Validation of an advanced practice physiotherapy model of care in an orthopaedic outpatient clinic.

BACKGROUND: In Canada, new models of orthopaedic care involving advanced practice physiotherapists (APP) are being implemented. In these new models, aimed at improving the efficiency of care for patients with musculoskeletal disorders, APPs diagnose, triage and conservatively treat patients. Formal validation of the efficiency and appropriateness of these emerging models is scarce. The purpose of this study is to assess the diagnostic agreement of an APP compared to orthopaedic surgeons as well as to assess treatment concordance, healthcare resource use, and patient satisfaction in this new model. METHODS: 120 patients presenting for an initial consult for hip or knee complaints in an outpatient orthopaedic hospital clinic in Montreal, Canada, were independently assessed by an APP and by one of three participating orthopaedic surgeons. Each health care provider independently diagnosed the patients and provided triage recommendations (conservative or surgical management). Proportion of raw agreement and Cohen's kappa were used to assess inter-rater agreement for diagnosis, triage, treatment recommendations and imaging tests ordered. Chi-Square tests were done in order to compare the type of conservative treatment recommendations made by the APP and the surgeons and Student t-tests to compare patient satisfaction between the two types of care. RESULTS: The majority of patients assessed were female (54%), mean age was 54.1 years and 91% consulted for a knee complaint. The raw agreement proportion for diagnosis was 88% and diagnostic inter-rater agreement was very high (κ=0.86; 95% CI: 0.80-0.93). The triage recommendations (conservative or surgical management) raw agreement proportion was found to be 88% and inter-rater agreement for triage recommendation was high (κ=0.77; 95% CI: 0.65-0.88). No differences were found between providers with respect to imaging tests ordered (p≥0.05). In terms of conservative treatment recommendations made, the APP gave significantly more education and prescribed more NSAIDs, joint injections, exercises and supervised physiotherapy (p<0.05). Patient satisfaction was significantly higher for APP care than for the surgeons care (p<0.05). CONCLUSION: The diagnoses and triage recommendations for patients with hip and knee disorders made by the APP were similar to the orthopaedic surgeons. These results provide evidence supporting the APP model for orthopaedic care.

Advanced practice physiotherapy in patients with musculoskeletal disorders: a systematic review.

BACKGROUND: The convergence of rising health care costs and physician shortages have made health care transformation a priority in many countries resulting in the emergence of new models of care that often involve the extension of the scope of practice for allied health professionals. Physiotherapists in advanced practice/extended scope roles have emerged as key providers in such new models, especially in settings providing services to patients with musculoskeletal disorders. However, evidence of the systematic evaluation of advance physiotherapy practice (APP) models of care is scarce. A systematic review was done to update the evaluation of physiotherapists in APP roles in the management of patients with musculoskeletal disorders. METHODS: Structured literature search was conducted in 3 databases (Medline, Cinahl and Embase) for articles published between 1980 and 2011. Included studies needed to present original quantitative data that addressed the impact or the effect of APP care. A total of 16 studies met all inclusion criteria and were included. Pairs of raters used four structured quality appraisal methodological tools depending on design of studies to analyse included studies. RESULTS: Included studies varied in designs and objectives and could be categorized in four areas: diagnostic agreement or accuracy compared to medical providers, treatment effectiveness, economic efficiency or patient satisfaction. There was a wide range in the quality of studies (from 25% to 93%), with only 43% of papers reaching or exceeding a score of 70% on the methodological quality rating scales. Their findings are however consistent and suggest that APP care may be as (or more) beneficial than usual care by physicians for patients with musculoskeletal disorders, in terms of diagnostic accuracy, treatment effectiveness, use of healthcare resources, economic costs and patient satisfaction. CONCLUSIONS: The emerging evidence suggests that physiotherapists in APP roles provide equal or better usual care in comparison to physicians in terms of diagnostic accuracy, treatment effectiveness, use of healthcare resources, economic costs and patient satisfaction. There is a need for more methodologically sound studies to evaluate the effectiveness APP care.

Prehabilitation improves physical function of individuals with severe disability from hip or knee osteoarthritis.

PURPOSE: To evaluate the effects of prehabilitation (enhancing physical capacity before total hip or knee joint arthroplasty) on pain and physical function of adults with severe hip and knee osteoarthritis (OA). METHODS: Consecutive patients (n=650) from 2006 to 2008 with hip or knee OA awaiting total joint arthroplasty (TJA) attended a hospital outpatient clinic for a prehabilitation assessment. All participants completed self-report (Lower Extremity Functional Scale [LEFS] and visual analogue scale for pain [VAS]) and functional performance measures (self-paced walk [SPW], timed stair, and timed up-and-go [TUG] tests). A subset of 28 participants with severe disability participated in a structured outpatient prehabilitation programme. Between-group differences were assessed via independent t-tests; paired Student's t-tests and Wilcoxon signed rank tests were used to compare changes in pain and function following the prehabilitation programme. RESULTS: A total of 28 individuals (16 female) with mean age 67 (SD 10) years and BMI 33 (8) kg/m(2) awaiting TJA (10 hips, 18 knees) participated in a prehabilitation programme of 9 (6) weeks' duration. Relative to baseline, there was significant improvement in LEFS score (mean change 7.6; 95% CI, 1.7-13.5; p=0.013), SPW (mean change 0.17 m/s; 95% CI, 0.07-0.26; p=0.001), TUG (mean change 4.2 s; 95% CI, 2.0-6.4; p<0.001), and stair test performance (mean change 3.8 s [SD 14.6]; p=0.005) following prehabilitation. CONCLUSION: This study presents preliminary evidence that prehabilitation improves physical function even in the most severely compromised patients with OA awaiting TJA.

Objectif : Évaluer l'effet, en termes de douleurs et d'incapacités, d'un programme de pré-réadaptation ayant pour but d'optimiser la condition de patients souffrant d'arthrose sévère en attente d'une arthroplastie totale de la hanche ou du genou Méthode : Une cohorte de 650 patients consécutifs souffrant d'arthrose de la hanche ou du genou en attente d'une arthroplastie ont subi une évaluation préchirurgicale dans une clinique externe. L'évaluation des participants comprenait des mesures auto-rapportées telles que l'échelle fonctionnelle des membres inférieurs (ÉFMI), des mesures de douleurs à l'aide d'échelles visuelles analogues (EVA) et des mesures de performance fonctionnelle (test de marche à vitesse libre, test chronométré des escaliers, test chronométré assis-debout [TUG]). Un sous-groupe de 28 participants souffrant d'incapacités sévères a participé à un programme structuré de pré-réadaptation.  Des tests de t de Student indépendants ont été utilisés pour évaluer les différences entre les deux groupes. Des tests de t de Student et des tests Wilcoxon pour mesures appariées ont été utilisés pour comparer les changements en termes de douleurs et d'incapacités suivant le programme de pré-réadaptation. Résultats : Au total, 28 individus (16 femmes, 12 hommes) avec un âge moyen (écart-type : ET) de 67 (10) ans et un IMC moyen de 33 (8) kg/m2 en attente d'une arthroplastie (10 hanches, 18 genoux) ont participé au programme de pré-réadaptation d'une durée moyenne de 9 (6) semaines. Suivant l'intervention, des changements significatifs ont été observés en termes d'incapacités fonctionnelles mesuré par l'ÉFMI (changement moyen de 7,6; IC 95%, 1,7­13,5; p=0,013), au test de marche à vitesse libre (changement moyen de 0,17 m/s; IC 95%: 0,07­0,26; p=0,001), au test TUG (changement moyen de 4,2 s; IC 95%, 2,0­6,4; p<0,001) et au test chronométré des escaliers (changement moyen de 3,8 s [ET :14,6]; p=0,005). Conclusion : Cette étude présente des évidences préliminaires qu'un programme de pré-réadaptation, chez des patients souffrant d'arthrose, en attente d'une arthroplastie du genou ou de la hanche, peut améliorer la fonction physique même chez les patients les plus sévèrement atteints.