Validation of the Subgroups for Targeted Treatment for Back (STarT Back) screening tool at a tertiary care centre.

BACKGROUND: The Subgroups for Targeted Treatment for Back (STarT Back) tool is a screening questionnaire developed to identify modifiable risk factors for back pain disability in primary care. Given the ability of this tool to assist with early identification of patients at high risk, we examined its concurrent convergent and known-group construct validity in tertiary care. METHODS: This was a case-control study of adult (age > 18 yr) patients with and without an active work-related compensation claim recruited from an academic health centre between August 2017 and May 2019. Patients in the study group were assessed by a physiotherapist and an orthopedic surgeon in a spine specialty program designed to assess and treat workplace injuries. The control group included patients referred to an orthopedic spine surgeon in a publicly funded specialty clinic where an advanced practice physiotherapist determined the need for surgical consultation. We used the Roland-Morris Disability Questionnaire (RMDQ) and the Hospital Anxiety and Depression Scale (HADS) to determine the convergent and known-group construct validity of the STarT Back tool. RESULTS: Fifty case and 50 control participants were included. We observed moderate to high association between the STarT Back total score, psychosocial subscore and risk categories and the RMDQ and HADS scores in the expected direction (p < 0.001). A significant association was observed between risk group allocation and depression (area under the curve values > 80), having a compensable injury and work status (p = 0.002-0.001). CONCLUSION: The STarT Back tool was able to differentiate between patients with and without a compensable injury and patients with different levels of work status. The tool has acceptable convergent and known-group construct validity and can assist in clinical decision-making in a tertiary care setting where adjunct psychologic management may be indicated.

Patient gender does not influence referral to an orthopaedic surgeon by advanced practice orthopaedic providers: a prospective observational study in Canada.

BACKGROUND: The role of an advanced practice physiotherapist has been introduced in many countries to improve access to care for patients with hip and knee arthritis. Traditional models of care have shown a gender bias, with women less often referred and recommended for surgery than men. This study sought to understand if patient gender affects access to care in the clinical encounter with the advanced practice provider. Our objectives were: (1) To determine if a gender difference exists in the clinical decision to offer a consultation with a surgeon; (2) To determine if a gender difference exists in patients' decisions to accept a consultation with a surgeon among those patients to whom it is offered; and, (3) To describe patients' reasons for not accepting a consultation with a surgeon. METHODS: This was a prospective study of 815 patients presenting to a tertiary care centre for assessment of hip and knee arthritis, with referral onward to an orthopaedic surgeon when indicated. We performed a multiple logistic regression analysis adjusting for severity to address the first objective and a simple logistic regression analysis to answer the second objective. Reasons for not accepting a surgical consultation were obtained by questionnaire. RESULTS: Eight hundred and fifteen patients (511 women, 304 men) fulfilled study eligibility criteria. There was no difference in the probability of being referred to a surgeon for men and women (difference adjusted for severity = - 0.02, 95% CI: - 0.07, 0.02). Neither was there a difference in the acceptance of a referral for men and women (difference = - 0.05, 95% CI: - 0.09, 0.00). Of the 14 reasons for declining a surgical consultation, 5 showed a difference with more women than men indicating a preference for non-surgical treatment along with fears/concerns about surgery. CONCLUSIONS: There is no strong evidence to suggest there is a difference in proportion of males and females proceeding to surgical consultation in the model of care that utilizes advanced practice orthopaedic providers in triage. This study adds to the evidence that supports the use of suitably trained alternate providers in roles that reduce wait times to care and add value in contexts where health human resources are limited. The care model is a viable strategy to assist in managing the growing backlog in orthopaedic care, recently exacerbated by the COVID-19 pandemic.

myHip&Knee: Improving Patient Engagement and Self-Management Through Mobile Technology.

Given the increasing volume of hip and knee replacement surgery with reduced hospital stays and resources, we explored technology to address gaps in patient care and enhance self-management. The team at the Holland Orthopaedic and Arthritic Centre of Sunnybrook Health Sciences Centre, which performs a high volume of joint replacement surgery, partnered with patients and a health technology company to create a mobile app: myHip&Knee. The results to date demonstrate that the app improves patient experience and reduces follow-up calls to surgeons' offices, ultimately reducing demand on healthcare resources. Early engagement of privacy and legal services, close patient and family collaboration and a well-developed evaluation strategy represent critical steps to successful development.

A qualitative study of patient education needs for hip and knee replacement.

BACKGROUND: Quality health information is key to patient engagement, self-management and an enhanced healthcare experience. There is strong evidence to support involving patients and their families in the development and evaluation of health-related educational material. These factors were the impetus for our high volume joint replacement centre to undertake a qualitative study to elicit patient experiences to inform the development of effective strategies and education along the care continuum for hip and knee replacement. METHODS: Purposively selected patients from postoperative follow-up clinics were recruited to participate in a focus group or telephone interview. We developed a semi-structured interview guide that addressed four specific aspects of the patient's experience with educational material: pre-surgery, hospital stay, recovery period and future recommendations. The focus groups and interviews continued to the point of saturation and were audio-recorded and transcribed verbatim. Interview transcripts were coded and then inductively organized into larger categories using thematic analysis. RESULTS: Six focus groups and seven telephone interviews were conducted, totalling 32 participants. One of the key themes that emerged was a need for more education concerning pain management post-operatively; specifically, patients wanted more information on expected levels of pain, pain medication usage, management of side effects and guidelines for weaning off the medication. There was surprising variability in patients' descriptions of their pre-surgery, surgery and recovery experiences. These corresponded to an equally diverse range of preferences for educational content, delivery and timing. Many patients reported using the web while others preferred traditional formats for information delivery. There was some interest in receiving education using mobile technology. CONCLUSIONS: Our findings validate the importance of multi-modal patient education tailored to individual preferences and experiences, which may differ according to such characteristics as gender and age. The gap in pain management information is a critical finding for healthcare providers working with patients undergoing joint replacement. Developing pain management education in different formats that addresses frequently asked questions will enhance patient engagement and, their overall experience and recovery.

Evaluation of an advanced-practice physiotherapist in triaging patients with lumbar spine pain: surgeon-physiotherapist level of agreement and patient satisfaction.

BACKGROUND: Surgery for lumbar spine pain is indicated for specific etiologies. Given the majority of individuals referred to spine surgeons are not surgical candidates, care delivery is inefficient, with consultations being of limited value for most. Using specially trained physiotherapists in triage is a human resource strategy that may optimize surgeons' time and the patient experience. METHODS: An advanced-practice physiotherapist (APP) and a surgeon assessed consecutive patients with lumbar spine pain presenting at an academic health centre's spine surgery clinic. The second assessor was blinded to the outcome of the first. We used the κ statistic to evaluate surgeon-APP level of chance-corrected agreement concerning patients' need for a surgical consultation. To assess satisfaction with the APP, patients completed a modified version of the validated Visit-specific Questionnaire. RESULTS: The sample included 102 participants (54 women) with a mean age of 54.3 ± 14.3 years and a mean Oswestry Disability Index score of 35.4 ± 16.6. The assessors' overall agreement was 86%. The κ coefficient for the need for a surgical consultation was 0.69 (95% confidence interval 0.54-0.84). The APP identified that 77% of patients did not require a surgical consultation. Twenty-one patients underwent surgery. Satisfaction scores for the APP were very high (mean score 92 out of 100). CONCLUSION: In triaging patients with lumbar spine pain, the APP and surgeon had a high level of agreement. An APP performing triage at a surgical centre can effectively reduce wait lists by 70%, reserving surgical consultations for those patients in whom they are indicated.

CONTEXTE: La chirurgie pour douleur lombaire est indiquée pour certaines étiologies spécifiques. Étant donné que la majorité des patients adressés à des orthopédistes spécialistes de la colonne vertébrale ne sont pas candidats à la chirurgie, la prestation des soins s'en trouve inefficiente, les consultations se révélant pour la plupart d'une utilité restreinte. Le recours à des physiothérapeutes spécialement formés à l'étape du triage est une stratégie axée sur les ressources humaines qui pourrait libérer les chirurgiens et améliorer l'expérience des patients. MÉTHODES: Un chirurgien et un physiothérapeute ayant suivi une formation avancée (FA) ont évalué des patients consécutifs atteints de douleur lombaire à la clinique de chirurgie pour la colonne vertébrale d'un centre hospitalier universitaire. Le deuxième examinateur n'était pas au courant de l'évaluation du premier. Nous avons utilisé la statistique κ pour évaluer le degré de concordance corrigée pour tenir compte de la concordance due au hasard entre chirurgien et physiothérapeute (FA) quant à la nécessité de faire voir le patient en chirurgie. Pour évaluer leur satisfaction à l'endroit du physiothérapeute (FA), on a administré aux patients une version modifiée du questionnaire VSQ-9 (validé et spécifique à une visite donnée). RÉSULTATS: L'échantillon incluait 102 participants (54 femmes) âgés en moyenne 54,3 ± 14,3 ans et ayant un score de 35,4 ± 16,6 au questionnaire Oswestry sur l'incapacité. La concordance globale entre les évaluateurs a été de 86 %. Le coefficient κ pour ce qui est de la nécessité d'une consultation en chirurgie a été de 0,69 (intervalle de confiance de 95 %, 0,54-0,84). Le physiothérapeute (FA) a jugé que 77 % des patients n'avaient pas besoin d'une consultation en chirurgie. Vingt et un patients ont subi une chirurgie. Les scores de satisfaction à l'endroit du physiothérapeute (FA) ont été très élevés (score moyen 92 sur 100). CONCLUSION: Au moment du triage des patients atteints de douleurs lombaires, les évaluations du physiothérapeute (FA) et du chirurgien ont étroitement concordé. Un physiothérapeute (FA) effectuant le triage dans un centre chirurgical peut efficacement réduire les listes d'attente de 70 %, en limitant les consultations en chirurgie aux patients chez qui elles sont indiquées.

Discordance between self-report and performance-based outcomes: Contribution of psychosocial factors.

The purpose of this study was to examine the role of psychosocial factors in the discordance between perceived and observed physical disability in patients with osteoarthritis of the hip or knee joint. This was a cross-sectional study of patients seen for consideration of joint arthroplasty surgery. Patients completed a psychosocial outcome measure, a patient self-reported functional scale, and two performance-based tests. Data of 121 patients, mean age, 67 (8), 81 (67%) females were used for analysis. The fear avoidance and positive affect domains had the strongest association with the discordance between the self-report and both performance outcome measures. Age, gender, and severity of osteoarthritis were associated with discordance in relation to walking. Fear avoidance beliefs and positive affect play important roles in perception of pain and function. Age, gender, and severity of arthritis should be taken into consideration for a more holistic approach to arthritis care.

Risk Stratification in a Tertiary Care Spine Centre: Comparison Between STarTBack and OSPRO-YF Screening Tools.

Purpose: STarT Back Screening Tool and OSPRO-YF scales have been reported to be accurate tools for estimating risk for the development of persistent pain or prolonged disability in primary care settings. We performed a comparison of construct convergent and known-group validity and ceiling floor effect (CFE) of these tools using a common sample of patients seen at a tertiary care spine centre. Methods: This was a cross-sectional study of patients with and without a work-related back injury. The Hospital Anxiety and Depression Scale (HADS) was used as the reference outcome measure for convergent validity. For known-group validity, we examined the ability of the scales to differentiate between different levels of compensation, presence of non-organic signs, and work status. The CFE values were calculated. Results: Fifty consecutive injured workers were included along with 50 patients without an active compensation claim related to their low back pain. STarTBack and OSPRO-YF had moderate to high associations with the depression component of the HADS (0.69 to 0.77 respectively) with a statistically significant difference in favour of the OSPRO-YF. STarTBack's risk stratification categories were able to differentiate patients with a compensable injury, non-organic signs, and inability to work (p values ranging from 0.002 to < 0.001). The physical activity and work fear-avoidance beliefs constructs of the OSPRO-YF consistently outperformed other yellow flag constructs (p values ranging from 0.008 to < 0.001). The psychological sub-score of STarTBack showed a ceiling effect. There was a floor effect for the negative affect domain of OSPRO-YF. Neither total score had a floor or ceiling effect. Conclusions: STarTBack and OSPRO-YF are short screening tools with acceptable convergent and known-group construct validity and no floor or ceiling effect of their total score. Both tools could assist with the identification, evaluation, and management of psychological distress in patients presenting to tertiary care spine centres.

Objectif : l'outil de dépistage STarT Back et les échelles OSPRO-YF sont considérés comme des mécanismes précis pour estimer le risque d'apparition d'une douleur persistante ou d'une invalidité prolongée en soins primaires. Les chercheurs ont comparé la validité convergente de construit, la validité des groupes connus et l'effet plafond-plancher (EPP) de ces outils auprès d'un échantillon commun de patients suivis dans un centre tertiaire du rachis. Méthodologie : étude transversale de patients atteints ou non d'une blessure dorsale liée au travail. Les chercheurs ont utilisé l'échelle HADS (anxiété et dépression à l'hôpital) comme mesure de référence des résultats pour déterminer la validité convergente. Pour ce qui est de la validité des groupes connus, ils ont examiné la capacité des échelles à distinguer les divers taux d'indemnisation, la présence de signes non organiques et la situation d'emploi et ont calculé les valeurs de l'EPP. Résultats : cinquante (50) travailleurs blessés consécutifs ont participé à l'étude, de même que 50 patients n'ayant pas de réclamation d'indemnisation active liée à leur douleur lombaire. Les outils STarTBack et OSPRO-YF étaient dotés d'associations modérées à élevées avec l'élément « depression ¼ de l'échelle HADS (0,69 à 0,77. respectivement), et la différence en faveur de l'échelle OSPRO-YF était statistiquement significative. Les catégories de stratification du risque de l'outil STarTBack pouvaient distinguer les patients atteints d'une blessure justifiant une indemnisation, les signes non organiques et l'incapacité de travailler (valeurs p de 0,002 à < 0,001). Les construits de l'activité physique et des comportements d'appréhension ou d'évitement de l'échelle OSPRO-YF étaient constamment supérieurs aux autres construits de drapeau jaune (valeurs p de 0,008 à < 0,001). Le sous-score psychologique de l'outil STarTBack avait un effet plafond, tandis que le domaine d'affect négatif de l'échelle OSPRO-YF avait un effet plancher. Aucun des scores totaux n'avait d'effet plancher ou plafond. Conclusions : STarTBack et OSPRO-YF sont de courts outils de dépistage à la validité de construit convergente et de groupes connus et dont le score total n'a ni effet plancher ni effet plafond. Les deux outils pourraient contribuer à déterminer, à évaluer et à prendre en charge la détresse psychologique chez les parents qui consultent dans un centre tertiaire du rachis.

Virtual performance measure in osteoarthritis: An innovative transformation of patient care.

Objectives: The purpose of this study was to develop and establish reliability and validity of a virtual performance measure (VPM) score that encompassed 10 videos in patients with osteoarthritis of the knee joint. Patients' experience and satisfaction were documented. Design: Forty videos were chosen for 10 functional tasks, with four videos showing increasing difficulty for each task. Patients were requested to choose the video that best reflected their own situation. Clinical and radiological findings and self-report and performance measures were completed. Results: Data of 100 patients, 70 (70%) females, mean age: 65 â€‹± â€‹9 were examined. The Cronbach's alpha coefficient that examined internal consistency of the VPM score was 0.92. The intraclass correlation value of 0.82 was obtained for test-retest reliability. Factor analysis showed three distinct domains. There was moderate correlations between the VPM score and the self-report and actual performance measures ranging from r â€‹= â€‹0.46 to 0.66. The VPM summated score of 10 activities was able to differentiate between candidates and non-candidates for knee arthroplasty, with the area under the curve value of 0.90 indicating excellent predictive validity. The overall patient experience and satisfaction was positive with 67% of participants feeling that virtual care could have an impact on minimizing physical presence in the clinic or hospital. Conclusions: The VPM is a reliable and valid outcome measure in patients with osteoarthritis of the knee joint. This digital tool has the potential to transform osteoarthritis care by providing a valid remote measurement of real-life functional limitations and reduce the burden of time consuming in-person tests.

Using outcome measure results to facilitate clinical decisions the first year after total hip arthroplasty.

STUDY DESIGN: Variable-occasion, repeated-measures design. OBJECTIVES: To model change in lower extremity functional status of patients 1 year after total hip arthroplasty (THA), using the Lower Extremity Functional Scale (LEFS) and the 6-minute walk test (6MWT), and, secondarily, to provide clinicians with useful data to guide practice. BACKGROUND: Given the prevalence of THA and current resource pressures, standardized outcome measures play an important role in providing physical therapists with objective knowledge about postoperative recovery and prognosis. METHODS: Seventy-five patients, with a mean age of 61 years and a diagnosis of hip osteoarthritis, consented to participate in the study. Assessments were conducted preoperatively and at multiple time points for up to 65 weeks postoperatively. Recovery was modeled using a nonlinear robust regression analysis for clustered data. The predictive ability of age, body mass index, and preoperative score was explored. RESULTS: Gender-based recovery curves were generated to depict the rate and amount of change in LEFS scores and 6MWT distances over the first year. Preoperative baseline 6MWT distance was the only covariate predictive of postarthroplasty 6MWT distances for both males and females. None of the covariates examined were significantly associated with postarthroplasty LEFS scores. CONCLUSION: Although there were variations in the recovery curves by measure, general patterns were noted. There was a rapid increase in both self-reported and physical performance measure scores for 12 to 15 weeks. Thereafter, we observed a slowing of recovery, with a plateau at 30 to 35 weeks for the 6MWT and later for the LEFS. These data can be used to make evidence-based decisions regarding prognosis and to guide the setting of measurable treatment goals. LEVEL OF EVIDENCE: Prognosis, level 1b.

Psychometric Properties of the OSPRO-YF Screening Tool in Patients with Shoulder Pathology.

Purpose: The Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) is a screening tool that incorporates many important psychosocial domains into one questionnaire to reduce the burden of completing multiple questionnaires. The objectives of this study were to examine the reliability and validity of the 10-item version of the OSPRO-YF with patients with shoulder conditions. Method: The study group consisted of injured workers with an active compensation claim for a shoulder injury. The control group consisted of patients with a complaint of shoulder pain but without a work-related shoulder injury. We examined reliability (internal consistency, test-retest) and validity (factorial, convergent, known groups). The Hospital Anxiety and Depression Scale; the Quick Disabilities of Arm, Shoulder and Hand; and the short Örebro Musculoskeletal Pain Screening Questionnaire were used for comparison. Results: Eighty patients had an active compensation claim, and 160 were in the control group. The intra-class correlation coefficient values for two observations of the domain scores varied from 0.91 to 0.94. The test-retest reliability of the dichotomous constructs was moderate to perfect for 8 of 11 constructs. The 10-item OSPRO-YF questionnaire had three distinct domains, as conceptualized by the developers: mood, fear avoidance, and positive affect-coping. The Cronbach's a coefficients for these domains were 0.88, 0.94, and 0.94, respectively. The associations between the psychological constructs and domains and the similar theoretically derived scales were moderate to high and in the expected direction. Of the 11 constructs of the OSPRO-YF, 10 differentiated between patients with and without a work-related injury (p-values ranging from 0.028 to < 0.001). Conclusions: The 10-item OSPRO-YF reduces the burden of using multiple questionnaires and has acceptable test-retest and internal consistency reliability and factorial, convergent, and known-groups validity.

Objectif : l'Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO­YF) est un outil de dépistage qui regroupe plusieurs volets psychosociaux importants dans un seul questionnaire pour réduire le désagrément de remplir de multiples questionnaires. La présente étude visait à examiner la fiabilité et la validité de la version en dix questions de l'OSPRO­YF chez les patients ayant des problèmes d'épaule. Méthodologie : le groupe d'étude se composait de travailleurs ayant une réclamation d'indemnisation active à cause d'une blessure à l'épaule. Le groupe témoin incluait des patients qui se plaignaient de douleur à l'épaule, mais d'origine non professionnelle. Les chercheurs ont examiné la fiabilité (cohérence interne, test­retest) et la validité (factorielle, convergente et groupes connus) de l'outil. L'échelle d'anxiété et de dépression à l'hôpital, le questionnaire rapide des incapacités du bras, de l'épaule et de la main et le questionnaire court de dépistage de la douleur musculosquelettique Örebro ont été utilisés à des fins comparatives. Résultats : au total, 80 patients avaient une réclamation d'indemnisation active et 160 faisaient partie du groupe témoin. Les valeurs du coefficient de corrélation intraclasse de deux observations se situaient entre 0,91 et 0,94. La fiabilité test­retest des construits dichotomiques était de modérée à parfaite pour huit des 11 construits. Le questionnaire OSPRO­YF en dix questions se divisait en trois volets distincts conceptualisés par les développeurs : humeur, évitement de la peur et affect positif ou adaptation. Les coefficients alpha de Cronbach de ces volets s'établissaient à 0,88, 0,94 et 0,94, respectivement. Les associations entre les construits psychologiques, les volets et les échelles semblables dérivées théoriquement étaient modérées à élevées et se situaient dans l'orientation prévue. Dix des 11 construits du questionnaire OSPRO­YF pouvaient distinguer les patients ayant ou non une blessure professionnelle (valeurs p entre 0,028 et < 0,001). Conclusions : l'OSPRO­YF en dix questions réduit le désagrément lié à l'utilisation de multiples questionnaires et présente une fiabilité test­retest et une cohérence interne acceptables, de même qu'une fiabilité factorielle, convergente et de groupe connu.

Reduced acromiohumeral distance and increased critical shoulder angle: implications for primary care clinicians.

Objectives: The literature indicates that reduced acromiohumeral distance (AHD) and increased critical shoulder angle (CSA) are associated with large and massive rotator cuff (RC) tears which may not be amenable to a successful repair. The purpose of this study was to examine the overall accuracy of these two radiographic features in diagnosing significant RC pathology. Methods: This was a diagnostic study of patients with shoulder pain. To examine the overall accuracy of the measurements, the area under the Receiver Operating Characteristic curves (AUC) were calculated. The validity indices (sensitivity, specificity and likelihood ratios) examined the predictive value of specific cutoff categories of AHD<6 mm and the CSA >35°. Results: Data of 200 consecutive patients; mean age: 59(11), 117 males were used for analysis. There was a weak inverse correlation (r = 0.46) between the AHD and CSA. The AUCs for presence and size of RC tear and different stages of fatty infiltration of supraspinatus and infraspinatus muscles varied from fair to excellent for AHD and poor to good for CSA. Specificity was high for the cutoff categories of both AHD and CSA (>90%). The positive LRs were large for AHD and small to moderate for CSA. Conclusion: The AHD and CSA were reliably measured in the true AP radiographic view. Both radiographic features (AHD<6mm and CSA>35°) were able to confirm the presence of a major RC pathology. However, the AHD<6 mm, an acquired radiologic abnormality secondary to failure of the RC muscles/tendons had better measurement properties. This information is of value to primary care physicians, sports medicine specialists and advanced practice physiotherapists in their clinical decision making.

Diagnostic Value of Acromiohumeral Distance in Rotator Cuff Pathology: Implications for Advanced-Practice Physiotherapists.

Purpose: The primary purpose of this study was to examine the inter-tester reliability and criterion validity of reduced acromiohumeral distance (AHD; <6 mm) visualized on plain radiographs in detecting rotator cuff (RC) pathology. The secondary objective was to examine the relationship between this radiographic feature and patient demographics and clinical examination. Method: This was a diagnostic study of patients seen in a tertiary care centre. Two advanced-practice physiotherapists measured AHD in two radiographic views. MRI was used as the gold standard. Results: A total of 150 consecutive patients (mean age 59 [SD 11] y, 57 women, 93 men) were included. AHD less than 6 millimetres was highly specific in both views for the presence of tear (99%), tear size (96%-98%), and fatty infiltration in the supraspinatus and infraspinatus muscles (93%-96%). The absence of AHD less than 6 millimetres was associated with a lack of advanced fatty infiltration in the supraspinatus and infraspinatus muscles (92%-100%). Sensitivity values were low for the presence and size of RC tear (21%-55%). We found a statistically significant positive association between the AHD categories and clinically observed muscle wasting and weakness of the RC muscles (p < 0.05). Conclusions: AHD less than 6 millimetres was reliably measured in plain radiographs and was strongly associated with important clinical and imaging features of advanced RC pathology; this may assist with clinical decision making by allowing judicious use of more costly investigations and referral for surgery.

Objectif : la présente étude avait comme objectif primaire d'examiner la fiabilité interévaluateur et la validité critérielle d'un intervalle acromio-huméral réduit (IAH < 6 mm) observé à la radiographie simple pour déceler une pathologie de la coiffe des rotateurs (CR). Son objectif secondaire consistait à examiner la relation entre cette caractéristique radiographique, la démographie des patients et l'examen clinique. Méthodologie : étude diagnostique de patients vus dans un centre de soins tertiaires. Deux physiothérapeutes en pratique avancée ont mesuré l'IAH sur deux vues radiographiques. L'imagerie par résonance magnétique servait de norme de référence. Résultats : au total, 150 patients consécutifs (âge moyen de 59 ans [ÉT 11], 57 femmes, 93 hommes) ont été inclus dans l'étude. Dans les deux vues radiographiques, l'IAH inférieur à 6 mm était hautement spécifique de la présence d'une déchirure (99 %), de la dimension de la déchirure (96 % à 98 %) et d'une infiltration graisseuse dans les muscles supra-épineux et infra-épineux (93 % à 96 %). L'absence d'IAH inférieur à 6 mm s'associait à l'absence d'infiltration graisseuse avancée dans les muscles supra-épineux et infra-épineux (92 % à 100 %). Les valeurs de sensibilité étaient faibles pour ce qui est de la présence et de la dimension d'une déchirure de la CR (21 % à 55 %). On constatait une association statistiquement significative entre les catégories d'IAH et une observation clinique d'amyotrophie et de faiblesse musculaire de la CR (p < 0,05). Conclusion : l'IAH inférieur à 6 mm était mesuré en toute fiabilité sur des radiographies simples et s'associait fortement à des caractéristiques de pathologie avancée de la CR, tant sur le plan de la clinique que de l'imagerie. Ces constatations pourraient contribuer aux prises de décision en favorisant l'utilisation judicieuse d'explorations plus coûteuses et de l'orientation en chirurgie.

A framework for the development and implementation of an advanced practice role for physiotherapists that improves access and quality of care for patients.

A new model of care has been implemented at the Sunnybrook Holland Orthopaedic and Arthritic Centre that expands the role of physiotherapists to improve access and quality of care for patients requiring hip and knee replacement surgery. An advanced practice physiotherapist (APP) role was created to support both referral management and post-operative care to reduce surgeon workload and better streamline services. This article describes our nine-step framework for implementing an APP role and can be used as a template for other organizations evolving similar roles. The framework was adapted from the participatory, evidence-based, patient-focused process for the development of an advanced practice nurse role. Key steps include (1) obtaining stakeholder consensus, (2) identifying barriers and facilitators and (3) developing the necessary administrative and training supports as well as clinical protocols and an evaluation framework. Approaching change in a series of small steps (plan-do-study-act [PDSA] methodology) alongside existing processes has facilitated buy-in and role acceptance. The early and continued involvement of decision-makers within the organization has been paramount to successful implementation. In addition, patient input has been central to the evolution of the role, with patient satisfaction a key indicator. The new role and model of care reconfigures traditional roles and introduces a team approach that results in timely access to care for patients. Benefits include an improved assessment process, enhanced education across the care continuum and improved coordination and delivery of services.

Impact of Radiographic Imaging of the Shoulder Joint on Patient Management: An Advanced-Practice Physical Therapist's Approach.

Purpose: Recent care innovations using advanced-practice physical therapists (APPs) as alternative health care providers are promising. However, information related to the clinical decision making of APPs is limited with respect to ordering shoulder-imaging investigations and the impact of these investigations on patient management. The purpose of this study was twofold: (1) to explore the clinical decision making of the APP providing care in a shoulder clinic by examining the relationship between clinical examination findings and reasons for ordering imaging investigations and (2) to examine the impact on patient management of ordered investigations such as plain radiographs, ultrasound (US), magnetic resonance imaging (MRI), and magnetic resonance arthrogram (MRA). Method: This was a prospective study of consecutive patients with shoulder complaints. Results: A total of 300 patients were seen over a period of 12 months. Plain radiographs were ordered for 241 patients (80%); 39 (13%) received MRI, 27 (9%) US, and 7 (2%) MRA. There was a relationship between clinical examination findings and ordering plain radiographs and US (ps=0.047 to <0.0001). Plain radiographs ordered to examine the biomechanics of the glenohumeral joint affected management (χ2 1=8.66, p=0.003). Finding a new diagnosis was strongly correlated with change in management for all imaging investigations (ps=0.001 to <0.0001). Conclusion: Skilled, extended-role physical therapists rely on history and clinical examination without overusing costly imaging. The most important indicator of change in management was finding a new diagnosis, regardless of the type of investigation ordered.

Objectif : innovation récente, la prestation de certains actes autrefois réservés aux chirurgiens orthopédistes par les physiothérapeutes en pratique avancée (PPA) est prometteuse. Cependant, on en connaît peu sur le lien entre la prise de décision clinique des PPA et les demandes de tests d'imagerie de l'épaule, ainsi que sur l'influence de ces tests sur la prise en charge des patients. Cette étude avait deux objectifs : 1) étudier la prise de décision clinique de PPA exerçant dans une clinique de l'épaule en examinant la relation entre les résultats de l'examen clinique et les motifs des demandes de tests d'imagerie et 2) examiner l'influence des tests demandés sur la prise en charge du patient, par exemple les radiographies simples, les échographies, les imageries par résonance magnétique (IRM) et les arthrographies par résonance magnétique (ARM). Méthodologie : cette étude prospective a été menée auprès de patients consécutifs se plaignant de problèmes à l'épaule. Résultats : au total, 300 patients ont été pris en charge sur une période de 12 mois. On a demandé des radiographies simples pour 241 patients (80 %), dont 39 (13 %) ont subi une IRM, 27 (9 %) une échographie et 7 (2 %) une ARM. On a observé un lien entre les résultats de l'examen clinique et la demande de radiographies simples et d'échographies (valeurs ps de 0,047 à <0,0001). Les radiographies simples demandées pour examiner la biomécanique de l'articulation scapulo-humérale ont eu une influence sur la prise en charge (χ2 1=8,66, p=0,003). La pose d'un nouveau diagnostic a été fortement corrélée à un changement de la prise en charge pour tous les tests d'imagerie (valeurs ps de 0,001 à <0,0001). Conclusion : les physiothérapeutes compétents ayant un champ de pratique élargi se fient à l'historique du patient et aux examens cliniques sans abuser des tests d'imagerie coûteux. L'indicateur de changement le plus important dans la prise en charge a été la pose d'un nouveau diagnostic, peu importe le type de test demandé.

Patients' perceptions of navigating "the system" for arthritis management: are they able to follow our recommendations?

PURPOSE: To understand whether a visit to a Hip/Knee Arthritis Assessment Centre (AC), where non-surgical candidates with arthritis are directed toward community resources and provided with a conservative treatment "prescription," contributes to patients' self-management and ability to access community resources. METHODS: A purposive sample of non-surgical patients was contacted 3-10 months after their AC visit. Three focus groups (n=20) and 20 semi-structured telephone interviews were conducted. Transcripts were systematically coded and analyzed using a qualitative descriptive research methodology. RESULTS: While participants generally reported that the AC visit improved self-management, analysis identified an emergent theme about the inadequacy of conservative management in general, subdivided into two sub-themes related to (1) limited access to high-quality, non-surgical treatment, such as physiotherapy and (2) health care providers' attitudes and approaches, which do not embrace chronic disease prevention and management. CONCLUSIONS: An AC visit contributes to arthritis self-management; however, the current health care system does not adequately support conservative treatment of chronic conditions. Treatment guidelines need to be tailored to the local health care context in which they are applied.

Objectif: Pour comprendre si une visite à un centre d'évaluation de l'arthrite de la hanche ou du genou, où des personnes qui ne sont pas candidates a grave; une intervention chirurgicale et ont de l'arthrite sont dirigées vers des ressources communautaires et reçoivent une « ordonnance ¼ portant sur un traitement de conservation, contribue à l'autoprise en charge par les patients et à leur capacité d'avoir accès aux ressources communautaires. Méthodes: On a communiqué, pendant 3 à 10 mois après leur visite au centre d'évaluation, avec un échantillon choisi à dessein de patients non candidats à une intervention chirurgicale. On a organisé trois groupes de discussion (n=20) et procédé à 20 entrevues téléphoniques semi structurées. Les comptes rendus ont été codés systématiquement et analysés au moyen d'une méthodologie de recherche descriptive qualitative. Résultats: Les participants ont signalé en général que les visites au centre d'évaluation amélioraient l'autoprise en charge, mais l'analyse a dégagé un thème émergent au sujet de l'insuffisance de la prise en charge conservatrice en général, subdivisé en deux sous-thèmes portant sur (1) l'accès limité à un traitement non chirurgical de grande qualité comme la physiothérapie et (2) les attitudes et les approches des fournisseurs de soins de santé qui n'adoptent pas la prévention et la prise en charge des maladies chroniques. Conclusions: Une visite à un centre d'évaluation contribue à l'autoprise en charge de l'arthrite, mais le système de santé actuel n'appuie pas adéquatement un traitement conservateur des problèmes chroniques. Il faut personnaliser les lignes directrices sur le traitement en fonction du contexte local des soins de santé où elles sont appliquées.

Evaluation of an advanced-practice physical therapist in a specialty shoulder clinic: diagnostic agreement and effect on wait times.

PURPOSE: To examine the role of an advanced-practice physiotherapist (APP) with respect to (1) agreement with an orthopaedic surgeon on diagnosis and management of patients with shoulder problems; (2) wait times; and (3) satisfaction with care. METHODS: This prospective study involved patients with shoulder complaints who were referred to a shoulder specialist in a tertiary care centre. Agreement was examined on seven major diagnostic categories, need for further examination and surgery, and type of surgical procedure. Wait times were compared between the APP- and surgeon-led clinics from referral date to date of initial consultation, date of final diagnostic test, and date of confirmed diagnosis and planned treatment. A modified and validated version of the Visit-Specific Satisfaction Instrument assessed satisfaction in seven domains. Kappa (κ) coefficients and bias- and prevalence-adjusted kappa (PABAK) values were calculated, and strength of agreement was categorized. Wait time and satisfaction data were examined using non-parametric statistics. RESULTS: Agreement on major diagnostic categories varied from 0.68 (good) to 0.96 (excellent). Agreement with respect to indication for surgery was κ=0.75, p<0.001; 95% CI, 0.62-0.88 (good). Wait time for APP assessment was significantly shorter than wait time for surgeon consultation at all time points (p<0.001); the surgeon's wait time was significantly reduced over 3 years. High satisfaction was reported in all components of care received from both health care providers. CONCLUSIONS: Using experienced physiotherapists in an extended role reduces wait times without compromising patient clinical management and overall satisfaction.

Objectif : Examiner le rôle du physiothérapeute en pratique avancée en ce qui a trait (1) aux accords avec un chirurgien orthopédique sur le diagnostic et la gestion de patients aux prises avec des problèmes à l'épaule; (2) au temps d'attente; (3) à la satisfaction par rapport aux soins. Méthode : Cette étude prospective a fait appel à des patients avec des douleurs à l'épaule qui ont été dirigés vers des spécialistes de l'épaule dans un centre de soins tertiaires. Les accords ont été examinés pour sept catégories de diagnostics, en fonction de la nécessité d'examens plus poussés ou de chirurgie et du type d'intervention chirurgicale projeté. On a comparé les temps d'attente pour le physiothérapeute en pratique avancée et les cliniques dirigées par un chirurgien à partir de la date où le patient a été redirigé à la consultation initiale, jusqu'à la date de diagnostic définitif, jusqu'à la date de diagnostic confirmé et jusqu'au traitement planifié. Une version modifiée et validée de l'instrument d'évaluation de la satisfaction à la suite d'une consultation (Visit-Specific Satisfaction Instrument) a permis de mesurer la satisfaction dans sept domaines. Les coefficients kappa (κ) et les valeurs kappa ajustées pour la prévalence et le biais (PABAK) ont été calculés et les accords ont été catégorisés selon leur force. Les données sur les temps d'attente et la satisfaction ont été examinées à l'aide de statistiques non paramétriques. Résultats : Le degré d'accord sur les diagnostics importants variait de 0,68 (bon) à 0,96 (excellent). Les accords en ce qui concerne le recours à la chirurgie étaient de κ=0,75, p<0,001, I.C. 95%, 0,62­0,88 (bon). Les temps d'attente pour une évaluation par un physiothérapeute en pratique avancée étaient considérablement plus courts que ceux pour une consultation auprès d'un chirurgien à toutes les étapes (p<0,001); les temps d'attente pour un chirurgien étaient considérablement réduits sur 3 ans. Un degré élevé de satisfaction a été observé dans toutes les composantes des soins prodigués par des fournisseurs de soins. Conclusions : Le recours à un physiothérapeute expérimenté dont la pratique s'étend hors des rôles traditionnels réduit les temps d'attente sans nuire à la gestion clinique du patient ni influer sur sa satisfaction globale.

Patients are satisfied with advanced practice physiotherapists in a role traditionally performed by orthopaedic surgeons.

PURPOSE: To measure and compare patient satisfaction with follow-up care in advanced practice physiotherapist (APP) and orthopaedic surgeon clinics for patients following total hip or knee replacement. METHOD: Consecutive patients attending either an APP-led or a surgeon-led review clinic were surveyed using a modified nine-item satisfaction questionnaire based on the Visit-Specific Satisfaction Instrument (VSQ-9). Chi-square analyses were used to examine differences in patient characteristics and type of visit. Independent t-tests were used to examine potential differences in patient satisfaction. RESULTS: Of the 123 participants, more than half were aged 65 years or older. Chi-squared analyses revealed no significant difference in participant characteristics (gender, age, and overall health status) between the two different types of clinics. There was a significant difference (χ(2) (4)=12.49, p=0.014) in the distribution of the timing of follow-up appointments. There was no significant difference between the groups in mean overall patient satisfaction scores on the modified VSQ-9 (p=0.34) nor in the mean of the sum of the seven items related to the service provider (p=0.85). Satisfaction scores for most of the service-provider items were above 90/100. CONCLUSION: Patients are highly satisfied with the care provided by APPs in follow-up clinics after joint replacement. Evaluation of the patient perspective is essential to any new role involving a shift in traditional practice boundaries.

Modelling knee range of motion post arthroplasty: clinical applications.

PURPOSE: To model change in knee range of motion (ROM) post total knee arthroplasty (TKA) and to show how this information can be incorporated into clinical decision making. METHOD: We applied a variable-occasion repeated-measures study design. Patients' knee flexion and extension ROM were assessed pre- and post arthroplasty over the ensuing 60 weeks. We examined change in ROM post TKA using linear and nonlinear mixed-effects modelling, and examined whether age, body mass index, prearthroplasty ROM, and gender were determinants of recovery in post-arthroplasty ROM. RESULTS: Of 93 eligible patients, 74 provided pre- and post-arthroplasty data. A random intercept nonlinear model fit the flexion data best, and a random intercept linear model fit the extension data best. Pre-arthroplasty ROM was found to be a determinant of recovery in ROM post arthroplasty. This finding was common to both flexion and extension models. CONCLUSIONS: Our study showed that the greatest improvement for knee ROM took place during the first 12 weeks post arthroplasty. Of the variables examined, only pre-arthroplasty ROM was a determinant of outcome (p<0.05). The study results provide clinicians with data to determine expected rates of improvement for patients as well as the projected maximum ROM, facilitating improved clinical decision making.