Accuracy of Clinical Diagnosis of Internal Derangement of the Knee by Extended Scope Physiotherapists and Orthopaedic Doctors

Autonomy-hindering scope for physiotherapy practice in African countries: Results of creatures and antinomies of regulatory laws

Background

Healthcare professionals in different countries are governed by laws and statutes for their scopes of practice to ensure that services are rendered by suitably licenced and qualified professionals in order to protect the public. A few of these laws are found to paradoxically hinder the autonomy of physiotherapy.

Objective

My article documents the autonomy-hindering scope for physiotherapy practice in selected African countries.

Method

The methodologies used in my article were both a review and comparative approach for the interpretation of statutes.

Results

Three African countries presented a clear legal definition of physiotherapy in their regulatory frameworks and regulated other rehabilitation professions as well. In my article, these regulations are referred to as ‘combo regulations’. The rationale for ‘combo regulations’ is not clear and found to hinder professional autonomy. Only one statute from Rwanda provided a scope for physiotherapy that was not autonomy-hindering.

Conclusion

There is, therefore, a need for urgent review of most laws regulating physiotherapy in the selected African countries to assist with the duty of protecting the public. All autonomy-hindering scopes for physiotherapy practice in African countries should be repealed and amended accordingly.

Clinical implications

A clear scope shall assist with protecting the public and clinical practice and clearly states ‘what physiotherapy is and what it is not’.

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.

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.

A Delphi Study of the Role Parameters and Requirements of Extended Scope Practice in Hand Therapy

Physiotherapists and occupational therapists working within hand therapy in the United Kingdom are undertaking roles working beyond their normal professional boundaries. The aim of this study was to reach consensus on the role parameters and required knowledge, training and competencies desirable for such extended roles. A panel of 21 expert stakeholders comprising hand therapy clinicians, educators, doctors, existing extended scope practitioners and a representative from a patient group participated in three survey rounds using the Delphi technique. They examined three groups of parameters with reference to the competencies, knowledge and activities desirable for such extended roles. A prioritised list of parameters was developed. Data were analysed using descriptive statistics. Response rates for each round were consistently 95% or greater. The results showed areas of clear consensus, with prioritisation supporting the development of an independent practitioner working without direct supervision by a medical practitioner. Specific criteria were identified for such practice with regards to knowledge, training and activities, such as the ability to order, understand and interpret clinical investigations. In-house formal training tailored to individual service needs was the favoured approach. The results of this study can inform the development of a national strategy for the implementation of new ways of working while ensuring the provision of a quality health service.

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.

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.

Triage for Patients with Spinal Complaints: A Systematic Review of the Literature

BACKGROUND AND PURPOSE

The aim of this study is to provide a systematic overview of the past decade of literature on processes of triage for patients with spinal pain, outcomes measured and markers of effectiveness.

METHODS

A systematic search of the literature with narrative synthesis of findings was conducted. Studies in English language of any design concerning spinal triage programmes for adults with acute or chronic spinal complaints were considered for inclusion. Electronic database searches were conducted in OVID, Medline, Embase, CINAHL, Health Source Nursing, Scopus and Web of Science. Additional references were sourced through pearling reference lists, and expert input. Findings were synthesized descriptively.

RESULTS

Of 216 potentially relevant records, 21 papers (20 studies) were included. There was little commonality in triage activities/programmes and outcomes, although physiotherapists were common members of triage programmes. Positive outcomes were reported most commonly for wait times, with several studies also reporting high levels of patient and physician satisfaction. Outcomes such as surgical conversion rates and selection accuracy were less clear.

DISCUSSION

Spinal triage programmes have the potential to improve efficiency of care for outpatients with spinal complaints. The evidence gaps in health outcomes, service models and cost effectiveness should be addressed by more robust prospective research designs. Copyright © 2015 John Wiley & Sons, Ltd.

Evaluating the outcomes of a podiatry-led assessment service in a public hospital orthopaedic unit

Background

In Australia, the demand for foot and ankle orthopaedic services in public health settings currently outweighs capacity. Introducing experienced allied health professionals into orthopaedic units to initiate the triage, assessment and management of patients has been proposed to help meet demand. The aim of this study was to evaluate the effect of introducing a podiatry-led assessment service in a public hospital orthopaedic unit. The outcomes of interest were determining: the proportion of patients discharged without requiring an orthopaedic appointment, agreement in diagnosis between the patient referral and the assessing podiatrist, the proportion of foot and ankle conditions presenting to the service, and the proportion of each condition to require an orthopaedic appointment.

Methods

This study audited the first 100 patients to receive an appointment at a new podiatry-led assessment service. The podiatrist triaged ‘Category 3’ referrals consisting of musculoskeletal foot and ankle conditions and appointments were provided for those considered likely to benefit from non-surgical management. Following assessment, patients were referred to an appropriate healthcare professional or were discharged. At the initial appointment or following a period of care, patients were discharged if non-surgical management was successful, surgery was not indicated, patients did not want surgery, and if patient’s failed to attend their appointments. All other patients were referred for an orthopaedic consultation as indicated.

Results

Ninety-five of the 100 patients (69 females and 31 males; mean age 51.9, SD 16.4 years) attended their appointment at the podiatry-led assessment service. The 95 referrals contained a total of 107 diagnoses, of which the podiatrist agreed with the diagnosis stated on the referral in 56 cases (Kappa =0.49, SE = 0.05). Overall, 34 of the 100 patients were referred to an orthopaedic surgeon and the remaining 66 patients were discharged from the orthopaedic waiting list without requiring an orthopaedic consultation.

Conclusions

Two-thirds of patients who had an appointment at the podiatry-led assessment service were discharged without requiring a surgical consultation. The introduction of a podiatry-led service assists with timely provision of patient care and ensures those with the greatest need for orthopaedic surgery have improved access to specialist care.

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.

Physiotherapy screening of patients referred for orthopaedic consultation in primary healthcare - a randomised controlled trial

A large proportion of patients who consult primary healthcare for musculoskeletal pain are referred for orthopaedic consultation, but only a small number of these patients are appropriate for orthopaedic intervention. Experienced physiotherapists have the appropriate knowledge to manage musculoskeletal disorders. The primary aim of this randomised study was therefore to evaluate a screening by a physiotherapist of patients referred for orthopaedic consultation compared to standard practice in primary care. Patients referred for orthopaedic consultation (n=203) were randomised to physiotherapy screening or standard practice. Selection accuracy for orthopaedic intervention and other referrals were analysed with proportion analysis. Patient views of the quality of care were analysed with Mann-Whitney U-test, waiting time with Independent t-test. There was higher selection accuracy for orthopaedic intervention in the physiotherapy screening group (p=0.002). A smaller proportion of patients in the screening group were referred back to their general practitioner (GP) (p<0.001) and a larger proportion to the physiotherapy clinic (p<0.001) compared to standard practice. The proportion of patients referred for further investigations was significantly lower in the physiotherapy screening group (p<0.039). Waiting time was shorter in the screening group (p<0.001). A large proportion of the patients reported no hesitation to attend the clinic for future care, no difference between the groups (p<0.95). The findings in this study suggest that an experienced physiotherapist effectively can screen patients referred for orthopaedic consultation in primary healthcare.

A single group follow-up study of non-surgical patients seen by physiotherapists working in expanded roles in orthopaedic departments: recall of recommendations, change in exercise and self-efficacy

BACKGROUND

Specially trained physiotherapists (advanced practice physiotherapists (APP)) are working in orthopaedic clinics to improve access to orthopaedic services and support chronic disease management. Little attention has been paid to the impact APPs may have on non-surgical patients. In non-surgical patients with hip or knee arthritis consulting an APP in an orthopaedic clinic, the objectives were to: 1) describe patients' recall of APP recommendations, use of self-management strategies, and barriers to management six weeks following consultation; and, 2) compare exercise behaviour and self-efficacy at baseline and six weeks.

FINDINGS

This was a single group pre-and post-intervention study of patients who saw an APP when consulting the orthopaedic departments of two hospitals. At baseline and six weeks participants completed the adapted Stanford Exercise Behaviour Scale (response options: none, < 60 minutes/week, 1-3 hours/week or > 3 hours/week), and the Chronic Disease Self-efficacy Scale (range 1-10; higher scores indicate higher self-efficacy). At follow-up participants completed questions on recall of APP recommendations, use of self-management strategies and barriers to management. Seventy three non-surgical patients with hip or knee arthritis participated, a response rate of 89% at follow-up. Seventy one percent of patients reported that the APP recommended exercise, of whom 83% reported exercising to manage their arthritis since the visit. Almost 50% reported an increase in time spent stretching; over 40% reported an increase in time spent walking or doing strengthening exercises at follow-up. Common barriers to arthritis management were time, cost and other health problems. Mean chronic disease self-efficacy scores significantly improved from 6.3 to 7.2 (p < 0.001). The mean difference was 0.95 (95% CI 0.43, 1.62); the effect size was 0.51.

CONCLUSIONS

This pilot study of an APP intervention for non-surgical patients referred for orthopaedic consultation showed promising results, particularly for enhancing use of conservative management strategies such as exercise.

New design of care: Assessment of an interdisciplinary orthopaedic clinic with a pivot nurse in the province of Quebec

BACKGROUND

New designs of care in orthopaedic clinics are needed to cope with the shortage of orthopaedic surgeons and the lengthening of waiting times.

OBJECTIVE

To assess the effectiveness of an interdisciplinary orthopaedic clinic with a pivot nurse in the Canadian province of Quebec with regard to accessibility, quality of care, efficacy and efficiency of the clinic, and patient's quality of life.

METHODS

Two strategies were developed: (1) a selected cohort of new patients attending an orthopaedic service from February to September 2008 were entered into a database recording patient details, source of referral, diagnosis, satisfaction, and quality of life (36-Item Short Form Health Survey version 2). In this setting, 2 sets of questionnaires were administered to the patients: the first one during the first visit and the second one, 2 months later. A total of 243 patients from the case control were compared with 89 patients of the case study, where an interdisciplinary orthopaedic clinic with a pivot nurse has been developed; (2) costs per patient were calculated using the staff timesheets provided by the two orthopaedic clinics.

RESULTS

The results showed a significant reduction in the waiting-list duration (accessibility) in the case study clinic owing to a strong decrease in the inappropriate consultations with the orthopaedic consultant. The quality of care remained high, and the target surgeries for total hip and knee replacement were reached, despite a strong shortage of orthopaedic doctors.

CONCLUSION

Interdisciplinary orthopaedic clinic with a pivot nurse is a new approach in the province of Quebec and first results are encouraging.

Expanding roles in orthopaedic care: a comparison of physiotherapist and orthopaedic surgeon recommendations for triage

RATIONALE, AIMS AND OBJECTIVES

Innovative service delivery models are emerging using physiotherapists in the assessment and management of patients referred for orthopaedic consultation. The primary objective of this study was to compare the clinical recommendations of specially trained physiotherapists with those of an orthopaedic surgeon on: (1) appropriateness to be seen by an orthopaedic surgeon; and (2) candidacy and willingness to undergo total joint replacement (TJR) for patients with hip or knee problems. A secondary objective was to examine their recommendations for non-surgical management and agreement on clinical diagnosis.

METHODS

Physiotherapists and orthopaedic surgeons independently assessed patients with hip and knee problems referred for consideration for TJR and completed a standardized form on treatment recommendations. Agreement between providers was determined using the kappa coefficient and per cent agreement.

RESULTS

Two physiotherapists and three orthopaedic surgeons participated in the study that included 45 and 17 patients with knee and hip problems respectively. In 91.8% (56/61) of cases, physiotherapists and orthopaedic surgeons agreed on the recommendation of appropriateness for the patient to see a surgeon (kappa 0.69). In discordant cases, the physiotherapists tended to refer for consultation. There was 85.5% (53/62) agreement on whether a patient was a candidate and willing to have TJR (kappa 0.70). The physiotherapists commonly recommended exercise and education for non-surgical patients. Orthopaedic surgeons most commonly referred patients to rehabilitation services.

CONCLUSIONS

Patients with hip or knee pain referred to orthopaedic surgeons can be appropriately referred for orthopaedic consultation by physiotherapists working in extended roles. Further research is required to evaluate the value-added and the most appropriate use of extended role physiotherapists.

Diagnostic and treatment concordance between a physiotherapist and an orthopedic surgeon--a pilot study

Musculoskeletal impairments affect one-third of the adult population, are one of the major contributors to lost time from work, and account for one-third of a general practitioner's caseload. These injuries respond well to physiotherapy, but access can be limited in a publicly funded health care system. Improved access to physiotherapy occurs in a collaborative model of care in orthopedic clinics however the extent to which the patient receives similar diagnoses and treatment recommendations has not been reported. The purpose of this study was to determine diagnostic concordance and accuracy, and treatment concordance between a physiotherapist and orthopedic surgeons. Twenty-five subjects in an orthopedic clinic were assessed by a physiotherapist and an orthopedic surgeon. Diagnosis and treatment recommendations were made by each separately. These were compared for concordance between professionals and diagnostic accuracy. The physiotherapist and the orthopedic surgeon had 90% concordance in diagnoses of knee and shoulder impairments, and 75% accuracy when compared to definitive diagnostic methods. They had 87% agreement in treatment recommendations, however, the physiotherapist gave three treatment recommendations per patient where the surgeon gave two. In a collaborative care context therefore, this study suggests, that physiotherapists have similar diagnostic capabilities to orthopedic surgeons, and they will enhance the conservative treatment options offered to orthopedic patients.

Characteristics of evolving models of care for arthritis: a key informant study

BACKGROUND

The burden of arthritis is increasing in the face of diminishing health human resources to deliver care. In response, innovative models of care delivery are developing to facilitate access to quality care. Most models have developed in response to local needs with limited evaluation. The primary objective of this study is to a) examine the range of models of care that deliver specialist services using a medical/surgical specialist and at least one other health care provider and b) document the strengths and challenges of the identified models. A secondary objective is to identify key elements of best practice models of care for arthritis.

METHODS

Semi-structured interviews were conducted with a sample of key informants with expertise in arthritis from jurisdictions with primarily publicly-funded health care systems. Qualitative data were analyzed using a constant comparative approach to identify common types of models of care, strengths and challenges of models, and key components of arthritis care.

RESULTS

Seventy-four key informants were interviewed from six countries. Five main types of models of care emerged. 1) Specialized arthritis programs deliver comprehensive, multidisciplinary team care for arthritis. Two models were identified using health care providers (e.g. nurses or physiotherapists) in expanded clinical roles: 2) triage of patients with musculoskeletal conditions to the appropriate services including specialists; and 3) ongoing management in collaboration with a specialist. Two models promoting rural access were 4) rural consultation support and 5) telemedicine. Key informants described important components of models of care including knowledgeable health professionals and patients.

CONCLUSION

A range of models of care for arthritis have been developed. This classification can be used as a framework for discussing care delivery. Areas for development include integration of care across the continuum, including primary care.