Physiotherapy practices in primary health care

Introduction: Physiotherapy was included in primary health care (PHC) in order to expand access and provide comprehensive care to the population. Objective: To understand the routine and tools used by physiotherapists in primary health care and analyze the determining factors in providing care in a municipality where every basic health unit (BHU) has a physiotherapist. Methods: This is a qualitative study of nineteen physiotherapists conducted in a city of Southern Brazil, using a semistructured interview and a methodological framework for discourse analysis. Results: The main tools routinely used in the physiotherapy service are individual appointments, home visits and group work. Physiotherapy practices are influenced by public health, municipal management and BHU policies, physiotherapy profile in addition to the characteristics of the coverage area and the population being treated. Introducing health promotion measures and implementing relational technologies are the main challenges for physiotherapists, and many of these professionals already recognize their importance in promoting comprehensive care. Conclusion: Physiotherapy practices and the tools used are in line with the Primary Care Family Health Support Center (NASF-AB) model of action recommended by public policies and have been effective for many health conditions. Knowing the routine of PHC physiotherapy services may help professional training and service management, with a view to producing physiotherapy care aimed at the principle of comprehensiveness and consolidating the role of physiotherapists at this level of care


Introduction
Primary health care (PHC), the preferred entry level of a health system, is characterized by the continuity and comprehensiveness of health measures. It forms the basis and determines the work of other care levels, guided by the main health problems of the community, which vary from country to country. 1 The World Health Organization The predominance and multicausality of chronic health conditions and their repercussions on the

Design
This is a qualitative study using discourse analysis. Initially, the 33 physiotherapists working in BHUs completed a characterization questionnaire. After their profile was identified, the participants were selected for interviews, and the following aspects considered for sample heterogeneity: time since graduation, academic degree, time working in PHC, type of BHU (urban or rural), and affiliation with the BHU. A total of 19 professionals were interviewed.

Data collection
The interviews were scheduled and conducted at the subjects' workplace between August and October 2017.

Physiotherapy practices in PHC
The standard work routine of physiotherapists mainly involves specific individual treatment, group-based work and home visits, the routine stipulates certain days for home visits, group physiotherapy days that are mine, The way in which the municipal service is organized is reflected in the practices performed. Some physiotherapists feel there is no opportunity for health promotion: actually, we are there to assess the patient, but ideally we should be promoting health (F14). One of those interviewed considered that the municipality already had the professionals, but that they needed to restructure the NASF, because what the NASF is doing today is not the NASF, since 70% rehabilitation and 30% promotion is not its true purpose; so physiotherapists have a more clinical than health promoting role (F19).
The physiotherapists of the municipality understand that some organizational aspects of the service need to be revised in order to enhance the care provided to the patients. This means expanding activities to include health promotion measures: Improve our availability to perform more NASF practices... I think there's lack of organization in planning these activities (F17).

Discussion
The work of physiotherapists in PHC, within the NASF-AB policy, has been increasingly debated in recent years, but there are still gaps in its understanding. The NASF-AB guidelines recommend that team services should always focus on their coverage area, based exclusively on referrals from family health teams; and that the service be structured to prioritize shared interprofessional treatment, with an exchange of knowledge, training and mutual responsibilities. 4 Starting from the new National Basic Care Policy to their funding model compromised their expansion and very existence. The NASF-AB can contribute to the production of comprehensive care in the SUS and, in this respect, provides a number of possibilities, but others can also be created at team meetings. 5 Assessment during individual treatment is one of the activities performed by physiotherapists, and they must be able to conduct clinical screening at the first PHC contact. 2 Given that musculoskeletal disorders are frequent in the general population and can be considered one of the major public health problems worldwide, 19 the demand for musculoskeletal assessments is frequent in PHC. By contrast, in order to improve the health of the population, prevention, promotion, education and treatment must be prioritized, incorporating the broad concept of health and autonomy. However, the time spent on these measures is incipient when compared to that dedicated to spontaneous demand, generating an excessive number of individual consultations. 20 In the present study, the spontaneous demand for individual treatment predominates in BHUs, occupying more than half of physiotherapists' time. Thus, it can be considered that health professionals are in a vulnerable situation, due to the large demand for individual treatment, which prevents NASF professionals from expanding their care options. 21 In this respect, it would be necessary to organize the municipal service studied to allow physiotherapists to broaden their services.
Group work, an important resource in PHC care, can be carried out in different modalities. Irrespective of its organization, shared care goes beyond just meeting biological needs and addresses the educational, psychological and social aspects of a group of people. 22 When groups are based on bonds, listening and support, they are a collective space for reflection, learning and decision making, creating health promotion opportunities, strengthening participants and preventing disease. 6 Accordinbg to Fernandes et al., 23 that patients have a positive perception about the group activities offered by the NASF, underscoring satisfactory therapeutic results and the creation of affective bonds, thereby strengthening interpersonal relations, well-being and improving quality of life.
Home visits involve physiotherapists going to the patient's home to provide care, learning or to investigate. 24 This working tool is indispensable for PHC physiotherapists as a means of promoting access and providing referrals and guidance for each case. 8,10, 24 Physiotherapists that act beyond the standard established in the municipality are considered workers with creative potential who use new practices not included in the guidelines and protocols. 25 Given that the proposal is unique to the municipality and that each BHU has its own management, analysis of the discourses regarding physiotherapy practices revealed the potential of each worker within their coverage area.
The technological tools of the NASF are innovative and essential in horizontal relationships between professionals. These new arrangements and working tools require new understanding of health-related work and a training process that allows professionals to acquire the skills to jointly face the challenges encountered. 14 Matrix support, the central element of the NASF proposal, contains two support dimensions: care support (clinical measures applied directly to patients) and technical-pedagogical action, which provides educational support for the team to share knowledge in the search for a solution to the population's needs. 5 The technical-pedagogical dimension is the most fragile in terms of the role of physiotherapy in the NASF, demonstrating the need to develop continuing education in health services in order to implement the actions recommended for physiotherapists, where matrix support involves interprofessional collaboration and knowledge sharing, working in networks, acting in an established coverage area, joint deliberation and co-management. 10,14 Whether due to internal or external team issues, the technological tools proposed by the NASF guidelines, such as matrix support, expanded clinical care and the PTS, are still underused and need to be part of the daily routine of physiotherapists in order to achieve effective care. 26 The PTS, for example, is not consistently implemented by the NASF in Londrina and other Brazilian municipalities, due to the amount of time needed and the difficulty in organizing the schedule of the different personnel involved. 6, 26 In the municipality under study, this tool was used by some of the professionals. The use of a genogram and ecomap, which allows visualizing the relation between patients and their family, the environment and the community, was not reported by the individuals interviewed.
Tools for use in the NASF are little represented, perhaps due to the resistance of professionals in adding to their work routine, in addition to the lack of knowledge and training profile of some professionals. 6  The shortcomings in the recording and execution of systematized planning, primarily in monitoring and assessment practices, compromises its organization and effectiveness. 29 The physiotherapists studied were required to keep a mandatory record of services

Authors´ contributions
CRB conducted all stages of the research and ADG guided them. Both were responsible for writing the article. BGC, CST, KSQSR and RSB were responsible for the formal analysis and review of the article.