Advanced practice physiotherapists can diagnose and triage patients with musculoskeletal disorders while providing effective care: a systematic review

The educational pathway to Advanced Practice for the physiotherapist: A systematic mixed studies review

BACKGROUND

Advanced Practice Physiotherapy (APP) is a higher level of practice grounded in 4 pillars: clinical practice, leadership, education and research. A critical step toward successful integration and sustainability of APP in healthcare systems is understanding the educational pathway to APP.

OBJECTIVES

1) To describe the post-licensure educational pathways that physiotherapists engage in to advance their level of practice. 2) To evaluate demonstration of the pillars of APP by the physiotherapist after traversing a post-licensure educational pathway.

METHODS

This systematic mixed studies review is reported in accordance with PRISMA and pre-registered (PROSPERO: CRD42024499563). 8 databases plus the grey literature were searched. 2 independent reviewers determined eligibility, extracted data, assessed quality (QuADS) and determined the overall confidence in the cumulative evidence (GRADE-CERQual).

RESULTS

81 studies (18 qualitative, 17 mixed methods, 46 quantitative) were included in a data based convergent qualitative synthesis. 6 distinct post-licensure educational pathways were described and evaluated: Masters level education, residency and fellowship programs, accredited area of practice education, mentorship, multiple encounter courses and single encounter courses.

CONCLUSION

There is a high level of confidence (GRADE-CERQual) in the finding that Masters level education consistently resulted in all 4 pillars demonstrated by the physiotherapist. Masters level education appears to be the optimal pathway to APP.

Physiotherapist managers views on advanced practice physiotherapy in Ireland. A qualitative study

INTRODUCTION

The introduction of physiotherapists working with advanced scope of practice has contributed to improvements in healthcare services.

OBJECTIVE

This qualitative study explores the views of physiotherapist managers on the Advanced Practice Physiotherapy role and the barriers and enablers to progression of this career pathway.

METHODS

A qualitative focus group study was conducted online with 10 purposefully sampled physiotherapist managers. The focus groups were audio-recorded, transcribed and thematically analyzed.

RESULTS

Three main themes were identified; 1) Physiotherapists working in advanced practice are recognized as experts and strong advocates for the physiotherapy profession; 2) Barriers to Advanced Practice Physiotherapy in Ireland include inconsistent role definition and protection, a lack of legislation and uncertainty concerning clinical governance; and 3) Physiotherapist managers can support Advanced Practice Physiotherapy through mentoring and resource provision, and implementation of the Advanced Practice Competency Framework.

CONCLUSION

Physiotherapist managers recognized the value of Advanced Practice Physiotherapy to the Irish health service but suggest that the role and reporting structures need to be clarified. They highlighted barriers preventing the full potential of this these roles being realized and provided suggestions to support the progression of this healthcare model.

Patients' Experience With Evaluation by Both a Musculoskeletal Physician and Physical Therapist in the Same Digital Visit: Survey Study

Background

Patients undergoing evaluation for musculoskeletal concerns are often seen by a physician and physical therapist in the in-person setting in a sequential manner. This process typically delays the onset of nonoperative care, inclusive of physical therapy, and creates the risk of inadequate clinical collaboration between physician and physical therapist. To address these issues, we designed a novel initial patient evaluation to a group visit in which both a specialty-trained musculoskeletal physician and physical therapist simultaneously evaluate a patient together in the digital encounter.

Objective

The aim of the study is to gain insights from patients on their experience with this innovative digital simultaneous musculoskeletal medical doctor and physical therapist (MD+PT) visit format for the initial evaluation of musculoskeletal concerns.

Methods

An electronic 7-question survey was sent to 750 patients who completed an MD+PT visit asking them to comment on prior musculoskeletal evaluations and their experience with the MD+PT format.

Results

In total, 195 (26%) patients responded to the survey with the frequent body regions of diagnosis being lumbar spine (n=65), knee (n=32), shoulder (n=21), cervical spine (n=20), hip (n=14), and hand (n=11). Most patients had prior musculoskeletal experience with a physician or nurse practitioner (171/195, 87.7%) or physical therapist (148/195, 75.9%) with nearly all such encounters in the in-person setting (161/171,94.2% for physician or nurse practitioner and 144/148, 97.3% for physical therapy). Only 3.1% (6/193) of patients reported seeing both a physician and physical therapist during the same in-person visit. Patients rated the simultaneous MD+PT visit very favorably: this type of digital evaluation saved them time (179/192, 93.2%) and permitted them to promptly start their treatment plan (174/192, 90.6%). Overall, 87.5% (168/192) rated the MD+PT visit as enjoyable, and 92.2% (177/192) responded that it increased their confidence with understanding their medical condition and how to start treating it.

Conclusions

Our early experience with the evaluation of patients with musculoskeletal conditions by both a specialty-trained musculoskeletal physician and physical therapist simultaneously in the same digital visit resulted in patients reporting a very positive experience with high satisfaction, engagement, and confidence in understanding their diagnosis and how to start treating it.

Diagnostic Concordance Between Physiotherapist and Emergency Physicians for Patients With a Musculoskeletal Disorder in the Emergency Department

BACKGROUND

Many patients present to the emergency department (ED) with a musculoskeletal disorder. In consequence, some hospitals have integrated autonomous management of musculoskeletal disorders by physiotherapists after triage. Although potential benefits were demonstrated, few studies have examined the agreement between physiotherapists' and emergency physicians' diagnosis. A better understanding of diagnostic concordance between physiotherapists and emergency physicians could inform the implementation of this care model.

METHODS AND FINDINGS

Secondary analysis of data obtained through a pilot pragmatic randomised clinical trial. Data from patients presenting a minor musculoskeletal disorder managed by a physiotherapist and an emergency physician were used. Diagnostic concordance was examined using raw agreement and Gwet's first-order agreement coefficient. Thirty-six participants were assessed by both professionals (36.8 ± 18.2 years; W: 55.6%). Overall raw agreement was 86.1% and the diagnostic concordance was almost perfect (Gwet's AC1: 0.84, 95% CI: 0.69-0.98). The most common disagreement was when physiotherapists suspected a bone fracture or contusion, whereas emergency physicians diagnosed a ligament or meniscus disorder.

CONCLUSIONS

Our results show excellent diagnostic concordance between physiotherapists and emergency physicians, thus supporting the safety of physiotherapy care in the ED. More studies are needed to confirm these results with a larger variety of diagnoses and age strata.

Physiotherapists as first-contact practitioners for patients with low back pain in French primary care: a pragmatic cluster randomised controlled trial

BACKGROUND

A new model of care enables French physiotherapists (PT) working in collaboration with family physicians (FP) to expand their usual scope of practice for patients with acute low back pain (LBP). The aim of our study is to evaluate the impact of this new first-contact physiotherapy (FCP) advanced practice model compared to usual FP care.

METHODS

A multicentre pragmatic non-inferiority cluster randomised controlled trial (RCT) has been conducted in six multidisciplinary primary healthcare centres in France. Patients from 20 to 55 years old with acute LBP consulted either the PT or the FP. PT independently assessed and managed patients including medication prescription. The primary outcome measure was disability at six weeks (Roland Morris Disability Questionnaire, range 0-24). Secondary outcomes include pain, risk disability prognosis, satisfaction with care, healthcare resources use and wait times. Data were collected at baseline, six and twelve weeks. Outcomes across arms were compared using mixed models regression analysis. Except for non-inferiority analysis of the primary outcome measure, other analyses were performed with a two-sided significance level of 0.05.

RESULTS

Sixty patients were recruited (PT: 32, FP: 28). The adjusted mean difference between groups for disability at 6 weeks was 0.39 in favour of the FP group (95%CI: -2.03; 2.81, p = 0.753). Considering a 5 points minimal clinically important difference, the FCP-led model of care was not inferior to usual FP care for the primary outcome. There was no statistically significant difference between groups in disability at 3 months and pain at 6 weeks and 3 months. PTs prescribed significantly less medications than FPs (p < 0.001). No statistically significant difference was found for other healthcare resource use outcomes, patients' satisfaction and wait times.

CONCLUSION

This is the first RCT to evaluate the impact of a FCP advanced practice model of care including medical delegated acts in a primary care setting. Our results suggest that the FCP-led model of care is not inferior to usual FP care regarding disability at 6 weeks. The FCP model could result in possible benefits in terms of healthcare resources use. Further adequate powered studies with larger sample size are needed to draw stronger conclusions.

TRIAL REGISTRATION

The study has been registered in ClinicalTrials.gov (NCT05200533) on the 20th of January 2022.

Is One Enough? The Effectiveness of a Single Session of Education and Exercise Compared to Multiple Sessions of a Multimodal Physiotherapy Intervention for Adults With Spinal Disorders in an Advanced Practice Physiotherapy Model of Care: A Randomized Controlled Trial

OBJECTIVE: To assess the effectiveness of a single session of education and exercise compared with multiple sessions of a multimodal physiotherapy intervention for adults with spinal disorders in an advanced practice physiotherapy specialized spine model of care. DESIGN: Pragmatic randomized controlled trial. METHODS: We randomized patients with spinal disorders, who were referred for a spinal surgery consultation and triaged as nonsurgical cases by an advanced practice physiotherapist, to a single session of education and prescription of an exercise program (n = 52) or multiple sessions (6 in total) of a multimodal physiotherapy intervention (n = 54). The primary outcomes were the short form Brief Pain Inventory pain severity scale (BPI-S) and the Brief Pain Inventory pain interference scale (BPI-I), and secondary outcomes included disability, quality of life, catastrophization, and satisfaction. Linear mixed models were used to assess differences between groups across time points at 6, 12, and 26 weeks. RESULTS: There were no significant between-group differences on the BPI-S and only a significant improvement at 6 weeks on the BPI-I in the multiple-session group (mean difference: -0.96/10; 95% CI, -1.87 to -0.05). There were no other statistically significant differences between groups, except for satisfaction where participants in the multiple-session group reported statistically significantly greater satisfaction on the 9-item Visit-Specific Satisfaction Questionnaire and the MedRisk questionnaire. Both groups saw significant improvements over time on all outcomes except for the BPI-S. CONCLUSION: Adding supervised multimodal physiotherapy sessions did not result in better clinical outcomes when compared to a single session of education and exercise. Patients were more satisfied with the multiple-session approach. J Orthop Sports Phys Ther 2024;54(10):1-13. Epub 9 September 2024. doi:10.2519/jospt.2024.12618.

The educational pathway to Advanced Practice for the physiotherapist: Protocol for a systematic mixed studies review

RATIONALE

Advanced Practice Physiotherapy (APP) is a post-licensure higher level of practice that requires distinctly increased skills, clinical reasoning and experience. The four pillars that underpin APP are clinical practice, leadership, education and research. Multiple systematic reviews support that APP is beneficial to health care systems. While APP exists in over a dozen countries, it has yet to reach international recognition. A steppingstone in gaining global acknowledgement is understanding the educational pathway that physiotherapists traverse to become Advanced Practitioners. No systematic review has synthesized evidence to describe and evaluate the educational pathway for physiotherapists to APP. Therefore, the objectives of this review are 1) to describe the post-licensure educational pathways that physiotherapists engage in to advance their level of practice, 2) to evaluate the pillars of APP demonstrated by the physiotherapist after traversing a post-licensure educational pathway.

MATERIALS AND METHODS

A systematic mixed studies review using a data based convergent qualitative synthesis design will be conducted. MEDLINE (Ovid), Embase, CINAHL, the Cochrane Library, Web of Science, PEDro, SportDiscus, ProQuest Education databases as well as the grey literature will be searched from inception to 02/29/2024. Studies that aim to describe and or evaluate the capacity of educational pathways to influence the level of practice of the physiotherapist will be included. Two independent reviewers will screen studies, extract data and assess methodological quality (Quality Assessment of Diverse Studies). Quantitative data will be 'qualitized', and all data will be synthesized via a clustered textual description and directed content analysis. After synthesis, two reviewers will assess confidence in the cumulative evidence (GRADE-CERQual), which will inform the discussion.

IMPLICATIONS

The optimal pathway(s) to Advanced Practice for the physiotherapist will be evaluated to inform future high-quality research investigating the effectiveness of post-licensure education in developing Advanced Practice physiotherapists.

Investigating the Use of Telemedicine by Health Care Providers to Diagnose and Manage Patients With Musculoskeletal Disorders: Systematic Review and Meta-Analysis

BACKGROUND

Access to care is a major challenge for patients with musculoskeletal disorders (MSKDs). Telemedicine is one of the solutions to improve access to care. However, initial remote diagnosis of MSKDs involves some challenges, such as the impossibility of touching the patient during the physical examination, which makes it more complex to obtain a valid diagnosis. No meta-analysis has been performed to date to synthesize evidence regarding the initial assessment including a physical evaluation using telemedicine to diagnose patients with MSKDs.

OBJECTIVE

This study aims to appraise the evidence on diagnostic and treatment plan concordance between remote assessment using synchronous or asynchronous forms of telemedicine and usual in-person assessment for the initial evaluation of various MSKDs.

METHODS

An electronic search was conducted up to August 2023 using terms related to telemedicine and assessment of MSKDs. Methodological quality of studies was assessed with the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Random-effect model meta-analyses were performed. The Grading of Recommendations, Assessment, Development, and Evaluations framework was used to synthesize the quality and certainty of the evidence.

RESULTS

A total of 23 concordance studies were eligible and included adult participants (N=1493) with various MSKDs. On the basis of high certainty, pooled κ and prevalence-adjusted and bias-adjusted κ for the diagnostic concordance between remote and in-person assessments of MSKDs were 0.80 (95% CI 0.72-0.89; 7 studies, 353 patients) and 0.83 (95% CI 0.76-0.89; 6 studies, 306 patients). On the basis of moderate certainty, pooled Gwet AC1 for treatment plan concordance between remote and in-person assessments of MSKDs was 0.90 (95% CI 0.80-0.99; 2 studies, 142 patients).

CONCLUSIONS

The diagnostic concordance for MSKDs is good to very good. Treatment plan concordance is probably good to excellent. Studies evaluating the accuracy to detect red and yellow flags as well as the potential increase in associated health care resources use, such as imaging tests, are needed.

Developing and embedding an advanced practice musculoskeletal physiotherapy service in public specialist outpatient services in Queensland: A health service masterclass

INTRODUCTION

The Musculoskeletal Physiotherapy Screening Clinic and Multi-disciplinary Service (MPSC&MDS) is an advanced practice physiotherapist-led model of care developed initially to address overburdened specialist orthopaedic outpatient public hospital services across Queensland, Australia.

PURPOSE

This Masterclass explores the experiences and success of embedding the MPSC&MDS state-wide across the Queensland public health system and its expansion in scale and reach to other specialist services. Key characteristics and development strategies are described that have collectively underpinned the expansion and sustainability of the service, using relevant stream sections and themes from a recommended musculoskeletal model of care framework.

IMPLICATIONS

The aim of this masterclass is to be informative for readers involved in the future development or refinement of similar models of care.