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

Introduction

The demand for musculoskeletal (MSK) care is rising, and is a growing challenge for general practice. Direct access to physiotherapy and other healthcare services may offer appropriate care for MSK pain patients but there is uncertainty regarding the effectiveness or efficiency of this approach in practice. This study aimed to review the evidence regarding characteristics, outcomes, barriers and facilitators of MSK triage and direct access services.

Methods

A comprehensive search of eight databases (including MEDLINE, EMBASE, and Cochrane library) up to February 2018 was conducted to identify studies (trials, cohorts and qualitative evidence) on direct access services for MSK in primary care settings. Using predefined inclusion and exclusion criteria, titles, abstracts, and subsequent full texts were independently screened by reviewers. Methodological quality of eligible studies was assessed using the mixed methods appraisal tool, and extracted data regarding study characteristics and results were independently reviewed. A narrative synthesis and grading of evidence was undertaken. Approaches to MSK triage and direct access were profiled along with their respective outcomes of care relating to patient-oriented and socioeconomic outcomes. Barriers and facilitators of each model of direct access services were also highlighted.

Results

9010 unique citations were screened, of which 26 studies were eligible. Three approaches (open access, combination and service pathway models) to MSK triage and direct access shared similar goals but were heterogeneous in application. MSK patients using direct access showed largely similar characteristics (age, sex and duration of symptoms) compared to GP-led care, although they were often younger, slightly more educated and with better socio-economic status than patients seen through GP-led care. Although many studies showed limitations in design or methods, outcomes of care (patient oriented outcomes of pain, and disability) did not show large differences between direct access and GP-led care. In most studies direct access patients were reported to have lower healthcare utilisation (fewer physiotherapy or GP consultations, analgesics or muscle relaxants prescriptions, or imaging procedures) and less time off work compared to GP-led care.

Discussion

This study provides insight into the current state of evidence regarding MSK triage and direct access services and highlights potential implications for future research, healthcare services planning, resource utilisation and organising care for MSK patients in primary care. There is consistent, although limited, evidence to suggest that MSK triage and direct access services lead to comparable clinical outcomes with lower healthcare consumption, and can help to manage GP workload. However, due to the paucity of strong empirical data from methodologically robust studies, a scale up and widespread roll out of direct access services cannot as yet be assumed to result in long term health and socio-economic gains. PROSPERO-ID: CRD42018085978.

Patients With Greater Stroke Severity and Premorbid Disability Are Less Likely to Receive Therapist Consultations and Intervention During Acute Care Hospitalization

BACKGROUND

A substantial number of patients with stroke never receive acute care therapy services, despite the fact that therapy after stroke reduces the odds of death and disability and improves patients' functioning.

OBJECTIVE

The aim of this study was to estimate the proportion of and factors associated with receipt of therapist consultations and interventions during acute care hospitalization following ischemic and hemorrhagic stroke.

DESIGN

This was a single-center longitudinal observational study.

METHODS

Adults with a diagnosis of ischemic or hemorrhagic stroke (N = 1366) were enrolled during their hospitalization in an acute stroke center in a large metropolitan area. The main outcomes were receipt of therapist consultations, interventions, or both.

RESULTS

Participants with acute hemorrhagic stroke (intracerebral: odds ratio [OR] = 0.34 [95% CI = 0.19-0.60]; subarachnoid: OR = 0.52 [95% CI = 0.28-0.99]) and with greater stroke severity by National Institutes of Health Stroke Scale (NIHSS) score (NIHSS score of > 15: OR = 0.34 [95% CI = 0.23-0.51]) were less likely to receive therapist consultations. Participants with moderate stroke severity (NIHSS score of 6-15: OR = 1.43 [95% CI = 1.01-2.33]) were more likely to receive therapy interventions. Those who were able to ambulate before admission were more than 5 times as likely to receive therapy interventions (OR = 5.08 [95% CI = 1.91-13.52]). Also, participants with longer lengths of stay (ie, more intensive care unit and non-intensive care unit days) were more likely to receive therapist consultations and interventions. Tests or procedures were the most common reasons for unsuccessful attempts to complete therapist consultations.

LIMITATIONS

Lack of operational and qualitative data prohibited detailed explorations of barriers to delivery of therapist consultations and interventions.

CONCLUSIONS

Approximately 1 in 4 participants with acute stroke received neither a consultation nor an intervention. Efforts to improve the delivery of acute care therapy services are needed to optimize care for these people.

Epilepsy: knowledge and attitudes of physiotherapists, occupational therapists, and speech therapists

Physiotherapists, occupational therapists, and speech therapists play a key role in the treatment of children with epilepsy. We performed a survey of therapists' knowledge of and attitudes towards epilepsy in two regions of Germany, the city of Leipzig and the rural district of Zwickau. Therapists of 29/68 (43%) outpatient practices and 4/9 (44%) hospitals took part. In total, 195 therapists participated: 63 (32%) physiotherapists, 74 (38%) occupational therapists, and 58 (30%) speech therapist. In 65%, epilepsy was subject of vocational training. Of all therapists, 8% claimed they had not treated epilepsy patients so far. During professional life, 43% had witnessed a seizure. Of all therapists, 44% correctly assumed a seizure could result in death. During a seizure, 42% would perform the obsolete measure of placing something solid in the patient's mouth, and 41% would administer a prescribed rescue medication. More information on epilepsy was requested by 92%.Conclusion: Most therapists treat patients with epilepsy, and almost half have already witnessed a seizure. Often, however, epilepsy is not subject of vocational training. The risk of a fatal outcome of a seizure is underestimated, and many therapists would perform obsolete measures. Knowledge of seizure management should be transmitted to therapists especially during vocational training.

Impact of funding allocation on physical therapist research productivity and DPT student graduates: an analysis using panel data

Financial support for institutional research is relatively stagnant, and thus institutions are likely to seek tuition revenue to offset the costs of research and teaching. It is likely that this has led to increases in tuition driven activities, and thus has limited research activities of academic physical therapy (PT) programs in particular. However, the relationships between sources of program revenue, the number of graduates from PT programs, and the scholarly production of PT faculty have not been studied. The purpose of this paper is to study the effects of types of funding-including research grants and tuition-on the number of physical therapy graduates from each program and the research productivity of physical therapy faculty. Data from 2008 to 2016 were utilized to perform a fixed-effects panel analysis. Panel models created predictions for the number of graduates and the number of peer-reviewed publications for programs from grant funding, annual tuition, and number of funded faculty members. In any given program, a 1% increase in annual tuition is associated with 24% more graduates per year, but a single percentage point increase in the mix of NIH grant funding over other funding types is associated with 8% fewer graduates, all else equal. For every 1% increase in annual tuition, a program can expect to have 41% fewer publications per year. Those institutions with higher numbers of graduates tended to have higher numbers of publications. Higher annual program tuition appears to be associated with both higher numbers of physical therapy graduates and lower levels of publications. Different funding sources have variable effects on degree production and scholarly productivity. Data are self-reported by programs on the Annual Accreditation Report, and cause and effect cannot be established through observational design.

Rehabilitation needs approached by health professionals at a rheumatism hospital

OBJECTIVE

The aim of the present study was to examine the characteristics of patients referred to occupational therapists (OTs), physiotherapists (PTs) and social workers (SWs) at a rehabilitation unit in a hospital specializing in rheumatology, and the rehabilitation needs that clinicians and patients agreed should be addressed in the encounters with the particular health professional groups.

METHODS

Consecutive hospitalized patients at a rheumatism hospital were recruited by the health professionals. Questions about patient characteristics and rehabilitation needs were posed. Free-text responses to questions about rehabilitation needs were coded by the International Classification of Functioning, Disability, and Health (ICF).

RESULTS

The patients varied considerably in age distribution, disease duration, disability level and diagnoses, and several patients had comorbidities. The rehabilitation needs classified under the component Body Function fell into the chapters: Sensory Functions and Pain (PTs), Functions of Cardiovascular System (PTs), Neuromusculoskeletal and Movement-Related Functions (OTs, PTs); under the Activity and Participation component, these were: General Tasks and Demands (OTs), Mobility (OTs), Self-Care (PTs), Interpersonal Interactions and Relationships (SWs) and Major Life Stress (SWs); and under the Environmental Factors component these were: Products and Technology (OTs) and Services, Systems and Politics (SWs).

CONCLUSIONS

The patients were fairly heterogeneous. The needs identified in the encounters with the different professional groups fell into all three components of the ICF, and there was only a minor overlap between the health professionals at the chapter level of the ICF.

Utilization of Manipulative Treatment for Spine and Shoulder Conditions Between Different Medical Providers in a Large Military Hospital

OBJECTIVE

To describe the use of manipulative treatment for shoulder and spine conditions among various provider types.

DESIGN

Retrospective observational cohort.

SETTING

Single military hospital.

PARTICIPANTS

Consecutive sample of patients (N=7566) seeking care for an initial spine or shoulder condition from January 1 to December 31, 2009.

INTERVENTIONS

Manipulative treatment (eg, manual therapy, spinal and joint manipulation).

MAIN OUTCOME MEASURE

Manipulation treatment was identified with procedure billing codes in the medical records. Spine and shoulder conditions were identified by using the International Classification of Diseases, 9th Revision codes. All data were abstracted from the Department of Defense Military Health System Management and Analysis Tool.

RESULTS

Of 7566 total patients seeking care, 2014 (26.6%) received manipulative treatment at least once, and 1883 of those received this treatment in a military facility (24.7%). Manipulative treatment was used most often for thoracic conditions and least often for shoulder conditions (50.8% and 24.2% of all patients). There was a total of 6706 unique medical visits with a manipulative treatment procedure (average of 3.3 manipulative treatment procedure visits per patient).

CONCLUSIONS

Manipulative treatment utilization rates for shoulder and spine conditions ranged from 26.6% to 50.2%. Chiropractors used manipulation the most and physical therapists the least.

Accuracy of Athletic Trainer and Physician Diagnoses in Sports Medicine

It is standard practice in high school athletic programs for certified athletic trainers to evaluate and treat injured student athletes. In some cases, a trainer refers an athlete to a physician for definitive medical management. This study was conducted to determine the rate of agreement between athletic trainers and physicians regarding assessment of injuries in student athletes. All high school athletes who were injured between 2010 and 2012 at 5 regional high schools were included in a research database. All patients who were referred for physician evaluation and treatment were identified and included in this analysis. A total of 286 incidents met the inclusion criteria. A total of 263 (92%) of the athletic trainer assessments and physician diagnoses were in agreement. In the 23 cases of disagreement, fractures and sprains were the most common injuries. Kappa analysis showed the highest interrater agreement in injuries classified as dislocations and concussions and the lowest interrater agreement in meniscal/labral injuries and fractures. In the absence of a confirmed diagnosis, agreement among health care providers can be used to infer accuracy. According to this principle, as agreement between athletic trainers and physicians improves, there is a greater likelihood of arriving at the correct assessment and treatment plan. Athletic trainers are highly skilled professionals who are well trained in the evaluation of athletic injuries. The current study showed that additional training in identifying fractures may be beneficial to athletic trainers and the athletes they treat. [Orthopedics. 2016; 39(5):e944-e949.].

Towards understanding the availability of physiotherapy services in rural Australia

INTRODUCTION

A recent exploration of factors affecting rural physiotherapy service provision revealed considerable variation in services available between communities of the study. Multiple factors combined to influence local service provision, including macro level policy and funding decisions, service priorities and fiscal constraints of regional health services and capacity and capabilities at the physiotherapy service level. The aim of this article is to describe the variation in local service provision, the factors influencing service provision and the impact on availability of physiotherapy services.

METHODS

A priority-sequence mixed methods design structured the collection and integration of qualitative and quantitative data. The investigation area, a large part of one Australian state, was selected for the number of physiotherapy services and feasibility of conducting site visits. Stratified purposive sampling permitted exploration of rural physiotherapy with subgroups of interest, including physiotherapists, their colleagues, managers, and other key decision makers. Participant recruitment commenced with public sector physiotherapists and progressed to include private practitioners, team colleagues and managers. Surveys were mailed to key physiotherapy contacts in each public sector service in the area for distribution to physiotherapists, their colleagues and managers within their facility. Private physiotherapist principals working in the same communities were invited by the researcher to complete the physiotherapy survey. The survey collected demographic data, rural experience, work setting and number of colleagues, services provided, perspectives on factors influencing service provision and decisions about service provision. Semi-structured interviews were conducted with consenting physiotherapists and other key decision makers identified by local physiotherapists. Quantitative survey data were recorded in spreadsheets and analysed using descriptive statistics. Interviews were recorded and transcribed verbatim, with transcripts provided to participants for review. Open-ended survey questions and interview transcripts were analysed thematically.

RESULTS

Surveys were received from 11/25 (44%) of facilities in the investigation area, with a response rate of 29.4% (16/54) from public sector physiotherapists. A further 18 surveys were received: five from principals of private physiotherapy practices and 13 from colleagues and managers. Nineteen interviews were conducted: with 14 physiotherapists (nine public, five private), four other decision makers and one colleague. Three decision makers declined an interview. The variation in physiotherapy service availability between the 11 communities of this study prompted the researchers to consider how such variation could be reflected. The influential factors that emerged from participant comments included rurality and population, size and funding model of public hospitals, the number of public sector physiotherapists and private practices, and the availability of specialised paediatric and rehabilitation services. The factors described by participants were used to develop a conceptual framework or index of rural physiotherapy availability.

CONCLUSIONS

It is important to make explicit the link between workforce maldistribution, the resultant rural workforce shortages and the implications for local service availability. This study sought to do so by investigating physiotherapy service provision within the rural communities of the investigation area. In doing so, varying levels of availability emerged within local communities. A conceptual framework combining key influencing factors is offered as a way to reflect the availability of physiotherapy services.

How work impairments and reduced work ability are associated with health care use in workers with musculoskeletal disorders, cardiovascular disorders or mental disorders

PURPOSE

The aim of this study was to explore how work impairments and work ability are associated with health care use by workers with musculoskeletal disorders (MSD), cardiovascular disorders (CVD), or mental disorders (MD).

METHODS

In this cross-sectional study, subjects with MSD (n = 2,074), CVD (n = 714), and MD (n = 443) were selected among health care workers in 12 Dutch organizations. Using an online questionnaire, data were collected on individual characteristics, health behaviors, work impairments, work ability, and consultation of a general practitioner (GP), physiotherapist, specialist, or psychologist in the past year. Univariate and multivariate logistic regression analyses were performed to explore the associations of work impairments and work ability with health care use.

RESULTS

Lower work ability was associated with a higher likelihood of consulting any health care provider among workers with common disorders (OR 1.05-1.45). Among workers with MSD work impairments increased the likelihood of consulting a GP (OR 1.55), specialist (OR 2.05), and physical therapist (OR 1.98). Among workers with CVD work impairments increased the likelihood of consulting a specialist (OR 1.94) and physical therapist (OR 2.73). Among workers with MD work impairments increased the likelihood of consulting a specialist (OR 1.79) and psychologist (OR 1.82).

CONCLUSION

Work impairments and reduced work ability were associated with health care use among workers with MSD, CVD, or MD. These findings suggest that addressing work-related problems in workers with common disorders may contribute in reducing health care needs.

Intra- and inter-observer reliability of the Trunk Impairment Scale for children with cerebral palsy

Standardized scales to evaluate qualities of trunk movements in children with dysfunction are sparse. An examination of the reliability of scales that may be useful in the clinic is important. The aim of this study was to examine the reliability of the Trunk Impairment Scale (TIS) for children with cerebral palsy (CP). Standardized scales are useful for treatment planning and evaluation. This was an intra- and inter-observer reliability study. Video recordings of 25 children, 20 with CP and 5 with no motor impairment, in the age group 5-12 years of age, were analyzed by three observers on two occasions. Intraclass correlation coefficients (ICC [1,1] and [3,1]) with 95% confidence intervals, standard error of measurement, kappa values and percent agreement, and Bland-Altman Plots were calculated. The relative reliability (intra- and inter-observer reliability) was very high for the total score and subscale score of the TIS: ICC [1,1] and [3,1] varied between .94 and 1.00. Kappa values for the items ranged from .45 to 1.00. The absolute reliability values for the parameters are reported. The Bland-Altman analysis showed consistency of scores. This study indicates that TIS is a reliable measure of trunk control for children, 5-12 years of age, with CP.

Work-related injuries among physiotherapists in public hospitals: a Southeast Asian picture

OBJECTIVES

A cross-sectional study was conducted to measure the prevalence of work-related injuries among physiotherapists in Malaysia and to explore the influence of factors such as gender, body mass index, years of work experience and clinical placement areas on the occurrence of work-related musculoskeletal disorders.

METHODS

Self-administered questionnaires adapted from the Nordic Musculoskeletal Questionnaire were sent to 105 physiotherapists at three main public hospitals in Kuala Lumpur, Malaysia. The questionnaire had 12 items that covered demographic information, areas of musculoskeletal problems and physiotherapy techniques that could contribute to work-related musculoskeletal disorders. The data obtained were analyzed using the Statistical Package for Social Science version 14 software.

RESULTS

The overall prevalence of work-related injuries during the past 12 months was 71.6%. Female therapists reported a significantly higher prevalence of work-related musculoskeletal disorders than the male therapists (73.0%, p,0.001). Significant differences were observed between the proportion of therapists who had work-related musculoskeletal disorders and those who did not for the group with a body mass index (BMI) .25 (x² = 9.0, p = 0.003) and the group with a BMI of 18-25 (x² = 7.8, p = 0.006). Manual therapy (58.6%) and lifting/transfer tasks (41.3%) were the two physiotherapy techniques that most often contributed to work-related musculoskeletal disorders.

CONCLUSION

Work-related injuries are significantly higher among the physiotherapists in Malaysia compared with many other countries. Female therapists reported a higher incidence of work-related musculoskeletal disorders in this study, and work-related musculoskeletal disorders were more common among therapists working in the pediatric specialty. This study contributes to the understanding of work-related disorders among physiotherapists from a southeast Asian perspective where the profession is in its development stage.

Burnout syndrome in Cypriot physiotherapists: a national survey

BACKGROUND

Burnout in the healthcare workers is formally defined as a state of physical, emotional and mental exhaustion caused by long-term involvement in situations that are emotionally demanding.

METHODS

Using a random stratified sampling method and taking into account geographical location, specialty and type of employment, 172 physiotherapists working both in the private and public sectors completed an anonymous questionnaire that included several aspects related to burnout; the MBI scale, questions related to occupational stress, and questions pertaining to self image.

RESULTS

Almost half (46%) of the 172 participants believed that their job is stressful. Approximately 57% of the physiotherapists who worked in the public sector and 40% of those who worked in the private sector (p = 0.038) reported that their job is stressful. In total, 21.1% of participants met Maslach's criteria for burnout. The point prevalence of burnout was as follows: (1) 13.8% of those who worked in the public sector and 25.5% of those in the private sector (2) 22.2% of males and 20% of females (3) 21.6% who were married, 18% who were single and 33.3% who were separated. Gender was found to be associated with the level of personal accomplishment (chi-squared test; p = 0.049), as 17.8% of men compared with 24.3% of women reported high personal accomplishment. The number of years of working as a physiotherapist correlated negatively (r = -0.229, p = 0.004) with the total depersonalization score. Regression analysis showed that the perception that the job is stressful (p < 0.001) and the low salary (p = 0.016) were significant predictors of high emotional exhaustion scores, while age group (p = 0.027) predicted high scores of depersonalization and the employment sector (p = 0.050) as well as the low salary predicted high personal accomplishment scores.

CONCLUSIONS

Burnout levels in physiotherapists in Cyprus ranged from low to moderate.

Entry-level physiotherapists' strategies to lower occupational injury risk in physiotherapy: A qualitative study

The purpose of this study was to identify entry-level physiotherapists perceptions of workplace injuries in private practice and the strategies they may use to reduce occupational injury risk in physiotherapy. Seventy-nine final year physiotherapy students were presented with a private practice workplace scenario, recent injury statistics, and common job risk factors in physiotherapy and were required to choose between the options of being a salaried employee or contractor and to discuss self-management strategies. This question was part of a substantive written examination that is a compulsory aspect of the final assessment for these students. Students identified nine categories for self-management and reducing injury risk with the majority of students choosing the option of being a contractor in preference to being a salaried employee. Regardless of the preferred employment option, students tended to select self-management strategies that would have a negative impact on income and service delivery and may be reflective of the relative inexperience of these students in private sector workplace settings. Given the high prevalence of work-related musculoskeletal disorders (WRMDs) in the 5 five years postgraduation, the findings from this study highlight the need for educational institutions and employers to address occupational health and risk factors in physiotherapy, which would include education on prevention as well as appropriate self-management strategies within each workplace.

A survey of respiratory and sleep services in New Zealand undertaken by the Thoracic Society of Australia and New Zealand (TSANZ)

AIMS

In 2004, the NZ Branch of the TSANZ published "Standards for Adult Respiratory and Sleep Services" on the Ministry of Health's (MoH) website.1 The aim of this survey was to evaluate each of the 21 District Health Boards' (DHBs) performance against the published standards, concentrating particularly on staffing, infrastructure, clinical support services, implementation of guidelines, quality assurance activity, and basic services (sleep, lung function, and oxygen).

METHODS

Postal questionnaire survey of all DHBs in late 2006.

RESULTS

All 21 DHBs responded. Only 10 of 21 DHBs were complying with the minimum standards of care. Main deficiencies in care related to: inadequate medical staffing rates, lack of quality assurance measures and insufficient laboratory testing (sleep and lung function). The lack of monitoring of such basic activities as outpatient clinic attendances, oxygen and sleep services, and the non implementation of treatment guidelines were of particular concern. Seven-fold variations in prescription of assisted ventilation equipment and oxygen therapy exist across the country.

CONCLUSIONS

When evaluated against minimum standards of care published in 2004, major gaps in service provision exist in New Zealand. Access to services is variable. There is a lack of national leadership and insufficient regional organisation leading to large gaps in service provision of even basic respiratory services. Immediate changes to the current service provision structures are required.

[Burnout in Spanish physiotherapists]

Diverse works on health sciences emphasise the importance of burnout in specific jobs. However, there is a lack of research about the presence of this syndrome in Spanish physiotherapists. The aims of this study were to determine the prevalence of burnout among physiotherapists and the relationship with work-related factors. 462 questionnaires were sent to health-centres. The questionnaire of work-related factors was administered, as well as the Maslach burnout inventory (MBI). 258 responses were received (55.8% response rate) from Murcia and Valencia. Regarding results 10 (4%) physiotherapists showed severe burnout. In relation to work-related factors, significant differences were observed. Although the percentage of physiotherapists with severe burnout was relatively low, it is important take into account that the syndrome requires the combined presence of three dimensions, which implies a very relevant situation of mental deterioration.

Recovery from disablement: what functional abilities do rehabilitation professionals value the most?

OBJECTIVE

To determine whether rehabilitation clinicians representing different therapeutic disciplines would choose to recover from profound disability differently.

DESIGN

Applying recovery preference exploration as a data-collection tool, clinicians imagined recovery from complete disability in each of the 18 activities assessed on the FIM instrument. We hypothesized that recovery-choice pathways would vary among the disciplines because of differences in training and practice focus. We compared each clinician's preference for imagined recovery of the ability to perform each FIM activity relative to the other 17. Item-level preferences were explored by discipline. The mean absolute difference (MAD) in the medians of the 18 FIM recovery preference values between each of the disciplines was used to quantify overall differences.

SETTING

Inpatient rehabilitation unit within a larger tertiary care urban hospital of an academic medical center.

PARTICIPANTS

Ninety-three clinicians actively providing care to patients in an inpatient rehabilitation setting classified into 5 groups anticipated to have similar types of practices: physicians and medical students (physician group), nurses, occupational and recreational therapists (occupational therapy [OT] group), physical therapists (physical therapy [PT] group), and neuropsychologists and social workers (psychology group).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Relative recovery preferences in 18 FIM activities.

RESULTS

The MAD value between the 2 groups with the least similar recovery values (physician and psychology groups) was 1.78 times larger than the MAD value between the 2 groups with the most similar recovery values (PT and OT groups).

CONCLUSIONS

There were subtle differences in recovery choice pathways that may logically relate to differences in the cognitive processes used in clinical decision making among the therapeutic discipline groups.

Interobserver agreement of the Gross Motor Function Classification System in an ambulant population of children with cerebral palsy

Gross Motor Function Classification System (GMFCS) level was reported by three independent assessors in a population of children with cerebral palsy (CP) aged between 4 and 18 years (n=184; 112 males, 72 females; mean age 10y 10mo [SD 3y 7mo]). A software algorithm also provided a computed GMFCS level from a regional CP registry. Participants had clinical diagnoses of unilateral (n=94) and bilateral (n=84) spastic CP, ataxia (n=4), dyskinesia (n=1), and hypotonia (n=1), and could walk independently with or without the use of an aid (GMFCS Levels I-IV). Research physiotherapist (n=184) and parent/guardian data (n=178) were collected in a research environment. Data from the child's community physiotherapist (n=143) were obtained by postal questionnaire. Results, using the kappa statistic with linear weighting (kappa(1w)), showed good agreement between the parent/guardian and research physiotherapist (kappa(1w)=0.75) with more moderate levels of agreement between the clinical physiotherapist and researcher (kappa(1w)=0.64) and the clinical physiotherapist and parent/guardian (kappa(1w)=0.57). Agreement was consistently better for older children (>2y). This study has shown that agreement with parent report increases with therapists'experience of the GMFCS and knowledge of the child at the time of grading. Substantial agreement between a computed GMFCS and an experienced therapist (kappa(1w)=0.74) also demonstrates the potential for extrapolation of GMFCS rating from an existing CP registry, providing the latter has sufficient data on locomotor ability.

[Complementary and alternative medicines taken by cancer patients]

244 cancer patients from 2 public hospitals (one adult, one pediatric) and one private clinic receiving chemotherapy were asked about complementary and alternative medicine (CAM). Nearly 28% used one or several CAM, especially homeopathy (60%), special diets or dietary supplements (44%), mistletoe (40%) and less frequently acupuncture or other treatments. These CAM are started 4 to 5 months after the onset of chemotherapy. The reasons for using CAM are enhance host defenses, better tolerance of treatment, but also for nearly 27% to treat cancer. All patients were treated by anticancer classical treatments and none thought to stop them. CAM are prescribed especially by homeopathic doctors. 30% of patients using CAM did not inform their oncologist of their CAM treatment. The same conclusions were drawn for the only 10 pediatric patients. The majority of all patients did not take any CAM before their cancer. In a multivariate analysis, female, young age (30-50 y) are correlated to CAM. All patients taking CAM are satisfied by the CAM treatment with good subjective results on their general status, fatigue and nausea-vomiting. These results are similar to other studies done in Europe.

Aggression and violence towards staff working with older patients

AIM

To investigate the incidence of violence and aggression towards staff working in elderly care wards and to consider the factors that influence the risk of experiencing such an incident.

METHOD

Questionnaires were administered to 287 nursing and therapy staff within a community health NHS trust in the West Midlands. A response rate of 34% (96) was achieved.

RESULTS

Fifty one per cent (49) of staff had experienced an incident of violence or aggression. There was a significant difference between the probability of experiencing violence and the occupation of the participant (chi2 = 0.035), with 65% (31 of 48) of nurses having experienced an incident, compared to only 42% (10 of 24) of occupational therapists and 27% (4 of 15) of physiotherapists.

CONCLUSION

This study should be replicated in a wider geographical area and apparent anomalies in frequency of assault by occupation need to be considered in future research.

Physiotherapy students' sources of stress, perceived course difficulty, and paid employment: comparison between Western Australia and United Kingdom

Physiotherapy education is changing, and educators are increasingly concerned about the levels of stress observed in students. Considerable research has investigated stressors in medical and nursing students; however, studies of physiotherapy students were conducted more than a decade ago. This study examined the sources of stress, perceived course difficulty, and hours of paid employment in undergraduate physiotherapy students in Western Australia (WA) and the United Kingdom (UK). The Undergraduate Sources of Stress questionnaire was administered to students in all years of Bachelor of Science (Physiotherapy) programs (n = 249 WA; n = 161 UK) and a Master of Physiotherapy (graduate entry) program (n = 24 WA) with an overall response rate of 70%. Academic concerns were rated highest for all students, particularly the amount to learn, time demands of the course, and conflict with other activities. The course was perceived to be more difficult than expected by 71% of students. Although the mean (SD) hours per week worked in paid employment by WA and UK students is 12.52 (13.90) and 7.16 (4.02), respectively, there was no correlation between any stress subscale and number of hours worked. Reducing the amount of content and revision of the outcomes of physiotherapy curricula could potentially reduce academic stress.

[Evaluation of needs in early post-stroke rehabilitation in Poland]

BACKGROUND AND PURPOSE

According to European Stroke Initiative (EUSI) recommendations every stroke patient should undergo rehabilitation. We aimed to evaluate the needs of comprehensive stroke in-patient rehabilitation in Poland.

MATERIALS AND METHODS

We designed and distributed a questionnaire evaluating rehabilitation departments in Poland, where stroke patients undergo early rehabilitation. Comprehensive rehabilitation was defined as: kinesitherapy (minimum 60 minutes/day), speech therapy (minimum 30 minutes 5 days a week), rehabilitation of other cognitive impairments and group kinesitherapy. We separated rehabilitation departments where comprehensive post-stroke rehabilitation is conducted, and calculated the number of beds in these departments only for stroke patients. We estimated the number of acute stroke patients in Poland. We evaluated the number of patients requiring in-patient rehabilitation based on results from the 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, where all stroke patients who need in-patient rehabilitation have such a possibility. We estimated the number of beds required in rehabilitation departments for stroke patients in Poland.

RESULTS

We obtained responses from 115 out of 172 (66.9%) rehabilitation departments. Comprehensive post-stroke rehabilitation is conducted in 11 departments. 159 beds in these departments are for stroke patients. From 64,896 acute stroke patients 9,927 will need in-patient rehabilitation. We need 604 more beds in rehabilitation departments for stroke patients in Poland.

CONCLUSION

Only 10% of rehabilitation departments could provide comprehensive stroke rehabilitation in Poland. At present, the number of beds in rehabilitation departments for stroke patients covers about 20.8% of actual needs. An increased number of rehabilitation beds for stroke patients could result in a decreased number of disabled post-stroke patients.

Use of medical doctors, physical therapists, and alternative practitioners by obese adults: does body weight dissatisfaction mediate extant associations?

OBJECTIVE

The objective of this study was to assess the association of obesity with the utilization of general practitioners (GP), medical specialists (MS), physical therapists (PT), and alternative practitioners (AP), and to elucidate whether body weight dissatisfaction mediates extant associations.

METHODS

In an adult population survey (KORA Survey S4 1999/2001) in Augsburg, Germany, anthropometric body mass [body mass index (BMI), kg/m(2)], utilization, physical comorbidities, functional limitations due to body weight, and body weight dissatisfaction were assessed and analyzed via multiple logistic regressions.

RESULTS

Obese adults (BMI>or=30) had around double odds of AP, GP, and PT utilization. Regarding AP and, to a lesser extent, PT, body weight dissatisfaction both had direct effects and mediated excess utilization. Most notably, the odds for AP use were about twofold in those who were dissatisfied, and the association of obesity and AP use diminished when adjustment for dissatisfaction was performed. Among overweight participants (25<or=BMI<30), only PT use was elevated and tended to be mediated by dissatisfaction as well.

CONCLUSION

Body weight dissatisfaction mediates obesity-attributable utilization of nonmedical health care providers, especially AP. Possibly, dissatisfaction leads to demands for psychosocial care that is expected to be offered by complementary and allied health professions. For health services utilization research, results call for a scrutiny of body weight dissatisfaction-a known barrier to adopting long-term healthy lifestyles. For practice, results indicate that AP and PT may have special opportunities to encourage the use of preventive services by obese adults.

Persistent back pain--why do physical therapy clinicians continue treatment? A mixed methods study of chiropractors, osteopaths and physiotherapists

AIMS

(a) To investigate how widespread is the use of long term treatment without improvement amongst clinicians treating individuals with low back pain. (b) To study the beliefs behind the reasons why chiropractors, osteopaths and physiotherapists continue to treat people whose low back pain appears not to be improving.

METHODS

A mixed methods study, including a questionnaire survey and qualitative analysis of semi-structured interviews. Questionnaire survey; 354/600 (59%) clinicians equally distributed between chiropractic, osteopathy and physiotherapy professions. Interview study; a purposive sample of fourteen clinicians from each profession identified from the survey responses. Methodological techniques ranged from grounded theory analysis to sorting of categories by both the research team and the subjects themselves.

RESULTS

At least 10% of each of the professions reported that they continued to treat patients with low back pain who showed almost no improvement for over three months. There is some indication that this is an underestimate. reasons for continuing unsuccessful management of low back pain were not found to be primarily monetary in nature; rather it appears to have much more to do with the scope of care that extends beyond issues addressed in the current physical therapy guidelines. The interview data showed that clinicians viewed their role as including health education and counselling rather than a 'cure or refer' approach. Additionally, participants raised concerns that discharging patients from their care meant sending them to into a therapeutic void.

CONCLUSION

Long-term treatment of patients with low back pain without objective signs of improvement is an established practice in a minority of clinicians studied. This approach contrasts with clinical guidelines that encourage self-management, reassurance, re-activation, and involvement of multidisciplinary teams for patients who do not recover. Some of the rationale provided makes a strong case for ongoing contact. However, the practice is also maintained through poor communication with other professions and mistrust of the healthcare system.

Barriers to school based physical therapy perceptions of physical therapists in a rural state

The enactment of the Education for All Handicapped Children Act provided children with disabilities the right to be educated with their peers in public schools. The related services provision of the Act requires public schools to hire appropriate personnel, including physical therapists, to enhance educational opportunities for children with disabilities.

PURPOSE

The purpose of this study was to explore perceived barriers to optimal school-based physical therapy practice and delivery identified by Idaho school-based therapists.

METHODS

Forty-eight Idaho school-based physical therapists were sent the survey instrument developed for this study. Thirty-six Idaho school-based therapists returned the survey (response rate 75%).

RESULTS

Data analysis substantiated four barriers to school-based physical therapy practice: financial constraints, administrative issues, personnel shortages, and limited understanding of disability law. A statistically significant difference (p < 0.05) was found between participant perceptions of barriers within their school and their perceptions of barriers statewide.

CONCLUSIONS

Overall, participants perceived, to varying degrees, that although barriers were present at the school level, state level barriers were even greater.

The impact of formal education and training on urodynamic practice in the United Kingdom: A survey

AIM

A previous survey of personnel performing urodynamics had shown that half of the respondents thought that their training had been inadequate. In order to address this the outcome of a 4-day practical course for teaching urodynamics, which has been running since 1995 at the Bristol Urological Institute, was reviewed. We were not aware of any published studies that have assessed the impact of formal urodynamic training on clinical practice. With this in mind we set out to determine whether the education and training we had given had changed urodynamic practice in the UK.

METHODS

Postal questionnaires were sent out to 84 delegates who had attended the course over a 2-year period (2001-2003). Paired questionnaires were used to assess urodynamic practice before and after the course and also to establish whether their practice had changed as a direct result of attending the certificate course.

RESULTS

The results suggested that 79% of those responders had changed their practice since completing the course. Significant changes to practice were observed in checking calibration, confidence in setting-up equipment, interpretation of urodynamic traces and ability to check the accuracy of the results.

CONCLUSIONS

The results of this survey suggest that attendance at a recognised urodynamic training course has had an impact on clinical practice in the UK. Training and education raises the level of confidence and ability to perform and interpret urodynamic investigations, which has wide implications for the accuracy, reliability and consistency of urodynamic investigations performed by those without formal training.

[Physiotherapists in private practice in France]

In France, most of the physiotherapists providing ambulatory care are in private practice: they are paid on a fee-for-service basis by the patients who are reimbursed by the Sickness Insurance Fund. A survey on a sample of 2000 (out of 40,000) private practitioners was undertaken in early 2004. As concerns their workload, only 4% think that it is "not sufficient" whereas 66% estimate it "certainly sufficient". Such a feature is noteworthy, as private practitioners are most often fearful of lack of work. In the coming years, one physiotherapist out of 10 envisages to increase his workload, whereas 27% are in favour of a reduction. Furthermore, the survey shows that more than one third of private physiotherapists plan to offer to patients services which are not listed in the contractual agreement document signed by their profession and the Sickness Insurance Fund. The trend is most noticeable among the young practitioners. As the feeling of medical doctors shortage is currently widespread in France, the public debates are focused on the issue of task delegation. After the survey, 54% private physiotherapists are in favour of task delegation, 24% have an opposite opinion and 22% do not express a clear-cut position. However, an in-depth analysis of the written answers to the question shows that a large majority do not accept to replace medical doctors for performing the tasks which are of a subordinate level, are not significant or are time-consuming (e.g. filling out the administrative forms). The question of vocabulary is fundamental in the matter. Moreover, a process of task delegation implies that certain tasks carried out by an overburdened profession are transferred to an other profession less heavily surcharged. Is it the case of French private physiotherapists whose two thirds declare that "their workload is certainly sufficient"?

Effect on the process of care of an active strategy to implement clinical guidelines on physiotherapy for low back pain: a cluster randomised controlled trial

OBJECTIVES

To evaluate the effect on the process of care of an active strategy to implement clinical guidelines on physiotherapy for low back pain.

DESIGN

A cluster randomised controlled trial comparing an active strategy with standard dissemination.

SETTING

Primary care physiotherapy practices.

PARTICIPANTS

113 physiotherapists were randomly allocated to receive the guidelines by mail (control group) or to receive an additional active strategy (intervention group) which consisted of a multifaceted programme including education, discussion, role playing, feedback, and reminders.

MAIN OUTCOME MEASURES

Adherence to the guidelines was measured by means of individual patients' forms recording the treatment completed by the physiotherapist. The forms were assessed using an algorithm based on the number of treatment sessions, treatment goals, interventions, and patient education.

RESULTS

Physiotherapists in the intervention group more often correctly limited the number of treatment sessions for patients with a normal course of back pain (OR 2.39; 95% CI 1.12 to 5.12), more often set functional treatment goals (OR 1.99; 95% CI 1.06 to 3.72), more often used mainly active interventions (OR 2.79; 95% CI 1.19 to 6.55), and more often gave adequate patient education (OR 3.59; 95% CI 1.35 to 9.55). They also adhered more to all four criteria (OR 2.05; 95% CI 1.15 to 3.65).

CONCLUSIONS

The active strategy moderately improved adherence to the guidelines. Active strategies are recommended to implement the clinical guidelines on physiotherapy for low back pain.

Under-Recognition of Polyneuropathy in Persons with Diabetes by Nonphysician Electrodiagnostic Services Providers

OBJECTIVE

Healthcare providers commonly refer patients to physiatrists and neurologists for electrodiagnostic testing when they have symptoms suggestive of a peripheral nerve disorder. Published practice guidelines specify that electrodiagnostic medicine consultants should possess special neurologic and procedural training in this area. We recently found that despite these practice guidelines, physical therapists, chiropractors, and podiatrists perform 17% of electrodiagnostic studies in the United States. These findings prompted the current investigation examining electrodiagnostic care across different providers for an important target population-persons with diabetes.

DESIGN

A retrospective cohort of patients with diabetes who underwent electrodiagnostic testing in 1998 was identified in the MarketScan Commercial Claims & Encounters Database (The MEDSTAT Group) using CPT and ICD9CM codes. This database represents the healthcare claims for 16 million Americans in private and employer-based health plans. The outcome of interest was the rate of polyneuropathy identification across different providers, controlling for patient characteristics.

RESULTS

There were 6381 electrodiagnostic encounters for persons with diabetes in 1998. Polyneuropathy identification rates were highest for physiatrists, osteopathic physicians, and neurologists (12.5%, 12.2%, and 11.9%, respectively). Podiatrists and physical therapists identified 2.4% and 2.1%, respectively, as having polyneuropathy-rates about one sixth that of physiatrists and neurologists despite controlling for casemix differences. Nonphysician providers who did not recognize polyneuropathy performed almost exclusively EMG testing (>90%) at the expense of nerve conduction studies.

CONCLUSIONS

This study raises concerns about the quality of electrodiagnostic testing by nonphysician providers for persons with diabetes. These results should prove useful for physicians, third-party payers, and health policy makers when confronting issues related to provision of electrodiagnostic services.

Physiotherapy management of low back pain: does practice match the Dutch guidelines?

The purpose of this study is to explore adherence by Dutch physiotherapists to the physiotherapists' guideline for non-specific low back pain. For this study data from the National Information Service for Allied Health Care were used. This is a registration network that continuously collects information about physiotherapy patients and their treatment episodes. Within this network, adherence to the low back pain guideline was assessed by three criteria based on the guideline. These criteria concerned the number of sessions, the treatment goals, and the interventions. Data from patients with 'non-specific low back pain' as the reason for referral and a completed treatment episode were selected (n = 1254); 90 therapists in 40 practices treated these patients. The criterion concerning the number of sessions applied only for patients with acute complaints and was met in 17% of these patients. In about half of the patients the criterion for the treatment goals as well as the criterion relating to the interventions was met. Treatment goals are aimed mainly at improving mobility functions and changing body position. In more than three-quarters of the treatment episodes manual interventions (massage or manual manipulation) and exercise therapy were used frequently. As considerable variation in guideline adherence was shown to exist among therapists, there is clearly room for improvement in the quality of the care.

Geriatric Referral Patterns for Physical Therapy

PURPOSE

The purposes of this study were to: (1) describe older adults being seen for physical therapy, (2) identify the most prevalent physician orders and physical therapy interventions, and (3) compare these results across US regions.

METHODS

A written questionnaire was mailed to a random sample of 1600 therapists. Therapists completed information for up to 10 patients including classification of diagnosis according to the Guide to Physical Therapist Practice.

ANALYSIS

Descriptive analyses were performed.

RESULTS

118 therapists provided information on 839 patients. More of the patients were women (65%) than men (35%); their average age was 76.4 years. Most patients were seen in the outpatient setting (56%) and over 70% were classified into one of the musculoskeletal diagnostic categories. "Evaluate and treat" was present in 66.2% of the physician orders. The 6 most frequently performed interventions were in the therapeutic exercise category.

CONCLUSION

Many physical therapists, even those who may not consider themselves geriatric physical therapists, are seeing older adults in a variety of settings. Knowledge about the diverse needs of older adults, therefore, is important for clinicians and students to meet the rising demand for quality physical therapy for this population.

Patterns of medical practice variation: variability in referral for back pain by New Zealand general practitioners

AIMS

To describe patterns of variation in referral among general practitioners, and to establish whether variability among practitioners within a geographic area is associated with high levels of utilisation in an area.

METHOD

Multilevel analysis of routinely collected primary care data. The four outcome measures were referral to physiotherapy, specialist assessment, radiology, and approval of earnings-related compensation.

RESULTS

The pattern of observed variability is not consistent for different referral activities: groups of general practitioners within one area may practice consistently in referral for one outcome, but be highly variable for another, while practitioners in other areas can show the reverse pattern. The degree of variability among GPs within geographic areas was not significantly correlated at the 95% level with the absolute level of referral to any of the referral options.

CONCLUSION

The mechanisms which drive variability operate at the level of the specific clinical management option, rather than at the level of the overall approach to management of the disease. Caution should be exercised about claims that reductions in variability will produce reductions in utilisation.

The Effects of Cognitive-Behavioral and Physical Therapy Preventive Interventions on Pain-Related Sick Leave

OBJECTIVE

Recent recommendations suggest that reassuring patients with an acute bout of low back pain and encouraging a return to normal activities may be helpful in preventing the development of chronic disability. There is also a question as to whether psychologic or physical therapy interventions actually add anything to such reassurance and advice in terms of preventing chronicity. This study aimed to ascertain the preventive effects on future sick leave and health-care utilization of adding on a cognitive-behavioral group intervention or a cognitive-behavioral group intervention and preventive physical therapy (focused on activity and exercise) relative to a minimal treatment group (examination, reassurance, and activity advice).

SUBJECTS

A total of 185 patients seeking care for nonspecific back or neck pain who were employed and at risk for developing long-term disability volunteered to participate in the study. Of these 185, 158 (85%) completed the pre- and 1-year follow-up assessments.

RESULTS

Significant differences were observed on the key outcome variables of future health-care utilization and work absenteeism. For health-care utilization, the cognitive-behavioral intervention group and preventive physical therapy group had significantly fewer healthcare visits than did the Minimal Treatment Group. For work absenteeism, the cognitive-behavioral intervention group and cognitive-behavioral intervention and preventive physical therapy group had fewer days during the 12-month follow-up than did the Minimal Treatment Group. The risk for developing long-term sick disability leave was more than five-fold higher in the Minimal Group as compared with the other 2 groups. However, there was no difference between the cognitive-behavioral intervention group and cognitive-behavioral intervention and preventive physical therapy group on sick leave.

CONCLUSION

Taken as a whole, this study shows that adding cognitive-behavioral intervention and cognitive-behavioral intervention and preventive physical therapy can enhance the prevention of long-term disability. There was no substantial difference in the results between the cognitive-behavioral intervention group and cognitive-behavioral intervention and preventive physical therapy group.

Canadian physical therapists' interest in web-based and computer-assisted continuing education

BACKGROUND AND PURPOSE

Distance education via computer-assisted learning (CAL), including Web-based and CD-ROM learning, confers a number of advantages compared with traditional learning methods. The purposes of this study were (1) to determine the interest of Canadian physical therapists in participating in continuing education using CAL methods and (2) to determine whether interest in CAL was related to type of employment, area of practice, education, computer skill and access, and other demographic variables.

SUBJECTS AND METHODS

A random sample of Canadian physical therapists and all members of cardiopulmonary interest groups were surveyed.

RESULTS

Of 1,426 survey questionnaires mailed, 69 were returned (58 were unopened and 11 were duplicates). From the remaining 1,357 potential survey responses, 757 responses were received, for an overall response rate of 56%. Seventy-eight percent of the respondents indicated their interest in participating in CAL. Factors associated with interest in CAL included 2 or more hours of Internet access per week, Internet access at both home and work, computer skill, education level, practice area, and belonging to a cardiopulmonary interest group.

DISCUSSION AND CONCLUSION

The findings indicate a large positive interest in CAL. Increasing CAL continuing education opportunities could increase options for physical therapists to meet professional expectations for continuing competency.

Do evidence-based guidelines have an impact in primary care? A cross-sectional study of Swedish physicians and physiotherapists

STUDY DESIGN

A cross-sectional study of physicians and physiotherapists in primary care.

OBJECTIVES

To survey how familiar clinicians were with evidence-based guidelines for back pain and their opinion about their clinical usefulness and to compare self-reported practice behavior with the guidelines.

SUMMARY OF BACKGROUND DATA

Guidelines, based on empirical evidence, are meant to ensure that patients get the most effective treatment. These evidence-based guidelines should steer clinical praxis, but clinicians may not read, let alone heed, them.

METHODS

Using a questionnaire, the authors surveyed all physicians and physiotherapists in primary health care in Orebro County, Sweden (N = 235).

RESULTS

Forty-two percent of the physicians and 37% of the physiotherapists were unfamiliar with the content of the guidelines, and 40% of the physicians and 25% of the physiotherapists were unfamiliar with the concept of 'red flags.' Less than half of the clinicians, 47%, were familiar both with the content of the guidelines and the concept of red flags. Their opinion about the guidelines showed that 54% of the physicians and 56% of the physiotherapists agreed that the guidelines were useful in clinical praxis. Concerning the self-reported practice behavior, the majority indicated that they followed the key points in the guidelines.

CONCLUSIONS

A relatively large proportion of clinicians were unfamiliar with the content of evidence-based guidelines and/or with the concept of red flags. The process of implementing research into clinical practice is in need of an overhaul, and the impact of guidelines on clinical practice may be questioned.

Predictors of Job Satisfaction among Physiotherapists in Turkey

The aim of this study was to investigate the level of job satisfaction among physiotherapists, and to identify the best predictors of job satisfaction. A self-administrated questionnaire survey was conducted in September 2003. Data were collected from 198 physiotherapists in 13 health care settings (five university hospitals, seven government hospitals, and one municipality hospital) located in Ankara, Turkey. Respondents were asked to complete a 31-item job satisfaction questionnaire. The response rate was 79.8%. The percentage of satisfied physiotherapists was 45.5%. There were no significant satisfaction differences between genders or between age groups. There was a positive relationship between the global satisfaction and domain scores (all ps<0.01). Logistic regression analysis showed that the most important predictors of job satisfaction were: (1) Leadership (OR=1.03, 95% CI 1.01 to 1.06), (2) Interpersonal relationships (OR=1.03, 95% CI 1.00 to 1.05), (3) Advancement (OR=1.02, 95% CI 1.00 to 1.05), and (4) Salary (OR=1.02, 95% CI 1.00 to 1.04). Specific job satisfaction dimensions indicate that highest dissatisfaction levels occur in the area of salary and advancement. Areas of dissatisfaction are signals for change.

Patterns of chest physiotherapy in Australian Intensive Care Units

PURPOSE

The aim of this study was to identify the availability of physiotherapy services in Australian Intensive Care Units (ICUs) and articulate the roles that physiotherapists and nursing staff play in the provision of chest physiotherapy.

MATERIALS AND METHODS

Telephone interviews with 71 clinical nurse managers and 6 physiotherapists of adult public Australian ICUs were undertaken. A structured interview schedule was developed from a review of the literature and a panel of experienced ICU clinicians and researchers to establish the frequency, components and personnel involved in the provision of chest physiotherapy.

RESULTS

Almost 90% (n = 67) of ICUs had physiotherapists available during the week but over 25% (n = 22) had "on-call" service only on weekends. Less than 10% had weekday (n = 7) or weekend (n = 6) evening physiotherapy coverage. While nurses were involved in the provision of all aspects of chest physiotherapy, physiotherapists were primarily involved in airway suctioning, percussions, vibrations, positioning, and mobilization.

CONCLUSIONS

The provision of chest physiotherapy services is often shared between physiotherapists and nurses, however, the actual therapies provided appears to vary depending on the provider. While strong evidence for chest physiotherapy procedures is lacking, the widespread use in the ICU suggests that it is an ideal setting for undertaking clinical research.

[Health care usage by Moroccans and Turks compared to the indigenous Dutch population: no higher consumption of health care and lower medication costs]

OBJECTIVE

Examination of whether health care consumption of Moroccan or Turkish insured under the Dutch national health system varies from that of the indigenous Dutch population.

DESIGN

Retrospective, transverse.

METHOD

Research was performed on the database of an insurance company concerning medication, referrals to a specialist, admissions to the hospital and use of physiotherapy. Data of 22,603 Moroccan and 15,190 Turkish persons from the records for 1999 were compared with a random sample of 17,976 other persons in the database and differences were tested after correction for differences in age and sex.

RESULTS

Foreigners received 50% less physiotherapy, while hospital admissions did not differ from the control group. The number of referrals to a specialist and the number of prescriptions for Moroccans appeared to be higher, but the number of consumers appeared to be equal to the control group. Turks on the contrary showed an equal number of referrals, but fewer prescriptions. The differences concerned mostly long-term physiotherapy and also referrals to specialists in internal medicine and gynaecology. Differences in prescriptions were found for certain medication groups. Costs for medication for foreigners were lower per insured person.

CONCLUSION

Foreigners did not have a higher consumption of health services than indigenous persons, whilst medication costs were lower.

Practice analysis: defining the clinical practice of primary contact physical therapy

STUDY DESIGN

Nonexperimental descriptive research design.

OBJECTIVE

To describe the frequency of use and perceived level of importance of professional responsibilities, procedures, and knowledge areas by physical therapists practicing in primary contact care settings and to compare these data to similar data from physical therapists practicing in nonprimary contact care settings.

BACKGROUND

Physical therapy services have moved toward a primary contact model of practice in response to changes in the health care delivery system. Several studies have reported the effectiveness of primary contact physical therapy. However, a practice analysis has not been performed to define the clinical practice of primary contact physical therapy.

METHODS AND MEASURES

A sample of 212 physical therapists practicing as primary contact providers in the military and civilian sectors, and a comparison group of 250 physical therapists not practicing as primary contact providers were surveyed. A Delphi technique was used to develop the survey instrument, which was pretested by a pilot group. The final survey instrument consisted of 171 items. Chi-square and Kruskal-Wallis tests were conducted to examine significant differences among the 3 groups (P<.001).

RESULTS

Of the 212 surveys mailed to the primary contact group, 119 (56.1%) responses were received (82 military physical therapists and 37 civilian physical therapists). Of the 250 surveys mailed to the comparison group, 103 (41.2%) responses were received. There were numerous significant differences among the 3 groups in professional responsibilities, procedures, and knowledge areas, most notably in the areas of selecting and ordering of imaging procedures, identifying signs and symptoms of nonmusculoskeletal conditions, establishing physical therapy diagnoses, and prescribing over-the-counter medications.

CONCLUSION

The study describes the clinical practice of physical therapists functioning in the role of primary contact providers or as members of a diverse team of health care professionals in primary care, which may provide curricular direction to professional, postprofessional, and clinical residency or fellowship-based educational settings.

Physiotherapists' pain beliefs and their influence on the management of patients with chronic low back pain

PURPOSE

Little is known about physiotherapists' pain beliefs and whether they influence behavior within therapeutic encounters with patients. This qualitative study explored physiotherapists' pain beliefs with the purpose of highlighting the nature of their beliefs and the role they played within their management of chronic low back pain.

METHODS

Six physiotherapists were purposefully sampled along with 12 of their patients with chronic low back pain (two patients each). A qualitative exploration of physiotherapists' pain beliefs within the context of a clinical situation was carried out using semistructured interviews and observations at designated stages throughout therapeutic encounters with their patients. The data were prepared and analyzed according to a grounded theory approach.

RESULTS

The themes that emerged from the data indicated that the pain beliefs of physiotherapists in this study were determined by a number of perspectives including their beliefs regarding the development of craft knowledge needed to manage chronic low back pain, beliefs regarding the clinical characteristics of patients with chronic low back pain they considered to be "good" to treat and the challenge of patients who were "difficult" to treat, and pain beliefs within the therapeutic encounter. A tentative theory was developed which proposed that the physiotherapists' biomedically oriented pain beliefs influenced their clinical reasoning processes including the explanations given to the patients.

CONCLUSIONS

The findings suggest that in order to maximize the rehabilitation potential of patients with chronic low back pain, physiotherapists need to be aware that their pain beliefs may influence their management of these patients.

Quality indicators and variation in primary care: modelling GP referral patterns

BACKGROUND

Health agencies frequently seek to develop indicators of the quality and performance of work done by clinicians. The validity of such indicators is a subject of debate among clinicians and health managers.

OBJECTIVES

Our aim was to quantify the effects of chance and small caseload on an indicator of referral behaviour for GPs.

METHODS

The study used random simulation of GP referral to physiotherapy and variance components analysis of routinely collected accident insurance data. It analysed 129 079 episodes of accident-related back pain in New Zealand which were managed by 2679 GPs. The main outcome measure was the percentage of back pain cases referred for physiotherapy and for specialist assessment and by each GP.

RESULTS

The observed number of GPs who refer to physiotherapy at high levels is satisfactorily accounted for by chance. The variability of practice among GPs within any one area is not related to the absolute level of referral.

CONCLUSION

The primary care setting, in which a low caseload for any one condition is the norm, presents challenges for measuring clinical performance. An emphasis upon changing the behaviour of GPs with extremely high levels on a performance indicator cannot necessarily be expected to have an impact upon the level of the indicator across a geographic area. Indicators for quality improvement should be used across whole populations of practitioners, rather than used to focus upon extremely high referring individuals.

The attitudes and beliefs of physiotherapy students to chronic back pain

OBJECTIVES

To describe the attitudes and beliefs of physiotherapy students to chronic low back pain (LBP) and to investigate whether these attitudes change following exposure to a teaching module on chronic back pain. Also, to investigate the effect of current or previous LBP on student attitudes and beliefs.

METHODS

Six hundred and eighteen third and fourth year undergraduate physiotherapy students completed the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS), 305 of these completing a further scale following exposure to a specialized teaching module about chronic back pain. The scale contains 15 statements that attribute patients' impairment and disability to pain. The student marked on a Likert scale how strongly they agreed with each item, with possible scores varying from 15-105.

RESULTS

The mean HC-PAIRS scores for Year 3 physiotherapy students in 1998, 1999, and 2000 were 54.2 (SD = 8.7), 55 (SD = 9.4), and 50.9 (SD = 9.3) respectively. The mean HC-PAIRS score for Year 4 physiotherapy students in 1998 was 52 (SD = 8.9). There was no difference in HC-PAIRS scores between subjects with and without a history of LBP (HC-PAIRS score 50.5 vs. 50.0 P = 0.4). There was a significant difference between the before and after teaching scores for Year 3 students surveyed immediately following the teaching module (1998 Year 3 cohort, mean difference -6.6, 95% CI -8.6 to -4.5, 2000 Year 3 cohort, mean difference -7.7, 95% CI -10.9 to -4.6); however this result needs to be viewed with caution due to the number of students unable to be followed up.

DISCUSSION

These results suggest that the attitudes and beliefs of third year physiotherapy students not exposed to teaching are similar to those of community providers. There is no difference between students with and without a history of LBP.

Clinical education of physiotherapy students in Australia: Perceptions of current models

The aim of this study was to seek opinions regarding the perceived advantages and disadvantages of the two main models of clinical education used in Australia. A questionnaire was designed specifically for this study and distributed to physiotherapists involved in clinical education at health units throughout Australia. There were 343 respondents (giving an approximate response rate of 74.5%). In most health units (78.4%) the model of clinical education currently used involves a number of physiotherapists sharing responsibility for the clinical education of students (SR model). Only a minority reported employing a designated clinical educator (DCE) to provide clinical education. Overall, respondents preferred the DCE model to the SR model. The perceived advantages of the DCE model included an increased time to devote to clinical education, improved consistency of supervision and decreased stress levels for staff.

Patient-reported use of health service resources compared with information from health providers

The objectives of the present study were to examine the accuracy of older people's reports of health services resource use after discharge from acute care compared with information from healthcare providers. Paired data were obtained from health providers and a consecutive sample of hospitalised patients (aged 60 years or over) enrolled in a randomised controlled trial of hospital-at-home versus usual acute care. Retrospective reports of the use (yes/no) and number of patient hospital admissions, and community nursing, physiotherapy, health visiting and general practitioner (GP) services were obtained between baseline, and 4- and 12-week follow-ups, although the recall period varied for different resources. The comparability of paired reports was examined by using crude and chance-corrected agreement, and by testing for systematic differences in the distribution of paired responses. Out of 219 patients enrolled in the trial, 190 and 185 patients provided data at 4 (87%) and 12 weeks (84%), respectively. Crude agreement was over 72% (range = 42-93%), and chance-corrected agreement was moderate or good (kappa coefficients from 0.23 to 0.71) for 11 out of 12 comparisons. Systematic differences in the pattern of paired responses were observed for seven comparisons. Patients more often reported receiving a routine GP home visit (by 12 weeks), whilst health providers reported statistically significantly (P < 0.05) more patients admitted to hospital (12 weeks) and more admissions per person, requesting a GP home visit (12 weeks) or surgery consultation, and having district nursing (4 and 12 weeks) and physiotherapy (4 weeks only). The data indicate that patients tend to underestimate resources used compared with health providers over relatively short time frames.

Increased physiotherapy in sheltered housing in Sweden: a study of structure and process in elderly care

The effect of increasing the level of physiotherapy services in elderly care was studied using an intervention and a control unit. The units had 20 and 2 hours of physiotherapy services per week, respectively. Physiotherapy and occupational therapy records were reviewed before and during the project. Physiotherapists also kept extended documentation over an 11-month period. Data analyses employed the chi-square test and content analysis. There was a significant increase in the number of patients receiving physiotherapy and occupational therapy within both units. No significant differences between the units were found for the number of patients receiving physiotherapy. The number of patients receiving occupational therapy differed significantly between units before as well as during the intervention. Primarily care assistants and auxiliary nurses initiated contact with the physiotherapists mainly for patient-orientated errands. Fifty per cent of the instructions given by the physiotherapist at the 20-hour unit related to movement-orientated activities of daily living. At the 2-hour unit, the majority of instructions (52%) were programme-orientated.

Development of an implementation strategy for physiotherapy guidelines on low back pain

In the Netherlands, clinical practice physiotherapy guidelines are mainly implemented by using passive implementation strategies. It is well known that these strategies are not effective in establishing changes in behaviour of health care professionals. Therefore, a new implementation strategy was developed for the physiotherapy guidelines on low back pain. This paper describes the method for the design of this strategy. A survey was conducted of 100 physiotherapy practices to identify perceived barriers to implementation of the guidelines and the most important discrepancies between current practice and recommendations of the guidelines. The strategy was further developed using a model for changing professionals' behaviour and systematic reviews on the effectiveness of implementation interventions. The most frequently reported barriers for implementation of the guidelines are related to a lack of knowledge or skills of physiotherapists. The most frequently reported discrepancies between physiotherapy practice and guidelines recommendations were related to the focus of the diagnostic process on impairments, the common use of passive physiotherapeutic interventions, the frequent use of a pain-contingent approach, and the expectations of the patient. The new implementation strategy consisted of multiple interventions, namely education, discussion, role-playing, feedback and reminders. The strategy addressed perceived barriers and discrepancies between current practice and the recommendations of the guidelines.

Randomized controlled trial of education and feedback for implementation of guidelines for acute low back pain

OBJECTIVE

The effect of clinical guidelines on resource utilization for complex conditions with substantial barriers to clinician behavior change has not been well studied. We report the impact of a multifaceted guideline implementation intervention on primary care clinician utilization of radiologic and specialty services for the care of acute low back pain.

DESIGN

Physician groups were randomized to receive guideline education and individual feedback, supporting patient education materials, both, or neither. The impact on guideline adherence and resource utilization was evaluated during the 12-month period before and after implementation.

PARTICIPANTS

Fourteen physician groups with 120 primary care physician and associate practitioners from 2 group model HMO practices.

INTERVENTIONS

Guideline implementation utilized an education/audit/feedback model with local peer opinion leaders. The patient education component included written and videotaped materials on the care of low back pain.

MAIN RESULTS

The clinician intervention was associated with an absolute increase in guideline-consistent behavior of 5.4% in the intervention group versus a decline of 2.7% in the control group (P =.04). The patient education intervention produced no significant change in guideline-consistent behavior, but was poorly adopted. Patient characteristics including duration of pain, prior history of low back pain, and number of visits during the illness episode were strong predictors of service utilization and guideline-consistent behavior.

CONCLUSIONS

Implementation of an education and feedback-supported acute low back pain care guideline for primary care clinicians was associated with an increase in guideline-consistent behavior. Patient education materials did not enhance guideline effectiveness. Implementation barriers could limit the utility of this approach in usual care settings.