Advanced Practice Physiotherapists Research Articles

Prospective validity of a clinical prediction rule for response to non-surgical multidisciplinary management of knee osteoarthritis in tertiary care: a multisite prospective longitudinal study

ObjectivesWe tested a previously developed clinical prediction tool—a nomogram consisting of four patient measures (lower patient-expected benefit, lower patient-reported knee function, greater knee varus angle and severe medial knee radiological...

The complex challenge of prescribing as an advanced clinical practice physiotherapist

Non-medical prescribing (NMP) has been developing in the UK over the last couple of decades. As part of their NMP course, the author explores some of the legal, professional and ethical complexities that await them and other Health and Care Professions Council workers upon conclusion of the Royal Pharmaceutical Society's competency framework for all prescribers. Focus is primarily directed towards the application of NMP by an individual with physiotherapists background, working in an advanced clinical practice (ACP) role in paediatric intensive care. This commentary critiques some of the dilemmas that may present regarding legislation, regulation and the inability to prescribe controlled drugs independently. Solutions using clinical management plans are presented, alongside ideas for future development of prescribing ACPs.

Advanced practice physiotherapists in primary health care: stakeholders’ views of a new scope of practice

Advanced practice physiotherapists in primary health care: stakeholders’ views of a new scope of practice

A survey of physiotherapist managers in Ireland and their views on the role of Advanced Practice Physiotherapists.

Within the current context of implementation of an Advanced Practice Grade, the Irish Society of Chartered Physiotherapists commissioned a survey of physiotherapy manager opinions regarding the role of Advanced Practice Physiotherapists. The aim of this survey was to explore the views of physiotherapist managers in relation to the characteristics, role, competencies and management of Advanced Practice Physiotherapists (APPs) in Ireland. Physiotherapist managers based in primary and secondary care settings in Ireland were invited to participate in a survey on Advanced Practice. Quantitative data from a custom designed online survey was analysed with descriptive statistics and qualitative data from open-ended survey questions were analysed using thematic analysis. The response rate to the survey was 32% (24/75). On average, respondents thought that 54% (range: 15%-80%) of an APPs time should be spent in clinical practice and between 17% and 20% variously on managerial and leadership, teaching and education and research and development duties. Four themes were identified from the surveys' open-ended questions related to the description of APP: 'Extended scope 'Advanced clinical training, knowledge, and decision-making', 'Autonomy, independence and responsibility', and 'Wider roles'. Irish physiotherapist managers recognised the extended scope of practice, expertise and multiple roles characteristic of APPs. They indicated the need for legislative changes and clarity around governance.

Advancing physiotherapy practice: A quality improvement project to train advanced practice physiotherapists to deliver caudal epidurals in a community setting

Advancing physiotherapy practice: A quality improvement project to train advanced practice physiotherapists to deliver caudal epidurals in a community setting

An evaluation of the effectiveness of an advanced practice physiotherapist in the emergency department setting in Ireland.

One of the means of easing increased pressure on emergency care worldwide has been the development of advanced musculoskeletal physiotherapy practice in the emergency department setting. This model of care is in its infancy in Ireland. To evaluate the effectiveness of an advanced practice physiotherapist working as a primary contact clinician in the emergency department at St. James's Hospital, Dublin. A three-month retrospective chart review was undertaken for patients assigned the advanced practice physiotherapist as their primary clinician during their emergency department attendance. Three widely accepted measures of quality in emergency medicine were used to evaluate effectiveness, namely, time from attendance to discharge, time from triage to assessment, and unplanned reattendance within seven days. A total of 129 patients were included in this study. Time from attendance to discharge was significantly less in the APP group (mean 208.5min, standard deviation 122.4min) than in the ED group (mean 377.1min, standard deviation 314.7min) (mean difference - 168.61 (95% C.I - 191.24- - 145.98)) (p < 0.001). Time from triage to assessment was significantly less in the APP group (mean 72.1min, standard deviation 51.9min) than in the ED group (mean 94.1min, standard deviation 96.5min) (mean difference - 22.08 (95% C.I - 31.28- - 12.89)) (p < 0.001). The unplanned reattendance rate was 3.9%. No adverse events were identified. The findings of this study indicate that an advanced practice physiotherapist can provide a timely, effective, and safe service for patients attending the emergency department with musculoskeletal complaints in Ireland.

Advanced practice physiotherapists can diagnose and triage patients with musculoskeletal disorders while providing effective care: a systematic review.

What is the diagnostic and surgical triage concordance between advanced practice physiotherapists (APPTs) and physicians? What is the clinical efficacy of advanced practice physiotherapy care compared with usual medical care? Systematic review with meta-analyses. Medline, Embase, Cochrane CENTRAL and CINAHL were searched up to March2022. Concordance studies on diagnostic or surgical triage between APPTs and physicians and randomised controlled trials comparing the clinical efficacy of an advanced practice physiotherapy (APP) model of care compared with usual medical care for participants with musculoskeletal disorders. Meta-analyses were performed for concordance and clinical outcomes. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to evaluate the certainty of evidence. Nineteen concordance studies (n= 1,745) and six randomised trials (n= 1,960) were included. Based on moderate-certainty evidence, the pooled Kappa for diagnostic concordance between APPTs and physicians was 0.76 (95% CI 0.68 to 0.85, n= 1,108). Based on high-certainty evidence, the pooled Kappa for surgical triage concordance was 0.71 (95% CI 0.63 to 0.78, n= 1,128). Based on moderate-certainty evidence, APP care resulted in a comparable or greater reduction in pain (MD -0.92 out of 10, 95% CI -1.75 to -0.10, n= 494) when compared with usual medical care at medium-term follow-up. Based on low-certainty evidence, APP care resulted in a comparable or greater reduction in disability (SMD -0.31, 95% CI -0.67 to 0.04, n= 535) when compared with usual medical care at medium-term follow-up. Concordance between APPTs and physicians is probably good to very good for diagnosis and good to very good for surgical triage of musculoskeletal disorders. Patients with musculoskeletal disorders managed in an APP model of care probably report comparable or greater pain and disability reductions when compared with usual medical care. CRD42022320950.

Assessing the feasibility of a clinical trial to evaluate an advanced practice physiotherapy model of care in chronic pain management: a feasibility study

BackgroundChronic pain management is challenging for health systems worldwide. Clinical practice guidelines recommend interprofessional chronic pain management, but chronic pain clinics often have lengthy wait-lists. Advanced practice physiotherapists (APP) in orthopedic clinics and emergency departments have provided effective care and reduced wait times. The purpose of this study is to determine the feasibility of a clinical trial to evaluate the effects of integrating an APP into a chronic pain clinic setting. The primary objectives are as follows: (1) determine the feasibility of implementing trial methods by evaluating participant recruitment rates, retention, and assessment completion; (2) determine the feasibility of implementing the APP model of care by monitoring care provided and treatment fidelity; and (3) assess contextual factors that may influence implementation of the APP model of care by exploring the perspectives of patient participants and healthcare providers related to the model of care.MethodsThis will be a single-arm feasibility study with embedded qualitative interviews to assess contextual factors influencing implementation by exploring participant and provider perspectives. Approximately 40 adults with chronic musculoskeletal pain referred for care at an interprofessional chronic pain clinic will be invited to participate in the feasibility study. Approximately 10–12 patient participants and 5–10 health professionals from the interprofessional team will be interviewed using an interpretive description approach. The APP model of care will involve participants seeing a physiotherapist as the first point of contact within the interprofessional team. The APP will complete an initial assessment and make care recommendations. Outcome measures planned for the full trial will be reported descriptively, including pain severity, pain interference, health-related quality of life, psychosocial risk factors for chronic pain, treatment satisfaction, perceived change, healthcare utilization, and healthcare costs over one year.DiscussionThis study will inform plans to implement a full-scale study to evaluate the impact of an APP model of care in an interprofessional chronic pain management program. The results of the full study are intended to inform stakeholders considering this model to improve patient-centered and health system outcomes in interprofessional pain management program settings.Trial registrationClinicalTrials.gov, NCT05336903 (Registered April 5, 2022).

Comparison of a validated decision-support tool to a standard of care triage system for knee osteoarthritis assessment: a proof-of-concept study.

Patients with knee osteoarthritis (OA) in northwestern Ontario are referred by their primary care provider (PCP) to a centralized assessment clinic for evaluation by an advanced practice physiotherapist (APP) to determine if they will require surgical management. However, many patients are found to not require surgical management, resulting in delays for patients who do. A decision-support tool was developed to address this issue and to guide treatment options by determining the need for surgical or nonsurgical approaches. We used a proof-of-concept method to assess the use of the decision-support tool in northwestern Ontario. Data from 100 consecutive patients assessed for knee OA management were collected from the Thunder Bay centralized assessment clinic. Two levels of agreement analyses (calculated using Cohen κ statistic) were performed, between the APP assessment decision (surgical or non-surgical) and the decision-support tool recommendation, and between the surgeon's decision (surgical or non-surgical) and the decision-support tool recommendation. We found a near-perfect agreement (κ = 0.870, n = 65) between the APP decision and the decision-support tool recommendation, when controlled for patient preference. There was a substantial level of agreement (κ = 0.618, n = 72) between the decision-support tool recommendation and the surgeon's decision. The decision-support tool recommendation showed considerable agreement with the decisions of the APP and surgeon indicating that it could be a valuable tool to guide PCPs caring for patients with knee OA. The applicability of a decision-support tool in northwestern Ontario displayed promising results, but further research is needed to examine the feasibility in a primary care setting.

Physiotherapy versus pain medication for managing chronic cervical radiculopathy: protocol for a multi-arm parallel-group randomized clinical trial

Background: Cervical radiculopathy (CR) is one of the prevalent causes of neck pain and disability. Physiotherapy and pain medications are the common nonoperative management, and in physiotherapy, there are many concepts of assessment and management. This study aims to determine the comparative effectiveness of three specialized physiotherapy approaches or only pain medications for managing CR cases. Methods: A prospective, assessor, and participant-blind, four-arm randomized control trial (RCT) has been planned to conduct on 160 patients with chronic cervical radiculopathy in 4 specialized centers of Dhaka city recruited between July and December 2022. Four groups (n=40) will be treated through structural diagnosis and management concept (SDM), regional approaches (RA), McKenzie mechanical diagnosis and therapy (MDT) concept prescribed by advanced practice physiotherapist (APP), or pain medications prescribed by the specialist physician for 4 weeks. The outcome will be evaluated in baseline, intermediate test (14 days), and post-treatment (28 days) through Brief Pain Inventory (BPI) for pain, Goniometer reading for cervical range of motion (ROM), and Neck disability index (NDI) as the primary outcome. The secondary outcome will be quality of life measured at baseline and post-treatment by the WHO quality of life questionnaire WHOQOL-BREF. Discussion: The study will compare the efficacy of the three physiotherapy approaches with pain medications when treating chronic cervical radiculopathy. The findings will provide evidence when demining the best conservative management approach for CR. Clinical Trial Registry India: CTRI/2022/03/040922 (08/03/2022)

Advanced practice physiotherapists in Scottish primary care: Axial Spondyloarthropathy epidemiology, time to diagnosis, and referrals to rheumatology.

(1) Generate empirical knowledge of a Musculoskeletal (MSK) Advanced Practice Physiotherapist (APP) Service in Scottish Primary Care; (2) Identify the incidence and baseline time to diagnosis of Axial Spondyloarthropathy (AxSpA); (3) Identify APP Rheumatology referral fulfilment of the NICE 2017 Guidelines and Spondylarthritis Diagnosis Evaluation (SPADE) Tool; (4) Calculate APP Rheumatology referral conversion rates for AxSpA diagnosis and further investigation; (5) Contribute towards the current body of literature for informing analysis of MSK APP services within Scottish Primary Care. An audit and evaluation approach was undertaken over a 3-year period (May 2019-April 2022). Relevant clinical cases from the whole-service data-set were identified and analysed, using retrospective electronic healthcare record review and descriptive statistical techniques. A total of 37,656 primary care MSK APP consultations took place, with N=19 suspected AxSpA referrals made to Rheumatology. N=6 cases of AxSpA were diagnosed by a Rheumatologist (31.6%). The mean age of individuals diagnosed with AxSpA was 39.6±8.8, and 66.7% (4/6) were female. Mean time to diagnosis was 3.4years, and incidence per-10,000 person-years was 1.6. Compliance of referrals with the NICE 2017 Guidelines and SPADE Tool Criteria was 78.9%. Of those diagnosed with AxSpA, 66.7% met both referral criterion sets. Those referred by an MSK APP from primary care had a 5.1year shorter time to diagnosis than the previous reported UK average of 8.5years. APPs identified relevant AxSpA features in referring to Rheumatology, and supported effective implementation of the local secondary care pathway.

P019 Improving new patient appointment utilisation in rheumatology advanced practice physiotherapy

Abstract Background/Aims Long Rheumatology waiting lists in the UK were further affected by the COVID-19 pandemic; resulting in negative impacts upon the timeliness and efficiency of patient care. The use of Advanced Practitioners within Rheumatology care pathways has been shown to be safe and effective; they can support the Rheumatology workforce and expedite care where patients are appropriately triaged to them. As part of a service provision change in a NHS Trust, an Advanced Practice Physiotherapist (APP) post was funded with the intent to harness these benefits. Initial utilisation of the APP appointments within the Rheumatology provision was found to be low and could be improved. A Quality Improvement (QI) Project was initiated, with the aim to increase APP appointment utilisation to at least 85% over a period of four months, and for at least 75% of these appointments to contain patients who had been appropriately triaged. Methods The ‘Model for Improvement’ was chosen as the QI approach. The project was led by an APP. Firstly, a stakeholder analysis was performed to identify staff with influence and interest in the project. A root cause analysis found lack of awareness of triaging clinicians and challenges with booking processes as potential reasons for lower-than-expected appointment utilisation. Change interventions were devised and tested over three Plan, Do, Study, Act (PDSA) cycles. PDSA one developed communication with booking and triage staff to clarify these processes with them. PDSA two educated clinical staff about the APP role, triage criteria and the booking procedures confirmed in PDSA one. PDSA three focused upon sustaining change by reinforcement of the topics established in PDSA two among staff. Outcome measures used were the percentage of available APP appointments utilised per week, and the percentage of these which contained patients who were appropriately triaged. Results APP appointment utilisation increased from a mean of 22% pre-project to 61% during the change intervention period. Sixty-three patients were seen over the 17-week change intervention period; of which 86% had been appropriately triaged. Data showed that 70% of the patients directed to the APP were managed by them (24% discharged and 46% reviewed). Of the remaining patients, 13% were followed up by a Rheumatologist, 12% did not attend and 5% had an alternative outcome such as awaiting advice. Conclusion This QI project led to an improvement in Rheumatology care provision locally. Engagement with support staff, education of clinical staff and implementation of clear standard operating procedures improved the utilisation of the Rheumatology APP resource. Results suggest that the APP role was effective locally in managing appropriately triaged patients, without a negative effect on patient care or other services. Continuing to improve utilisation will support management of the Rheumatology waiting list and improve patient care. Disclosure S. East: None. G.J. McCall: None. P.A. Watson: None. P. Smith: None.

E050 Developing multidisciplinary models of care in rheumatology at University College London Hospital: 18 months of learning from conception to delivery and beyond

Abstract Background/Aims The COVID-19 pandemic has placed unprecedented pressures on NHS departments, with demand rapidly outstripping capacity. The British Society for Rheumatology ‘Rheumatology Workforce: a crisis in numbers (2021)’ highlighted the need to provide innovative ways of delivering rheumatology specialist care. At University College London Hospitals (UCLH) we created a rheumatology multidisciplinary team (MDT) clinic to meet rising demands on our service. The aims of the Rheumatology MDT clinic were to: reduce new appointment/follow-up waiting times, increase clinic capacity, incorporate musculoskeletal (MSK) point of care ultrasound, reduce number of hospital visits and add value to each clinic encounter. Methods We ran a 6-month pilot, supported by our outpatient transformation team, incorporating a Rheumatology Advanced Practice Physiotherapist (APP), Clinical Nurse Specialist (CNS) and MSK ultrasound within a Consultant clinic. The success of the pilot helped secure funding for a further 12 months. Over 18 months we have implemented: APP/Consultant enhanced triage - up to 40% of referrals were appropriate for APP assessment, including regional MSK problems and back pain. This increased capacity for consultant-led appointments. Standardisation of time-lapse between CNS and consultant follow-up appointments to ensure appropriate spacing between patient encounters. Facilitated overbooking of urgent cases afforded by additional capacity provided by the APP. MSK ultrasound embedded in the clinic template. ‘Zoom’ patient education webinars facilitated by MDT members and wider disciplines e.g. dietetics, to empower self-management and reduce the administrative burden of patient emails/phone calls occurring outside the clinic. Patient participation sessions and feedback to help shape the service. Results During the 6-month pilot we reduced our waiting time for follow-up appointments from 9 months to 2. We now have capacity to book 1-2 urgent cases each week. Pre-MDT the average wait from consultant referral to physiotherapist appointment was 55 days. The MDT allows for same day assessment (reducing 2-3 patient journeys a clinic) and where suitable, facilitates discharge or onwards referral to the appropriate service. A dedicated MDT CNS has shortened treatment times, reduced email traffic between CNS and consultant and allows for same day, joint decision-making resulting in fewer appointments. Zoom webinar feedback has been positive. Patients value the broad expertise of allied health professionals which supports self-management. Embedding ultrasound allows for same day diagnostics, decreased referrals to radiology and reduced hospital visits. Conclusion Our MDT model has reduced waiting lists, decreased treatment delays and cut hospital attendances. Point of care ultrasound allows for same day decision making and abolishes the cost and diagnostic delay associated with referrals to radiology or outsourced providers. Shared decision-making adds value to outpatient attendances, which is reflected in patients’ positive feedback. The MDT model maximises the existing workforce skill set by enhancing the APP and CNS role, allowing patients immediate access to their expertise. Disclosure F. Higgs: None. D. Ludwig: None. N. Allotey: None. S. Begum: None. J. Burton: None.

P050 GIRFT in action: Advanced Practice Physiotherapist and Advanced Practice Nurse expertise provides valuable triage and assessment clinics for non-urgent Rheumatology referrals

Abstract Background/Aims Rheumatology referrals classified as non-urgent/routine are commonly non-inflammatory conditions or medically non-urgent and can have significant waiting times for appointments. These waits were further escalated by the COVID-19 pandemic. Early intervention for non-inflammatory conditions can be crucial to good outcomes and long wait-times can have significant adverse impacts while appropriate care pathways are determined. Recent UK GIRFT recommendations include using non-medical health professional expertise in assessment and management pathways to support right place, right time, right care. This study evaluated effectiveness, impacts and patient experiences of Advanced Practice Physiotherapist (APP) and Advanced Practice Nurse (APN) Triage and Assessment Clinics for routine new referrals. Methods The non-urgent/routine referral waiting list was e-triaged by a Rheumatology APP and APN supported by clinical record searches. Patients were contacted by telephone to update on clinical status and appointment requirements determined. Triage criteria were applied to determine new referrals suitable for APP and APN Rheumatology clinics, which included low likelihood of inflammatory disease or new referrals for known diagnosis/stable conditions. Clinics were undertaken with collocated Consultant clinical supervision. Assessment findings were discussed and management agreed, or seen if needed. With waiting list attrition, clinics were expanded to include Consultant-determined stable condition reviews and follow-up reviews for non-suspected inflammatory disease. Results At 01 July 2021, 214 new routine referrals were waiting a Consultant appointment (n=103 over 2yrs). Since service initiation, clinic outcomes to date include: 69% (n = 243/358) new routine referrals discharged to GP or directed to right pathway with information, advice and self-management resources; 8% (n=29) escalated to urgent; 3% (11/358) with medical complexity remained on Consultant waitlist. Most common presentations seen included: Osteoarthritis (general or hand); Back and other spinal pain; Fibromyalgia; Persistent Fatigue and Widespread Pain; JHS/hEDS; Positive ANA without clinical features; Musculoskeletal conditions- other. To date, no patients have been re-referred and 329 new patient and 89 follow-up Consultant direct consultations have been spared. There is currently no wait-time for non-urgent/routine appointments. Patient experience feedback on the service has offered a 100% recommendation to continue and expressed highly positive experiences with the MDT approach. Patients value the breadth of expertise and care support, and the timely, thorough and professional service provided. Conclusion Rheumatology non-urgent/routine new referrals with low probability of underlying autoimmune conditions may be effectively and efficiently managed in a collaborative model using an advanced practice physiotherapist and nurse. This innovation has expanded a traditionally medical pathway to an MDT model utilising value-adding non-medical expertise in service delivery. It has enhanced interdisciplinary learning and is a valued, collaborative approach to patient care. The initiative provides support to GIRFT recommendations of using an MDT skill-set to support improved patient access, service efficiencies and earlier intervention. Disclosure C. McCrum: Grants/research support; Funding grant to provide professional education workshops- Novartis, Janssen. B. Zeljkovic: None. C. Perera: None.

VALIDITY OF THE VIRTUAL SEVERITY SCORING SYSTEM IN PATIENTS WITH KNEE OSTEOARTHRITIS

The Severity Scoring System (SSS) is a guide to interpreting findings across clinical, functional, and radiological findings, used by qualified, specially trained physiotherapists in the advanced practice role in order to provide consistency in determining the severity of the patient's condition and need for surgical consultation. The system has been utilized for over 14 years as a part of standardized assessment and management care and was incorporated into virtual care in 2020 following the pandemic restrictions. The present study examined the validity of the modified SSS in virtual care.Patients who were referred to the Rapid Access Clinic (RAC), were contacted via phone by two experienced advanced practice practitioners (APPs) from May to July 2020, when in-person care was halted due to the pandemic. The virtual interview included taking history, completing self-reported measures for pain and functional ability and reviewing the radiological reports.A total of 63 patients were interviewed (mean age 68, SD=9), 34 (54%) females. Of 63 patients, 33 (52%) were considered a candidate for total knee arthroplasty (TKA). Men and women were comparable in age, P4 and LEFS scores. The TKA candidates had a significantly higher SSS (p&lt;0.0001) and pain scores (p=0.024). The variability of the total SSS score explained by the functional, clinical and radiological components of the tool were 55%, 48% and 4% respectively, highlighting the more important role of patient's clinical history and disability in the total SSS.The virtual SSS is a valid tool in directing patients for surgical management when used by highly trained advanced practice physiotherapists. A large component of the SSS is based on clinical data and patient disability and the APP's skillset rather than severity of pathology found on imaging.

Patient-Reported Experiences of Musculoskeletal Virtual Care Delivered by Advanced Practice Physiotherapists

Purpose: To better understand patients’ perspectives on virtual care (VC) delivered by advanced practice physiotherapists (APPs) for hip/knee, foot/ankle, shoulder/elbow, and low back related symptoms. Method: A patient satisfaction questionnaire was developed and distributed electronically to all patients seen by APPs from August 1, 2020 to January 31, 2021. The questionnaire contained quantitative items using a 5-point Likert scale and open-ended questions that yielded qualitative findings. Descriptive statistics were applied to the quantitative data. Qualitative findings were analyzed using a qualitative description approach to identify recurrent themes. Results: Response rate was 74% (374/505) across all clinics. Videoconference was the most common delivery method (91.7%). Overall satisfaction with VC was very high (4.7–4.8/5). Emergent qualitative themes were related to Personal Connection; Preparatory Materials; Virtual Physical Examination; Practical Advantages of VC; Virtual Waiting Room; and Technical Issues. Conclusion: Overall, across several facets including personal connection, patient experience with VC for a variety of musculoskeletal conditions was rated high. Clinically, a systematic approach to the physical examination with preparatory patient education materials was key to positive patient experience.

"Outcome evaluation of physiotherapy &amp; drug management for chronic cervical radiculopathy"

Background: Cervical radiculopathy (CR) is one of the prevalent causes of neck pain and disability. Physiotherapy and pain medications are the common nonoperative management, and in Physiotherapy, there are many concepts of assessment and management. This study aims to determine the comparative effectiveness of three specialized physiotherapy approaches or only pain medications for managing CR cases. Methods: A prospective, assessor, and participant-blind, four-arm Randomized control trial (RCT) has been conducted on 120 patients with chronic cervical radiculopathy in 4 specialized centers of Dhaka city recruited between July and December 2022. Four groups (n=30) was treated through structural diagnosis and management concept (SDM), regional approaches (RA), McKenzie mechanical diagnosis and therapy (MDT) concept prescribed by advanced practice physiotherapist (APP), or pain medications prescribed by the specialist physician for 4 weeks. Discussion: After 24 sessions every group shows improvement in neck pain, ROM, disability and quality of life. During intermediate analysis (14days), no group shows more significant changes than another. After post changes (24days) the pain severity score differ significantly only between Medication and RA, RA and Medication; mean pain affective interference score differ between Medication and RA, RA and Medication; and pain physical interference between Medication and RA; RA and Medication. Mean score of ROM were significantly different between medication and RA, Medication and SDM; MDT and RA, MDT and SDM; RA and Medication, RA and MDT; SDM and Medication, SDM and MDT. Besides mean score of WHOQOL Brief (physical) were significantly different between Medication and SDM (p=.000); MDT and SDM (p=.000); RA and SDM (p=.045); SDM and Medication (p=.000), SDM and MDT (p=.000), SDM and RA. Overall improvement (mean score changes) found in pain, ROM, disability, QOL among all groups. Trial registered to the Clinical Trial Registry India CTRI/2022/03/040922 on 08/03/2022.

Advanced practice physiotherapy care in emergency departments for patients with musculoskeletal disorders: a pragmatic cluster randomized controlled trial and cost analysis

BackgroundAdvanced practice physiotherapy (APP) models of care where physiotherapists are primary contact emergency department (ED) providers are promising models of care to improve access, alleviate physicians’ burden, and offer efficient centered patient care for patients with minor musculoskeletal disorders (MSKD).ObjectivesTo compare the effectiveness of an advanced practice physiotherapist (APPT)-led model of care with usual ED physician care for persons presenting with a minor MSKD, in terms of patient-related outcomes, health care resources utilization, and health care costs.MethodsThis trial is a multicenter stepped-wedge cluster randomized controlled trial (RCT) with a cost analysis. Six Canadian EDs (clusters) will be randomized to a treatment sequence where patients will either be managed by an ED APPT or receive usual ED physician care. Seven hundred forty-four adults with a minor MSKD will be recruited. The main outcome measure will be the Brief Pain Inventory Questionnaire. Secondary measures will include validated self-reported disability questionnaires, the EQ-5D-5L, and other health care utilization outcomes such as prescription of imaging tests and medication. Adverse events and re-visits to the ED for the same complaint will also be monitored. Health care costs will be measured from the perspective of the public health care system using time-driven activity-based costing. Outcomes will be collected at inclusion, at ED discharge, and at 4, 12, and 26 weeks following the initial ED visit. Per-protocol and intention-to-treat analyses will be performed using linear mixed models with a random effect for cluster and fixed effect for time.DiscussionMSKD have a significant impact on health care systems. By providing innovative efficient pathways to access care, APP models of care could help relieve pressure in EDs while providing efficient care for adults with MSKD.Trial registrationClinicalTrials.govNCT05545917. Registered on September 19, 2022

Advanced Practice Physiotherapists and the implementation of the JIGSAW-E model for the management of osteoarthritis in Scottish primary care settings: a qualitative case study

ObjectiveTo explore the acceptability, barriers and enablers of NICE guidelines for osteoarthritis in the Scottish primary care setting using the Joint Implementation of Guidelines for Osteoarthritis in Western Europe (JIGSAW-E) model and investigate the role of Advanced Physiotherapy Practitioners (APPs) in providing evidence-based care. DesignA qualitative case study comprised of semi-structured interviews followed by a workshop with participants. Setting10 Scottish primary care practices. ParticipantsSix general practitioners (GPs) and eight APPs were interviewed. Twenty-three practitioners attended the workshop including 22 physiotherapists and one GP. ResultsWhile both GPs and APPs recognised the need to improve and standardise osteoarthritis care delivery, this study found that APPs were better situated to implement the evidence-based model. Barriers to implementation included lack of time for training, limited appointment time for GPs to consult and discuss medication use with patients, limitation of disease specific guidelines for patients with complex multimorbidity, and system-based barriers such as electronic data collection and high staff turnover. The key enabler was practitioners’ motivation to provide optimal, standardised quality care for osteoarthritis. To increase acceptance, ownership and usability for both practitioners and patients, the JIGSAW-E model materials required adaptation to the local context. ConclusionThis study provides evidence that the JIGSAW-E model is acceptable in Scottish primary care. Furthermore, the evolving roles of GPs and APPs within multidisciplinary primary care teams provides a platform to implement the JIGSAW-E model, where APPs are well placed to provide leadership and training in the delivery of evidence-based care for osteoarthritis.

A multi-site prospective, observational study of physiotherapist independent prescribing activity across musculoskeletal clinics in the United Kingdom

ObjectiveTo establish how advanced practice physiotherapists in the UK working in the musculoskeletal specialty are utilising their independent non-medical prescribing skills. DesignMulti-site, prospective, descriptive observational study. Ethics reference No: ERN_19–0994). MethodThe study was conducted by seven advanced practitioners, across seven clinical sites representative of advanced musculoskeletal practice in the UK, between 1st October 2019–March 31, 2020. Advanced physiotherapy practitioner independent prescribers working in a variety of musculoskeletal specialty areas collected data across 5 contexts of musculoskeletal clinical service: first contact practice, primary care, community triage, secondary care orthopaedics, secondary care rheumatology and private practice. Quantitative data were analysed descriptively with qualitative data analysed/synthesised via thematic analysis. ResultsPrescribing activity data for n = 2470 patients were collected. Prescribing activity was highest for the treatment of nociceptive pain (51.3%) and inflammation (39.6%). Most prescribing activity occurred in the first 2–6 weeks (34.1%) following onset of condition. Medicines optimisation accounted for most of prescribing activity (18.1%), followed by over-the-counter medication recommendation (15.5%). De-prescribing accounted for 10.8% of all prescribing activity recorded. Qualitative data were synthesised into 4 themes: multimodal physiotherapeutic approach, joint decision making and patient choice, working with complexity, and legal and regulatory restriction. ConclusionsPhysiotherapist independent prescribing was used within all health sectors in conjunction with advanced skills in musculoskeletal physiotherapy as part of a multimodal physiotherapeutic approach. Prescribing activity was dictated by the clinicians' clinical reasoning and use of joint decision-making. Prescribing activity for acute back and neuropathic radicular pain was limited secondary to recent reclassification of gabapentin and pregabalin.