Triage of knee pain by an Extended Scope Physiotherapist (ESP) in an orthopaedic clinic: A clinical audit

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.

"You're stuck in the middle here": a qualitative study of GPs' experiences of managing knee pain attributed to a degenerative meniscal tear

BACKGROUND

Exercise is the recommended first-line therapy for a degenerative meniscal tear (DMT). Despite this, knee pain attributed to DMTs are a common presentation to specialist orthopaedic clinics. In the primary care setting, the general practitioner (GP) plays a central role in managing patients with knee pain, but to date their perspective has not been explored in relation to DMTs. This study explored GPs' experiences of managing people with knee pain attributed to a DMT.

METHODS

A qualitative research design was adopted and practices in the South and Mid-West of Ireland were contacted via recruitment emails circulated through professional and research networks. Interested GPs contacted the researchers via email, and purposive and snowball sampling was used for recruitment. Semi-structured interviews were conducted online or over the telephone. Interviews were digitally recorded and transcribed. Data was analysed using an inductive approach to thematic analysis. Ethical approval was granted by the Irish College of General Practitioners (ICGP_REC_21_0031).

RESULTS

Seventeen semi-structured one-on-one interviews were conducted. Three main themes were identified with related subthemes: (1) GPs' experiences of relational aspects of care, (2) GP beliefs about what constitutes best care for patients with a DMT, and (3) how GP practice is enacted within the current healthcare setting. GPs described the challenge of maintaining a strong clinical alliance, while managing perceived patient expectations of a 'quick fix' and advanced imaging. They reported slowing down clinical decisions and feeling 'stuck' with limited options when conservative treatment had failed. GPs believed that exercise should be the core treatment for DMTs and emphasised engaging patients in an active approach to recovery. Some GPs believed arthroscopy had a role in circumstances where patients didn't improve with physiotherapy. Limited access to public physiotherapy and orthopaedic services hampered GPs' management plans and negatively impacted patient outcomes.

CONCLUSIONS

GP beliefs around what constitutes best care for a DMT generally aligned with the evidence base. Nonetheless, there was sometimes tension between these beliefs and the patient's own treatment expectations. The ability to enact their beliefs was hampered by limited access to conservative management options, sometimes leading to early escalation of care.

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.

Orthopaedic consultant surgeons perceptions of an advanced practice physiotherapy service in paediatrics: A qualitative study

OBJECTIVES

The objective of this study is to determine orthopaedic consultants' perceptions of an advanced practice physiotherapy (APP) service in paediatrics.

DESIGN

This is a qualitative study that use semi-structured interviews to explore consultant doctors' experiences of an APP paediatric orthopaedic service and its development. Data were transcribed verbatim and subsequently underwent thematic analysis.

PARTICIPANTS

Five orthopaedic consultants in two hospital settings participated, and all of whom had experience of working with paediatric orthopaedic APPs.

RESULTS

Seven themes were derived from the analysis, with all participants in the study identifying factors affecting the development of the service and demonstrating broad support for the APP role, with benefits noted as including improved efficiency of service, expansion of skill mix within the team, positive impressions of the standard of care and improved education and liaison with the families and community practitioners at large.

CONCLUSIONS

This paper highlights many of the factors that should be considered when introducing an APP service in an outpatient setting. This study demonstrates consistent cross-site positive regard in the skill and competency of the APP in paediatric orthopaedics, to enhance orthopaedic services for children.

Advancing Early Identification of Axial Spondyloarthritis: An Interobserver Comparison of Extended Role Practitioners and Rheumatologists

OBJECTIVE

To compare clinical impression and confidence of extended role practitioners (ERP) with those of rheumatologists experienced in axial spondyloarthritis (axSpA) according to (1) evaluation of patients with chronic back pain assessed for axSpA; and (2) magnetic resonance imaging (MRI) recommendation for further investigation of these patients.

METHODS

Patients with ≥ 3 months of back pain and age of onset < 45 years were referred for axSpA evaluation. An ERP assessed consecutive patients and recorded standardized clinical information in written form. Three rheumatologists subsequently evaluated each patient based on the recorded information. Patients were classified as having axSpA or mechanical back pain based on clinical and investigative findings. Level of confidence was noted for classification and MRI indication. Agreement between assessors was evaluated using percentage agreement and κ coefficient.

RESULTS

Fifty-seven patients were assessed. Interobserver agreement of clinical impression for all raters was moderate (κ = 0.52). Agreement of clinical impression between ERP and rheumatologists ranged between 71.2% (κ = 0.41) and 79.7% (κ = 0.57). Agreement of clinical impression among rheumatologists ranged from 74.1% (κ = 0.49) to 79.7% (κ = 0.58). All rater agreement for MRI indication was fair (κ = 0.37). ERP agreement with rheumatologist for MRI recommendation ranged from 64.2% (κ = 0.32) to 75% (κ = 0.48). Agreement for MRI indication among rheumatologists ranged from 62.9% (κ = 0.27) to 74% (κ = 0.47). Confidence in clinical impression was similar among all practitioners.

CONCLUSION

ERP with specialty training in inflammatory arthritis demonstrate clinical impressions comparable with those of rheumatologists in the assessment of axSpA. Incorporation of such roles into existing models of care may assist in early detection of axSpA.

Advanced musculoskeletal physiotherapy: Barriers and enablers to multi-site implementation

OBJECTIVES

Advanced musculoskeletal physiotherapy (AMP) services are a safe, effective model of care, but without broad-scale healthcare implementation to date. The aim of the present study was to identify the barriers and enablers to implementation of 12 AMP services from the perspective of clinical staff.

METHODS

In a qualitative study, 12 participants (physiotherapists), from 12 different healthcare networks (seven metropolitan, three regional, two rural), were included. Their departments implemented AMP services (orthopaedic postoperative joint replacement review, n = 10; general orthopaedic, n = 1; emergency, n = 1; and neurosurgery n = 1) over a 12-month period. Participants completed a structured survey specifically designed for the study. Thematic analysis was used, with themes mapped to the validated Theoretical Domains Framework.

RESULTS

Nine major themes emerged from the data regarding barriers and enablers to the implementation of the AMP services from the perspective of clinical staff. These were: demand/capacity; model of care; the organization; stakeholders; communication; planning and processes; evaluation; workforce; and learning and assessment framework. Important enablers included engagement and buy-in from key stakeholders and medical staff, and well-established AMP learning frameworks for training and operational frameworks. Barriers included competitive funding environment, and issues that hindered effective communication. The knowledge, skills, availability, motivation and experience of the advanced musculoskeletal physiotherapists had a large impact on the implementation.

CONCLUSIONS

The study identified a number of factors that should be considered for successful implementation of AMP services across healthcare services or wider healthcare networks.

Effect of extended scope physiotherapists assessments in orthopaedic diagnostic setting: a systematic review

BACKGROUND

Patients with musculoskeletal diseases can potentially be assessed by an extended scope physiotherapist (ESP) instead of by an orthopaedic surgeon (OS).

OBJECTIVES

To evaluate the effectiveness of the diagnostic musculoskeletal assessment performed by ESP compared to OS.

DATA SOURCES

MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, CINAHL, PEDro and reference lists of included studies and previous reviews were searched in November 2015.

ELIGIBILITY CRITERIA

Studies were included if they evaluated adults with a musculoskeletal disease referred to an outpatient orthopaedic clinic where a diagnostic assessment had been conducted by an ESP.

DATA EXTRACTION

Data were extracted using a customised data extraction sheet. Two reviewers using checklists evaluated methodological independently.

RESULTS

We included one randomised controlled trial and 31 observational studies. Diagnostic agreement between ESPs and OSs was 65 to 100% across studies. Health care cost savings for diagnostic assessments performed by ESPs were 27 to 49% compared to OSs. Overall, 77 to 100% of the patients were satisfied with the ESP assessment. Results were comparable on diagnostic agreement, cost and satisfaction in studies with high, moderate and low risk of bias.

LIMITATIONS

Risk of bias in the included studies.

CONCLUSION AND IMPLICATION OF KEY FINDINGS

Diagnostic assessments performed by ESP may be as beneficial as or even better than assessment performed by OSs in terms diagnostic agreement, costs and satisfaction. However, the methodological quality was generally too low to determine the clear effectiveness of ESP assessment, and more high quality studies are needed. Systematic review registration number: PROSPERO CRD42014014229.

Patient-reported outcome measures in advanced musculoskeletal physiotherapy practice: a systematic review

OBJECTIVE

Advanced practice physiotherapists (APPs), also known as extended scope physiotherapists, provide a new model of service delivery for musculoskeletal (MSK) disorders. Research to date has largely focused on health service efficiencies, with less emphasis on patient outcomes. The present systematic review aimed to identify the patient-reported outcome measures (PROMs) being utilized by APPs.

METHOD

A wide search strategy was employed, including the PubMed, Embase, CINAHL, CENTRAL and PEDro databases, to identify studies relating to PROMs utilized by APPs in MSK healthcare settings. PROMs identified were classified into predetermined outcome domains, with additional contextual data extracted.

RESULTS

Of the initial 12,302 studies, 38 met the inclusion criteria. These involved APPs across different settings, utilizing 72 different PROMs and most commonly capturing: Patient Satisfaction, Quality of Life (QoL), Functional Status, and Pain; and, less frequently: Global Status (i.e. overall improvement), Psychological Well-Being, Work ability, and Healthcare Consumption and Costs. The quality of the PROMs varied greatly, with Satisfaction most commonly measured utilizing non-standardized locally-devised tools; the EuroQol five-dimensions questionnaire (EuroQoL-5D) and 36-Item Short-Form (SF-36) cited most frequently to capture QoL; and the Visual Analogue Scale (VAS) to capture Pain. No key measure was identified to capture Functional Status, with 15 different tools utilized.

CONCLUSION

APPs utilized a multiplicity of PROMs across a range of MSK disorders. The present review will act as an important resource, informing the selection of outcomes for MSK disorders, with a view to greater standardization of outcome measurement in MSK clinical practice, service evaluation and research.

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.

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

INTRODUCTION

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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