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

Biopsychosocial predictors of short-term success among people with low back pain referred to a physiotherapy spinal triage service

BACKGROUND

A spinal triage assessment service may impact a wide range of patient outcomes. Investigating potential predictors of success or improvement may reveal why some people improve and some do not, as well as help to begin to explain potential mechanisms for improvements. The objective of this study was to determine which factors were associated with improved short-term self-reported pain, function, general health status, and satisfaction in people undergoing a spinal triage assessment performed by physiotherapists.

METHODS

Participants with low back-related complaints were recruited from people referred to a spinal triage assessment program (N=115). Participants completed baseline questionnaires covering a range of sociodemographic, clinical, and psychological features. Self-reported measures of pain, function, quality of life, and satisfaction were completed at 4 weeks following the assessment. Determination of "success" was based on minimal important change scores of select outcome measures. Multivariate logistic regression was used to explore potential predictors of success for each outcome.

RESULTS

Despite the complex and chronic presentation of most participants, some reported improvements in outcomes at 4 weeks post assessment with the highest proportion of participants demonstrating improvement (according to the minimal important change scores) in the Medical Outcomes Survey 36-item short-form version 2 physical component summary score (48.6%) and the lowest proportion of participants having improvements in the Numeric Pain Rating Scale (11.5%). A variety of different sociodemographic, psychological, clinical, and other variables were associated with success or improvement in each respective outcome.

CONCLUSION

There may be a potential mechanism of reassurance that occurs during the spinal triage assessment process as those with higher psychological distress (measured by the Fear Avoidance Beliefs Questionnaire and the Distress and Risk Assessment Measure) were more likely to improve on certain outcomes. The use of an evaluation framework guided by a biopsychosocial model may help determine potential mechanisms of action for a physiotherapy-delivered triage program.

The Queensland Health Ministerial Taskforce on health practitioners’ expanded scope of practice: consultation findings

Objective Queensland Health established a Ministerial Taskforce to consult on and make recommendations for the expansion of the scope of practice of allied health roles. This paper describes the findings from the stakeholder consultation. Methods The Ministerial Taskforce was chaired by the Assistant Minister for Health and included high-level representation from allied health, nursing, medicine, unions, consumers and universities. Widespread engagement was undertaken with stakeholders representing staff from a wide cross-section of health service provision, training and unions. Participants also tendered evidence of models incorporating full-scope and extended scope tasks undertaken by allied health professionals. Results The consultation incorporated 444 written submissions and verbal feedback from over 200 participants. The findings suggest that full scope of practice is often restricted within the Queensland public health system, resulting in underuse of allied health capacity and workforce inefficiencies. However, numerous opportunities exist to enhance patient care by extending current roles, including prescribing and administering medications, requesting investigations, conducting procedures and reporting results. The support needed to realise these opportunities includes: designing patient-centred models of service delivery (including better hours of operation and delegation to support staff); leadership and culture change; funding incentives; appropriate education and training; and clarifying responsibility, accountability and liability for outcomes. The taskforce developed a series of recommendations and an implementation strategy to operationalise the changes. Conclusions The Ministerial Taskforce was an effective and efficient process for capturing broad-based engagement for workforce change while ensuring high-level support and involving potential adversaries in the decision-making processes. What is known about the topic? Anecdotal evidence exists to suggest that allied health professionals do not work to their full scope of practice and there is potential to enhance health service efficiencies by ensuring practitioners are supported to work to their full scope of practice. What does this paper add? This paper presents the findings from a large-scale consultation, endorsed by the highest level of state government, that reinforces the perceptions that allied health professionals do not work to full scope of practice, identifies several barriers to working to full scope and extended scope of practice, and opportunities for workforce efficiencies arising from expanding scope of practice. The top-down engagement process should expedite the implementation of workforce change. What are the implications for practitioners? High-level engagement and support is an effective and efficient way to broker change and overcome intraprofessional barriers to workforce change policies. However, practitioners are often prevented from expanding their roles through an implied need to ‘ask for permission’, when, in fact, the only barriers to extending their role are culture and historical practice.

Advanced musculoskeletal physiotherapy clinical education framework supporting an emerging new workforce

Objective A project, funded by the Department of Health and Human Services, was conducted with the aim of developing a clinical education framework that included an agreed competency standard and credentialing process to support advanced musculoskeletal physiotherapy roles. This paper describes the process undertaken to achieve this and presents the outcomes of implementation. Methods A multistep approach was taken. Initial steps included conducting a scoping review of the literature and focus groups of advanced musculoskeletal physiotherapists. The project team mapped out the structure of the framework. This was followed by a working party of subject matter experts developing an agreed competency standard. The framework was implemented at six hospitals across Australia and formally evaluated by an external evaluator. Results The clinical education framework developed includes a competency-based training and assessment program supported by learning resources and a mentoring program. It was successfully implemented across a diverse range of hospitals and received a positive evaluation. Conclusions As the prevalence of musculoskeletal conditions increases, a new workforce of advanced musculoskeletal physiotherapists is emerging. A clinical education framework has been developed to address the specific needs of the population, organisations and experienced musculoskeletal physiotherapists recruited to these roles. A competent workforce has direct benefits for the community, healthcare organisations and the physiotherapy profession. What is known about the topic? The uptake and development of advanced musculoskeletal physiotherapy services have increased significantly and are now commonplace in many public hospitals across Australia. There is a need to ensure that physiotherapists working in these roles are suitably educated, trained and competent to perform these expanded roles. Although there has been some work undertaken in this area in the UK, there has been no consistent approach applied with respect to experience, clinical education, training and competency attainment to undertake these roles in Australia. What does this paper add? This paper introduces a clinical education framework and describes the method undertaken to develop and implement a competency standard and credentialing process to support physiotherapists undertaking advanced musculoskeletal physiotherapy services roles. The clinical education framework was developed collaboratively with experienced clinicians across a range of health services and advanced musculoskeletal physiotherapy roles, ensuring a consistent but flexible approach for the wider implementation of advanced musculoskeletal physiotherapy roles. What are the implications for practitioners? The clinical education framework provides a comprehensive, consistent and clearly articulated pathway to support physiotherapists undertaking various advanced musculoskeletal physiotherapy roles. The model uses adult learning principles and provides a standard approach for education and assessment. The model is designed to be flexible and adaptable to support the local context, as well as emerging areas of advanced practice.

Extended roles for allied health professionals: an updated systematic review of the evidence

Background

Internationally, health care services are under increasing pressure to provide high quality, accessible, timely interventions to an ever increasing aging population, with finite resources. Extended scope roles for allied health professionals is one strategy that could be undertaken by health care services to meet this demand. This review builds upon an earlier paper published in 2006 on the evidence relating to the impact extended scope roles have on health care services.

Methods

A systematic review of the literature focused on extended scope roles in three allied health professional groups, ie, physiotherapy, occupational therapy, and speech pathology, was conducted. The search strategy mirrored an earlier systematic review methodology and was designed to include articles from 2005 onwards. All peer-reviewed published papers with evidence relating to effects on patients, other professionals, or the health service were included. All papers were critically appraised prior to data extraction.

Results

A total of 1,000 articles were identified by the search strategy; 254 articles were screened for relevance and 21 progressed to data extraction for inclusion in the systematic review.

Conclusion

Literature supporting extended scope roles exists; however, despite the earlier review calling for more robust evaluations regarding the impact on patient outcomes, cost-effectiveness, training requirements, niche identification, or sustainability, there appears to be limited research reported on the topic in the last 7 years. The evidence available suggests that extended scope practice allied health practitioners could be a cost-effective and consumer-accepted investment that health services can make to improve patient outcomes.

Physiotherapy triage assessment of patients referred for orthopaedic consultation - Long-term follow-up of health-related quality of life, pain-related disability and sick leave

INTRODUCTION

The literature indicates that physiotherapy triage assessment can be efficient for patients referred for orthopaedic consultation, however long-term follow up of patient reported outcome measures are not available.

AIM

To report a long-term evaluation of patient-reported health-related quality of life, pain-related disability, and sick leave after a physiotherapy triage assessment of patients referred for orthopaedic consultation compared with standard practice.

METHODS

Patients referred for orthopaedic consultation (n = 208) were randomised to physiotherapy triage assessment or standard practice. The randomised cohort was analysed on an intention-to-treat (ITT) basis. The patient reported outcome measures EuroQol VAS (self-reported health-state), EuroQol 5D-3L (EQ-5D) and Pain Disability Index (PDI) were assessed at baseline and after 3, 6 and 12 months. EQ VAS was analysed using a repeated measure ANOVA. PDI and EQ-5D were analysed using a marginal logistic regression model. Sick leave was analysed for the 12 months following consultation using a Mann-Whitney U-test.

RESULTS

The patients rated a significantly better health-state at 3 after physiotherapy triage assessment [mean difference -5.7 (95% CI -11.1; -0.2); p = 0.04]. There were no other statistically significant differences in perceived health-related quality of life or pain related disability between the groups at any of the follow-ups, or sick leave.

CONCLUSION

This study reports that the long-term follow up of the patient related outcome measures health-related quality of life, pain-related disability and sick leave after physiotherapy triage assessment did not differ from standard practice, indicating the possible benefits of implementation of this model of care.

Orthopaedic triage: cost effectiveness, diagnostic/surgical and management rates

Purpose

– The purpose of this paper is to investigate cost effectiveness, diagnostic rates, surgical percentage and appropriateness for orthopaedic referrals and number of patients able to be seen in orthopaedic triage from GP orthopaedic referrals.

Design/methodology/approach

– The study involved triaging paper referrals for orthopaedic outpatients to an interface service, orthotics or continue normal route. Data were collected on outcome of the interface appointment and outcomes for those patients referred to orthopaedics from the appointment.

Findings

– The study demonstrated a 27.3 per cent cost saving from the normal orthopaedic route with 86.1 per cent of patients able to be managed by an extended scope physiotherapist (ESP) without requiring orthopaedic assessment. Appropriateness of onward orthopaedic referrals was 80.5 per cent with surgery conversion rate of 75 per cent.

Originality/value

– Although triage and ESP positions have been studied before, this is the first known study to look at cost effectiveness across the patient pathway despite this being a large reason for the creation of these positions. Further larger studies are required to build upon this base in terms of demonstrating the cost effectiveness of the value of these positions.

Assessment of the level of agreement in the interpretation of plain radiographs of lumbar spondylosis among clinical physiotherapists in Ghana

BACKGROUND

Objective physical assessment of patients with lumbar spondylosis involves plain film radiographs (PFR) viewing and interpretation by the radiologists. Physiotherapists also routinely assess PFR within the scope of their practice. However, studies appraising the level of agreement of physiotherapists' PFR interpretation with radiologists are not common in Ghana.

METHOD

Forty-one (41) physiotherapists took part in the cross-sectional survey. An assessment guide was developed from findings of the interpretation of three PFR of patients with lumbar spondylosis by a radiologist. The three PFR were selected from a pool of different radiographs based on clarity, common visible pathological features, coverage body segments and short post production period. Physiotherapists were required to view the same PFR after which they were assessed with the assessment guide according to the number of features identified correctly or incorrectly. The score range on the assessment form was 0-24, interpreted as follow: 0-8 points (low), 9-16 points (moderate) and 17-24 points (high) levels of agreement. Data were analyzed using one sample t-test and fisher's exact test at α = 0.05.

RESULTS

The mean score of interpretation for the physiotherapists was 12.7 ± 2.6 points compared to the radiologist's interpretation of 24 points (assessment guide). The physiotherapists' levels were found to be significantly associated with their academic qualification (p = 0.006) and sex (p = 0.001). However, their levels of agreement were not significantly associated with their age group (p = 0.098), work settings (p = 0.171), experience (p = 0.666), preferred PFR view (p = 0.088) and continuing education (p = 0.069).

CONCLUSIONS

The physiotherapists' skills fall short of expectation for interpreting PFR of patients with lumbar spondylosis. The levels of agreement with radiologist's interpretation have no link with year of clinial practice, age, work settings and continuing education. Thus, routine PFR viewing techniques should be made a priority in physiotherapists' continuing professional education.

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.

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.

System integration and clinical utilization of the Advanced Clinician Practitioner in Arthritis Care (ACPAC) Program-Trained Extended Role Practitioners in Ontario: a two-year, system-level evaluation

BACKGROUND

The Advanced Clinician Practitioner in Arthritis Care (ACPAC) program was developed in 2005 to prepare experienced physical and occupational therapists to function as extended role practitioners (ERPs) within models of arthritis care across Ontario, Canada.

PURPOSE

To examine the system-level integration and clinical utilization of the ACPAC program-trained ERP.

METHOD

A longitudinal survey was administered to all ACPAC graduates over a two-year period (n=30).

RESULTS

The majority of ERPs were physical therapists working in urban settings. Family physicians or physician specialists referred the majority of patients. The longest median wait time to access ERPs' services was 22 days. Half of the ERPs triaged patients, and most of those who did triage (75%) worked under medical directives. Approximately half (51.6%) of the patients seen had a diagnosis of osteoarthritis, followed by rheumatoid arthritis (14.7%).

CONCLUSION

Understanding the system-level impact of this unique human resource can help to shape healthcare planning and delivery of care.

The role of clinical specialist physiotherapists in the management of low back pain in a spinal triage clinic

BACKGROUND

Traditional care pathways for patients with low back pain (LBP) where general practitioners (GPs) refer to consultant specialists can lead to excessive waiting times for patients and questionable use of health care resources. The evaluation of more cost effective pathways is a priority.

AIMS

The study aims to determine if clinical specialist physiotherapists can allocate patients into the three distinct diagnostic triage categories in line with international guidelines. A secondary aim is to examine the utility of baseline domains to inform clinical decision making.

METHODS

A review of LBP patients (n = 1,532) consecutively referred between 2008 and 2010 to a physiotherapy led spinal triage clinic was undertaken. Baseline demographics, pain severity (Visual Analogue Scale), disability (Roland Morris Disability Questionnaire), distress (Distress and Risk Assessment Method), mobility and function were assessed. Relationships between these factors were analysed.

RESULTS

Eighty-five percent of the population were deemed suitable for conservative management and were referred for either group exercise intervention (n = 1,125, 73 %) or individual treatment (n = 178, 12 %), in line with clinical guidelines. Fourteen percent were discharged and only 1 % required a specialist opinion. Patients allocated to the three management streams could be clearly discriminated by baseline measures of pain, distress, disability and function (p < 0.01).

CONCLUSION

Clinical Specialist physiotherapists are effective in assessing and selecting appropriate care pathways for LBP patients in line with international LBP clinical guidelines. The utility of the physical and psychological measures to differentiate between groups of varying clinical severity has important implications for treatment selection and management.