1
|
Baumbach L, Feddern W, Kretzler B, Hajek A, König HH. Cost-Effectiveness of Treatments for Musculoskeletal Conditions Offered by Physiotherapists: A Systematic Review of Trial-Based Evaluations. SPORTS MEDICINE - OPEN 2024; 10:38. [PMID: 38613739 PMCID: PMC11016054 DOI: 10.1186/s40798-024-00713-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 04/02/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Musculoskeletal conditions are a leading contributor to disability worldwide. The treatment of these conditions accounts for 7% of health care costs in Germany and is often provided by physiotherapists. Yet, an overview of the cost-effectiveness of treatments for musculoskeletal conditions offered by physiotherapists is missing. This review aims to provide an overview of full economic evaluations of interventions for musculoskeletal conditions offered by physiotherapists. METHODS We systematically searched for publications in Medline, EconLit, and NHS-EED. Title and abstracts, followed by full texts were screened independently by two authors. We included trial-based full economic evaluations of physiotherapeutic interventions for patients with musculoskeletal conditions and allowed any control group. We extracted participants' information, the setting, the intervention, and details on the economic analyses. We evaluated the quality of the included articles with the Consensus on Health Economic Criteria checklist. RESULTS We identified 5141 eligible publications and included 83 articles. The articles were based on 78 clinical trials. They addressed conditions of the spine (n = 39), the upper limb (n = 8), the lower limb (n = 30), and some other conditions (n = 6). The most investigated conditions were low back pain (n = 25) and knee and hip osteoarthritis (n = 16). The articles involved 69 comparisons between physiotherapeutic interventions (in which we defined primary interventions) and 81 comparisons in which only one intervention was offered by a physiotherapist. Physiotherapeutic interventions compared to those provided by other health professionals were cheaper and more effective in 43% (18/42) of the comparisons. Ten percent (4/42) of the interventions were dominated. The overall quality of the articles was high. However, the description of delivered interventions varied widely and often lacked details. This limited fair treatment comparisons. CONCLUSIONS High-quality evidence was found for physiotherapeutic interventions to be cost-effective, but the result depends on the patient group, intervention, and control arm. Treatments of knee and back conditions were primarily investigated, highlighting a need for physiotherapeutic cost-effectiveness analyses of less often investigated joints and conditions. The documentation of provided interventions needs improvement to enable clinicians and stakeholders to fairly compare interventions and ultimately adopt cost-effective treatments.
Collapse
Affiliation(s)
- Linda Baumbach
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Wiebke Feddern
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Benedikt Kretzler
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - André Hajek
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| |
Collapse
|
2
|
Wong WSY, Sun CM, Koh HY, Tan LRH, Huang Y. Reducing wait times and medical costs for patients: the physiotherapy-led Spine Triage and Rehabilitation (STAR) Clinic. BMJ Open Qual 2024; 13:e002670. [PMID: 38599767 PMCID: PMC11015258 DOI: 10.1136/bmjoq-2023-002670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 03/09/2024] [Indexed: 04/12/2024] Open
Abstract
The Sengkang General Hospital Orthopaedic Spine Outpatient Service is facing a growing challenge of increasing number of referrals and waiting times, placing a significant burden on the system. Primary care referrals have an average wait time of 61.1 days, with 34.5%f patients waiting longer than 60 days from referral to appointment, to see a spine physician.Back pain is a very common presentation, with the vast majority resolving after conservative management which commonly includes analgesia, physiotherapy and reassurance. Unfortunately, many referrals from primary care involve patients who have yet to explore the avenues of conservative management with 90% of our referrals being managed without surgery. Globally, triage services in Western countries conducted by allied health professionals have shown to be an effective method at addressing the escalating wait times with high satisfaction rates. We have endeavoured to emulate this within our department through the implementation of the Spine Triage and Rehabilitation (STAR) Clinic. The STAR clinic aims to empower physiotherapists with the ability to triage patients into surgical and non-surgical categories with their primary physiotherapy expertise to reduce waiting times and increase outpatient capacity.More than 300 patients were recruited, and their progress was tracked over 13 months under the four Ss of: waiting timeS, cost Savings, Safety and patient Satisfaction. This pilot study has been overwhelmingly positive, with significantly reduced waiting times and high cost savings, without any compromise on patient safety and satisfaction.
Collapse
Affiliation(s)
| | | | - Hun Yi Koh
- Lee Kong Chian School of Medicine, Singapore
| | | | - Yilun Huang
- Sengkang General Hospital, Singapore
- SingHealth Duke-NUS Academic Medical Centre, Singapore
| |
Collapse
|
3
|
Lafrance S, Desmeules F, Charron M, Elkaim LM, Fernandes J, Santaguida C. Advanced practice physiotherapy surgical triage and management of adults with spinal disorders referred to specialized spine medical care: a retrospective observational study. Physiother Theory Pract 2024; 40:704-713. [PMID: 36594598 DOI: 10.1080/09593985.2022.2158699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 12/03/2022] [Indexed: 01/04/2023]
Abstract
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.
Collapse
Affiliation(s)
- Simon Lafrance
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Maisonneuve-Rosemont Hospital Research Center, Université de Montréal Affiliated Research Center, Montreal, QC, Canada
| | - François Desmeules
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Maisonneuve-Rosemont Hospital Research Center, Université de Montréal Affiliated Research Center, Montreal, QC, Canada
| | - Maxime Charron
- Maisonneuve-Rosemont Hospital Research Center, Université de Montréal Affiliated Research Center, Montreal, QC, Canada
| | - Lior M Elkaim
- Department of Neurology and Neurosurgery, Faculty of Medicine, McGill University, McGill University Health Center, Montreal, QC, Canada
| | - Julio Fernandes
- Hôpital du Sacré-Coeur de Montréal Research Center, Université de Montréal Affiliated Research Center, Montreal, QC, Canada
- Department of Surgery, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Carlo Santaguida
- Department of Neurology and Neurosurgery, Faculty of Medicine, McGill University, McGill University Health Center, Montreal, QC, Canada
| |
Collapse
|
4
|
Ó Mír M, Casey MB, Smart KM. A survey of physiotherapist managers in Ireland and their views on the role of Advanced Practice Physiotherapists. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2024; 29:e2064. [PMID: 38069448 DOI: 10.1002/pri.2064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 10/18/2023] [Accepted: 10/23/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND Within the current context of implementation of an Advanced Practice Grade, the Irish Society of Chartered Physiotherapists commissioned a survey of physiotherapy manager opinions regarding the role of Advanced Practice Physiotherapists. OBJECTIVES The aim of this survey was to explore the views of physiotherapist managers in relation to the characteristics, role, competencies and management of Advanced Practice Physiotherapists (APPs) in Ireland. METHODS Physiotherapist managers based in primary and secondary care settings in Ireland were invited to participate in a survey on Advanced Practice. Quantitative data from a custom designed online survey was analysed with descriptive statistics and qualitative data from open-ended survey questions were analysed using thematic analysis. RESULTS The response rate to the survey was 32% (24/75). On average, respondents thought that 54% (range: 15%-80%) of an APPs time should be spent in clinical practice and between 17% and 20% variously on managerial and leadership, teaching and education and research and development duties. Four themes were identified from the surveys' open-ended questions related to the description of APP: 'Extended scope 'Advanced clinical training, knowledge, and decision-making', 'Autonomy, independence and responsibility', and 'Wider roles'. CONCLUSION Irish physiotherapist managers recognised the extended scope of practice, expertise and multiple roles characteristic of APPs. They indicated the need for legislative changes and clarity around governance.
Collapse
Affiliation(s)
- Marie Ó Mír
- Irish Society of Chartered Physiotherapists (ISCP), Royal College of Surgeons, St Stephen's Green, Dublin, Ireland
| | - Maire-Brid Casey
- Discipline of Physiotherapy, School of Medicine, Trinity Centre for Health Sciences, St James's Hospital, Dublin, Ireland
| | - Keith M Smart
- UCD School of Public Health, Physiotherapy and Sports Science, Health Sciences Centre, University College Dublin, Dublin, Ireland
| |
Collapse
|
5
|
Kara ÖS, Torgutalp SS, Turhan E, Dönmez G, Korkusuz F. Operative treatment in non-emergency sports injuries: a sports medicine clinic experience. PHYSICIAN SPORTSMED 2023; 51:596-602. [PMID: 36416053 DOI: 10.1080/00913847.2022.2151325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE To elucidate referrals from sports medicine clinic (SMC) to orthopedics, consensus rates among physicians and surgeons on surgical need in these patients, and reasoning of the patients who refused to have surgery despite the recommendations by both groups in non-emergency sports injury patients. METHODS We conducted a retrospective cohort analysis by using the administrative and referral records of a sports medicine clinic for the 15 months between October 2017 and January 2019. Gender, age, diagnosis, and type of sport were compared between two groups (patients referred to orthopedics vs patients treated in SMC). Agreement between orthopedics and SMC on surgical need in those patients who were referred to orthopedics was evaluated. We additionally screened the hospital archive for surgery reports of patients recommended surgery, and, if a patient did not have a surgery record, we investigated the reasons by telephone interview and categorized these reasons. RESULTS Surgical evaluation needed for 4.7% (n = 155) of the patients. Patients referred to orthopedics were younger (median: 22.0 years), mostly male (n = 119, 76.8%), and involved in contact sports (n = 108, 69.7%) (p < 0.001 for all) compared to patients treated conservatively. Majority of the consultations were made owing to certain diagnoses such as cruciate/collateral ligament sprain (n = 70, 45.2%), meniscal tear (n = 21, 13.5%), and cartilage injuries (n = 15, 9.7%). Most of the patients diagnosed with Achilles tendon rupture (n = 2, 100%) and patellar instability (n = 13, 81.3%) were referred to surgery. Orthopedics agreed with the sports medicine physicians' opinions in most cases (n = 110, 71.0%). Thirty-four patients (30.9%) recommended surgery by the surgeon postponed/refused the treatment for various reasons or had surgery in another hospital. CONCLUSION Most non-emergency sports injuries can be treated conservatively. Young and male patients participating in contact sports are more likely to need surgical treatment. Non-surgeon musculoskeletal health-care providers may consider referring patients to orthopedics considering the data demonstrated in this study. Nevertheless, patient's motivation to undergo an operation should be considered before referring to orthopedics.
Collapse
Affiliation(s)
- Ömer Serkan Kara
- Department of Sports Medicine, Hacettepe University Medical Faculty, 06230, Ankara, Turkey
- Department of Sports Medicine, Health Sciences, University Gülhane Medical Faculty, 06010, Ankara, Turkey
| | - Serife Seyma Torgutalp
- Department of Sports Medicine, Hacettepe University Medical Faculty, 06230, Ankara, Turkey
| | - Egemen Turhan
- Department of Orthopedic and Traumatology, Hacettepe University Medical Faculty, 06230, Ankara, Turkey
| | - Gürhan Dönmez
- Department of Sports Medicine, Hacettepe University Medical Faculty, 06230, Ankara, Turkey
| | - Feza Korkusuz
- Department of Sports Medicine, Hacettepe University Medical Faculty, 06230, Ankara, Turkey
| |
Collapse
|
6
|
Nelson EO, Freeman J, Worth R, Brody LT. Private physical therapy practice implementation of direct referral for radiograph imaging: an administrative case report. Physiother Theory Pract 2023; 39:2234-2240. [PMID: 35414339 DOI: 10.1080/09593985.2022.2063772] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 03/17/2022] [Accepted: 03/30/2022] [Indexed: 10/18/2022]
Abstract
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.
Collapse
Affiliation(s)
- Evan O Nelson
- Department of Family Medicine and Community Health,School of Medicine and Public Health, Doctor of Physical Therapy Program, University of Wisconsin-Madison, Madison, WI, USA
| | - Jd Freeman
- Department of Physical Therapy, Lincoln Orthopedic Physical Therapy, Lincoln, NE, USA
| | - Rob Worth
- Department of Physical Therapy, Advanced Physical Therapy and Sports Medicine, Appleton, WI, USA
| | - Lori Thein Brody
- Department of Orthopedics and Rehabilitation, University of Wisconsin Hospital and Clinics, UW Clinics Research Park, Madison, WI, USA
| |
Collapse
|
7
|
Lafrance S, Vincent R, Demont A, Charron M, Desmeules F. Advanced practice physiotherapists can diagnose and triage patients with musculoskeletal disorders while providing effective care: a systematic review. J Physiother 2023; 69:220-231. [PMID: 37714771 DOI: 10.1016/j.jphys.2023.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 06/19/2023] [Accepted: 08/10/2023] [Indexed: 09/17/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Simon Lafrance
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, Canada; Hôpital Maisonneuve-Rosemont Research Center, Université de Montréal Affiliated Research Center, Montreal, Canada.
| | - Raphaël Vincent
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, Canada; Hôpital Maisonneuve-Rosemont Research Center, Université de Montréal Affiliated Research Center, Montreal, Canada
| | | | - Maxime Charron
- Hôpital Maisonneuve-Rosemont Research Center, Université de Montréal Affiliated Research Center, Montreal, Canada
| | - François Desmeules
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, Canada; Hôpital Maisonneuve-Rosemont Research Center, Université de Montréal Affiliated Research Center, Montreal, Canada
| |
Collapse
|
8
|
Gallotti M, Campagnola B, Cocchieri A, Mourad F, Heick JD, Maselli F. Effectiveness and Consequences of Direct Access in Physiotherapy: A Systematic Review. J Clin Med 2023; 12:5832. [PMID: 37762773 PMCID: PMC10531538 DOI: 10.3390/jcm12185832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 08/24/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
Background. Direct access in physiotherapy (DAPT) occurs when a patient has the ability to self-refer to physical therapy without physician referral. This model of care in musculoskeletal diseases (MSDs) has shown better outcomes than the traditional-based medical model of care that requires physician referral to access physiotherapist services. This traditional physician referral often results in a delay in care. Unfortunately, DAPT is still not permitted in many countries. Objectives. The primary objective of this systematic review was to compare the effectiveness, safety, and the accuracy of DAPT compared to the physician-led model of care for the management of patients with musculoskeletal disorders. The secondary objective of the present study is to define the physiotherapists' characteristics or qualifications involved in DAPT. Materials and methods. Databases searched included: Medline, Scopus and Web of Science. Databases were searched from their inception to July 2022. Research strings were developed according to the PICO model of clinical questions (patient, intervention, comparison, and outcome). Free terms or synonyms (e.g., physical therapy; primary health care; direct access; musculoskeletal disease; cost-effectiveness) and when possible MeSH (Medical Subject Headings) terms were used and combined with Boolean operators (AND, OR, NOT). Risk of bias assessment was carried out through Version 2 of the Cochrane risk-of-bias tool (ROB-2) for randomized controlled trials (RCTs) and the Newcastle Ottawa Scale (NOS) for observational studies. Authors conducted a qualitative analysis of the results through narrative analysis and narrative synthesis. The narrative analysis was provided for an extraction of the key concepts and common meanings of the different studies, while the summary narrative provided a textual combination of data. In addition, a quantitative analysis was conducted comparing the analysis of the mean and differences between the means. Results. Twenty-eight articles met the inclusion criteria and were analyzed. Results show that DAPT had a high referral accuracy and a reduction in the rate of return visits. The medical model had a higher use of imaging, drugs, and referral to another specialist. DAPT was found to be more cost-effective than the medical model. DAPT resulted in better work-related outcomes and was superior when considering patient satisfaction. There were no adverse events noted in any of the studies. In regard to health outcomes, there was no difference between models. ROB-2 shows an intermediate risk of bias risk for the RCTs with an average of 6/9 points for the NOS scale for observational studies. Conclusion. DAPT is a safe, less expensive, reliable triage and management model of care that results in higher levels of satisfaction for patients compared to the traditional medical model. Prospero Registration Number: CRD42022349261.
Collapse
Affiliation(s)
- Marco Gallotti
- Catholic University of the Sacred Heart, Rome Campus, 00168 Rome, Italy
| | - Benedetta Campagnola
- University Hospital Foundation Campus Bio-Medico, Rome University, 00128 Rome, Italy
| | | | - Firas Mourad
- Department of Physiotherapy, LUNEX International University of Health, Exercise and Sports, 4671 Luxembourg, Luxembourg
- Luxembourg Health & Sport Sciences Research Institute A.s.b.l., 50, Avenue du Parc des Sports, 4671 Luxembourg, Luxembourg
| | - John D. Heick
- Department of Physical Therapy, Northern Arizona University, P.O. Box 15105, Flagstaff, AZ 86011, USA
| | - Filippo Maselli
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
| |
Collapse
|
9
|
Gustavsson L, Mohaddes M, Samsson K, Beischer S. No major difference in perceived quality of care in patients with hip or knee osteoarthritis assessed in a physical therapy-led triage compared with standard care: a randomized controlled trial. BMC Musculoskelet Disord 2023; 24:530. [PMID: 37386368 DOI: 10.1186/s12891-023-06659-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 06/22/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Physical therapy-led orthopedic triage is a care model used to optimize pathways for patients with hip or knee osteoarthritis. However, scientific evidence of the effectiveness of this model of care is still limited and only a few studies report patients' perception of it. The aim of this study was to compare patients' perceived quality of care after physical therapy-led triage with standard practice in a secondary care setting for patients with primary hip or knee osteoarthritis. METHODS In this randomized study, patients with hip or knee osteoarthritis referred for an orthopedic consultation received either physical therapy-led triage (n = 344) or a standard care assessment by an orthopedic surgeon (n = 294). To evaluate the patients' perceived quality of care, a short version of the Quality from the Patient's Perspective (QPP) questionnaire was sent to the patients within a week after their assessment. The primary outcome was the statement "I received the best examination and treatment" on QPP. RESULTS A total of 348 patients (70%, physical therapy-led triage: n = 249, standard care: n = 199) answered the questionnaire. No significant difference was found in the primary outcome between the groups (p = 0.6). Participants in the triage group perceived themselves to have received significantly better information about how to take care of their osteoarthritis (p = 0.017) compared with the standard care group. The standard care group reported that they participated in the decision-making process to a greater extent (p = 0.005), that their expectations were met to a greater degree (p = 0.013), and that their care depended more on their need for care rather than the caregivers' routines (0.007). CONCLUSION Both groups report high perceived quality of care. Significant differences were found in four of 14 questions, one in favor of the physical therapist and three in favor of the standard care group. The findings of this study are in line with previous research and support the use of this care model for patients with hip or knee OA in secondary care. However, due to the dropout size, the results should be interpreted with caution. TRIAL REGISTRATION Clinical Trials NCT04665908, registered 14/12/2020.
Collapse
Affiliation(s)
- Linnea Gustavsson
- Institute of Clinical Sciences, Department of Orthopaedics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden.
- Sportrehab, Gothenburg, Sweden.
| | - Maziar Mohaddes
- Institute of Clinical Sciences, Department of Orthopaedics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Karin Samsson
- Institute of Neuroscience and Rehabilitation, Department of Health and Rehabilitation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Capio Ortho Center Göteborg, Gothenburg, Sweden
| | - Susanne Beischer
- Sportrehab, Gothenburg, Sweden
- Institute of Neuroscience and Rehabilitation, Department of Health and Rehabilitation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
10
|
Massey BJ, Grandeo J, Favaro L, Bliss R, Gagnon K, Young JL. Physical therapy students' application of an imaging decision rule for acute knee pain. Physiother Theory Pract 2023:1-11. [PMID: 37128903 DOI: 10.1080/09593985.2023.2206482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
BACKGROUND Evidence supports direct referral for imaging by physical therapists. Accuracy and self-efficacy for imaging decisions have not been investigated in entry-level doctor of physical therapy (DPT) students. OBJECTIVE The purpose of this study was to understand the relationship between entry-level DPT instruction and accuracy and self-efficacy for imaging referral due to acute knee trauma. A second purpose was to identify relationships between accuracy and self-efficacy. METHODS An online survey was sent via e-mail to program directors in accredited DPT programs in the United States with an invitation to forward the survey to DPT students. The survey captured demographic information and included five questions that assessed the respondent's ability to apply the Ottawa Knee Rules (OKR). Self-efficacy was assessed using the Physiotherapist Student Self-Efficacy (PSE) questionnaire, a self-rated 5-point Likert scaled tool. RESULTS Of 240 surveys, DPT students who completed imaging coursework had greater accuracy and higher self-efficacy (68.0% correct (95% CI, 63.6-72.5), PSE = 3.67, P < .001) compared to students who had not (45.8% correct (95% CI, 40.8-50.7), PSE = 2.67, P < .001). Conclusion: Accuracy by DPT students who completed imaging coursework was significantly improved and comparable to values from autonomous providers.
Collapse
Affiliation(s)
- B James Massey
- Doctor of Science Program in Physical Therapy, Bellin College, Green Bay, WI, USA
- Department of Physical Therapy, Wingate University, Wingate, NC, USA
| | - Jason Grandeo
- Doctor of Science Program in Physical Therapy, Bellin College, Green Bay, WI, USA
- School of Physical Therapy, University of Lynchburg, Lynchburg, VA, USA
| | - Laura Favaro
- Doctor of Science Program in Physical Therapy, Bellin College, Green Bay, WI, USA
- Department of Physical Therapy, Daemen University, Amherst, NY, USA
| | - Rebecca Bliss
- Doctor of Science Program in Physical Therapy, Bellin College, Green Bay, WI, USA
- School of Physical Therapy, University of Lynchburg, Lynchburg, VA, USA
- Department of Physical Therapy, University of Missouri, Columbia, MO, USA
| | - Kendra Gagnon
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jodi L Young
- Doctor of Science Program in Physical Therapy, Bellin College, Green Bay, WI, USA
| |
Collapse
|
11
|
Crowell MS, Mason JS, Morris JB, Dummar MK, Kuwik PA. Diagnostic Imaging for Distal Extremity Injuries in Direct Access Physical Therapy: An Observational Study. Int J Sports Phys Ther 2023; 18:431-438. [PMID: 37020437 PMCID: PMC10069368 DOI: 10.26603/001c.73314] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/14/2023] [Indexed: 04/03/2023] Open
Abstract
Background Military physical therapists practicing direct-access routinely utilize diagnostic imaging and numerous published case reports demonstrate the ability of physical therapists to diagnose and appropriately disposition patients with foot/ankle and wrist/hand fractures. However, no larger cohort studies have explored the utilization of diagnostic imaging by physical therapists to detect fractures. Hypothesis/Purpose To describe the utilization of diagnostic imaging in foot/ankle and wrist/hand injuries by physical therapists in a direct-access sports physical therapy clinic. Study Design Retrospective cohort study. Methods The Agfa Impax Client 6 image viewing software (IMPAX) was searched from 2014 to 2018 for patients with diagnostic imaging ordered for foot/ankle and wrist/hand injuries. The Armed Forces Health Longitudinal Technology Application (AHLTA) electronic medical record was independently reviewed by the principal and co-investigator physical therapists. Data extracted were demographics and elements from the patient history and physical examination. Results In foot/ankle injuries, physical therapists diagnosed a fracture in 16% of the 177 cases and waited for an average of 3.9 days and 1.3 visits before ordering imaging. In wrist/hand injuries, physical therapists diagnosed a fracture in 24% of the 178 cases and waited for an average of 3.7 days and 1.2 visits before ordering imaging. The time to definitive care from the initial physical therapy evaluation was significantly different (p = 0.04) for foot/ankle fractures (0.6 days) compared to wrist/hand fractures (5.0 days). The Ottawa Ankle Rules demonstrated a negative likelihood ratio (-LR) of 0.11 (0.02, 0.72) and a positive likelihood ratio (+LR) of 1.99 (1.62, 2.44) for the diagnosis of foot/ankle fracture. Conclusions Physical therapists utilizing diagnostic imaging in a direct-access sports physical therapy clinic diagnosed fractures in similar proportions for foot/ankle and wrist/hand injuries and quickly dispositioned patients to definitive care for those fractures. The diagnostic accuracy of the Ottawa Ankle Rules was similar to previously reported values. Level of Evidence Level 3.
Collapse
Affiliation(s)
- Michael S Crowell
- Baylor University - Keller Army Community Hospital Division 1 Sports Physical Therapy Fellowship
| | - John S Mason
- Army-Baylor Doctoral Program in Physical Therapy
| | - Jamie B Morris
- Baylor University - Keller Army Community Hospital Division 1 Sports Physical Therapy Fellowship
| | - Max K Dummar
- Baylor University - Keller Army Community Hospital Division 1 Sports Physical Therapy Fellowship
| | - Paul A Kuwik
- Baylor University - Keller Army Community Hospital Division 1 Sports Physical Therapy Fellowship
| |
Collapse
|
12
|
Jirasakulsuk N, Saengpromma P, Khruakhorn S. Real-Time Telerehabilitation in Older Adults With Musculoskeletal Conditions: Systematic Review and Meta-analysis. JMIR Rehabil Assist Technol 2022; 9:e36028. [PMID: 36048520 PMCID: PMC9478822 DOI: 10.2196/36028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 06/14/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022] Open
Abstract
Background Real-time telerehabilitation (TR) is a new strategy for delivering rehabilitation interventions to older adults with musculoskeletal conditions, to provide continuity to conventional services and mitigate travel-related barriers. Objective We aimed to examine the effectiveness of treatment delivered via real-time TR services compared to conventional services among older adults with musculoskeletal conditions, in terms of physical performance, treatment adherence, and cost-effectiveness. Methods A literature search of randomized controlled trials (RCTs) published from January 2000 to April 2022 was conducted in six online databases: Cochrane Library, PubMed (ie, MEDLINE), PEDro, ClinicalKey, EBSCO, and ProQuest. The main eligibility criterion for articles was the use of real-time TR among older adults with musculoskeletal conditions to improve physical performance. Two reviewers screened 2108 abstracts and found 10 studies (n=851) that met the eligibility criteria. Quality assessment was based on version 2 of Cochrane’s risk-of-bias tool for RCTs, in order to assess the methodological quality of the selected articles. Results were pooled for meta-analyses, based on the primary outcome measures, and were reported as standardized mean differences (SMDs) with 95% CIs. A fixed model was used, and subgroup analysis was performed to check for possible factors influencing TR’s effectiveness based on different treatments, controls, and outcome measures. Results The search and screening process identified 10 papers that collectively reported on three musculoskeletal conditions in older adults and three types of TR programs. Aggregate results suggested that real-time TR, compared to conventional treatment, was more effective at improving physical performance regarding balance (SMD 0.63, 95% CI 0.36-0.9; I2=58.5%). TR was slightly better than usual care at improving range of motion (SMD 0.28, 95% CI 0.1-0.46; I2=0%) and muscle strength (SMD 0.76, 95% CI 0.32-1.2; I2=59.60%), with moderate to large effects. Subgroup analyses suggested that real-time TR had medium to large effects favoring the use of smartphones or tablets (SMD 0.92, 95% CI 0.56-1.29; I2=45.8%), whereas the use of personal computers (SMD 0.25, 95% CI –0.16 to 0.66; I2=0%) had no effect on improving balance and was comparable to conventional treatment. Conclusions We found that real-time TR improved physical performance in older adults with musculoskeletal conditions, with an effectiveness level equal to that of conventional face-to-face treatment. Therefore, real-time TR services may constitute an alternative strategy for the delivery of rehabilitation services to older adults with musculoskeletal conditions to improve their physical performance. We also observed that the ideal device for delivering TR is the smartphone. Results suggested that the use of smartphones for TR is driven by ease of use among older adults. We encourage future studies in areas related to rehabilitation in older adults, in addition to examination of physical performance outcomes, to gain additional knowledge about comprehensive care. Trial Registration PROSPERO CRD42021287289; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=287289
Collapse
Affiliation(s)
- Nathaphon Jirasakulsuk
- Department of Physical Therapy, Faculty of Allied Health Sciences, Thammasat University, Pathum Thani, Thailand
| | - Pattaridaporn Saengpromma
- Department of Physical Therapy, Faculty of Allied Health Sciences, Thammasat University, Pathum Thani, Thailand
| | - Santhanee Khruakhorn
- Department of Physical Therapy, Faculty of Allied Health Sciences, Thammasat University, Pathum Thani, Thailand
| |
Collapse
|
13
|
Wong J, Chipchase L, Gupta A. Agreement between hand therapists and hand surgeons in the management of adults with closed metacarpal fractures. Musculoskelet Sci Pract 2022; 60:102560. [PMID: 35378408 DOI: 10.1016/j.msksp.2022.102560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 03/24/2022] [Accepted: 03/26/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Hand therapists often work in roles which require an advanced level of experience as Advanced Scope Practitioners (ASP). However, it is not known whether clinical decisions are similar between hand therapists and surgeons when managing simple hand fractures. OBJECTIVES To determine the level of agreement between (i) a hand therapist and five hand surgeons and (ii) three hand therapists, for the management of adults with closed metacarpal fracture(s). DESIGN A prospective, blinded, crossover inter-rater reliability study. METHOD Patient volunteers with closed metacarpal fracture(s) were assessed independently in the first study (n = 90) by a hand therapist and one of five hand surgeons and in the second study (n = 57) by three hand therapists in a randomised order, with each practitioner recording whether the patient participant should be managed conservatively, trialled with conservative or offered surgical treatment. The level of agreement between the hand therapist and hand surgeons was calculated using Cohen's kappa coefficient and between the three hand therapists by calculating Fleiss' Kappa. The observed agreement was also calculated as the proportion of cases for which the assessors had agreement for management. RESULTS There was good agreement between the hand therapist and surgeons (k = 0.68; 95% CI: 0.537-0.831) and amongst the three hand therapists (k = 0.663; 95% CI: 0.554-0.773) in determining the management of adults with closed metacarpal fracture(s). CONCLUSIONS Hand therapists and surgeons make similar management decision for patients with metacarpal fractures supporting the role of hand therapists as ASP.
Collapse
Affiliation(s)
- Jade Wong
- Fairfield Hospital, Polding St. & Prairievale Rd., Prairiewood, 2176, NSW, Australia; Western Sydney University, Narellan Rd., Campbelltown, 2560, NSW, Australia.
| | - Lucy Chipchase
- Flinders University, College of Nursing and Health Sciences, Sturt Rd., Bedford Park, 5042, SA, Australia.
| | - Amitabh Gupta
- Western Sydney University, Narellan Rd., Campbelltown, 2560, NSW, Australia.
| |
Collapse
|
14
|
Taubert ST, Burns CL, Ward EC, Bassett L. Implementation of a speech and language therapy-led referring model for videofluoroscopic swallow studies: An evaluation of service outcomes. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2022; 57:512-523. [PMID: 35141997 DOI: 10.1111/1460-6984.12700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 11/11/2021] [Accepted: 12/21/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Videofluoroscopic swallow studies (VFSS) are integral to diagnosing and supporting dysphagia management. However, in many countries, only doctors are authorized to complete medical imaging request forms, in accordance with radiation safety regulations. This can impact workflow and timely access to VFSS. Enhanced scope of practice (ESP) models of care exist, where speech and language therapists (SLTs) are authorized to complete VFSS request forms. However, formal evaluations of these ESP models are currently lacking. AIMS The primary aim of this study was to examine service outcomes regarding the safety and efficiency of SLTs completing VFSS request forms compared with the medical referring model (standard care). The secondary aim was to ascertain the impacts on SLTs' daily workflow and the utility of training for SLTs to complete VFSS requests. METHODS & PROCEDURES The study involved a mixed-method design. First, referrals completed using standard care versus those completed under the new SLT-led VFSS referring model were compared for efficiency (days to request completion, number of contacts between staff to complete requests and delay to VFSS appointments) and safety (compliance with radiation safety standards for requests, adverse events and change to dysphagia management to justify radiation exposure). Semi-structured interviews were then conducted with SLT referrers (n = 7) exploring the impacts of the model on daily workflow and the utility of training. OUTCOMES & RESULTS VFSS inpatient requests were examined across a 3-month period (n = 61 requests) using the standard model, and for 6 months (n = 109 requests) following the introduction of SLT-led VFSS referring. Regarding efficiency, there was no significant difference between the two models, with most request forms taking less than or equal to 1 day to be completed. Adherence to radiation safety requirements was significantly greater in the SLT-led VFSS referring model compared with the standard model (p < 0.001) in relation to the overall requisite clinical information being documented on the request forms. No adverse events occurred and 100% of VFSSs led to changed dysphagia management. Interviews of VFSS referring SLTs revealed that completing requests was not complex or onerous, and that the training equipped them well to undertake the role. CONCLUSIONS & IMPLICATIONS The SLT-led VFSS referring model was feasible for SLTs and resulted in satisfactory efficiency and greater adherence to radiation safety requirements for VFSS request forms than the standard model. Improved information on VFSS request forms provides clearer justification for the radiation procedure and helps optimize the diagnostic yield of VFSS. The evidence supports further widespread adoption of this model. WHAT THIS PAPER ADDS What is already known on the subject Models of care permitting selected allied health professionals to refer patients for diagnostic radiology procedures have been established to achieve healthcare efficiencies. Evidence supports the safety and efficiency of physiotherapists referring to radiology. However, limited published outcome data exist regarding models of SLTs referring for radiology procedures, such as VFSS. What this paper adds to existing knowledge This study describes the implementation of a SLT-led VFSS inpatient referring model in a quaternary hospital and examines service outcomes. The findings reveal that VFSS request forms completed in the SLT-led referring model had greater adherence to radiation safety standards compared with the standard referring model. Efficiency was similar across both models and there were no adverse events. Completing VFSS requests did not disrupt daily workflow for SLTs and training was effective preparation for the role. What are the potential or actual clinical implications of this work? Results demonstrate that the SLT-led VFSS referral model can be safely and appropriately implemented in the inpatient setting. Improved quality of information documented on request forms by SLTs increases adherence with radiation safety standards, providing clearer justification for radiation assessments and potentially eliciting more targeted diagnostic information to inform dysphagia treatment planning. These findings may support other hospital services to establish this type of referring model.
Collapse
Affiliation(s)
- Shana T Taubert
- Metro North Hospital and Health Service, Royal Brisbane & Women's Hospital, Herston, QLD, Australia
- School of Health & Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Clare L Burns
- Metro North Hospital and Health Service, Royal Brisbane & Women's Hospital, Herston, QLD, Australia
- School of Health & Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
- Centre for Research Excellence in Telehealth, The University of Queensland, Brisbane, QLD, Australia
| | - Elizabeth C Ward
- School of Health & Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
- Centre for Research Excellence in Telehealth, The University of Queensland, Brisbane, QLD, Australia
- Metro South Hospital and Health Service, Centre for Functioning and Health Research, Brisbane, QLD, Australia
| | - Lynell Bassett
- Metro North Hospital and Health Service, Royal Brisbane & Women's Hospital, Herston, QLD, Australia
| |
Collapse
|
15
|
Crowell MS, Mason JS, McGinniss JH. Musculoskeletal Imaging for Low Back Pain in Direct Access Physical Therapy Compared to Primary Care: An Observational Study. Int J Sports Phys Ther 2022; 17:237-246. [PMID: 35136693 PMCID: PMC8805092 DOI: 10.26603/001c.31720] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/19/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Overutilization of diagnostic imaging is associated with poor outcomes and increased costs. Physical therapists demonstrate the ability to order diagnostic imaging safely and appropriately, and early access to physical therapy reduces unnecessary imaging, lowers healthcare costs, and improves outcomes. HYPOTHESIS/PURPOSE The primary purpose of this study was to compare rates of compliance with the National Committee for Quality Assurance - Healthcare Effectiveness Data and Information Set (HEDIS) recommendations for diagnostic imaging in low back pain between physical therapists and primary care providers in young, athletic patients. STUDY DESIGN Retrospective cohort study. METHODS Military Health System Data Repository (MDR) data from January 2019 to May 2020 was reviewed for compliance with the low back pain HEDIS recommendation. The low back pain imaging HEDIS measure identifies the percentage of patients who did not have an imaging study (plain X-ray, MRI, CT Scan) ordered on the first encounter with a diagnosis of low back pain or in the 28 days following that first diagnosis. Chi-square tests compared HEDIS compliance rates, with α = 0.05 set a priori. RESULTS From January 2019 to May 2020, in patients age 18-24, the MDR database identified 1,845 total visits for LBP identified in the Physical Therapy Clinic and 467 total visits for LBP in the Primary Care Clinic. In the Physical Therapy Clinic, 96.7% of encounters did not have imaging ordered within the first 28 days of onset of symptoms, compared with 82.0% in the Primary Care Clinic (p < .001). CONCLUSIONS Utilizing data from a national standardized healthcare performance measure, physical therapists practicing in a direct-access setting were significantly more likely than primary care providers to adhere to guidelines for low back pain imaging in young, athletic patients. LEVEL OF EVIDENCE Level 3.
Collapse
Affiliation(s)
- Michael S Crowell
- Baylor University - Keller Army Community Hospital Division 1 Sports Physical Therapy Fellowship
| | - John S Mason
- Baylor University - Keller Army Community Hospital Division 1 Sports Physical Therapy Fellowship
| | - John H McGinniss
- Baylor University - Keller Army Community Hospital Division 1 Sports Physical Therapy Fellowship
| |
Collapse
|
16
|
Lafrance S, Demont A, Thavorn K, Fernandes J, Santaguida C, Desmeules F. Economic evaluation of advanced practice physiotherapy models of care: a systematic review with meta-analyses. BMC Health Serv Res 2021; 21:1214. [PMID: 34753487 PMCID: PMC8579553 DOI: 10.1186/s12913-021-07221-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 10/25/2021] [Indexed: 12/03/2022] Open
Abstract
Background The objective of this systematic review is to appraise evidence on the economic evaluations of advanced practice physiotherapy (APP) care compared to usual medical care. Methods Systematic searches were conducted up to September 2021 in selected electronic bibliographical databases. Economic evaluation studies on an APP model of care were included. Economic data such as health care costs, patient costs, productivity losses were extracted. Methodological quality of included studies was assessed with the Effective Public Health Practice Project tool and the Critical Appraisal Skills Programme checklist. Meta-analyses were performed and mean differences (MD) in costs per patient were calculated using random-effect inverse variance models. Certainty of the evidence was assessed with the GRADE Approach. Results Twelve studies (n = 14,649 participants) including four randomized controlled trials, seven analytical cohort studies and one economic modeling study were included. The clinical settings of APP models of care included primary, emergency and specialized secondary care such as orthopaedics, paediatrics and gynaecology. The majority of the included participants were adults with musculoskeletal disorders (n = 12,915). Based on low quality evidence, health system costs including salaries, diagnostic tests, medications, and follow-up visits were significantly lower with APP care than with usual medical care, at 2 to 12-month follow-up (MD: -139.08 €/patient; 95%CI: -265.93 to -12.23; n = 7648). Based on low quality evidence, patient costs including travel and paid medication prescriptions, or treatments were significantly higher with APP care compared to usual medical care, at 2 to 6-month follow-up (MD: 29.24 €/patient; 95%CI: 0.53 to 57.95 n = 1485). Based on very low quality evidence, no significant differences in productivity losses per patient were reported between both types of care (MD: 590 €/patient; 95%CI: -100 to 1280; n = 819). Conclusions This is the first systematic review and meta-analysis on the economic evaluation of APP models of care. Low quality evidence suggests that APP care might result in lower health care costs, but higher patient costs compared to usual medical care. Costs differences may vary depending on various factors such as the cost methodology used and on the clinical setting. More evidence is needed to evaluate cost benefits of APP models of care. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07221-6.
Collapse
Affiliation(s)
- Simon Lafrance
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada. .,Maisonneuve-Rosemont Hospital Research Center, Université de Montréal Affiliated Research Center, Montreal, Quebec, Canada.
| | - Anthony Demont
- INSERM 1123 ECEVE, Faculty of Medicine, Paris-Diderot University, Paris, France.,Physiotherapy School, University of Orleans, Orleans, France
| | - Kednapa Thavorn
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Julio Fernandes
- Hôpital du Sacré-Coeur de Montréal Research Center, Université de Montréal Affiliated Research Center, Montreal, Quebec, Canada.,Department of Surgery, Faculty of Medecine, Université de Montréal, Montreal, Quebec, Canada
| | - Carlo Santaguida
- Department of Neurology and Neurosurgery, Faculty of Medecine, McGill University Health Center, Montreal, Quebec, Canada
| | - François Desmeules
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Maisonneuve-Rosemont Hospital Research Center, Université de Montréal Affiliated Research Center, Montreal, Quebec, Canada
| |
Collapse
|
17
|
Robarts S, Denis S, Kennedy D, Dickson P, Juma S, Palinkas V, Rachevitz M, Boljanovic-Susic D, Stratford P. Patient gender does not influence referral to an orthopaedic surgeon by advanced practice orthopaedic providers: a prospective observational study in Canada. BMC Health Serv Res 2021; 21:952. [PMID: 34511124 PMCID: PMC8435171 DOI: 10.1186/s12913-021-06965-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/26/2021] [Indexed: 11/29/2022] Open
Abstract
Background The role of an advanced practice physiotherapist has been introduced in many countries to improve access to care for patients with hip and knee arthritis. Traditional models of care have shown a gender bias, with women less often referred and recommended for surgery than men. This study sought to understand if patient gender affects access to care in the clinical encounter with the advanced practice provider. Our objectives were: (1) To determine if a gender difference exists in the clinical decision to offer a consultation with a surgeon; (2) To determine if a gender difference exists in patients’ decisions to accept a consultation with a surgeon among those patients to whom it is offered; and, (3) To describe patients’ reasons for not accepting a consultation with a surgeon. Methods This was a prospective study of 815 patients presenting to a tertiary care centre for assessment of hip and knee arthritis, with referral onward to an orthopaedic surgeon when indicated. We performed a multiple logistic regression analysis adjusting for severity to address the first objective and a simple logistic regression analysis to answer the second objective. Reasons for not accepting a surgical consultation were obtained by questionnaire. Results Eight hundred and fifteen patients (511 women, 304 men) fulfilled study eligibility criteria. There was no difference in the probability of being referred to a surgeon for men and women (difference adjusted for severity = − 0.02, 95% CI: − 0.07, 0.02). Neither was there a difference in the acceptance of a referral for men and women (difference = − 0.05, 95% CI: − 0.09, 0.00). Of the 14 reasons for declining a surgical consultation, 5 showed a difference with more women than men indicating a preference for non-surgical treatment along with fears/concerns about surgery. Conclusions There is no strong evidence to suggest there is a difference in proportion of males and females proceeding to surgical consultation in the model of care that utilizes advanced practice orthopaedic providers in triage. This study adds to the evidence that supports the use of suitably trained alternate providers in roles that reduce wait times to care and add value in contexts where health human resources are limited. The care model is a viable strategy to assist in managing the growing backlog in orthopaedic care, recently exacerbated by the COVID-19 pandemic. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06965-5.
Collapse
Affiliation(s)
- Susan Robarts
- Holland Orthopaedic and Arthritic Centre, Sunnybrook Health Sciences Centre, 43 Wellesley Street East, Toronto, ON, M4Y 1H1, Canada. .,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Suzanne Denis
- Holland Orthopaedic and Arthritic Centre, Sunnybrook Health Sciences Centre, 43 Wellesley Street East, Toronto, ON, M4Y 1H1, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Deborah Kennedy
- Holland Orthopaedic and Arthritic Centre, Sunnybrook Health Sciences Centre, 43 Wellesley Street East, Toronto, ON, M4Y 1H1, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Patricia Dickson
- Holland Orthopaedic and Arthritic Centre, Sunnybrook Health Sciences Centre, 43 Wellesley Street East, Toronto, ON, M4Y 1H1, Canada.,Department of Occupational Science & Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Shahiroz Juma
- Holland Orthopaedic and Arthritic Centre, Sunnybrook Health Sciences Centre, 43 Wellesley Street East, Toronto, ON, M4Y 1H1, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Veronica Palinkas
- Holland Orthopaedic and Arthritic Centre, Sunnybrook Health Sciences Centre, 43 Wellesley Street East, Toronto, ON, M4Y 1H1, Canada
| | - Maria Rachevitz
- Holland Orthopaedic and Arthritic Centre, Sunnybrook Health Sciences Centre, 43 Wellesley Street East, Toronto, ON, M4Y 1H1, Canada
| | - Dragana Boljanovic-Susic
- Holland Orthopaedic and Arthritic Centre, Sunnybrook Health Sciences Centre, 43 Wellesley Street East, Toronto, ON, M4Y 1H1, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Paul Stratford
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
18
|
Lafrance S, Santaguida C, Perreault K, Bath B, Thavorn K, Feldman D, Hébert LJ, Fernandes J, Desmeules F. Single session compared with multiple sessions of education and exercise for older adults with spinal pain in an advanced practice physiotherapy model of care: protocol for a randomised controlled trial. BMJ Open 2021; 11:e053004. [PMID: 34493525 PMCID: PMC8424421 DOI: 10.1136/bmjopen-2021-053004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To assess the effectiveness and cost-effectiveness of a single session compared with multiple sessions of education and exercise for older adults with spinal pain treated conservatively in an advanced practice physiotherapy model of care. METHODS AND ANALYSIS In this pragmatic randomised controlled trial, 152 older adults (≥65 years old) with neck or back pain initially referred for a consultation in neurosurgery, but treated conservatively, will be recruited through the advanced practice physiotherapy neurosurgery CareAxis programme in the Montreal region (Quebec, Canada). In the CareAxis programme, older patients with spinal pain are triaged by an advance practice physiotherapist and are offered conservative care and only potential surgical candidates are referred to a neurosurgeon. Participants will be randomised into one of two arms: 1-a single session or 2-multiple sessions (6 sessions over 12 weeks) of education and exercise with the advance practice physiotherapist (1:1 ratio). The primary outcome measure will be the Brief Pain Inventory (pain severity and interference subscales). Secondary measures will include self-reported disability (the Neck Disability Index or Oswestry Disability Index), the Pain Catastrophizing Scale, satisfaction with care questionnaires (9-item Visit-specific Satisfaction Questionnaire and MedRisk), and the EQ-5D-5L. Participants' healthcare resources use and related costs will be measured. Outcomes will be collected at baseline and at 6, 12 and 26 weeks after enrolment. Intention-to-treat analyses will be performed, and repeated mixed-model analysis of variance will assess differences between treatment arms. Cost-utility analyses will be conducted from the perspective of the healthcare system. ETHICS AND DISSEMINATION Ethics approval has been obtained from the Comité d'éthique de la recherche du CIUSS de l'Est-de-l'Île-de-Montréal (FWA00001935 and IRB00002087). Results of this study will be presented to different stakeholders, published in peer-reviewed journals and presented at international conferences. PROTOCOL VERSION V.4 August 2021. TRIAL REGISTRATION NUMBER NCT04868591; Pre-results.
Collapse
Affiliation(s)
- Simon Lafrance
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
- Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Montreal, Quebec, Canada
| | - Carlo Santaguida
- Department of Neurology and Neurosurgery, Faculty of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Kadija Perreault
- Center for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec City, Quebec, Canada
- Department of Rehabilitation, Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Brenna Bath
- School of Rehabilitation Science, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- Canadian Centre for Health and Safety in Agriculture, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Kednapa Thavorn
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Debbie Feldman
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
- Centre for Research in Public Health (CReSP), Université de Montréal and Centre for Interdisciplinary Research in Rehabilitation (CRIR), Montreal, Quebec, Canada
| | - Luc J Hébert
- Department of Rehabilitation, Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Julio Fernandes
- Université de Montréal Affiliated Research Center, Hôpital du Sacré-Cœur de Montréal Research Center, Montreal, Quebec, Canada
- Department of Surgery, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - François Desmeules
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
- Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Montreal, Quebec, Canada
| |
Collapse
|
19
|
Rath L, Faletra A, Downing N, Rushton A. Cross-sectional UK survey of advanced practice physiotherapy: characteristics and perceptions of existing roles. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2021. [DOI: 10.12968/ijtr.2020.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background/aims Few studies have investigated the characteristics of advanced practice physiotherapy in the UK to evaluate current context and implementation. The aim of this study was to understand how advanced practice physiotherapy is implemented in the UK. Methods A cross-sectional online descriptive national questionnaire was developed, using a previous survey and literature, comprising 33 closed, Likert-scale and open questions. Data analysis was undertaken using frequencies and thematic analysis. All 646 members of the Advanced Practice Physiotherapy Network were invited to participate. Results A total of 142 (22% response) reported 13 job titles; 40% had experienced ≥1 title change; most (50.7%) preferred ‘advanced practice physiotherapist’. High level job satisfaction was identified but barriers prevent fulfilment of the four advanced practice physiotherapy pillars: clinical practice, leadership and management, education and research. High level clinical skills and facilitating patient pathways were key to role differentiation. Problems included lack of support, inconsistency between responsibility and reward, and no consistent framework for advanced practice physiotherapy roles. Conclusions Advanced practice physiotherapists are largely satisfied, but significant variation exists in titles and implementation of roles. A consistent advanced practice physiotherapy framework is required.
Collapse
Affiliation(s)
- Lucy Rath
- Bupa Health Centre Bristol, Bupa Health Clinics, Bristol, UK
| | - Agostino Faletra
- Queen Elizabeth Hospital, Gateshead NHS Foundation Trust, Gateshead, UK
| | | | - Alison Rushton
- School of Physical Therapy, Western University, London, Ontario, Canada
- Centre of Precision Rehabilitation for Spinal Pain, School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, UK
| |
Collapse
|
20
|
Pokorny MA, Thorne PR, Lee AC, Whitfield BCS, Wilson WJ. Parental satisfaction with an advanced audiology-led triage service in paediatric ENT outpatient clinics. Int J Audiol 2021; 61:159-165. [PMID: 34061705 DOI: 10.1080/14992027.2021.1930207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The advanced audiology-led service is designed to triage and manage children who are referred to Ear Nose and Throat (ENT) outpatient services with middle ear or hearing concerns. This service has resulted in shorter waiting times for children to receive ENT treatment, and improved ENT capacity. The aim of this study was to explore parental satisfaction with the advanced audiology-led ENT service and to determine if there were cultural or process factors affecting satisfaction. DESIGN Prospective cross-sectional study using a modified Visit-Specific Satisfaction Questionnaire (VSQ-9) survey. STUDY SAMPLE One hundred and thirteen parents of children consecutively attending a first appointment in the advanced audiology-led service recruited between October 2016 and October 2017. RESULTS There were a total of 100 valid responses (rate of 88.5%). The survey showed high levels of satisfaction. Satisfaction scores were significantly higher for items related to interactions with the audiologist compared to items related to waiting times. There were no differences in satisfaction across cultural groups. Parents were equally satisfied with the service whether their child was managed independently by the audiologist or required another appointment for medical input. CONCLUSIONS The advanced audiology-led service had high levels of satisfaction from parents attending with their children.
Collapse
Affiliation(s)
- Michelle A Pokorny
- Discipline of Audiology, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Peter R Thorne
- Section of Audiology, School of Population Health, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand.,Eisdell Moore Centre, University of Auckland, Auckland, New Zealand
| | - Arier C Lee
- Section of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
| | - Bernard C S Whitfield
- Logan Hospital Integrated Specialist ENT Service, Metro South Health Service District, Queensland Health, Queensland, Australia
| | - Wayne J Wilson
- Discipline of Audiology, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| |
Collapse
|
21
|
Keil AP, Hazle C, Maurer A, Kittleson C, Watson D, Young B, Rezac S, Epsley S, Baranyi B. Referral for Imaging in Physical Therapist Practice: Key Recommendations for Successful Implementation. Phys Ther 2021; 101:6121965. [PMID: 33764462 DOI: 10.1093/ptj/pzab013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 08/09/2020] [Accepted: 12/06/2020] [Indexed: 01/01/2023]
Abstract
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.
Collapse
Affiliation(s)
- Aaron Paul Keil
- Department of Physical Therapy, University of Illinois at Chicago College of Applied Health Sciences, Chicago, Illinois, USA
| | - Charles Hazle
- College of Health and Sciences, University of Kentucky, Lexington, Kentucky, USA
| | - Amma Maurer
- Department of Radiology, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Connie Kittleson
- Physical Therapy, Columbia Saint Mary's Hospital Ozaukee, Mequon, Wisconsin, USA
| | - Daniel Watson
- 15th Medical Group, Joint Base Pearl Harbor-Hickam, Honolulu, Hawaii, USA
| | - Brian Young
- Physical Therapy, Baylor University, Waco, Texas, USA
| | - Scott Rezac
- Rezac and Associates Physical Therapy, Colorado Springs, Colorado, USA
| | - Scott Epsley
- Philadelphia 76ers, Philadelphia, Pennsylvania, USA
| | - Brian Baranyi
- Department of Physical Therapy, University of Illinois at Chicago College of Applied Health Sciences, Chicago, Illinois, USA
| |
Collapse
|
22
|
Sebanayagam V, Chakur N, Baffoe NA, Reed B, Weinberger J, Twardy BS, Veltman J. Adding a Physical Therapist to the Health Care Team in an HIV Clinic Increases Physical Therapy Referrals and Reduces Opioid Prescriptions Provided for Chronic Musculoskeletal Pain in Patients Living With HIV. Open Forum Infect Dis 2021; 8:ofab047. [PMID: 33728359 PMCID: PMC7944341 DOI: 10.1093/ofid/ofab047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/27/2021] [Indexed: 11/30/2022] Open
Abstract
Background Musculoskeletal (MSK) pain is common in people living with HIV (PLWH). Health care providers sometimes prescribe opioids to control pain, which may lead to opioid misuse. An interdisciplinary approach that includes physical therapy has been successful in managing MSK pain in various health care settings. Therefore, we sought to find the impact of recruiting a physical therapist (PT) on the number of opioid prescriptions and physical therapy referrals made by physicians in training to manage MSK pain in PLWH. Methods We performed a retrospective chart review of patients seen by Internal Medicine physicians in training in an HIV clinic in Detroit before (2017) and after (2018) recruiting a PT to the health care team and collected demographic and clinical data. We also surveyed the trainees to assess how the PT addition influenced their learning. Institutional review board waiver was obtained. Results Results showed that of all PLWH seen at the clinic, 28/249 (11%) and 37/178 (21%) had chronic MSK pain in the 2017 and 2018 data sets, respectively. In 2017, all 28 patients with MSK pain were prescribed opioids. This decreased in 2018 after the PT addition (10/37 patients; P < .0001). The number of physical therapy referrals significantly increased after the PT addition (2017: 5/28 patients; 2018: 17/37 patients; P = .03). Trainees felt that the PT helped improve their examination skills and develop a treatment plan for patients. Conclusions The addition of a PT encouraged physicians in training to utilize nonopioid management of MSK pain in PLWH and enhanced their learning experience, as perceived by the trainees.
Collapse
Affiliation(s)
| | | | - Nana Ama Baffoe
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Brian Reed
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | | | - Brandon S Twardy
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Jennifer Veltman
- Wayne State University School of Medicine, Detroit, Michigan, USA
| |
Collapse
|
23
|
Hon S, Ritter R, Allen DD. Cost-Effectiveness and Outcomes of Direct Access to Physical Therapy for Musculoskeletal Disorders Compared to Physician-First Access in the United States: Systematic Review and Meta-Analysis. Phys Ther 2021; 101:5999910. [PMID: 33245117 DOI: 10.1093/ptj/pzaa201] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 03/09/2020] [Accepted: 10/08/2020] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Direct access to physical therapy provides an alternative to physician-first systems for patients who need physical therapy for musculoskeletal disorders (MSDs). Direct access across multiple countries and the United States (US) military services has produced improved functional outcomes and/or cost-effectiveness at clinical and health care system levels; however, data remain scarce from civilian health care systems within the United States. The purpose of this study was to compare evidence regarding costs and clinical outcomes between direct access and physician-first systems in US civilian health services. METHODS A database search of PubMed, CINAHL, Cochrane Reviews, and PEDro was conducted through May 2019. Studies were selected if they specified civilian US, physical therapy for MSDs, direct access or physician-first, and extractable outcomes for cost, function, or number of physical therapy visits. Studies were excluded if interventions utilized early or delayed physical therapy access compared with physician-first. Five retrospective studies met the criteria. Means and standard deviations for functional outcomes, cost, and number of visits were extracted, converted to effect sizes (d) and 95% CI, and combined into grand effect sizes using fixed-effect or random-effects models depending on significance of the Q heterogeneity statistic. RESULTS Direct access to physical therapy showed reduced physical therapy costs (d = -0.23; 95% CI = -0.35 to -0.11), total health care costs (d = -0.19; 95% CI = -0.32 to -0.07), and number of physical therapy visits (d = -0.17; 95% CI = -0.29 to -0.05) compared to physician-first systems. Disability decreased in both direct access (d = -1.78; 95% CI = -2.28 to -1.29) and physician-first (d = -0.89; 95% CI = -0.92 to -0.85) groups; functional outcome improved significantly more with direct access (z score = 0.89; 95% CI = 0.40 to 1.39). CONCLUSIONS Direct access to physical therapy is more cost-effective, resulting in fewer visits than physician-first access in the United States, with greater functional improvement. IMPACT These findings within civilian US health care services support a cost-effective health care access alternative for spine-related MSDs and can inform health care policy makers.
Collapse
Affiliation(s)
- Sandra Hon
- Graduate Program in Physical Therapy, University California, San Francisco/San Francisco State University, San Francisco, California, USA
| | - Richard Ritter
- Graduate Program in Physical Therapy, University California, San Francisco/San Francisco State University, San Francisco, California, USA
| | - Diane D Allen
- Graduate Program in Physical Therapy, University California, San Francisco/San Francisco State University, San Francisco, California, USA
| |
Collapse
|
24
|
Madsen MN, Kirkegaard ML, Klebe TM, Linnebjerg CL, Villumsen SMR, Due SJ, Trøstrup J, Rossen CB, Birk HO, Elmengaard B, Mikkelsen LR. Inter-professional agreement and collaboration between extended scope physiotherapists and orthopaedic surgeons in an orthopaedic outpatient shoulder clinic - a mixed methods study. BMC Musculoskelet Disord 2021; 22:4. [PMID: 33397350 PMCID: PMC7784386 DOI: 10.1186/s12891-020-03831-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/25/2020] [Indexed: 11/19/2022] Open
Abstract
Background Extended scope physiotherapists (ESP) are increasingly supplementing orthopaedic surgeons (OS) in diagnosing patients with musculoskeletal disorders. Studies have reported satisfactory diagnostic and treatment agreement between ESPs and OSs, but methodological study quality is generally low, and only few studies have evaluated inter-professional collaboration. Our aims were: 1) to evaluate agreement on diagnosis and treatment plan between ESPs and OSs examining patients with shoulder disorders, 2) to explore and evaluate their inter-professional collaboration. Methods In an orthopaedic outpatient shoulder clinic, 69 patients were examined independently twice on the same day by an ESP and an OS in random order. Primary and secondary diagnoses (nine categories) and treatment plan (five categories, combinations allowed) were registered by each professional and compared. Percentage of agreement and kappa-values were calculated. Two semi-structured focus-group interviews were performed with ESPs and OSs, respectively. Interviews were based on the theoretical concept of Relational Coordination, encompassing seven dimensions of communication and relationship among professionals. A thematic analysis was conducted.
Results Agreement on primary diagnosis was 62% (95% CI: [50; 73]). ESPs and OSs agreed on the combination of diagnoses in 79% (95% CI: [70; 89]) of the cases. Partial diagnostic agreement (one professional’s primary diagnosis was also registered as either primary or secondary diagnosis by the other) was 96% (95% CI: [91; 100]). Across treatment categories, agreement varied between 68% (95% CI: [57; 79]) and 100%. In 43% (95% CI: [31; 54]) of the cases, ESP and OS had full concordance between treatment categories chosen, while they agreed on at least one recommendation in 96% (95% CI: [91; 100]). Positive statements of all dimensions of relational coordination were found. Three themes especially important in the inter-professional collaboration emerged: Close communication, equal and respectful relationship and professional skills.
Conclusions In the majority of cases, the ESP and OS registered the same or partly the same diagnosis and treatment plan. Indications of a high relational coordination implying a good inter-professional collaboration were found. Our results support that ESPs and OSs can share the task of examining selected patients with shoulder disorders in an orthopaedic clinic. Trial registration ClinicalTrials.gov Identifier: NCT03343951. Registered 10 November 2017 Supplementary Information The online version contains supplementary material available at 10.1186/s12891-020-03831-z.
Collapse
Affiliation(s)
| | | | | | | | | | - Stine Junge Due
- Elective Surgery Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Jeanette Trøstrup
- Elective Surgery Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | | | - Hans Okkels Birk
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Brian Elmengaard
- Elective Surgery Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Lone Ramer Mikkelsen
- Elective Surgery Centre, Silkeborg Regional Hospital, Silkeborg, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
25
|
Burley T, Brody LT, Boissonnault WG, Ross MD. Development of a Musculoskeletal Imaging Competency Examination for Physical Therapists. Phys Ther 2020; 100:2254-2265. [PMID: 32885236 DOI: 10.1093/ptj/pzaa154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/21/2020] [Indexed: 02/09/2023]
Abstract
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.
Collapse
Affiliation(s)
- Troy Burley
- Rocky Mountain University of Health Professions, Provo, Utah
| | - Lori T Brody
- Sports and Spine Physical Therapy, University of Wisconsin, Mt. Horeb, Wisconsin
| | | | - Michael D Ross
- Department of Physical Therapy, Daemen College, 4380 Main Street, Amherst, NY 14426 (USA)
| |
Collapse
|
26
|
Lafrance S, Lapalme JG, Méquignon M, Santaguida C, Fernandes J, Desmeules F. Advanced practice physiotherapy for adults with spinal pain: a systematic review with meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 30:990-1003. [PMID: 33123757 DOI: 10.1007/s00586-020-06648-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/23/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To appraise the available evidence on advanced practice physiotherapy (APP) models of care (MoC) in specialized secondary care such as orthopaedic, rheumatology or neurosurgery outpatients' clinics for adults with spinal pain. METHODS Systematic review with meta-analysis. Electronic searches were conducted up to July 2020 in Medline, Embase, Cochrane CENTRAL and CINAHL. Studies on APP MoC in specialized secondary care for adults with spinal pain were included. RESULTS Eighteen studies (n = 9405), including two randomized controlled trials and sixteen observational studies were included. One study was considered at high quality, fourteen studies were considered of moderate quality and three were considered of low quality. Pooled results for change in disability for patients with spinal pain reported no significant difference between APP and usual medical care (UMC). Mean wait time for initial consultation was lower with APP (1-9.4 weeks) than with UMC MoC (23-65 weeks). Following the implementation of APP MoC, wait time for a consultation with a medical specialist was reduced (6-16 weeks). Physiotherapists in APP MoC managed independently 89.2% of the patients referred (n = 8393). Stakeholders and patients reported high satisfaction with APP care. CONCLUSIONS APP MoC and UMC likely result in comparable pain, disability and quality of life improvement for adults with spinal pain. However, APP MoC have the potential to improve health care access by reducing wait time for consultation in specialized care and maintaining a high level of satisfaction among stakeholders and patients.
Collapse
Affiliation(s)
- Simon Lafrance
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada. .,Hôpital Maisonneuve-Rosemont Research Center, Université de Montréal Affiliated Research Center, Montreal, QC, Canada.
| | - Jean-Gabriel Lapalme
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada.,Hôpital Maisonneuve-Rosemont Research Center, Université de Montréal Affiliated Research Center, Montreal, QC, Canada
| | - Marianne Méquignon
- Hôpital Maisonneuve-Rosemont Research Center, Université de Montréal Affiliated Research Center, Montreal, QC, Canada
| | - Carlo Santaguida
- Department of Neurology and Neurosurgery, Faculty of Medecine, McGill University Health Center, Montreal, QC, Canada
| | - Julio Fernandes
- Hôpital du Sacré-Coeur de Montréal Research Center, Université de Montréal Affiliated Research Center, Montreal, QC, Canada.,Department of Surgery, Faculty of Medecine, Université de Montréal, Montreal, QC, Canada
| | - François Desmeules
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada.,Hôpital Maisonneuve-Rosemont Research Center, Université de Montréal Affiliated Research Center, Montreal, QC, Canada
| |
Collapse
|
27
|
Samsson KS, Grimmer K, Larsson MEH, Morris J, Bernhardsson S. Effects on health and process outcomes of physiotherapist-led orthopaedic triage for patients with musculoskeletal disorders: a systematic review of comparative studies. BMC Musculoskelet Disord 2020; 21:673. [PMID: 33038935 PMCID: PMC7548042 DOI: 10.1186/s12891-020-03673-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/24/2020] [Indexed: 11/13/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- K S Samsson
- Region Västra Götaland, Research and Development Primary Health Care, Gothenburg, Sweden.
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- GHP Ortho Center Gothenburg, Gothenburg, Sweden.
| | - K Grimmer
- Department of Physiotherapy, Stellenbosch University, Cape Town, South Africa
| | - M E H Larsson
- Region Västra Götaland, Research and Development Primary Health Care, Gothenburg, Sweden
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - J Morris
- University of South Australia, Adelaide, Australia
- The Canberra Hospital, Canberra, Australia
| | - S Bernhardsson
- Region Västra Götaland, Research and Development Primary Health Care, Gothenburg, Sweden
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
28
|
Osteoarthritis Hip and Knee Service (OAHKS) in a community health setting compared to the hospital setting: A feasibility study for a new care pathway. Musculoskelet Sci Pract 2020; 49:102167. [PMID: 32769073 DOI: 10.1016/j.msksp.2020.102167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 03/09/2020] [Accepted: 04/07/2020] [Indexed: 12/22/2022]
Abstract
AIM OsteoArthritis Hip and Knee Service (OAHKS) clinics involve assessment and triage by advanced musculoskeletal physiotherapists for patients referred to orthopaedic clinics in public hospitals. This study explored the feasibility of implementing an OAHKS clinic in a community setting. METHODS The domains of feasibility explored in this mixed methods study were acceptability (patient, general practitioner and orthopaedic surgeon), demand (referrals, waiting times) efficacy potential (management decision, conversion-to-surgery rates) and practicality (number and type of discussions between advanced musculoskeletal physiotherapist and doctors, adverse events). Results from a community-based OAHKS were compared with hospital-based OAHKS over a 9-month period in the same metropolitan health region. RESULTS A total of 91 eligible patients attended an OAHKS clinic (40 community-based, 51 hospital-based). Both the community-based and hospital-based OAHKS had high patient and general practitioner satisfaction, with small differences in favour of community-based OAHKS. Waiting times were significantly shorter in community-based OAHKS for both initial appointment [community-based OAHKS mean 17 days (SD11), hospital-based OAHKS mean 155 days (SD38)] and commencing non-surgical management [community-based OAHKS mean 32 days (SD22), hospital-based OAHKS mean 67 days (SD32)]. Referral rate to orthopaedics was substantially lower from community-based OAHKS (3%) compared with hospital-based OAHKS (33%) [odds ratio 0.05 (95% CI 0.01-0.41)]. There were no adverse events. CONCLUSION Community-based OAHKS is feasible, and acceptable to patients and general practitioners, with potential benefits indicated in this study including shorter waiting times for assessment and commencing non-surgical management programs.
Collapse
|
29
|
Fennelly O, Desmeules F, O'Sullivan C, Heneghan NR, Cunningham C. Advanced musculoskeletal physiotherapy practice: Informing education curricula. Musculoskelet Sci Pract 2020; 48:102174. [PMID: 32560874 DOI: 10.1016/j.msksp.2020.102174] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/15/2020] [Accepted: 04/22/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Physiotherapists are operating at an advanced level of practice, usually on ad hoc basis with inhouse training, in response to the increasing burden of musculoskeletal (MSK) disorders. Discrepancies in role-specific education of advanced practice physiotherapists (APPs) creates challenges in ensuring a quality service, workforce mobility and formal recognition. This study reviewed existing MSK APP competency frameworks and education offerings, and explored physiotherapist learning needs with a view to informing international standardisation of MSK APP education curricula. METHODS A scoping review of the literature and relevant university and regulatory websites identified APP competency frameworks and education curricula, which were verified by international experts. Content analysis, performed on the identified competencies and modules, produced a list of themes existing in MSK advanced practice internationally. A survey based on those themes identified the learning priorities of physiotherapists (n = 25) participating in an APP symposium in Ireland. RESULTS Six APP competency frameworks and eleven curricula from the UK, Canada and Australia were identified. Themes emerging, regarding MSK APP practice internationally, included both entry-level physiotherapy (e.g., Assessment and Diagnosis) and traditionally medically-controlled tasks (e.g., Injection Therapy), as well as Research, Leadership, Service Development, Professional-related Matters and Education. Participating physiotherapists more commonly prioritised competencies which would be deemed beyond entry level physiotherapy skills (i.e., Radiology versus Manual Therapy). CONCLUSION Despite variances in profiles of APPs both between and within countries, common themes emerged regarding their expected competencies and skills. This study provides the foundation for the adoption of internationally-recognised MSK APP competencies and education standards.
Collapse
Affiliation(s)
- Orna Fennelly
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Belfield, Dublin, Ireland.
| | | | - Cliona O'Sullivan
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Belfield, Dublin, Ireland.
| | - Nicola R Heneghan
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, United Kingdom.
| | - Caitriona Cunningham
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Belfield, Dublin, Ireland.
| |
Collapse
|
30
|
Razmjou H, Palinkas V, Christakis M, Kennedy D, Robarts S. Diagnostic Value of Acromiohumeral Distance in Rotator Cuff Pathology: Implications for Advanced-Practice Physiotherapists. Physiother Can 2020; 72:52-62. [PMID: 34385749 DOI: 10.3138/ptc-2018-0084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
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.
Collapse
Affiliation(s)
- Helen Razmjou
- Department of Rehabilitation, Holland Orthopaedic & Arthritic Centre.,Sunnybrook Research Institute.,Department of Physical Therapy
| | - Veronica Palinkas
- Department of Rehabilitation, Holland Orthopaedic & Arthritic Centre.,Department of Physical Therapy
| | - Monique Christakis
- Department of Medical Imaging, Sunnybrook Health Sciences Centre.,Department of Medical Imaging, Faculty of Medicine, University of Toronto, Toronto
| | - Deborah Kennedy
- Department of Rehabilitation, Holland Orthopaedic & Arthritic Centre.,Department of Physical Therapy.,School of Rehabilitation Science, McMaster University, Hamilton, Ont
| | - Susan Robarts
- Department of Rehabilitation, Holland Orthopaedic & Arthritic Centre.,Sunnybrook Research Institute.,Department of Physical Therapy
| |
Collapse
|
31
|
Caffrey A, Smart KM, FitzGerald O. Physiotherapist-Led Triage at a Rheumatology-Based Musculoskeletal Assessment Clinic: an 18-Month Service Evaluation of Activity and Outcomes. ACR Open Rheumatol 2019; 1:213-218. [PMID: 31777797 PMCID: PMC6858023 DOI: 10.1002/acr2.1022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective Physiotherapist‐led musculoskeletal triage clinics are an effective and efficient means of managing patients presenting with musculoskeletal disorders in primary and secondary care. Data regarding the activity and outcomes of physiotherapist‐led triage in hospital‐based outpatient rheumatology clinics are scarce. Thus, the aim of this study was to undertake a service evaluation of activity and outcomes of a physiotherapist‐led rheumatology‐based Musculoskeletal Assessment Clinic (MAC). The primary objective was to quantify the proportion of patients independently managed by the clinical specialist physiotherapists (CSPs). Methods A retrospective service evaluation was undertaken of all patients who attended the Rheumatology MAC at St Vincent's University Hospital, Dublin (SVUH) between August 2012 and February 2014. The Clinical Audit Department of SVUH approved the study. Data were analyzed using descriptive statistics. Results Five hundred and eight patients attended the MAC: 76% were female and the mean age was 55 years and ranged between 18‐91. Seventy‐five percent of patients were independently managed by the CSP without needing to see a consultant rheumatologist, whereas 17% were referred to the rheumatology team. Eighty‐seven percent of patients referred to the rheumatology team had rheumatological intervention (eg, injection, medical management, or multidisciplinary rehabilitation). A substantially higher proportion of patients with regional musculoskeletal pain and degenerative conditions were independently managed by the CSP compared with those who had rheumatological/inflammatory conditions. Conclusion The majority of patients who attended the MAC were independently managed by the physiotherapists, suggesting that physiotherapist‐led triage may be a useful and efficient means of managing a proportion of patients referred for a specialist rheumatological consultation.
Collapse
|
32
|
Lockwood P, Pittock L. Multi-professional image interpretation: Performance in preliminary clinical evaluation of appendicular radiographs. Radiography (Lond) 2019; 25:e95-e107. [DOI: 10.1016/j.radi.2019.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 04/12/2019] [Accepted: 04/23/2019] [Indexed: 11/26/2022]
|
33
|
Yin D, Cabana F, Tousignant-Laflamme Y, Bédard S, Tousignant M. Can a physiotherapy student assume the role of an advanced practice physiotherapist in Orthopaedic surgery triage? A prospective observational study. BMC Musculoskelet Disord 2019; 20:498. [PMID: 31664983 PMCID: PMC6819565 DOI: 10.1186/s12891-019-2864-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 10/09/2019] [Indexed: 11/22/2022] Open
Abstract
Background Advanced practice physiotherapists (APP) have helped improve accessibility to orthopaedic outpatient care. Several studies have validated the APP practice model in orthopaedic care, demonstrating high agreement between APPs and orthopaedic surgeons (OS) regarding diagnosis and management. However, as APPs tend to be experienced senior physiotherapists, such a study involving physiotherapy students (PS) has not yet been explored. The objective of this study was to evaluate the agreement for orthopaedic diagnoses and surgical triage between a PS and OSs. Methods A prospective study involving a final year PS and seven OSs was conducted in a university hospital, after the PS had undergone a three-week intensive training. Eighty-six adult patients referred to OSs for knee osteoarthritis, hip osteoarthritis or shoulder problem were independently evaluated by the PS, and then re-evaluated by an OS. The diagnoses and surgical triage recommendations of both clinicians were analyzed for agreement using raw percent agreement and Cohen’s kappa. Patient satisfaction with the outpatient clinic experience was noted using a modified version of the Visit-Specific Satisfaction Instrument. Results Our sample consisted of 86 patients (mean age = 63.4 years). Reasons for consultation included shoulder problems (36%), knee osteoarthritis (52%) and hip osteoarthritis (12%). The raw percent agreement for diagnosis was 95.3%. The agreement for surgical triage was high (κ = 0.86, 95% CI: 0.74–0.98) with a raw agreement of 94.2%. Patient satisfaction was high. Conclusions The PS and OSs made similar diagnoses and triage recommendations suggesting that clinical experience alone is not a prerequisite for physiotherapists to help increase accessibility to orthopaedic care.
Collapse
Affiliation(s)
- David Yin
- Université de Sherbrooke, 3001, 12e Avenue Nord, Sherbrooke, Québec, Canada.,Centre de recherche du CHUS, 3001, 12e Avenue Nord, Sherbrooke, Québec, Canada
| | - François Cabana
- Université de Sherbrooke, 3001, 12e Avenue Nord, Sherbrooke, Québec, Canada.,CIUSSS de l'Estrie-CHUS, 3001, 12e Avenue Nord, Sherbrooke, Québec, Canada.,Centre de recherche du CHUS, 3001, 12e Avenue Nord, Sherbrooke, Québec, Canada
| | - Yannick Tousignant-Laflamme
- Université de Sherbrooke, 3001, 12e Avenue Nord, Sherbrooke, Québec, Canada.,Centre de recherche du CHUS, 3001, 12e Avenue Nord, Sherbrooke, Québec, Canada
| | - Sonia Bédard
- Centre de recherche du CHUS, 3001, 12e Avenue Nord, Sherbrooke, Québec, Canada
| | - Michel Tousignant
- Université de Sherbrooke, 3001, 12e Avenue Nord, Sherbrooke, Québec, Canada. .,Centre de recherche sur le vieillissement, 1036 Rue Belvédère Sud, Sherbrooke, Québec, Canada.
| |
Collapse
|
34
|
Mabry LM, Notestine JP, Moore JH, Bleakley CM, Taylor JB. Safety Events and Privilege Utilization Rates in Advanced Practice Physical Therapy Compared to Traditional Primary Care: An Observational Study. Mil Med 2019; 185:e290-e297. [DOI: 10.1093/milmed/usz176] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 05/23/2019] [Indexed: 01/16/2023] Open
Abstract
Abstract
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.
Collapse
Affiliation(s)
- Lance M Mabry
- High Point University, Department of Physical Therapy, One University Parkway, High Point, NC
| | - Jeffrey P Notestine
- 11th Medical Group, Physical Therapy Department, 1060 W Perimeter Rd, Joint Base Andrews, MD
| | - Josef H Moore
- Army-Baylor University Doctoral Program in Physical Therapy, ATTN: MCCS-WBB-GT, 3630 Stanley Road, Bldg 2841, Suite 1301, Joint Base San Antonio – Fort Sam Houston, TX
| | - Chris M Bleakley
- High Point University, Department of Physical Therapy, One University Parkway, High Point, NC
| | - Jeffrey B Taylor
- High Point University, Department of Physical Therapy, One University Parkway, High Point, NC
| |
Collapse
|
35
|
Ho CM, Thorstensson CA, Nordeman L. Physiotherapist as primary assessor for patients with suspected knee osteoarthritis in primary care-a randomised controlled pragmatic study. BMC Musculoskelet Disord 2019; 20:329. [PMID: 31301739 PMCID: PMC6626628 DOI: 10.1186/s12891-019-2690-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 06/24/2019] [Indexed: 12/18/2022] Open
Abstract
Background In Swedish primary care, the healthcare process for patients with knee osteoarthritis (KOA) can be initiated by a physician or physiotherapist assessment. However, it is unclear how the different assessments affect the healthcare processes and patient reported outcomes over time. The purpose of this study was to examine the differences in health-related quality of life (HrQoL), adjusted for pain and physical function, for patients with KOA when the healthcare process is initiated by a physiotherapist assessment compared to a physician assessment in primary care. Methods An assessor-blinded randomised controlled pragmatic trial. Using a computer-generated list of random numbers, patients seeking primary care during 2013–2017 with suspected KOA were randomised to either a physiotherapist or physician for primary assessment and treatment. Data was collected before randomisation and at 3, 6, and 12-month follow-ups. Primary outcome was HrQoL using EuroQol 5 dimensions 3 levels questionnaire, index (EQ-5D-3L index) and a visual analogue scale (VAS) (EQ-5D-3L VAS); pain intensity was measured with VAS (0–100) and physical function measured with the 30-s chair stand test. Mixed effect model analyses compared repeated measures of HrQoL between groups. The significance level was p < 0.05 and data was applied with intention-to-treat. Results Patients were randomised to either a physiotherapist (n = 35) or physician (n = 34) for primary assessment. All 69 patients were included in the analyses. There were no significant differences in HrQoL for patients assessed by a physiotherapist or a physician as primary assessor (EQ-5D-3L index, p = 0.18; EQ-5D-3L VAS, p = 0.49). We found that HrQoL changed significantly 12 months after baseline assessment for all patients regardless of assessor (EQ-5D-3L index, p < 0.001; EQ-5D-3 L VAS, p = 0.0049). No adverse events or side effects were reported. Conclusions There were no differences in HrQoL, when adjusted for pain and physical function, for patients with KOA when the healthcare process was initiated with physiotherapist assessment compared to physician assessment in primary care. Both assessments resulted in significantly higher HrQoL at the 12-month follow-up. The results imply that physiotherapists and physicians in primary care are equally qualified as primary assessors. Trial registration Retrospectively registered at http://clinicaltrial.gov, ID: NCT03715764. Electronic supplementary material The online version of this article (10.1186/s12891-019-2690-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Chan-Mei Ho
- Region Västra Götaland, Närhälsan Health Unit, Primary Health Care, Lidköping, Sweden. .,Department of Health and Rehabilitation, Unit of Physiotherapy, University of Gothenburg, Sahlgrenska Academy, Institute of Neuroscience and Physiology, Gothenburg, Sweden.
| | - Carina A Thorstensson
- Department of Health and Rehabilitation, Unit of Physiotherapy, University of Gothenburg, Sahlgrenska Academy, Institute of Neuroscience and Physiology, Gothenburg, Sweden.,Department of Neurobiology, Care sciences and Society, Unit of Physiotherapy, Karolinska Institutet, Stockholm, Sweden
| | - Lena Nordeman
- Department of Health and Rehabilitation, Unit of Physiotherapy, University of Gothenburg, Sahlgrenska Academy, Institute of Neuroscience and Physiology, Gothenburg, Sweden.,Region Västra Götaland, Närhälsan, Research and Development Primary Health Care, Research and Development Center Södra Älvsborg, Borås, Sweden
| |
Collapse
|
36
|
Cottrell M, Judd P, Comans T, Easton P, Chang AT. Comparing fly-in fly-out and telehealth models for delivering advanced-practice physiotherapy services in regional Queensland: An audit of outcomes and costs. J Telemed Telecare 2019; 27:32-38. [PMID: 31280639 DOI: 10.1177/1357633x19858036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Recruitment of advanced-practice physiotherapists to regional and rural healthcare facilities in Queensland, Australia remains a challenge. To overcome this barrier, two different service delivery models (Fly-In, Fly-Out (FIFO), Telehealth) were trialled by one regional facility. This study aims to describe the economic- and service-related outcomes of these two methods of service delivery. METHODS A retrospective audit was conducted where two nine-week time periods were selected for each service delivery model. Outcomes of interests include patient demographics and case-mix, service utilisation, clinical actions, adverse events and costs. Net financial position for both models was calculated based upon costs incurred and revenue generated by service activity. RESULTS A total of 33 appointment slots were recorded for each service delivery model. Patient case-mix was variable, where the Telehealth model predominately involved patients with musculoskeletal spinal conditions managed from a neurosurgical waiting list. Appointment slot utilisation and pattern of referral for further investigations were similar between models. No safety incidents occurred in either service delivery model. An estimated cost-savings of 13% for the Telehealth model could be achieved when compared to the FIFO model. DISCUSSION Telehealth is a safe, efficient and viable option when compared to a traditional in-person outreach service, while providing cost-savings. Telehealth should be seen as a service delivery medium in which sustainable recruitment of advanced-practice physiotherapists to regional and rural healthcare facilities can be achieved.
Collapse
Affiliation(s)
- Michelle Cottrell
- Physiotherapy Department, Royal Brisbane & Women's Hospital, Australia
| | - Perry Judd
- Physiotherapy Department, Royal Brisbane & Women's Hospital, Australia
| | - Tracy Comans
- Centre for Health Services Research, University of Queensland, Australia
| | - Paula Easton
- Physiotherapy Department, Mackay Base Hospital, Australia
| | - Angela T Chang
- Centre for Allied Health Research, Royal Brisbane & Women's Hospital, Australia
| |
Collapse
|
37
|
Gross DP, Emery DJ, Long A, Reese H, Whittaker JL. A descriptive study of physiotherapist use of publicly funded diagnostic imaging modalities in Alberta, Canada. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2019. [DOI: 10.1080/21679169.2018.1505947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Douglas P. Gross
- Department of Physical Therapy, University of Alberta, Edmonton, Canada
| | - Derek J. Emery
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Canada
| | - Audrey Long
- Bonavista Physiotherapy Clinic, Calgary, Canada
| | - Hilary Reese
- LifeMark at Academy Place Physiotherapy Clinic, Edmonton, Canada
| | - Jackie L. Whittaker
- Department of Physical Therapy, University of Alberta, Edmonton, Canada
- Glen Sather Sports Medicine Clinic, University of Alberta, Edmonton, Canada
| |
Collapse
|
38
|
Froment FP, Olson KA, Hooper TL, Shaffer SM, Sizer PS, Woodhouse LJ, Brismée JM. Large variability found in musculoskeletal physiotherapy scope of practice throughout WCPT and IFOMPT affiliated countries: An international survey. Musculoskelet Sci Pract 2019; 42:104-119. [PMID: 31102821 DOI: 10.1016/j.msksp.2019.04.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 04/18/2019] [Accepted: 04/20/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Advanced practice physiotherapy (APP) rights are part of the evolution of the Physical Therapy profession. To date, no study has investigated musculoskeletal APP rights within the World Confederation for Physical Therapy (WCPT). OBJECTIVE To investigate musculoskeletal APP rights for physical therapists worldwide and examine the relationship between level of education (entry and post-professional) and direct access for countries that are vs. are not members of the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT). DESIGN Cross-sectional study with descriptive and exploratory online surveys. METHODS An electronic survey-based descriptive and exploratory investigation was conducted. We assessed variability between WCPT member organizations descriptively and the strength of the relationships among the number and types of APP rights with: (1) country affiliation to IFOMPT; (2) entry-level professional degree; (3) post-professional training; and (4) direct access. RESULTS Some countries reported having the right to practice all 20 APP rights while others reported no APP rights. Countries with IFOMPT member organization countries displayed fair correlation (rs = .48, p < .03) between entry-level physical therapy degrees and number of APP rights. IFOMPT member organization countries were less likely to require post-professional training for direct access and manipulation. CONCLUSION APP rights for countries with direct access were significantly higher than for countries without direct access. IFOMPT member organizations demonstrated higher APP rights prevalence and were less likely to require post-professional training to obtain the right to direct access and perform manipulation.
Collapse
Affiliation(s)
- Frédéric P Froment
- Department of Rehabilitation Sciences, School of Health Professions, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
| | - Kenneth A Olson
- Northern Rehab Physical Therapy Specialists, DeKalb, Illinois, USA; International Federation of Orthopaedic Manipulative Physical Therapists, New Zealand
| | - Troy L Hooper
- Department of Rehabilitation Sciences, School of Health Professions, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Stephen M Shaffer
- Doctor of Physical Therapy Program, Congdon School of Health Sciences, High Point University, High Point, NC, USA
| | - Phillip S Sizer
- Department of Rehabilitation Sciences, School of Health Professions, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Linda J Woodhouse
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Alberta, Canada
| | - Jean-Michel Brismée
- Department of Rehabilitation Sciences, School of Health Professions, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| |
Collapse
|
39
|
Juneja H, Platon R, Soerensen UM, Praestegaard J. The Emergency Physiotherapy Practitioner (EPP) – a descriptive case study of development and implementation in two Danish hospitals. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2019. [DOI: 10.1080/21679169.2019.1578825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Hemant Juneja
- Faculty of Physiotherapy, Center of Nutrition and Rehabilitation, University College Absalon, Naestved, Denmark
| | - Ruxandra Platon
- Department of Physiotherapy and Occupational Therapy, Naestved-Slagelse-Ringsted Hospitals, Naestved, Denmark
| | | | - Jeanette Praestegaard
- Faculty of Physiotherapy, Center of Nutrition and Rehabilitation, University College Absalon, Naestved, Denmark
| |
Collapse
|
40
|
Seabrook M, Schwarz M, Ward EC, Whitfield B. Implementation of an extended scope of practice speech-language pathology allied health practitioner service: An evaluation of service impacts and outcomes. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2019; 21:65-74. [PMID: 28952361 DOI: 10.1080/17549507.2017.1380702] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 07/28/2017] [Accepted: 09/11/2017] [Indexed: 06/07/2023]
Abstract
PURPOSE Extended scope of practice roles can address health service challenges and enhance patient services; however there has been limited research of extended scope roles in the discipline of speech-language pathology (SLP). The aim of this study was to examine the clinical outcomes and service impacts of a Speech-Language Pathology Allied Health Practitioner (SLP AHP) led dysphagia and dysphonia service within an Integrated Specialist Ear Nose and Throat (ENT) Service. METHOD Low risk referrals were triaged by ENT from the waiting list into the SLP AHP dysphagia and dysphonia clinic. Outcomes from an initial 6-month pilot phase (n = 43) and 6-month implementation phase (n = 158) were evaluated. RESULT Approximately 70% of patients managed in the SLP AHP clinic in both phases were discharged without requiring separate ENT appointments. There were no adverse events. In the pilot phase, only 4.3% of medium priority and 10% of low priority referrals were seen within clinically recommended time frames. This improved to 90% in the final three months of the implementation phase. CONCLUSION With appropriate governance and risk management, an extended scope SLP AHP service for low risk dysphagia and dysphonia can achieve safe, effective and beneficial changes to ENT service delivery.
Collapse
Affiliation(s)
- Marnie Seabrook
- a Speech Pathology and Audiology Department , Logan Hospital , Meadowbrook , Australia
| | - Maria Schwarz
- a Speech Pathology and Audiology Department , Logan Hospital , Meadowbrook , Australia
- b School of Health and Rehabilitation Sciences , The University of Queensland , Brisbane , Australia
| | - Elizabeth C Ward
- b School of Health and Rehabilitation Sciences , The University of Queensland , Brisbane , Australia
- c Centre for Functioning and Health Research , Queensland Health , Brisbane , Australia , and
| | - Bernard Whitfield
- d Integrated Specialist ENT Service, Department of Otolaryngology Head and Neck Surgery, Division of Surgery , Logan Hospital , Meadowbrook , Australia
| |
Collapse
|
41
|
Agreement between telehealth and in-person assessment of patients with chronic musculoskeletal conditions presenting to an advanced-practice physiotherapy screening clinic. Musculoskelet Sci Pract 2018; 38:99-105. [PMID: 30366292 DOI: 10.1016/j.msksp.2018.09.014] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 09/18/2018] [Accepted: 09/29/2018] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To determine the level of agreement between a telehealth and in-person assessment of a representative sample of patients with chronic musculoskeletal conditions referred to an advanced-practice physiotherapy screening clinic. DESIGN Repeated-measures study design. PARTICIPANTS 42 patients referred to the Neurosurgical & Orthopaedic Physiotherapy Screening Clinic (Queensland, Australia) for assessment of their chronic lumbar spine, knee or shoulder condition. INTERVENTION Participants underwent two consecutive assessments by different physiotherapists within a single clinic session. In-person assessments were conducted as per standard clinical practice. Telehealth assessments took place remotely via videoconferencing. Six Musculoskeletal Physiotherapists were paired together to perform both assessment types. MAIN OUTCOME MEASURES Clinical management decisions including (i) recommended management pathways, (ii) referral to allied health professions, (iii) clinical diagnostics, and (iv) requirement for further investigations were compared using reliability and agreement statistics. RESULTS There was substantial agreement (83.3%; 35/42 cases) between in-person and telehealth assessments for recommended management pathways. Moderate to near perfect agreement (AC1 = 0.58-0.9) was reached for referral to individual allied health professionals. Diagnostic agreement was 83.3% between the two delivery mediums, whilst there was substantial agreement (81%; AC1 = 0.74) when requesting further investigations. Overall, participants were satisfied with the telehealth assessment. CONCLUSION There is a high level of agreement between telehealth and in-person assessments with respect to clinical management decisions and diagnosis of patients with chronic musculoskeletal conditions managed in an advanced-practice physiotherapy screening clinic. Telehealth can be considered as a viable and effective medium to assess those patients who are unable to attend these services in person.
Collapse
|
42
|
Ross M, Adams K, Engle K, Enser T, Muehlemann A, Schenk R, Tall M. The knowledge of low back pain management between physical therapists and family practice physicians. J Man Manip Ther 2018; 26:264-271. [PMID: 30455553 DOI: 10.1080/10669817.2018.1500772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Objectives: The purpose of this study was to compare knowledge in managing patients with low back pain (LBP) between physical therapists and family practice physicians. Methods: Seventy-three physical therapists and 30 family practice physicians completed standardized examinations assessing knowledge, attitudes, the usefulness of clinical practice guidelines, and management strategies for patients with LBP. Beliefs of physical therapists and family practice physicians about LBP were compared using relative risks and independent t-tests. Results: Scores related to knowledge, attitudes, and the usefulness of clinical practice guidelines were generally similar between the groups. In addition, there was no difference between the groups for knowledge regarding optimal management strategies for patients with LBP. However, physical therapists were less likely to have difficulty assessing motivation levels of patients with LBP compared to family practice physicians (64.6% vs 26.7%; relative risk: 2.41 [95% confidence interval: 1.30-4.48] and physical therapists were less likely to agree that interventions by health care providers have little positive effect on the natural history of acute LBP (17.8% vs. 50.0%; relative risk: 0.36 [95% confidence interval: 0.19-0.66]). Discussion: The results of this study may have implications for third-party payers and health care administrators regarding the utilization of physical therapists in the management of patients with LBP in expanded scopes of practice, including direct access and potential placement in primary care clinics.
Collapse
Affiliation(s)
- Michael Ross
- Department of Physical Therapy, Daemen College, Amherst, NY, USA
| | - Kurtis Adams
- Department of Physical Therapy, Daemen College, Amherst, NY, USA
| | - Kara Engle
- Department of Physical Therapy, Daemen College, Amherst, NY, USA
| | - Travis Enser
- Department of Physical Therapy, Daemen College, Amherst, NY, USA
| | | | - Ron Schenk
- Department of Physical Therapy, Daemen College, Amherst, NY, USA
| | - Michael Tall
- San Antonio Uniformed Health Educational Consortium, Fort Sam Houston, TX, USA
| |
Collapse
|
43
|
Stenner K, Edwards J, Mold F, Otter S, Courtenay M, Moore A, Carey N. Medicines management activity with physiotherapy and podiatry: A systematic mixed studies review. Health Policy 2018; 122:1333-1339. [PMID: 30337160 DOI: 10.1016/j.healthpol.2018.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 10/01/2018] [Accepted: 10/03/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Making best use of existing skills to increase service capacity is a global challenge. The aim was to systematically review physiotherapy and podiatrist prescribing and medicines management activity, including evidence of impact on patient care, levels of knowledge and attitudes towards extended medicines role. METHODS A search of MEDLINE, CINAHL, and Cochrane databases, using terms to identify prescribing and medicines management across a range of roles, was conducted from January 1985 to May 2016 for physiotherapy, and January 1968 to May 2016 for podiatry. Hand searching of citations and databases from professional organisations was undertaken. Data were extracted and analysed descriptively, and quality appraised by 2 reviewers using the mixed methods appraisal tool. RESULTS 1316 papers were identified, and 21 included in the review. No studies were identified that reported prescribing and no studies specific to podiatry met the inclusion criteria. Physiotherapists were highly involved in administering medicines, providing medicines advice, and recommending new medicines. Patient satisfaction, cost and outcomes were equivalent when comparing physiotherapist-led injection therapy to traditional care. Pharmacology knowledge was variable and unmet training needs identified. CONCLUSION Medicines management practices were identified in physiotherapy and positive outcomes of extended scope physiotherapy. There was a lack of evidence regarding podiatric practice. Review of educational preparation for medicines management is recommended along with evaluation of medicines management practice.
Collapse
Affiliation(s)
- Karen Stenner
- School of Health Sciences, University of Surrey, UK.
| | - Jude Edwards
- School of Health Sciences, University of Surrey, UK
| | - Freda Mold
- School of Health Sciences, University of Surrey, UK
| | - Simon Otter
- School of Health Science, University of Brighton, UK
| | | | - Ann Moore
- Centre for Health Research, School of Health Sciences, University of Brighton, UK
| | - Nicola Carey
- School of Health Sciences, University of Surrey, UK
| |
Collapse
|
44
|
Brismée JM, Pape JL, Woodhouse LJ, Reid D, Bellot N, Matthijs OC, Reumont F, Sobczak S. Reflections and Future Directions on Extending Physical Therapist Scope of Practice to Improve Quality of Care and Preserve Health Care Resources. Phys Ther 2018; 98:827-829. [PMID: 29982663 DOI: 10.1093/ptj/pzy080] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 03/30/2018] [Indexed: 11/13/2022]
Affiliation(s)
- Jean-Michel Brismée
- Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Mail Stop 6223, Lubbock, TX 79430 (USA)
| | - John L Pape
- Department of Physiotherapy, University Hospital of North Tees, Stockton on Tees, United Kingdom
| | - Linda J Woodhouse
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Alberta, Canada
| | - Duncan Reid
- School of Clinical Sciences, Auckland University of Technology, Auckland New Zealand
| | - Nicolas Bellot
- School of Health Sciences, University of Brighton, Eastbourne, United Kingdom; and LVW Physiotherapy, Hoeilaart, Belgium
| | | | - François Reumont
- Physical Therapy Department, Forme & Fonctionnement Humain Research Unit, HELHA, Belgium
| | - Stéphane Sobczak
- Département d'anatomie, Université du Québec à Trois-Rivières (UQTR), Trois-Rivières, Québec, Canada
| |
Collapse
|
45
|
Holøyen PK, Stensdotter AK. Patients with spondyloarthritis are equally satisfied with follow-up by physiotherapist and rheumatologist. Musculoskeletal Care 2018; 16:388-397. [PMID: 29573538 DOI: 10.1002/msc.1241] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 01/31/2018] [Accepted: 02/02/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE International guidelines recommend that patients with spondyloarthritis (SpA) have lifelong physiotherapy, as physical activity and exercise are essential for optimizing health throughout the course of the disease. The aim of the present study was to investigate if a physiotherapy-led outpatient clinic specializing in SpA could provide satisfactory follow-up as an alternative to standard visits with a rheumatologist (RT). We hypothesized that satisfaction would be similar in patients followed by a physiotherapist (PT) or an RT. METHODS A total of 68 patients were randomized to follow-up every fourth month by a PT or RT, for three visits in total. Patient satisfaction was evaluated using the Leeds Satisfaction Questionnaire (LSQ). Function, mobility and disease activity were rated using the Bath Ankylosing Spondylitis Functional Index (BASFI), Mobility Index (BASMI) and Ankylosing Spondylitis Disease Activity Score (ASDAS). RESULTS Patients were equally satisfied with PT and RT follow-up at the first (p = 0.062) and last (p = 0.710) visit. At the second visit, the RT group was seen by a nurse, and was more satisfied than the PT group (p = 0.015). Function deteriorated in both the PT (p = 0.014) and RT (p = 0.007) groups. Mobility increased in the PT group (p = 0.020). Disease activity was not affected. CONCLUSIONS Patients seem to be equally satisfied with either of the follow-up regimes. The PT-led follow-up did not seem to affect the patients' course of disease negatively. The results indicate that it would be safe to implement a PT-led clinic for patients with SpA in specialist health services, but longer-term follow-up is necessary to support the findings of this study.
Collapse
Affiliation(s)
- Pauline Kjelsvik Holøyen
- Department of Rheumatology, Ålesund Hospital, Ålesund, Norway
- Faculty of Medicine and Health Sciences, Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ann-Katrin Stensdotter
- Faculty of Medicine and Health Sciences, Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| |
Collapse
|
46
|
Fennelly O, Blake C, FitzGerald O, Breen R, Ashton J, Brennan A, Caffrey A, Desmeules F, Cunningham C. Advanced practice physiotherapy-led triage in Irish orthopaedic and rheumatology services: national data audit. BMC Musculoskelet Disord 2018; 19:181. [PMID: 29859072 PMCID: PMC5984783 DOI: 10.1186/s12891-018-2106-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 05/21/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Many people with musculoskeletal (MSK) disorders wait several months or years for Consultant Doctor appointments, despite often not requiring medical or surgical interventions. To allow earlier patient access to orthopaedic and rheumatology services in Ireland, Advanced Practice Physiotherapists (APPs) were introduced at 16 major acute hospitals. This study performed the first national evaluation of APP triage services. METHOD Throughout 2014, APPs (n = 22) entered clinical data on a national database. Analysis of these data using descriptive statistics determined patient wait times, Consultant Doctor involvement in clinical decisions, and patient clinical outcomes. Chi square tests were used to compare patient clinical outcomes across orthopaedic and rheumatology clinics. A pilot study at one site identified re-referral rates to orthopaedic/rheumatology services of patients managed by the APPs. RESULTS In one year, 13,981 new patients accessed specialist orthopaedic and rheumatology consultations via the APP. Median wait time for an appointment was 5.6 months. Patients most commonly presented with knee (23%), lower back (22%) and shoulder (15%) disorders. APPs made autonomous clinical decisions regarding patient management at 77% of appointments, and managed patient care pathways without onward referral to Consultant Doctors in more than 80% of cases. Other onward clinical pathways recommended by APPs were: physiotherapy referrals (42%); clinical investigations (29%); injections administered (4%); and surgical listing (2%). Of those managed by the APP, the pilot study identified that only 6.5% of patients were re-referred within one year. CONCLUSION This national evaluation of APP services demonstrated that the majority of patients assessed by an APP did not require onward referral for a Consultant Doctor appointment. Therefore, patients gained earlier access to orthopaedic and rheumatology consultations in secondary care, with most patients conservatively managed.
Collapse
Affiliation(s)
- Orna Fennelly
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | - Catherine Blake
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | - Oliver FitzGerald
- Department of Rheumatology, St. Vincent’s University Hospital, Dublin, Ireland
| | | | - Jennifer Ashton
- Department of Physiotherapy, Beaumont Hospital, Dublin, Ireland
| | - Aisling Brennan
- Department of Physiotherapy, Adelaide and Meath Hospital, Tallaght Dublin, Ireland
| | - Aoife Caffrey
- Department of Rheumatology, St. Vincent’s University Hospital, Dublin, Ireland
- Bone and Joint Clinic, St. Vincent’s University Hospital, Dublin, Ireland
| | - François Desmeules
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Canada
| | - Caitriona Cunningham
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| |
Collapse
|
47
|
Ashford S, Nair A, Williams H, Esdon J, Steed A, Nyein K, Turner-Stokes L. Spasticity management with botulinum toxin: A comparison of UK physiotherapy and rehabilitation medicine injectors. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2018. [DOI: 10.12968/ijtr.2018.25.5.215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background/Aims: To compare patient outcomes following botulinum toxin (BoNT) injection by either physiotherapy or rehabilitation medicine (medical) professionals over a 3-year period. Methods: A retrospective, observational cohort study was conducted in a specialised rehabilitation service providing spasticity management including BoNT injection and physical therapy (group therapy, individual therapy, self-exercise, and physical management programmes). Individualised goals were established before treatment using goal attainment scaling (GAS) by the multidisciplinary team. The Arm Activity measure (ArmA) was used to evaluate upper limb function and the Modified Ashworth Scale (MAS) used to evaluate spasticity. Findings: A total of 262 patients were injected. Mean GAS T-score after treatment for the group was 50.2 ± 6.7. GAS T-score for physiotherapy injectors (n=214 (82% of participants)) was 50.2 ± 6.4 and for rehabilitation medicine injectors (n=48 (18%)) 50.3 ± 7.9. No significant differences were identified in terms of goal achievement, upper limb passive function, or spasticity reduction between physiotherapy and rehabilitation medicine injectors. Differences were identified at both baseline (physiotherapist mean 49.7; rehabilitation medicine mean 46.6) and follow-up for active function (physiotherapist mean=49.7; rehabilitation medicine mean=47.8) (ArmA active function subscale; p=0.03). No reportable adverse effects were recorded. No difference in the complexity of injection (such as complex clinical presentation, anticoagulation, or technical difficulty) between the injector groups was identified. Conclusions: Clinical outcomes were comparable between physiotherapy and rehabilitation medicine injectors. No difference in side effect profile or complexity of injection was identified. In this cohort, injection of BoNT by a physiotherapist was as effective in terms of GAS as that undertaken by a rehabilitation medicine physician.
Collapse
Affiliation(s)
- Stephen Ashford
- Regional Hyper-acute Rehabilitation Unit, Northwick Park Hospital, London; King's College London, Faculty of Nursing, Midwifery and Palliative Care, London, UK
| | - Ajoy Nair
- Alderbourne Rehabilitation Unit, Hillingdon Hospital, Hillingdon Foundation Trust, Uxbridge, UK
| | - Heather Williams
- Regional Hyper-acute Rehabilitation Unit, Northwick Park Hospital, London, UK
| | - James Esdon
- Regional Hyper-acute Rehabilitation Unit, Northwick Park Hospital, London, UK
| | - Aideen Steed
- Regional Hyper-acute Rehabilitation Unit, Northwick Park Hospital, London, UK
| | - Kyaw Nyein
- Regional Hyper-acute Rehabilitation Unit, Northwick Park Hospital, London, UK
| | - Lynne Turner-Stokes
- Regional Hyper-acute Rehabilitation Unit, Northwick Park Hospital,, London, UK; King's College London, Faculty of Nursing, Midwifery and Palliative Care, London, UK
| |
Collapse
|
48
|
The development and practical application of a simulation model to inform musculoskeletal service delivery in an Australian public health service. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.orhc.2017.07.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
49
|
Décary S, Fallaha M, Pelletier B, Frémont P, Martel-Pelletier J, Pelletier JP, Feldman DE, Sylvestre MP, Vendittoli PA, Desmeules F. Diagnostic validity and triage concordance of a physiotherapist compared to physicians' diagnoses for common knee disorders. BMC Musculoskelet Disord 2017; 18:445. [PMID: 29137611 PMCID: PMC5686957 DOI: 10.1186/s12891-017-1799-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 11/01/2017] [Indexed: 11/10/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- S. Décary
- 0000 0001 2292 3357grid.14848.31School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, QC Canada
- Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l’Est-de-l’Île-de-Montréal, Montreal, QC Canada
| | - M. Fallaha
- 0000 0001 2292 3357grid.14848.31Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, QC, Canada. Centre intégré universitaire de santé et de services sociaux de l’Est-de-l’Île-de-Montréal, Montreal, QC Canada
| | - B. Pelletier
- 0000 0001 2292 3357grid.14848.31Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, QC, Canada. Centre intégré universitaire de santé et de services sociaux de l’Est-de-l’Île-de-Montréal, Montreal, QC Canada
| | - P. Frémont
- 0000 0004 1936 8390grid.23856.3aDepartment of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, QC Canada
| | - J. Martel-Pelletier
- 0000 0001 0743 2111grid.410559.cOsteoarthritis Research Unit, University of Montreal Hospital Research Center (CRCHUM), Montreal, QC Canada
| | - J.-P. Pelletier
- 0000 0001 0743 2111grid.410559.cOsteoarthritis Research Unit, University of Montreal Hospital Research Center (CRCHUM), Montreal, QC Canada
| | - D. E. Feldman
- 0000 0001 2292 3357grid.14848.31School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, QC Canada
| | - M.-P. Sylvestre
- 0000 0001 2292 3357grid.14848.31Department of Social Preventive Medicine, School of Public Health, Université de Montréal, Montreal, QC Canada
| | - P.-A. Vendittoli
- Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l’Est-de-l’Île-de-Montréal, Montreal, QC Canada
- 0000 0001 2292 3357grid.14848.31Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, QC, Canada. Centre intégré universitaire de santé et de services sociaux de l’Est-de-l’Île-de-Montréal, Montreal, QC Canada
| | - F. Desmeules
- 0000 0001 2292 3357grid.14848.31School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, QC Canada
- Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Centre intégré universitaire de santé et de services sociaux de l’Est-de-l’Île-de-Montréal, Montreal, QC Canada
| |
Collapse
|
50
|
Razmjou H, Christakis M, Kennedy D, Robarts S, Holtby R. Impact of Radiographic Imaging of the Shoulder Joint on Patient Management: An Advanced-Practice Physical Therapist's Approach. Physiother Can 2017; 69:351-360. [PMID: 30369703 DOI: 10.3138/ptc.2016-41pc] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
Collapse
Affiliation(s)
- Helen Razmjou
- Department of Rehabilitation.,Sunnybrook Research Institute.,Department of Physical Therapy
| | - Monique Christakis
- Department of Medical Imaging, Sunnybrook Health Sciences Centre.,Department of Medical Imaging, Faculty of Medicine, University of Toronto, Toronto
| | - Deborah Kennedy
- Department of Rehabilitation.,Department of Physical Therapy.,School of Rehabilitation Science, McMaster University, Hamilton, Ont
| | | | - Richard Holtby
- Department of Orthopaedic Surgery, Holland Orthopaedic & Arthritic Centre
| |
Collapse
|