; 2. Challenging learners' biography; 3. Ensuring relevance and authenticity; 4. The context in which the above themes works in. Conclusion: CR skills can be advanced in a critical collaborative learning culture. Professional socialisation encouraged students to critically reflect on their programme experiences and on their professional biography. Interactive sharing of experiences and reflective conversations during challenging clinically relevant problem solving activities facilitated depth of analysis. This collaborative working environment facilitated identifying areas of application and relevance to practice. Implications: The study provided evidence that would support planning and delivery of PG MPT education aiming to advance CR skills. - In terms of curriculum planning, the programme should be creating social spaces that: Allow critical collaborative problem solving, reflection and peer review; Challenge students' identity and professional experience; Are relevant to participants' practice. - Educators who aim to advance CR should have pedagogical skills to facilitate such environment instead of only delivering content.