Physical Therapists' Ability to Distinguish Between Inflammatory and Noninflammatory Arthritis and to Appropriately Refer Patients to a Rheumatologist

Do physical therapists follow evidence-based practices for treatment of inflammatory arthritis? Results from an online survey

BACKGROUND

Physical therapists (PTs) should know how to best treat patients with inflammatory arthritis.

OBJECTIVE

To document interventions chosen by PTs for patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS) and whether choices follow evidence-based practice.

METHODS

Licensed musculoskeletal PTs in Quebec, Canada responded to an online survey. Descriptive statistics illustrated proportions for each treatment choice and inferential statistics explored associations with demographic and practice-related factors.

RESULTS

There were 298 PTs who responded to the survey. For both RA and AS respectively, most common interventions were mobility exercises (91.0%; 98.3%) and patient education (90.1%; 92.8%). For both cases, slightly >60% selected strengthening exercises. Passive forms of therapy were chosen by 36% of PTs for RA and 58% for AS. Aerobic exercise was rarely selected. PTs working in the public sector were less likely to use manual therapy for both RA (Odds Ratio (OR) 0.43, 95% confidence interval (CI) 0.22,0.86) and AS (OR 0.46, 95% CI 0.22,0.97).

CONCLUSIONS

Most PTs chose mobility exercises and patient education, representing evidence-based approaches. Despite current recommendations, strengthening and especially aerobic exercises were not used as much. There is a need to increase awareness regarding the benefits of strengthening and aerobic exercise for these patients.

A UK survey evaluation of First Contact Practitioners' and musculoskeletal physiotherapists' confidence, recognition, and referral of suspected axial spondyloarthritis

BACKGROUND

Axial Spondyloarthritis is an inflammatory disease associated with significant diagnostic delays. Steen et al. (2021) found inadequate consideration of axial Spondyloarthritis (axSpA) in physiotherapists back pain assessments. Since the previous survey, increased professional education on axSpA has occurred and First Contact Practitioners (FCPs), now widely established in General Practice, are key in supporting earlier recognition.

OBJECTIVES

(1) To re-evaluate physiotherapists' and evaluate FCPs' awareness, knowledge, and confidence in screening for and recognising features of axSpA and criteria prompting referral to rheumatology. (2) To compare these results to previous research (Steen et al., 2021).

DESIGN

As per Steen et al. (2021), an online survey was undertaken combining back pain vignettes (reflecting axSpA, non-specific low back pain [NSLBP] and radicular syndrome) and questioning on features of suspected axSpA.

RESULTS

165 surveys were analysed. Only 73% (n = 120/165) of respondents recognised the axSpA vignette compared to NSLBP 91% (n = 80/88) and radicular syndrome 88% (n = 68/77). An improvement in axSpA recognition was demonstrated compared with previous data. FCPs performed slightly better with 77% (n = 67/87) of respondents recognising the axSpA vignette. Adequate awareness of national referral guidance was evident in only 55% of 'clinical reasoning' and 6% of 'further subjective screening' responses. There was still misplaced confidence in recognising clinical features of axSpA compared to knowledge levels shown, including high importance given to inflammatory markers.

CONCLUSION(S)

Musculoskeletal physiotherapists demonstrate some improved knowledge and awareness of axSpA compared with previous study findings. Consideration of axSpA is still not universal in musculoskeletal physiotherapists' or FCPs' approaches to persistent back pain assessments and awareness of national referral guidance remains limited. This study highlights the continued need for professional education. Enhanced knowledge of screening and referral criteria in musculoskeletal clinical practice would support earlier diagnosis and better outcomes.

Knowledge and appropriateness of care of family physicians and physiotherapists in the management of shoulder pain: a survey study in the province of Quebec, Canada

BACKGROUND

Shoulder pain is difficult to diagnose and treat with half of those affected still symptomatic six months after initial consultation. This may be explained by primary care management not conforming to evidence-based practice. This survey evaluated physiotherapists (PTs) and family physicians' (FPs) knowledge and appropriateness of care in shoulder pain management.

METHODS

A survey sent to PTs and FPs in the province of Quebec, Canada presented four clinical vignettes with cases of rotator cuff (RC) tendinopathy, acute full-thickness RC tear, adhesive capsulitis and traumatic anterior glenohumeral instability. Respondents indicated diagnosis, indications for imaging, specialists' referrals, and choice of treatments. Answers were compared to recommendations from clinical practice guidelines (CPGs). Participants' responses were compared between types of providers with Fisher's exact test.

RESULTS

Respondents (PTs = 175, FPs = 76) were mostly women with less than ten years of experience. More than 80% of PTs and 84% of FPs correctly diagnosed cases presented. Despite this practice not being recommended, more FPs than PTs recommended an imaging test in the initial management of RC tendinopathy (30% compared to 13%, p = 0.001) and adhesive capsulitis (51% compared to 22%, p = 0.02). For full-thickness RC tear and shoulder instability, up to 72% of FPs and 67% of PTs did not refer to a specialist for a surgical opinion, although recommended by CPGs. For RC tendinopathy, 26% of FPs and 2% of PTs (p < 0.001) would have prescribed a corticosteroid infiltration, which is not recommended in the initial management of this disorder. For adhesive capsulitis, significantly more FPs (76%) than PTs (62%) (p < 0.001) suggested an intra-articular corticosteroid infiltration, as recommended by CPGs. For all presented vignettes, up to 95% of family physicians adequately indicated they would refer patients for physiotherapy. In prioritizing rehabilitation interventions, up to 42% of PTs did not consider active exercises as a priority and up to 65% selected passive modalities that are not recommended for all shoulder pain vignettes.

CONCLUSIONS

Most FPs and PTs were able to make adequate diagnoses and select appropriate treatments for shoulder pain, but practices opposed to evidence-based recommendations were chosen by several respondents. Further training of FPs and PTs may be needed to optimize primary care management of different shoulder disorders.

Rheumatologists' Acceptance of Patient Referrals from Physical Therapists

We surveyed Canadian rheumatologists regarding beliefs about physical therapists' (PTs) ability to refer patients appropriately to rheumatologists and whether they would accept such referrals. Most (86.9%) believed that PTs can appropriately refer to rheumatologists. However, only 48.2% of rheumatologists would be very or extremely likely to accept a referral from a PT they knew, and 23.5% would accept a referral from a PT they did not know. Conversely, 90.5% would accept a referral from a PT if they could bill it as a full consult. We conclude that being able to bill PT referrals as full consults may potentially enhance the acceptance of PT referrals.