A randomised controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments

Cost-Effectiveness of Treatments for Musculoskeletal Conditions Offered by Physiotherapists: A Systematic Review of Trial-Based Evaluations

BACKGROUND

Musculoskeletal conditions are a leading contributor to disability worldwide. The treatment of these conditions accounts for 7% of health care costs in Germany and is often provided by physiotherapists. Yet, an overview of the cost-effectiveness of treatments for musculoskeletal conditions offered by physiotherapists is missing. This review aims to provide an overview of full economic evaluations of interventions for musculoskeletal conditions offered by physiotherapists.

METHODS

We systematically searched for publications in Medline, EconLit, and NHS-EED. Title and abstracts, followed by full texts were screened independently by two authors. We included trial-based full economic evaluations of physiotherapeutic interventions for patients with musculoskeletal conditions and allowed any control group. We extracted participants' information, the setting, the intervention, and details on the economic analyses. We evaluated the quality of the included articles with the Consensus on Health Economic Criteria checklist.

RESULTS

We identified 5141 eligible publications and included 83 articles. The articles were based on 78 clinical trials. They addressed conditions of the spine (n = 39), the upper limb (n = 8), the lower limb (n = 30), and some other conditions (n = 6). The most investigated conditions were low back pain (n = 25) and knee and hip osteoarthritis (n = 16). The articles involved 69 comparisons between physiotherapeutic interventions (in which we defined primary interventions) and 81 comparisons in which only one intervention was offered by a physiotherapist. Physiotherapeutic interventions compared to those provided by other health professionals were cheaper and more effective in 43% (18/42) of the comparisons. Ten percent (4/42) of the interventions were dominated. The overall quality of the articles was high. However, the description of delivered interventions varied widely and often lacked details. This limited fair treatment comparisons.

CONCLUSIONS

High-quality evidence was found for physiotherapeutic interventions to be cost-effective, but the result depends on the patient group, intervention, and control arm. Treatments of knee and back conditions were primarily investigated, highlighting a need for physiotherapeutic cost-effectiveness analyses of less often investigated joints and conditions. The documentation of provided interventions needs improvement to enable clinicians and stakeholders to fairly compare interventions and ultimately adopt cost-effective treatments.

Reducing wait times and medical costs for patients: the physiotherapy-led Spine Triage and Rehabilitation (STAR) Clinic

The Sengkang General Hospital Orthopaedic Spine Outpatient Service is facing a growing challenge of increasing number of referrals and waiting times, placing a significant burden on the system. Primary care referrals have an average wait time of 61.1 days, with 34.5%f patients waiting longer than 60 days from referral to appointment, to see a spine physician.Back pain is a very common presentation, with the vast majority resolving after conservative management which commonly includes analgesia, physiotherapy and reassurance. Unfortunately, many referrals from primary care involve patients who have yet to explore the avenues of conservative management with 90% of our referrals being managed without surgery. Globally, triage services in Western countries conducted by allied health professionals have shown to be an effective method at addressing the escalating wait times with high satisfaction rates. We have endeavoured to emulate this within our department through the implementation of the Spine Triage and Rehabilitation (STAR) Clinic. The STAR clinic aims to empower physiotherapists with the ability to triage patients into surgical and non-surgical categories with their primary physiotherapy expertise to reduce waiting times and increase outpatient capacity.More than 300 patients were recruited, and their progress was tracked over 13 months under the four Ss of: waiting timeS, cost Savings, Safety and patient Satisfaction. This pilot study has been overwhelmingly positive, with significantly reduced waiting times and high cost savings, without any compromise on patient safety and satisfaction.

Advanced practice physiotherapy surgical triage and management of adults with spinal disorders referred to specialized spine medical care: a retrospective observational study

INTRODUCTION

In this novel advanced practice physiotherapy (APP) model of care, advanced practice physiotherapists (APPTs) assess, triage, and manage adults with spinal disorders to alleviate the growing demands in specialized spine medical care.

OBJECTIVES

To describe this APP model of care, to assess change in disability 3 months after rehabilitation care and to assess surgical triage and diagnostic concordance between APPTs and spine surgeons.

METHODS

In this retrospective observational study, consecutive patients who completed the 3-month follow-up data were analyzed. Sociodemographic, clinical characteristics, and self-reported disabilities including the Oswestry Disability Index (ODI) and Neck Disability Index (NDI) at baseline and 3 months were extracted. Paired t-tests were used to assess changes in disability. Surgical triage and diagnostic concordance between APPTs and surgeons were measured with raw agreement, Cohen's Kappa, and PABAK.

RESULTS

In this model, trained APPTs triaged surgical candidates and provided rehabilitation care including education and exercises to patients with spinal disorders. The APPTs referred only 18/46 participants to spine surgeons. Surgical triage and diagnostic concordance were high with raw agreement of 94% and 89%. At the 3-month follow-up, significant improvements in disability were observed among nonsurgical candidates with back (mean difference (MD): -13.0/100 [95%CI: -19.8 to -6.3], n = 23) or neck disorders (MD: -16.0/100 [95%CI: -29.6 to -2.4], n = 5), but not among surgical candidates referred by APPTs to spine surgeons.

CONCLUSION

In this limited sample, adults with spinal disorders that were initially referred to a spine surgeon by family physicians were effectively assessed, triaged, and managed by an APPT.

A survey of physiotherapist managers in Ireland and their views on the role of Advanced Practice Physiotherapists

BACKGROUND

Within the current context of implementation of an Advanced Practice Grade, the Irish Society of Chartered Physiotherapists commissioned a survey of physiotherapy manager opinions regarding the role of Advanced Practice Physiotherapists.

OBJECTIVES

The aim of this survey was to explore the views of physiotherapist managers in relation to the characteristics, role, competencies and management of Advanced Practice Physiotherapists (APPs) in Ireland.

METHODS

Physiotherapist managers based in primary and secondary care settings in Ireland were invited to participate in a survey on Advanced Practice. Quantitative data from a custom designed online survey was analysed with descriptive statistics and qualitative data from open-ended survey questions were analysed using thematic analysis.

RESULTS

The response rate to the survey was 32% (24/75). On average, respondents thought that 54% (range: 15%-80%) of an APPs time should be spent in clinical practice and between 17% and 20% variously on managerial and leadership, teaching and education and research and development duties. Four themes were identified from the surveys' open-ended questions related to the description of APP: 'Extended scope 'Advanced clinical training, knowledge, and decision-making', 'Autonomy, independence and responsibility', and 'Wider roles'.

CONCLUSION

Irish physiotherapist managers recognised the extended scope of practice, expertise and multiple roles characteristic of APPs. They indicated the need for legislative changes and clarity around governance.

Operative treatment in non-emergency sports injuries: a sports medicine clinic experience

PURPOSE

To elucidate referrals from sports medicine clinic (SMC) to orthopedics, consensus rates among physicians and surgeons on surgical need in these patients, and reasoning of the patients who refused to have surgery despite the recommendations by both groups in non-emergency sports injury patients.

METHODS

We conducted a retrospective cohort analysis by using the administrative and referral records of a sports medicine clinic for the 15 months between October 2017 and January 2019. Gender, age, diagnosis, and type of sport were compared between two groups (patients referred to orthopedics vs patients treated in SMC). Agreement between orthopedics and SMC on surgical need in those patients who were referred to orthopedics was evaluated. We additionally screened the hospital archive for surgery reports of patients recommended surgery, and, if a patient did not have a surgery record, we investigated the reasons by telephone interview and categorized these reasons.

RESULTS

Surgical evaluation needed for 4.7% (n = 155) of the patients. Patients referred to orthopedics were younger (median: 22.0 years), mostly male (n = 119, 76.8%), and involved in contact sports (n = 108, 69.7%) (p < 0.001 for all) compared to patients treated conservatively. Majority of the consultations were made owing to certain diagnoses such as cruciate/collateral ligament sprain (n = 70, 45.2%), meniscal tear (n = 21, 13.5%), and cartilage injuries (n = 15, 9.7%). Most of the patients diagnosed with Achilles tendon rupture (n = 2, 100%) and patellar instability (n = 13, 81.3%) were referred to surgery. Orthopedics agreed with the sports medicine physicians' opinions in most cases (n = 110, 71.0%). Thirty-four patients (30.9%) recommended surgery by the surgeon postponed/refused the treatment for various reasons or had surgery in another hospital.

CONCLUSION

Most non-emergency sports injuries can be treated conservatively. Young and male patients participating in contact sports are more likely to need surgical treatment. Non-surgeon musculoskeletal health-care providers may consider referring patients to orthopedics considering the data demonstrated in this study. Nevertheless, patient's motivation to undergo an operation should be considered before referring to orthopedics.

Private physical therapy practice implementation of direct referral for radiograph imaging: an administrative case report

BACKGROUND

Prior research indicates physical therapists make appropriate, judicious diagnostic imaging referrals, but have not described how to implement imaging referral processes in organizations without an imaging department.

OBJECTIVE

This administrative case report describes the implementation of a direct referral process for radiographic imaging in a private physical therapy practice.

CASE DESCRIPTION

Guided by the Interactive Systems Framework, a collaborative business agreement between a physical therapist-owned practice, musculoskeletal urgent care clinic, and radiology practice provided a clinical process for physical therapists to directly refer patients for radiographic imaging.

OUTCOMES

When clinically appropriate, physical therapists signed referrals for radiographic imaging that was acquired by qualified urgent care clinic staff, interpreted by a radiologist, and reported to the physical therapist. The physical therapist, urgent care clinic, and radiologist bill for the physical therapy evaluation, technical component, and professional component, respectively. In the 5 months following implementation, 5 referrals were acquired within 15 minutes, the interpretation was returned within 30 minutes, and all entities received insurance reimbursement.

CONCLUSION

This clinical process allows the physical therapist to execute clinical decision making within the scope of physical therapist practice, yet expeditiously acquire imaging studies to facilitate appropriate patient care. Formal collaboration between discrete organizations provided a system to deliver the necessary imaging services.

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

QUESTIONS

What is the diagnostic and surgical triage concordance between advanced practice physiotherapists (APPTs) and physicians? What is the clinical efficacy of advanced practice physiotherapy care compared with usual medical care?

DESIGN

Systematic review with meta-analyses.

LITERATURE SEARCH

Medline, Embase, Cochrane CENTRAL and CINAHL were searched up to March 2022.

STUDY SELECTION CRITERIA

Concordance studies on diagnostic or surgical triage between APPTs and physicians and randomised controlled trials comparing the clinical efficacy of an advanced practice physiotherapy (APP) model of care compared with usual medical care for participants with musculoskeletal disorders.

DATA SYNTHESIS

Meta-analyses were performed for concordance and clinical outcomes. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to evaluate the certainty of evidence.

RESULTS

Nineteen concordance studies (n = 1,745) and six randomised trials (n = 1,960) were included. Based on moderate-certainty evidence, the pooled Kappa for diagnostic concordance between APPTs and physicians was 0.76 (95% CI 0.68 to 0.85, n = 1,108). Based on high-certainty evidence, the pooled Kappa for surgical triage concordance was 0.71 (95% CI 0.63 to 0.78, n = 1,128). Based on moderate-certainty evidence, APP care resulted in a comparable or greater reduction in pain (MD -0.92 out of 10, 95% CI -1.75 to -0.10, n = 494) when compared with usual medical care at medium-term follow-up. Based on low-certainty evidence, APP care resulted in a comparable or greater reduction in disability (SMD -0.31, 95% CI -0.67 to 0.04, n = 535) when compared with usual medical care at medium-term follow-up.

CONCLUSION

Concordance between APPTs and physicians is probably good to very good for diagnosis and good to very good for surgical triage of musculoskeletal disorders. Patients with musculoskeletal disorders managed in an APP model of care probably report comparable or greater pain and disability reductions when compared with usual medical care.

REGISTRATION

CRD42022320950.

Effectiveness and Consequences of Direct Access in Physiotherapy: A Systematic Review

Background. Direct access in physiotherapy (DAPT) occurs when a patient has the ability to self-refer to physical therapy without physician referral. This model of care in musculoskeletal diseases (MSDs) has shown better outcomes than the traditional-based medical model of care that requires physician referral to access physiotherapist services. This traditional physician referral often results in a delay in care. Unfortunately, DAPT is still not permitted in many countries. Objectives. The primary objective of this systematic review was to compare the effectiveness, safety, and the accuracy of DAPT compared to the physician-led model of care for the management of patients with musculoskeletal disorders. The secondary objective of the present study is to define the physiotherapists' characteristics or qualifications involved in DAPT. Materials and methods. Databases searched included: Medline, Scopus and Web of Science. Databases were searched from their inception to July 2022. Research strings were developed according to the PICO model of clinical questions (patient, intervention, comparison, and outcome). Free terms or synonyms (e.g., physical therapy; primary health care; direct access; musculoskeletal disease; cost-effectiveness) and when possible MeSH (Medical Subject Headings) terms were used and combined with Boolean operators (AND, OR, NOT). Risk of bias assessment was carried out through Version 2 of the Cochrane risk-of-bias tool (ROB-2) for randomized controlled trials (RCTs) and the Newcastle Ottawa Scale (NOS) for observational studies. Authors conducted a qualitative analysis of the results through narrative analysis and narrative synthesis. The narrative analysis was provided for an extraction of the key concepts and common meanings of the different studies, while the summary narrative provided a textual combination of data. In addition, a quantitative analysis was conducted comparing the analysis of the mean and differences between the means. Results. Twenty-eight articles met the inclusion criteria and were analyzed. Results show that DAPT had a high referral accuracy and a reduction in the rate of return visits. The medical model had a higher use of imaging, drugs, and referral to another specialist. DAPT was found to be more cost-effective than the medical model. DAPT resulted in better work-related outcomes and was superior when considering patient satisfaction. There were no adverse events noted in any of the studies. In regard to health outcomes, there was no difference between models. ROB-2 shows an intermediate risk of bias risk for the RCTs with an average of 6/9 points for the NOS scale for observational studies. Conclusion. DAPT is a safe, less expensive, reliable triage and management model of care that results in higher levels of satisfaction for patients compared to the traditional medical model. Prospero Registration Number: CRD42022349261.

No major difference in perceived quality of care in patients with hip or knee osteoarthritis assessed in a physical therapy-led triage compared with standard care: a randomized controlled trial

BACKGROUND

Physical therapy-led orthopedic triage is a care model used to optimize pathways for patients with hip or knee osteoarthritis. However, scientific evidence of the effectiveness of this model of care is still limited and only a few studies report patients' perception of it. The aim of this study was to compare patients' perceived quality of care after physical therapy-led triage with standard practice in a secondary care setting for patients with primary hip or knee osteoarthritis.

METHODS

In this randomized study, patients with hip or knee osteoarthritis referred for an orthopedic consultation received either physical therapy-led triage (n = 344) or a standard care assessment by an orthopedic surgeon (n = 294). To evaluate the patients' perceived quality of care, a short version of the Quality from the Patient's Perspective (QPP) questionnaire was sent to the patients within a week after their assessment. The primary outcome was the statement "I received the best examination and treatment" on QPP.

RESULTS

A total of 348 patients (70%, physical therapy-led triage: n = 249, standard care: n = 199) answered the questionnaire. No significant difference was found in the primary outcome between the groups (p = 0.6). Participants in the triage group perceived themselves to have received significantly better information about how to take care of their osteoarthritis (p = 0.017) compared with the standard care group. The standard care group reported that they participated in the decision-making process to a greater extent (p = 0.005), that their expectations were met to a greater degree (p = 0.013), and that their care depended more on their need for care rather than the caregivers' routines (0.007).

CONCLUSION

Both groups report high perceived quality of care. Significant differences were found in four of 14 questions, one in favor of the physical therapist and three in favor of the standard care group. The findings of this study are in line with previous research and support the use of this care model for patients with hip or knee OA in secondary care. However, due to the dropout size, the results should be interpreted with caution.

TRIAL REGISTRATION

Clinical Trials NCT04665908, registered 14/12/2020.

Physical therapy students' application of an imaging decision rule for acute knee pain

BACKGROUND

Evidence supports direct referral for imaging by physical therapists. Accuracy and self-efficacy for imaging decisions have not been investigated in entry-level doctor of physical therapy (DPT) students.

OBJECTIVE

The purpose of this study was to understand the relationship between entry-level DPT instruction and accuracy and self-efficacy for imaging referral due to acute knee trauma. A second purpose was to identify relationships between accuracy and self-efficacy.

METHODS

An online survey was sent via e-mail to program directors in accredited DPT programs in the United States with an invitation to forward the survey to DPT students. The survey captured demographic information and included five questions that assessed the respondent's ability to apply the Ottawa Knee Rules (OKR). Self-efficacy was assessed using the Physiotherapist Student Self-Efficacy (PSE) questionnaire, a self-rated 5-point Likert scaled tool.

RESULTS

Of 240 surveys, DPT students who completed imaging coursework had greater accuracy and higher self-efficacy (68.0% correct (95% CI, 63.6-72.5), PSE = 3.67, P < .001) compared to students who had not (45.8% correct (95% CI, 40.8-50.7), PSE = 2.67, P < .001). Conclusion: Accuracy by DPT students who completed imaging coursework was significantly improved and comparable to values from autonomous providers.

Diagnostic Imaging for Distal Extremity Injuries in Direct Access Physical Therapy: An Observational Study

Background

Military physical therapists practicing direct-access routinely utilize diagnostic imaging and numerous published case reports demonstrate the ability of physical therapists to diagnose and appropriately disposition patients with foot/ankle and wrist/hand fractures. However, no larger cohort studies have explored the utilization of diagnostic imaging by physical therapists to detect fractures.

Hypothesis/Purpose

To describe the utilization of diagnostic imaging in foot/ankle and wrist/hand injuries by physical therapists in a direct-access sports physical therapy clinic.

Study Design

Retrospective cohort study.

Methods

The Agfa Impax Client 6 image viewing software (IMPAX) was searched from 2014 to 2018 for patients with diagnostic imaging ordered for foot/ankle and wrist/hand injuries. The Armed Forces Health Longitudinal Technology Application (AHLTA) electronic medical record was independently reviewed by the principal and co-investigator physical therapists. Data extracted were demographics and elements from the patient history and physical examination.

Results

In foot/ankle injuries, physical therapists diagnosed a fracture in 16% of the 177 cases and waited for an average of 3.9 days and 1.3 visits before ordering imaging. In wrist/hand injuries, physical therapists diagnosed a fracture in 24% of the 178 cases and waited for an average of 3.7 days and 1.2 visits before ordering imaging. The time to definitive care from the initial physical therapy evaluation was significantly different (p = 0.04) for foot/ankle fractures (0.6 days) compared to wrist/hand fractures (5.0 days). The Ottawa Ankle Rules demonstrated a negative likelihood ratio (-LR) of 0.11 (0.02, 0.72) and a positive likelihood ratio (+LR) of 1.99 (1.62, 2.44) for the diagnosis of foot/ankle fracture.

Conclusions

Physical therapists utilizing diagnostic imaging in a direct-access sports physical therapy clinic diagnosed fractures in similar proportions for foot/ankle and wrist/hand injuries and quickly dispositioned patients to definitive care for those fractures. The diagnostic accuracy of the Ottawa Ankle Rules was similar to previously reported values.

Level of Evidence

Level 3.

Real-Time Telerehabilitation in Older Adults With Musculoskeletal Conditions: Systematic Review and Meta-analysis

Background

Real-time telerehabilitation (TR) is a new strategy for delivering rehabilitation interventions to older adults with musculoskeletal conditions, to provide continuity to conventional services and mitigate travel-related barriers.

Objective

We aimed to examine the effectiveness of treatment delivered via real-time TR services compared to conventional services among older adults with musculoskeletal conditions, in terms of physical performance, treatment adherence, and cost-effectiveness.

Methods

A literature search of randomized controlled trials (RCTs) published from January 2000 to April 2022 was conducted in six online databases: Cochrane Library, PubMed (ie, MEDLINE), PEDro, ClinicalKey, EBSCO, and ProQuest. The main eligibility criterion for articles was the use of real-time TR among older adults with musculoskeletal conditions to improve physical performance. Two reviewers screened 2108 abstracts and found 10 studies (n=851) that met the eligibility criteria. Quality assessment was based on version 2 of Cochrane’s risk-of-bias tool for RCTs, in order to assess the methodological quality of the selected articles. Results were pooled for meta-analyses, based on the primary outcome measures, and were reported as standardized mean differences (SMDs) with 95% CIs. A fixed model was used, and subgroup analysis was performed to check for possible factors influencing TR’s effectiveness based on different treatments, controls, and outcome measures.

Results

The search and screening process identified 10 papers that collectively reported on three musculoskeletal conditions in older adults and three types of TR programs. Aggregate results suggested that real-time TR, compared to conventional treatment, was more effective at improving physical performance regarding balance (SMD 0.63, 95% CI 0.36-0.9; I²=58.5%). TR was slightly better than usual care at improving range of motion (SMD 0.28, 95% CI 0.1-0.46; I²=0%) and muscle strength (SMD 0.76, 95% CI 0.32-1.2; I²=59.60%), with moderate to large effects. Subgroup analyses suggested that real-time TR had medium to large effects favoring the use of smartphones or tablets (SMD 0.92, 95% CI 0.56-1.29; I²=45.8%), whereas the use of personal computers (SMD 0.25, 95% CI –0.16 to 0.66; I²=0%) had no effect on improving balance and was comparable to conventional treatment.

Conclusions

We found that real-time TR improved physical performance in older adults with musculoskeletal conditions, with an effectiveness level equal to that of conventional face-to-face treatment. Therefore, real-time TR services may constitute an alternative strategy for the delivery of rehabilitation services to older adults with musculoskeletal conditions to improve their physical performance. We also observed that the ideal device for delivering TR is the smartphone. Results suggested that the use of smartphones for TR is driven by ease of use among older adults. We encourage future studies in areas related to rehabilitation in older adults, in addition to examination of physical performance outcomes, to gain additional knowledge about comprehensive care.

Trial Registration

PROSPERO CRD42021287289; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=287289

Agreement between hand therapists and hand surgeons in the management of adults with closed metacarpal fractures

BACKGROUND

Hand therapists often work in roles which require an advanced level of experience as Advanced Scope Practitioners (ASP). However, it is not known whether clinical decisions are similar between hand therapists and surgeons when managing simple hand fractures.

OBJECTIVES

To determine the level of agreement between (i) a hand therapist and five hand surgeons and (ii) three hand therapists, for the management of adults with closed metacarpal fracture(s).

DESIGN

A prospective, blinded, crossover inter-rater reliability study.

METHOD

Patient volunteers with closed metacarpal fracture(s) were assessed independently in the first study (n = 90) by a hand therapist and one of five hand surgeons and in the second study (n = 57) by three hand therapists in a randomised order, with each practitioner recording whether the patient participant should be managed conservatively, trialled with conservative or offered surgical treatment. The level of agreement between the hand therapist and hand surgeons was calculated using Cohen's kappa coefficient and between the three hand therapists by calculating Fleiss' Kappa. The observed agreement was also calculated as the proportion of cases for which the assessors had agreement for management.

RESULTS

There was good agreement between the hand therapist and surgeons (k = 0.68; 95% CI: 0.537-0.831) and amongst the three hand therapists (k = 0.663; 95% CI: 0.554-0.773) in determining the management of adults with closed metacarpal fracture(s).

CONCLUSIONS

Hand therapists and surgeons make similar management decision for patients with metacarpal fractures supporting the role of hand therapists as ASP.

Implementation of a speech and language therapy-led referring model for videofluoroscopic swallow studies: An evaluation of service outcomes

BACKGROUND

Videofluoroscopic swallow studies (VFSS) are integral to diagnosing and supporting dysphagia management. However, in many countries, only doctors are authorized to complete medical imaging request forms, in accordance with radiation safety regulations. This can impact workflow and timely access to VFSS. Enhanced scope of practice (ESP) models of care exist, where speech and language therapists (SLTs) are authorized to complete VFSS request forms. However, formal evaluations of these ESP models are currently lacking.

AIMS

The primary aim of this study was to examine service outcomes regarding the safety and efficiency of SLTs completing VFSS request forms compared with the medical referring model (standard care). The secondary aim was to ascertain the impacts on SLTs' daily workflow and the utility of training for SLTs to complete VFSS requests.

METHODS & PROCEDURES

The study involved a mixed-method design. First, referrals completed using standard care versus those completed under the new SLT-led VFSS referring model were compared for efficiency (days to request completion, number of contacts between staff to complete requests and delay to VFSS appointments) and safety (compliance with radiation safety standards for requests, adverse events and change to dysphagia management to justify radiation exposure). Semi-structured interviews were then conducted with SLT referrers (n = 7) exploring the impacts of the model on daily workflow and the utility of training.

OUTCOMES & RESULTS

VFSS inpatient requests were examined across a 3-month period (n = 61 requests) using the standard model, and for 6 months (n = 109 requests) following the introduction of SLT-led VFSS referring. Regarding efficiency, there was no significant difference between the two models, with most request forms taking less than or equal to 1 day to be completed. Adherence to radiation safety requirements was significantly greater in the SLT-led VFSS referring model compared with the standard model (p < 0.001) in relation to the overall requisite clinical information being documented on the request forms. No adverse events occurred and 100% of VFSSs led to changed dysphagia management. Interviews of VFSS referring SLTs revealed that completing requests was not complex or onerous, and that the training equipped them well to undertake the role.

CONCLUSIONS & IMPLICATIONS

The SLT-led VFSS referring model was feasible for SLTs and resulted in satisfactory efficiency and greater adherence to radiation safety requirements for VFSS request forms than the standard model. Improved information on VFSS request forms provides clearer justification for the radiation procedure and helps optimize the diagnostic yield of VFSS. The evidence supports further widespread adoption of this model.

WHAT THIS PAPER ADDS

What is already known on the subject Models of care permitting selected allied health professionals to refer patients for diagnostic radiology procedures have been established to achieve healthcare efficiencies. Evidence supports the safety and efficiency of physiotherapists referring to radiology. However, limited published outcome data exist regarding models of SLTs referring for radiology procedures, such as VFSS. What this paper adds to existing knowledge This study describes the implementation of a SLT-led VFSS inpatient referring model in a quaternary hospital and examines service outcomes. The findings reveal that VFSS request forms completed in the SLT-led referring model had greater adherence to radiation safety standards compared with the standard referring model. Efficiency was similar across both models and there were no adverse events. Completing VFSS requests did not disrupt daily workflow for SLTs and training was effective preparation for the role. What are the potential or actual clinical implications of this work? Results demonstrate that the SLT-led VFSS referral model can be safely and appropriately implemented in the inpatient setting. Improved quality of information documented on request forms by SLTs increases adherence with radiation safety standards, providing clearer justification for radiation assessments and potentially eliciting more targeted diagnostic information to inform dysphagia treatment planning. These findings may support other hospital services to establish this type of referring model.

Musculoskeletal Imaging for Low Back Pain in Direct Access Physical Therapy Compared to Primary Care: An Observational Study

BACKGROUND

Overutilization of diagnostic imaging is associated with poor outcomes and increased costs. Physical therapists demonstrate the ability to order diagnostic imaging safely and appropriately, and early access to physical therapy reduces unnecessary imaging, lowers healthcare costs, and improves outcomes.

HYPOTHESIS/PURPOSE

The primary purpose of this study was to compare rates of compliance with the National Committee for Quality Assurance - Healthcare Effectiveness Data and Information Set (HEDIS) recommendations for diagnostic imaging in low back pain between physical therapists and primary care providers in young, athletic patients.

STUDY DESIGN

Retrospective cohort study.

METHODS

Military Health System Data Repository (MDR) data from January 2019 to May 2020 was reviewed for compliance with the low back pain HEDIS recommendation. The low back pain imaging HEDIS measure identifies the percentage of patients who did not have an imaging study (plain X-ray, MRI, CT Scan) ordered on the first encounter with a diagnosis of low back pain or in the 28 days following that first diagnosis. Chi-square tests compared HEDIS compliance rates, with α = 0.05 set a priori.

RESULTS

From January 2019 to May 2020, in patients age 18-24, the MDR database identified 1,845 total visits for LBP identified in the Physical Therapy Clinic and 467 total visits for LBP in the Primary Care Clinic. In the Physical Therapy Clinic, 96.7% of encounters did not have imaging ordered within the first 28 days of onset of symptoms, compared with 82.0% in the Primary Care Clinic (p < .001).

CONCLUSIONS

Utilizing data from a national standardized healthcare performance measure, physical therapists practicing in a direct-access setting were significantly more likely than primary care providers to adhere to guidelines for low back pain imaging in young, athletic patients.

LEVEL OF EVIDENCE

Level 3.

Economic evaluation of advanced practice physiotherapy models of care: a systematic review with meta-analyses

Background

The objective of this systematic review is to appraise evidence on the economic evaluations of advanced practice physiotherapy (APP) care compared to usual medical care.

Methods

Systematic searches were conducted up to September 2021 in selected electronic bibliographical databases. Economic evaluation studies on an APP model of care were included. Economic data such as health care costs, patient costs, productivity losses were extracted. Methodological quality of included studies was assessed with the Effective Public Health Practice Project tool and the Critical Appraisal Skills Programme checklist. Meta-analyses were performed and mean differences (MD) in costs per patient were calculated using random-effect inverse variance models. Certainty of the evidence was assessed with the GRADE Approach.

Results

Twelve studies (n = 14,649 participants) including four randomized controlled trials, seven analytical cohort studies and one economic modeling study were included. The clinical settings of APP models of care included primary, emergency and specialized secondary care such as orthopaedics, paediatrics and gynaecology. The majority of the included participants were adults with musculoskeletal disorders (n = 12,915). Based on low quality evidence, health system costs including salaries, diagnostic tests, medications, and follow-up visits were significantly lower with APP care than with usual medical care, at 2 to 12-month follow-up (MD: -139.08 €/patient; 95%CI: -265.93 to -12.23; n = 7648). Based on low quality evidence, patient costs including travel and paid medication prescriptions, or treatments were significantly higher with APP care compared to usual medical care, at 2 to 6-month follow-up (MD: 29.24 €/patient; 95%CI: 0.53 to 57.95 n = 1485). Based on very low quality evidence, no significant differences in productivity losses per patient were reported between both types of care (MD: 590 €/patient; 95%CI: -100 to 1280; n = 819).

Conclusions

This is the first systematic review and meta-analysis on the economic evaluation of APP models of care. Low quality evidence suggests that APP care might result in lower health care costs, but higher patient costs compared to usual medical care. Costs differences may vary depending on various factors such as the cost methodology used and on the clinical setting. More evidence is needed to evaluate cost benefits of APP models of care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07221-6.

Patient gender does not influence referral to an orthopaedic surgeon by advanced practice orthopaedic providers: a prospective observational study in Canada

Background

The role of an advanced practice physiotherapist has been introduced in many countries to improve access to care for patients with hip and knee arthritis. Traditional models of care have shown a gender bias, with women less often referred and recommended for surgery than men. This study sought to understand if patient gender affects access to care in the clinical encounter with the advanced practice provider. Our objectives were: (1) To determine if a gender difference exists in the clinical decision to offer a consultation with a surgeon; (2) To determine if a gender difference exists in patients’ decisions to accept a consultation with a surgeon among those patients to whom it is offered; and, (3) To describe patients’ reasons for not accepting a consultation with a surgeon.

Methods

This was a prospective study of 815 patients presenting to a tertiary care centre for assessment of hip and knee arthritis, with referral onward to an orthopaedic surgeon when indicated. We performed a multiple logistic regression analysis adjusting for severity to address the first objective and a simple logistic regression analysis to answer the second objective. Reasons for not accepting a surgical consultation were obtained by questionnaire.

Results

Eight hundred and fifteen patients (511 women, 304 men) fulfilled study eligibility criteria. There was no difference in the probability of being referred to a surgeon for men and women (difference adjusted for severity = − 0.02, 95% CI: − 0.07, 0.02). Neither was there a difference in the acceptance of a referral for men and women (difference = − 0.05, 95% CI: − 0.09, 0.00). Of the 14 reasons for declining a surgical consultation, 5 showed a difference with more women than men indicating a preference for non-surgical treatment along with fears/concerns about surgery.

Conclusions

There is no strong evidence to suggest there is a difference in proportion of males and females proceeding to surgical consultation in the model of care that utilizes advanced practice orthopaedic providers in triage. This study adds to the evidence that supports the use of suitably trained alternate providers in roles that reduce wait times to care and add value in contexts where health human resources are limited. The care model is a viable strategy to assist in managing the growing backlog in orthopaedic care, recently exacerbated by the COVID-19 pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06965-5.

Single session compared with multiple sessions of education and exercise for older adults with spinal pain in an advanced practice physiotherapy model of care: protocol for a randomised controlled trial

OBJECTIVES

To assess the effectiveness and cost-effectiveness of a single session compared with multiple sessions of education and exercise for older adults with spinal pain treated conservatively in an advanced practice physiotherapy model of care.

METHODS AND ANALYSIS

In this pragmatic randomised controlled trial, 152 older adults (≥65 years old) with neck or back pain initially referred for a consultation in neurosurgery, but treated conservatively, will be recruited through the advanced practice physiotherapy neurosurgery CareAxis programme in the Montreal region (Quebec, Canada). In the CareAxis programme, older patients with spinal pain are triaged by an advance practice physiotherapist and are offered conservative care and only potential surgical candidates are referred to a neurosurgeon. Participants will be randomised into one of two arms: 1-a single session or 2-multiple sessions (6 sessions over 12 weeks) of education and exercise with the advance practice physiotherapist (1:1 ratio). The primary outcome measure will be the Brief Pain Inventory (pain severity and interference subscales). Secondary measures will include self-reported disability (the Neck Disability Index or Oswestry Disability Index), the Pain Catastrophizing Scale, satisfaction with care questionnaires (9-item Visit-specific Satisfaction Questionnaire and MedRisk), and the EQ-5D-5L. Participants' healthcare resources use and related costs will be measured. Outcomes will be collected at baseline and at 6, 12 and 26 weeks after enrolment. Intention-to-treat analyses will be performed, and repeated mixed-model analysis of variance will assess differences between treatment arms. Cost-utility analyses will be conducted from the perspective of the healthcare system.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the Comité d'éthique de la recherche du CIUSS de l'Est-de-l'Île-de-Montréal (FWA00001935 and IRB00002087). Results of this study will be presented to different stakeholders, published in peer-reviewed journals and presented at international conferences.

PROTOCOL VERSION

V.4 August 2021.

TRIAL REGISTRATION NUMBER

NCT04868591; Pre-results.

Cross-sectional UK survey of advanced practice physiotherapy: characteristics and perceptions of existing roles

Background/aims

Few studies have investigated the characteristics of advanced practice physiotherapy in the UK to evaluate current context and implementation. The aim of this study was to understand how advanced practice physiotherapy is implemented in the UK.

Methods

A cross-sectional online descriptive national questionnaire was developed, using a previous survey and literature, comprising 33 closed, Likert-scale and open questions. Data analysis was undertaken using frequencies and thematic analysis. All 646 members of the Advanced Practice Physiotherapy Network were invited to participate.

Results

A total of 142 (22% response) reported 13 job titles; 40% had experienced ≥1 title change; most (50.7%) preferred ‘advanced practice physiotherapist’. High level job satisfaction was identified but barriers prevent fulfilment of the four advanced practice physiotherapy pillars: clinical practice, leadership and management, education and research. High level clinical skills and facilitating patient pathways were key to role differentiation. Problems included lack of support, inconsistency between responsibility and reward, and no consistent framework for advanced practice physiotherapy roles.

Conclusions

Advanced practice physiotherapists are largely satisfied, but significant variation exists in titles and implementation of roles. A consistent advanced practice physiotherapy framework is required.

Parental satisfaction with an advanced audiology-led triage service in paediatric ENT outpatient clinics

OBJECTIVE

The advanced audiology-led service is designed to triage and manage children who are referred to Ear Nose and Throat (ENT) outpatient services with middle ear or hearing concerns. This service has resulted in shorter waiting times for children to receive ENT treatment, and improved ENT capacity. The aim of this study was to explore parental satisfaction with the advanced audiology-led ENT service and to determine if there were cultural or process factors affecting satisfaction.

DESIGN

Prospective cross-sectional study using a modified Visit-Specific Satisfaction Questionnaire (VSQ-9) survey.

STUDY SAMPLE

One hundred and thirteen parents of children consecutively attending a first appointment in the advanced audiology-led service recruited between October 2016 and October 2017.

RESULTS

There were a total of 100 valid responses (rate of 88.5%). The survey showed high levels of satisfaction. Satisfaction scores were significantly higher for items related to interactions with the audiologist compared to items related to waiting times. There were no differences in satisfaction across cultural groups. Parents were equally satisfied with the service whether their child was managed independently by the audiologist or required another appointment for medical input.

CONCLUSIONS

The advanced audiology-led service had high levels of satisfaction from parents attending with their children.

Referral for Imaging in Physical Therapist Practice: Key Recommendations for Successful Implementation

In recent years, the use of diagnostic imaging in physical therapist practice in the United States has gained considerable interest. In several countries around the world and in the US military, patient direct referral for diagnostic imaging has been considered normative practice for decades. US physical therapy program accreditation standards now stipulate that diagnostic imaging content must be included in physical therapist educational curricula. The American Physical Therapy Association has made efforts to pursue practice authority for imaging referral. A recent review of state practice acts and other statutory language concluded that many states have no prohibitions against physical therapists referring for imaging studies. Additionally, physical therapists can now pursue certification as musculoskeletal sonographers. In light of these advances, and with a growing number of physical therapists serving patients who have not yet seen another health care provider, it may be helpful for those who have been actively involved in the use of imaging in physical therapist practice to provide their collective recommendations to serve as a guideline to those interested in incorporating this practice privilege. The purpose of this perspective article is to provide an overview of the key elements necessary for effective implementation of referral for imaging in physical therapist practice while emphasizing the cornerstone of effective communication.

Adding a Physical Therapist to the Health Care Team in an HIV Clinic Increases Physical Therapy Referrals and Reduces Opioid Prescriptions Provided for Chronic Musculoskeletal Pain in Patients Living With HIV

Background

Musculoskeletal (MSK) pain is common in people living with HIV (PLWH). Health care providers sometimes prescribe opioids to control pain, which may lead to opioid misuse. An interdisciplinary approach that includes physical therapy has been successful in managing MSK pain in various health care settings. Therefore, we sought to find the impact of recruiting a physical therapist (PT) on the number of opioid prescriptions and physical therapy referrals made by physicians in training to manage MSK pain in PLWH.

Methods

We performed a retrospective chart review of patients seen by Internal Medicine physicians in training in an HIV clinic in Detroit before (2017) and after (2018) recruiting a PT to the health care team and collected demographic and clinical data. We also surveyed the trainees to assess how the PT addition influenced their learning. Institutional review board waiver was obtained.

Results

Results showed that of all PLWH seen at the clinic, 28/249 (11%) and 37/178 (21%) had chronic MSK pain in the 2017 and 2018 data sets, respectively. In 2017, all 28 patients with MSK pain were prescribed opioids. This decreased in 2018 after the PT addition (10/37 patients; P < .0001). The number of physical therapy referrals significantly increased after the PT addition (2017: 5/28 patients; 2018: 17/37 patients; P = .03). Trainees felt that the PT helped improve their examination skills and develop a treatment plan for patients.

Conclusions

The addition of a PT encouraged physicians in training to utilize nonopioid management of MSK pain in PLWH and enhanced their learning experience, as perceived by the trainees.

Cost-Effectiveness and Outcomes of Direct Access to Physical Therapy for Musculoskeletal Disorders Compared to Physician-First Access in the United States: Systematic Review and Meta-Analysis

OBJECTIVE

Direct access to physical therapy provides an alternative to physician-first systems for patients who need physical therapy for musculoskeletal disorders (MSDs). Direct access across multiple countries and the United States (US) military services has produced improved functional outcomes and/or cost-effectiveness at clinical and health care system levels; however, data remain scarce from civilian health care systems within the United States. The purpose of this study was to compare evidence regarding costs and clinical outcomes between direct access and physician-first systems in US civilian health services.

METHODS

A database search of PubMed, CINAHL, Cochrane Reviews, and PEDro was conducted through May 2019. Studies were selected if they specified civilian US, physical therapy for MSDs, direct access or physician-first, and extractable outcomes for cost, function, or number of physical therapy visits. Studies were excluded if interventions utilized early or delayed physical therapy access compared with physician-first. Five retrospective studies met the criteria. Means and standard deviations for functional outcomes, cost, and number of visits were extracted, converted to effect sizes (d) and 95% CI, and combined into grand effect sizes using fixed-effect or random-effects models depending on significance of the Q heterogeneity statistic.

RESULTS

Direct access to physical therapy showed reduced physical therapy costs (d = -0.23; 95% CI = -0.35 to -0.11), total health care costs (d = -0.19; 95% CI = -0.32 to -0.07), and number of physical therapy visits (d = -0.17; 95% CI = -0.29 to -0.05) compared to physician-first systems. Disability decreased in both direct access (d = -1.78; 95% CI = -2.28 to -1.29) and physician-first (d = -0.89; 95% CI = -0.92 to -0.85) groups; functional outcome improved significantly more with direct access (z score = 0.89; 95% CI = 0.40 to 1.39).

CONCLUSIONS

Direct access to physical therapy is more cost-effective, resulting in fewer visits than physician-first access in the United States, with greater functional improvement.

IMPACT

These findings within civilian US health care services support a cost-effective health care access alternative for spine-related MSDs and can inform health care policy makers.

Inter-professional agreement and collaboration between extended scope physiotherapists and orthopaedic surgeons in an orthopaedic outpatient shoulder clinic - a mixed methods study

Background

Extended scope physiotherapists (ESP) are increasingly supplementing orthopaedic surgeons (OS) in diagnosing patients with musculoskeletal disorders. Studies have reported satisfactory diagnostic and treatment agreement between ESPs and OSs, but methodological study quality is generally low, and only few studies have evaluated inter-professional collaboration. Our aims were: 1) to evaluate agreement on diagnosis and treatment plan between ESPs and OSs examining patients with shoulder disorders, 2) to explore and evaluate their inter-professional collaboration.

Methods

In an orthopaedic outpatient shoulder clinic, 69 patients were examined independently twice on the same day by an ESP and an OS in random order. Primary and secondary diagnoses (nine categories) and treatment plan (five categories, combinations allowed) were registered by each professional and compared. Percentage of agreement and kappa-values were calculated.

Two semi-structured focus-group interviews were performed with ESPs and OSs, respectively. Interviews were based on the theoretical concept of Relational Coordination, encompassing seven dimensions of communication and relationship among professionals. A thematic analysis was conducted.

Results

Agreement on primary diagnosis was 62% (95% CI: [50; 73]). ESPs and OSs agreed on the combination of diagnoses in 79% (95% CI: [70; 89]) of the cases. Partial diagnostic agreement (one professional’s primary diagnosis was also registered as either primary or secondary diagnosis by the other) was 96% (95% CI: [91; 100]). Across treatment categories, agreement varied between 68% (95% CI: [57; 79]) and 100%. In 43% (95% CI: [31; 54]) of the cases, ESP and OS had full concordance between treatment categories chosen, while they agreed on at least one recommendation in 96% (95% CI: [91; 100]).

Positive statements of all dimensions of relational coordination were found. Three themes especially important in the inter-professional collaboration emerged: Close communication, equal and respectful relationship and professional skills.

Conclusions

In the majority of cases, the ESP and OS registered the same or partly the same diagnosis and treatment plan. Indications of a high relational coordination implying a good inter-professional collaboration were found. Our results support that ESPs and OSs can share the task of examining selected patients with shoulder disorders in an orthopaedic clinic.

Trial registration

ClinicalTrials.gov Identifier: NCT03343951. Registered 10 November 2017

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-020-03831-z.

Development of a Musculoskeletal Imaging Competency Examination for Physical Therapists

OBJECTIVE

The number of physical therapists with imaging ordering privileges is increasing; however, a known level of competency and knowledge is generally lacking within the profession, as is a method to determine practitioner competency. The purpose of this study was to develop a valid musculoskeletal (MSK) imaging competency examination for physical therapists.

METHODS

This 3-round Delphi method study utilized experts to reach consensus on examination content and development. Round 1 was completed by 37 experts. The last 2 rounds were completed by 35 experts. Experts rated questions on a 5-point Likert rating scale of importance (1 = not at all important, 5 = very important). Consensus was achieved with an a priori decision of (1) >75% agreement of the expert panel rating and ≥4 on the Likert scale, and (2) ≥.90 on Cronbach alpha and intraclass correlation coefficients. Experts recommended a passing score of 75%. The examination was subsequently reviewed by a panel of 5 radiologists.

RESULTS

The Delphi method and radiologist panel review resulted in the 151-question Burley Readiness Examination (BRE) for MSK Imaging Competency. Interrater agreement and internal consistency of the Delphi panel were excellent, with an average intraclass correlation coefficient and Cronbach alpha of .928 and .950, respectively.

CONCLUSIONS

The BRE is a tool that has the potential to demonstrate practitioners' level of baseline competency with MSK imaging. Additional testing among physical therapists will provide further validation and reliability of the examination.

IMPACT

The use and application of diagnostic imaging is becoming more widespread in physical therapist practice throughout the United States. The BRE could potentially have broader implications for health care utilization and cost in the area of MSK imaging.

Advanced practice physiotherapy for adults with spinal pain: a systematic review with meta-analysis

OBJECTIVE

To appraise the available evidence on advanced practice physiotherapy (APP) models of care (MoC) in specialized secondary care such as orthopaedic, rheumatology or neurosurgery outpatients' clinics for adults with spinal pain.

METHODS

Systematic review with meta-analysis. Electronic searches were conducted up to July 2020 in Medline, Embase, Cochrane CENTRAL and CINAHL. Studies on APP MoC in specialized secondary care for adults with spinal pain were included.

RESULTS

Eighteen studies (n = 9405), including two randomized controlled trials and sixteen observational studies were included. One study was considered at high quality, fourteen studies were considered of moderate quality and three were considered of low quality. Pooled results for change in disability for patients with spinal pain reported no significant difference between APP and usual medical care (UMC). Mean wait time for initial consultation was lower with APP (1-9.4 weeks) than with UMC MoC (23-65 weeks). Following the implementation of APP MoC, wait time for a consultation with a medical specialist was reduced (6-16 weeks). Physiotherapists in APP MoC managed independently 89.2% of the patients referred (n = 8393). Stakeholders and patients reported high satisfaction with APP care.

CONCLUSIONS

APP MoC and UMC likely result in comparable pain, disability and quality of life improvement for adults with spinal pain. However, APP MoC have the potential to improve health care access by reducing wait time for consultation in specialized care and maintaining a high level of satisfaction among stakeholders and patients.

Effects on health and process outcomes of physiotherapist-led orthopaedic triage for patients with musculoskeletal disorders: a systematic review of comparative studies

BACKGROUND

Physiotherapist-led (PT-led) orthopaedic triage is an evolving model of care for patients with musculoskeletal disorders. Objectives for this study were to establish the current evidence body on the impact of PT-led orthopaedic triage on health, quality, and service outcomes for patients referred for orthopaedic consultation, compared with standard (orthopaedic surgeon) care.

METHODS

Medline, EMBASE, Scopus and CINAHL were searched from inception until 7 May 2018; search updated 24 April 2020. Search terms (including derivatives) included physiotherapy, advanced/extended scope, musculoskeletal/orthopaedic, triage. The search was framed as Population = patients referred for orthopaedic consultation; Intervention = PT-led orthopaedic triage; Comparison = standard care; Outcomes = health, quality and process outcomes. Only randomised controlled trials (RCTs) and prospective comparative cohort studies were eligible for inclusion. Screening, study selection, data extraction, and assessment of methodological quality were performed independently by reviewer pairs. Quality was scored with the Downs and Black checklist. Certainty of evidence was determined using GRADE. PROSPERO registration number CRD42017070950.

RESULTS

We included two RCTs and eleven cohort studies (n = 1357 participants) of variable methodological quality (range 14-23 of possible 28). Certainty of evidence was low to moderate. There was no difference between PT-led orthopaedic triage and standard care for patient-reported outcomes (two RCTs). Perceived quality of care with PT-led orthopaedic triage was higher (two RCTs, four cohort studies) or equal (one cohort study) compared with standard care. PT-led orthopaedic triage had higher surgery conversion rates (one RCT, three cohort studies) (55-91% vs 22-38%), lower (two RCTs) or equal rate (two cohort studies) of referral for investigations, shorter waiting times (one RCT, one cohort study), and lower costs (one RCT). Furthermore, there was high agreement between physiotherapists' and orthopaedic surgeons' treatment approach (eight cohort studies), referral for investigation (five cohort studies), and diagnosis (nine cohort studies). Study limitations were the low number of RCTs, and variable methodological quality.

CONCLUSIONS

Evidence of low to moderate certainty suggests that PT-led orthopaedic triage leads to similar diagnostic decisions as standard care, has a higher conversion-to-surgery rate, reduces waiting times, is cost effective and valued by patients, and that health outcomes are equivalent.

Osteoarthritis Hip and Knee Service (OAHKS) in a community health setting compared to the hospital setting: A feasibility study for a new care pathway

AIM

OsteoArthritis Hip and Knee Service (OAHKS) clinics involve assessment and triage by advanced musculoskeletal physiotherapists for patients referred to orthopaedic clinics in public hospitals. This study explored the feasibility of implementing an OAHKS clinic in a community setting.

METHODS

The domains of feasibility explored in this mixed methods study were acceptability (patient, general practitioner and orthopaedic surgeon), demand (referrals, waiting times) efficacy potential (management decision, conversion-to-surgery rates) and practicality (number and type of discussions between advanced musculoskeletal physiotherapist and doctors, adverse events). Results from a community-based OAHKS were compared with hospital-based OAHKS over a 9-month period in the same metropolitan health region.

RESULTS

A total of 91 eligible patients attended an OAHKS clinic (40 community-based, 51 hospital-based). Both the community-based and hospital-based OAHKS had high patient and general practitioner satisfaction, with small differences in favour of community-based OAHKS. Waiting times were significantly shorter in community-based OAHKS for both initial appointment [community-based OAHKS mean 17 days (SD11), hospital-based OAHKS mean 155 days (SD38)] and commencing non-surgical management [community-based OAHKS mean 32 days (SD22), hospital-based OAHKS mean 67 days (SD32)]. Referral rate to orthopaedics was substantially lower from community-based OAHKS (3%) compared with hospital-based OAHKS (33%) [odds ratio 0.05 (95% CI 0.01-0.41)]. There were no adverse events.

CONCLUSION

Community-based OAHKS is feasible, and acceptable to patients and general practitioners, with potential benefits indicated in this study including shorter waiting times for assessment and commencing non-surgical management programs.

Advanced musculoskeletal physiotherapy practice: Informing education curricula

INTRODUCTION

Physiotherapists are operating at an advanced level of practice, usually on ad hoc basis with inhouse training, in response to the increasing burden of musculoskeletal (MSK) disorders. Discrepancies in role-specific education of advanced practice physiotherapists (APPs) creates challenges in ensuring a quality service, workforce mobility and formal recognition. This study reviewed existing MSK APP competency frameworks and education offerings, and explored physiotherapist learning needs with a view to informing international standardisation of MSK APP education curricula.

METHODS

A scoping review of the literature and relevant university and regulatory websites identified APP competency frameworks and education curricula, which were verified by international experts. Content analysis, performed on the identified competencies and modules, produced a list of themes existing in MSK advanced practice internationally. A survey based on those themes identified the learning priorities of physiotherapists (n = 25) participating in an APP symposium in Ireland.

RESULTS

Six APP competency frameworks and eleven curricula from the UK, Canada and Australia were identified. Themes emerging, regarding MSK APP practice internationally, included both entry-level physiotherapy (e.g., Assessment and Diagnosis) and traditionally medically-controlled tasks (e.g., Injection Therapy), as well as Research, Leadership, Service Development, Professional-related Matters and Education. Participating physiotherapists more commonly prioritised competencies which would be deemed beyond entry level physiotherapy skills (i.e., Radiology versus Manual Therapy).

CONCLUSION

Despite variances in profiles of APPs both between and within countries, common themes emerged regarding their expected competencies and skills. This study provides the foundation for the adoption of internationally-recognised MSK APP competencies and education standards.

Diagnostic Value of Acromiohumeral Distance in Rotator Cuff Pathology: Implications for Advanced-Practice Physiotherapists

Purpose: The primary purpose of this study was to examine the inter-tester reliability and criterion validity of reduced acromiohumeral distance (AHD; <6 mm) visualized on plain radiographs in detecting rotator cuff (RC) pathology. The secondary objective was to examine the relationship between this radiographic feature and patient demographics and clinical examination. Method: This was a diagnostic study of patients seen in a tertiary care centre. Two advanced-practice physiotherapists measured AHD in two radiographic views. MRI was used as the gold standard. Results: A total of 150 consecutive patients (mean age 59 [SD 11] y, 57 women, 93 men) were included. AHD less than 6 millimetres was highly specific in both views for the presence of tear (99%), tear size (96%-98%), and fatty infiltration in the supraspinatus and infraspinatus muscles (93%-96%). The absence of AHD less than 6 millimetres was associated with a lack of advanced fatty infiltration in the supraspinatus and infraspinatus muscles (92%-100%). Sensitivity values were low for the presence and size of RC tear (21%-55%). We found a statistically significant positive association between the AHD categories and clinically observed muscle wasting and weakness of the RC muscles (p < 0.05). Conclusions: AHD less than 6 millimetres was reliably measured in plain radiographs and was strongly associated with important clinical and imaging features of advanced RC pathology; this may assist with clinical decision making by allowing judicious use of more costly investigations and referral for surgery.

Physiotherapist-Led Triage at a Rheumatology-Based Musculoskeletal Assessment Clinic: an 18-Month Service Evaluation of Activity and Outcomes

Objective

Physiotherapist‐led musculoskeletal triage clinics are an effective and efficient means of managing patients presenting with musculoskeletal disorders in primary and secondary care. Data regarding the activity and outcomes of physiotherapist‐led triage in hospital‐based outpatient rheumatology clinics are scarce. Thus, the aim of this study was to undertake a service evaluation of activity and outcomes of a physiotherapist‐led rheumatology‐based Musculoskeletal Assessment Clinic (MAC). The primary objective was to quantify the proportion of patients independently managed by the clinical specialist physiotherapists (CSPs).

Methods

A retrospective service evaluation was undertaken of all patients who attended the Rheumatology MAC at St Vincent's University Hospital, Dublin (SVUH) between August 2012 and February 2014. The Clinical Audit Department of SVUH approved the study. Data were analyzed using descriptive statistics.

Results

Five hundred and eight patients attended the MAC: 76% were female and the mean age was 55 years and ranged between 18‐91. Seventy‐five percent of patients were independently managed by the CSP without needing to see a consultant rheumatologist, whereas 17% were referred to the rheumatology team. Eighty‐seven percent of patients referred to the rheumatology team had rheumatological intervention (eg, injection, medical management, or multidisciplinary rehabilitation). A substantially higher proportion of patients with regional musculoskeletal pain and degenerative conditions were independently managed by the CSP compared with those who had rheumatological/inflammatory conditions.

Conclusion

The majority of patients who attended the MAC were independently managed by the physiotherapists, suggesting that physiotherapist‐led triage may be a useful and efficient means of managing a proportion of patients referred for a specialist rheumatological consultation.

Can a physiotherapy student assume the role of an advanced practice physiotherapist in Orthopaedic surgery triage? A prospective observational study

Background

Advanced practice physiotherapists (APP) have helped improve accessibility to orthopaedic outpatient care. Several studies have validated the APP practice model in orthopaedic care, demonstrating high agreement between APPs and orthopaedic surgeons (OS) regarding diagnosis and management. However, as APPs tend to be experienced senior physiotherapists, such a study involving physiotherapy students (PS) has not yet been explored. The objective of this study was to evaluate the agreement for orthopaedic diagnoses and surgical triage between a PS and OSs.

Methods

A prospective study involving a final year PS and seven OSs was conducted in a university hospital, after the PS had undergone a three-week intensive training. Eighty-six adult patients referred to OSs for knee osteoarthritis, hip osteoarthritis or shoulder problem were independently evaluated by the PS, and then re-evaluated by an OS. The diagnoses and surgical triage recommendations of both clinicians were analyzed for agreement using raw percent agreement and Cohen’s kappa. Patient satisfaction with the outpatient clinic experience was noted using a modified version of the Visit-Specific Satisfaction Instrument.

Results

Our sample consisted of 86 patients (mean age = 63.4 years). Reasons for consultation included shoulder problems (36%), knee osteoarthritis (52%) and hip osteoarthritis (12%). The raw percent agreement for diagnosis was 95.3%. The agreement for surgical triage was high (κ = 0.86, 95% CI: 0.74–0.98) with a raw agreement of 94.2%. Patient satisfaction was high.

Conclusions

The PS and OSs made similar diagnoses and triage recommendations suggesting that clinical experience alone is not a prerequisite for physiotherapists to help increase accessibility to orthopaedic care.

Safety Events and Privilege Utilization Rates in Advanced Practice Physical Therapy Compared to Traditional Primary Care: An Observational Study

Introduction

The general practitioner shortage in the United States coupled with a growing number of Americans living with disability has fueled speculation of non-physician providers assuming a greater role in musculoskeletal healthcare. Previous physician shortages have been similarly addressed, and expanding physical therapy (PT) scope of practice may best serve to fill this need. Resistance to expanding PT practice focuses on patient safety as PTs assume the roles traditionally performed by primary care providers. While studies have shown advanced practice PT to be safe, none have compared safety events in advanced practice PT compared to primary care to determine if there are increased patient risks. Therefore, the purpose of our study is to examine the rate of safety events and utilization of services in an advanced practice PT clinic compared to a primary care clinic. A secondary aim of our study was to report safety events associated with spinal manipulation and dry needling procedures.

Materials and Methods

Productivity and safety data were retrospectively collected from Malcolm Grow Medical Center from 2015 to 2017 for the Family Health Clinic (FHC) and an advanced practice Physical Therapy Clinic (PTC). Chi-square tests for independence, risk ratios (RR) and 95% confidence intervals (95%) were used to compare the relationship between the frequency of (1) patient encounters and clinical procedures and (2) clinical procedures and safety events.

Results

Seventy-five percent (12/16) of safety events reported in the PTC were defined as near misses compared to 50% (28/56) within the FHC (RR 1.5; 95% CIs: 1.0 to 2.2). Safety events were more likely to reach patients in the FHC compared to the PTC (RR 1.9; 95% CIs: 0.8 to 4.7). Safety events associated with minor harm to patients was n = 4 and n = 3 in the FHC and PTC respectively. No sentinel events, intentional harm events, nor actual events with more than minor harm were reported in either clinic. Significant relationships indicated that prescriptions, laboratory studies, imaging studies and referrals, were all more likely to be ordered in the FHC than the PTC (p < 0.01). The PTC ordered one diagnostic imaging study for every 37 encounters compared to one in every 5 encounters in the FHC. The PTC similarly referred one patient to another healthcare provider for every 52 encounters, fewer than the one per every 3 encounters in the FHC. There was a significant relationship between encounters and diagnoses, indicating a higher number of diagnoses per encounter in the FHC, though the difference of 0.31 diagnoses per encounter may not be clinically meaningful (p < 0.01). A total of 1,818 thrust manipulations and 2,910 dry needling procedures were completed without any reported safety events.

Conclusion

These results suggest advanced practice PT has a similar safety profile to primary care. The authority to order musculoskeletal imaging and refer to other clinicians were among the most commonly utilized privileges and may be of primary importance when establishing an advanced practice PT clinic. These results support research showing advanced practice PT may lead to reductions in specialty referrals, diagnostic imaging, and pharmaceutical interventions.

Physiotherapist as primary assessor for patients with suspected knee osteoarthritis in primary care-a randomised controlled pragmatic study

Background

In Swedish primary care, the healthcare process for patients with knee osteoarthritis (KOA) can be initiated by a physician or physiotherapist assessment. However, it is unclear how the different assessments affect the healthcare processes and patient reported outcomes over time. The purpose of this study was to examine the differences in health-related quality of life (HrQoL), adjusted for pain and physical function, for patients with KOA when the healthcare process is initiated by a physiotherapist assessment compared to a physician assessment in primary care.

Methods

An assessor-blinded randomised controlled pragmatic trial. Using a computer-generated list of random numbers, patients seeking primary care during 2013–2017 with suspected KOA were randomised to either a physiotherapist or physician for primary assessment and treatment. Data was collected before randomisation and at 3, 6, and 12-month follow-ups. Primary outcome was HrQoL using EuroQol 5 dimensions 3 levels questionnaire, index (EQ-5D-3L index) and a visual analogue scale (VAS) (EQ-5D-3L VAS); pain intensity was measured with VAS (0–100) and physical function measured with the 30-s chair stand test. Mixed effect model analyses compared repeated measures of HrQoL between groups. The significance level was p < 0.05 and data was applied with intention-to-treat.

Results

Patients were randomised to either a physiotherapist (n = 35) or physician (n = 34) for primary assessment. All 69 patients were included in the analyses. There were no significant differences in HrQoL for patients assessed by a physiotherapist or a physician as primary assessor (EQ-5D-3L index, p = 0.18; EQ-5D-3L VAS, p = 0.49). We found that HrQoL changed significantly 12 months after baseline assessment for all patients regardless of assessor (EQ-5D-3L index, p < 0.001; EQ-5D-3 L VAS, p = 0.0049). No adverse events or side effects were reported.

Conclusions

There were no differences in HrQoL, when adjusted for pain and physical function, for patients with KOA when the healthcare process was initiated with physiotherapist assessment compared to physician assessment in primary care. Both assessments resulted in significantly higher HrQoL at the 12-month follow-up. The results imply that physiotherapists and physicians in primary care are equally qualified as primary assessors.

Trial registration

Retrospectively registered at http://clinicaltrial.gov, ID: NCT03715764.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2690-1) contains supplementary material, which is available to authorized users.

Comparing fly-in fly-out and telehealth models for delivering advanced-practice physiotherapy services in regional Queensland: An audit of outcomes and costs

INTRODUCTION

Recruitment of advanced-practice physiotherapists to regional and rural healthcare facilities in Queensland, Australia remains a challenge. To overcome this barrier, two different service delivery models (Fly-In, Fly-Out (FIFO), Telehealth) were trialled by one regional facility. This study aims to describe the economic- and service-related outcomes of these two methods of service delivery.

METHODS

A retrospective audit was conducted where two nine-week time periods were selected for each service delivery model. Outcomes of interests include patient demographics and case-mix, service utilisation, clinical actions, adverse events and costs. Net financial position for both models was calculated based upon costs incurred and revenue generated by service activity.

RESULTS

A total of 33 appointment slots were recorded for each service delivery model. Patient case-mix was variable, where the Telehealth model predominately involved patients with musculoskeletal spinal conditions managed from a neurosurgical waiting list. Appointment slot utilisation and pattern of referral for further investigations were similar between models. No safety incidents occurred in either service delivery model. An estimated cost-savings of 13% for the Telehealth model could be achieved when compared to the FIFO model.

DISCUSSION

Telehealth is a safe, efficient and viable option when compared to a traditional in-person outreach service, while providing cost-savings. Telehealth should be seen as a service delivery medium in which sustainable recruitment of advanced-practice physiotherapists to regional and rural healthcare facilities can be achieved.

Large variability found in musculoskeletal physiotherapy scope of practice throughout WCPT and IFOMPT affiliated countries: An international survey

BACKGROUND

Advanced practice physiotherapy (APP) rights are part of the evolution of the Physical Therapy profession. To date, no study has investigated musculoskeletal APP rights within the World Confederation for Physical Therapy (WCPT).

OBJECTIVE

To investigate musculoskeletal APP rights for physical therapists worldwide and examine the relationship between level of education (entry and post-professional) and direct access for countries that are vs. are not members of the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT).

DESIGN

Cross-sectional study with descriptive and exploratory online surveys.

METHODS

An electronic survey-based descriptive and exploratory investigation was conducted. We assessed variability between WCPT member organizations descriptively and the strength of the relationships among the number and types of APP rights with: (1) country affiliation to IFOMPT; (2) entry-level professional degree; (3) post-professional training; and (4) direct access.

RESULTS

Some countries reported having the right to practice all 20 APP rights while others reported no APP rights. Countries with IFOMPT member organization countries displayed fair correlation (r_s = .48, p < .03) between entry-level physical therapy degrees and number of APP rights. IFOMPT member organization countries were less likely to require post-professional training for direct access and manipulation.

CONCLUSION

APP rights for countries with direct access were significantly higher than for countries without direct access. IFOMPT member organizations demonstrated higher APP rights prevalence and were less likely to require post-professional training to obtain the right to direct access and perform manipulation.

Implementation of an extended scope of practice speech-language pathology allied health practitioner service: An evaluation of service impacts and outcomes

PURPOSE

Extended scope of practice roles can address health service challenges and enhance patient services; however there has been limited research of extended scope roles in the discipline of speech-language pathology (SLP). The aim of this study was to examine the clinical outcomes and service impacts of a Speech-Language Pathology Allied Health Practitioner (SLP AHP) led dysphagia and dysphonia service within an Integrated Specialist Ear Nose and Throat (ENT) Service.

METHOD

Low risk referrals were triaged by ENT from the waiting list into the SLP AHP dysphagia and dysphonia clinic. Outcomes from an initial 6-month pilot phase (n = 43) and 6-month implementation phase (n = 158) were evaluated.

RESULT

Approximately 70% of patients managed in the SLP AHP clinic in both phases were discharged without requiring separate ENT appointments. There were no adverse events. In the pilot phase, only 4.3% of medium priority and 10% of low priority referrals were seen within clinically recommended time frames. This improved to 90% in the final three months of the implementation phase.

CONCLUSION

With appropriate governance and risk management, an extended scope SLP AHP service for low risk dysphagia and dysphonia can achieve safe, effective and beneficial changes to ENT service delivery.

Agreement between telehealth and in-person assessment of patients with chronic musculoskeletal conditions presenting to an advanced-practice physiotherapy screening clinic

OBJECTIVE

To determine the level of agreement between a telehealth and in-person assessment of a representative sample of patients with chronic musculoskeletal conditions referred to an advanced-practice physiotherapy screening clinic.

DESIGN

Repeated-measures study design.

PARTICIPANTS

42 patients referred to the Neurosurgical & Orthopaedic Physiotherapy Screening Clinic (Queensland, Australia) for assessment of their chronic lumbar spine, knee or shoulder condition.

INTERVENTION

Participants underwent two consecutive assessments by different physiotherapists within a single clinic session. In-person assessments were conducted as per standard clinical practice. Telehealth assessments took place remotely via videoconferencing. Six Musculoskeletal Physiotherapists were paired together to perform both assessment types.

MAIN OUTCOME MEASURES

Clinical management decisions including (i) recommended management pathways, (ii) referral to allied health professions, (iii) clinical diagnostics, and (iv) requirement for further investigations were compared using reliability and agreement statistics.

RESULTS

There was substantial agreement (83.3%; 35/42 cases) between in-person and telehealth assessments for recommended management pathways. Moderate to near perfect agreement (AC1 = 0.58-0.9) was reached for referral to individual allied health professionals. Diagnostic agreement was 83.3% between the two delivery mediums, whilst there was substantial agreement (81%; AC1 = 0.74) when requesting further investigations. Overall, participants were satisfied with the telehealth assessment.

CONCLUSION

There is a high level of agreement between telehealth and in-person assessments with respect to clinical management decisions and diagnosis of patients with chronic musculoskeletal conditions managed in an advanced-practice physiotherapy screening clinic. Telehealth can be considered as a viable and effective medium to assess those patients who are unable to attend these services in person.

The knowledge of low back pain management between physical therapists and family practice physicians

Objectives: The purpose of this study was to compare knowledge in managing patients with low back pain (LBP) between physical therapists and family practice physicians. Methods: Seventy-three physical therapists and 30 family practice physicians completed standardized examinations assessing knowledge, attitudes, the usefulness of clinical practice guidelines, and management strategies for patients with LBP. Beliefs of physical therapists and family practice physicians about LBP were compared using relative risks and independent t-tests. Results: Scores related to knowledge, attitudes, and the usefulness of clinical practice guidelines were generally similar between the groups. In addition, there was no difference between the groups for knowledge regarding optimal management strategies for patients with LBP. However, physical therapists were less likely to have difficulty assessing motivation levels of patients with LBP compared to family practice physicians (64.6% vs 26.7%; relative risk: 2.41 [95% confidence interval: 1.30-4.48] and physical therapists were less likely to agree that interventions by health care providers have little positive effect on the natural history of acute LBP (17.8% vs. 50.0%; relative risk: 0.36 [95% confidence interval: 0.19-0.66]). Discussion: The results of this study may have implications for third-party payers and health care administrators regarding the utilization of physical therapists in the management of patients with LBP in expanded scopes of practice, including direct access and potential placement in primary care clinics.

Medicines management activity with physiotherapy and podiatry: A systematic mixed studies review

OBJECTIVE

Making best use of existing skills to increase service capacity is a global challenge. The aim was to systematically review physiotherapy and podiatrist prescribing and medicines management activity, including evidence of impact on patient care, levels of knowledge and attitudes towards extended medicines role.

METHODS

A search of MEDLINE, CINAHL, and Cochrane databases, using terms to identify prescribing and medicines management across a range of roles, was conducted from January 1985 to May 2016 for physiotherapy, and January 1968 to May 2016 for podiatry. Hand searching of citations and databases from professional organisations was undertaken. Data were extracted and analysed descriptively, and quality appraised by 2 reviewers using the mixed methods appraisal tool.

RESULTS

1316 papers were identified, and 21 included in the review. No studies were identified that reported prescribing and no studies specific to podiatry met the inclusion criteria. Physiotherapists were highly involved in administering medicines, providing medicines advice, and recommending new medicines. Patient satisfaction, cost and outcomes were equivalent when comparing physiotherapist-led injection therapy to traditional care. Pharmacology knowledge was variable and unmet training needs identified.

CONCLUSION

Medicines management practices were identified in physiotherapy and positive outcomes of extended scope physiotherapy. There was a lack of evidence regarding podiatric practice. Review of educational preparation for medicines management is recommended along with evaluation of medicines management practice.

Patients with spondyloarthritis are equally satisfied with follow-up by physiotherapist and rheumatologist

OBJECTIVE

International guidelines recommend that patients with spondyloarthritis (SpA) have lifelong physiotherapy, as physical activity and exercise are essential for optimizing health throughout the course of the disease. The aim of the present study was to investigate if a physiotherapy-led outpatient clinic specializing in SpA could provide satisfactory follow-up as an alternative to standard visits with a rheumatologist (RT). We hypothesized that satisfaction would be similar in patients followed by a physiotherapist (PT) or an RT.

METHODS

A total of 68 patients were randomized to follow-up every fourth month by a PT or RT, for three visits in total. Patient satisfaction was evaluated using the Leeds Satisfaction Questionnaire (LSQ). Function, mobility and disease activity were rated using the Bath Ankylosing Spondylitis Functional Index (BASFI), Mobility Index (BASMI) and Ankylosing Spondylitis Disease Activity Score (ASDAS).

RESULTS

Patients were equally satisfied with PT and RT follow-up at the first (p = 0.062) and last (p = 0.710) visit. At the second visit, the RT group was seen by a nurse, and was more satisfied than the PT group (p = 0.015). Function deteriorated in both the PT (p = 0.014) and RT (p = 0.007) groups. Mobility increased in the PT group (p = 0.020). Disease activity was not affected.

CONCLUSIONS

Patients seem to be equally satisfied with either of the follow-up regimes. The PT-led follow-up did not seem to affect the patients' course of disease negatively. The results indicate that it would be safe to implement a PT-led clinic for patients with SpA in specialist health services, but longer-term follow-up is necessary to support the findings of this study.

Advanced practice physiotherapy-led triage in Irish orthopaedic and rheumatology services: national data audit

BACKGROUND

Many people with musculoskeletal (MSK) disorders wait several months or years for Consultant Doctor appointments, despite often not requiring medical or surgical interventions. To allow earlier patient access to orthopaedic and rheumatology services in Ireland, Advanced Practice Physiotherapists (APPs) were introduced at 16 major acute hospitals. This study performed the first national evaluation of APP triage services.

METHOD

Throughout 2014, APPs (n = 22) entered clinical data on a national database. Analysis of these data using descriptive statistics determined patient wait times, Consultant Doctor involvement in clinical decisions, and patient clinical outcomes. Chi square tests were used to compare patient clinical outcomes across orthopaedic and rheumatology clinics. A pilot study at one site identified re-referral rates to orthopaedic/rheumatology services of patients managed by the APPs.

RESULTS

In one year, 13,981 new patients accessed specialist orthopaedic and rheumatology consultations via the APP. Median wait time for an appointment was 5.6 months. Patients most commonly presented with knee (23%), lower back (22%) and shoulder (15%) disorders. APPs made autonomous clinical decisions regarding patient management at 77% of appointments, and managed patient care pathways without onward referral to Consultant Doctors in more than 80% of cases. Other onward clinical pathways recommended by APPs were: physiotherapy referrals (42%); clinical investigations (29%); injections administered (4%); and surgical listing (2%). Of those managed by the APP, the pilot study identified that only 6.5% of patients were re-referred within one year.

CONCLUSION

This national evaluation of APP services demonstrated that the majority of patients assessed by an APP did not require onward referral for a Consultant Doctor appointment. Therefore, patients gained earlier access to orthopaedic and rheumatology consultations in secondary care, with most patients conservatively managed.

Spasticity management with botulinum toxin: A comparison of UK physiotherapy and rehabilitation medicine injectors

Background/Aims:

To compare patient outcomes following botulinum toxin (BoNT) injection by either physiotherapy or rehabilitation medicine (medical) professionals over a 3-year period.

Methods:

A retrospective, observational cohort study was conducted in a specialised rehabilitation service providing spasticity management including BoNT injection and physical therapy (group therapy, individual therapy, self-exercise, and physical management programmes). Individualised goals were established before treatment using goal attainment scaling (GAS) by the multidisciplinary team. The Arm Activity measure (ArmA) was used to evaluate upper limb function and the Modified Ashworth Scale (MAS) used to evaluate spasticity.

Findings:

A total of 262 patients were injected. Mean GAS T-score after treatment for the group was 50.2 ± 6.7. GAS T-score for physiotherapy injectors (n=214 (82% of participants)) was 50.2 ± 6.4 and for rehabilitation medicine injectors (n=48 (18%)) 50.3 ± 7.9. No significant differences were identified in terms of goal achievement, upper limb passive function, or spasticity reduction between physiotherapy and rehabilitation medicine injectors. Differences were identified at both baseline (physiotherapist mean 49.7; rehabilitation medicine mean 46.6) and follow-up for active function (physiotherapist mean=49.7; rehabilitation medicine mean=47.8) (ArmA active function subscale; p=0.03). No reportable adverse effects were recorded. No difference in the complexity of injection (such as complex clinical presentation, anticoagulation, or technical difficulty) between the injector groups was identified.

Conclusions:

Clinical outcomes were comparable between physiotherapy and rehabilitation medicine injectors. No difference in side effect profile or complexity of injection was identified. In this cohort, injection of BoNT by a physiotherapist was as effective in terms of GAS as that undertaken by a rehabilitation medicine physician.

Diagnostic validity and triage concordance of a physiotherapist compared to physicians' diagnoses for common knee disorders

BACKGROUND

Emergence of more autonomous roles for physiotherapists warrants more evidence regarding their diagnostic capabilities. Therefore, we aimed to evaluate diagnostic and surgical triage concordance between a physiotherapist and expert physicians and to assess the diagnostic validity of the physiotherapist's musculoskeletal examination (ME) without imaging.

METHODS

This is a prospective diagnostic study where 179 consecutive participants consulting for any knee complaint were independently diagnosed and triaged by two evaluators: a physiotherapist and one expert physician (orthopaedic surgeons or sport medicine physicians). The physiotherapist completed only a ME, while the physicians also had access to imaging to make their diagnosis. Raw agreement proportions and Cohen's kappa (k) were calculated to assess inter-rater agreement. Sensitivity (Se) and specificity (Sp), as well as positive and negative likelihood ratios (LR+/-) were calculated to assess the validity of the ME compared to the physicians' composite diagnosis.

RESULTS

Primary knee diagnoses included anterior cruciate ligament injury (n = 8), meniscal injury (n = 36), patellofemoral pain (n = 45) and osteoarthritis (n = 79). Diagnostic inter-rater agreement between the physiotherapist and physicians was high (k = 0.89; 95% CI:0.83-0.94). Inter-rater agreement for triage recommendations of surgical candidates was good (k = 0.73; 95% CI:0.60-0.86). Se and Sp of the physiotherapist's ME ranged from 82.0 to 100.0% and 96.0 to 100.0% respectively and LR+/- ranged from 23.2 to 30.5 and from 0.03 to 0.09 respectively.

CONCLUSIONS

There was high diagnostic agreement and good triage concordance between the physiotherapist and physicians. The ME without imaging may be sufficient to diagnose or exclude common knee disorders for a large proportion of patients. Replication in a larger study will be required as well as further assessment of innovative multidisciplinary care trajectories to improve care of patients with common musculoskeletal disorders.

Impact of Radiographic Imaging of the Shoulder Joint on Patient Management: An Advanced-Practice Physical Therapist's Approach

Purpose: Recent care innovations using advanced-practice physical therapists (APPs) as alternative health care providers are promising. However, information related to the clinical decision making of APPs is limited with respect to ordering shoulder-imaging investigations and the impact of these investigations on patient management. The purpose of this study was twofold: (1) to explore the clinical decision making of the APP providing care in a shoulder clinic by examining the relationship between clinical examination findings and reasons for ordering imaging investigations and (2) to examine the impact on patient management of ordered investigations such as plain radiographs, ultrasound (US), magnetic resonance imaging (MRI), and magnetic resonance arthrogram (MRA). Method: This was a prospective study of consecutive patients with shoulder complaints. Results: A total of 300 patients were seen over a period of 12 months. Plain radiographs were ordered for 241 patients (80%); 39 (13%) received MRI, 27 (9%) US, and 7 (2%) MRA. There was a relationship between clinical examination findings and ordering plain radiographs and US (ps=0.047 to <0.0001). Plain radiographs ordered to examine the biomechanics of the glenohumeral joint affected management (χ² ₁=8.66, p=0.003). Finding a new diagnosis was strongly correlated with change in management for all imaging investigations (ps=0.001 to <0.0001). Conclusion: Skilled, extended-role physical therapists rely on history and clinical examination without overusing costly imaging. The most important indicator of change in management was finding a new diagnosis, regardless of the type of investigation ordered.