First-contact physiotherapists' perceived competency in a new model of care for low back pain patients: a mixed methods study.

Background: A new advanced practice model of care enables French physiotherapists to perform medical acts for low back pain (LBP) patients as first-contact physiotherapists (FCPs). Objective: The aim of this study is to determine the self-perceived competency of FCPs and to further explore factors underpinning this feeling. Methods: A mixed-methods explanatory sequential design was conducted. A survey was used to self-assess the perceived competency of FCPs in performing medical tasks. Semi-structured interviews were then performed to explore determining factors of perceived competency. Inductive thematic analysis was performed. Results: Nine FCPs answered the survey and were interviewed (mean age 40.1, standard deviation [SD]: ±10.0). FCPs felt very competent with making medical diagnosis (3.44/4, SD: ±0.53), analgesic prescription (3.11, SD: ±0.78) and referring onward to physiotherapy (3.78, SD: ±0.55). They did not feel competent with nonsteroidal anti-inflammatory drug prescription (2.78, SD: ±0.67) and issuing sick leave certificate (2.67, SD: ±1.0). The main identified influencing factors were previous FCPs' experience, training, knowledge, collaboration with family physicians, high responsibility and risk management associated with decision-making. Conclusion: French FCPs appeared to have the necessary skills to directly manage LBP patients without medical referral. Future training focusing on analgesic prescription and issuing sick leave certificate is however needed.

Patients presenting with musculoskeletal disorders in the emergency department: A qualitative study of their experiences when cared by advanced practice physiotherapists in the province of Québec.

BACKGROUND: Advanced practice physiotherapy (APP) models of care are promising to alleviate pressure in emergency departments (EDs) where physiotherapists' new roles include being a first-contact practitioner and leading the overall care and management of patients with minor musculoskeletal disorders (MSKDs) to alleviate ED physicians' caseload. PURPOSE: To explore patients' acceptability, experience, satisfaction, and perception of a new APP-led model of care in the ED. METHODS: Patients presenting to the ED with a minor MSKD and who agreed to participate in a multicenter, pan-Canadian randomized controlled trial assessing the efficacy and costs of an APP model of care were invited to participate in this qualitative study. Semi-structured interviews were performed to identify themes related to their experiences with this model. Verbatim transcripts were coded and analysed using an inductive thematic analysis. RESULTS: 11 patients participated and three themes were identified: 1- They were satisfied with the care received within the model; 2- They found APPs to have the appropriate skill set to manage MSKDs and to assume medical-delegated tasks; 3- Timely access to care was a key factor in the acceptability of this model and participants believed physiotherapists were appropriate first-contact practitioners. One participant proposed that the APP model of care should also offer follow-up care. CONCLUSION: Participants had a positive experience of care in this new model. These results support the implementation of APP models of care in EDs as the participants appear receptive to new roles for APPs.

"Cooperation between physicians and physios fosters trust you know": a qualitative study exploring patients' experience with first-contact physiotherapy for low back pain in French primary care.

BACKGROUND: Physiotherapists working in collaboration with family physicians in French multidisciplinary primary healthcare clinics are now able to manage acute low back pain patients as first-contact practitioners in advanced practice roles. This includes medical act delegation such as making a medical diagnosis and prescribing medication. The aim of this study is to explore patients' experience and perceptions when attending a first-contact physiotherapist (FCP) in an advanced practice collaborative primary care model for acute low back pain (LBP). METHODS: A qualitative study using semi-structured interviews was conducted. Patients that consulted a FCP for acute LBP care in new collaborative model were included. Interviews were transcribed verbatim and inductive thematic analysis was performed to generate themes related to patients' experience and perceptions. RESULTS: Ten patients were interviewed (3 women, 7 men; mean age 36.5 ± 9.63 years). All LBP participants experienced important level of pain and disability. Four overarching themes related to patients' experience with the new FCP model were formalized: 1) "Going to see a physiotherapist who specializes in painful movements, well that makes sense to me", 2) "Physiotherapist offered to give me exercises to do at home to relieve the back pain", 3) "I went there feeling confident", 4) "The physiotherapist can do more than just send you to see more appropriate people". Participants highlighted the need to receive timely and high-quality care and were receptive with being autonomously managed by a FCP. Overall, patients' experiences with FCP model of care were positive. Participants were highly confident in the FCP's ability to perform delegated medical tasks including making a medical diagnosis and prescribing oral medication such as analgesic drugs. Patients felt that a greater expansion of FCPs' scope of practice was needed to improve the model. CONCLUSION: Findings from this study can inform the implementation of FCP in countries where patients are not typically granted FCP by underlining that patients are favourable towards the advance practice model as such models support timely and high-quality care. Further research is needed to better determine the future advance practice physiotherapists' scope of practice in French primary and secondary care settings.

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

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

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

A Model of Triage of Serious Spinal Pathologies and Therapeutic Options Based on a Delphi Study.

Background and Objectives: The relevance of red flags in serious spinal pathology (SSP) has evolved throughout the last years. Recently, new considerations have been proposed to expand the consideration of red flags. The purpose of this study was to determine, approve and test a model for the triage and management process of SSPs based on the latest data available in the literature. Materials and Methods: The SSP model was initially built on the basis of a literature review. The model was further determined and approved by an expert panel using a Delphi process. Finally, clinical scenarios were used to test the applicability of the model. Results: After three rounds of the Delphi process, panellists reached a consensus on a final version of the model. The use of clinical scenarios by experts brought about reflexive elements both for the determined model and for the SSPs depicted in the clinical cases. Conclusions: The validation of the model and its implementation in the clinical field could help assess the skills of first-line practitioners managing spinal pain patients. To this end, the development of additional clinical scenarios fitting the determined model should be further considered.

Efficacy of physiotherapy interventions for the management of adults with cervicogenic headache: A systematic review and meta-analyses.

OBJECTIVE: To update and appraise the efficacy of physiotherapy for adults with cervicogenic headache. LITERATURE SURVEY: Bibliographic searches were conducted up to October 2021 for randomized controlled trials (RCTs), assessing the efficacy of physiotherapy interventions for adults with cervicogenic headache, in five databases: CINAHL, Physiotherapy Evidence Database (PEDro), PubMed, Sage Journals, and Wiley Online Library. METHODOLOGY: Data extraction of included trials was conducted by two reviewers according to a standardized extraction form. The PEDro tool and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach were used for grading evidence. Results from trials with similar interventions and with similar outcome measures were pooled into separate meta-analyses. A qualitative synthesis was performed for studies that were not pooled into meta-analyses. SYNTHESIS: Fourteen trials were included. Moderate-certainty evidence indicates that manual therapy significantly reduces headache frequency (mean difference [MD]: -0.93 episodes/week; 95% confidence interval [CI]: -1.40 to -0.46; 2 RCTs; n = 265) compared to sham manual therapy, and headache frequency (MD: -1.23 episodes/week; 95% CI: -1.55 to -0.91; 3 RCTs; n = 126) and intensity (MD: -1.63/10; 95% CI: -2.15 to -1.10; 4 RCTs; n = 208) compared to no treatment in the short term. At 12-month follow-up, moderate-certainty evidence indicates that manual therapy did not lead to greater reduction in headache intensity (MD Visual Analog Scale 0-10: -0.12; 95% CI: -0.49 to 0.26; 2 RCTs; n = 265) or frequency (MD: -0.32 episodes/week; 95% CI: -0.91 to 0.28; 2 RCTs; n = 265) when compared to a sham manual therapy. In the long-term, in one high quality trial, neck exercise significantly reduced headache intensity compared to no treatment (MD: -1.51/10; 95% CI: -2.52 to -0.50; n = 100) or to aerobic exercises in another trial of moderate quality (MD: -1.15/10; 95% CI: -2.1 to -0.20; n = 180). CONCLUSIONS: Manual therapy in the short term and neck exercise in the long term may be efficacious to treat adults with cervicogenic headache. More high-quality evidence is needed and future results may change the current conclusions. Trial Registration Prospero: #CRD42019135858.

Acceptability of a task sharing and shifting model between family physicians and physiotherapists in French multidisciplinary primary healthcare centres: a cross-sectional survey.

OBJECTIVES: The rising prevalence of musculoskeletal disorders increases pressure on primary care services. In France, patients with musculoskeletal disorders are referred to physiotherapist (PT) by family physician (FP). To improve access to musculoskeletal care, a new model of task sharing and shifting is implemented between FPs and PTs for patients with acute low back pain. This new model enables French PTs to expand their usual scope of practice by receiving patients as first-contact practitioner, diagnosing low back pain, prescribing sick leave and analgesic medication. The aim of this study is to investigate the acceptability of FPs and PTs regarding this new model. DESIGN: A cross-sectional survey design was used. Acceptability was measured using a questionnaire on the perception of the model and the perception of PTs' skills to manage low back pain. Descriptive analyses were performed to compare results among participants. SETTING: French FPs and PTs working in multidisciplinary primary healthcare centres were invited to complete an online survey. PARTICIPANTS: A total of 174 respondents completed the survey (81 FPs and 85 PTs). RESULTS: A majority of participants had a positive perception of the task sharing and shifting model. A majority of the participants were mostly or totally favourable towards the implementation of the model (FPs: n=46, 82% and PTs: n=40, 82%). The perceived level of competencies of PTs to manage acute low back pain was high. The confidence level of FPs was higher than that of PTs regarding PTs' ability to adequately diagnose low back pain, refer patient to physiotherapy and prescribe sick leave or analgesic medication. CONCLUSION: Based on this limited sample of participants, there appears to be good acceptability of the task sharing and shifting model for acute low back pain. Additional studies are needed to better determine the factors affecting the acceptability of such a model.

Multimodal Interventions Including Rehabilitation Exercise for Older Adults With Chronic Musculoskeletal Pain: A Systematic Review and Meta-analyses of Randomized Controlled Trials.

BACKGROUND AND PURPOSE: Musculoskeletal disorders (MSKDs) are the most common causes of disabilities for older adults. The aim of this systematic review and meta-analysis is to assess the effectiveness of multimodal interventions including exercise rehabilitation for older adults with chronic MSKDs. METHODS: A literature search was conducted up to February 2019 in 5 bibliographical databases to identify randomized controlled trials (RCTs) that compared multimodal interventions including exercise rehabilitation with usual medical care or no intervention. Randomized controlled trials were assessed with the Cochrane risk-of-bias tool. Meta-analyses were performed and pooled mean differences (MDs) or standardized mean differences (SMDs) were calculated. RESULTS: Sixteen RCTs (n = 2322 participants) were included. One RCT was considered at low risk of bias, 8 had some concerns of bias, and 7 had a high risk of bias. Participants suffered from hip or knee osteoarthritis (OA) (n = 12 RCTs), low back pain (LBP) (n = 2 RCTs) and generalized chronic pain (GCP) (n = 2 RCTs). Multimodal interventions were significantly more effective than usual care to decrease pain (visual analog scale, out of 10 points) in the short term, MD: -0.71 (95% confidence interval [CI] -1.08 to -0.34, n = 900), and in the long term: MD: -0.52 (95% CI -0.98 to -0.05, n = 575), but these differences are not considered clinically important. In terms of disabilities, multimodal interventions were also significantly more effective than usual care. The SMDs were -0.47 (95% CI -0.61 to -0.34, n = 903) and -0.29 (95% CI -0.46 to -0.13, n = 568) for OA trials in the short and long terms, respectively, and -0.47 (95% CI -0.81 to -0.12, n = 211) for LBP and GCP trials in the short term. The magnitude of these effects may be considered as small to moderate. CONCLUSION: Multimodal intervention including exercise rehabilitation combined with usual medical care is an efficacious therapeutic option to reduce disabilities in older adults with chronic MSKDs. A significant but not clinically important effect was observed for pain. The most beneficial component of the multimodal interventions in terms of education, exercises, or medication remains to be determined.

The impact of direct access physiotherapy compared to primary care physician led usual care for patients with musculoskeletal disorders: a systematic review of the literature.

PURPOSE: To update and appraise the available evidence with respect to the impact of direct access physiotherapy compared to primary care physician-led usual medical care for patients with musculoskeletal disorders in terms of efficacy, health care utilization and processes, health care costs, patient satisfaction, and compliance. MATERIALS AND METHODS: Systematic searches were conducted in five bibliographic databases up to June 2019. Studies presenting quantitative data of any research related to direct access physiotherapy for patients with musculoskeletal disorders were included. Two independent raters reviewed the studies, conducted the methodological quality assessment and a data extraction regarding patient outcomes, adverse events, health care utilization and processes, patient satisfaction, and health care costs. RESULTS: Eighteen studies of weak to moderate quality were included. Five studies found no significant differences in pain reduction between usual primary care physician-led medical care and direct access physiotherapy. Four studies reported better clinical outcomes in patients with direct access in terms of function and quality of life. In terms of health care costs, four studies demonstrated that costs were lower with direct access and one study reported similar costs between both types of care. CONCLUSION: Emerging evidence of weak to moderate quality suggest that direct access physiotherapy could provide better outcomes in terms of disability, quality of life, and healthcare costs compared to primary physician-led medical care for patients with musculoskeletal disorders but not for pain outcomes. These conclusions could be modified when higher quality trials are published. CLINICAL RELEVANCE: Direct access physiotherapy for patients with musculoskeletal disorders appears as a promising model to improve efficiency of care and reduce health care costs, but more methodologically sound studies are required to formally conclude. TRIAL REGISTRATION PROSPERO: #CRD42018095604IMPLICATIONS FOR REHABILITATIONEmerging evidence of weak to moderate quality indicates that direct access physiotherapy could provide better outcomes in terms of disability, quality of life and healthcare costs compared to primary physician led usual medical care for musculoskeletal disorders patients.Direct access physiotherapy may lead to increased access to care and a more efficient use of health care resources.Direct access physiotherapy does not appear to improve pain outcomes compared to primary care physician-led usual medical care.