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Tawiah AK, Stokes E, Wieler M, Desmeules F, Finucane L, Lewis J, Warren J, Lundon K, Noblet T, Cunningham C, Woodhouse LJ. Evaluating the importance of a core competency and capability framework for advanced practice physiotherapy: A cross-sectional survey. Physiother Theory Pract 2024:1-13. [PMID: 38912894 DOI: 10.1080/09593985.2024.2368593] [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: 02/24/2024] [Accepted: 06/11/2024] [Indexed: 06/25/2024]
Abstract
INTRODUCTION The need for a global core competency and capability framework for advanced practice physiotherapy is important due to the rapidly changing nature of health care delivery internationally and the need to standardize advanced practice physiotherapy. OBJECTIVE To determine the importance of a proposed international core competency and capability framework for advanced practice physiotherapy. METHODS We conducted a cross-sectional online survey of advanced practice physiotherapists across seven countries. The importance of each competency and capability was rated on a five-point agreement Likert scale. Participants were from the United Kingdom, Ireland, Australia, New Zealand, Canada, Switzerland and Argentina. RESULTS A total of 99 participants completed the survey, comprising 63% (57/90) females and 33% (30/90) males. Sixty percent, 60% (54/90), had over 20 years of experience. The survey participants represented a diverse geographic distribution, with 25% (23/90) from Australia, 25% (23/90) from Canada, 18% (6/90) from New Zealand, and 18% (6/90) from the United Kingdom. Four percent 4% (4/90) from Ireland, and 4% (4/90) from other countries (Switzerland and Argentina). The survey revealed a strong consensus among participants, with all competencies and capabilities ranked as high and considered important to advanced practice. CONCLUSION This study demonstrates a consensus among advanced practice physiotherapists across seven countries on the importance of a proposed competency and capability framework. The findings highlight the need for a global standard in advanced practice physiotherapy, particularly in light of the rapidly changing healthcare landscape.
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Affiliation(s)
- Andrews K Tawiah
- School of Physical Therapy, Faculty of Health Sciences, Western University, London, ON, Canada
| | - Emma Stokes
- Trinity College Dublin, The University of Dublin, College Green, Dublin, Ireland
| | - Marguerite Wieler
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Corbett Hall, Canada
| | | | - Laura Finucane
- Sussex MSK Partnership, Eastbourne, UK
- Department of Health, Social Care and Education, St Georges University London, London, UK
| | - Jeremy Lewis
- Therapy Department, Central London Community Healthcare National Health Service Trust, London, UK
- Clinical Therapies, University of Limerick, Limerick, Ireland
| | - Jonathan Warren
- Strategic Team, Office of Health and Disability Commissioner, Technology One House, Wellington, New Zealand
| | - Katie Lundon
- Office of Continuing Professional Development, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Tim Noblet
- Department of Health, Social Care and Education, St Georges University London, London, UK
- Physiotherapy Department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Caitriona Cunningham
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Belfield, Dublin, Ireland
| | - Linda J Woodhouse
- School of Medicine, Department of Public Health & Community Medicine, Division of Physical Therapy- Phoenix, Tufts University, Phoenix, AZ, USA
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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.
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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
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Nouni-García R, Carbonell-Soliva Á, Orozco-Beltrán D, López-Pineda A, Tomás-Rodríguez MI, Gil-Guillén VF, Quesada JA, Carratalá-Munuera C. Association of Visiting the Physiotherapist with Mortality in the Spanish General Population: A Population-Based Cohort Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2187. [PMID: 38138290 PMCID: PMC10744916 DOI: 10.3390/medicina59122187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023]
Abstract
Background and Objectives: The purpose of this retrospective population-based cohort study was to analyse the association between attendance of physiotherapy with mortality in the Spanish general population and describe the profile of people who do not visit a physiotherapist in Spain. Material and Methods: The data sources were the 2011/2012 National Health Survey (ENSE11) and the national database of death in Spain, and the participants were all adult respondents in the ENSE11. Results: Of 20,397 people, 1101 (5.4%) visited the physiotherapist the previous year, and the cumulative incidence of total mortality was 5.4% (n = 1107) at a mean follow-up of 6.2 years. Visiting the physiotherapist was associated with lower all-cause mortality in the population residing in Spain, quantified at 30.1% [RR = 0.699; 95% CI (0.528-0.927); p = 0.013]. The factors associated with not visiting a physiotherapist were the following: rating one's health as good (9.8%; n = 1017; p < 0.001), not having any hospital admission in the previous year (9.6%; n = 1788; p < 0.001), not having visited the general practitioner in the previous month (9.6%; n = 1408; p < 0.001), and not having attended a day hospital in the previous year (9.7%; n = 1836; p < 0.001). Conclusions: Visiting a physiotherapist was associated with a lower mortality from all causes in the population living in Spain.
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Affiliation(s)
- Rauf Nouni-García
- Institute of Health and Biomedical Research of Alicante, General University Hospital of Alicante, Diagnostic Center, Fifth Floor, Pintor Baeza Street, 12, 03110 Alicante, Spain; (R.N.-G.); (V.F.G.-G.)
- Network for Research on Chronicity, Primary Care and Health Promotion (RICAPPS), 03550 San Juan de Alicante, Spain; (D.O.-B.); (J.A.Q.); (C.C.-M.)
- Clinical Medicine Department, School of Medicine, University of Miguel Hernández de Elche, Ctra, Nacional N-332 s/n, 03550 San Juan de Alicante, Spain;
| | - Álvaro Carbonell-Soliva
- Clinical Medicine Department, School of Medicine, University of Miguel Hernández de Elche, Ctra, Nacional N-332 s/n, 03550 San Juan de Alicante, Spain;
- The Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), University Hospital of San Juan de Alicante, Ctra, Nacional N-332 s/n, 03550 San Juan de Alicante, Spain
| | - Domingo Orozco-Beltrán
- Network for Research on Chronicity, Primary Care and Health Promotion (RICAPPS), 03550 San Juan de Alicante, Spain; (D.O.-B.); (J.A.Q.); (C.C.-M.)
- Clinical Medicine Department, School of Medicine, University of Miguel Hernández de Elche, Ctra, Nacional N-332 s/n, 03550 San Juan de Alicante, Spain;
- The Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), University Hospital of San Juan de Alicante, Ctra, Nacional N-332 s/n, 03550 San Juan de Alicante, Spain
| | - Adriana López-Pineda
- Network for Research on Chronicity, Primary Care and Health Promotion (RICAPPS), 03550 San Juan de Alicante, Spain; (D.O.-B.); (J.A.Q.); (C.C.-M.)
- Clinical Medicine Department, School of Medicine, University of Miguel Hernández de Elche, Ctra, Nacional N-332 s/n, 03550 San Juan de Alicante, Spain;
- The Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), University Hospital of San Juan de Alicante, Ctra, Nacional N-332 s/n, 03550 San Juan de Alicante, Spain
| | - María Isabel Tomás-Rodríguez
- Pathology and Surgery Department, School of Medicine, University of Miguel Hernández de Elche, Ctra, Nacional N-332 s/n, 03550 Alicante, Spain;
| | - Vicente F. Gil-Guillén
- Institute of Health and Biomedical Research of Alicante, General University Hospital of Alicante, Diagnostic Center, Fifth Floor, Pintor Baeza Street, 12, 03110 Alicante, Spain; (R.N.-G.); (V.F.G.-G.)
- Network for Research on Chronicity, Primary Care and Health Promotion (RICAPPS), 03550 San Juan de Alicante, Spain; (D.O.-B.); (J.A.Q.); (C.C.-M.)
- Clinical Medicine Department, School of Medicine, University of Miguel Hernández de Elche, Ctra, Nacional N-332 s/n, 03550 San Juan de Alicante, Spain;
| | - José A. Quesada
- Network for Research on Chronicity, Primary Care and Health Promotion (RICAPPS), 03550 San Juan de Alicante, Spain; (D.O.-B.); (J.A.Q.); (C.C.-M.)
- Clinical Medicine Department, School of Medicine, University of Miguel Hernández de Elche, Ctra, Nacional N-332 s/n, 03550 San Juan de Alicante, Spain;
| | - Concepción Carratalá-Munuera
- Network for Research on Chronicity, Primary Care and Health Promotion (RICAPPS), 03550 San Juan de Alicante, Spain; (D.O.-B.); (J.A.Q.); (C.C.-M.)
- Clinical Medicine Department, School of Medicine, University of Miguel Hernández de Elche, Ctra, Nacional N-332 s/n, 03550 San Juan de Alicante, Spain;
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Keller F, Allet L, Meichtry A, Scascighini L, Scheermesser M, Wirz M, Nast I. Diagnostic and decision-making abilities of Swiss physiotherapists in a simulated direct access setting. Physiother Theory Pract 2023; 39:2336-2351. [PMID: 35645163 DOI: 10.1080/09593985.2022.2077269] [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: 08/13/2021] [Revised: 05/07/2022] [Accepted: 05/08/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Direct access to physiotherapy requires physiotherapists to recognize red flags and determine adequate management plans. PURPOSE Investigate Swiss physiotherapists' ability to diagnose and triage patients in a simulated direct access setting and whether their characteristics were associated with correct diagnoses and decision-making. METHODS We conducted a national online survey using a questionnaire containing 12 first-contact case scenarios. A linear mixed model estimated scores for correct diagnoses and management decisions, differences between musculoskeletal (MSK), non-critical medical (non-CrM), and critical medical (CrM) case scenarios, and the estimated effects of physiotherapists' characteristics. RESULTS The linear mixed model of data from 1492 participants estimated 55.0% correct diagnoses (62.7% for non-CrM, 61.7% for MSK, and 40.5% for CrM scenarios) and 71.2% correct management decisions (78.1% for non-CrM, 73.0% for MSK, and 62.3% for CrM scenarios). For correct diagnoses, the 'academic education/continuing education' variable showed significant estimated effects for the MSK and CrM scenarios, as did 'professional experience' for the non-CrM scenarios, and the '≥ 50% musculoskeletal patients in consultations' variable for all scenario groups. For correct management decisions, 'academic education/continuing education' variable showed significant estimated effects in CrM scenarios, as did 'professional experience' in non-CrM and CrM scenarios, and the '≥ 50% musculoskeletal patients in consultations' variable in MSK scenarios. CONCLUSION The estimated effects of physiotherapists' characteristics on correct diagnoses and management decisions showed substantial heterogeneity. Improving Swiss physiotherapists' screening abilities remains important. Further research is required to develop innovative educational concepts and improve training for screening for red flags.
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Affiliation(s)
- Fabienne Keller
- School of Health Sciences, Institute of Physiotherapy, ZHAW Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Lara Allet
- School of Health Sciences Valais-Wallis, University of Applied Sciences and Arts of Western Switzerland HES-SO, Sion, Switzerland
- Department of Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - André Meichtry
- School of Health Sciences, Institute of Physiotherapy, ZHAW Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Luca Scascighini
- Competence Centre for Healthcare Practices and Policies, Department of Business Economics, Health and Social Care, University of Applied Sciences and Arts of Southern Switzerland SUPSI, Manno, Switzerland
| | - Mandy Scheermesser
- School of Health Sciences, Institute of Physiotherapy, ZHAW Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Markus Wirz
- School of Health Sciences, Institute of Physiotherapy, ZHAW Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Irina Nast
- School of Health Sciences, Institute of Physiotherapy, ZHAW Zurich University of Applied Sciences, Winterthur, Switzerland
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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.
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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
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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.
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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.
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Lewis KJ, Coppieters MW, Vicenzino B, Hughes I, Ross L, Schmid AB. Occupational Therapists, Physiotherapists and Orthopaedic Surgeons Agree on the Decision for Carpal Tunnel Surgery. Int J Health Policy Manag 2022; 11:1001-1008. [PMID: 33590739 PMCID: PMC9808184 DOI: 10.34172/ijhpm.2020.227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 11/23/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Therapist-led pathways have been proposed as waitlist management strategies prior to surgery for conditions such as carpal tunnel syndrome (CTS) in public hospitals. These models of care typically shift the initial care of patients and decision-making from surgeons to therapists and, have been shown to reduce the number of patients requiring surgery and improve wait-times. This occurs despite limited evidence of surgeon-therapist agreement on key decisions, such as the need for surgery. The purpose of this was study was to assess the agreement between therapists and orthopaedic surgeons regarding the need for surgery for patients who have CTS. METHODS This blinded inter-rated agreement study was embedded in a multicentre randomised parallel groups trial of 105 patients with CTS referred to four orthopaedic departments and waitlisted for an appointment. The trial evaluated the effect of a therapist-led care pathway on the need for surgery and outcomes related to symptoms and function. Patients were randomised to either remain on the orthopaedic waitlist or receive group education, a splint and home exercises. The decision on the need for surgery at 6 months was made by a member of the orthopaedic consultant team or by one of the 14 participating therapists. The therapists and surgeons were blinded to each other's decision. Agreement was determined using percentage agreement, kappa coefficients (k), prevalence-adjusted and bias-adjusted kappa (PABAK), and Gwet's first-order agreement coefficient (AC1). RESULTS Substantial agreement was seen between therapists and surgeons regarding the need for surgery (PABAK=0.74 (0.60-0.88)). Agreement was significantly associated with experience (P=.02). Therapists with advanced experience and scope of practice demonstrated perfect agreement with surgeons (PABAK=1.00 (95% CI: 1.00-1.00)). Mid-career therapists demonstrated substantial agreement (PABAK=0.67 (95% CI: 0.42-0.91)) and early-career therapists demonstrated fair agreement (PABAK=0.43 (95% CI: -0.04-0.90)). CONCLUSION Therapists with advanced scope of practice make decisions that are consistent with orthopaedic surgeons.
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Affiliation(s)
- Karina J. Lewis
- Occupational Therapy Department, Gold Coast University Hospital, Southport, QLD, Australia
| | - Michel W. Coppieters
- Menzies Health Institute Queensland, Griffith University, Brisbane and Gold Coast, QLD, Australia
- Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bill Vicenzino
- School of Health and Rehabilitation Sciences: Physiotherapy, The University of Queensland, Brisbane, QLD, Australia
| | - Ian Hughes
- Office of Research Governance and Development, Gold Coast University Hospital, Southport, QLD, Australia
| | - Leo Ross
- Division of Allied Health, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia
| | - Annina B. Schmid
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Abstract
The phenomenon of flares is a common feature in the daily life of people with osteoarthritis (OA). Characterized by episodes of sudden-onset increases in signs and symptoms, their impact can often be distressing and disabling. Despite their potential to have both short-term and long-term consequences for patients across the whole course of the condition, their occurrence and optimal management are not fully understood. This article provides a contemporary perspective on defining OA flares and their potential triggers, and offers suggestions for how health professionals might explore flare patterns with patients in clinical practice and frame timely best-practice treatment approaches.
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Affiliation(s)
- Martin J Thomas
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire ST5 5BG, UK; Haywood Academic Rheumatology Centre, Midlands Partnership NHS Foundation Trust, Haywood Hospital, Burslem, Staffordshire ST6 7AG, UK.
| | | | - Tuhina Neogi
- Department of Medicine, Section of Rheumatology, Boston University School of Medicine, 650 Albany Street, Suite X-200, Boston, MA 02118, USA
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Ho-Henriksson CM, Svensson M, Thorstensson CA, Nordeman L. Physiotherapist or physician as primary assessor for patients with suspected knee osteoarthritis in primary care - a cost-effectiveness analysis of a pragmatic trial. BMC Musculoskelet Disord 2022; 23:260. [PMID: 35300671 PMCID: PMC8932301 DOI: 10.1186/s12891-022-05201-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 03/07/2022] [Indexed: 11/17/2022] Open
Abstract
Background Over the next decade, the number of osteoarthritis consultations in health care is expected to increase. Physiotherapists may be considered equally qualified as primary assessors as physicians for patients with knee osteoarthritis. However, economic evaluations of this model of care have not yet been described. To determine whether physiotherapists as primary assessors for patients with suspected knee osteoarthritis in primary care are a cost-effective alternative compared with traditional physician-led care, we conducted a cost-effectiveness analysis alongside a randomized controlled pragmatic trial. Methods Patients were randomized to be assessed and treated by either a physiotherapist or physician first in primary care. A cost-effectiveness analysis compared costs and effects in quality adjusted life years (QALY) for the different care models. Analyses were applied with intention to treat, using complete case dataset, and missing data approaches included last observation carried forward and multiple imputation. Non-parametric bootstrapping was conducted to assess sampling uncertainty, presented with a cost-effectiveness plane and cost-effectiveness acceptability curve. Results 69 patients were randomized to a physiotherapist (n = 35) or physician first (n = 34). There were significantly higher costs for physician visits and radiography in the physician group (p < 0.001 and p = 0.01). Both groups improved their health-related quality of life 1 year after assessment compared with baseline. There were no statistically significant differences in QALYs or total costs between groups. The incremental cost-effectiveness ratio for physiotherapist versus physician was savings of 24,266 €/lost QALY (societal perspective) and 15,533 €/lost QALY (health care perspective). There is a 72–80% probability that physiotherapist first for patients with suspected knee osteoarthritis is less costly and differs less than ±0.1 in QALY compared to traditional physician-led care. Conclusion These findings suggest that physiotherapist-led care model might reduce health care costs and lead to marginally less QALYs, but confidence intervals were wide and overlapped no difference at all. Health consequences depending on the profession of the first assessor for knee osteoarthritis seem to be comparable for physiotherapists and physicians. Direct access to physiotherapist in primary care seems to lead to fewer physician consultations and radiography. However, larger clinical trials and qualitative studies to evaluate patients’ perception of this model of care are needed. Clinical trial registration The study was retrospectively registered in clinicaltrial.gov, ID: NCT03822533. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05201-3.
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Affiliation(s)
- Chan-Mei Ho-Henriksson
- Region Västra Götaland, Primary Care Rehabilitation, Närhälsan Lidköping Rehabmottagning, Lidköping, Sweden. .,Department of Health and rehabilitation, Unit of Physiotherapy, University of Gothenburg, Sahlgrenska Academy, Institute of Neuroscience and Physiology, Gothenburg, Sweden.
| | - Mikael Svensson
- University of Gothenburg, Sahlgrenska Academy, Institute of Medicine, School of Public Health and Community Medicine, 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.,Research and Development Department at Region Halland, Halmstad, 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, Research, Education, Development and Innovation, Primary Health Care, Research, Education, Development and Innovation Centre Södra Älvsborg, Borås, Sweden
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10
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Gagnon R, Perreault K, Berthelot S, Matifat E, Desmeules F, Achou B, Laroche M, Van Neste C, Tremblay S, Leblond J, Hébert LJ. Direct-access physiotherapy to help manage patients with musculoskeletal disorders in an emergency department: Results of a randomized controlled trial. Acad Emerg Med 2021; 28:848-858. [PMID: 33617696 DOI: 10.1111/acem.14237] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The objective was to evaluate the effects of direct-access physiotherapy on patients presenting with a musculoskeletal disorder (MSKD) to the emergency department (ED) on clinical outcomes and use of health care resources. METHODS We conducted a randomized controlled trial in an academic ED in Québec City, Canada. We included patients aged 18 to 80 years with minor MSKD. The intervention group had direct access to a physiotherapist (PT) in the ED immediately after triage and prior to physician assessment, and the control group received usual care by the emergency physician without PT intervention. The key variables included clinical outcomes (pain, interference of pain on function) and resources use (ED return visit, medications, diagnostic tests, additional consultations). They were analyzed using descriptive statistics and compared between groups using two-way analyses of variance, log-linear analysis, and chi-square tests. RESULTS Seventy-eight patients suffering from MSKDs were included (40.2 ± 17.6 years old; 44% women). For the primary clinical outcome, participants in the PT group (n = 40) had statistically lower levels of pain and pain interference at 1 and 3 months. In terms of resource use, participants in the PT group returned significantly less often to the ED. At baseline and 1 month, less prescription medication was used, including opioids, but there were no differences at 3 months. Although over-the-counter medication was recommended more at baseline in the PT group, there were no differences in use at 1 month, and the PT group had used them less at 3 months. There were no differences between groups at follow-up for imaging tests, other professionals consulted, and hospitalization rates. CONCLUSION Patients presenting with a MSKD to the ED with direct access to a PT had better clinical outcomes and used less services and resources than those in the usual care group after ED discharge and up to 3 months after discharge.
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Affiliation(s)
- Rose Gagnon
- Center for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS) Quebec Quebec Canada
- Centre intégré universitaire de santé et de services sociaux (CIUSSS) de la Capitale‐Nationale Quebec Quebec Canada
- Departments of Rehabilitation, Medicine and Radiology and Nuclear Medicine Faculty of Medicine Université Laval Quebec Quebec Canada
| | - Kadija Perreault
- Center for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS) Quebec Quebec Canada
- Centre intégré universitaire de santé et de services sociaux (CIUSSS) de la Capitale‐Nationale Quebec Quebec Canada
- Departments of Rehabilitation, Medicine and Radiology and Nuclear Medicine Faculty of Medicine Université Laval Quebec Quebec Canada
| | - Simon Berthelot
- Departments of Rehabilitation, Medicine and Radiology and Nuclear Medicine Faculty of Medicine Université Laval Quebec Quebec Canada
- CHU de Québec–Université Laval Quebec Quebec Canada
- Centre de recherche du CHU de Québec–Université Laval Quebec Quebec Canada
| | - Eveline Matifat
- Faculté de Médecine École de RéhabilitationUniversité de Montréal Montreal Quebec Canada
- Maisonneuve‐Rosemont Hospital Research Centre Orthopaedic Clinical Research Unit Centre de recherche de l’Hôpital Maisonneuve‐RosemontCIUSSS de l’Est‐de‐l’Île‐de‐Montréal Montreal Quebec Canada
| | - François Desmeules
- Faculté de Médecine École de RéhabilitationUniversité de Montréal Montreal Quebec Canada
- Maisonneuve‐Rosemont Hospital Research Centre Orthopaedic Clinical Research Unit Centre de recherche de l’Hôpital Maisonneuve‐RosemontCIUSSS de l’Est‐de‐l’Île‐de‐Montréal Montreal Quebec Canada
| | | | | | | | | | - Jean Leblond
- Center for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS) Quebec Quebec Canada
- Centre intégré universitaire de santé et de services sociaux (CIUSSS) de la Capitale‐Nationale Quebec Quebec Canada
| | - Luc J. Hébert
- Center for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS) Quebec Quebec Canada
- Centre intégré universitaire de santé et de services sociaux (CIUSSS) de la Capitale‐Nationale Quebec Quebec Canada
- Departments of Rehabilitation, Medicine and Radiology and Nuclear Medicine Faculty of Medicine Université Laval Quebec Quebec Canada
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11
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Lowry V, Bass A, Vukobrat T, Décary S, Bélisle P, Sylvestre MP, Desmeules F. Higher psychological distress in patients seeking care for a knee disorder is associated with diagnostic discordance between health care providers: a secondary analysis of a diagnostic concordance study. BMC Musculoskelet Disord 2021; 22:650. [PMID: 34330250 PMCID: PMC8325325 DOI: 10.1186/s12891-021-04534-9] [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: 01/09/2021] [Accepted: 07/20/2021] [Indexed: 11/25/2022] Open
Abstract
Background Knee disorders are highly prevalent and may be a disabling condition. An accurate diagnosis is necessary to guide toward a rapid and efficient management of knee disorders. However, the ability to make a valid diagnosis is often complex for clinicians and evidence is mainly focused on clinician cognitive biases or errors produced during clinical reasoning. The aim of this secondary exploratory analysis is to identify patient-specific characteristics associated with diagnostic discordance between health care providers in making a diagnosis for a new knee disorder. Methods We performed a secondary analysis of a diagnostic study comparing the diagnostic ability of a physiotherapist to medical musculoskeletal specialists. Patients’ socio-demographic, psychosocial and clinical characteristics were compared between the concordant and discordant diagnostic groups. Psychosocial symptoms were evaluated using the validated Kessler 6 (K6) questionnaire. We performed multivariable logistic regressions using the Bayesian Information Criterion to identify the most probable model including patients’ characteristics associated with diagnostic discordance. Overall probability of identified variables to explain diagnostic discordance and associated odd ratios (OR) with 95% credibility intervals (95% CrI) were calculated. Results Overall, 279 participants were evaluated by a physiotherapist and medical musculoskeletal specialists. The mean age of the participants was 49.1 ± 15.8 years and 57.7% were female. The most common disorder was osteoarthritis (n = 117, 18.8% of cases were discordant). The most probable model explaining diagnostic discordance (11.13%) included having depressive symptoms, which was associated with an increased probability of diagnostic discordance (OR: 3.9; 95% CrI: 1.9 – 8.0) and having a higher number of comorbidities, which was associated with a decreased probability of diagnostic discordance (OR: 0.6; 95% CrI: 0.5 – 0.9). The depression item of the K6 questionnaire had a 99.4% chance to be included in a model explaining diagnostic discordance. Other variables taken separately had less than 50% chance to be included in a model explaining diagnostic discordance and cannot be considered significant. Conclusion Our results suggest that depressive symptoms may increase the risk of knee diagnostic discordance. Clinicians may be more likely to make diagnostic errors and should be more cautious when evaluating patients with knee disorders suffering from psychological distress. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04534-9.
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Affiliation(s)
- Véronique Lowry
- School 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, 5415 Blvd L'Assomption, Pav. Rachel Tourigny, Montréal, QC, H1T 2M4, Canada.
| | - Alec Bass
- School 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, 5415 Blvd L'Assomption, Pav. Rachel Tourigny, Montréal, QC, H1T 2M4, Canada
| | - Tatiana Vukobrat
- 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, 5415 Blvd L'Assomption, Pav. Rachel Tourigny, Montréal, QC, H1T 2M4, Canada
| | - Simon Décary
- School of Rehabilitation, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Patrick Bélisle
- Montreal Health Innovations Coordinating Center, Montreal Hearth Institute, Montreal, QC, Canada
| | - Marie-Pierre Sylvestre
- Department of Social Preventive Medicine, School of Public Health, Université de Montréal, Montreal, QC, Canada
| | - François Desmeules
- School 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, 5415 Blvd L'Assomption, Pav. Rachel Tourigny, Montréal, QC, H1T 2M4, Canada
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12
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Matifat E, Perreault K, Roy JS, Aiken A, Gagnon E, Mequignon M, Lowry V, Décary S, Hamelin B, Ambrosio M, Farley N, Pelletier D, Carlesso L, Desmeules F. Concordance between physiotherapists and physicians for care of patients with musculoskeletal disorders presenting to the emergency department. BMC Emerg Med 2019; 19:67. [PMID: 31707978 PMCID: PMC6842540 DOI: 10.1186/s12873-019-0277-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 10/11/2019] [Indexed: 11/26/2022] Open
Abstract
Background Overcrowding in emergency departments (ED) is a major concern worldwide. To answer increasing health care demands, new models of care including advanced practice physiotherapists (APP) have been implemented in EDs. The purpose of this study was to assess diagnostic, treatment and discharge plan concordance between APPs and ED physicians for patients consulting to the ED for minor musculoskeletal disorders (MSKD). Methods Patients presenting to two EDs in Montréal (Canada) with a minor MSKD were recruited and independently assessed by an APP and ED physician. Both providers had to formulate diagnosis, treatment and discharge plans. Cohen’s kappa (κ) and Prevalence and Bias Adjusted Kappas (PABAK) with associated 95%CI were calculated. Chi Square and t-tests were used to compare treatment, discharge plan modalities and patient satisfaction between providers. Results One hundred and thirteen participants were recruited, mean age was 50.3 ± 17.4 years old and 51.3% had an atraumatic MSKD. Diagnostic inter-rater agreement between providers was very good (κ = 0.81; 95% CI: 0.72–0.90). In terms of treatment plan, APPs referred significantly more participants to physiotherapy care than ED physicians (κ = 0.27; PABAK = 0.27; 95% CI: 0.07–0.45; p = 0.003). There was a moderate inter-rater agreement (κ = 0.46; PABAK = 0.64; 95% CI: 0.46–0.77) for discharge plans. High patient satisfaction was reported with no significant differences between providers (p = 0.57). Conclusion There was significant agreement between APPs and ED physicians in terms of diagnosis and discharge plans, but more discrepancies regarding treatment plans. These results tend to support the integration of APPs in ED settings, but further prospective evaluation of the efficiency of these types of models is warranted.
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Affiliation(s)
- E Matifat
- Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montréal, Québec, Canada.,CIUSSS Est-de-l'Île-de-Montréal, Québec, Canada
| | - K Perreault
- Center for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS), Québec, Québec, Canada.,Departement of Rehabilitation, Faculty of Medicine, Laval University, Québec, Québec, Canada
| | - J-S Roy
- Center for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS), Québec, Québec, Canada.,Departement of Rehabilitation, Faculty of Medicine, Laval University, Québec, Québec, Canada
| | - A Aiken
- Faculty of Health, Dalhousie University, Halifax, Canada
| | - E Gagnon
- CIUSSS Est-de-l'Île-de-Montréal, Québec, Canada
| | - M Mequignon
- Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montréal, Québec, Canada.,Université de Picardie Jules Verne, Amiens, France
| | - V Lowry
- Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montréal, Québec, Canada.,School of Rehabilitation, Faculty of Medicine, University of Montréal, Montréal, Québec, Canada
| | - S Décary
- Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montréal, Québec, Canada
| | - B Hamelin
- CIUSSS Est-de-l'Île-de-Montréal, Québec, Canada
| | - M Ambrosio
- CIUSSS Centre-Ouest-de-l'Île-de-Montréal, Québec, Canada
| | - N Farley
- School of Rehabilitation, Faculty of Medicine, University of Montréal, Montréal, Québec, Canada.,CIUSSS Centre-Ouest-de-l'Île-de-Montréal, Québec, Canada
| | - D Pelletier
- Ordre Professionnel de la Physiothérapie du Québec, Montréal, Québec, Canada
| | - L Carlesso
- Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montréal, Québec, Canada.,School of Rehabilitation, Faculty of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - F Desmeules
- Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montréal, Québec, Canada. .,School of Rehabilitation, Faculty of Medicine, University of Montréal, Montréal, Québec, Canada.
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13
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Button K, Morgan F, Weightman AL, Jones S. Musculoskeletal care pathways for adults with hip and knee pain referred for specialist opinion: a systematic review. BMJ Open 2019; 9:e027874. [PMID: 31488471 PMCID: PMC6731906 DOI: 10.1136/bmjopen-2018-027874] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE Musculoskeletal care pathways are variable and inconsistent. The aim of this systematic review was to evaluate the evidence for the clinical and/or cost effectiveness of current care pathways for adults with hip and/or knee pain referred for specialist opinion. DESIGN Systematic review. DATA SOURCES Electronic database searches were carried out in MEDLINE, MEDLINE In-Process, Cumulative Index of Nursing and Allied Health Literature, Embase, PEDro, PubMed, Web of Science, Cochrane Central and Health Management Information Consortium without language restriction from 1990 onwards. Websites were reviewed for grey literature. ELIGIBILITY CRITERIA All study designs and documents that considered care pathways for adults with musculoskeletal hip and/or knee pain referred for specialist opinion were screened by two reviewers. Risk of bias was assessed using The Critical Appraisal Skills Programme checklist for randomised controlled trials and the Joanna Briggs Institute checklists. DATA EXTRACTION AND SYNTHESIS Data extraction and quality assessment were performed by one reviewer and checked by a second. Findings are reported narratively. RESULTS The titles and abstracts of 1248 articles were screened and 140 full-text articles retrieved. 19 papers reporting 17 studies met the study inclusion criteria. Quality was low due to study design and methodological flaws. Most of the outcomes relate to organisational process at the 'meso' level of a whole systems approach. CONCLUSION It can be concluded that the pathway is not linear, containing variations and activity loops. The available evidence suggests that, from the point of referral for specialist opinion, a model is required that integrates the skills of all the different healthcare professionals and streamlining is required to ensure that individuals are seen by the healthcare professional that best meets their needs. There is very limited evidence of patient experience informing knee and hip care pathways. PROSPERO REGISTRATION NUMBER CRD42016035510.
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Affiliation(s)
- Kate Button
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Fiona Morgan
- Specialist Unit for Review Evidence (SURE), University Library Service, Cardiff University, Cardiff, UK
| | | | - Stephen Jones
- Trauma and Orthopaedics, Cardiff and Vale University Health Board, Cardiff, UK
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14
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Jovic D, Mulford J, Ogden K, Zalucki N. Diagnosis and management of chronic hip and knee pain in a Tasmanian orthopaedic clinic: a study assessing the diagnostic and treatment planning decisions of an advanced scope physiotherapist. Aust J Prim Health 2019; 25:60-65. [DOI: 10.1071/py18076] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 09/20/2018] [Indexed: 11/23/2022]
Abstract
The aim of this study is to investigate the clinical effectiveness of an advanced practice physiotherapist triaging patients referred from primary care to the orthopaedic clinic with chronic hip and knee pain. An exploratory study design was used to assess 87 consecutive patients referred from general practice in Northern Tasmania. Patients were assessed by both an advanced practice physiotherapist and a consultant orthopaedic surgeon. Diagnostic and treatment decisions were compared, with the orthopaedic consultant decision defined as the gold standard. By using these decisions, over and under referral rates to orthopaedics could be calculated, as well as the surgical conversion rate. Conservative care of patients referred to the orthopaedic clinic with hip and knee pain was limited. The diagnostic agreement between the advanced scope physiotherapist and the orthopaedic surgeon was almost perfect (weighted kappa 0.93 (95% CI 0.87–1.00)), with treatment agreement substantial (weighted kappa 0.75 (95% CI 0.62–0.89)). Under a physiotherapist-led triage service, the surgical conversion rate doubled from 38% to 78%. An advanced physiotherapist assessing and treating patients with chronic hip and knee pain made decisions that match substantially with decisions made by an orthopaedic consultant. A model of care utilising an advanced physiotherapist in this way has the potential to support high-quality orthopaedic care in regional centres.
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15
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Décary S, Desmeules F. Response to Letter to the Editor regarding "Concerns for Potential Risk of Bias in Diagnostic Validity Study of Patellofemoral Pain". Arch Phys Med Rehabil 2018; 99:1932-1933. [PMID: 29920231 DOI: 10.1016/j.apmr.2018.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 05/30/2018] [Indexed: 10/14/2022]
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16
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Clinical diagnosis of partial or complete anterior cruciate ligament tears using patients' history elements and physical examination tests. PLoS One 2018; 13:e0198797. [PMID: 29894492 PMCID: PMC5997333 DOI: 10.1371/journal.pone.0198797] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 05/25/2018] [Indexed: 01/13/2023] Open
Abstract
Objective To assess the diagnostic validity of clusters combining history elements and physical examination tests to diagnose partial or complete anterior cruciate ligament (ACL) tears. Design Prospective diagnostic study. Settings Orthopaedic clinics (n = 2), family medicine clinics (n = 2) and community-dwelling. Participants Consecutive patients with a knee complaint (n = 279) and consulting one of the participating orthopaedic surgeons (n = 3) or sport medicine physicians (n = 2). Interventions Not applicable. Main outcome measures History elements and physical examination tests performed independently were compared to the reference standard: an expert physicians’ composite diagnosis including history elements, physical tests and confirmatory magnetic resonance imaging. Penalized logistic regression (LASSO) was used to identify history elements and physical examination tests associated with the diagnosis of ACL tear and recursive partitioning was used to develop diagnostic clusters. Diagnostic accuracy measures including sensitivity (Se), specificity (Sp), predictive values and positive and negative likelihood ratios (LR+/-) with associated 95% confidence intervals (CI) were calculated. Results Forty-three individuals received a diagnosis of partial or complete ACL tear (15.4% of total cohort). The Lachman test alone was able to diagnose partial or complete ACL tears (LR+: 38.4; 95%CI: 16.0–92.5). Combining a history of trauma during a pivot with a “popping” sensation also reached a high diagnostic validity for partial or complete tears (LR+: 9.8; 95%CI: 5.6–17.3). Combining a history of trauma during a pivot, immediate effusion after trauma and a positive Lachman test was able to identify individuals with a complete ACL tear (LR+: 17.5; 95%CI: 9.8–31.5). Finally, combining a negative history of pivot or a negative popping sensation during trauma with a negative Lachman or pivot shift test was able to exclude both partial or complete ACL tears (LR-: 0.08; 95%CI: 0.03–0.24). Conclusion Diagnostic clusters combining history elements and physical examination tests can support the differential diagnosis of ACL tears compared to various knee disorders.
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Décary S, Feldman D, Frémont P, Pelletier JP, Martel-Pelletier J, Fallaha M, Pelletier B, Belzile S, Sylvestre MP, Vendittoli PA, Desmeules F. Initial derivation of diagnostic clusters combining history elements and physical examination tests for symptomatic knee osteoarthritis. Musculoskeletal Care 2018; 16:370-379. [PMID: 29781110 DOI: 10.1002/msc.1245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 03/15/2018] [Accepted: 03/16/2018] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The aim of the present study was to assess the validity of clusters combining history elements and physical examination tests to diagnose symptomatic knee osteoarthritis (SOA) compared with other knee disorders. METHODS This was a prospective diagnostic accuracy study, in which 279 consecutive patients consulting for a knee complaint were assessed. History elements and standardized physical examination tests were obtained independently by a physiotherapist and compared with an expert physician's composite diagnosis, including clinical examination and imaging. Recursive partitioning was used to develop diagnostic clusters for SOA. Diagnostic accuracy measures were calculated, including sensitivity, specificity, and positive and negative likelihood ratios (LR+/-), with associated 95% confidence intervals (CIs). RESULTS A total of 129 patients had a diagnosis of SOA (46.2%). Most cases (76%) had combined tibiofemoral and patellofemoral knee OA and 63% had radiological Kellgren-Lawrence grades of 2 or 3. Different combinations of history elements and physical examination tests were used in clusters accurately to discriminate SOA from other knee disorders. These included age of patients, body mass index, presence of valgus/varus knee misalignment, palpable knee crepitus and limited passive knee extension. Two clusters to rule in SOA reached an LR+ of 13.6 (95% CI 6.5 to 28.4) and three clusters to rule out SOA reached an LR- of 0.11 (95% CI 0.06 to 0.20). DISCUSSION Diagnostic clusters combining history elements and physical examination tests were able to support the differential diagnosis of SOA compared with various knee disorders without relying systematically on imaging. This could support primary care clinicians' role in the efficient management of these patients.
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Affiliation(s)
- Simon Décary
- School 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
| | - Debbie Feldman
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, QC, Canada
| | - Pierre Frémont
- Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, QC, Canada
| | - Jean-Pierre Pelletier
- Osteoarthritis Research Unit, University of Montreal Hospital Research Center (CRCHUM), Montreal, QC, Canada
| | - Johanne Martel-Pelletier
- Osteoarthritis Research Unit, University of Montreal Hospital Research Center (CRCHUM), Montreal, QC, Canada
| | - Michel Fallaha
- Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec, Canada
| | - Bruno Pelletier
- Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec, Canada
| | - Sylvain Belzile
- Department of Surgery, Laval University Hospital Center (CHUL), Laval University, QC, Quebec, Canada
| | - Marie-Pierre Sylvestre
- Department of Social Preventive Medicine, School of Public Health, University of Montreal Hospital Research Center (CRCHUM), Montreal, QC, Canada
| | - Pascal-André 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.,Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec, Canada
| | - François Desmeules
- School 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
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