General Practitioners' Views About an Orthopaedic Clinical Assessment Service

How is the emerging role of domiciliary physiotherapists who treat residents with dementia in nursing homes perceived by allied health professionals? A phenomenological interview study

Dementia affects majority of older residents in nursing homes and physiotherapists are regularly involved with this population. However, little is known about the role of physiotherapists who treat residents with dementia in nursing homes. The aim of this paper was to report on an interpretivist qualitative exploration of the perceptions of both the providers of and referrers to domiciliary physiotherapy for residents with dementia in nursing homes in London. In 2015, we conducted semi-structured interviews with 10 purposively sampled participants - two were providers of physiotherapy for residents with dementia in nursing homes, five were referrers to these providers and three occupied dual roles. A thematic analysis of the verbatim transcripts identified three main themes. First were perceptions of a multifaceted but unclear role, focused on both conventional 'physical' physiotherapy interventions and specialist care, the latter being reliant on knowledge and confidence that physiotherapists did not always feel they possessed. Second were the stated challenges to the role, including the focus and organisation of the nursing home setting, with perceived lack of emphasis on rehabilitation; the progressive and demanding nature of dementia itself; a lack of continuity of nursing home and visiting health professional staff with associated need to entrust physiotherapy intervention to multiple others and the final challenge was the difficulty measuring impact. Third, despite the challenges, enablers of the role were experienced, namely collaborative working and positive previous experiences of referrers. Joining these themes were underpinning concepts of complexity and uncertainty in relation to the physiotherapy role in this setting. This paper highlights a need for enhanced collaborative working in clinical practice, enabled at organisational level, to help address some of the uncertainties expressed around the physiotherapists' role with residents with dementia in nursing homes and thereby enable improvements to processes and outcomes of their interventions.

Views of general practitioners toward physiotherapy management of osteoarthritis-a qualitative study

Background: Osteoarthritis (OA) is a major cause of pain and physical disability, and general practitioners (GPs) are usually the first point of contact for patients. Physiotherapy has been shown as effective in the management of lower-limb OA. The aim was to explore the beliefs of GPs on the physiotherapy management of lower-limb OA in primary care. Methods: This is a qualitative study evaluating GP views about physiotherapy in Sheffield, South Yorkshire, UK. Participating GPs were recruited by systematic sampling, and invitation was given to GPs in 10 practices in the four localities in Sheffield. Semistructured interviews were completed and framework analysis was used to analyze the data. Results: Eight GPs were interviewed and six themes emerged from analysis of the data: perspective on OA, management strategy, views on patients, views on physiotherapy, working collaboratively, and suggestions for service improvements. GPs had a positive impression and knowledge of physiotherapy, but lacked understanding of the processes involved in treatment and limited awareness of clinical guidelines regarding the management of OA. Improvements in communication and collaborative working were critical issues suggested by the participants. Conclusion: This study found that GPs who were interviewed had a limited understanding on the role of physiotherapists and of clinical guidelines. Interprofessional communication was not as good as it should have been. A reconfiguration of the Sheffield musculoskeletal pathway may help achieve more effective collaborative working and a better outcome for patients.

Advanced practice physiotherapy in paediatric orthopaedics: innovation and collaboration to improve service delivery

INTRODUCTION

One in eight paediatric primary care presentations is for a musculoskeletal (MSK) disorder. These patients are frequently referred to paediatric orthopaedic surgeons; however, up to 50% of referrals are for normal variants. This results in excessive wait-times and impedes access for urgent surgical cases. Adult MSK medicine has successfully utilised advanced practice physiotherapists (APP) managing non-surgical candidates, with documented benefits both to patients and services. There is a gap in the literature with regard to APP in paediatric orthopaedics.

AIM

In this review, we investigate demands on paediatric orthopaedic services, examine the literature regarding APP in paediatric orthopaedics and explore the value the role has to offer current outpatient services.

RESULTS

Paediatric orthopaedic services are under-resourced with concurrent long wait times. Approximately 50% of referrals are for normal variants, which do not require specialist intervention. Poor musculoskeletal examination skills and low diagnostic confidence amongst primary care physicians have been identified as a cause of inappropriate referrals. APP clinics for normal variants have reported independent management rate and discharge rates of 95% and marked reduction in patient wait times.

CONCLUSION

There is limited evidence to support the APP in paediatric orthopaedics. Further studies are needed investigating diagnostic agreement, patient/stakeholder satisfaction, patient outcomes and economic evaluation. Paediatric orthopaedics is in crisis as to how to effectively manage the overwhelming volume of referrals. Innovative multidisciplinary solutions are required so that the onus is not solely on physicians to provide all services. The APP in paediatric orthopaedics may be part of the solution.