Clinical diagnostic accuracy and magnetic resonance imaging of patients referred by physical therapists, orthopaedic surgeons, and nonorthopaedic providers

Evaluation of an advanced-practice physical therapist in a specialty shoulder clinic: diagnostic agreement and effect on wait times

PURPOSE

To examine the role of an advanced-practice physiotherapist (APP) with respect to (1) agreement with an orthopaedic surgeon on diagnosis and management of patients with shoulder problems; (2) wait times; and (3) satisfaction with care.

METHODS

This prospective study involved patients with shoulder complaints who were referred to a shoulder specialist in a tertiary care centre. Agreement was examined on seven major diagnostic categories, need for further examination and surgery, and type of surgical procedure. Wait times were compared between the APP- and surgeon-led clinics from referral date to date of initial consultation, date of final diagnostic test, and date of confirmed diagnosis and planned treatment. A modified and validated version of the Visit-Specific Satisfaction Instrument assessed satisfaction in seven domains. Kappa (κ) coefficients and bias- and prevalence-adjusted kappa (PABAK) values were calculated, and strength of agreement was categorized. Wait time and satisfaction data were examined using non-parametric statistics.

RESULTS

Agreement on major diagnostic categories varied from 0.68 (good) to 0.96 (excellent). Agreement with respect to indication for surgery was κ=0.75, p<0.001; 95% CI, 0.62-0.88 (good). Wait time for APP assessment was significantly shorter than wait time for surgeon consultation at all time points (p<0.001); the surgeon's wait time was significantly reduced over 3 years. High satisfaction was reported in all components of care received from both health care providers.

CONCLUSIONS

Using experienced physiotherapists in an extended role reduces wait times without compromising patient clinical management and overall satisfaction.

Direct access compared with referred physical therapy episodes of care: a systematic review

BACKGROUND

Evidence suggests that physical therapy through direct access may help decrease costs and improve patient outcomes compared with physical therapy by physician referral.

PURPOSE

The purpose of this study was to conduct a systematic review of the literature on patients with musculoskeletal injuries and compare health care costs and patient outcomes in episodes of physical therapy by direct access compared with referred physical therapy.

DATA SOURCES

Ovid MEDLINE, CINAHL (EBSCO), Web of Science, and PEDro were searched using terms related to physical therapy and direct access. Included articles were hand searched for additional references.

STUDY SELECTION

Included studies compared data from physical therapy by direct access with physical therapy by physician referral, studying cost, outcomes, or harm. The studies were appraised using the Centre for Evidence-Based Medicine (CEBM) levels of evidence criteria and assigned a methodological score.

DATA EXTRACTION

Of the 1,501 articles that were screened, 8 articles at levels 3 to 4 on the CEBM scale were included. There were statistically significant and clinically meaningful findings across studies that satisfaction and outcomes were superior, and numbers of physical therapy visits, imaging ordered, medications prescribed, and additional non-physical therapy appointments were less in cohorts receiving physical therapy by direct access compared with referred episodes of care. There was no evidence for harm.

DATA SYNTHESIS

There is evidence across level 3 and 4 studies (grade B to C CEBM level of recommendation) that physical therapy by direct access compared with referred episodes of care is associated with improved patient outcomes and decreased costs.

LIMITATIONS

Primary limitations were lack of group randomization, potential for selection bias, and limited generalizability.

CONCLUSIONS

Physical therapy by way of direct access may contain health care costs and promote high-quality health care. Third-party payers should consider paying for physical therapy by direct access to decrease health care costs and incentivize optimal patient outcomes.

The case for orthopaedic medicine in Israel

BACKGROUND

Musculoskeletal complaints are probably the most frequent reasons for visiting a doctor. They comprise more than a quarter of the complaints to primary practitioners and are also the most common reason for referral to secondary or tertiary medicine. The clinicians most frequently consulted on musculoskeletal problems, and probably perceived to know most on the topic are orthopaedic surgeons. But in Israel, there is significant ambivalence with various aspects of the consultations provided by orthopaedic surgeons, both among the public and among various groups of clinicians, particularly family practitioners and physiotherapists.

METHODS

In order to understand this problem we integrate new data we have collected with previously published data. New data include the rates of visits to orthopaedic surgeons per annum in one of Israel's large non-profit HMO's, and the domains of the visits to an orthopaedic surgeon.

RESULTS

Orthopaedic surgeons are the third most frequently contracted secondary specialists in one of the Israeli HMO's. Between 2009 and 2012 there was a 1.7% increase in visits to orthopaedists per annum (P < 0.0001, after correction for population growth). Almost 80% of the domains of the problems presented to an orthopaedic surgeon were in fields orthopaedic surgeons have limited formal training.

DISCUSSION

While orthopaedic surgeons are clearly the authority on surgical problems of the musculoskeletal system, most musculoskeletal problems are not surgical, and the orthopaedic surgeon often lacks training in these areas which might be termed orthopaedic medicine. Furthermore, in Israel and in many other developed countries there is no accessible medical specialty that studies these problems, trains medical students in the subject and focuses on treating these problems. The neglect of this area which can be called the "Orthopaedic Medicine Lacuna" is responsible for inadequate treatment of non-surgical problems of the musculoskeletal system with immense financial implications. We present a preliminary probe into possible solutions which could be relevant to many developed countries.

Intra- and interdisciplinary agreement in the rating of acromioclavicular joint dislocations

BACKGROUND

Acromioclavicular (AC) joint dislocation is a common injury observed and treated by physicians from several disciplines; proper classification and communication of the diagnosis between physicians is essential to manage injuries properly. This study assessed inter- and intradepartmental agreement in the rating of AC joint dislocations and compared departments of orthopedic surgery, musculoskeletal (MSK) radiology, and emergency medicine (EM).

METHODS

Fifty radiographs indicating a random distribution of AC dislocations (Rockwood types I, II, III, and V) were sent to 25 resident, fellow, and attending physicians; the study group consisted of orthopedic surgeons (n = 9), MSK radiologists (n = 7), and EM physicians (n = 9). Dislocations were rated by physicians using the Rockwood classification (excluding type IV) and rating agreement was derived using the multirater κ statistic.

RESULTS

Moderate rating agreement was found among orthopedic surgeons (κ = 0.5147), which was higher than among radiologists (κ = 0.3628) or EM physicians (κ = 0.1894). Interdisciplinary rating agreement was highest between orthopedic surgeons and MSK radiologists and lowest between MSK radiologists and EM physicians. Attending orthopedic surgeons showed the highest rating agreement (κ = 0.5167) compared with attending MSK radiologists (κ = 0.3585) and attending EM physicians (κ = 0.2612). In-training orthopedic surgeons had higher rating agreement (κ = 0.4918) than in-training MSK radiologists (κ = 0.4218) and in-training EM physicians (κ = 0.1410).

DISCUSSION

Orthopedic surgeons exhibited the highest intradepartmental rating agreement in assessing AC joint injuries, but interdepartmental rating agreement was low. It is unclear if low interdepartmental rating agreement reflects classification or training weaknesses; recognition of these differences may help develop a more standardized education for physicians to improve the management of AC joint injuries.

CONCLUSIONS

Interdisciplinary rating agreement of AC joint injuries is low. Further study may help improve education and communication about AC joint injuries among physicians.

Physiotherapy screening of patients referred for orthopaedic consultation in primary healthcare - a randomised controlled trial

A large proportion of patients who consult primary healthcare for musculoskeletal pain are referred for orthopaedic consultation, but only a small number of these patients are appropriate for orthopaedic intervention. Experienced physiotherapists have the appropriate knowledge to manage musculoskeletal disorders. The primary aim of this randomised study was therefore to evaluate a screening by a physiotherapist of patients referred for orthopaedic consultation compared to standard practice in primary care. Patients referred for orthopaedic consultation (n=203) were randomised to physiotherapy screening or standard practice. Selection accuracy for orthopaedic intervention and other referrals were analysed with proportion analysis. Patient views of the quality of care were analysed with Mann-Whitney U-test, waiting time with Independent t-test. There was higher selection accuracy for orthopaedic intervention in the physiotherapy screening group (p=0.002). A smaller proportion of patients in the screening group were referred back to their general practitioner (GP) (p<0.001) and a larger proportion to the physiotherapy clinic (p<0.001) compared to standard practice. The proportion of patients referred for further investigations was significantly lower in the physiotherapy screening group (p<0.039). Waiting time was shorter in the screening group (p<0.001). A large proportion of the patients reported no hesitation to attend the clinic for future care, no difference between the groups (p<0.95). The findings in this study suggest that an experienced physiotherapist effectively can screen patients referred for orthopaedic consultation in primary healthcare.

A spinal triage programme delivered by physiotherapists in collaboration with orthopaedic surgeons

PURPOSE

To describe the characteristics of participants in a physiotherapist spinal triage programme, compare the profiles of patients for whom surgery was and was not recommended by a surgeon, and determine the surgical yield among those referred to surgeons.

METHODS

Data were collected retrospectively by reviewing charts of people who used the service over a 3-year period (2003-2006). Data from up to1,096 people were used in the analysis; complete data were available for 299 people. Descriptive statistics were used to summarize demographics, clinical features, and management recommendations. Characteristics of those who were and were not recommended for surgery were examined using Pearson's chi-square or Fisher's Exact tests.

RESULTS

The majority of 746 participants were classified as "mechanical spine" (92.5%), 2.9% were "other body part," 2.5% were "medical/other," and only 2% were classified as "surgical spine." Recommendations for surgery (by a surgeon) were independent of patients' age, sex, duration of symptoms, residence (urban/rural), source of health care funding, and diagnosis. The surgical yield was 80%.

CONCLUSIONS

Most people were not considered candidates for surgery. Triage assessment by physiotherapists can increase the efficiency of an orthopaedic surgeon's caseload by reducing the number of non-surgical referrals and can thus help to ensure more timely access to appropriate health care.

Undetected pectoralis major tendon rupture in a patient referred to a physical therapist in a combat environment: a case report

BACKGROUND AND PURPOSE

This case report describes a patient who was referred to a physical therapist for treatment of a shoulder strain and was eventually diagnosed with a rupture of the pectoralis major tendon that required surgical repair. The purpose of this case report is to highlight the management of this injury within the unique constraints of a combat environment.

CASE DESCRIPTION

A 29-year-old man, currently serving as an active duty soldier in the U.S. Army in Iraq, had a sudden onset of right shoulder pain during the concentric portion of a bench press. He was seen by a physician immediately after the injury, diagnosed with a shoulder strain, and referred to a physical therapist for a sling and exercise instruction. On the basis of the history and physical examination findings, which were consistent with a pectoralis major tendon rupture, the physical therapist placed a consult to an orthopedic surgeon in the United States through teleconsultation because orthopedic surgeons were not easily accessible in Iraq for nonemergency musculoskeletal referrals. Subsequently, the orthopedic surgeon advised evacuating the patient out of Iraq for surgical treatment.

OUTCOMES

By means of magnetic resonance imaging, the patient was diagnosed as having a rupture of the pectoralis major tendon at the musculotendinous junction near its insertion into the greater tubercle of the humerus that required surgical repair. At 3 months after surgery, the patient had full pain-free shoulder active range of motion and had progressed well through his strengthening program in a manner that allowed return to full duty. At 6 months after surgery, the patient maintained full duty status, was performing a routine of strength training 3 times per week, and had met all of his rehabilitation and personal goals.

DISCUSSION

Successful treatment of this patient depended on analysis of the history and physical examination findings by the physical therapist to form an accurate diagnosis. In addition, timely medical evacuation and referral to an orthopedic surgeon for surgical treatment were coordinated in a combat environment. Completion of a progressive rehabilitation program after pectoralis major tendon repair also contributed to this patient's full recovery and return to duty. Had the physical therapist only followed the initial referral request, given this patient's military duties and sports and recreational activities, this case probably would have resulted in suboptimal outcomes.

The role of U.S. military physical therapists during recent combat campaigns

U.S. military physical therapists have a proud history of providing medical care during operational deployments ranging from war to complex humanitarian emergencies. Regardless of austerity of environment or intensity of hostility, U.S. military physical therapists serve as autonomous providers, evaluating and treating service members with and without physician referral. This perspective article suggests that the versatility of U.S. military physical therapist practice enables them not only to diagnose musculoskeletal injuries but also to provide a wide range of definitive care and rehabilitation, reducing the need for costly evacuation. War is not sport, but the delivery of skilled musculoskeletal physical therapy services as close to the point of injury as possible parallels the sports medicine model for on- or near-field practice. This model that mixes direct access with near-immediate access enhances outcomes, reduces costs, and allows other health care team members to work at the highest levels of their licensure.

Clinical reasoning and advanced practice privileges enable physical therapist point-of-care decisions in the military health care system: 3 clinical cases

BACKGROUND AND PURPOSE

Physical therapists frequently make important point-of-care decisions for musculoskeletal injuries and conditions. In the Military Health System (MHS), these decisions may occur while therapists are deployed in support of combat troops, as well as in a more traditional hospital setting. Proficiency with the musculoskeletal examination, including a fundamental understanding of the diagnostic role of musculoskeletal imaging, is an important competency for physical therapists. The purpose of this article is to present 3 cases managed by physical therapists in unique MHS settings, highlighting relevant challenges and clinical decision making.

CASE DESCRIPTION

Three cases are presented involving conditions where the physical therapist was significantly involved in the diagnosis and clinical management plan. The physical therapist's clinical privileges, including the ability to order appropriate musculoskeletal imaging procedures, were helpful in making clinical decisions that facilitate timely management. The cases involve patients with an ankle sprain and Maisonneuve fracture, a radial head fracture, and a pelvic neoplasm referred through medical channels as knee pain.

OUTCOMES

Clinical pathways from point of care are discussed, as well as the reasoning that led to decisions affecting definitive care for each of these patients. In each case, emergent treatment and important combat evacuation decisions were based on a combination of examination and management decisions.

DISCUSSION

Physical therapists can provide important contributions to the primary management of patients with musculoskeletal conditions in a variety of settings within the MHS. In the cases described, advanced clinical privileges contributed to the success in this role.

A systematic review classifies sources of bias and variation in diagnostic test accuracy studies

OBJECTIVE

To classify the sources of bias and variation and to provide an updated summary of the evidence of the effects of each source of bias and variation.

STUDY DESIGN AND SETTING

We conducted a systematic review of studies of any design with the main objective of addressing bias or variation in the results of diagnostic accuracy studies. We searched MEDLINE, EMBASE, BIOSIS, the Cochrane Methodology Register, and Database of Abstracts of Reviews of Effects (DARE) from 2001 to October 2011. Citation searches based on three key papers were conducted, and studies from our previous review (search to 2001) were eligible. One reviewer extracted data on the study design, objective, sources of bias and/or variation, and results. A second reviewer checked the extraction.

RESULTS

We summarized the number of studies providing evidence of an effect arising from each source of bias and variation on the estimates of sensitivity, specificity, and overall accuracy.

CONCLUSIONS

We found consistent evidence for the effects of case-control design, observer variability, availability of clinical information, reference standard, partial and differential verification bias, demographic features, and disease prevalence and severity. Effects were generally stronger for sensitivity than for specificity. Evidence for other sources of bias and variation was limited.

Validation of an advanced practice physiotherapy model of care in an orthopaedic outpatient clinic

BACKGROUND

In Canada, new models of orthopaedic care involving advanced practice physiotherapists (APP) are being implemented. In these new models, aimed at improving the efficiency of care for patients with musculoskeletal disorders, APPs diagnose, triage and conservatively treat patients. Formal validation of the efficiency and appropriateness of these emerging models is scarce. The purpose of this study is to assess the diagnostic agreement of an APP compared to orthopaedic surgeons as well as to assess treatment concordance, healthcare resource use, and patient satisfaction in this new model.

METHODS

120 patients presenting for an initial consult for hip or knee complaints in an outpatient orthopaedic hospital clinic in Montreal, Canada, were independently assessed by an APP and by one of three participating orthopaedic surgeons. Each health care provider independently diagnosed the patients and provided triage recommendations (conservative or surgical management). Proportion of raw agreement and Cohen's kappa were used to assess inter-rater agreement for diagnosis, triage, treatment recommendations and imaging tests ordered. Chi-Square tests were done in order to compare the type of conservative treatment recommendations made by the APP and the surgeons and Student t-tests to compare patient satisfaction between the two types of care.

RESULTS

The majority of patients assessed were female (54%), mean age was 54.1 years and 91% consulted for a knee complaint. The raw agreement proportion for diagnosis was 88% and diagnostic inter-rater agreement was very high (κ=0.86; 95% CI: 0.80-0.93). The triage recommendations (conservative or surgical management) raw agreement proportion was found to be 88% and inter-rater agreement for triage recommendation was high (κ=0.77; 95% CI: 0.65-0.88). No differences were found between providers with respect to imaging tests ordered (p≥0.05). In terms of conservative treatment recommendations made, the APP gave significantly more education and prescribed more NSAIDs, joint injections, exercises and supervised physiotherapy (p<0.05). Patient satisfaction was significantly higher for APP care than for the surgeons care (p<0.05).

CONCLUSION

The diagnoses and triage recommendations for patients with hip and knee disorders made by the APP were similar to the orthopaedic surgeons. These results provide evidence supporting the APP model for orthopaedic care.

The role of MRI in musculoskeletal practice: a clinical perspective

This clinical perspective presents an overview of current and potential uses for magnetic resonance imaging (MRI) in musculoskeletal practice. Clinical practice guidelines and current evidence for improved outcomes will help providers determine the situations when an MRI is indicated. The advanced competency standard of examination used by physical therapists will be helpful to prevent overuse of musculoskeletal imaging, reduce diagnostic errors, and provide the appropriate clinical context to pathology revealed on MRI. Physical therapists are diagnostically accurate and appropriately conservative in their use of MRI consistent with evidence-based principles of diagnosis and screening.

Advanced practice physiotherapy in patients with musculoskeletal disorders: a systematic review

Background

The convergence of rising health care costs and physician shortages have made health care transformation a priority in many countries resulting in the emergence of new models of care that often involve the extension of the scope of practice for allied health professionals. Physiotherapists in advanced practice/extended scope roles have emerged as key providers in such new models, especially in settings providing services to patients with musculoskeletal disorders. However, evidence of the systematic evaluation of advance physiotherapy practice (APP) models of care is scarce. A systematic review was done to update the evaluation of physiotherapists in APP roles in the management of patients with musculoskeletal disorders.

Methods

Structured literature search was conducted in 3 databases (Medline, Cinahl and Embase) for articles published between 1980 and 2011. Included studies needed to present original quantitative data that addressed the impact or the effect of APP care. A total of 16 studies met all inclusion criteria and were included. Pairs of raters used four structured quality appraisal methodological tools depending on design of studies to analyse included studies.

Results

Included studies varied in designs and objectives and could be categorized in four areas: diagnostic agreement or accuracy compared to medical providers, treatment effectiveness, economic efficiency or patient satisfaction. There was a wide range in the quality of studies (from 25% to 93%), with only 43% of papers reaching or exceeding a score of 70% on the methodological quality rating scales. Their findings are however consistent and suggest that APP care may be as (or more) beneficial than usual care by physicians for patients with musculoskeletal disorders, in terms of diagnostic accuracy, treatment effectiveness, use of healthcare resources, economic costs and patient satisfaction.

Conclusions

The emerging evidence suggests that physiotherapists in APP roles provide equal or better usual care in comparison to physicians in terms of diagnostic accuracy, treatment effectiveness, use of healthcare resources, economic costs and patient satisfaction. There is a need for more methodologically sound studies to evaluate the effectiveness APP care.

Physiotherapists in emergency departments: responsibilities, accountability and education

Emergency physiotherapy roles have evolved within the UK and are increasingly being adopted in Australia in response to a need for greater workforce flexibility and improved service provision to meet growing patient demand. This paper discusses the need for the physiotherapy profession to develop evidence-based regulatory, ethical and educative frameworks to keep pace with the changing clinical environment and service delivery in emergency departments. Definitions of Emergency Physiotherapy as either advanced practice or extended scope of practice are identified, and the implications for both regulation of practice and education are highlighted. Suggestions for education in areas of clinical skills, ethical understanding and legal and professional knowledge are highlighted as important areas to support physiotherapists moving into this area of practice.

A comparison of health care use for physician-referred and self-referred episodes of outpatient physical therapy

OBJECTIVE

To compare patient profiles and health care use for physician-referred and self-referred episodes of outpatient physical therapy (PT).

DATA SOURCE

Five years (2003-2007) of private health insurance claims data, from a Midwest insurer, on beneficiaries aged 18-64.

STUDY DESIGN

Retrospective analyses of health care use of physician-referred (N = 45,210) and self-referred (N = 17,497) ambulatory PT episodes of care was conducted, adjusting for age, gender, diagnosis, case mix, and year.

DATA COLLECTION/EXTRACTION

Physical therapy episodes began with the physical therapist initial evaluation and ended on the last date of service before 60 days of no further visits. Episodes were classified as physician-referred if the patient had a physician claim from a reasonable referral source in the 30 days before the start of PT.

PRINCIPAL FINDINGS

The self-referred group was slightly younger, but the two groups were very similar in regard to diagnosis and case mix. Self-referred episodes had fewer PT visits (86 percent of physician-referred) and lower allowable amounts ($0.87 for every $1.00), after covariate adjustment, but did not differ in related health care utilization after PT.

CONCLUSIONS

Health care use during PT episodes was lower for those who self-referred, after adjusting for key variables, but did not differ after the PT episode.

Taking responsibility for the early assessment and treatment of patients with musculoskeletal pain: a review and critical analysis

Musculoskeletal pain is common across all populations and costly in terms of impact on the individual and, more generally, on society. In most health-care systems, the first person to see the patient with a musculoskeletal problem such as back pain is the general practitioner, and access to other professionals such as physiotherapists, chiropractors, or osteopaths is still either largely controlled by a traditional medical model of referral or left to self-referral by the patient. In this paper, we examine the arguments for the general practitioner-led model and consider the arguments, and underpinning evidence, for reconsidering who should take responsibility for the early assessment and treatment of patients with musculoskeletal problems.

Direct consumer access to physical therapy in Michigan: challenges to policy adoption

Background. Michigan is 1 of only 4 states that require a physician referral or prescription before a consumer can receive treatment from a physical therapist.Objective. The purpose of the present analysis was to examine why the most recent attempts to pass direct access legislation in Michigan failed.Methods. The Policy Analysis Triangle approach, which considers the relevant actors, processes, and context in which a policy must be considered, was used to analyze legislative efforts to attain direct access in Michigan during the 2001–2002, 2003–2004, and 2005–2006 legislative sessions. Data sources included Michigan House and Senate legislative analyses, literature review, stakeholder position statements, political action committee contributions, and expert opinion.Results. Three successive direct access legislative attempts failed despite an increasing body of evidence supporting direct access and an increasing number of states allowing direct access. Proponents represented a relatively small number of individuals with limited political influence. Opponents represented a larger number of individuals who were able to exert greater political influence through large political action committee contributions and through physician legislators in positions of power who had influence over the bills' dispositions.Conclusions. Several prominent contextual and process-related barriers to policy adoption must be overcome in future attempts at direct access based on the findings from this analysis: (1) a limited constituency supporting direct access with regard to number of individuals and their political influence, (2) a perception that only the physician can independently diagnose and treat patient problems, and (3) legislators in positions of power who oppose a bill [corrected].

Patient and referring health care provider satisfaction with a physiotherapy spinal triage assessment service

PURPOSE

To evaluate participant and referring care provider satisfaction associated with a spinal triage assessment service delivered by physiotherapists in collaboration with orthopedic surgeons.

METHODS

People with low back-related complaints were recruited from those referred to a spinal triage assessment program delivered by physiotherapists. Measures of patient and provider satisfaction were completed at approximately 4 weeks after the assessment. The satisfaction surveys were analyzed quantitatively with descriptive statistics and qualitatively with an inductive thematic approach of open and axial coding.

RESULTS

A total of 108/115 participants completed the posttest satisfaction survey. Sixty-six percent of participants were "very satisfied" with the service and 55% were "very satisfied" with the recommendations that were made. Only 18% of referring care providers completed the satisfaction survey and 90.5% of those were "very satisfied" with the recommendations. Sixty-one participants and 14 care providers provided comments which revealed a diverse range of themes which were coded into positive (ie, understanding the problem, communication, customer service, efficiency, and management direction), negative (ie, lack of detail, time to follow-up, cost) and neutral related to the triage service, and an "other" category unrelated to the service (ie, chronic symptoms, comorbidities, and limited access to health care.)

CONCLUSION

The quantitative results of the participant survey demonstrated very high levels of satisfaction with the service and slightly less satisfaction with the recommendations that were made. Satisfaction of referring care providers with the recommendations and report was also high, but given the low response rate, these results should be interpreted with caution. Qualitative analysis of participant and provider comments revealed a diverse range of themes. These other issues may be important contextual factors that have the potential to impact patient relevant outcomes.

Physical therapist practice and the role of diagnostic imaging

For healthcare providers involved in the management of patients with musculoskeletal disorders, the ability to order diagnostic imaging is a beneficial adjunct to screening for medical referral and differential diagnosis. A trial of conservative treatment, such as physical therapy, is often recommended prior to the use of imaging in many treatment guidelines for the management of musculoskeletal conditions. In the United States, physical therapists are becoming more autonomous and can practice some degree of direct access in 48 states and Washington, DC. Referral for imaging privileges could increase the effectiveness and efficiency of healthcare delivery, particularly in combination with direct access management. This clinical commentary proposes that, given the American Physical Therapy Association's goal to have physical therapists as primary care musculoskeletal specialists of choice, it would be beneficial for physical therapists to have imaging privileges in their practice. The purpose of this commentary is 3-fold: (1) to make a case for the use of imaging privileges by physical therapists, using a historical perspective; (2) to discuss the barriers preventing physical therapists from having this privilege; and (3) to offer suggestions on strategies and guidelines to facilitate the appropriate inclusion of referral for imaging privileges in physical therapist practice. J Orthop Sports Phys Ther 2011;41(11):829-837. doi:10.2519/jospt.2011.3556.

Patients are satisfied with advanced practice physiotherapists in a role traditionally performed by orthopaedic surgeons

PURPOSE

To measure and compare patient satisfaction with follow-up care in advanced practice physiotherapist (APP) and orthopaedic surgeon clinics for patients following total hip or knee replacement.

METHOD

Consecutive patients attending either an APP-led or a surgeon-led review clinic were surveyed using a modified nine-item satisfaction questionnaire based on the Visit-Specific Satisfaction Instrument (VSQ-9). Chi-square analyses were used to examine differences in patient characteristics and type of visit. Independent t-tests were used to examine potential differences in patient satisfaction.

RESULTS

Of the 123 participants, more than half were aged 65 years or older. Chi-squared analyses revealed no significant difference in participant characteristics (gender, age, and overall health status) between the two different types of clinics. There was a significant difference (χ(2) (4)=12.49, p=0.014) in the distribution of the timing of follow-up appointments. There was no significant difference between the groups in mean overall patient satisfaction scores on the modified VSQ-9 (p=0.34) nor in the mean of the sum of the seven items related to the service provider (p=0.85). Satisfaction scores for most of the service-provider items were above 90/100.

CONCLUSION

Patients are highly satisfied with the care provided by APPs in follow-up clinics after joint replacement. Evaluation of the patient perspective is essential to any new role involving a shift in traditional practice boundaries.

Medical screening and evacuation: cauda equina syndrome in a combat zone

STUDY DESIGN

Resident's case problem.

BACKGROUND

Cauda equina syndrome (CES) is a rare, potentially devastating, disorder and is considered a true neurologic emergency. CES often has a rapid clinical progression, making timely recognition and immediate surgical referral essential.

DIAGNOSIS

A 32-year-old male presented to a medical aid station in Iraq with a history of 4 weeks of insidious onset and recent worsening of low back, left buttock, and posterior left thigh pain. He denied symptoms distal to the knee, paresthesias, saddle anesthesia, or bowel and bladder function changes. At the initial examination, the patient was neurologically intact throughout all lumbosacral levels with negative straight-leg raises. He also presented with severely limited lumbar flexion active range of motion, and reduction of symptoms occurred with repeated lumbar extension. At the follow-up visit, 10 days later, he reported a new, sudden onset of saddle anesthesia, constipation, and urinary hesitancy, with physical exam findings of right plantar flexion weakness, absent right ankle reflex, and decreased anal sphincter tone. No advanced medical imaging capabilities were available locally. Due to suspected CES, the patient was medically evacuated to a neurosurgeon and within 48 hours underwent an emergent L4-5 laminectomy/decompression. He returned to full military duty 18 weeks after surgery without back or lower extremity symptoms or neurological deficit.

DISCUSSION

This case demonstrates the importance of continual medical screening for physical therapists throughout the patient management cycle. It further demonstrates the importance of immediate referral to surgical specialists when CES is suspected, as rapid intervention offers the best prognosis for recovery.

LEVEL OF EVIDENCE

Differential diagnosis, level 4. J Orthop Sports Phys Ther 2009;39(7):541-549, Epub 24 February 2009. doi: 10.2519/jospt.2009.2999.

Expanding roles in orthopaedic care: a comparison of physiotherapist and orthopaedic surgeon recommendations for triage

RATIONALE, AIMS AND OBJECTIVES

Innovative service delivery models are emerging using physiotherapists in the assessment and management of patients referred for orthopaedic consultation. The primary objective of this study was to compare the clinical recommendations of specially trained physiotherapists with those of an orthopaedic surgeon on: (1) appropriateness to be seen by an orthopaedic surgeon; and (2) candidacy and willingness to undergo total joint replacement (TJR) for patients with hip or knee problems. A secondary objective was to examine their recommendations for non-surgical management and agreement on clinical diagnosis.

METHODS

Physiotherapists and orthopaedic surgeons independently assessed patients with hip and knee problems referred for consideration for TJR and completed a standardized form on treatment recommendations. Agreement between providers was determined using the kappa coefficient and per cent agreement.

RESULTS

Two physiotherapists and three orthopaedic surgeons participated in the study that included 45 and 17 patients with knee and hip problems respectively. In 91.8% (56/61) of cases, physiotherapists and orthopaedic surgeons agreed on the recommendation of appropriateness for the patient to see a surgeon (kappa 0.69). In discordant cases, the physiotherapists tended to refer for consultation. There was 85.5% (53/62) agreement on whether a patient was a candidate and willing to have TJR (kappa 0.70). The physiotherapists commonly recommended exercise and education for non-surgical patients. Orthopaedic surgeons most commonly referred patients to rehabilitation services.

CONCLUSIONS

Patients with hip or knee pain referred to orthopaedic surgeons can be appropriately referred for orthopaedic consultation by physiotherapists working in extended roles. Further research is required to evaluate the value-added and the most appropriate use of extended role physiotherapists.

Diagnostic and treatment concordance between a physiotherapist and an orthopedic surgeon--a pilot study

Musculoskeletal impairments affect one-third of the adult population, are one of the major contributors to lost time from work, and account for one-third of a general practitioner's caseload. These injuries respond well to physiotherapy, but access can be limited in a publicly funded health care system. Improved access to physiotherapy occurs in a collaborative model of care in orthopedic clinics however the extent to which the patient receives similar diagnoses and treatment recommendations has not been reported. The purpose of this study was to determine diagnostic concordance and accuracy, and treatment concordance between a physiotherapist and orthopedic surgeons. Twenty-five subjects in an orthopedic clinic were assessed by a physiotherapist and an orthopedic surgeon. Diagnosis and treatment recommendations were made by each separately. These were compared for concordance between professionals and diagnostic accuracy. The physiotherapist and the orthopedic surgeon had 90% concordance in diagnoses of knee and shoulder impairments, and 75% accuracy when compared to definitive diagnostic methods. They had 87% agreement in treatment recommendations, however, the physiotherapist gave three treatment recommendations per patient where the surgeon gave two. In a collaborative care context therefore, this study suggests, that physiotherapists have similar diagnostic capabilities to orthopedic surgeons, and they will enhance the conservative treatment options offered to orthopedic patients.

Direct access to physical therapy in the Netherlands: results from the first year in community-based physical therapy

BACKGROUND

In 2006, direct access to physical therapy was introduced in the Netherlands. Before this policy measure, evaluation and treatment by a physical therapist were only possible following referral by a physician.

OBJECTIVE

The objectives of this study were to investigate how many patients use direct access and to establish whether these patients have a different profile than referred patients.

METHODS

Electronic health care data from the National Information Service for Allied Health Care (LiPZ), a nationally representative registration network of 93 Dutch physical therapists working in 43 private practices, were used.

RESULTS

In 2006, 28% of the patients seen by a physical therapist came by direct access. Patients with non-further-specified back problems, patients with nonspecific neck complaints, and higher-educated patients were more likely to refer themselves to a physical therapist, as were patients with health problems lasting for less than 1 month. Younger patients made more use of direct access. In addition, patients with recurring complaints more often referred themselves, as did patients who had received earlier treatment by a physical therapist. Patients with direct access received fewer treatment sessions. Compared with 2005, there was no increase in the number of patients visiting a physical therapist.

LIMITATIONS

Data came only from physical therapists working on general conditions in general practices. Severity of complaints is not reported.

CONCLUSIONS

A large, specific group of patients utilized self-referral, but the total number of patients seen by a physical therapist remained the same. In the future, it is important to evaluate the consequences of direct access, both on quality aspects and on cost-effectiveness.

Decision-making ability of physical therapists: physical therapy intervention or medical referral

BACKGROUND AND PURPOSE

Opponents of direct access to physical therapy argue that physical therapists may overlook serious medical conditions. More information is needed to determine the ability of physical therapists to practice safely in direct-access environments. The purpose of this study was to describe the ability of physical therapists to make decisions about the management of patients in a direct-access environment.

SUBJECTS

Of a random sample of 1,000 members of the Private Practice Section of the American Physical Therapy Association, 394 participated.

METHODS

A survey included 12 hypothetical case scenarios. For each case, participants determined whether they would provide intervention without referral, provide intervention and refer, or refer before intervention. The percentage of correct decisions for each group of scenarios was calculated for each participant, and participants were classified as having made correct decisions for 100% of cases or less for each group. Three sets of logistic regressions were completed to determine the characteristics of the participants in relation to the decision category.

RESULTS

The average percentages of correct decisions were 87%, 88%, and 79% for musculoskeletal, noncritical medical, and critical medical conditions, respectively. Of all participants, approximately 50% made correct decisions for all cases within each group. The odds of making 100% correct decisions if a physical therapist had an orthopedic specialization were 2.23 (95% confidence interval=1.35-3.71) for musculoskeletal conditions and 1.89 (95% confidence interval=1.14-3.15) for critical medical conditions.

DISCUSSION AND CONCLUSION

Physical therapists with an orthopedic specialization were almost twice as likely to make correct decisions for critical medical and musculoskeletal conditions.

Musculoskeletal imaging in physical therapist practice

This article presents an overview of current concepts of evidence-based diagnosis using a variety of imaging modalities for a broad spectrum of musculoskeletal conditions and syndromes. There is limited but increasing evidence that physical therapists appropriately use diagnostic studies in clinical practice. Pathology revealed by diagnostic studies must be viewed in the context of the complete examination, as pathology is common in the asymptomatic population. Special diagnostic challenges are presented by patients with areas of referred pain, multiple injuries or multiple areas of pathology, neoplasms, and infections. Plain film radiographs have been overused in the clinical management of many conditions, including low back pain. Clinical decision rules provide simple evidence-based guidelines for the appropriate use of imaging studies.

Primary care physical therapy practice models

The purpose of this paper is to provide a brief background on the concept of primary care physical therapy, describe 3 existing models of primary care physical therapy, explore their similarities and differences, and discuss the potential implications and opportunities for the profession. The programs at US Army medical facilities, Kaiser Permanente Northern California, and the Department of Veterans Affairs Salt Lake City Health Care System are presented by the author affiliated with each respective program.

Risk determination for patients with direct access to physical therapy in military health care facilities

STUDY DESIGN

Nonexperimental, retrospective, descriptive design.

OBJECTIVES

This study was designed to ascertain whether direct access to physical therapy placed military health care beneficiaries at risk for adverse events related to their management.

BACKGROUND

Military health care beneficiaries have the option at most US military hospitals and clinics to first enter the health care system through physical therapy by direct access, without referral from another privileged health care provider. This level of autonomous practice incurs broad responsibilities and raises concern regarding the delivery of safe, competent, and appropriate patient care administered by physical therapists (PTs) when patients are not first examined and then referred by a physician or other privileged health care provider. While military PTs practice autonomously in a variety of health care settings, they do not work independently within any facility. Military PTs and physicians rely on one another for sharing and collaboration of information regarding patient care and clinical research as warranted. Additionally, military PTs are indirectly supervised by physicians.

METHODS AND MEASURES

To reduce provider bias, a retrospective analysis was performed at 25 military health care sites (6 Army, 11 Navy, and 8 Air Force) on patients seen in physical therapy from October 1999 through January 2003. During this 40-month period, 95 PTs (88 military and 7 civilian) were credentialed to provide care throughout the various medical sites. Descriptive statistics were analyzed for total workload, number of new patients seen with and without referral, documented patient adverse events reported to each facility's Risk Management Office, and any disciplinary or legal action against a physical therapist.

RESULTS

During the 40-month observation period, 472 013 patient visits were recorded. Of these, 112 653 (23.9%) were new patients, with 50 799 (45.1%) of the new patients seen through direct access without physician referral. Throughout the 40-month data collection period, there were no reported adverse events resulting from the PTs' diagnoses or management, regardless of how patients accessed physical therapy services. Additionally, none of the PTs had their credentials or state licenses modified or revoked for disciplinary action. There also had been no litigation cases filed against the US Government involving PTs during the same period.

CONCLUSIONS

The findings from this preliminary study clearly demonstrate that patients seen in military health care facilities are at minimal risk for gross negligent care when evaluated and managed by PTs, with or without physician referral. The significance of these findings with respect to direct access is important for not only our beneficiaries but also our profession and the facilities in which we practice.