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

Acceptability of physiotherapists as primary care practitioners for the care of people with musculoskeletal disorders: a French population-based cross-sectional survey

OBJECTIVES

In France, early access to physiotherapy for people with musculoskeletal disorders (MSKDs) depends on prescription and referral by the family physician in the physician-led model of care. The readiness of French people for direct access to physiotherapy is not known. This survey aims to identify the perceptions of French adults regarding physiotherapists' competence to diagnose and manage MSKDs if they were primary care practitioners, confidence in their ability to provide quality care, and satisfaction with the last episode of care for those concerned; and to identify factors associated with these three variables.

DESIGN

French population-based cross-sectional survey.

PARTICIPANTS

A representative sample of the French adult population was surveyed between June 2020 and September 2021.

OUTCOME MEASURES

Collected variables included previous physiotherapy experience, perception of competence to diagnose and manage MSKDs as primary care practitioners, confidence about quality of care, and self-referral preferences. Multivariate logistic regression analyses were performed to identify the factors associated with these three variables.

RESULTS

A total of 1000 participants completed the survey; 854 (85%) believed that physiotherapists would be competent primary care practitioners, and 920 (92%) were confident about the quality of care. Most had previously consulted a physiotherapist (n = 823, 82%); of these, 762 (91%) were satisfied with care received.

CONCLUSION

This large sample of French adults considered physiotherapists as competent to diagnose and treat some MSKDs as primary care practitioners, and that they provided quality care. Further studies should investigate the scope of care, safety, and efficacy of a direct access physiotherapy model. CONTRIBUTION OF PAPER.

Musculoskeletal Care Within the Holistic Health and Fitness Team: A 12-month Retrospective Review

INTRODUCTION

People are the Army's greatest strength and most valuable asset. The Holistic Health and Fitness (H2F) performance team was designed to optimize Soldiers' individual performance potential and well-being by becoming stronger, faster, and more ready in the physical and nonphysical domains of health and wellness. The H2F team is a human performance readiness platform composed of a team of professionals to include: strength and conditioning specialists, dietitian, nutrition care technician, occupational therapist, certified occupational therapist assistant, cognitive performance specialist, certified athletic trainers (ATs), physical therapists, and physical therapy technician. In the military health care system, where resources are limited, it is important to consider the H2F musculoskeletal (MSK) team as an integral part of the military health care system.

METHODS

For the 12-months analyzed, we tracked AT, physical therapy, and occupational therapy initial encounters, follow-ups, and rehabilitative treatment encounters. A retrospective analysis of ankle injuries, postoperative patients, and concussions was completed.

RESULTS

During the 12-month period, a total of 946 initial AT, physical therapy, and occupational therapy evaluations were completed. Including follow-ups and rehabilitative treatments, a total of 4862 MSK medical encounters were completed during this time.

DISCUSSION

The subanalysis comparing primary care manager-based care to H2F physical therapy and AT group for ankle injuries demonstrated a reduction in imaging, days on profile, and reduction in referral to specialty care. The subanalysis of postoperative MSK care within the H2F footprint demonstrates not only a 93% return to duty rate but minimizing lost duty time due to appointment location. For all 6 acute concussions identified, they were successful in Progressive Return to Activity, with an average of 4 occupational therapy visits and return to duty within 3 weeks of injury. Utilization of the H2F MSK care platform is essential to providing timely and efficient MSK care to return Soldiers to duty.

CONCLUSION

To optimize Soldiers lethality and maintain a high level of readiness during the challenges of multi-domain operations, the Army developed the H2F team. This description of MSK care within an H2F team describes the importance of utilizing the H2F MSK care team within the military health care system to reduce cost, health care utilization, and minimize duty time lost to MSK injuries.

Lower Extremity Musculoskeletal Injuries in United States Active Duty Service Members: Prevalence/Incidence, Health Care Utilization, and Cost Analysis Spanning Fiscal Years 2016-2021

INTRODUCTION

Lower Extremity musculoskeletal injuries (LE MSKIs) represent a significant portion of overuse injuries in active duty service members (ADSMs). However, variations in study methods and research gaps related to LE MSKIs have prevented Department of Defense (DoD) leaders from assessing the burden of these conditions. The purpose of this study was to report the incidence, prevalence, and types of LE MSKIs sustained by ADSMs across four branches of service and describe associated health care utilization and private sector costs.

MATERIALS AND METHODS

This was a retrospective, longitudinal population study, including ADSMs from the Air Force, Army, Marine Corps, and Navy. Prevalence and incidence rates for LE MSKIs, associated health care utilization, and costs were obtained by querying electronic health records (EHR) from military treatment facilities (MTFs), private sector care (PC) claims, and theater medical data from the Military Health System Data Repository (MDR) from October 1, 2015 to September 30, 2021 (FY16-21). Utilization associated with LE MSKIs in both the direct care (DC) and PC settings was classified into mutually exclusive outpatient encounter categories and acute inpatient stays. PC costs related to LE MSKIs were captured for each year.

RESULTS

In FY21, LE MSKIs occurred in 25.3% of ADSMs (n = 378,615). A higher proportion of females sustained an LE MSKI (33.3%), compared to males (23.7%). From FY16-21, the Army had the highest annual prevalence of LE MSKIs (30.9-35.5%), followed by the Air Force (23.8-31.0%), Marine Corps (23.4-27.0%), and Navy (17.2-19.8%). Incidence rate patterns were similar, with the Army sustaining LE MSKIs at 320 to 377 injuries per 1,000 person-years, followed by the Air Force (241-318), Marines (255-288), and Navy (173-203). Overuse/non-specific MSKIs of the knee were the most common injury type and body region affected, respectively. There were 10,675,543 DC and 1,875,307 PC outpatient encounters from FY16-21 with a primary or secondary diagnosis of LE MSKI. The Air Force was most reliant on PC, with 21.5 to 36.8% of LE MSKI-related encounters occurring outside MTFs during FY16-21. Over $99 million was paid by TRICARE on LE MSKI in FY21 alone with Same Day Surgeries accounting for almost half ($48 million) of this total.

CONCLUSIONS

Among U.S. ADSMs, LE MSKIs remain highly prevalent and costly. We observed disparities across the Services in the prevalence and incidence of LE MSKIs, and their respective reliance on the private sector for management of these conditions. Findings from this work may support military leaders and MSKI researchers who seek to reduce the impact of LE MSKIs on the readiness and overall health of the U.S. Military.

Identifying physical therapists' attitudes, beliefs, and barriers toward diagnostic imaging referral: a mixed-methods study

OBJECTIVE

Ten states, including the District of Columbia, have laws that currently permit physical therapists (PTs) to directly order diagnostic imaging (DI) in the United States. Military and civilian PTs order DI judiciously and appropriately demonstrating optimal patient outcomes and satisfaction when compared to other medical professionals. However, no studies have explored perceived attitudes, beliefs, and barriers to PT DI referral specific to North Dakota (ND). Therefore, the purpose of this mixed-methods study was to identify ND PTs' attitudes, beliefs, and barriers toward DI referral.

METHODS

A total of 147 participants completed an online survey with a subset of 17 participants agreeing to an interview. Frequency counts of demographic data and perceived barriers were completed. A binary logistic regression was run on demographic data. One-on-one interviews were conducted with a thematic coding process completed within a qualitative analysis.

RESULTS

Seventy-four percent of PTs reported not currently referring for DI, although 71% felt that it would improve their patient outcomes. PTs with post-professional training (OR = 4.59), a doctorate degree (OR = 3.84), practicing in an orthopaedic or sports setting (OR = 3.55), and practicing within an urban setting of ND (OR = 3.01) were more likely to refer for DI. The main barriers identified in the survey included: (1) the logistics of performing a DI referral, (2) DI referrals only privileged to other medical providers, (3) provider/work relationship dynamics, (4) the cost of continuing education (CE), (5) and the inability to identify CE. One-on-one interviews further identified five main themes related to DI referral.

DISCUSSION/CONCLUSION

Several barriers identified resulted in 74.1% of PTs not directly referring for DI, although certain characteristics (post-professional training, doctorate degree, orthopaedic/sports setting, practicing in an urban area in ND) were more likely to refer for DI. This study may help improve future adoption and implementation of DI referral in current and future states.

Physical therapist awareness of diagnostic imaging referral jurisdictional scope of practice: an observational study

OBJECTIVES

To examine physical therapist awareness and utilization of imaging referral privileges in the United States (US) and how it relates to direct access frequency.

METHODS

This study utilized survey data collected in 2020-2021 from US physical therapists. Subjects were asked about imaging referral jurisdictional authority in their state. Responses were analyzed for accuracy and compared to the level of jurisdictional authority and its impact on imaging referral. Analysis of imaging skills performance and imaging referral practices were compared to direct access frequency.

RESULTS

Only 42.0% of physical therapists practicing in states that allow imaging referral were aware of this privilege. Those practicing where imaging referral was allowed via state legislation were significantly more likely (p < 0.01) to be aware of this privilege (71.4%) compared to those granted by the state board (25.2%). Those aware of their imaging referral scope were more likely (p < 0.01) to practice imaging referral (44.5%) compared to those who were unaware (3.2%). Direct access frequency was positively associated with imaging skill performance and imaging referral practice (p < 0.01). Doctors of Physical Therapy, residency/fellowship-trained physical therapists, and board-certified physical therapists all reported practicing greater frequency of direct access (p < 0.01).

DISCUSSION/CONCLUSION

There is a striking lack of awareness of imaging privileges among physical therapists as influenced by the level of jurisdictional scope. These results suggest that the lack of awareness may have a dampening effect on diagnostic imaging referrals. The American Physical Therapy Association should consider engaging with state boards to raise imaging privilege awareness.

Core competencies for first contact physiotherapists in a direct access model of care for adults with musculoskeletal disorders: A scoping review

INTRODUCTION

To optimise the management of Musculoskeletal disorders (MSKDs), many countries have implemented direct access to physiotherapy; however, the core competencies required for first contact physiotherapists (PTs) have not been precisely defined. The aim of this scoping review is to identify and describe the core competencies required for first contact PTs treating adults with MSKDs.

METHODS

We conducted a scoping review of the literature by searching eight databases and grey literature up to July 2023. We performed a thematic analysis of the competencies identified based on predefined themes relevant to first contact physiotherapy in direct access models in primary or emergency care settings.

RESULTS

Sixty-five articles were included. Seventeen core competencies were identified and grouped into 5 themes: (1) Assessment and examination; (2) Management and interventions; (3) Communication; (4) Cooperation and collaboration; and (5) Professionalism and leadership.

CONCLUSIONS

Our findings provide an international perspective on the core competencies required for first contact PTs.

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.

A preliminary exploration of attitudes, beliefs, and barriers to physical therapists' practices in ordering diagnostic imaging

BACKGROUND

Diagnostic imaging (DI) studies are useful resources for examining musculoskeletal (MSK) conditions. When DI is used appropriately, it is an important tool for physical therapists (PTs).

OBJECTIVE

The purpose of this study was to explore the attitudes, beliefs, and barriers to PTs' practices in referring to DI in Saudi Arabia (SA).

METHODS

For this quantitative cross-sectional study, an online self-reported questionnaire was designed and distributed. A total of 138 PTs participated in the study.

RESULTS

Although most PTs had access to DI, few reported being able to order DI. The PTs demonstrated positive attitudes regarding their ability to refer patients for DI. Nevertheless, some PTs have adopted several beliefs and awareness of PTs regarding the clinical appropriateness of referring to DI, which may increase the unnecessary utilisation of DI requests. More than half of the PTs in this study reported that they were unfamiliar with the clinical rules used for prescribing imaging.

CONCLUSION

This study highlights recommendations to improve PTs' practices towards DI in SA, such as providing more DI courses targeting PTs and including clinical rules within DI education in undergraduate studies. Furthermore, a clear governmental policy is needed to permit PTs to refer to DI when specific criteria are met.

Physical Therapists Are Routinely Performing the Requisite Skills to Directly Refer for Musculoskeletal Imaging: An Observational Study

OBJECTIVES

To explore if physical therapists are practicing skills necessary to refer patients for musculoskeletal imaging.

METHODS

An expert panel established a list of nine requisite skills to refer for musculoskeletal imaging. A blinded expert panel validated the list using a 5-point Likert scale. The skills list was examined via an electronic survey distributed to United States physical therapists.

RESULTS

4,796 respondents were included. Each of the nine skills were routinely performed by a majority of the respondents (range: 54.52-94.72%). Respondents routinely performed 6.95 (± 0.06) skills, with 67.41% routinely performing seven or more skills. Doctors of physical therapy routinely performed more imaging skills (7.15 ± 0.06) compared to their masters- (6.44 ± 0.19) and bachelors-trained (5.95 ± 0.21) counterparts (p < 0.001). Residency/fellowship-trained physical therapists were more likely to routinely perform more imaging skills (7.60 ± 0.11 vs. 6.79 ± 0.07, p < 0.001). Imaging skill performance was greater among board-certified physical therapists (7.39 ± 0.09 vs. 6.71 ± 0.08, p < 0.001) and APTA members (7.06 ± 0.07 vs. 6.65 ± 0.12, p < 0.001).

CONCLUSION

Physical therapists are routinely practicing the requisite imaging skills to directly refer to a radiologist for musculoskeletal imaging.

Spinal pain patients seeking care in primary care and referred to physiotherapy: A cross-sectional study on patients characteristics, referral information and physiotherapy care offered by general practitioners and physiotherapists in France

Objectives

To describe spinal pain patients referred by their treating general practitioners to physiotherapy care, examine to which extent physiotherapy interventions proposed by general practitioners and physiotherapists were compliant to evidence based recommendations, and evaluate concordance between providers in terms of diagnosis and contraindications to physiotherapy interventions.

Methods

This study included spinal pain patients recruited from a random sample of sixty French physiotherapists. Physiotherapists were asked to supply patients’ physiotherapy records and characteristics from the general practitioner’s physiotherapy referral for the five new consecutive patients referred to physiotherapy. General practitioner’s physiotherapy referral and physiotherapists’ clinical findings characteristics were analyzed and compared to evidence-based recommendations using Chi-squared tests. Cohen’s kappas were calculated for diagnosis and contraindications to physiotherapy interventions.

Results

Three hundred patients with spinal pain were included from sixty physiotherapists across France. The mean age of the patients was 48.0 ± 7.2 years and 53% were female. The most common spinal pain was low back pain (n = 147). Diagnoses or reason of referral formulated by general practitioners were present for 27% of all patients (n = 82). Compared to general practitioners, physiotherapists recommended significantly more frequently recommended interventions such as education, spinal exercises or manual therapy. General practitioners prescribed significantly more frequently passive physiotherapy approaches such as massage therapy and electrotherapy. The overall proportion of agreement beyond chance for identification of a diagnosis or reason of referral was 41% with a weak concordance (κ = 0.19; 95%CI: 0.08–0.31). The overall proportion of compliant physiotherapists was significantly higher than for general practitioners (76.7% vs 47.0%; p<0.001).

Conclusions

We found that information required for the referral of spinal pain patients to physiotherapy is often incomplete. The majority of general practitioners did not conform to evidence-based recommendations in terms of prescribed specific physiotherapy care; in contrast to a majority of physiotherapists.

Trial registration

ClinicalTrials.gov: NCT04177121

Magnetic Resonance Imaging for Elbow Pathology: Overused by Both Orthopaedic Surgeons and Primary Care Providers

Background

Magnetic resonance imaging (MRI) use by both orthopedic surgeons and primary care providers (PCP) for analysis of elbow pathology is expensive and growing in frequency. In light of this, scrutiny regarding the appropriate utilization of this technology is increasing. Currently, there is no literature investigating the appropriateness of MRI use for complex elbow pathology from either orthopedic surgeons or PCPs.

Methods

A retrospective chart review was performed on consecutive elbow MRIs performed at a tertiary care center between January 1, 2012, and December 31, 2015. A total of 225 patients were included. Patients meeting the inclusion criteria were divided into two cohorts, determined by whether the ordering provider was an orthopedic surgeon or a PCP. MRI referrals were made by orthopedic surgeons in 94 patients and by nonorthopedic surgery providers in 131 patients. MRI diagnoses of no pathology, muscle/tendon tear, neuritis/nerve injury, tendinosis, ligament injury/instability, osteoarthritis/degenerative joint disease/decreased range of motion/contracture, or fracture/osteochondral injury were analyzed, as were the interventions of no intervention, nonprocedural treatment (therapy, orthosis, or nonoperative modality), nonsurgical procedure/referral for procedure, referral to surgeon, surgery, additional imaging/electrodiagnostic nerve testing, or other.

Results

1. Orthopedic surgeons are more accurate in their diagnoses after MRI, while PCPs order more MRI scans for ‘routine’ diagnoses typically made without MRI. 2. When the MRI did not validate an orthopedic surgeon’s preimaging diagnosis, rates of surgery decreased. The same discrepancy in diagnosis leads to an increase in orthopedic surgeon referrals within the PCP cohort. 3. An MRI was ordered for “pain” by orthopedic surgeons and PCPs in approximately 30% of the patients in both groups with a similarly low rate of pathology discovery.

Conclusions

The unexpected result of this study is that there is still a large quantity of MRI exams being conducted by orthopedic surgeons for the preMRI diagnosis of “pain.” In both groups, there was a similar rate of negative imaging. We expected orthopedic surgeons who have advanced knowledge in musculoskeletal pathology would be less likely to order an MRI for pain and would also less likely order an MRI that resulted in no pathology. This places an increased and unnecessary burden on the financial aspect of the health care system.

A call to action: direct access to physical therapy is highly successful in the US military. When will professional bodies, legislatures, and payors provide the same advantages to all US civilian physical therapists?

OBJECTIVES

In 2000, the American PT Association (APTA) published its Vision statement advocating for DA (DA) to PT. This narrative review of the literature aims to identify the current state of DA in the United States (US) and compare that status to the US Military.

METHODS

Initial PubMed search in the English language with keywords physical therapy (PT), physiotherapy, DA, self-referral, and primary contact from the year 2000 onwards with subsequent focused searches using keywords DA/self-referral/primary contact of physical therapists/physiotherapists on outcomes/autonomous practice/economic impact/patient satisfaction yielded 103 applicable studies on the topic. This paper excluded 40 international articles to focus on US military and civilian research.

RESULTS

Current literature supports Physical Therapists (PTs) in an initial contact role based on patient safety, satisfaction, access to care, efficiency, healthcare utilization, and potential cost savings.

CONCLUSIONS

Despite its success in the US Military, DA to PT in the US civilians remains limited and incomplete. PTs still await unrestricted DA and privileges associated with autonomous practice including the ability to order imaging and prescribe some medications.

Validation of the international classification of functioning, disability, and health (ICF) core sets for musculoskeletal conditions in a primary health care setting from physiotherapists' perspective using the Delphi method

PURPOSE

To analyze the possibilities of using ICF core sets for musculoskeletal conditions in primary care physiotherapy units of the Health Service of "Castilla y León" (Spain).

METHODS

A three-round Delphi study was conducted by physiotherapists working in a primary care setting. The data obtained were linked to second-level ICF categories and their relevance was assessed by the participants. The most relevant categories were compared with those present in the existing ICF core sets for musculoskeletal conditions.

RESULTS

Eighty-four physiotherapists participated in the survey. The consensus was reached for 45 ICF categories and 5 personal factors after the survey. Thirty-five of these categories were present in the Comprehensive Core Set for post-acute Musculoskeletal Conditions. In addition, 35 categories present in the core set were not considered relevant from the participants' perspective.

CONCLUSIONS

Physiotherapists mainly considered movement-related categories as relevant. The ICF core set for post-acute musculoskeletal conditions comprises many of these categories and can therefore be taken as a basis for the adoption of ICF in the clinical context.

RELEVANCE

Primary care physiotherapists should be aware of the advantages of using ICF in their clinical settings.Implications for RehabilitationThis study shows which body functions and structures, activities and participation, environmental factors, and personal characteristics are relevant from primary care physiotherapists' perspective assessing persons with musculoskeletal conditions.The Comprehensive ICF Core Set for Subacute Musculoskeletal Conditions includes most of the categories identified in this study, but they need to be refined to fully represent the primary care physiotherapists' perspective.The results of this study support the use of the Comprehensive ICF Core Set for Subacute Musculoskeletal Conditions as a basis for operationalizing ICF in this clinical setting.

Physiotherapist or physician as primary assessor for patients with suspected knee osteoarthritis in primary care - a cost-effectiveness analysis of a pragmatic trial

Background

Over the next decade, the number of osteoarthritis consultations in health care is expected to increase. Physiotherapists may be considered equally qualified as primary assessors as physicians for patients with knee osteoarthritis. However, economic evaluations of this model of care have not yet been described. To determine whether physiotherapists as primary assessors for patients with suspected knee osteoarthritis in primary care are a cost-effective alternative compared with traditional physician-led care, we conducted a cost-effectiveness analysis alongside a randomized controlled pragmatic trial.

Methods

Patients were randomized to be assessed and treated by either a physiotherapist or physician first in primary care. A cost-effectiveness analysis compared costs and effects in quality adjusted life years (QALY) for the different care models. Analyses were applied with intention to treat, using complete case dataset, and missing data approaches included last observation carried forward and multiple imputation. Non-parametric bootstrapping was conducted to assess sampling uncertainty, presented with a cost-effectiveness plane and cost-effectiveness acceptability curve.

Results

69 patients were randomized to a physiotherapist (n = 35) or physician first (n = 34). There were significantly higher costs for physician visits and radiography in the physician group (p < 0.001 and p = 0.01). Both groups improved their health-related quality of life 1 year after assessment compared with baseline. There were no statistically significant differences in QALYs or total costs between groups. The incremental cost-effectiveness ratio for physiotherapist versus physician was savings of 24,266 €/lost QALY (societal perspective) and 15,533 €/lost QALY (health care perspective). There is a 72–80% probability that physiotherapist first for patients with suspected knee osteoarthritis is less costly and differs less than ±0.1 in QALY compared to traditional physician-led care.

Conclusion

These findings suggest that physiotherapist-led care model might reduce health care costs and lead to marginally less QALYs, but confidence intervals were wide and overlapped no difference at all. Health consequences depending on the profession of the first assessor for knee osteoarthritis seem to be comparable for physiotherapists and physicians. Direct access to physiotherapist in primary care seems to lead to fewer physician consultations and radiography. However, larger clinical trials and qualitative studies to evaluate patients’ perception of this model of care are needed.

Clinical trial registration

The study was retrospectively registered in clinicaltrial.gov, ID: NCT03822533.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05201-3.

Physiotherapists’ perception of physicians’ referral of patients for physiotherapy in the Nigerian health system

Background

As the physiotherapy profession gradually evolves into a more autonomous profession, physicians continue to play a major role in the clinical practice of physical therapists globally, particularly as a source of patient referral. Therefore, an evaluation of Nigerian physiotherapists’ (NPTs) perception of physician’s referral (PR) of patients for physiotherapy may be a critical indicator of the relationship between the two professionals in the Nigerian health sector. The objective of the study was to determine the perception of Nigerian NPTs on the PR of patients for physiotherapy and the influence of demographic characteristics on the perception. The study was an online survey involving one hundred and fifty-four respondents. The instrument for the study was an 11-item self-developed questionnaire with two domains: demographics and perception. The participants were blind respondents reached through different physiotherapists’ WhatsApp platforms in Nigeria. The responses were collated electronically after 2 months and analyzed with the Statistical Package for Social Sciences (SPSS) version 23.

Results

The respondents have a negative perception of the 9 out of the 11-questionnaire items that were used to test the physiotherapists’ perception of the physicians’ referral of patients for physiotherapy in Nigeria health facilities. There was no significant difference (p>0.05) across the respondents’ gender, place of employment, areas of specialization, and educational qualifications and the respondents’ perception of doctors’ referrals of patients for physiotherapy. However, there was a significant difference (p<0.05) in each of the participants’ perceptions across the respondents’ years of practice, with the participants who had less than 5 years of practice having the least score.

Conclusions

Nigerian physiotherapists have a negative perception of physicians’ referral of patients for physiotherapy, and the perception was only influenced by the years of practice of the respondents.

Implementation of Direct Access Physical Therapy Within the Military Medical System

INTRODUCTION

Readiness is the Army's number one priority. Physical therapists (PTs) are musculoskeletal (MSK) experts and have been serving as physician extenders in a direct access role in the military since Vietnam. Utilizing a PT in the direct access role has demonstrated a reduction in imaging, medication prescribed, number of physical therapy visits, and overall reduction in healthcare utilization.

MATERIALS AND METHODS

The Joint Base Lewis-McChord physical therapy service line initiated a readiness-focused direct access initiative in May 2018. A simple algorithm was developed to help screen and identify appropriate service members for direct access physical therapy sick call. Physical therapy sick call hours were established at seven Joint Base Lewis-McChord Physical Therapy clinics.

RESULTS

During the initial 18 months of this direct access PT initiative, a total of 3,653 initial physical therapy evaluations were completed. Injury location included 26% (953) knee, 26% (945) ankle, 16% (585) low back, 15% (551) shoulder, 9% (316) hip, and 8% (303) leg.

CONCLUSION

In the military, where readiness is the number one priority, it is essential that we optimize the medical resources available to our service members in order to minimize lost duty days and overall long-term disability. This project demonstrates a way to optimize the military healthcare system in order to reduce cost and healthcare utilization and minimize duty days lost to MSK injuries. Utilizing a conservative estimate, $3.6 million was potentially saved in military healthcare utilization costs. The subanalysis performed at one clinic comparing referral-based care with the direct access model demonstrated a reduction in imaging, days on profile, cost savings, reduction in referral to specialty care, and decreased long-term disability. In the military healthcare system, where our primary care team resources are limited, it is important to consider the PT as part of the acute MSK injury management team.

Physiotherapists' perspectives on barriers to implementation of direct access of physiotherapy services in the United Arab Emirates: A cross-sectional study

BACKGROUND

There are two primary ways of accessing physiotherapy for service users around the world. The direct access, as opposed to the indirect access which requires a referral from a general physician, has several merits including better quality, timeliness, cost effectiveness of treatment and better probability of preventing acute conditions from turning into chronic ailments. Despite these benefits, several countries including the UAE, do not allow direct access to physiotherapists. This study aims to understand the level of awareness among practicing physiotherapists in the United Arab Emirates (UAE) about direct access and to determine whether any of their demographic variables influence the way they perceive the concept. Further, the study sought to explore the perceived barriers and benefits of direct access according to the participating physiotherapists.

SUBJECTS AND METHODS

An observational cross-sectional study was employed. The questionnaire survey developed by Bury and Stokes in 2013 was adapted and employed in this study. The instrument had six sections with close-ended items using a Likert five-point scale to rate them. Two hundred and sixty-four physiotherapists answered the questionnaire shared with them through a web link. Finally, MANOVA was employed to explore any influence of demographic variables on the opinions of the respondents.

RESULTS

The findings showed that 70% of participants were aware about direct access while nearly 30% were completely unaware. Younger physiotherapists were more willing to endorse the practice whereas older ones were more apprehensive of the barriers. The main barriers reported were the limited support from the physicians and policy makers, professional autonomy, and the limited scope of practice for the physiotherapists, as well as evidence-based practice. The impact of demographic variables on direct access indicated that physiotherapists under the age of 23 endorsed direct access more strongly than other age groups.

CONCLUSION

More efforts are needed to implement direct access in the UAE, considering the benefits of improved professional status, cost savings, patient satisfaction, and higher efficiency. This study recommends leadership support, professional autonomy, and mentorship as possible ways to achieve this goal.

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.

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.

Telehealth and Physical Therapy Clinical Decision Making in a Patient with a Falcine Meningioma

Telehealth utilizes information technologies and communication networks to deliver healthcare and education with lower costs and improved access, quality, and efficiency of healthcare services. This report describes the application of telehealth for medical screening, clinical decision making, and medical referral in a physical therapy practice. The patient described was a 50-year old man who contacted his physical therapist via telephone for a chief complaint of worsening left sided numbness and tingling that began insidiously 2 days prior. Further questioning revealed that the patient also complained of left ankle weakness, and slight unsteadiness with walking. He had not been feeling well and had been experiencing increasing bouts of unexplained fatigue over the previous two months that were now interfering with his work and recreational activities. The patient was evaluated by his physician the next day. Magnetic resonance imaging of the brain revealed a large (4 cm) falcine meningioma in the right parietal region. The patient was immediately referred to a neurosurgeon and underwent a craniotomy and tumor resection ten days later and subsequent gamma knife radiosurgery of the residual tumor bed two months after craniotomy and tumor resection. Follow-up imaging one year later revealed no evidence of recurrence or residual tumor. This patient case underscores the importance of recognizing signs and symptoms of serious disease, and how referral following telehealth via telephone can inform diagnosis.

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.

Physical therapy musculoskeletal imaging authority: A survey of the World Confederation for Physical Therapy Nations

OBJECTIVES

Medical evidence largely supports PTs in expanded roles, however, healthcare policy within the United States (USA) typically restricts PTs from ordering musculoskeletal (MSK) imaging. It is unknown how MSK imaging policy in the USA compares to other World Confederation for Physical Therapy (WCPT) member nations. The primary objective of our study was to investigate the authority of PTs to order MSK imaging. A secondary objective was to identify factors associated with the authority for PTs to order MSK imaging.

METHODS

111 WCPT member nations were surveyed over a 2-month period on the authority of PTs ordering MSK imaging within their nation. A secondary analysis utilizing a step-wise binary regression compared member nation demographic statistics to MSK imaging authority.

RESULTS

81 member nations responded to the survey. 31 (38.3%) of member nations reported having some level of PT MSK imaging authority while 50 (61.7%) did not. Member nations with lower per capita healthcare costs were significantly more likely to allow PTs to order MSK imaging (p = 0.02). Those with direct access authority were 7.4 times more likely to authorize PTs to order MSK imaging (p < 0.01). Entry-level clinical degree and years of entry-level collegiate credit were not associated with imaging authority.

CONCLUSION

This is the first study to report MSK imaging policy within the WCPT member nations. While many nations within the WCPT allow PTs to order MSK imaging, the majority of nations still restrict PTs from such practice. Lower per capita healthcare costs and direct access authority were significant predictors of MSK imaging authority, however, causation cannot be established within the confines of this study. Future studies should consider issues such as restrictive policy origin (i.e. governmental vs. institutional), insurance reimbursement (i.e. private vs. public sector policy), and limitations on imaging modality.

Concordance between physiotherapists and physicians for care of patients with musculoskeletal disorders presenting to the emergency department

Background

Overcrowding in emergency departments (ED) is a major concern worldwide. To answer increasing health care demands, new models of care including advanced practice physiotherapists (APP) have been implemented in EDs. The purpose of this study was to assess diagnostic, treatment and discharge plan concordance between APPs and ED physicians for patients consulting to the ED for minor musculoskeletal disorders (MSKD).

Methods

Patients presenting to two EDs in Montréal (Canada) with a minor MSKD were recruited and independently assessed by an APP and ED physician. Both providers had to formulate diagnosis, treatment and discharge plans. Cohen’s kappa (κ) and Prevalence and Bias Adjusted Kappas (PABAK) with associated 95%CI were calculated. Chi Square and t-tests were used to compare treatment, discharge plan modalities and patient satisfaction between providers.

Results

One hundred and thirteen participants were recruited, mean age was 50.3 ± 17.4 years old and 51.3% had an atraumatic MSKD. Diagnostic inter-rater agreement between providers was very good (κ = 0.81; 95% CI: 0.72–0.90). In terms of treatment plan, APPs referred significantly more participants to physiotherapy care than ED physicians (κ = 0.27; PABAK = 0.27; 95% CI: 0.07–0.45; p = 0.003). There was a moderate inter-rater agreement (κ = 0.46; PABAK = 0.64; 95% CI: 0.46–0.77) for discharge plans. High patient satisfaction was reported with no significant differences between providers (p = 0.57).

Conclusion

There was significant agreement between APPs and ED physicians in terms of diagnosis and discharge plans, but more discrepancies regarding treatment plans. These results tend to support the integration of APPs in ED settings, but further prospective evaluation of the efficiency of these types of models is warranted.

The impact of direct access physiotherapy compared to primary care physician led usual care for patients with musculoskeletal disorders: a systematic review of the literature

PURPOSE

To update and appraise the available evidence with respect to the impact of direct access physiotherapy compared to primary care physician-led usual medical care for patients with musculoskeletal disorders in terms of efficacy, health care utilization and processes, health care costs, patient satisfaction, and compliance.

MATERIALS AND METHODS

Systematic searches were conducted in five bibliographic databases up to June 2019. Studies presenting quantitative data of any research related to direct access physiotherapy for patients with musculoskeletal disorders were included. Two independent raters reviewed the studies, conducted the methodological quality assessment and a data extraction regarding patient outcomes, adverse events, health care utilization and processes, patient satisfaction, and health care costs.

RESULTS

Eighteen studies of weak to moderate quality were included. Five studies found no significant differences in pain reduction between usual primary care physician-led medical care and direct access physiotherapy. Four studies reported better clinical outcomes in patients with direct access in terms of function and quality of life. In terms of health care costs, four studies demonstrated that costs were lower with direct access and one study reported similar costs between both types of care.

CONCLUSION

Emerging evidence of weak to moderate quality suggest that direct access physiotherapy could provide better outcomes in terms of disability, quality of life, and healthcare costs compared to primary physician-led medical care for patients with musculoskeletal disorders but not for pain outcomes. These conclusions could be modified when higher quality trials are published.

CLINICAL RELEVANCE

Direct access physiotherapy for patients with musculoskeletal disorders appears as a promising model to improve efficiency of care and reduce health care costs, but more methodologically sound studies are required to formally conclude.

TRIAL REGISTRATION PROSPERO

#CRD42018095604IMPLICATIONS FOR REHABILITATIONEmerging evidence of weak to moderate quality indicates that direct access physiotherapy could provide better outcomes in terms of disability, quality of life and healthcare costs compared to primary physician led usual medical care for musculoskeletal disorders patients.Direct access physiotherapy may lead to increased access to care and a more efficient use of health care resources.Direct access physiotherapy does not appear to improve pain outcomes compared to primary care physician-led usual medical care.

Ordering of Diagnostic Imaging by Physical Therapists: A 5-Year Retrospective Practice Analysis

BACKGROUND

Significant progress has been made in implementing direct access. As more therapists transition into direct access roles, it seems prudent to consider how additional resources common to other first-contact providers might impact patient care.

OBJECTIVES

Direct referral for diagnostic imaging by physical therapists is relatively rare in the civilian setting and little has been published on the subject. The primary objective of this study was to examine the appropriateness of diagnostic imaging studies referred by civilian physical therapists at an academic medical center. Secondary objectives were to track reimbursement data and overall use rates.

DESIGN

This was a single-center, retrospective practice analysis of 10 physical therapists over a period of nearly 5 years.

METHODS

The electronic medical record was reviewed for each patient who had an imaging referral placed by a physical therapist. Relevant clinical exam findings and patient history were provided to a radiologist who then applied the American College of Radiology Appropriateness Criteria to determine appropriateness. Reimbursement data and therapist use rates were also evaluated.

RESULTS

Of the 108 total imaging studies, 91% were considered appropriate. Overall, use rates per direct access evaluation were 9% for plain film x-rays and 4% for advanced imaging. Reimbursement was 100%.

LIMITATIONS

This study was limited to 10 physical therapists at 1 practice location. Appropriateness was evaluated by 1 radiologist. The educational background of referring therapists was not evaluated.

CONCLUSIONS

Physical therapists demonstrated appropriate use of diagnostic imaging in the vast majority of cases (91%). They were judicious in their use of imaging, and there were no issues with reimbursement. These findings could be useful for physical therapists interested in acquiring diagnostic imaging referral privileges.

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.

Team-based musculoskeletal assessment and healthcare quality indicators: A systematic review

The primary objective of this review was to describe health quality indicator (HQI) outcomes of team-based musculoskeletal (MSK) assessments aimed at directing patient care. Secondary objectives included determining the most commonly assessed HQIs, extent of team collaboration, and the healthcare practitioners that most commonly comprise MSK-assessment teams. This review was registered in the PROSPERO database and conducted according to PRISMA guidelines. Five databases were systematically searched to August 2017. Studies selected met a priori inclusion criteria and investigated an HQI outcome of a primary or intermediate care MSK team-based assessment aimed at directing treatment. Two independent raters assessed study quality [Downs and Black (DB) criteria] and level of evidence (Oxford Centre of Evidence-Based Medicine model). Ten studies were included. The majority were low-quality [median DB score 14/32 (range 6-18)] pre-experimental studies (level 4 evidence). Heterogeneity in methodology and HQIs precluded meta-analyses. Hospital length-of-stay (LOS; 3/10 studies) and pain level (3/10) were the most common HQIs investigated. Teams (9/10) were most commonly comprised of a physiotherapist and another healthcare practitioner. Most teams (8/10) demonstrated low-levels of collaboration. There is limited low-level evidence to suggest that team-based MSK assessments are associated with improved clinical outcomes (i.e., pain, quality-of-life) and shorter LOS.

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.

Evaluation of an advanced-practice physiotherapist in triaging patients with lumbar spine pain: surgeon-physiotherapist level of agreement and patient satisfaction

BACKGROUND

Surgery for lumbar spine pain is indicated for specific etiologies. Given the majority of individuals referred to spine surgeons are not surgical candidates, care delivery is inefficient, with consultations being of limited value for most. Using specially trained physiotherapists in triage is a human resource strategy that may optimize surgeons' time and the patient experience.

METHODS

An advanced-practice physiotherapist (APP) and a surgeon assessed consecutive patients with lumbar spine pain presenting at an academic health centre's spine surgery clinic. The second assessor was blinded to the outcome of the first. We used the κ statistic to evaluate surgeon-APP level of chance-corrected agreement concerning patients' need for a surgical consultation. To assess satisfaction with the APP, patients completed a modified version of the validated Visit-specific Questionnaire.

RESULTS

The sample included 102 participants (54 women) with a mean age of 54.3 ± 14.3 years and a mean Oswestry Disability Index score of 35.4 ± 16.6. The assessors' overall agreement was 86%. The κ coefficient for the need for a surgical consultation was 0.69 (95% confidence interval 0.54-0.84). The APP identified that 77% of patients did not require a surgical consultation. Twenty-one patients underwent surgery. Satisfaction scores for the APP were very high (mean score 92 out of 100).

CONCLUSION

In triaging patients with lumbar spine pain, the APP and surgeon had a high level of agreement. An APP performing triage at a surgical centre can effectively reduce wait lists by 70%, reserving surgical consultations for those patients in whom they are indicated.

Systematic Clinical Reasoning in Physical Therapy (SCRIPT): Tool for the Purposeful Practice of Clinical Reasoning in Orthopedic Manual Physical Therapy

BACKGROUND AND PURPOSE

Clinical reasoning is essential to physical therapist practice. Solid clinical reasoning processes may lead to greater understanding of the patient condition, early diagnostic hypothesis development, and well-tolerated examination and intervention strategies, as well as mitigate the risk of diagnostic error. However, the complex and often subconscious nature of clinical reasoning can impede the development of this skill. Protracted tools have been published to help guide self-reflection on clinical reasoning but might not be feasible in typical clinical settings.

CASE DESCRIPTION

This case illustrates how the Systematic Clinical Reasoning in Physical Therapy (SCRIPT) tool can be used to guide the clinical reasoning process and prompt a physical therapist to search the literature to answer a clinical question and facilitate formal mentorship sessions in postprofessional physical therapist training programs.

OUTCOMES

The SCRIPT tool enabled the mentee to generate appropriate hypotheses, plan the examination, query the literature to answer a clinical question, establish a physical therapist diagnosis, and design an effective treatment plan. The SCRIPT tool also facilitated the mentee's clinical reasoning and provided the mentor insight into the mentee's clinical reasoning. The reliability and validity of the SCRIPT tool have not been formally studied.

DISCUSSION

Clinical mentorship is a cornerstone of postprofessional training programs and intended to develop advanced clinical reasoning skills. However, clinical reasoning is often subconscious and, therefore, a challenging skill to develop. The use of a tool such as the SCRIPT may facilitate developing clinical reasoning skills by providing a systematic approach to data gathering and making clinical judgments to bring clinical reasoning to the conscious level, facilitate self-reflection, and make a mentored physical therapist's thought processes explicit to his or her clinical mentor.

Diagnostic validity of physical examination tests for common knee disorders: An overview of systematic reviews and meta-analysis

INTRODUCTION

More evidence on diagnostic validity of physical examination tests for knee disorders is needed to lower frequently used and costly imaging tests.

OBJECTIVE

To conduct a systematic review of systematic reviews (SR) and meta-analyses (MA) evaluating the diagnostic validity of physical examination tests for knee disorders.

METHODS

A structured literature search was conducted in five databases until January 2016. Methodological quality was assessed using the AMSTAR.

RESULTS

Seventeen reviews were included with mean AMSTAR score of 5.5 ± 2.3. Based on six SR, only the Lachman test for ACL injuries is diagnostically valid when individually performed (Likelihood ratio (LR+):10.2, LR-:0.2). Based on two SR, the Ottawa Knee Rule is a valid screening tool for knee fractures (LR-:0.05). Based on one SR, the EULAR criteria had a post-test probability of 99% for the diagnosis of knee osteoarthritis. Based on two SR, a complete physical examination performed by a trained health provider was found to be diagnostically valid for ACL, PCL and meniscal injuries as well as for cartilage lesions.

CONCLUSION

When individually performed, common physical tests are rarely able to rule in or rule out a specific knee disorder, except the Lachman for ACL injuries. There is low-quality evidence concerning the validity of combining history elements and physical tests.

Perceived quality of physiotherapist-led orthopaedic triage compared with standard practice in primary care: a randomised controlled trial

BACKGROUND

Physiotherapist-led orthopaedic triage, where physiotherapists diagnose and determine management plans, aims to enhance effectiveness and provide the best care. However, scientific evidence for the effectiveness of this model of care remains limited, and there are few studies reporting on patients' perceptions of the care provided. The purpose of this study was to evaluate patients' perceived quality of care in a physiotherapist-led orthopaedic triage in primary care, compared with standard practice.

METHODS

In a randomised controlled trial, patients of working age referred for orthopaedic consultation at a primary healthcare clinic in Sweden received either physiotherapist-led triage (n = 102) or standard practice (orthopaedic surgeon assessment) (n = 101). Neither subjects nor clinicians were blinded. The questionnaire Quality from the Patient's Perspective (QPP) was used to evaluate perceived quality of care focusing on the caregivers' medical-technical competence and identity-orientated approach. Also, to what extent patients' expectations were met, and their intention to follow advice was evaluated.

RESULTS

For this study, 163 patients (80 %) were analysed (physiotherapist-led triage (n = 83), standard practice (n = 80)). Participants perceived significantly higher quality of care with the triage than with the standard practice in regards to receiving best possible examination and treatment (medical-technical competence) (p < 0.001). This was also found in regards to receiving information about examination and treatment (p < 0.001), results (p < 0.001), and self-care (p < 0.001), the caregiver's understanding (p < 0.001), respect (p < 0.001) and commitment (p < 0.001) as well as the opportunity to participate in decision-making (p = 0.01) (identity-orientated approach). Participants in the physiotherapist-led triage group reported to a significantly higher extent that their expectations of the treatment were met (p < 0.001), as well as the intent to follow the advice and instructions received (p = 0.019).

CONCLUSIONS

This paper reports on patients' perceptions of quality of care in a physiotherapist-led orthopaedic triage compared with standard practice. Patients in both groups reported that they perceived good quality of care, with the patients in the physiotherapist-led triage reporting significantly higher perceived quality of care than those in the standard practice group. This model of care seems to meet patients' expectations and result in a greater intention to follow advice and instructions for self-management. Our findings are in line with existing literature that this model of care provides an opportunity to shape patient-centered care that can improve access and offer care on the most appropriate level, with maintained good quality of care.

TRIAL REGISTRATION

Clinical Trials NCT02265172 . Registered 10 June 2014.

Agreement Between a Physical Therapist and an Orthopedic Surgeon in Children Referred for Gait Abnormalities

PURPOSE

To compare diagnostic and treatment agreement between a physical therapist (PT) and a pediatric orthopedic surgeon for gait variations in children.

METHODS

This pilot study involved children referred to a pediatric orthopedic surgeon for typical gait variations. A PT and an orthopedic surgeon individually assessed each child, making conclusions regarding diagnoses, treatment, and follow-up. Agreement was determined using κ values.

RESULTS

Twenty-five children (9 months to 11 years) were assessed. The PT and the surgeon had substantial agreement on contributors to the atypical gait patterns (76% agreement; κ = 0.67; 95% confidence interval [CI] = 0.45-0.90) and almost perfect agreement on underlying diagnosis of gait variation (93% agreement; κ = 0.89; 95% CI = 0.75-1.0), with substantial agreement for treatment (82% agreement; κ = 0.72; 95% CI = 0.47-0.97) and follow-up recommendations (84% agreement; κ = 0.63; 95% CI = 0.24-1.0).

CONCLUSIONS

A pediatric PT and an orthopedic surgeon had substantial to almost perfect agreement for diagnoses, treatment, and follow-up in children referred for gait abnormalities.

The Clinical Effectiveness of the Extended-Scope Physiotherapist Role in Musculoskeletal Triage: A Systematic Review

BACKGROUND

Extended-scope physiotherapists (ESPs) are working in musculoskeletal (MSK) triage clinics to assess, diagnose and refer patients for appropriate management. However, there is inadequate appraisal of their clinical effectiveness.

OBJECTIVES

The aim of the present systematic review was to appraise the evidence on the diagnostic ability of ESPs in MSK triage, and patient and general practitioner (GP) satisfaction when seen by an ESP in a MSK clinic.

METHOD

CINAHL, AMED, MEDLINE and EMBASE databases were searched from 1989 to February 2014 using the keywords 'physiotherapy', 'extended practitioner' and 'musculoskeletal disease'. Data extraction was compiled using the Centre for Reviews and Dissemination (2009) method. Diagnostic accuracy studies were assessed for methodological quality using the Scottish Intercollegiate Guideline Network (SIGN). Patient/GP satisfaction was assessed using a tool adapted by Desmeules et al. (2012).

RESULTS

From 146 studies initially identified, 14 were eligible for review. Only one diagnostic study was of high quality, and satisfaction study scores ranged from 40% to 73%. All studies reported favourable outcomes for ESPs in MSK triage clinics, with ESPs demonstrating a good level of diagnostic ability in comparison with a gold standard such as surgery. In addition, patients and GPs were satisfied with the overall performance and service provided by ESPs.

CONCLUSION

The evidence suggests that ESPs are clinically effective. However, there were methodological shortcomings in the reviewed studies, and further research, using larger sample sizes, multiple locations and comparisons of the same patient cohorts, would strengthen the evidence available to influence future commissioning of these services. Copyright © 2015 John Wiley & Sons, Ltd.

Imaging in conjunction with physical therapy in management of a patient with history of thoracic tumour

BACKGROUND

Physical therapy care for musculoskeletal conditions includes an ongoing process that systematically considers and prioritises diagnostic hypotheses. These diagnostic hypotheses include those that are typical for common musculoskeletal conditions, and must also include more rare conditions that would require care outside the scope of practice of the physical therapist. When additional screening is required, physical therapists collaborate with other providers or directly order the appropriate tests to rule out suspected pathology.

CASE DESCRIPTION

This article illustrates the use of musculoskeletal imaging ordered by a physical therapist to guide ongoing management of a patient with back pain and a history of cancer.

OUTCOMES

The patient successfully returned to moderate-intensity sport activities after a course of physical therapy.

DISCUSSION

This case provides an example of how clinical diagnostic reasoning combined with clinical privileges to order musculoskeletal imaging can facilitate diagnostic accuracy in a timely and cost-efficient manner.

Ordering diagnostic imaging: a survey of ontario physiotherapists' opinions on an expanded scope of practice

PURPOSE

To explore Ontario physiotherapists' opinions on their ability to order diagnostic imaging (DI).

METHODS

An online questionnaire was sent to all registered members of the College of Physiotherapists of Ontario. Descriptive statistics were calculated using response frequencies. Practice characteristics were compared using χ(2) tests and Wilcoxon rank-sum tests.

RESULTS

Of 1,574 respondents (21% response rate), 42% practised in orthopaedics and 53% in the public sector. Most physiotherapists were interested in ordering DI (72% MRI/diagnostic ultrasound, 78% X-rays/computed tomography scans). Respondents with an orthopaedic caseload of 50% or more (p<0.001) and those in the private sector (p<0.001) were more interested in ordering DI. Respondents preferred a DI course that combined face-to-face and Web-based components and one that was specific to their area of practice. Most respondents perceived minimal barriers to the uptake of ordering DI, and most agreed that support from other health care professionals would facilitate uptake.

CONCLUSION

The majority of Ontario physiotherapists are interested in ordering DI. For successful implementation of a health care change, such as physiotherapists' ability to order DI, educational needs and barriers to and facilitators of the uptake of the authorized activity should be considered.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

An overview of 5 years of patient self-referral for physical therapy in the Netherlands

BACKGROUND

Self-referral for physical therapy was introduced in 2006 in the Netherlands. Internationally, debate on self-referral is still ongoing.

OBJECTIVE

The aim of this study was to evaluate the effects of self-referral for physical therapy in the Netherlands, focusing on volume of general practice and physical therapy care (incidence rates and utilization of services).

DESIGN

The study was based on monitoring data from existing data sources.

METHODS

Longitudinal electronic medical record data from general practitioners (GPs) and physical therapists participating in the NIVEL Primary Care Database were used, as well as public data from Statistics Netherlands. Descriptive statistics and Poisson multilevel regression analyses were used for analyzing the data.

RESULTS

Incidence rates of back (including low back), shoulder, and neck pain in general practice declined slightly from 2004 to 2009. No linear trends were found for number of contacts in GP care for back (including low back) and neck pain. The number of patients visiting physical therapists and the proportion of self-referrers are growing. Self-referrers receive treatment less often after initial intake than referred patients, and the mean number of visits is lower.

LIMITATIONS

This study was based on data of various patient populations from existing data sources.

CONCLUSIONS

The current study indicates that self-referral in the Netherlands has fulfilled most expectations held prior to its introduction, although no changes to the workload of GP care have been found. Use of physical therapy grew, but due to population aging and increasing prevalence of chronic diseases, it remains unclear whether self-referral affects health care utilization. Therefore, cost-benefit analyses are recommended.

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

Purpose

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

Design/methodology/approach

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

Findings

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

Originality/value

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