Clinical Specialist Physiotherapist Research Articles

Informing low back pain care from the ground up: Survey of national musculoskeletal triage physiotherapists in Ireland

BackgroundHealthcare is changing to meet the challenge of a rising musculoskeletal burden associated with the expanding, aging population. Clinicians, important stakeholders in healthcare provision, have crucial insights into service improvement, but clinician consultation is a shortcoming in healthcare development. In Ireland, specialist physiotherapist-led musculoskeletal (MSK) triage services operate at the primary-secondary care interface to expedite patient care. ObjectivesTo inform future development of low back pain (LBP) care in Ireland through profiling the operationalisation of the national MSK triage service for LBP, including access, referral management, clinical investigations, onward referral options, access to multidisciplinary team (MDT) services and integration with primary healthcare services. DesignCross-sectional observational study using a bespoke, anonymous electronic survey. ParticipantsThirty-eight clinical specialist physiotherapists working in national programme Irish MSK triage services. ResultsThirty-eight MSK Triage physiotherapists submitted responses (response rate 72%). There was considerable site-dependent variation in LBP service provision, with discrepancies in access to triage services, wait times, referral processing and prioritisation, access to clinical investigations and onward referral options. Most respondents (81%) reported wait times exceeding the three-month target; 75% reported that the level of clinical autonomy associated with their role limited service efficiency; 75% were dissatisfied with primary-secondary care service integration. Respondents identified insufficient availability of primary care multidisciplinary services. ConclusionLack of standardisation of LBP services exists in Ireland. Services would benefit from improved standardisation, reduced wait times, national accreditation and a defined scope of advanced physiotherapy practice and the development of nationwide community multidisciplinary infrastructure with enhanced interservice communication.

‘Look up from the waiting list and see the bigger picture’: a qualitative analysis of clinical specialist physiotherapist perspectives on low back pain care in Ireland

IntroductionHealthcare systems are struggling to deliver high-quality low back pain (LBP) care. In 2012 specialist physiotherapist-led musculoskeletal (MSK) triage services were introduced in Irish hospitals to expedite patient care and alleviate pressure on elective orthopaedic/ rheumatology consultant clinics. Specialist physiotherapists have expertise to inform health service improvement and reform, but their perspectives of LBP healthcare delivery have received scant attention. ObjectivesTo explore specialist physiotherapists’ perspectives on LBP care in Ireland, the barriers and facilitators to quality LBP care and the development of MSK interface services in primary care settings. DesignCross-sectional observational study using an anonymous electronic survey with thematic framework analysis of response data from open-ended questions. ParticipantsThirty-four clinical specialist physiotherapists in Irish MSK triage services. ResultsThematic analysis resulted in six overarching themes, grouped into two categories. One category pertained to LBP healthcare in Ireland with the following three themes: 1) Inadequate health services for patients with LBP; 2) Need for defined LBP clinical pathways; 3) Need for a multisectoral approach to spine health. Themes in the second category, pertaining to the development of community-based MSK interface services, were: 4) Concern regarding isolation from secondary care services; 5) Unrealistic expectations of MSK triage; 6) Improved communication and collaboration with primary care services. ConclusionSpecialist physiotherapists have concerns regarding LBP health services and persistence of a biomedical, secondary care-led approach. They advocate for investment in primary care multi-disciplinary teams, enhanced integration across primary and secondary care, development of a national clinical pathway and a multisectoral approach. Contribution of paper•This study captures, for the first time, the perspectives of specialist physiotherapists on LBP healthcare delivery enabling a better understanding of the ‘on-the-ground’ issues in delivering quality LBP healthcare.•Opportunities for LBP healthcare service improvement are identified at micro, meso and macro health system levels.•The findings can be used to inform the development and implementation of a new national LBP clinical pathway and community-based MSK triage clinics.

AN ANALYSIS OF A PREOPERATIVE PHYSIOTHERAPY AND OCCUPATIONAL THERAPY LIMB RECONSTRUCTION SERVICE FOR CHILDREN WITH PERTHES’ DISEASE IN THE REPUBLIC OF IRELAND

IntroductionLegg-Calve-Perthes (Perthes Disease) was first recognised by three physicians, Arthur Legg (1874–1939), Jacqui Calve (1875–1954) and George Perthes (1869 – 1927) in 1910. Perthes disease is a rare childhood condition that affects the hip. It occurs when the blood supply to the femoral head is disrupted. Without this blood supply, the bone cells die and avascular necrosis can occur. The Herring classification is used to diagnose the stages of Perthes Disease. It is an important prognostic factor. There are three classifications, Herring A, B and C. Herring A has no involvement of the lateral pillar with no density changes noted on x-ray. Herring B has at least 50% of the lateral pillar height maintained on x-ray. Herring C has less than 50% of the lateral pillar height on x-ray (Herring et al, 1992). Children with Perthes disease require specialist Limb Reconstruction team throughout their treatment journey, this includes Orthopaedic surgery and therapy (Physiotherapy and Occupational Therapy). The National Limb Reconstruction Therapy Team is based at the National Orthopaedic Hospital, Cappagh. The therapy team consists of 1 Clinical Specialist Physiotherapist, 1 Senior Physiotherapist and 1 Senior Occupational Therapist who provide input to this cohort. This study aims to analyse the importance of a comprehensive pre-operative assessment by the therapy team (Physiotherapist and Occupational Therapist) to maximise patient outcomes post operatively.MethodologyThis is a quantitative research study conducted by the National Limb Reconstructive Therapy Service of the National Orthopaedic Hospital in Cappagh, Dublin. The inclusion criteria for this study consisted of:Age – Patient must be part of the Paediatric Service, i.e., under the age of 16.Diagnosis – Patient must have a diagnosis of Perthes Disease with a Herring Classification documented.Application of a Hip Distractor Frame formed part of the patient's surgical management.Surgery was completed by Mr Connor Green.Surgery was completed between January 2021 and December 2022.Patient were required to have their external hip distractor frame removed by December 2022.Exclusion Criteria: Those not meeting the above inclusion criteria. Following the inclusion criteria, a number of cases were identified of which 10 cases were selected at random. A retrospective analysis of these samples was completed. The medical charts were reviewed as well as patient electronic healthcare records. Microsoft Excel was utilised to analyse the data and capture results.ResultsFrom analysing the data, the following results were identified:80% of the sample cohort had a length of stay of 5 days following surgery. There were two outliers due to infection who had a length of stay of 14 days.90% of the sample received a pre-operative Physiotherapy and Occupational Therapy assessment. This assessment included information gathering regarding the child's home and social environment; their functional baseline and anticipated post-operative needs. Standardised and non-standardised assessments were used.88.89% of those who completed a pre-operative assessment required referral to community Occupational Therapy teams for equipment provision (wheelchair, transfer aids) to allow for timely discharge.On average, each patient in the sample required 17 physiotherapy outpatient sessions prior to handover to the community teams.100% of our sample required post operation onward referral for MDT input in the community (Occupational Therapy and Physiotherapy).ConclusionsThe importance of a multi-disciplinary approach towards family and children was highlighted in this study. A comprehensive pre-operative therapy assessment optimizes care for this cohort by preparing them in terms of equipment provisions, local team input and expectations for therapy. The data suggests future Limb Reconstruction team should include Physiotherapy and Occupational Therapy as part of the multi-disciplinary team, in the treatment of children with Perthe's Disease. We suggest an MDT pre-assessment is completed to optimize patient care, reduce length of stay and improve patient satisfaction in the acute hospital setting.

AB102. SOH23ABS_250. A profile of patients with shoulder pain attending the musculoskeletal triage clinic in Connolly Hospital

Background: Clinical specialist physiotherapists (CSP) have been assessing patients in musculoskeletal (MSK) triage clinics nationally since 2010. There is a close correlation between physiotherapists and surgeons in making the correct diagnosis. Physiotherapy involving a structured exercise program is the first line treatment for patients with rotator cuff related shoulder pain (RCRSP) and is recommended prior to orthopaedic consultant referral. The benefit of an early magnetic resonance imaging (MRI) in these patients is questionable and may cause patients undue concern about normal age-related changes in their shoulder.

Minimum standards of clinical practice for physiotherapists working in critical care units in Ireland: a modified Delphi technique

INTRODUCTION: Physiotherapists in Irish hospitals with critical care units deliver physiotherapy services 24 hours a day, seven days a week. There is a perceived lack of consistency in the level of clinical competence, required skills and content of training between hospitals, compounded by the absence of a national policy, procedure or clinical framework for physiotherapists working in critical care. The study aimed to identify the minimum standards of clinical practice expected of physiotherapists working in critical care settings in Ireland. METHODS: A modified Delphi technique was used to survey a panel of senior and clinical specialist physiotherapists working in critical care units in Ireland to obtain consensus of items. The questionnaire of 214 items was completed over three rounds. Items were determined ‘Essential/Not Essential/Unsure’ by participants. Items that did not reach consensus were included in the subsequent round with additional items suggested by participants. RESULTS: 25/46(54%) physiotherapists completed the first round, with 17 and 13 completing round 2 and round 3 respectively. A total of 220 items were included, 120 of which were deemed essential for a minimum standards of independent clinical practice in Irish critical care units. Fifty-six items were considered not essential while consensus was not reached on 44 items. CONCLUSIONS: This study identified 120 items of knowledge and clinical skills considered essential as a minimum standard by physiotherapists working in Irish critical care units. Further discussion is required to determine how these results can be applied to guide clinical practice for physiotherapists working in critical care in Ireland.

PRO111 Using Expert Judgement to Inform Decision Making WHEN the Evidence Base Is Limited: A Case Study in Haemophilia

Benefits associated with physical activity (PA) for people with haemophilia (PWH) may include improvements in joint, bone and muscle health. However, the factor VIII activity level required to avoid a bleeding episode with PA is unknown. We therefore sought to determine if clinically acceptable estimates could be generated using a modified version of the Sheffield Elicitation Framework (SHELF), a formal approach for eliciting judgements regarding probability distributions. A panel of 9 haemophilia experts which included five consultant haemotologists, two clinical specialist physiotherapists, one haemophilia nurse consultant and one patient advocate participated. Based on the 2017 National Hemophilia Foundation (NHF) PA descriptions, clinical experts estimated factor levels at which a bleed could be avoided. The estimates were elicited using an adapted version of the SHELF Roulette method. Probability distributions for each scenario were combined and presented to the panel of experts. All responses were judged to be correct applications of the SHELF method and estimates were combined. The final set of outcomes and approach were accepted by the panel and may be used to inform future research and evaluation for factor VIII activity level required to avoid a bleeding episode with PA. Important health care decisions are required often where the evidence base is limited. SHELF is a formal approach for harnessing expert judgements. SHELF can be used to promote evidence-based practice by use of a methodological tool to facilitate the combination of expert judgement to guide health care decisions.

A randomised controlled trial of multimodal physiotherapy versus advice for recent onset, painful cervical radiculopathy \u2013 the PACeR trial protocol

BackgroundA research gap exists for optimal management of cervical radiculopathy in the first 12 weeks and short term natural history of the condition is somewhat unclear, although thought to be favourable. The primary aim of this assessor blinded, superiority, 2 parallel group randomised controlled trial is to investigate the effects of a 4 week physiotherapy programme (6–8 sessions) of manual therapy, exercise and upper limb neural unloading tape, compared to a control of weekly phone advice; on disability, pain and selected biopsychosocial measures, in acute and sub-acute cervical radiculopathy patients. A secondary aim is to identify whether any baseline variables, symptom duration or group allocation can predict outcome.MethodsParticipants are recruited from GP referrals in an urban setting, from a neurosurgery non-urgent waiting list and from self-referral through Facebook advertising. Eligible participants (n = 64) are diagnosed with radiculopathy based on a clinical prediction rule and must have symptoms of unilateral, single level, radiculopathy for between 2 and 12 weeks, without having yet received physiotherapy. Random 1:1 group allocation (using variable block sizes), allocation concealment, blinded assessment and intention to treat analysis are being employed. Treatment is provided by clinical specialist physiotherapists in primary and secondary care settings. Outcomes are measured at baseline, 4 (primary endpoint) and 12 weeks. Participants’ report of pain, disability and their rating of recovery is also recorded by telephone interview at 6 months. Statistical analysis of between group differences will be performed with ANOVAs and MANOVAs, and multivariable regression analysis will be undertaken to explore predictor variables. Ethical approval for this study has been received from the Beaumont Hospital and Irish College of General Practitioners Research Ethics Committees. The trial is registered at ClinicalTrials.gov (NCT02449200).DiscussionAn internal pilot study to test retention and recruitment strategies led to trial expansion and this is now a multi centre trial involving 5 clinical sites.Trial registrationNCT02449200. Registered 20/05/15.

Physiotherapist-Led Triage at a Rheumatology-Based Musculoskeletal Assessment Clinic: an 18-Month Service Evaluation of Activity and Outcomes.

ObjectivePhysiotherapist‐led musculoskeletal triage clinics are an effective and efficient means of managing patients presenting with musculoskeletal disorders in primary and secondary care. Data regarding the activity and outcomes of physiotherapist‐led triage in hospital‐based outpatient rheumatology clinics are scarce. Thus, the aim of this study was to undertake a service evaluation of activity and outcomes of a physiotherapist‐led rheumatology‐based Musculoskeletal Assessment Clinic (MAC). The primary objective was to quantify the proportion of patients independently managed by the clinical specialist physiotherapists (CSPs).MethodsA retrospective service evaluation was undertaken of all patients who attended the Rheumatology MAC at St Vincent's University Hospital, Dublin (SVUH) between August 2012 and February 2014. The Clinical Audit Department of SVUH approved the study. Data were analyzed using descriptive statistics.ResultsFive hundred and eight patients attended the MAC: 76% were female and the mean age was 55 years and ranged between 18‐91. Seventy‐five percent of patients were independently managed by the CSP without needing to see a consultant rheumatologist, whereas 17% were referred to the rheumatology team. Eighty‐seven percent of patients referred to the rheumatology team had rheumatological intervention (eg, injection, medical management, or multidisciplinary rehabilitation). A substantially higher proportion of patients with regional musculoskeletal pain and degenerative conditions were independently managed by the CSP compared with those who had rheumatological/inflammatory conditions.ConclusionThe majority of patients who attended the MAC were independently managed by the physiotherapists, suggesting that physiotherapist‐led triage may be a useful and efficient means of managing a proportion of patients referred for a specialist rheumatological consultation.

Clinical agreement of MSK out-patient (OP)B6 physiotherapist and Clinical Specialist Physiotherapist (CSP) in the management of patients with MSK conditions

Clinical agreement of MSK out-patient (OP)B6 physiotherapist and Clinical Specialist Physiotherapist (CSP) in the management of patients with MSK conditions

Health and Social Care Professions Rise to the Challenge Admission Avoidance in Emergency Departments

Patients with mobility issues with potential for same day discharge in EDs This paper describes how Emergency Department (ED) based initiatives, developed by Health and Social Care Professionals (HSCP’s) enhance cost effective access to timely high quality patient care in the ED Initiatives have been introduced in response to Increasing demands on healthcare services, including patient flow Escalating health costs and the need to direct funding where it is most effective “best person – best place –best time “ Continuous developments in knowledge and skills and advanced roles of HSCP’s Nationally, HSCP’s have developed various practice initiatives in ED. However the largest growth in HSCP activity nationally is one that addresses the increased number of patients with mobility issues who have the potential for same day discharge. These initiatives support interdisciplinary and cross programme partnerships (e.g. with the National Clinical Programmes for Older Persons and the Acute Medicine Programme) as well as bridging hospital and community practice. Examples of these initiatives include Mobility Assessment and Discharge Rapid Admission Prevention Interdisciplinary Frail Intervention Therapy Team SWOT Social Work and Occupational Therapy PhAst Physiotherapy Assessment and Treatment HSCP Rapid Access and Treatment Benefits demonstrated include admission avoidance, reduced length of stay in ED, increased discharge rates, reduction in re-attendance and improved patient and staff satisfaction. The presentation will detail these initiatives and their benefits Rosie Quinn rosie.quinn@hse.ie Clinical Specialist Physiotherapist (Our Lady of Lourdes Hospital Drogheda) and Therapy Lead Emergency Medicine Programme (all HSCP leads on these initiatives have been contacted and have agreed to share their data – they will be acknowledged individually in any presentation given)

In-patient physiotherapy for adults on veno-venous extracorporeal membrane oxygenation - United Kingdom ECMO Physiotherapy Network: A consensus agreement for best practice.

Clinical specialist physiotherapists from the five severe respiratory failure centres in England where respiratory extracorporeal membrane oxygenation (ECMO) is practiced have established this consensus agreement for physiotherapy best practice. The severe respiratory failure centres are Wythenshawe Hospital, Manchester; Glenfield Hospital, Leicester; Papworth Hospital, Cambridge; Guy's and St Thomas' Hospital, London and The Royal Brompton Hospital, London. Although research into physiotherapy and ECMO is increasing, there is not a sufficient amount to write evidence-based guidelines; hence the development of a consensus document, using knowledge and experience of the specialist physiotherapists working with patients receiving ECMO. The document outlines safety aspects, practicalities and additional treatment considerations for physiotherapists conducting respiratory care and physical rehabilitation.

Effect of clinical specialist physiotherapists in orthopaedic diagnostic setting – a systematic review

Effect of clinical specialist physiotherapists in orthopaedic diagnostic setting – a systematic review

ASSESSING THE BENEFITS OF HAVING A SPECIALIST PAEDIATRIC PHARMACIST AND PHYSIOTHERAPIST IN THE COMMUNITY TO IMPROVE CHILDHOOD ASTHMA OUTCOMES

IntroductionThe local Clinical Commissioning Group has funded an innovative one-year pilot project to assess the value of providing specialist paediatric pharmacist and physiotherapist support direct to families and health care...

Orthopaedic triage at a physiotherapist-led ‘Musculoskeletal Assessment Clinic’: a seven-month service evaluation of outcomes

A number of clinical specialist physiotherapist (CSP)-led musculoskeletal triage clinics have been established in the Republic of Ireland as a means of managing patients referred for an outpatient orthopaedic consultation. The purpose of this study was to evaluate the outcomes of a recently established 'Musculoskeletal Assessment Clinic' (MAC) in St Vincent's University Hospital (SVUH) Dublin. We identified the (a) number of patients independently managed by the CSPs and (b) conversion rate to orthopaedic intervention as a useful measure of this. University College Dublin Research Ethics Committee granted ethical exemption and the Clinical Audit Department of SVUH approved the study. A retrospective service evaluation was carried out on all orthopaedic patients who attended the MAC between January and July 2012. Data were analysed using SPSS v20 using descriptive statistics. Seven-hundred and fourteen patients attended the MAC, 54 % of whom were female; mean age 50 years (range 12-89). The majority of patients were diagnosed with low back pain (35 %) and knee osteoarthritis (16 %). The majority of patients who attended the MAC (76 %) were independently managed by the CSPs without need for orthopaedic consultation; from a valid sample (n = 110), 80 patients required orthopaedic intervention, a conversion rate of 73 %. The most common interventions were arthroplasty (22 %) and arthroscopy (16 %). The findings of this service evaluation indicate that a significant number of patients referred for an orthopaedic consultation may be managed independently by a CSP and that onward referrals for orthopaedic consultation were highly appropriate.

The role of clinical specialist Physiotherapists in the management of low back pain in a Spinal Triage Clinic

Traditional care pathways for patients with low back pain (LBP) where general practitioners (GPs) refer to consultant specialists can lead to excessive waiting times for patients and questionable use of health care resources. The evaluation of more cost effective pathways is a priority. The study aims to determine if clinical specialist physiotherapists can allocate patients into the three distinct diagnostic triage categories in line with international guidelines. A secondary aim is to examine the utility of baseline domains to inform clinical decision making. A review of LBP patients (n = 1,532) consecutively referred between 2008 and 2010 to a physiotherapy led spinal triage clinic was undertaken. Baseline demographics, pain severity (Visual Analogue Scale), disability (Roland Morris Disability Questionnaire), distress (Distress and Risk Assessment Method), mobility and function were assessed. Relationships between these factors were analysed. Eighty-five percent of the population were deemed suitable for conservative management and were referred for either group exercise intervention (n = 1,125, 73 %) or individual treatment (n = 178, 12 %), in line with clinical guidelines. Fourteen percent were discharged and only 1 % required a specialist opinion. Patients allocated to the three management streams could be clearly discriminated by baseline measures of pain, distress, disability and function (p < 0.01). Clinical Specialist physiotherapists are effective in assessing and selecting appropriate care pathways for LBP patients in line with international LBP clinical guidelines. The utility of the physical and psychological measures to differentiate between groups of varying clinical severity has important implications for treatment selection and management.

Southampton hand course

The Southampton hand course—formally known as the Wessex instructional hand course—is a one day course organised by hand surgeons, clinical specialist physiotherapists, and senior occupational therapists. It is held annually in Southampton and is in its seventh year. The course is for any health professional actively involved in the diagnosis, treatment, and rehabilitation of conditions (of any aetiology) that affect the hand. Refreshingly, participants on the course reflected actual clinical practice—peers, juniors, or seniors whom we work with from all branches of the multidisciplinary team, such as plastic surgeons, orthopaedic surgeons, emergency medicine doctors, physiotherapists, and occupational therapists. Trainees …

A 6-month evaluation of a clinical specialist physiotherapist's role in a fracture clinic

A 6-month evaluation of a clinical specialist physiotherapist's role in a fracture clinic

Cauda equina syndrome: The development of a citywide physiotherapy pathway of care

Cauda Equina Syndrome (CES) is a very rare condition in patients with low back pain (LBP), however, the discovery of CES is seen as a surgical emergency. With the rapid rolling out of patient self-referral to outpatient physiotherapy, there is an increased likelihood of physiotherapists being exposed to this condition. However, the literature to date has focused on CES from a medical perspective and clear physiotherapy guidelines have not been reviewed. To improve and standardize the citywide management of such patients a pathway of care was developed. Clinical specialist physiotherapists oversaw the development guided by orthopaedic and neurosurgery consultants. The results of a three-cycle audit suggest this evidence-based pathway of care is an effective tool in identifying patients with CES.