Telerehabilitation consultations with a physiotherapist for chronic knee pain versus in-person consultations in Australia: the PEAK non-inferiority randomised controlled trial.

BACKGROUND: Telerehabilitation whether perceived as less effective than in-person care for musculoskeletal problems. We aimed to determine if physiotherapy video conferencing consultations were non-inferior to in-person consultations for chronic knee pain. METHODS: In this non-inferiority randomised controlled trial, we recruited primary care physiotherapists from 27 Australian clinics. Using computer-generated blocks, participants with chronic knee pain consistent with osteoarthritis were randomly assigned (1:1, stratified by physiotherapist and clinic) in-person or telerehabilitation (ie, video conferencing) physiotherapist consultations. Participants and physiotherapists were unmasked to group assignment. Both groups had five consultations over 3 months for strengthening, physical activity, and education. Primary outcomes were knee pain (on a numerical rating scale of 0-10) and physical function (using the Western Ontario and McMaster Universities osteoarthritis index of 0-68) at 3 months after randomisation. Primary analysis was by modified intention-to-treat using all available data. This trial is registered with the Australian and New Zealand Clinical Trials Registry, ACTRN12619001240134. FINDINGS: Between Dec 10, 2019, and June 17, 2022, 394 adults were enrolled, with 204 allocated to in-person care and 190 to telerehabilitation. 15 primary care physiotherapists were recruited. At 3 months, 383 (97%) participants provided information for primary outcomes and both groups reported improved pain (mean change 2·98, SD 2·23 for in-person care and 3·14, 1·87 for telerehabilitation) and function (10·20, 11·63 and 10·75, 9·62, respectively). Telerehabilitation was non-inferior for pain (mean difference 0·16, 95% CI -0·26 to 0·57) and function (1·65, -0·23 to 3·53). The number of participants reporting adverse events was similar between groups (40 [21%] for in-person care and 35 [19%] for telerehabilitation) and none were serious. INTERPRETATION: Telerehabilitation with a physiotherapist is non-inferior to in-person care for chronic knee pain. FUNDING: National Health and Medical Research Council.

Role of physical therapy in adult chronic non-bacterial osteitis: patients' and therapists' perspectives.

OBJECTIVES: Chronic nonbacterial osteitis (CNO) is a rare bone disease causing pain and functional impairment. We aimed to explore the application of physical therapy (PT) for adult CNO from the patients' and primary care therapists' perspective. METHOD: Cross-sectional study among the Dutch adult CNO cohort (1992-present). A survey on PT-use for axial spondylarthritis was adapted for CNO. Patients using PT in the past 2 years (recent PT-users) were asked about modalities, perceived effects, satisfaction, and preferences for provision. Their current physical therapists were invited to complete a self-developed survey covering therapy details and educational preferences. RESULTS: 80/199 invited patients and 14/16 invited therapists completed the survey respectively. 41 (51%) patients used PT for CNO in the preceding 2 years, 14 (18%) used PT >2 years back, and 25 (31%) never used PT. Recent PT-users (n=41) reported diverse treatment modalities, involving massage (61%), joint mobilizations (44%), breathing exercises (49%), muscle strengthening (32%) and counselling through of home-exercises (46%) and pain education (32%). 64% of all patients desired greater emphasis from physicians regarding the role of PT. Most therapists would appreciate referral letters with CNO-specific information (93%), and consultations with specialized therapists (86%). CONCLUSIONS: In this study, two-third of adult CNO patients had -ever or recently- used PT, which involved variable therapeutic modalities. Most patients were receptive to a larger role of PT in CNO-management and most therapists preferred CNO-specific information to optimize their care. These findings provide a foundation for the development and systematic evaluation of CNO-specific PT.

Barriers and facilitators to implementation of an exercise and education programme for osteoarthritis: a qualitative study using the consolidated framework for implementation research.

Targeted efforts to better understand the barriers and facilitators of stakeholders and healthcare settings to implementation of exercise and education self-management programmes for osteoarthritis (OA) are needed. This study aimed to explore the barriers and facilitators to the implementation of Good Life with osteoArthritis in Denmark (GLA:D), a supervised group guideline-based OA programme, across Irish public and private healthcare settings. Interviews with 10 physiotherapists (PTs; 8 public) and 9 people with hip and knee OA (PwOA; 4 public) were coded by the Consolidated Framework for Implementation Research (CFIR) constructs in a case memo (summary, rationale, quotes). The strong positive/negative implementation determinants were identified collaboratively by rating the valence and strength of CFIR constructs on implementation. Across public and private settings, PTs and PwOA strongly perceived GLA:D Ireland as evidence-based, with easily accessible education and modifiable marketing/training materials that meet participants' needs, improve skills/confidence and address exercise beliefs/expectations. Despite difficulties in scheduling sessions (e.g., work/caring responsibilities), PTs in public and private settings perceived advantages to implementation over current clinical practice (e.g., shortens waiting lists). Only PTs in public settings reported limited availability of internal/external funding, inappropriate space, marketing/training tools, and inadequate staffing. Across public and private settings, PwOA reported adaptability, appropriate space/equipment and coaching/supervision, autonomy, and social support as facilitators. Flexible training and tailored education for stakeholders and healthcare settings on guideline-based OA management may promote implementation. Additional support on organising (e.g., scheduling clinical time), planning (e.g., securing appropriate space, marketing/training tools), and funding (e.g., accessing dedicated internal/external grants) may strengthen implementation across public settings.

The perceptions of nurses and physicians in primary care of rehabilitation for frail older adults.

OBJECTIVES: To investigate the perceptions of primary care nurses and physicians of the potential contributions of physiotherapists (PTs) and occupational therapists (OTs) in the treatment of frail older persons, as well as the obstacles to, and opportunities for, collaboration. DESIGN: A qualitative study. PARTICIPANTS AND SETTING: Nurses (n = 9) and physicians (n = 8) in primary care in the county council [14 women (82%)] with experience working with older people. METHOD: Interview study conducted with a semi-structured interview guide. Analyses were carried out with content analysis with an inductive approach. RESULTS: The analysis resulted in six categories: knowledge of physiotherapy and occupational therapy interventions; what triggers the need for physiotherapy and occupational therapy?; the availability of rehabilitation interventions; teamwork opportunities and difficulties; motivating the patient; the site of the rehabilitation. CONCLUSIONS: Close and clear collaboration between nurses and physicians and PTs and OTs is an important factor in ensuring that rehabilitation interventions provide the greatest possible benefit to the patient. Improving communication between different healthcare providers and clarifying the contact routes is a prerequisite for patients to be able to get the rehabilitation they need. More research is needed to determine the best approach to achieving this goal.

Using Twitter (X) to Mobilize Knowledge for First Contact Physiotherapists: Qualitative Study.

BACKGROUND: Twitter (now X) is a digital social network commonly used by health care professionals. Little is known about whether it helps health care professionals to share, mobilize, and cocreate knowledge or reduce the time between research knowledge being created and used in clinical practice (the evidence-to-practice gap). Musculoskeletal first contact physiotherapists (FCPs) are primary care specialists who diagnose and treat people with musculoskeletal conditions without needing to see their general practitioner (family physician) first. They often work as a sole FCP in practice; hence, they are an ideal health care professional group with whom to explore knowledge mobilization using Twitter. OBJECTIVE: We aimed to explore how Twitter is and can be used to mobilize knowledge, including research findings, to inform FCPs' clinical practice. METHODS: Semistructured interviews of FCPs with experience of working in English primary care were conducted. FCPs were purposively sampled based on employment arrangements and Twitter use. Recruitment was accomplished via known FCP networks and Twitter, supplemented by snowball sampling. Interviews were conducted digitally and used a topic guide exploring FCP's perceptions and experiences of accessing knowledge, via Twitter, for clinical practice. Data were analyzed thematically and informed by the knowledge mobilization mindlines model. Public contributors were involved throughout. RESULTS: In total, 19 FCPs consented to the interview (Twitter users, n=14 and female, n=9). Three themes were identified: (1) How Twitter meets the needs of FCPs, (2) Twitter and a journey of knowledge to support clinical practice, and (3) factors impeding knowledge sharing on Twitter. FCPs described needs relating to isolated working practices, time demands, and role uncertainty. Twitter provided rapid access to succinct knowledge, the opportunity to network, and peer reassurance regarding clinical cases, evidence, and policy. FCPs took a journey of knowledge exchange on Twitter, including scrolling for knowledge, filtering for credibility and adapting knowledge for in-service training and clinical practice. Participants engaged best with images and infographics. FCPs described misinformation, bias, echo chambers, unprofessionalism, hostility, privacy concerns and blurred personal boundaries as factors impeding knowledge sharing on Twitter. Consequently, many did not feel confident enough to actively participate on Twitter. CONCLUSIONS: This study explores how Twitter is and can be used to mobilize knowledge to inform FCP clinical practice. Twitter can meet the knowledge needs of FCPs through rapid access to succinct knowledge, networking opportunities, and professional reassurance. The journey of knowledge exchange from Twitter to clinical practice can be explained by considering the mindlines model, which describes how FCPs exchange knowledge in digital and offline contexts. Findings demonstrate that Twitter can be a useful adjunct to FCP practice, although several factors impede knowledge sharing on the platform. We recommend social media training and enhanced governance guidance from professional bodies to support the use of Twitter for knowledge mobilization.

Framework to leverage physical therapists for the assessment and treatment of chemotherapy-induced peripheral neurotoxicity (CIPN).

PURPOSE: Chemotherapy-induced peripheral neurotoxicity (CIPN) is a highly prevalent, dose-limiting, costly, and tough-to-treat adverse effect of several chemotherapy agents, presenting as sensory and motor dysfunction in the distal extremities. Due to limited effective treatments, CIPN can permanently reduce patient function, independence, and quality of life. One of the most promising interventions for CIPN is physical therapy which includes exercise, stretching, balance, and manual therapy interventions. Currently, there are no physical therapy guidelines for CIPN, thus limiting its uptake and potential effectiveness. METHODS: Utilizing the authors' collective expertise spanning physical therapy, symptom management research, oncology, neurology, and treating patients with CIPN, we propose a comprehensive clinical workflow for physical therapists to assess and treat CIPN. This workflow is based on (1) physical therapy guidelines for treating neurologic symptoms like those of CIPN, (2) results of clinical research on physical therapy and exercise, and (3) physical therapy clinical judgement. RESULTS: We present detailed tables of pertinent physical therapy assessment and treatment methods that can be used in clinical settings. CIPN assessment should include detailed sensory assessment, objective strength assessments of involved extremities, and validated physical performance measures incorporating static and dynamic balance, gait, and functional mobility components. CIPN treatment should involve sensorimotor, strength, balance, and endurance-focused interventions, alongside a home-based exercise prescription that includes aerobic training. We conclude with action items for oncology teams, physical therapists, patients, and researchers to best apply this framework to address CIPN. CONCLUSIONS: Physical therapists are in a unique position to help assess, prevent, and treat CIPN given their training and prevalence, yet there are no physical therapy clinical practice guidelines for CIPN. Our preliminary suggestions for CIPN assessments and treatments can catalyze the development of guidelines to assess and treat CIPN. We urge oncology teams, physical therapists, patients, and researchers to develop, adapt, and disseminate this framework to help alleviate the burden of chemotherapy on patients with cancer.

Physiotherapists' perspectives of barriers and facilitators to effective community provision after hip fracture: a qualitative study in England.

PURPOSE: to investigate physiotherapists' perspectives of effective community provision following hip fracture. METHODS: qualitative semi-structured interviews were conducted with 17 community physiotherapists across England. Thematic analysis drawing on the Theoretical Domains Framework identified barriers and facilitators to implementation of effective provision. Interviews were complemented by process mapping community provision in one London borough, to identify points of care where suggested interventions are in place and/or could be implemented. RESULTS: four themes were identified: ineffective coordination of care systems, ineffective patient stratification, insufficient staff recruitment and retention approaches and inhibitory fear avoidance behaviours. To enhance care coordination, participants suggested improving access to social services and occupational therapists, maximising multidisciplinary communication through online notation, extended physiotherapy roles, orthopaedic-specific roles and seven-day working. Participants advised the importance of stratifying patients on receipt of referrals, at assessment and into appropriately matched interventions. To mitigate insufficient staff recruitment and retention, participants proposed return-to-practice streams, apprenticeship schemes, university engagement, combined acute-community rotations and improving job description advertisements. To reduce effects of fear avoidance behaviour on rehabilitation, participants proposed the use of patient-specific goals, patient and carer education, staff education in psychological strategies or community psychologist access. Process mapping of one London borough identified points of care where suggested interventions to overcome barriers were in place and/or could be implemented. CONCLUSION: physiotherapists propose that effective provision of community physiotherapy following hip fracture could be improved by refining care coordination, utilising stratification techniques, employing enhanced recruitment and retainment strategies and addressing fear avoidance behaviours.

Essential Competencies in Entry-Level Neurologic Physical Therapist Education.

BACKGROUND AND PURPOSE: The Academy of Neurologic Physical Therapy's (ANPT) 2021 Strategic Plan identified development of core competencies for neurologic physical therapy as a priority. The Curricular Competencies Task Force was appointed to establish competencies for entry-level neurologic physical therapist (PT) education to facilitate the delivery of current and consistent content across educational programs. SUMMARY OF KEY POINTS: A sequential exploratory process was used. First, the task force chairs, utilizing an established conceptual framework for competency-based education and a review of the broader literature, established competency domains to specifically apply to neurologic PT practice. Second, Nominal Group Technique (NGT), a structured method for small group discussion to reach consensus, was adopted. Nominal Group Technique meetings focused on developing specific competencies within each domain of neurologic PT practice by the full task force. After competencies were identified through the NGT process, the task force chairs reviewed and refined the competencies to ensure they represented distinct and specific knowledge, skill, and/or attitude within neurologic PT practice. The domains and competencies were then submitted to ANPT membership via survey for review. Member comments were qualitatively analyzed, with edits made to the competencies prior to submission to ANPT Board of Directors for approval. RECOMMENDATIONS FOR ENTRYLEVEL PT NEUROLOGIC EDUCATION: Seven essential domains were identified: participation, communication and collaboration, health promotion and wellness, movement science, assistive technology and equipment, evidence-based practice, and provider health and wellness. Essential competencies operationalize each domain. Competencies are not prescriptive but provide guidance, allowing educators to determine how to best incorporate into their curricula.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A427 ).

Pelvic floor muscle training with biofeedback or feedback from a physiotherapist for urinary and anal incontinence after childbirth - a systematic review.

BACKGROUND: Childbirth is one of the biggest risk factors for incontinence. Urinary and anal incontinence can cause pain and social limitations that affect social life, cohabitation, and work. There is currently no up-to-date literature study on the effect of pelvic floor muscle training with feedback from a physiotherapist, which involves verbal instructions based on vaginal and anal digital palpation, compared to treatment without feedback (e.g., recommendations for pelvic floor muscle training). AIM: The objective of this systematic review was to examine the scientific evidence regarding the impact of pelvic floor muscle training (PFMT) with feedback from a physiotherapist and/or biofeedback on urinary and anal incontinence in women during the first six months following vaginal delivery, compared to treatment without feedback. METHODS: The literature search was conducted in the databases PubMed, Cochrane, and CINAHL. In addition, a manual search was conducted. The search terms consisted of MeSH terms and synonyms in the respective search block including population, intervention, and study design, as well as the terms pelvic floor and postpartum. An evaluation of each included study was conducted for methodological quality, evidence value, and clinical relevance. RESULTS: Eight studies were included, three of which showed a significant difference between groups, in favor of the intervention group that received pelvic floor muscle training with feedback from a physiotherapist and/or biofeedback. Due to the varying results and insufficient quality for the majority of the studies, the scientific basis was considered insufficient. CONCLUSION: The scientific evidence for pelvic floor muscle training with feedback from a physiotherapist or biofeedback on postpartum urinary and anal incontinence compared to treatment without feedback is considered insufficient. Further research on the subject is needed. The study is registered in PROSPERO CRD42022361296.

The willingness and barriers to collaborate in the care of frail older adults: perspectives of primary care professionals.

BACKGROUND: This study investigated the perspectives of primary care professionals, in particular general practitioners, registered nurses, physiotherapists and occupational therapists, on inter-professional collaboration, the barriers and the facilitators they perceive in the care of the frail older population. METHODS: We conducted a qualitative study. In-depth interviews with healthcare professionals were performed, using open-ended questions about their perceptions on the care of frail older adults and inter-professional collaboration. Data was analyzed following the Basic Logical Model of Abduction and Creswell's coding method. RESULTS: Healthcare professionals indicated that when they explored problems complementary to the reasons for older people to contact a healthcare professional, these additional problems often seemed to be the main problem. They also stated that there was too little inter-professional collaboration in the care of complex chronic issues and lack of a shared vision on collaboration. Collaboration is still limited too much to contacting established professions. Health information technology can support both, inter-professional collaboration and working on an evidence-based manner. It can also be a facilitator to inform patients. The availability and use of health information technology differs between the professions. Success factors and barriers for sustainable collaboration were identified on several levels, namely innovation, individual, professional, patient, social context, context of the organization, economic and political context. CONCLUSIONS: Our study shed light on the willingness and barriers in collaboration of healthcare professionals in primary care for older adults. There is little inter-professional collaboration, despite the willingness of the healthcare professionals to collaborate.

Healthcare professionals' perceptions of using a digital patient educational programme as part of cardiac rehabilitation in patients with coronary artery disease - a qualitative study.

BACKGROUND: Participation in cardiac rehabilitation in patients with coronary artery disease (CAD) remains underutilised. Digital educational programmes, as part of cardiac rehabilitation, are emerging as a means of increasing accessibility, but healthcare professionals' perceptions of implementing and using these programmes are not known. The aim of the study was therefore to explore healthcare professionals ̓ perceptions and experiences of implementing and using a digital patient educational programme (DPE) as part of cardiac rehabilitation after acute CAD. METHODS: Individual semi-structured interviews were performed with 12 nurses and physiotherapists, ten women with a median age of 49.5 (min 37- max 59) years, with experience of using the DPE as part of a phase II cardiac rehabilitation programme in Region Västra Götaland, Sweden. The interviews were transcribed verbatim and analysed with inductive content analysis according to Graneheim and Lundman. RESULTS: An overall theme was identified throughout the unit of analysis: "Digital patient education - a complement yet not a replacement". Within this theme, three main categories were identified: "Finding ways that make implementation work", "Accessibility to information for confident and involved patients" and "Reaching one another in a digital world". Each main category contains a number of sub-categories. CONCLUSIONS: This study adds new knowledge on healthcare professionals' perceptions of a digital patient educational programme as a valuable and accessible alternative to centre-based education programmes as part of cardiac rehabilitation for patients with CAD. The participants highlighted the factors necessary for a successful implementation, such as support through the process and sufficient time from the employer to learn the system and to create new routines in daily practice. Future research is needed to further understand the impact of digital education systems in the secondary prevention of CAD. Ultimately, hybrid models, where the choice of delivery depends on the preferences of the individual patient, would be the optimal model of care for the future.

Continuity of Care Advocate Model (CCAM): Healthcare Workers' Perspectives on Quality Stroke Care at an Acute Unit, Rehabilitation Center and Community Rehabilitation Program in Singapore.

Physicians, nurses, social workers, and allied health professionals including physiotherapists and occupational therapists play important roles as they work closely with stroke survivors to improve functional independence in daily activities and quality of life. Yet, in Singapore little is known about their perspectives on what constitute quality stroke care based on their clinical experiences. In this project, our qualitative interviews with 15 healthcare workers at a major stroke center in the country yielded a Continuity of Care Advocate Model (CCAM) to help us better understand our participants' experience-based perspectives on quality stroke care. We found that CCAM, constructed based on the perspectives of HCWs across a stroke care continuum, is a holistic model of quality stroke care which prioritizes support for patients and their families throughout the patient's health trajectory. We conclude by discussing how this model is aligned with and differs from current research on definitions of care continuity.

Cooperation between health professionals in primary care for the management of musculoskeletal disorders a narrative review / Modèles de partage des tâches impliquant les kinésithérapeutes pour la prise en charge des troubles musculosquelettiques en soins primaires: une revue narrative

Introduction: The current medical shortage and increasing healthcare needs lead to the overcrowding of primary care services. In an effort to cope with this, task sharing models of care have been implemented between healthcare professionals. Varied terms are used to describe these models. In France, "cooperation protocol" pathways have been established between general practitioners and physiotherapists. Objective: The aim of this narrative review is to define the terms used to describe models of task sharing involving physiotherapists for musculoskeletal care and to describe these models and their impact in order to suggest evolution prospects of French experimentations. Results: Delegation, task shifting, substitution, supplementation and advanced practice terms were found in the literature. A clear distinction is suggested between substitution and supplementation. Advanced practice physiotherapy is internationally defined and recognized. Advanced practice physiotherapy models of care seem to improve care access and quality of care without increasing costs. In France, two cooperation protocols have been implemented between general practitioners and physiotherapists for musculoskeletal disorders. Regarding the obstacles to their deployment, these models could evolve considering the international and formally defined framework of advanced practice physiotherapy. Conclusions: Task sharing models of care involving physiotherapists could be promising strategies to improve access to care for patients with musculoskeletal disorders. Further studies are needed to better define the models, their objectives and to evaluate their impact in the French context.

Introduction: L'engorgement des services de soins primaires et l'augmentation de la demande de soins conduisent à des difficultés croissantes d'accès aux soins de premier recours pour les patients souffrant de troubles musculosquelettiques. Pour y faire face, plusieurs modèles de partage de tâches entre les professionnels de santé sont mis en place. Dans la littérature, différentes notions sont employées pour décrire ces modèles. En France, ces expérimentations peuvent prendre la forme de « protocoles de coopération ¼ établis entre les médecins généralistes et les kinésithérapeutes. Objectif: Cette revue narrative vise à définir les notions employées pour décrire les modèles de partage de tâches impliquant les kinésithérapeutes dans la prise en charge des troubles musculosquelettiques à l'international, puis à décrire ces modèles et leur impact pour aboutir à des perspectives d'évolution des expérimentations françaises. Résultats: Les notions de « délégation ¼, de « transfert ¼, de « substitution ¼, de « supplémentation ¼ et de « pratique avancée ¼ sont employées dans la littérature. À la différence des termes « délégation ¼ et « transfert ¼, une distinction claire est retrouvée entre la substitution et la supplémentation. La pratique avancée en kinésithérapie est quant à elle, définie et reconnue à l'international. Elle permettrait d'améliorer l'accès et la qualité des soins, sans augmentation des coûts. En France, deux protocoles nationaux de coopération entre les médecins généralistes et les kinésithérapeutes existent pour les troubles musculo-squelettiques. En tenant compte des freins à leur déploiement rencontrés sur le terrain, ces modèles gagneraient à être repensés en s'inspirant du cadre international de la pratique avancée en kinésithérapie. Conclusions: Les modèles de partage de tâches impliquant les kinésithérapeutes en soins primaires semblent être des leviers d'amélioration de l'accès aux soins pour les patients souffrant de troubles musculosquelettiques. Davantage d'études permettant de mieux définir les modèles, leurs objectifs et d'en évaluer l'efficacité dans le contexte français restent nécessaires.

Healthcare professionals feel empowered by implementing a hospital-based multifaceted intervention: a qualitative study using inductive thematic analysis.

BACKGROUND: Most patients are insufficiently physically active during their hospital stay, and this is associated with poor health and delayed recovery. Hospital-based multifaceted interventions aim to encourage patients to engage in physical activity. Ban Bedcentricity is one such intervention. Its value - and that of others similar to it - for healthcare professionals has not been studied yet. Whether an intervention looks and feels right, and whether it does the job well, is important for healthcare professionals and thus its use. Understanding value for healthcare professionals seems crucial for the long-term adoption and implementation of interventions. Therefore, we studied healthcare professionals' perceptions of value in terms of the implementation of a multifaceted intervention that aimed at improving physically active behaviour in patients during their hospital stay. METHODS: Using Ban Bedcentricity as a case study to focus on healthcare professionals' perceptions about multifaceted interventions, we conducted a qualitative study between November 2019 and September 2020. Semi-structured interviews were conducted with purposefully selected physicians, physiotherapists, and nurses (assistants) until theoretical data saturation was reached. Inductive thematic analysis was used to identify key themes and develop a conceptual model. RESULTS: We interviewed 15 healthcare professionals and formulated six key themes from these interviews. The participants said that Ban Bedcentricity empowered them in their beliefs about the importance of physical activity for hospitalized patients (theme 1). They also indicated that it made them more aware of the value of physical activity (theme 2) and skilled to promote physical activity as part of their professional role (theme 3). Similarly, they noted that it enabled them to shift from providing hands-on support to verbal coaching (theme 4). Other aspects that the participants valued were the increased possibilities for teamwork (theme 5) and the routinized physical activity promotion in usual care (theme 6). The challenges discussed by the participants were prioritizing activities that promoted physical activity, especially because of a high workload, and avoiding relapses of new routinized work practices related to physical activity promotion if insufficient long-term support and training were provided. CONCLUSIONS: Our conceptual model shows that the implementation of a hospital-based multifaceted intervention by healthcare professionals empowers their beliefs, and improves their awareness, skills, professional roles, teamwork, and work routinization. These values are typically overlooked, despite potentially being important facilitators for long-term implementation.

Promotion of physical activity in older adults: facilitators and barriers experienced by healthcare personnel in the context of reablement.

BACKGROUND: Being physically active is important for maintaining function and independence in older age. However, there is insufficient knowledge about how to successfully promote physical activity (PA) among home-dwelling older adults with functional challenges in real-life healthcare settings. Reablement is an interdisciplinary, person-centered approach to restoring function and independence among older adults receiving home care services; it also may be an opportunity to promote PA. However, reablement occurs in many different contexts that influence how PA can be integrated within reablement. This study aimed to identify facilitators and barriers experienced by healthcare professionals (HCPs) that influence the promotion of PA within the context of reablement. METHODS: This exploratory qualitative study is guided by a realist perspective and analyzed through inductive content analysis. Sixteen HCPs, including occupational therapists, physical therapists, registered nurses, and home care workers, participated in semi-structured interviews. The HCPs were recruited from four Norwegian municipalities with diverse sizes and different organizational models of reablement. RESULTS: The HCPs experienced several facilitators and barriers at the participant, professional, organizational, and system levels that influenced how they promoted PA through reablement. Factors related to the individual person and their goals were considered key to how the HCPs promoted PA. However, there were substantial differences among reablement settings regarding the degree to which facilitators and barriers at other levels influenced how HCPs targeted individual factors. These facilitators and barriers influenced how the HCPs reached out to people who could benefit from being more physically active; targeted individual needs, desires and progression; and promoted continued PA habits after reablement. CONCLUSIONS: These findings exemplify the complexity of facilitators and barriers that influence the promotion of PA within the reablement context. These factors are important to identify and consider to develop and organize healthcare services that facilitate older adults to be active. We recommend that future practice and research in reablement acknowledge the variations between settings and consider mechanisms on a participant and professional level and within an integrated care perspective.

The introduction of advanced practice physiotherapy within Dutch primary care is a quest for possibilities, added value, and mutual trust: a qualitative study amongst advanced practice physiotherapists and general practitioners.

BACKGROUND: Despite the increased deployment and added value of Advanced Practitioner Physiotherapy (APP) in musculoskeletal care internationally, APP is not yet widely accepted within Dutch primary care. This may be due to specific constraints in the implementation of APP within the Dutch healthcare system. This study aimed to explore the experiences and perceptions of Advanced Practitioner Physiotherapists (APPs) and General Practitioners (GPs) with respect to implementing APP within Dutch primary care. METHODS: This explorative and interpretive qualitative study included 12 APPs and 3 GPs who were in various stages of implementing an APP care model. Semi-structured interviews were conducted between January and March 2021. The topic list was based on existing literature, the personal input of researchers, and the Constellation Approach framework. Data were analysed using a thematic inductive approach. RESULTS: Four main themes emerged from the data; 1) Both GPs' trust in APP and a clear added value of APP are critical for starting implementation, 2) APPs need continuous support from GPs, 3) APPs believe that their position needs strengthening, and 4) Implementation of the APP model creates tension over ownership. These four themes highlight the perceived difficulties in gaining trust, lack of clarity over the added value of APP, ambiguity over APPs' professional profile and positioning, a need on behalf of GPs to maintain authority, lack of reimbursement structure, and the struggle APPs face to strike a balance with current care. CONCLUSION: This study demonstrates that implementing an APP model of care is challenging, in part, because the deployment of APP does not sufficiently align with the core values of GPs, while GPs appear reluctant to hand over control of elements of patient care to APPs. APPs do not appear to have ownership over the implementation, given their strong dependence on the practice, values and needs of GPs. TRIAL REGISTRATION: Ethical approval was obtained from the Medical Ethics Committee of VU University Medical Centre in Amsterdam; reference number 2020.17 . All participants were asked to provide written informed consent prior to participating in the study.

Patients' and clinicians' experiences with stratified exercise therapy in knee osteoarthritis: a qualitative study.

BACKGROUND: We have developed a model of stratified exercise therapy that distinguishes three knee osteoarthritis (OA) subgroups ('high muscle strength subgroup', 'low muscle strength subgroup', 'obesity subgroup'), which are provided subgroup-specific exercise therapy (supplemented by a dietary intervention for the 'obesity subgroup'). In a large clinical trial, this intervention was found to be no more effective than usual exercise therapy. The present qualitative study aimed to explore experiences from users of this intervention, in order to identify possible improvements. METHODS: Qualitative research design embedded within a cluster randomized controlled trial in a primary care setting. A random sample from the experimental arm (i.e., 15 patients, 11 physiotherapists and 5 dieticians) was interviewed on their experiences with receiving or applying the intervention. Qualitative data from these semi-structured interviews were thematically analysed. RESULTS: We identified four themes: one theme regarding the positive experiences with the intervention and three themes regarding perceived barriers. Although users from all 3 perspectives (patients, physiotherapists and dieticians) generally perceived the intervention as having added value, we also identified several barriers, especially for the 'obesity subgroup'. In this 'obesity subgroup', physiotherapists perceived obesity as difficult to address, dieticians reported that more consultations are needed to reach sustainable weight loss and both physiotherapists and dieticians reported a lack of interprofessional collaboration. In the 'high muscle strength subgroup', the low number of supervised sessions was perceived as a barrier by some patients and physiotherapists, but as a facilitator by others. A final theme addressed barriers to knee OA treatment in general, with lack of motivation as the most prominent of these. CONCLUSION: Our qualitative study revealed a number of barriers to effective application of the stratified exercise therapy, especially for the 'obesity subgroup'. Based on these barriers, the intervention and its implementation could possibly be improved. Moreover, these barriers are likely to account at least partly for the lack of superiority over usual exercise therapy. TRIAL REGISTRATION: The Netherlands National Trial Register (NTR): NL7463 (date of registration: 8 January 2019).

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

BACKGROUND: Over the next decade, the number of osteoarthritis consultations in health care is expected to increase. Physiotherapists may be considered equally qualified as primary assessors as physicians for patients with knee osteoarthritis. However, economic evaluations of this model of care have not yet been described. To determine whether physiotherapists as primary assessors for patients with suspected knee osteoarthritis in primary care are a cost-effective alternative compared with traditional physician-led care, we conducted a cost-effectiveness analysis alongside a randomized controlled pragmatic trial. METHODS: Patients were randomized to be assessed and treated by either a physiotherapist or physician first in primary care. A cost-effectiveness analysis compared costs and effects in quality adjusted life years (QALY) for the different care models. Analyses were applied with intention to treat, using complete case dataset, and missing data approaches included last observation carried forward and multiple imputation. Non-parametric bootstrapping was conducted to assess sampling uncertainty, presented with a cost-effectiveness plane and cost-effectiveness acceptability curve. RESULTS: 69 patients were randomized to a physiotherapist (n = 35) or physician first (n = 34). There were significantly higher costs for physician visits and radiography in the physician group (p < 0.001 and p = 0.01). Both groups improved their health-related quality of life 1 year after assessment compared with baseline. There were no statistically significant differences in QALYs or total costs between groups. The incremental cost-effectiveness ratio for physiotherapist versus physician was savings of 24,266 €/lost QALY (societal perspective) and 15,533 €/lost QALY (health care perspective). There is a 72-80% probability that physiotherapist first for patients with suspected knee osteoarthritis is less costly and differs less than ±0.1 in QALY compared to traditional physician-led care. CONCLUSION: These findings suggest that physiotherapist-led care model might reduce health care costs and lead to marginally less QALYs, but confidence intervals were wide and overlapped no difference at all. Health consequences depending on the profession of the first assessor for knee osteoarthritis seem to be comparable for physiotherapists and physicians. Direct access to physiotherapist in primary care seems to lead to fewer physician consultations and radiography. However, larger clinical trials and qualitative studies to evaluate patients' perception of this model of care are needed. CLINICAL TRIAL REGISTRATION: The study was retrospectively registered in clinicaltrial.gov, ID: NCT03822533.

Development and internal validation of a machine learning prediction model for low back pain non-recovery in patients with an acute episode consulting a physiotherapist in primary care.

BACKGROUND: While low back pain occurs in nearly everybody and is the leading cause of disability worldwide, we lack instruments to accurately predict persistence of acute low back pain. We aimed to develop and internally validate a machine learning model predicting non-recovery in acute low back pain and to compare this with current practice and 'traditional' prediction modeling. METHODS: Prognostic cohort-study in primary care physiotherapy. Patients (n = 247) with acute low back pain (≤ one month) consulting physiotherapists were included. Candidate predictors were assessed by questionnaire at baseline and (to capture early recovery) after one and two weeks. Primary outcome was non-recovery after three months, defined as at least mild pain (Numeric Rating Scale > 2/10). Machine learning models to predict non-recovery were developed and internally validated, and compared with two current practices in physiotherapy (STarT Back tool and physiotherapists' expectation) and 'traditional' logistic regression analysis. RESULTS: Forty-seven percent of the participants did not recover at three months. The best performing machine learning model showed acceptable predictive performance (area under the curve: 0.66). Although this was no better than a'traditional' logistic regression model, it outperformed current practice. CONCLUSIONS: We developed two prognostic models containing partially different predictors, with acceptable performance for predicting (non-)recovery in patients with acute LBP, which was better than current practice. Our prognostic models have the potential of integration in a clinical decision support system to facilitate data-driven, personalized treatment of acute low back pain, but needs external validation first.

Implementing a Stratified Vocational Advice Intervention for People on Sick Leave with Musculoskeletal Disorders: A Multimethod Process Evaluation.

Purpose To perform a process evaluation of a stratified vocational advice intervention (SVAI), delivered by physiotherapists in primary care, for people on sick leave with musculoskeletal disorders participating in a randomised controlled trial. The research questions concerned how the SVAI was delivered, the content of the SVAI and the physiotherapists' experiences from delivering the SVAI. Methods We used qualitative and quantitative data from 148 intervention logs documenting the follow-up provided to each participant, recordings of 18 intervention sessions and minutes from 20 meetings with the physiotherapists. The log data were analysed with descriptive statistics. A qualitative content analysis was performed of the recordings, and we identified facilitators and barriers for implementation from the minutes. Results Of 170 participants randomised to the SVAI 152 (89%) received the intervention and 148 logs were completed. According to the logs, 131 participants received the correct number of sessions (all by telephone) and 146 action plans were developed. The physiotherapists did not attend any workplace meetings but contacted stakeholders in 37 cases. The main themes from the recorded sessions were: 'symptom burden', 'managing symptoms', 'relations with the workplace' and 'fear of not being able to manage work'. The physiotherapists felt they were able to build rapport with most participants. However, case management was hindered by the restricted number of sessions permitted according to the protocol. Conclusion Overall, the SVAI was delivered in accordance with the protocol and is therefore likely to be implementable in primary care if it is effective in reducing sick leave.