Current status and correlates of physicians' referral diagnoses for physical therapy

Spinal pain patients seeking care in primary care and referred to physiotherapy: A cross-sectional study on patients characteristics, referral information and physiotherapy care offered by general practitioners and physiotherapists in France

Objectives

To describe spinal pain patients referred by their treating general practitioners to physiotherapy care, examine to which extent physiotherapy interventions proposed by general practitioners and physiotherapists were compliant to evidence based recommendations, and evaluate concordance between providers in terms of diagnosis and contraindications to physiotherapy interventions.

Methods

This study included spinal pain patients recruited from a random sample of sixty French physiotherapists. Physiotherapists were asked to supply patients’ physiotherapy records and characteristics from the general practitioner’s physiotherapy referral for the five new consecutive patients referred to physiotherapy. General practitioner’s physiotherapy referral and physiotherapists’ clinical findings characteristics were analyzed and compared to evidence-based recommendations using Chi-squared tests. Cohen’s kappas were calculated for diagnosis and contraindications to physiotherapy interventions.

Results

Three hundred patients with spinal pain were included from sixty physiotherapists across France. The mean age of the patients was 48.0 ± 7.2 years and 53% were female. The most common spinal pain was low back pain (n = 147). Diagnoses or reason of referral formulated by general practitioners were present for 27% of all patients (n = 82). Compared to general practitioners, physiotherapists recommended significantly more frequently recommended interventions such as education, spinal exercises or manual therapy. General practitioners prescribed significantly more frequently passive physiotherapy approaches such as massage therapy and electrotherapy. The overall proportion of agreement beyond chance for identification of a diagnosis or reason of referral was 41% with a weak concordance (κ = 0.19; 95%CI: 0.08–0.31). The overall proportion of compliant physiotherapists was significantly higher than for general practitioners (76.7% vs 47.0%; p<0.001).

Conclusions

We found that information required for the referral of spinal pain patients to physiotherapy is often incomplete. The majority of general practitioners did not conform to evidence-based recommendations in terms of prescribed specific physiotherapy care; in contrast to a majority of physiotherapists.

Trial registration

ClinicalTrials.gov: NCT04177121

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.

Navigating the Intersection Between Persistent Pain and the Opioid Crisis: Population Health Perspectives for Physical Therapy

The physical therapy profession has recently begun to address its role in preventing and managing opioid use disorder (OUD). This topic calls for discussion of the scope of physical therapist practice, and the profession's role, in the prevention and treatment of complex chronic illnesses, such as OUD. OUD is not just an individual-level problem. Abundant scientific literature indicates OUD is a problem that warrants interventions at the societal level. This upstream orientation is supported in the American Physical Therapy Association's vision statement compelling societal transformation and its mission of building communities. Applying a population health framework to these efforts could provide physical therapists with a useful viewpoint that can inform clinical practice and research, as well as develop new cross-disciplinary partnerships. This Perspective discusses the intersection of OUD and persistent pain using the disease prevention model. Primordial, primary, secondary, and tertiary preventive strategies are defined and discussed. This Perspective then explains the potential contributions of this model to current practices in physical therapy, as well as providing actionable suggestions for physical therapists to help develop and implement upstream interventions that could reduce the impact of OUD in their communities.

The impact of direct access physiotherapy compared to primary care physician led usual care for patients with musculoskeletal disorders: a systematic review of the literature

PURPOSE

To update and appraise the available evidence with respect to the impact of direct access physiotherapy compared to primary care physician-led usual medical care for patients with musculoskeletal disorders in terms of efficacy, health care utilization and processes, health care costs, patient satisfaction, and compliance.

MATERIALS AND METHODS

Systematic searches were conducted in five bibliographic databases up to June 2019. Studies presenting quantitative data of any research related to direct access physiotherapy for patients with musculoskeletal disorders were included. Two independent raters reviewed the studies, conducted the methodological quality assessment and a data extraction regarding patient outcomes, adverse events, health care utilization and processes, patient satisfaction, and health care costs.

RESULTS

Eighteen studies of weak to moderate quality were included. Five studies found no significant differences in pain reduction between usual primary care physician-led medical care and direct access physiotherapy. Four studies reported better clinical outcomes in patients with direct access in terms of function and quality of life. In terms of health care costs, four studies demonstrated that costs were lower with direct access and one study reported similar costs between both types of care.

CONCLUSION

Emerging evidence of weak to moderate quality suggest that direct access physiotherapy could provide better outcomes in terms of disability, quality of life, and healthcare costs compared to primary physician-led medical care for patients with musculoskeletal disorders but not for pain outcomes. These conclusions could be modified when higher quality trials are published.

CLINICAL RELEVANCE

Direct access physiotherapy for patients with musculoskeletal disorders appears as a promising model to improve efficiency of care and reduce health care costs, but more methodologically sound studies are required to formally conclude.

TRIAL REGISTRATION PROSPERO

#CRD42018095604IMPLICATIONS FOR REHABILITATIONEmerging evidence of weak to moderate quality indicates that direct access physiotherapy could provide better outcomes in terms of disability, quality of life and healthcare costs compared to primary physician led usual medical care for musculoskeletal disorders patients.Direct access physiotherapy may lead to increased access to care and a more efficient use of health care resources.Direct access physiotherapy does not appear to improve pain outcomes compared to primary care physician-led usual medical care.

Surgeon-Therapist Communication: Do All Members See Eye-to-Eye?

BACKGROUND

Poor interprofessional collaboration has been shown to negatively affect patient care within many fields of medicine. Growing evidence is suggesting that improved interprofessional collaboration can positively affect patient care. Postoperative rehabilitation of many orthopedic conditions necessitates the combined efforts of surgeons, and therapists. There is a paucity of literature examining collaboration among orthopedic surgeons and therapists regarding postoperative rehabilitation.

OBJECTIVES

The following study examines the perceived quality of communications between orthopedic surgeons and therapists employing an online survey. We hypothesized that collaborative practice patterns result in improved perceptions of communication.

METHODS

Ethics board approval was obtained. Subjects consisted of orthopedic surgeons, licensed physiotherapists and certified athletic therapists. The online survey was distributed through the Canadian Orthopaedic Association (COA), the Canadian Physiotherapy Association (CPA) and the Canadian Athletic Therapists Association (CATA). Data analysis was performed using Stata/IC 12.1 (Stata Corp, College Station, TX, USA). Descriptive statistics were calculated to determine the median responses and ranges. Median responses were compared using the Kruskal-Wallis one-way analysis of variance. Qualitative analysis regarding text responses was performed by three reviewers.

RESULTS

Responses were received from all specialties (COA 164, CPA 524, CATA 163). There were significant differences in the perceived quality of communication by quantitative and qualitative analysis (p < 0.001). Analysis of communication within practice patterns of stand-alone versus collaborative revealed improved perception of communication quality with increased contact. 65.6% of responders that practiced as stand-alone had a negative view of interprofessional communication. 48.4% of responders in a collaborative practice had a positive view of interprofessional communication. Analysis of the preferred form of communication found that orthopedic surgeons felt the most useful referral information was a pre-printed consult sheet (odds ratio [OR] = 1.56, p < 0.001), whereas therapists were more likely to rank consult notes (OR = 1.27, p < 0.042) and operative reports (OR = 1.20, p < 0.092) as a more useful form of communication.

CONCLUSIONS

Collaborative practice shows improved perceptions of communication between specialties. Orthopedic surgeons perceive a higher quality of communication than therapists. Therapists and orthopedic surgeons also do not agree on the information that should be relayed between the specialties regarding postoperative rehabilitation.

Organizational boundaries of medical practice: the case of physician ownership of ancillary services

Physician ownership of in-office ancillary services (IOASs) has come under increasing scrutiny. Advocates of argue that IOASs allow physicians to supervise the quality and coordination of care. Critics have argued that IOASs create financial incentives for physicians to increase ancillary service volume. In this paper we develop a conceptual framework to evaluate the tradeoffs associated with physician ownership of IOASs. There is some evidence supporting the existence of scope and transaction economies in IOASs. Improvement in flow and continuity of care are likely to generate scope economies and improvements in quality monitoring and reductions in consumer transaction costs are likely to generate transaction economies. Other factors include the capture of upstream and downstream profits, but these incentives are likely to be small compared to scope and transaction economies. Policy debates on the merits of IOASs should include an explicit assessment of these tradeoffs.This research was supported in part by funding from the American Association of Orthopaedic Surgeons (AAOS).

Direct consumer access to physical therapy in Michigan: challenges to policy adoption

Background. Michigan is 1 of only 4 states that require a physician referral or prescription before a consumer can receive treatment from a physical therapist.Objective. The purpose of the present analysis was to examine why the most recent attempts to pass direct access legislation in Michigan failed.Methods. The Policy Analysis Triangle approach, which considers the relevant actors, processes, and context in which a policy must be considered, was used to analyze legislative efforts to attain direct access in Michigan during the 2001–2002, 2003–2004, and 2005–2006 legislative sessions. Data sources included Michigan House and Senate legislative analyses, literature review, stakeholder position statements, political action committee contributions, and expert opinion.Results. Three successive direct access legislative attempts failed despite an increasing body of evidence supporting direct access and an increasing number of states allowing direct access. Proponents represented a relatively small number of individuals with limited political influence. Opponents represented a larger number of individuals who were able to exert greater political influence through large political action committee contributions and through physician legislators in positions of power who had influence over the bills' dispositions.Conclusions. Several prominent contextual and process-related barriers to policy adoption must be overcome in future attempts at direct access based on the findings from this analysis: (1) a limited constituency supporting direct access with regard to number of individuals and their political influence, (2) a perception that only the physician can independently diagnose and treat patient problems, and (3) legislators in positions of power who oppose a bill [corrected].

Case Report: Schizophrenia Discovered during the Patient Interview in a Man with Shoulder Pain Referred for Physical Therapy

PURPOSE

The purpose of this case report is to demonstrate the importance of a thorough patient interview. The case involves a man referred for physical therapy for a musculoskeletal dysfunction; during the patient interview, a psychiatric disorder was recognized that was later identified as schizophrenia. A secondary purpose is to educate physical therapists on the recognizable signs and symptoms of schizophrenia.Client description: A 19-year-old male patient with chronic shoulder, elbow, and wrist pain was referred for physical therapy. During the interview, the patient reported that he was receiving signals from an electronic device implanted in his body.Measures and outcome: The physical therapist's initial assessment identified a disorder requiring medical referral. Further management of the patient's musculoskeletal dysfunction was not appropriate at this time.

INTERVENTION

The patient was referred for further medical investigation, as he was demonstrating signs suggestive of a psychiatric disorder. The patient was diagnosed with schizophrenia by a psychiatrist and was prescribed Risperdal.

IMPLICATIONS

This case study reinforces the importance of a thorough patient interview by physical therapists to rule out non-musculoskeletal disorders. Patients seeking neuromusculoskeletal assessment and treatment may have undiagnosed primary or secondary psychiatric disorders that require recognition by physical therapists and possible medical referral.

Orthopedic surgeons and physical therapists differ in assessment of need for physical therapy after traumatic lower-extremity injury

BACKGROUND

Lower-extremity injuries constitute the leading cause of trauma hospitalizations among people under the age of 65 years. Rehabilitation has the potential to favorably influence the outcomes associated with traumatic lower-extremity injuries.

OBJECTIVES

The objectives of this study were to explore variability in surgeon and physical therapist assessments of the need for physical therapy in patients with traumatic lower-extremity injuries and to determine the factors associated with assessments of need.

DESIGN

This study was a retrospective cohort investigation.

METHODS

Participants were 395 patients treated by reconstruction in the Lower-Extremity Assessment Project. They were evaluated at 8 level I trauma centers at 3, 6, and 12 months after hospitalization by an orthopedic surgeon and a physical therapist to determine the need for physical therapy. Analyses included multilevel logistic regression.

RESULTS

Chi-square analyses showed that surgeon and therapist assessments of need differed statistically across trauma centers. Surgeons were more likely to assess a need for therapy at 3 months when participants had low work self-efficacy, impaired knee flexion range of motion (ROM), and weight-bearing limitations and at 6 and 12 months when participants had impaired knee flexion ROM and weight-bearing and balance limitations. Therapists were more likely to assess a need for therapy at 3 months when participants had moderate to severe pain and at 6 and 12 months when participants had low work self-efficacy, pain, impaired knee flexion ROM, and balance limitations.

CONCLUSIONS

The results revealed variability in assessments of the need for physical therapy at the provider and trauma center levels. Differences in provider assessments highlight the need for communication and further investigation into the outcomes and timing of physical therapy for the treatment of traumatic lower-extremity injuries.

Physical therapist management of acute and chronic low back pain using the World Health Organization's International Classification of Functioning, Disability and Health

BACKGROUND AND PURPOSE

The World Health Organization's Classification of Functioning, Disability and Health (WHO-ICF) model was developed to describe, classify, and measure function in health care practice and research. Recently, this model has been promoted as a successor to the Nagi model by some authors in the physical therapy literature. However, conceptual work in demonstrating use of the WHO-ICF model in physical therapist management of individual patients remains sparse. The purpose of this case report series is to demonstrate the application of the WHO-ICF model in clinical reasoning and physical therapist management of acute and chronic low back pain.

CASE DESCRIPTION

Two patients, 1 with acute low back pain and 1 with chronic low back pain, were treated pragmatically using the WHO-ICF model and other applicable models of clinical reasoning.

INTERVENTION

Manual therapy, exercise, and education interventions were directed toward relevant body structure and function impairments, activity limitations, and contextual factors based on their hypothesized contribution to functioning and disability.

OUTCOME

Both patients demonstrated clinically significant improvements in measures of pain, disability, and psychosocial factors after 3 weeks and 10 weeks of intervention, respectively.

DISCUSSION

The WHO-ICF model appears to provide an effective framework for physical therapists to better understand each person's experience with his or her disablement and assists in prioritizing treatment selection. The explicit acknowledgment of personal and environmental factors aids in addressing potential barriers. The WHO-ICF model integrates well with other models of practice such as Sackett's principles of evidence-based practice, the rehabilitation cycle, and Edwards and colleagues' clinical reasoning model. Future research should examine outcomes associated with the use of the WHO-ICF model using adequately designed clinical trials.

Is a prescriptive or an open referral related to physical therapy outcomes in patients with lumbar spine-related problems?

STUDY DESIGN

Retrospective review of medical records.

OBJECTIVES

To describe characteristics of patients with lumbar spine dysfunction, and to compare functional outcome and number of visits to physical therapy according to type of physician referral.

BACKGROUND

The type of referral, characterized as prescriptive or open, has been associated with the perceived amount of supervision that is required for the provision of physical therapy care. The rationale for prescriptive referrals is not consistent with autonomous physical therapy practice, and may be deemed unnecessary if such referrals are associated with equivalent outcomes.

METHODS AND MEASURES

Medical records of patients treated within a rehabilitation provider network between October 2002 and December 2003 were reviewed retrospectively for administrative and clinical variables. Subjects were selected if they completed the Roland Morris Questionnaire (RMQ) on admission and discharge from physical therapy care. Associations between referral type, discharge RMQ scores, and number of visits were determined using independent t tests and were further examined using stepwise multiple regression analysis.

RESULTS

Ninety-six records met inclusion criteria, of which 54 (56.2%) had open referrals and 41 (43.8%) had prescriptive referrals. Type of referral was not associated with number of visits in bivariate or in multivariate analysis. Prescriptive referrals were associated with higher discharge RMQ scores, representing greater disability, in bivariate analysis (t test, P = .03); however, this association was attenuated in multivariate analyses after adjustment for physician status as primary care practitioner or specialist.

CONCLUSION

Prescriptive referrals were not associated with enhanced outcomes of physical therapy care.