Quality improvement in physiotherapy services.

Purpose The purpose of this paper is to evaluate a process change in physiotherapy services and to explore factors that may have influenced the outcomes. Design/methodology/approach This is a multiple case study and information was gathered from eight physiotherapy teams over 24 months. Findings The process change was successfully implemented in six teams. It had a clear, positive effect on service quality provided to patients in three teams. Whilst quality also improved in three other teams, other issues make changes difficult to assess. Factors that enabled process change to be effective are suggested. Research limitations/implications The findings are based on results achieved by only eight English teams. Practical implications This process change may be appropriate for other teams providing therapy services if attention is paid to potential enabling factors, and a learning approach is adopted to designing and introducing the change. Originality/value To the best of the authors' knowledge, no other longitudinal process change study in therapy services has been published.

A questionnaire to identify patellofemoral pain in the community: an exploration of measurement properties.

BACKGROUND: Community-based studies of patellofemoral pain (PFP) need a questionnaire tool that discriminates between those with and those without the condition. To overcome these issues, we have designed a self-report questionnaire which aims to identify people with PFP in the community. STUDY DESIGNS: comparative study and cross-sectional study. STUDY POPULATION: comparative study: PFP patients, soft-tissue injury patients and adults without knee problems. Cross-sectional study: adults attending a science festival. INTERVENTION: comparative study participants completed the questionnaire at baseline and two weeks later. Cross-sectional study participants completed the questionnaire once. The optimal scoring system and threshold was explored using receiver operating characteristic curves, test-retest reliability using Cohen's kappa and measurement error using Bland-Altman plots and standard error of measurement. Known-group validity was explored by comparing PFP prevalence between genders and age groups. RESULTS: Eighty-four participants were recruited to the comparative study. The receiver operating characteristic curves suggested limiting the questionnaire to the clinical features and knee pain map sections (AUC 0.97 95 % CI 0.94 to 1.00). This combination had high sensitivity and specificity (over 90 %). Measurement error was less than the mean difference between the groups. Test-retest reliability estimates suggest good agreement (N = 51, k = 0.74, 95 % CI 0.52-0.91). The cross-sectional study (N = 110) showed expected differences between genders and age groups but these were not statistically significant. CONCLUSION: A shortened version of the questionnaire, based on clinical features and a knee pain map, has good measurement properties. Further work is needed to validate the questionnaire in community samples.

A comparison of manual therapy and active rehabilitation in the treatment of non specific low back pain with particular reference to a patient's Linton & Hallden psychological screening score: a pilot study.

BACKGROUND: Clinical guidelines for the management of back pain frequently recommend 'manual therapy' as a first line intervention, with psychosocial screening and 'active rehabilitation' for those not improving at 6 weeks post onset. The potential for psychosocial factors to predict treatment response and therefore outcome has not been adequately explored. The purpose of this pilot study was to determine the feasibility of a study to compare manual therapy and active rehabilitation outcomes for subjects with sub-acute/chronic back pain, investigate whether any difference in outcome was related to psychosocial factors, and to inform the design of a main study. METHODS: A convenience sample of 39 patients with non-specific low back pain referred to the physiotherapy department of an acute NHS Trust hospital was recruited over a nine month period. Patients completed the Linton and Hallden psychological screening questionnaire (LH) and were allocated to a low LH (105 or below) or high LH (106 or above) scoring group. The low or high LH score was used to sequentially allocate patients to one of two treatment groups - Manual Therapy comprising physiotherapy based on manual means as chosen by the treating therapist or Active Rehabilitation comprising a progressive exercise and education programme - with the first low LH scoring patient being allocated to active rehabilitation and the next to manual therapy and so on. Treatment was administered for eight sessions over a four-week period and outcome measures were taken at baseline and at four weeks. Measures used were the Roland Morris Questionnaire (RMQ), two components of the Short Form McGill (total pain rating index [PRI] and pain intensity via visual analogue scale [VAS]), and the LH. RESULTS: The manual therapy group demonstrated a greater treatment effect compared with active rehabilitation for RMQ (mean difference 3.6, 95% CI 1.1 - 6.2, p = 0.006) and PRI (7.1, 95% CI 2.0 - 12.2, p = 0.007) and marginally significant results for VAS (15, 95% CI -1.1 to 31.2, p = 0.067). A linear model allowing for confounding effects and the interaction between high or low LH scores supported these results. The interaction effect was not significant for any outcome measure but this could be due to an insufficient number of subjects to detect this effect. CONCLUSION: Comparative evaluation of manual therapy and active rehabilitation with reference to LH psychosocial scores is likely to be detectable by the methods used here. However several alterations to the study design are recommended for the main study. A pragmatic trial using a randomisation process with stratification on the LH score and priori power analysis to determine sample size are suggested for the main study.

Evaluation of a primary care musculoskeletal clinical assessment service: a preliminary study.

OBJECTIVES: To evaluate the clinical effectiveness of a primary care musculoskeletal clinical assessment service (MCAS). The MCAS is a triage and treatment service for the management of patients with musculoskeletal conditions. DESIGN: Prospective observational cohort study. PARTICIPANTS: Consecutive patients with musculoskeletal disorders referred to the MCAS from primary care over a 6-month period. INTERVENTIONS: Patients were managed within the service in accordance with usual MCAS management/treatment pathways. MAIN OUTCOME MEASURES: Previously validated self-administered questionnaires were selected as outcome measures in order to facilitate the use of postal responses. These comprised two generic health status questionnaires (Short Form 36, EuroQol EQ-5D), a pain assessment using a visual analogue scale and two measures of patient satisfaction (Perceived Improvement Evaluation, Deyo and Diehl satisfaction questionnaire). Outcome measures were taken at baseline, and 3 and 12 months after recruitment. RESULTS: In total, 217 patients were recruited into the study. Significant improvement was demonstrated with EuroQol at 3 and 12 months (P=0.043 and 0.035, respectively) and the pain visual analogue scale at 3 and 12 months (P=0.001 and 0.002, respectively). No significant differences were demonstrated with Short Form 36 (P=0.73 and 0.87). The mean patient-perceived improvement was 33% at 3 months and 46% at 12 months. Results showed high levels of patient satisfaction, with 72% of patients indicating total satisfaction with all aspects of the MCAS. CONCLUSIONS: Nationally, models similar to the MCAS have been developed to help improve care for patients and achieve the 18-week access target. This preliminary study shows the possible benefits of adopting this model of care, and identifies the need for further research.