Abstract
BackgroundEmergence of more autonomous roles for physiotherapists warrants more evidence regarding their diagnostic capabilities. Therefore, we aimed to evaluate diagnostic and surgical triage concordance between a physiotherapist and expert physicians and to assess the diagnostic validity of the physiotherapist’s musculoskeletal examination (ME) without imaging.MethodsThis is a prospective diagnostic study where 179 consecutive participants consulting for any knee complaint were independently diagnosed and triaged by two evaluators: a physiotherapist and one expert physician (orthopaedic surgeons or sport medicine physicians). The physiotherapist completed only a ME, while the physicians also had access to imaging to make their diagnosis. Raw agreement proportions and Cohen’s kappa (k) were calculated to assess inter-rater agreement. Sensitivity (Se) and specificity (Sp), as well as positive and negative likelihood ratios (LR+/−) were calculated to assess the validity of the ME compared to the physicians’ composite diagnosis.ResultsPrimary knee diagnoses included anterior cruciate ligament injury (n = 8), meniscal injury (n = 36), patellofemoral pain (n = 45) and osteoarthritis (n = 79). Diagnostic inter-rater agreement between the physiotherapist and physicians was high (k = 0.89; 95% CI:0.83–0.94). Inter-rater agreement for triage recommendations of surgical candidates was good (k = 0.73; 95% CI:0.60–0.86). Se and Sp of the physiotherapist’s ME ranged from 82.0 to 100.0% and 96.0 to 100.0% respectively and LR+/− ranged from 23.2 to 30.5 and from 0.03 to 0.09 respectively.ConclusionsThere was high diagnostic agreement and good triage concordance between the physiotherapist and physicians. The ME without imaging may be sufficient to diagnose or exclude common knee disorders for a large proportion of patients. Replication in a larger study will be required as well as further assessment of innovative multidisciplinary care trajectories to improve care of patients with common musculoskeletal disorders.
Highlights
Emergence of more autonomous roles for physiotherapists warrants more evidence regarding their diagnostic capabilities
To adequately take on these autonomous roles, physiotherapists need to be able to provide a valid clinical diagnostic impression and be able to refer accurately patients to other providers or surgical candidates to orthopaedic surgeons; they need do this in manner that is as effective as physicians with expertise in musculoskeletal disorders would do [1]
We found high diagnostic agreement and good triage agreement as well as high diagnostic validity for the musculoskeletal examination (ME) performed by the physiotherapist in patients suffering from common knee disorders and consulting in primary and secondary care settings
Summary
Emergence of more autonomous roles for physiotherapists warrants more evidence regarding their diagnostic capabilities. Evidence shows the limited ability of medical providers to perform an appropriate physical examination to make a diagnosis [4, 5] This has led to an overreliance on imaging or inappropriate referral to specialists to confirm a diagnosis, which incurs increasing health care costs and unnecessary delays to initiate conservative care [4,5,6,7,8]. To adequately take on these autonomous roles, physiotherapists need to be able to provide a valid clinical diagnostic impression and be able to refer accurately patients to other providers or surgical candidates to orthopaedic surgeons; they need do this in manner that is as effective as physicians with expertise in musculoskeletal disorders would do [1]. A systematic review reported that, based on moderate quality studies, inter-rater agreement kappa values ranged from 0.69 to 1.00 for diagnostic agreement between physiotherapists and orthopaedic surgeons and kappa values ranging from 0.52 to 0.70 for the triage of surgical candidates, indicating moderate to high agreement between providers [12]
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