Physiotherapy students' perspectives of online e-learning for interdisciplinary management of chronic health conditions: a qualitative study.

BACKGROUND: To qualitatively explore physiotherapy students' perceptions of online e-learning for chronic disease management using a previously developed, innovative and interactive, evidence-based, e-learning package: Rheumatoid Arthritis for Physiotherapists e-Learning (RAP-eL). METHODS: Physiotherapy students participated in three focus groups in Perth, Western Australia. Purposive sampling was employed to ensure maximum heterogeneity across age, gender and educational background. To explore students' perspectives on the advantages and disadvantages of online e-learning, ways to enhance e-learning, and information/learning gaps in relation to interdisciplinary management of chronic health conditions, a semi-structured interview schedule was developed. Verbatim transcripts were analysed using inductive methods within a grounded theory approach to derive key themes. RESULTS: Twenty-three students (78 % female; 39 % with previous tertiary qualification) of mean (SD) age 23 (3.6) years participated. Students expressed a preference for a combination of both online e-learning and lecture-style learning formats for chronic disease management, citing flexibility to work at one's own pace and time, and access to comprehensive information as advantages of e-learning learning. Personal interaction and ability to clarify information immediately were considered advantages of lecture-style formats. Perceived knowledge gaps included practical application of interdisciplinary approaches to chronic disease management and developing and implementing physiotherapy management plans for people with chronic health conditions. CONCLUSIONS: Physiotherapy students preferred multi-modal and blended formats for learning about chronic disease management. This study highlights the need for further development of practically-oriented knowledge and skills related to interdisciplinary care for people with chronic conditions among physiotherapy students. While RAP-eL focuses on rheumatoid arthritis, the principles of learning apply to the broader context of chronic disease management.

Health Care Professionals' Decision Making Related to Mobility and Safety for People in the Hospital: A Scoping Review.

OBJECTIVE: Mobility dysfunction can have an impact on safety, and this fact is particularly relevant to hospital settings. There are no clear standards for how health care professionals should approach the aim to encourage mobility without compromising safety. The objective of this scoping review was to identify factors that shape health care professionals' decision making for people in hospitals, in situations in which mobility and safety are taken into consideration. METHODS: For this scoping review, 4 databases (Medline, CINAHL, PubMed, and Scopus) were searched. Terms previously agreed upon were used to identify peer-reviewed articles related to decision making by health care professionals in hospital settings (acute and rehabilitation), in which safety and mobility were factors for consideration. An initial screening of titles and abstracts was conducted by a single reviewer. Two reviewers independently screened the full texts of the remaining articles. The key findings of the articles were synthesized to determine common themes. RESULTS: After 10,717 articles were screened, 28 met the inclusion criteria. Ten themes influencing decision making were identified: Clinical factors assessed; health care professional experience; limited use of standardized tests; impact of institutional governance; risk/benefit trade-off; capacity for decision making; role of the multidisciplinary team; families and others; communication; and fear of negative outcomes. CONCLUSION: A wide range of factors influence health care professionals' decision making. The decisions can be complex, and individual priorities may vary in the balancing of safety with promotion of independence. Health care professionals rely on experience, clinical judgment, and shared decision making. IMPACT: This review brings attention to many factors that contribute to decision making when mobility and safety are the factors. Health care professionals should include patients' values and monitor the impact of their personal preferences on this process.

The effectiveness of pulsed electrical stimulation in the management of osteoarthritis of the knee: results of a double-blind, randomized, placebo-controlled, repeated-measures trial.

OBJECTIVE: To determine the effectiveness of subsensory, pulsed electrical stimulation (PES) in the symptomatic management of osteoarthritis (OA) of the knee. METHODS: This was a double-blind, randomized, placebo-controlled, repeated-measures trial in 70 participants with clinical and radiographically diagnosed OA of the knee who were randomized to either PES or placebo. The primary outcome was change in pain score over 26 weeks measured on a 100-mm visual analog scale (VAS). Other measures included pain on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), function on the WOMAC, patient's global assessment of disease activity (on a 100-mm VAS), joint stiffness on the WOMAC, quality of life on the Medical Outcomes Study Short-Form 36 (SF-36) health survey, physical activity (using the Human Activity Profile and an accelerometer), and global perceived effect (on an 11-point scale). RESULTS: Thirty-four participants were randomized to PES and 36 to placebo. Intent-to-treat analysis showed a statistically significant improvement in VAS pain score over 26 weeks in both groups, but no difference between groups (mean change difference 0.9 mm [95% confidence interval -11.7, 13.4]). Similarly, there were no differences between groups for changes in WOMAC pain, function, and stiffness scores (-5.6 [95% confidence interval -14.9, 3.6], -1.9 [95% confidence interval -9.7, 5.9], and 3.7 [95% confidence interval -6.0, 13.5], respectively), SF-36 physical and mental component summary scores (1.7 [95% confidence interval -1.5, 4.8] and 1.2 [95% confidence interval -2.9, 5.4], respectively), patient's global assessment of disease activity (-2.8 [95% confidence interval -13.9, 8.4]), or activity measures. Fifty-six percent of the PES-treated group achieved a clinically relevant 20-mm improvement in VAS pain score at 26 weeks compared with 44% of controls (12% [95% confidence interval -11%, 33%]). CONCLUSION: In this sample of subjects with mild-to-moderate symptoms and moderate-to-severe radiographic OA of the knee, 26 weeks of PES was no more effective than placebo.

Patient experiences of referral practices and primary care physiotherapy for chronic nonspecific low back pain.

BACKGROUND: Low back pain (LBP) clinical practice guidelines recommend referral for patients with persistent LBP however discordance persists between recommended care and implementation in practice. Understanding patient experiences of referral practices and physiotherapy care could be important for optimizing LBP management in primary care settings. PURPOSE: This study explored referral experiences of people with nonspecific LBP in Australian primary care and their knowledge and experience of physiotherapy. METHODS: An interpretive descriptive qualitative framework was used with 17 participants interviewed from community-based physiotherapy practices. RESULTS: Four themes described the participants' experiences of referrals in primary care settings: 1) Referral practices ranged from formal to informal to non-existent; 2) Fragmented inter-and intra-professional LBP care management; 3) Patient perceived differences in the roles of physiotherapists and specialist physiotherapists; and 4) Patient nominated barriers and facilitators to optimal referral practices. CONCLUSION: Physiotherapists support people with LBP to improve strength and function, whereas the specialist physiotherapist's role was seen as more holistic. Referral pathways that align to clinical guideline recommendations for non-surgical management and treatment remain underdeveloped. Improved referral pathways to clinicians such as physiotherapists with additional credentialed skills and competence in musculoskeletal care could improve people's experiences of care and health outcomes.

Patient perspectives of care pathways for people with low back pain: A qualitative study.

BACKGROUND: Low back pain (LBP) care pathways aim to enhance health outcomes through patient-clinician mutual decision-making and care coordination. However, challenges to successful translation into practice include patients' understanding, expectation, and acceptance of treatment and management strategies for LBP. This study explored patients' perspectives and/or experience of care pathways and their involvement in decision-making in primary care. METHODS: A qualitative descriptive design was adopted. Semi-structured interviews were conducted with 14 participants with LBP recruited from the community. Inductive thematic analysis of the qualitative data was conducted within the design framework to enable a systematic comparison of experiences across participants and within individual cases. RESULTS: Five themes described participant perspectives and understanding of care pathways: i) care pathways can guide decision-making; ii) familiarity with no and/or stepped care pathway, but preference for matched or blend of care pathways; iii) engaging in shared decision-making; iv) patient-related barriers to implementation; v) patient-related facilitators to implementation. CONCLUSIONS: Participants felt that existing care pathways did not meet their needs when pain persisted. Participants preferred matched or hybrid care pathways and suggested that implementation of such pathways should focus on addressing an individual's needs. Adopting a holistic approach, and clarity in shared decision-making, were deemed crucial for effective implementation of LBP pathways in practice. Consumer (patient) engagement in the design of LBP care pathways is recommended.

Physical activity and sedentary behaviour in a residential aged care facility.

OBJECTIVE: To evaluate sedentary behaviour and physical activity levels in independently mobile older adults with and without dementia living in residential aged care. METHODS: Sedentary behaviour and physical activity were measured in 37 residents of an aged care facility using an accelerometer worn during waking hours for five days. RESULTS: Participants with valid accelerometer data (n = 28) spent 85% of the time sedentary, and 12% in low-intensity, 2% in light-intensity and 1% in moderate-to-vigorous-intensity physical activity. Over half of sedentary time was accumulated in bouts of greater than 30 minutes. Physical activity at any level of intensity was performed in bouts of less than 10 minutes. CONCLUSION: Residents were highly sedentary and inactive. In particular, the short duration of each bout of activity amongst lengthy periods of sedentary behaviour was a substantial finding. The study suggests the need to develop innovative ways of breaking up sedentary behaviour in residential aged care.

The effectiveness of pulsed electrical stimulation (E-PES) in the management of osteoarthritis of the knee: a protocol for a randomised controlled trial.

BACKGROUND: Osteoarthritis (OA) of the knee is one of the main causes of musculoskeletal disability in the western world. Current available management options provide symptomatic relief (exercise and self-management, medication and surgery) but do not, in general, address the disease process itself. Moreover, adverse effects and complications with some of these interventions (medication and surgery) and the presence of co-morbidities commonly restrict their use. There is clearly a need to investigate treatments that are more widely applicable for symptom management and which may also directly address the disease process itself. In two randomised controlled trials of four and 12 weeks duration, pulsed electrical stimulation was shown to be effective in managing the symptoms of OA of the knee. Laboratory and animal studies demonstrate the capacity of externally applied electric and electromagnetic fields to positively affect chondrocyte proliferation and extracellular matrix protein production. This latter evidence provides strong theoretical support for the use of electrical stimulation to maintain and repair cartilage in the clinical setting and highlights its potential as a disease-modifying modality. METHODS/DESIGN: A double-blind, randomised, placebo-controlled, repeated measures trial to examine the effectiveness of pulsed electrical stimulation in providing symptomatic relief for people with OA of the knee over 26 weeks. Seventy people will be recruited and information regarding age, gender, body mass index and medication use will be recorded. The population will be stratified for age, gender and baseline pain levels. Outcome measures will include pain (100 mm VAS and WOMAC 3.1), function (WOMAC 3.1), stiffness (WOMAC 3.1), patient global assessment (100 mm VAS) and quality of life (SF-36). These outcomes will be measured at baseline, four, 16 and 26 weeks. Activity levels will be measured at baseline and 16 weeks using accelerometers and the Human Activity Profile questionnaire. A patient global perceived effect scale (11-point Likert) will be completed at 16 and 26 weeks. DISCUSSION: This paper describes the protocol for a randomised, double-blind, placebo-controlled trial that will contribute to the evidence regarding the use of sub-sensory pulsed electrical stimulation in the management of OA of the knee. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN12607000492459.

Limited interface between physiotherapy primary care and people with severe mental illness: a qualitative study.

QUESTIONS: How do mental health professionals perceive the role of physiotherapists in the care of people with severe and persistent mental illness, and what factors do they perceive as influencing access to physiotherapy services? How do people with severe and persistent mental illness understand the potential role of physiotherapy in their healthcare, and what factors do they perceive as influencing access to physiotherapy services? DESIGN: Qualitative study. PARTICIPANTS: Twenty-four mental health professionals and 35 people with severe and persistent mental illness. METHODS: Interview schedules were developed to explore participants' understanding of physiotherapy, as well as barriers and enablers to service access. Focus groups and interviews were conducted for each group of participants. Transcripts were analysed using an inductive approach to derive key themes. RESULTS: Both the mental health professionals and the people with severe and persistent mental illness expressed a limited understanding of the role and relevance of physiotherapy for physical health in mental healthcare. Common barriers to service access were cost, transport and lack of motivation. Likewise, enablers of reduced cost, provision of transport and education about physiotherapy to improve their understanding were identified. The health system structure and perceived lack of mental health knowledge by physiotherapists influenced referrals from mental health professionals. Consequently, education in mental health for physiotherapists and integration of the service within mental health were identified as potential enablers to physiotherapy access. CONCLUSION: Limited understanding about physiotherapy and its relevance to physical health in mental healthcare among mental health professionals and people with severe and persistent mental illness was found to be a key factor influencing service access. Limited physiotherapy presence and advocacy within mental health were also highlighted. There is a need for greater understanding about physiotherapy among stakeholders, and for physiotherapists to be well equipped with skills and knowledge in mental health to facilitate greater involvement. [Lee S, Waters F, Briffa K, Fary RE (2017) Limited interface between physiotherapy primary care and people with severe mental illness: a qualitative study. Journal of Physiotherapy 63: 168-174].

Assessing Implementation Readiness and Success of an e-Resource to Improve Prelicensure Physical Therapy Workforce Capacity to Manage Rheumatoid Arthritis.

Study Design Prospective within-subject, cross-sectional, between-group, nested qualitative designs within an implementation science framework. Background Physical therapy is recommended for rheumatoid arthritis (RA) care, yet prelicensure RA curriculum time remains limited. Objectives To determine readiness for, and success of, implementing an e-learning tool, Rheumatoid Arthritis for Physiotherapists e-Learning (RAP-eL), within the prelicensure physical therapy curriculum. Methods All physical therapy students in a 1-year cohort in 2014 had RAP-eL embedded in their curriculum. Rheumatoid Arthritis for Physiotherapists e-Learning is an online platform that delivers RA disease information with translation to clinical practice. Implementation readiness, determined by acceptability of RAP-eL to students, was evaluated using focus groups (n = 23). Implementation success was measured using quantitative data from a previously validated questionnaire, including changes in students' self-reported confidence in knowledge (out of 45) and skills (out of 40) in managing RA after 4 weeks of access to RAP-eL, retention of learning over 14 months, and differences in workforce readiness between students in the cohort who had access to RAP-eL and a historical control cohort. Results Acceptability of RAP-eL was confirmed from qualitative data, demonstrating implementation readiness. Short-term improvements were observed in RA knowledge (mean difference, 16.6; 95% confidence interval [CI]: 15.7, 17.6) and RA skills (mean difference, 14.9; 95% CI: 13.9, 15.9; n = 137). Retention was demonstrated after 14 months (P<.001; n = 62). Students in the 1-year cohort who had RAP-eL embedded in the curriculum scored significantly higher on knowledge (mean difference, 3.6; 95% CI: 1.3, 5.9) and skills (mean difference, 3.3; 95% CI: 0.9, 5.7; n = 62) compared to those without RAP-eL (n = 36). Rheumatoid Arthritis for Physiotherapists e-Learning remains embedded in the curriculum. Conclusion This study demonstrated both readiness and success of the sustainable implementation of RAP-eL within a prelicensure physical therapy curriculum. J Orthop Sports Phys Ther 2017;47(9):652-663. doi:10.2519/jospt.2017.7281.

Policy-into-practice for rheumatoid arthritis: randomized controlled trial and cohort study of e-learning targeting improved physiotherapy management.

OBJECTIVE: To examine the effectiveness of a physiotherapy-specific, web-based e-learning platform, "RAP-el," in best-practice management of rheumatoid arthritis (RA) using a single-blind, randomized controlled trial (RCT) and prospective cohort study. METHODS: Australian-registered physiotherapists were electronically randomized into intervention and control groups. The intervention group accessed RAP-eL over 4 weeks. Change in self-reported confidence in knowledge and skills was compared between groups at the end of the RCT using linear regression conditioned for baseline scores by a blinded assessor, using intent-to-treat analysis. Secondary outcomes included physiotherapists' satisfaction with RA management and responses to RA-relevant clinical statements and practice-relevant vignettes. Retention was evaluated in a cohort study 8 weeks after the RCT. RESULTS: Eighty physiotherapists were randomized into the intervention and 79 into the control groups. Fifty-six and 48, respectively, provided baseline data. Significant between-group differences were observed for change in confidence in knowledge (mean difference 8.51; 95% confidence interval [95% CI] 6.29, 10.73; effect size 1.62) and skills (mean difference 7.26; 95% CI 5.1, 9.4; effect size 1.54), with the intervention group performing better. Satisfaction in ability to manage RA, 4 of the 6 clinical statements, and responses to vignettes demonstrated significant improvement in the intervention group. Although 8-week scores showed declines in most outcomes, their clinical significance remains uncertain. CONCLUSION: RAP-eL can improve self-reported confidence, likely practice behaviors and satisfaction in physiotherapists' ability to manage people with RA, and improve their clinical knowledge in several areas of best-practice RA management in the short term.

Upper cervical instability associated with rheumatoid arthritis: what to 'know' and what to 'do'.

This case report describes a patient who presented with cervical spinal pain and headaches associated with atlanto-axial subluxation (AAS) secondary to rheumatoid arthritis (RA). For physiotherapists, especially less experienced clinicians, the significant risks associated with using manual assessment and treatment techniques in such a patient require careful consideration right at the start of a consultation. The focus of the case is therefore on the recognition of AAS in this patient with RA, highlighting the clinical findings that alert clinicians to this possibility and explaining the requisite knowledge and skills required to safely and effectively manage this patient. The use of screening tools to help clinicians identify possible RA in its pre-diagnosis stage and the clinical signs and symptoms that raise the index of suspicion for AAS, are discussed. The relevant contraindications and precautions associated with manual treatments directed at the upper cervical spine, and which may have potentially serious negative consequences, including quadriplegia and mortality, are addressed. Finally, the implications for the use of manual assessment and treatment of patients with RA and co-morbid AAS are addressed.

Physiotherapy co-management of rheumatoid arthritis: identification of red flags, significance to clinical practice and management pathways.

Rheumatoid arthritis (RA) is a chronic, systemic, autoimmune disease. Physiotherapy interventions for people with RA are predominantly targeted at ameliorating disability resulting from articular and peri-articular manifestations of the disease and providing advice and education to improve functional capacity and quality of life. To ensure safe and effective care, it is critical that physiotherapists are able to identify potentially serious articular and peri-articular manifestations of RA, such as instability of the cervical spine. Additionally, as primary contact professionals, it is essential that physiotherapists are aware of the potentially serious extra-articular manifestations of RA. This paper provides an overview of the practice-relevant manifestations associated with RA that might warrant further investigation by a medical practitioner (red flags), their relevance to physiotherapy practice, and recommended management pathways.

Translating Policy into Practice for Community-Based Management of Rheumatoid Arthritis: Targeting Professional Development Needs among Physiotherapists.

Introduction. Contemporary health policy promotes delivery of community-based health services to people with musculoskeletal conditions, including rheumatoid arthritis (RA). This emphasis requires a skilled workforce to deliver safe, effective care. We aimed to explore physiotherapy workforce readiness to co-manage consumers with RA by determining the RA-specific professional development (PD) needs in relation to work and educational characteristics of physiotherapists in Western Australia (WA). Methods. An e-survey was sent to physiotherapists regarding their confidence in co-managing people with RA and their PD needs. Data including years of clinical experience, current RA clinical caseload, professional qualifications, and primary clinical area of practice were collected. Results. 273 physiotherapists completed the survey. Overall confidence in managing people with RA was low (22.7-58.2%) and need for PD was high (45.1-95.2%). Physiotherapists with greater years of clinical experience, a caseload of consumers with RA, postgraduate qualifications in musculoskeletal physiotherapy, or who worked in the musculoskeletal area were more confident in managing people with RA and less likely to need PD. Online and face-to-face formats were preferred modes of PD delivery. Discussion. To enable community-based RA service delivery to be effectively established, subgroups within the current physiotherapy workforce require upskilling in the evidence-based management of consumers with RA.

Disease-specific knowledge and clinical skills required by community-based physiotherapists to co-manage patients with rheumatoid arthritis.

OBJECTIVE: While strong evidence supports the role of physiotherapy in the co-management of patients with rheumatoid arthritis (RA), it remains unclear what constitutes the essential disease-specific knowledge and clinical skills required by community-based physiotherapists to effectively and safely deliver recommended care. This study aimed to identify essential disease-specific knowledge and skills, link these with evidence from clinical guidelines, and broadly determine the professional development (PD) needs and confidence related to the management of RA among physiotherapists. METHODS: An international Delphi panel of rheumatologists, physiotherapists, and consumers (n = 27) identified essential disease-specific knowledge and clinical skills over 3 rounds. Physiotherapy-relevant recommendations from high-quality, contemporary clinical guidelines were linked to Delphi responses. Finally, an e-survey of PD needs among registered physiotherapists (n = 285) was undertaken. RESULTS: Overarching themes identified by the Delphi panel across the RA disease stages included the need for excellent communication, the importance of a multidisciplinary team and early referral, adoption of chronic disease management principles, and disease monitoring. Of the essential Delphi themes, 86.7% aligned with clinical guideline recommendations. Up to 77.5% of physiotherapists reported not being confident in managing patients with RA. Across the range of essential knowledge and skills themes, 45.1-93.5% and 71.1-95.2% of respondents, respectively, indicated they would benefit from or definitely need PD. CONCLUSION: To effectively manage RA, community-based physiotherapists require excellent communication skills and disease-specific knowledge, including understanding the role of the multidisciplinary team and the principles of early referral, chronic disease management, and monitoring. Physiotherapists identified a need for PD to develop these skills.

Monophasic electrical stimulation produces high rates of adverse skin reactions in healthy subjects.

Monophasic pulsed electrical stimulation (PES) has been reported to improve pain and function in osteoarthritis of the knee with few side effects. This use of monophasic current is contrary to conventional thinking where it is often associated with adverse skin reactions. The objectives of this study were to compare the rates of adverse skin reactions, using independently developed subsensory monophasic PES in healthy subjects, with those described in previous studies and compare the rate of adverse skin reactions after using the monophasic PES with that after using the same shaped electrical waveform that is asymmetrically biphasic. Healthy subjects (n=25) with no contraindications to electrical stimulation were administered subsensory, monophasic, and biphasic PES sequentially to the knee region for approximately 10 minutes each. Stimulation intensities; duration of stimulation; description of sensation reported; skin condition after intervention; and duration of skin reaction were all recorded. Fifty-two percent of subjects experienced adverse skin reactions using monophasic PES. This was significantly different from the reported rates in three of the four previous studies (p<0.04). Only one subject (4%) using the biphasic current demonstrated an adverse skin reaction. Results support the caution advised in the electrotherapy literature when using monophasic electrical stimulation.

Effectiveness of pulsed electrical stimulation in the management of osteoarthritis of the knee: three case reports.

This report examines the symptomatic and functional changes associated with subsensory threshold, pulsed electrical stimulation (PES) treatment for osteoarthritis of the knee in three patients. Two females and one male over age 60, with radiologically diagnosed osteoarthritis of the knee, were treated with PES. The intervention was delivered for eight hours daily at home using a portable, battery-operated unit over 16 weeks. Treatment outcome data were collected at three time points with results plotted for visual examination. Pain, function, patient global assessment, quality of life, global perceived effectiveness, and ambulatory activity levels were measured. The device was well tolerated with adherence levels of 63%, 83%, and 102% of target dose. Perceived global effectiveness of treatment was high for two of the three patients (+3 and +4.5 out of 5), but the third patient reported no change. Scores for pain, global assessment, function, and ambulation were internally consistent with global treatment effect. It is concluded that the PES device was well tolerated, and subsensory PES may provide an effective nonpharmaceutical, noninvasive addition to the management of osteoarthritis of the knee over 16 weeks.