A systematic review and evidence synthesis of non-medical triage, self-referral and direct access services for patients with musculoskeletal pain

Outcomes of direct access telehealth physical therapy for patients with musculoskeletal pain: a single cohort observational retrospective study

BACKGROUND

Telehealth direct access physical therapy is becoming more prevalent in the management of outpatient musculoskeletal pain. This innovative model affords more opportunity to reach potential patients who otherwise would not be able to access services due to geographical isolation, travel barriers, and timely access to quality care.

OBJECTIVE

The purpose of the study was to investigate if pain, function, and ability to perform jobs improved after direct access telehealth physical therapy in patients with musculoskeletal pain.

METHODS

A single cohort retrospective design was implemented to offer telehealth physical therapy to patients with musculoskeletal pain from March to November 2021. Eligible patients were at least 18 years old, located in California, and had a history of peripartum pelvic dysfunction, muscle pain, joint pain, or neural symptoms. Paired-samples t-tests and the Wilcoxon signed-rank test were used to analyze normally distributed and non-parametric data (α = 0.05), respectively, to compare pretest and post scores.

RESULTS

Based on 89 participants, paired-samples t-tests showed statistically significant differences in function [t(87) = 20.71, p < .0001] and pain [t(82) = -8.15, p < .0001]. Wilcoxon's signed-rank test showed statistically significant differences in ability to perform job (Z = -7.345, p < .0001).

CONCLUSION

This study demonstrated that in a cohort of individuals with multiregional musculoskeletal pain, there was a decrease in pain and improvements in function and ability to perform job after direct access telehealth physical therapy.

Reducing strain on primary healthcare systems through innovative models of care: the impact of direct access physiotherapy for musculoskeletal conditions-an interrupted time series analysis

OBJECTIVES

To evaluate the longitudinal impact of introducing a national, direct access physiotherapy model of care on the rates of primary and secondary care consultations for musculoskeletal (MSK) conditions.

DESIGN

Interrupted time series analysis using segmented linear regression.

SETTING

Norway primary care PARTICIPANTS: A cohort of 82 072 participants was derived from 3 population-based health surveys conducted across separate geographical regions in Norway. All participants surveyed were eligible for inclusion as a national representative sample of the Norwegian population. Registered MSK consultations were linked to the Norwegian Control and Payment of Health Reimbursement database and the Norwegian Patient Register using the International Classification of Primary Care diagnostic medical codes L-chapter for MSK conditions and spine related International Classification of Diseases, 10th Revision, codes.

INTERVENTION

Direct access to physiotherapy model of care introduced nationally in Norway in 2018. This model allowed Norwegians to consult directly with qualified physiotherapists for MSK conditions (eg, back pain, knee osteoarthritis) without the need for a medical referral in order to claim a social security reimbursement.

MAIN OUTCOMES MEASURED

Rates of primary care consultations per 10 000 population (general practitioner (GP) and physiotherapist consultations) and secondary care (specialist consultations and surgical procedures) measured from 2014 to 2021.

RESULTS

The introduction of the direct access physiotherapy model was associated with an immediate stepped reduction of 391 general practice consultations per 10 000 population, (95% CI: -564 to -216), without an associated change in physiotherapy consultations. Subgroup analyses suggested there was an associated reduction in physiotherapy consultations for those in the lowest education group of 150 consultations per quarter (95% CI:-203 to -97), 70 consultations per quarter in the intermediate education group (95% CI:-115 to -27) and a stepped reduction of 2 spinal surgical procedures per 10 000 population, for those aged between 40 and 60 years (95% CI: -3 to -1) following the introduction of the direct access physiotherapy model.

CONCLUSION

The national introduction of a direct access to physiotherapy model of care was associated with a reduction in the workload of GPs for the management of MSK conditions. The use of physiotherapists in direct contact roles is a potential strategic model to reduce the burden on the GP workforce in primary care worldwide.

Patient experience of the process to diagnosis of chronic limb-threatening ischaemia: A qualitative study

INTRODUCTION

Delays exist at each stage of the chronic limb-threatening ischaemia (CLTI) care pathway, but there is little known about patient factors influencing delay to diagnosis of CLTI. This study explores the experiences and perceptions of patients recently diagnosed with CLTI.

METHODS

A qualitative interview study was conducted. Sixteen participants underwent semi-structured interviews. Reflexive thematic analysis was performed on the data, aiming to understand factors which can influence delay in the CLTI care pathway.

RESULTS

Five interrelated themes were developed: CLTI is a devastating condition; Reluctance to ask for help; When we are empowered we get better care; Luck plays a role in the process to diagnosis; and Vascular units can do better, comprising sub-themes of information transfer-consider communication and arterial versus non-arterial centres-proximity isn't everything.

CONCLUSIONS

The five themes generated from the interview data describe factors relevant to delay given meaning by participants who have lived experience of CLTI. Theme content should be noted by clinicians, commissioners and providers looking to improve care pathways for patients with CLTI. The importance of awareness for the public, patients and clinicians linked ideas in some themes and interventions to raise awareness should be considered.

Prognostic Factors and Treatment Effect Modifiers for Physical Health, Opioid Prescription, and Health Care Utilization in Patients With Musculoskeletal Disorders in Primary Care: Exploratory Secondary Analysis of the STEMS Randomized Trial of Direct Access to Physical Therapist-Led Care

OBJECTIVE

The aims of the study were to identify prognostic factors associated with health care outcomes in patients with musculoskeletal (MSK) conditions in primary care and to determine whether characteristics associated with choice of care modify treatment effects of a direct-access physical therapist-led pathway in addition to general practitioner (GP)-led care compared to GP-led care alone.

METHODS

A secondary analysis of a 2-parallel-arm, cluster randomized controlled trial involving general practices in the United Kingdom was conducted. Practices were randomized to continue offering GP-led care or to also offer a direct-access physical therapist-led pathway. Data from adults with MSK conditions who completed the 6-month follow-up questionnaire were analyzed. Outcomes included physical health, opioid prescription, and self-reported health care utilization over 6 months. Treatment effect modifiers were selected a priori from associations in observational studies. Multivariable regression models identified potential prognostic factors, and interaction analysis tested for potential treatment effect modifiers.

RESULTS

Analysis of 767 participants indicated that baseline pain self-efficacy, pain severity, and having low back pain statistically predicted outcomes at 6 months. Higher pain self-efficacy scores at baseline were associated with improved physical health scores, reduced opioid prescription, and less health care utilization. Higher bodily pain at baseline and having low back pain were associated with worse physical health scores and increased opioid prescription. Main interaction analyses did not reveal that patients' age, level of education, duration of symptoms, or MSK presentation influenced response to treatment, but visual trends suggested those in the older age group proceeded to fewer opioid prescriptions and utilized less health care when offered direct access to physical therapy.

CONCLUSIONS

Patients with MSK conditions with lower levels of pain self-efficacy, higher pain severity, and presenting with low back pain have less favorable clinical and health care outcomes in primary care. Prespecified characteristics did not modify the treatment effect of the offer of a direct-access physical therapist-led pathway compared to GP-led care.

IMPACT

Patients with MSK conditions receiving primary care in the form of direct-access physical therapist-led or GP-led care who have lower levels of self-efficacy, higher pain severity, and low back pain are likely to have a less favorable prognosis. Age and duration of symptoms should be explored as potential patient characteristics that modify the treatment response to a direct-access physical therapist-led model of care.

A narrative synthesis of the effectiveness and acceptability of musculoskeletal first contact physiotherapy practitioner roles in primary care

BACKGROUND

Musculoskeletal (MSK) First Contact Practitioners (FCP), diagnostic clinicians with expertise in the assessment and management of undifferentiated MSK conditions in primary care have been widely employed in the United Kingdom since 2020. The role aims to bring specialist clinical knowledge to patients at the first point of contact and reduce the burden on existing primary care services. Since the national adoption of the role, little has been published to support the effectiveness or acceptability of the role. This narrative synthesis review aims to highlight and summarise the current body of evidence.

METHODOLOGY

An adapted systematic review was carried out to inform thematic reporting and narrative synthesis, under the sub-themes of clinical outcomes, patient satisfaction, acceptability and cost analysis.

RESULTS

Eight publications were included in the review, reporting improvements in clinical outcomes in patients seen by MSK FCP, patient satisfaction and general acceptability of the role. However, all data were collected from observational studies and qualitative sources, some of which were found to be of low methodological quality.

CONCLUSION

Although the review identified consistent positivity relating to effectiveness, satisfaction and acceptability across the reviewed publications, conclusions are limited due to the relatively recent introduction of the FCP role leading to limited availability of relevant publications.

One and Done? The Effectiveness of a Single Session of Physiotherapy Compared With Multiple Sessions to Reduce Pain and Improve Function and Quality of Life in Patients With a Musculoskeletal Disorder: A Systematic Review With Meta-analyses

OBJECTIVE

To compare single and multiple physiotherapy sessions to improve pain, function, and quality of life (QoL) in patients with musculoskeletal disorders (MSKDs).

DATA SOURCES

AMED, Cinahl, SportsDiscus, Medline, Cochrane Register of Clinical Trials, Physiotherapy Evidence Database, and reference lists.

STUDY SELECTION

Randomized controlled trials (RCTs) comparing single and multiple physiotherapy sessions for MSKDs.

DATA EXTRACTION

Two reviewers extracted data and assessed risk of bias and certainty of evidence using Cochrane Risk of Bias tool 2.0 and Grading of Recommendation Assessment, Development, and Evaluation.

DATA SYNTHESIS

Six RCTs (n=2090) were included (conditions studied: osteoporotic vertebral fracture, neck, knee, and shoulder pain). Meta-analyses with low-certainty evidence showed a significant pain improvement at 6 months in favor of multiple sessions compared with single session interventions (3 RCTs; n=1035; standardized mean difference [SMD]: 0.29; 95% CI: 0.05 to 0.53; P=.02) but this significant difference in pain improvement was not observed at 3 months (4 RCTs; n=1312; SMD: 0.39; 95% CI: -0.11 to 0.89; P=.13) and at 12 months (4 RCTs; n=1266; SMD: -0.05; 95% CI: -0.49 to 0.39; P=.82). Meta-analyses with low-certainty evidence showed no significant differences in function at 3 (4 RCTs; n=1583; SMD: 0.05; 95% CI: -0.11 to 0.21; P=.56), 6 (4 RCTs; n=1538; SMD: 0.06; 95% CI: -0.12 to 0.23; P=.53) and 12 months (4 RCTs; n=1528; SMD: 0.08; 95% CI: -0.08 to 0.25; P=.30) and QoL at 3 (4 RCTs; n=1779; SMD: 0.08; 95% CI: -0.02 to 0.17; P=.12), 6 (3 RCTs; n=1206; SMD: 0.03; 95% CI: -0.08 to 0.14; P=.59), and 12 months (4 RCTs; n=1729; SMD: -0.03; 95% CI: -0.12 to 0.07; P=.58).

CONCLUSIONS

Low certainty meta-analyses found no clinically significant differences in pain, function, and QoL between single and multiple physiotherapy sessions for MSKD management for the conditions studied. Future research should compare the cost-effectiveness of those different models of care.

Required competencies for French physiotherapists for direct access to primary care for patients with musculoskeletal disorders: consensus statement based on a Delphi survey

BACKGROUND

Physiotherapists who will practice in direct access model of care must acquire the required competencies to ensure adequate and safe patient care. There is no set of required competencies for French physiotherapists.

OBJECTIVE

To develop a consensus on a minimum set of competencies that French physiotherapists should acquire to practice in direct access to primary care with patients with musculoskeletal disorders.

METHODS

The survey was conducted by 1) definition of an initial set of competencies based on a scoping review up to September 2021, 2) implementation of a two-round Delphi survey from October 2021 to January 2022 to obtain consensus on the domains and competencies required in the French context, and 3) consultation at group meeting on February 2022 to finalize and validate the final set of competencies.

RESULTS

Five domains and 52 competencies were identified from the scoping review. Twenty health-care professionals' experts (i.e. family physicians, emergency physicians, and physiotherapists) and two health-care users took part in the Delphi survey. A consensus was reached on 27 required competencies grouped within five domains.

CONCLUSION

A consensus-based, contemporary set of competencies required for direct access practice with patients with musculoskeletal disorders has been identified that may contribute to the update of entry-level and lifelong learning curricula for French physiotherapists.

First-contact physiotherapists' perceived competency in a new model of care for low back pain patients: a mixed methods study

Background

A new advanced practice model of care enables French physiotherapists to perform medical acts for low back pain (LBP) patients as first-contact physiotherapists (FCPs).

Objective

The aim of this study is to determine the self-perceived competency of FCPs and to further explore factors underpinning this feeling.

Methods

A mixed-methods explanatory sequential design was conducted. A survey was used to self-assess the perceived competency of FCPs in performing medical tasks. Semi-structured interviews were then performed to explore determining factors of perceived competency. Inductive thematic analysis was performed.

Results

Nine FCPs answered the survey and were interviewed (mean age 40.1, standard deviation [SD]: ±10.0). FCPs felt very competent with making medical diagnosis (3.44/4, SD: ±0.53), analgesic prescription (3.11, SD: ±0.78) and referring onward to physiotherapy (3.78, SD: ±0.55). They did not feel competent with nonsteroidal anti-inflammatory drug prescription (2.78, SD: ±0.67) and issuing sick leave certificate (2.67, SD: ±1.0). The main identified influencing factors were previous FCPs' experience, training, knowledge, collaboration with family physicians, high responsibility and risk management associated with decision-making.

Conclusion

French FCPs appeared to have the necessary skills to directly manage LBP patients without medical referral. Future training focusing on analgesic prescription and issuing sick leave certificate is however needed.

Impact of direct access on the quality of primary care musculoskeletal physiotherapy: a scoping review from a patient, provider, and societal perspective

Introduction

Worldwide many countries provide direct access in physiotherapy. The aim of this scoping review was to synthesize the available evidence on the quality of primary care musculoskeletal physiotherapy from different perspectives.

Methods

Systematic searches were conducted in three databases up to September 2022. Studies were included when regarding assessment of at least one of the following perspectives: patient (quality of Life, patient satisfaction, pain, functioning, adverse events), provider (treatment compliance, responsibility, liability, status, prestige, job satisfaction), and society (number of referrals, amount of medical imaging, medication use, number of sessions needed for rehabilitation, and overall costs and cost-effectiveness). Selection and methodological quality assessment of systematic reviews were performed. Data extraction and analysis were performed separately for systematic reviews and individual primary studies.

Results

Five systematic reviews as well as 17 primary studies were included. From a patient perspective, no significant effect of direct access was found for pain and a tendency in favour of direct access was found for quality of life, functioning, and well-being. Concerning providers, higher treatment compliance was found in direct access to physiotherapy and decision-making was more accurate. From a societal perspective, significant differences in favour of direct access physiotherapy were found for waiting time, prescribed medication, and medical imaging. In addition, there was a tendency towards lower health care costs.

Conclusions

Emerging evidence suggests that direct access physiotherapy could provide at least equal quality of care for patients and better opportunities for providers and the society on selected outcomes.

Implementation of community physiotherapy in primary care: one-year results of an on-call physiotherapy service

BACKGROUND

Primary health care systems have a key role in meeting health needs of community, including function. The aim of this paper is to describe the population involved in the Community Physiotherapist project and their health outcomes over a one-year period.

METHODS

The Community Physiotherapist is an on-call service which requires a request by general practitioners or medical specialists. Reason for prescription, waiting time for service delivery, diagnostic categories, provided intervention, number of interventions and outcomes were recorded for everyone included in the project. Possible differences in characteristics between individuals referred by medical specialists and general practitioners were also investigated.

RESULTS

From January to December 2022, 409 individuals were referred to the Community Physiotherapist pathway. Functional goals were achieved in 79.5% of interventions, without reported adverse events. In most cases physiotherapists provided counselling or caregiver training and 3.3% of individuals needed a full rehabilitation program. The groups of individuals referred by the two types of prescribers showed no significant differences, apart, as expected, from their median age.

CONCLUSIONS

The introduction of the Community Physiotherapist model within the primary care setting allows to provide appropriate, effective and safe interventions. Sharing the project among all the health professionals helped to support its appropriateness and effectiveness. Results also indicate that a new organizational model, such as the Community Physiotherapist, will take a long time to be implemented.

Core competencies for first contact physiotherapists in a direct access model of care for adults with musculoskeletal disorders: A scoping review

INTRODUCTION

To optimise the management of Musculoskeletal disorders (MSKDs), many countries have implemented direct access to physiotherapy; however, the core competencies required for first contact physiotherapists (PTs) have not been precisely defined. The aim of this scoping review is to identify and describe the core competencies required for first contact PTs treating adults with MSKDs.

METHODS

We conducted a scoping review of the literature by searching eight databases and grey literature up to July 2023. We performed a thematic analysis of the competencies identified based on predefined themes relevant to first contact physiotherapy in direct access models in primary or emergency care settings.

RESULTS

Sixty-five articles were included. Seventeen core competencies were identified and grouped into 5 themes: (1) Assessment and examination; (2) Management and interventions; (3) Communication; (4) Cooperation and collaboration; and (5) Professionalism and leadership.

CONCLUSIONS

Our findings provide an international perspective on the core competencies required for first contact PTs.

Description of the abilities of physiotherapists in terms of diagnostic hypothesis and management decision for self-referred patients with musculoskeletal disorders in France using clinical vignettes: A cross-sectional survey

BACKGROUND

Direct access to physiotherapy has been introduced in several countries. In France, the healthcare system is evolving towards its introduction; however, no study has described the ability of physiotherapists in this context.

OBJECTIVE

To describe the ability of physiotherapists practicing in France to formulate correct diagnostic hypotheses and make appropriate management decisions using clinical vignettes.

METHODS

Pre-existing validated clinical vignettes were used and integrated into a numerical questionnaire. The percentages of correct answers were calculated from the results concerning the choice of diagnostic hypothesis and the management decision, both overall and for the three different patient categories: musculoskeletal, non-critical medical, and critical medical.

RESULTS

Four hundred eighty-two participants (1.7%) responded to the study. For the formulation of a diagnostic hypothesis, there were 43.0% (415/964), 26.6% (128/482), and 17.8% (86/482) correct answers respectively for the musculoskeletal, non-critical medical, and critical medical categories. For management decisions, there were 60.8% (586/964), 61.6% (297/482), and 85.1% (410/482) correct answers respectively for the same categories.

CONCLUSIONS

Our results related to the management decision were better than those for the diagnostic hypothesis, especially for the critical medical category. There is still room for improvement. It might be interesting to support this initial study by using more clinical vignettes validated in a French context.

Continued Opioid Use and Adverse Events Following Provision of Opioids for Musculoskeletal Pain in the Emergency Department: A Systematic Review and Meta-Analysis

BACKGROUND

The prevalence of continued opioid use or serious adverse events (SAEs) following opioid therapy in the emergency department (ED) for musculoskeletal pain is unclear. The aim of this review was to examine the prevalence of continued opioid use and serious adverse events (SAEs) following the provision of opioids for musculoskeletal pain in the emergency department (ED) or at discharge.

METHODS

Records were searched from MEDLINE, EMBASE and CINAHL from inception to 7 October 2022. We included randomised controlled trials and observational studies enrolling adult patients with musculoskeletal pain who were administered and/or prescribed opioids in the ED. Continued opioid use and opioid misuse data after day 4 since ED discharge were extracted. Adverse events were coded using the Common Terminology Criteria for Adverse Events (CTCAE), and those rated as grades 3-4 (severe or life-threatening) and grade 5 (death) were considered SAEs. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool.

RESULTS

Seventy-two studies were included. Among opioid-naïve patients who received an opioid prescription, 6.8-7.0% reported recent opioid use at 3-12 months after discharge, 4.4% filled ≥ 5 opioid prescriptions and 3.1% filled > 90-day supply of opioids within 6 months. The prevalence of SAEs was 0.02% [95% confidence interval (CI) 0, 0.2%] in the ED and 0.1% (95% CI 0, 1.5%) within 2 days. One study observed 42.9% of patients misused opioids within 30 days after discharge.

CONCLUSIONS

Around 7% of opioid-naïve patients with musculoskeletal pain receiving opioid therapy continue opioid use at 3-12 months after ED discharge. SAEs following ED administration of an opioid were uncommon; however, studies only monitored patients for 2 days.

PROTOCOL REGISTRATION

10.31219/osf.io/w4z3u.

Effectiveness and Consequences of Direct Access in Physiotherapy: A Systematic Review

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.

Diagnosing knee osteoarthritis in patients, differences between general practitioners and orthopedic surgeons: a retrospective cohort study

BACKGROUND

knee complaints are one of the most common reasons to consult the general practitioners in the Netherlands and contribute to the increasing burden on general practitioners. A proportion of patients that are referred to orthopedic outpatient clinics are potentially referred unnecessarily. We believe osteoarthritis is not always considered by general practitioners as the cause of atraumatic knee complaints. This may impede early recognition and timely care of osteoarthritis complaints and lead to unnecessary referrals.

METHODS

the aim of this study was to compare the frequency of (differential) diagnosis of osteoarthritis mentioned in referral letters of general practitioners with the frequency of osteoarthritis mentioned as orthopedic diagnosis at the outpatient clinic. Therefore we conducted a retrospective cohort study based on data collected from referral letters and the corresponding outpatient clinic reports of patients with atraumatic knee complaints of 45 years or older referred to a regional hospital in Nijmegen, The Netherlands in the period from 1-6-2019 until 1-01-2020.

RESULTS

a total of 292 referral letters were included. In the younger aged patients (45-54 years) osteoarthritis was mentioned less frequent and meniscal lesions were mentioned more frequent in referral letters when compared to diagnoses made at the outpatient clinic. Differences in differential diagnosis of osteoarthritis as well as meniscal lesions between orthopedic surgeon and general practitioners were found (both p < 0.001, McNemar). Matching diagnoses were present in 58.2% when all referral letters were analyzed (n = 292) and 75.2% when only referrals containing a differential diagnosis were analyzed (n = 226). Matching diagnoses were present in 31.6% in the younger age categories (45-54 years). A linear trend showing fewer matching diagnoses in younger patient categories was observed (p < 0.001).

CONCLUSIONS

Osteoarthritis was less frequently mentioned in general practitioner referral letters among the differential diagnosis then it was diagnosed at the outpatient clinic, especially in younger patients (45-54 years). Also matching diagnoses in younger patients were evidently lower than in older patients, partly explained by underdiagnosing of osteoarthritis in younger patients in this cohort. Better recognition of osteoarthritis in younger patients and changing the diagnostic approach of general practitioners might improve efficacy in knee care. Future research should focus on the effectiveness of musculoskeletal triage, the need for multidisciplinary educational programs for patients and promotion of conservative treatment modalities among general practitioners.

Influence of Initial Health Care Provider on Subsequent Health Care Utilization for Patients With a New Onset of Low Back Pain: A Scoping Review

OBJECTIVE

The aim of this research was to examine the scope of evidence for the influence of a nonmedical initial provider on health care utilization and outcomes in people with low back pain (LBP).

METHODS

Using scoping review methodology, we conducted an electronic search of 4 databases from inception to June 2021. Studies investigating the management of patients with a new onset of LBP by a nonmedical initial health care provider were identified. Pairs of reviewers screened titles, abstracts, and eligible full-text studies. We extracted health care utilization and patient outcomes and assessed the methodological quality of the included studies using the Joanna Briggs Institute checklist. Two reviewers descriptively analyzed the data and categorized findings by outcome measure.

RESULTS

A total of 26,462 citations were screened, and 11 studies were eligible. Studies were primarily retrospective cohort designs using claims-based data. Four studies had a low risk of bias. Five health care outcomes were identified: medication, imaging, care seeking, cost of care, and health care procedures. Patient outcomes included patient satisfaction and functional recovery. Compared with patients initiating care with medical providers, those initiating care with a nonmedical provider showed associations with reduced opioid prescribing and imaging ordering rates but increased rates of care seeking. Results for cost of care, health care procedures, and patient outcomes were inconsistent.

CONCLUSIONS

Prioritizing nonmedical providers at the first point of care may decrease the use of low-value care, such as opioid prescribing and imaging referral, but may lead to an increased number of health care visits in the care of people with LBP. High-quality randomized controlled trials are needed to confirm our findings.

IMPACT

This scoping review provides preliminary evidence that nonmedical practitioners, as initial providers, may help reduce opioid prescription and selective imaging in people with LBP. The trend observed in this scoping review has important implications for pathways of care and the role of nonmedical providers, such as physical therapists, within primary health care systems.

LAY SUMMARY

This scoping review provides preliminary evidence that nonmedical practitioners, as initial providers, might help reduce opioid prescription and selective imaging in people with LBP. High-quality randomized controlled trials are needed to confirm these findings.

Physiotherapists' knowledge of and adherence to evidence-based practice guidelines and recommendations for ankle sprains management: a cross-sectional study

BACKGROUND

Lateral ankle sprain (LAS) is a common and burdensome injury. However, the quality of its management is scant. Nowadays, physiotherapy management of musculoskeletal diseases seems to be generally not based on research evidence. Studies that investigated the knowledge-to-practice gap in LAS management are yet to be carried out. Therefore, this research investigated physiotherapists' knowledge of and adherence to LAS Clinical Practice Guidelines (CPGs) and recommendations.

METHODS

A cross-sectional study based on an online survey structured in three sections. The first section collected demographic data. The second section showed two clinical cases (with positive and negative Ottawa Ankle Rules (OAR), respectively). The participants indicated which treatments they would adopt to manage them. Participants were classified as 'following', 'partially following', 'partially not following' and 'not following' the CPGs and recommendations. In the third section, participants expressed their agreement with different CPG and recommendation statements through a 1-5 Likert scale.

RESULTS

In total, 483 physiotherapists (age: 34 ± 10; female 38%, male 61.5%, other 0.5%) answered the survey: 85% completed the first two sections, 76% completed all three sections. In a case of acute LAS with negative OAR, 4% of the participants were considered as 'following' recommended treatments, 68% as 'partially following', 23% as 'partially not following', and 5% as 'not following'. In a case of acute LAS with positive OAR, 37% were considered 'following' recommended treatments, 35% as 'partially following', and 28% as 'not following'. In the third section, the consensus was achieved for 73% of the statements.

CONCLUSION

This study showed that although there is a good knowledge about first-line recommended treatments, a better use of CPGs and recommendations should be fostered among physiotherapists. Our results identify an evidence-to-practice gap in LAS management, which may lead to non-evidence-based practice behaviors.

A call to action: direct access to physical therapy is highly successful in the US military. When will professional bodies, legislatures, and payors provide the same advantages to all US civilian physical therapists?

OBJECTIVES

In 2000, the American PT Association (APTA) published its Vision statement advocating for DA (DA) to PT. This narrative review of the literature aims to identify the current state of DA in the United States (US) and compare that status to the US Military.

METHODS

Initial PubMed search in the English language with keywords physical therapy (PT), physiotherapy, DA, self-referral, and primary contact from the year 2000 onwards with subsequent focused searches using keywords DA/self-referral/primary contact of physical therapists/physiotherapists on outcomes/autonomous practice/economic impact/patient satisfaction yielded 103 applicable studies on the topic. This paper excluded 40 international articles to focus on US military and civilian research.

RESULTS

Current literature supports Physical Therapists (PTs) in an initial contact role based on patient safety, satisfaction, access to care, efficiency, healthcare utilization, and potential cost savings.

CONCLUSIONS

Despite its success in the US Military, DA to PT in the US civilians remains limited and incomplete. PTs still await unrestricted DA and privileges associated with autonomous practice including the ability to order imaging and prescribe some medications.

Validation of the international classification of functioning, disability, and health (ICF) core sets for musculoskeletal conditions in a primary health care setting from physiotherapists' perspective using the Delphi method

PURPOSE

To analyze the possibilities of using ICF core sets for musculoskeletal conditions in primary care physiotherapy units of the Health Service of "Castilla y León" (Spain).

METHODS

A three-round Delphi study was conducted by physiotherapists working in a primary care setting. The data obtained were linked to second-level ICF categories and their relevance was assessed by the participants. The most relevant categories were compared with those present in the existing ICF core sets for musculoskeletal conditions.

RESULTS

Eighty-four physiotherapists participated in the survey. The consensus was reached for 45 ICF categories and 5 personal factors after the survey. Thirty-five of these categories were present in the Comprehensive Core Set for post-acute Musculoskeletal Conditions. In addition, 35 categories present in the core set were not considered relevant from the participants' perspective.

CONCLUSIONS

Physiotherapists mainly considered movement-related categories as relevant. The ICF core set for post-acute musculoskeletal conditions comprises many of these categories and can therefore be taken as a basis for the adoption of ICF in the clinical context.

RELEVANCE

Primary care physiotherapists should be aware of the advantages of using ICF in their clinical settings.Implications for RehabilitationThis study shows which body functions and structures, activities and participation, environmental factors, and personal characteristics are relevant from primary care physiotherapists' perspective assessing persons with musculoskeletal conditions.The Comprehensive ICF Core Set for Subacute Musculoskeletal Conditions includes most of the categories identified in this study, but they need to be refined to fully represent the primary care physiotherapists' perspective.The results of this study support the use of the Comprehensive ICF Core Set for Subacute Musculoskeletal Conditions as a basis for operationalizing ICF in this clinical setting.

Usability Testing of a Digital Assessment Routing Tool for Musculoskeletal Disorders: An Iterative Convergent Mixed Methods Study (Preprint)

Background

Musculoskeletal disorders negatively affect millions of patients worldwide, placing significant demand on health care systems. Digital technologies that improve clinical outcomes and efficiency across the care pathway are development priorities. We developed the musculoskeletal Digital Assessment Routing Tool (DART) to enable self-assessment and immediate direction to the right care.

Objective

We aimed to assess and resolve all serious DART usability issues to create a positive user experience and enhance system adoption before conducting randomized controlled trials for the integration of DART into musculoskeletal management pathways.

Methods

An iterative, convergent mixed methods design was used, with 22 adult participants assessing 50 different clinical presentations over 5 testing rounds across 4 DART iterations. Participants were recruited using purposive sampling, with quotas for age, habitual internet use, and English-language ability. Quantitative data collection was defined by the constructs within the International Organization for Standardization 9241-210-2019 standard, with user satisfaction measured by the System Usability Scale. Study end points were resolution of all grade 1 and 2 usability problems and a mean System Usability Scale score of ≥80 across a minimum of 3 user group sessions.

Results

All participants (mean age 48.6, SD 15.2; range 20-77 years) completed the study. Every assessment resulted in a recommendation with no DART system errors and a mean completion time of 5.2 (SD 4.44, range 1-18) minutes. Usability problems were reduced from 12 to 0, with trust and intention to act improving during the study. The relationship between eHealth literacy and age, as explored with a scatter plot and calculation of the Pearson correlation coefficient, was performed for all participants (r=–0.2; 20/22, 91%) and repeated with a potential outlier removed (r=–0.23), with no meaningful relationships observed or found for either. The mean satisfaction for daily internet users was highest (19/22, 86%; mean 86.5, SD 4.48; 90% confidence level [CL] 1.78 or –1.78), with nonnative English speakers (6/22, 27%; mean 78.1, SD 4.60; 90% CL 3.79 or –3.79) and infrequent internet users scoring the lowest (3/22, 14%; mean 70.8, SD 5.44; 90% CL 9.17 or –9.17), although the CIs overlap. The mean score across all groups was 84.3 (SD 4.67), corresponding to an excellent system, with qualitative data from all participants confirming that DART was simple to use.

Conclusions

All serious DART usability issues were resolved, and a good level of satisfaction, trust, and willingness to act on the DART recommendation was demonstrated, thus allowing progression to randomized controlled trials that assess safety and effectiveness against usual care comparators. The iterative, convergent mixed methods design proved highly effective in fully evaluating DART from a user perspective and could provide a blueprint for other researchers of mobile health systems.

International Registered Report Identifier (IRRID)

RR2-10.2196/27205

Physiotherapist or physician as primary assessor for patients with suspected knee osteoarthritis in primary care - a cost-effectiveness analysis of a pragmatic trial

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.

Direct Access to Physical Therapy: Should Italy Move Forward?

Direct access to physical therapy (DAPT) is the patient’s ability to self-refer to a physical therapist, without previous consultation from any other professional. This model of care has been implemented in many healthcare systems since it has demonstrated better outcomes than traditional models of care. The model of DAPT mainly focuses on the management of musculoskeletal disorders, with a huge epidemiological burden and worldwide healthcare systems workload. Among the healthcare professionals, physical therapists are one of the most accessed for managing pain and disability related to musculoskeletal disorders. Additionally, the most updated guidelines recommend DAPT as a first-line treatment because of its cost-effectiveness, safety, and patients’ satisfaction compared to other interventions. DAPT was also adopted to efficiently face the diffuse crisis of the declining number of general practitioners, reducing their caseload by directly managing patients’ musculoskeletal disorders traditionally seen by general practitioners. World Physiotherapy organization also advocates DAPT as a new approach, with physical therapy in a primary care pathway to better control healthcare expenses. Thus, it is unclear why the Italian institutions have decided to recognize new professions instead of focusing on the growth of physical therapy, a long-established and autonomous health profession. Furthermore, it is unclear why DAPT is still not fully recognized, considering the historical context and its evidence. The future is now: although still preliminary, the evidence supporting DAPT is promising. Hard skills, academic paths, scientific evidence, and the legislature argue that this paradigm shift should occur in Italy.

Validation of a Musculoskeletal Digital Assessment Routing Tool: Protocol for a Pilot Randomized Crossover Noninferiority Trial

Background

Musculoskeletal conditions account for 16% of global disability, resulting in a negative effect on millions of patients and an increasing demand for health care use. Digital technologies to improve health care outcomes and efficiency are considered a priority; however, innovations are rarely tested with sufficient rigor in clinical trials, which is the gold standard for clinical proof of safety and efficacy. We have developed a new musculoskeletal digital assessment routing tool (DART) that allows users to self-assess and be directed to the right care. DART requires validation in a real-world setting before implementation.

Objective

This pilot study aims to assess the feasibility of a future trial by exploring the key aspects of trial methodology, assessing the procedures, and collecting exploratory data to inform the design of a definitive randomized crossover noninferiority trial to assess DART safety and effectiveness.

Methods

We will collect data from 76 adults with a musculoskeletal condition presenting to general practitioners within a National Health Service (NHS) in England. Participants will complete both a DART assessment and a physiotherapist-led triage, with the order determined by randomization. The primary analysis will involve an absolute agreement intraclass correlation (A,1) estimate with 95% CI between DART and the clinician for assessment outcomes signposting to condition management pathways. Data will be collected to allow the analysis of participant recruitment and retention, randomization, allocation concealment, blinding, data collection process, and bias. In addition, the impact of trial burden and potential barriers to intervention delivery will be considered. The DART user satisfaction will be measured using the system usability scale.

Results

A UK NHS ethics submission was done during June 2021 and is pending approval; recruitment will commence in early 2022, with data collection anticipated to last for 3 months. The results will be reported in a follow-up paper in 2022.

Conclusions

This study will inform the design of a randomized controlled crossover noninferiority study that will provide evidence concerning mobile health DART system clinical signposting in an NHS setting before real-world implementation. Success should produce evidence of a safe, effective system with good usability, potentially facilitating quicker and easier patient access to appropriate care while reducing the burden on primary and secondary care musculoskeletal services. This rigorous approach to mobile health system testing could be used as a guide for other developers of similar applications.

Trial Registration

ClinicalTrials.gov NCT04904029; http://clinicaltrials.gov/ct2/show/NCT04904029

International Registered Report Identifier (IRRID)

PRR1-10.2196/31541

Protocol for a cluster-randomized non-inferiority trial of the effect of direct access to publicly subsidized physiotherapy for adults with musculoskeletal pain

BACKGROUND

In the Danish healthcare system, direct access to physiotherapy is an option, but public subsidy for treatment requires referral from a general practitioner. To relieve general practice of unnecessary consultations and provide patients with easier access to relevant treatment, direct access to publicly subsidized physiotherapy has been suggested.

METHODS

Direct access to subsidized physiotherapy will be evaluated in a controlled design and has a duration of one year. Physiotherapy clinics invite eligible patients to participate in the evaluation. Participants complete questionnaires at baseline and six weeks and six months after baseline. Physical health status (ShortForm-12v2) is the primary outcome. In addition, the evaluation will assess the use of services in general practice, physiotherapy, specialists in private practice and hospitals and referrals to diagnostic imaging. A process evaluation will assess the attitude to and implementation of direct access to subsidized physiotherapy through the experiences and attitudes of local general practitioners, secretaries and physiotherapists in participating clinics.

DISCUSSION

This intervention may affect the point of entry to health care services. For the intervention group the physiotherapists assume responsibility in symptom assessment. During recruitment registration of red flags in physiotherapy is closely monitored. The results of the study may be used to assess if direct access to subsidized physiotherapy is a way to relieve the workload in general practice while maintaining or improving patient level outcomes.

TRIAL REGISTRATION

The project was reported to The Committee on Health Research Ethics of the Capital Region of Denmark with protocol number J.nr.: H-19074802. The Committee assessed the project as not registrable and therefore can be implemented without further permission. This trial has been registered at the Danish Data Protection Agency (J.nr.: P-2019-672). The trial has been registered at ClinicalTrials.gov (identifiers: NCT04900480).

Evaluation of the First Contact Physiotherapy (FCP) model of primary care: patient characteristics and outcomes

OBJECTIVE

First Contact Physiotherapy (FCP) is a primary care model where expert musculoskeletal (MSK) physiotherapists undertake the first patient consultation, to enhance MSK-patient care and free-up GP capacity. The authors report the quantitative findings from the FCP National Evaluation (Phase 3) which evaluated the FCP model against success criteria.

DESIGN AND SETTING

A mixed-methods 24-month service evaluation involving 40 FCP sites and 240 FCPs across England.

METHODS

An online platform collected patient-reported experience and outcomes following the FCP consultation and at 1, 2 and 3-months follow-up. These included the Keele STarT MSK Tool, pain intensity (0-10 NRS scale), Musculoskeletal Health Questionnaire (MSK-HQ, range 0-56), and Friends-and-Family Test.

RESULTS

Over 13 months, 2825 patients were invited by email and 24% (n=680) completed their initial questionnaire. Their mean age was 56.2 (SD 14.9), 61% were female, ethnicity was 97% white, mean pain intensity was 6.1 (SD 2.13) and mean MSK-HQ score was 33.8 (SD 9.5). At 3-months follow-up (n=370) there was a 2.8 (CI 2.5 to 3.1) mean pain intensity reduction from baseline, a mean 7.1 (6.0 to 8.2) score improvement in MSK-HQ and 64% reporting overall improvement (much better/better) since seeing the FCP. One of the six success criteria was not met; 29% of those in employment reported receiving specific work advice from the FCP (target ≥75%).

CONCLUSION

Ahead of the planned scale-up of the FCP primary care model across the UK, this evaluation provides useful data on patients who access this service, their short-term clinical outcomes and whether key success criteria are being met.

Primary care physiotherapists ability to make correct management decisions - is there room for improvement? A mixed method study

Background

With increasing interest in direct access to physiotherapy, it is important to consider the physiotherapists (PTs) ability to make correct management decisions, because identification of differential diagnostic pathologies and timely referral for specialist care is vital for patient safety.

The aims of the study were to investigate PTs ability to make correct management decisions in patients presenting with musculoskeletal conditions and to identify explanatory factors associated with this ability. Furthermore, we wanted to explore the PTs views on the identified factors.

Methods

The study was a mixed methods study with an explanatory sequential design consisting of a questionnaire survey and semi-structured interviews. The questionnaire comprised 12 clinical vignettes describing patient scenarios for musculoskeletal conditions, non-critical medical conditions and critical medical conditions. Based on this, the PTs indicated whether the patient should be managed by the PT or were in need of medical referral. Associations between correct decisions and explanatory variables was analyzed by mixed- effects logistic regression. Interviews were performed with nine PTs to explore their reactions to the results. A directed content analysis was performed.

Results

A total of 195 PTs participated in the questionnaire survey and 9 PTs were interviewed. Overall, PTs were more likely to make correct management decisions in the musculoskeletal conditions category, whereas wrong decisions were more often chosen for underlying medical conditions categories. Positive associations between correct management decision in the critical medical category were found for experience: odds ratio (OR) 2.73 (1.33;5.57) and passed quality audit OR 2.90 (1.50;5.58). In the interviews, PTs expressed concerns about the differential diagnostic abilities. They all noted, that experience is immensely important in the clinical reasoning process because the ability to recognise diagnostic patterns evolves over time. Furthermore, the quality audit seems to address and systematize the clinical reasoning process and workflow within the clinics.

Conclusion

The lack of ability to make correct management decision in critical medical categories and the uncertainties expressed by PT’s should raise concern, as direct access to physiotherapy is already well-established and the results indicate that patient safety could be at risk. The findings that experience and passed quality audit was associated with correct management decisions highlights the need for ongoing awareness and education into differential diagnostics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01546-1.

Clinical Guidance to Optimize Work Participation After Injury or Illness: The Role of Physical Therapists

Work rehabilitation refers to the process of assisting workers to remain at work or return to work (RTW) in a safe and productive manner, while limiting the negative impact of restricted work, unemployment, and work disability. The primary purpose of this clinical practice guideline (CPG) is to systematically review available scientific evidence and provide a set of evidence-based recommendations for effective physical therapy evaluation, treatment, and management of individuals experiencing limitations in the ability to participate in work following injury or illness. J Orthop Sports Phys Ther 2021;51(8):CPG1-CPG102. doi:10.2519/jospt.2021.0303.

Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care

OBJECTIVES

The largest proportion of general practitioner (GP) magnetic resonance imaging (MRI) is musculoskeletal (MSK), with consistent annual growth. With limited supporting evidence and potential harms from early imaging overuse, we evaluated practice to improve pathways and patient safety.

METHODS

Cohort evaluation of routinely collected diagnostic and general practice data across a UK metropolitan primary care population. We reviewed patient characteristics, results and healthcare utilisation.

RESULTS

Of 306 MSK-MRIs requested by 107 clinicians across 29 practices, only 4.9% (95% CI ±2.4%) appeared clearly indicated and only 16.0% (95% CI ±4.1%) received appropriate prior therapy. 37.0% (95% CI ±5.5%) documented patient imaging request. Most had chronic symptoms and half had psychosocial flags. Mental health was addressed in only 11.8% (95% CI ±6.3%) of chronic sufferers with psychiatric illness, suggesting a solely pathoanatomical approach to MSK care. Only 7.8% (95% CI ±3.0%) of all patients were appropriately managed without additional referral. 1.3% (95% CI ±1.3%) of scans revealed diagnoses leading to change in treatment (therapeutic yield). Most imaged patients received pathoanatomical explanations to their symptoms, often based on expected age or activity-related changes. Only 16.7% (95% CI ±4.2%) of results appeared correctly interpreted by GPs, with spurious overperception of surgical targets in 65.4% (95% CI ±5.3%) who suffered 'low-value' (ineffective, harmful or wasteful) post-MRI referral cascades due to misdiagnosis and overdiagnosis. Typically, 20%-30% of GP specialist referrals convert to a procedure, whereas MRI-triggered referrals showed near-zero conversion rate. Imaged patients experienced considerable delay to appropriate care. Cascade costs exceeded direct-MRI costs and GP-MSK-MRI potentially more than doubles expenditure compared with physiotherapist-led assessment services, for little-to-no added therapeutic yield, unjustifiable by cost-consequence or cost-utility analysis.

CONCLUSION

Unfettered GP-MSK-MRI use has reached unaccceptable indication creep and disutility. Considerable avoidable harm occurs through ubiquitous misinterpretation and salient low-value referral cascades for two-thirds of imaged patients, for almost no change in treatment. Any marginally earlier procedural intervention for a tiny fraction of patients is eclipsed by negative consequences for the vast majority. Only 1-2 patients need to be scanned for one to suffer mismanagement. Direct-access imaging is neither clinically, nor cost-effective and deimplementation could be considered in this setting. GP-MSK-MRI fuels unnecessary healthcare utilisation, generating nocebic patient beliefs and expectations, whilst appropriate care is delayed and a high burden of psychosocial barriers to recovery appear neglected.

Radiographer advanced and consultant practice and community diagnostic hubs - a vision for the future

OBJECTIVES

This article combines a brief narrative review of the Richards Report with an overview of current radiographer advanced and consultant clinical practice (ACCP) to provide suggestions for future ACCP within radiography.

KEY FINDINGS

The 'Diagnostics: Recovery and Renewal' report by Professor Sir Mike Richards, published in 2020, has identified a need for improvements to be made to diagnostic services. His recommendations include the introduction of Community Diagnostic Hubs (CDHs) that would provide quicker and easier access to diagnostic tests for patients⁽¹⁾ A narrative review around the concept of Advanced and Consultant Clinical Practice (ACCP) for radiographers demonstrates the capability of the radiographers to expand their role. The article concludes with a vision of how CDHs could potentially provide multiple career pathways for radiographers working at this level of practice.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

It is acknowledged that some of these concepts are a combination of visionary and aspirational in outlook rather than being entirely based on current practice. The intention of this article, and the implications for practice, are to support on-going discussions to enable radiography, as a profession, to seek ways and opportunities to do things differently whilst ensuring that the patient remains at the centre of the services delivered.

Usability Testing of a Digital Assessment Routing Tool: Protocol for an Iterative Convergent Mixed Methods Study

BACKGROUND

Musculoskeletal conditions account for 16% of global disability, resulting in a negative effect on millions of patients and an increasing burden on health care utilization. Digital technologies that improve health care outcomes and efficiency are considered a priority; however, innovations are often inadequately developed and poorly adopted. Further, they are rarely tested with sufficient rigor in clinical trials-the gold standard for clinical proof of efficacy. We have developed a new musculoskeletal Digital Assessment Routing Tool (DART) that allows users to self-assess and be directed to the right care. DART requires usability testing in preparation for clinical trials.

OBJECTIVE

This study will use the iterative convergent mixed methods design to assess and mitigate all serious usability issues to optimize user experience and adoption. Using this methodology, we will provide justifiable confidence to progress to full-scale randomized controlled trials when DART is integrated into clinical management pathways. This study protocol will provide a blueprint for future usability studies of mobile health solutions.

METHODS

We will collect qualitative and quantitative data from 20-30 participants aged 18 years and older for 4 months. The exact number of participants recruited will be dependent on the number of iterative cycles required to reach the study end points. Building on previous internal testing and stakeholder involvement, quantitative data collection is defined by the constructs within the ISO 9241-210-2019 standard and the system usability scale, providing a usability score for DART. Guided by the participant responses to quantitative questioning, the researcher will focus the qualitative data collection on specific usability problems. These will then be graded to provide the rationale for further DART system improvements throughout the iterative cycles.

RESULTS

This study received approval from the Queen Mary University of London Ethics of Research Committee (QMREC2018/48/048) on June 4, 2020. At manuscript submission, study recruitment was on-going, with data collection to be completed and results published in 2021.

CONCLUSIONS

This study will provide evidence concerning mobile health DART system usability and acceptance determining system improvements required to support user adoption and minimize suboptimal system usability as a potential confounder within subsequent noninferiority clinical trials. Success should produce a safe effective system with excellent usability, facilitating quicker and easier patient access to appropriate care while reducing the burden on primary and secondary care musculoskeletal services. This deliberately rigorous approach to mobile health innovation could be used as a guide for other developers of similar apps.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/27205.

Can Haglund's Syndrome Be Misdiagnosed as Low Back Pain? Findings from a Case Report in Physical Therapy Direct Access

Background: Haglund’s syndrome (HS) is a painful condition that is caused by an exostosis of the posterior superior part of the calcaneus coupled with Achilles tendinopathy and retrocalcaneal bursitis. Both for the proper musculoskeletal assessment and for the differential diagnosis process of possible concurrent diseases deriving from other anatomical areas, the diagnosis of HS is still a challenge. Case Presentation: A 41-year-old male amateur runner was diagnosed and treated for low back pain and referred leg pain by his general practitioner. Due to ineffective results, he self-presented to a physical therapist (PT) with intense right heel pain, radiating up to the leg and to the lumbopelvic region. Results: The PT’s examination and interview relating to the sports activities led to the correct diagnosis and a proper orthopedic referral. At the one-year follow-up, the patient reported regular pain-free marathon running. Discussion: This case report highlights the central role of PTs working in direct access environments as primary care healthcare professionals for the management of musculoskeletal diseases, and their abilities in identifying patients with suspected pathologic conditions that may need referral for imaging, medical assessment or surgical intervention.

Broadening diversity through creative involvement to identify research priorities

BACKGROUND

Patient and public involvement (PPI) can help with steering and shaping research prioritisation and execution. However, some groups of people may not be encouraged to take part and their voices may be seldom listened to in the production of research. This is important to consider because they may have poorer healthcare experiences. We tried using art as a vehicle for including individuals not necessarily invited to be part of research priority setting.

METHODS

We contacted existing groups and organisations to reach people not routinely supported to be part of PPI. We targeted individuals: a) with dementia, b) with a mental and physical health condition, c) of South Asian heritage. We ran a workshop with each group at which individuals shared their experiences of healthcare. A young amateur artist also attended, who produced a piece of artwork afterwards that reflected the research priorities raised. We held a Twitter chat to discuss these pieces of art and the processes involved in their generation.

RESULTS

From each workshop, we produced a list of research priorities. These included: a) improving coordination of care for people with dementia, b) information needs and anxiety/guilt around accessing care for people with physical and mental health conditions, c) supporting discussion of women's health issues in South Asian communities. These priorities were reflected in three pieces of art, which can be viewed online. Feedback from those at workshops suggested that the artwork helped them to feel that their voice had been heard and triggered their interest in how research is developed. Those involved in the Twitter chat commented that art was one means through which researchers could connect with a range of groups in a PPI context when preparing and producing a study.

CONCLUSIONS

We found the medium of art to be an effective way of including a range of people in research prioritisation setting. This approach could be useful for future PPI, building on what we have learnt from the project described in this paper.