A Systematic Review of Clinical Practice Guidelines for Physical Therapist Management of Patellofemoral Pain.

OBJECTIVE: The purpose of this study was to conduct a systematic review to evaluate clinical practice guidelines for the physical therapist management of patellofemoral pain. METHODS: Five electronic databases (CINAHL, Embase, Medline, Psychinfo, Cochrane Library) were searched from January 2013 to October 2019. Additional search methods included searching websites that publish clinical practice guidelines containing recommendations for physical therapist management of patellofemoral pain. Characteristics of the guidelines were extracted, including recommendations for examination, interventions, and evaluation applicable to physical therapist practice. Quality assessment was conducted using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, applicability of recommendations to physical therapist practice was examined using the AGREE Recommendation Excellence instrument, and convergence of recommendations across guidelines was assessed. RESULTS: Four clinical practice guidelines were included. One guideline evaluated as higher quality provided the most clinically applicable set of recommendations for examination, interventions, and evaluation processes to assess the effectiveness of interventions. Guideline-recommended interventions were consistent for exercise therapy, foot orthoses, patellar taping, patient education, and combined interventions and did not recommend the use of electrotherapeutic modalities. Two guidelines evaluated as higher quality did not recommend using manual therapy (in isolation), dry needling, and patellar bracing. CONCLUSION: Recommendations from higher-quality clinical practice guidelines may conflict with routine physical therapist management of patellofemoral pain. This review provides guidance for clinicians to deliver high-value physical therapist management of patellofemoral pain. IMPACT: This review addresses an important gap between evidence and practice in the physical therapist management of patellofemoral pain. LAY SUMMARY: If you have kneecap pain, this review offers guidance for your physical therapist to provide examination processes, treatments, and evaluation processes that are recommended by high-quality guidelines.

Osteoarthritis Hip and Knee Service (OAHKS) in a community health setting compared to the hospital setting: A feasibility study for a new care pathway.

AIM: OsteoArthritis Hip and Knee Service (OAHKS) clinics involve assessment and triage by advanced musculoskeletal physiotherapists for patients referred to orthopaedic clinics in public hospitals. This study explored the feasibility of implementing an OAHKS clinic in a community setting. METHODS: The domains of feasibility explored in this mixed methods study were acceptability (patient, general practitioner and orthopaedic surgeon), demand (referrals, waiting times) efficacy potential (management decision, conversion-to-surgery rates) and practicality (number and type of discussions between advanced musculoskeletal physiotherapist and doctors, adverse events). Results from a community-based OAHKS were compared with hospital-based OAHKS over a 9-month period in the same metropolitan health region. RESULTS: A total of 91 eligible patients attended an OAHKS clinic (40 community-based, 51 hospital-based). Both the community-based and hospital-based OAHKS had high patient and general practitioner satisfaction, with small differences in favour of community-based OAHKS. Waiting times were significantly shorter in community-based OAHKS for both initial appointment [community-based OAHKS mean 17 days (SD11), hospital-based OAHKS mean 155 days (SD38)] and commencing non-surgical management [community-based OAHKS mean 32 days (SD22), hospital-based OAHKS mean 67 days (SD32)]. Referral rate to orthopaedics was substantially lower from community-based OAHKS (3%) compared with hospital-based OAHKS (33%) [odds ratio 0.05 (95% CI 0.01-0.41)]. There were no adverse events. CONCLUSION: Community-based OAHKS is feasible, and acceptable to patients and general practitioners, with potential benefits indicated in this study including shorter waiting times for assessment and commencing non-surgical management programs.

Primary contact physiotherapy in emergency departments can reduce length of stay for patients with peripheral musculoskeletal injuries compared with secondary contact physiotherapy: a prospective non-randomised controlled trial.

OBJECTIVE: To evaluate if direct physiotherapy assessment and management of patients presenting to emergency departments with musculoskeletal injuries (primary contact physiotherapy) results in reduced length of stay without any increase in adverse effects compared with secondary contact physiotherapy, where patients are seen by a physiotherapist after initial assessment by a doctor. DESIGN: Prospective non-randomised controlled trial. SETTING: Three metropolitan emergency departments. PARTICIPANTS: Adults (n=315) presenting to emergency departments with peripheral musculoskeletal injuries were allocated to primary or secondary contact physiotherapy; 306 participants completed the study. Patients with serious pathology, open fractures and spinal pain were excluded. INTERVENTION: A single episode of physiotherapy. MAIN OUTCOME MEASURES: Primary outcome measures were patient length of stay, waiting time and treatment time. Secondary outcome measures were re-presentations to the emergency department, imaging referrals, patient satisfaction and emergency department staff acceptance. RESULTS: Primary contact physiotherapy resulted in a reduction in length of stay of 59.5 minutes [95% confidence interval (CI) 38.4 to 80.6] compared with secondary contact physiotherapy, with a reduced waiting time of 25.0 minutes (95%CI 12.1 to 38.0) and a reduced treatment time of 34.9 minutes (95%CI 16.2 to 53.6). There were no differences between the groups in imaging referrals or re-presentations. Patients strongly agreed (≥82%) that they were satisfied with their management, and 96% of emergency department staff agreed that primary contact physiotherapists had appropriate skills and knowledge to provide emergency care. CONCLUSION: Experienced musculoskeletal physiotherapists working in emergency departments can be the first point of contact for patients with simple, semi-urgent and non-urgent peripheral musculoskeletal injuries, resulting in decreased waiting times and length of stay for patients without any adverse effects.