Extended Scope Practitioners Research Articles

CSP2023: 317 - A cross sectional survey of physiotherapists views on the role of extended scope practitioner within oncology

CSP2023: 317 - A cross sectional survey of physiotherapists views on the role of extended scope practitioner within oncology

REST: a preoperative tailored sleep intervention for patients undergoing total knee replacement – feasibility study for a randomised controlled trial

ObjectivesTo test the feasibility of a randomised controlled trial (RCT) of a novel preoperative tailored sleep intervention for patients undergoing total knee replacement.DesignFeasibility two-arm two-centre RCT using 1:1 randomisation with...

Can we develop consensus on long-term follow-up and surveillance of primary shoulder arthroplasty? A study protocol using a real-time Delphi technique among expert clinicians in the UK

BackgroundShoulder arthroplasty incidence is projected to continue its exponential growth and the resultant burden of monitoring patients with shoulder arthroplasty implants creates significant pressure on orthopaedic services. Surveillance offers the...

REST: A PROSPECTIVE RANDOMIZED FEASIBILITY STUDY ASSESSING THE IMPACT OF A TAILORED SLEEP INTERVENTION IN PATIENTS UNDERGOING TOTAL KNEE ARTHROPLASTY

AbstractIntroductionThere is a need to develop approaches to reduce chronic pain after total knee replacement. There is an established link between disturbed sleep and pain. We tested the feasibility of a trial evaluating the clinical and cost-effectiveness of a pre-operative sleep assessment and complex intervention package for improving long-term pain after TKR.MethodologyREST was a feasibility multi-centre randomised controlled trial with embedded qualitative study and health economics. Participants completed baseline measures and were randomised to usual care or the intervention, a tailored sleep assessment and behavioural intervention package delivered by an extended scope practitioner three months pre-operatively with a follow-up call up at four-weeks. Patient reported outcomes were assessed at baseline, one-week pre-surgery, and 3-months post-surgery.Results57 patients were randomised and 20 had surgery within the study timelines. All patients allocated the intervention attended an appointment and most engaged with treatment. The intervention group reported improvements in sleep (Sleep Conditions Indicator) and neuropathic pain (painDETECT) scores. Participants found the sleep treatments and study processes to be acceptable. The mean cost of the intervention was estimated at £134.45 per patient.ConclusionThe feasibility study has shown that patient recruitment is feasible, engagement with and adherence to the intervention is high, and the intervention is acceptable to patients and clinicians. Preliminary findings show that the intervention group had improved sleep quality and had reduced levels of pre-operative neuropathic pain. This study has demonstrated that a full RCT is feasible and identified areas for improvement to optimize the trial design.

SUPPORT AND TREATMENT AFTER JOINT REPLACEMENT (STAR): TRANSLATING TRIAL FINDINGS INTO NHS PRACTICE

AbstractIntroductionTotal knee replacement (TKR) aims to reduce pain and functional limitations. Despite a good outcome for many, 15–20% patients report chronic pain three months after TKR.The STAR Care Pathway is a clinically important and cost effective treatment to improve pain outcomes over 1 year for people with chronic pain at 3 months after total knee replacement surgery. The care pathway is delivered by specially trained Extended Scope Practitioners (ESPs).There is a gap between research findings and translation into practice. This work shows how the STAR trial findings were implemented into NHS practice at a single centre and the further work required to enable national implementation.MethodologyTrial findings were presented to NHS managers with a business case for an implementation pilot. Trial documentation was adapted for use in usual care using the COM-B model for behaviour change and evidence-based approaches to increase the return of postal questionnaires. Trial sites were contacted to understand their capacity to implement the intervention locally.ResultsThe STAR care pathway was successfully implemented into NHS practice with a screening response rate of 83%. It is now permanently part of usual care at North Bristol NHS Trust. Trial centres indicated that lack of availability of STAR trained ESPs as a barrier to implementation. The trial manual and training session were adapted for online delivery in partnership with Health Education England.ConclusionThe STAR care pathway has been successfully embedded into NHS care. A toolkit and online clinician training package enables national implementation.

The STAR care pathway for patients with pain at 3 months after total knee replacement: a multicentre, pragmatic, randomised, controlled trial

SummaryBackgroundApproximately 20% of people experience chronic pain after total knee replacement, but effective treatments are not available. We aimed to evaluate the clinical effectiveness and cost-effectiveness of a new care pathway for chronic pain after total knee replacement.MethodsWe did an unmasked, parallel group, pragmatic, superiority, randomised, controlled trial at eight UK National Health Service (NHS) hospitals. People with chronic pain at 3 months after total knee replacement surgery were randomly assigned (2:1) to the Support and Treatment After Replacement (STAR) care pathway plus usual care, or to usual care alone. The STAR intervention aimed to identify underlying causes of chronic pain and enable onward referrals for targeted treatment through a 3-month post-surgery assessment with an extended scope practitioner and telephone follow-up over 12 months. Co-primary outcomes were self-reported pain severity and pain interference in the replaced knee, assessed with the Brief Pain Inventory (BPI) pain severity and interference scales at 12 months (scored 0–10, best to worst) and analysed on an as-randomised basis. Resource use, collected from electronic hospital records and participants, was valued with UK reference costs. Quality-adjusted life-years (QALYs) were calculated from EQ-5D-5L responses. This trial is registered with ISRCTN, ISRCTN92545361.FindingsBetween Sept 6, 2016, and May 31, 2019, 363 participants were randomly assigned to receive the intervention plus usual care (n=242) or to receive usual care alone (n=121). Participants had a median age of 67 years (IQR 61 to 73), 217 (60%) of 363 were female, and 335 (92%) were White. 313 (86%) patients provided follow-up data at 12 months after randomisation (213 assigned to the intervention plus usual care and 100 assigned to usual care alone). At 12 months, the mean between-group difference in the BPI severity score was −0·65 (95% CI −1·17 to −0·13; p=0·014) and the mean between-group difference in the BPI interference score was −0·68 (−1·29 to −0·08; p=0·026), both favouring the intervention. From an NHS and personal social services perspective, the intervention was cost-effective (greater improvement with lower cost), with an incremental net monetary benefit of £1256 (95% CI 164 to 2348) at £20 000 per QALY threshold. One adverse reaction of participant distress was reported in the intervention group.InterpretationSTAR is a clinically effective and cost-effective intervention to improve pain outcomes over 1 year for people with chronic pain at 3 months after total knee replacement surgery.FundingNational Institute for Health Research.

Implementation of the JIGSAW-E model for osteoarthritis. A role for Extended Scope Practitioners in primary care

Purpose: The Joint Implementation of Guidelines for Osteoarthritis (OA) in Western Europe (JIGSAW-E) model has been implemented across parts of Europe. It aims to optimise quality primary care, support self-management and promote the use of NICE guidelines. The aim of this project was to explore the feasibility of implementing the JIGSAW-E model in Scottish primary care.

P017 Out of outlier status: local observations from the National Early Inflammatory Arthritis Audit

Abstract Background/Aims The National Early Inflammatory Arthritis Audit (NEIAA) provides a powerful lever for driving up quality. Rheumatology services benchmark care against NICE quality standards (QS) 33. Notifications are sent out quarterly to Trusts at risk of being an outlier and outliers are identified in the annual report. After being named as an outlier, this project describes our journey to improve compliance against QS2 (patients are seen in a rheumatology clinic within 3 weeks of referral and QS3 (patients with rheumatoid arthritis (RA) are started on DMARDs within 6 weeks of referral). Methods Data submitted to the NEIAA online tool during year one were downloaded for analysis. Results were presented to the Rheumatology Multi-Disciplinary Team, the patient pathway was mapped, driver diagrams were developed by the team and areas for improvement identified and changes implemented. Data from year two were downloaded for comparison. Results In total 530 patients were recruited to the audit: 262 in year 1 and 268 in year 2. 77 (29%) in year 1 and 73 (27%) in year 2 had confirmed RA and were included in this analysis. All patients had a baseline form completed, and 61 (86%) and 56 (77%) had a 3-month follow-up form completed for year 1 and 2, respectively. The demographics were very similar for years 1 and 2. In year 1, 10% of all patients were seen within 3 weeks of being referred and 7% in the RA cohort started DMARD therapy within 6 weeks of referral. This compared to 54% and 56%, respectively, in year 2. Changes implemented relating to QS2 included referral guidelines for primary care, prompts when requesting rheumatoid factor and CCP antibodies and changes to the wording of antibody reports, increased triage capacity, simplifying the booking process and increased new appointment capacity (additional consultant, upskilling extended scope practitioner). QS3 changes implemented included increasing drug education and monitoring clinic capacity and improved sign-posting to National Rheumatoid Arthritis Society. Initial combination therapy was more prevalent in sero-positive patients and those with a high DAS28 during both years. In year 1, disease activity at baseline vs. 3 months was: remission/low disease activity in 8% vs. 54%, moderate in 45% vs. 39% and high in 47% vs. 7%. In year 2, rates at baseline vs. 3 months were: remission/low disease activity 12% vs. 69%, moderate in 60% vs. 25% and high in 28% vs. 6%. Conclusion Significant changes have been made which have resulted in an improvement in performance against QS2 and 3. Disease activity at baseline was lower, potentially as a result of seeing patients sooner and this has resulted in better outcomes for patients at 3 months. Ongoing data collection will allow the team to determine outcomes at 12 months. Disclosure E. MacPhie: Other; EM is the secretary of the North West Rheumatology Club, these regional meetings have been funding by an unrestricted educational grant from UCB and are now sponsored by Abbvie. L. Ashcroft: None. J. Brazendale: None. N. Foreman: None. S. Gilbert: None. C. Greenall: None. S. Horton: None. I. Lewis: None. A. Madan: None. C. Rao: None. S. Fish: None.

Future-proofing the primary care workforce: A qualitative study of home visits by emergency care practitioners in the UK

Background Broadening the skill-mix in general practice is advocated to build resilience into the primary care workforce. However, there is little understanding of how extended-scope practitioners from different disciplines, such as paramedicine and nursing, embed into roles traditionally ascribed to general practitioners (GPs). Objectives This study sought to explore patients' and professionals' experiences of a primary care home visiting service delivered by emergency care practitioners (ECPs), in place of GPs; to determine positive impacts/unintended consequences and establish whether interdisciplinary working was achieved. Methods Three practices in England piloted an ECP (extended-scope practitioners with a paramedic or nursing background) home visiting service (November 2018–March 2019). Following the pilot, focus groups were conducted with each of the three primary healthcare teams (14 participants, including eight GPs), and one with ECPs (five participants) and nine individual patient interviews. Data were analysed using a modified framework approach. Results The impact of ECP home visiting on GP workload and patient care was perceived as positive by patients, GPs and ECPs. Initial preconceptions of GPs and patients about the ECP role and expertise, and reservations about the appropriacy of ECPs for home visiting, were perceived to have been overcome by the expertise and interpersonal skills of ECPs. Fostering a culture of collaboration between ECPs and GPs was instrumental to remodelling professional boundaries at the practice level. Conclusion Broadening the skill-mix to incorporate extended-scope practitioners such as ECPs, to deliver primary care home visiting, presents an opportunity to increase resilience in the general practice workforce.

P06 Driving up quality: local observations from the National Early Inflammatory Arthritis Audit

Abstract Background The National Early Inflammatory Arthritis Audit (NEIAA) provides the opportunity for rheumatology services to benchmark the care they provide against NICE quality standards (QS) 33. It provides a mechanism to identify where improvements can be made. This project assessed compliance against QS2: patients are seen in a rheumatology clinic within 3 weeks of referral and QS3: patients with newly diagnosed RA should be offered short-term glucocorticoids and a combination of DMARDs within 6 weeks of referral. Methods Data submitted to the NEIAA online tool during the first year of the audit were downloaded for analysis. Results were presented to the Rheumatology Multi-Disciplinary Team. The patient pathway was mapped, driver diagrams were developed by the team and areas for improvement identified. Results In total 246 patients were recruited to the audit, 71(29%) had confirmed rheumatoid arthritis (RA) and were included in the follow-up cohort. All patients had a baseline form completed, and 61 (86%) had a 3-month follow-up form completed. The mean patient age in the RA cohort was 62 years (range: 26-88). Rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPA) status was recorded in 69 (97%) and 63 (88%) respectively with, 33 (52%) positive for RF and 26 (38%) for ACPA. Twenty-two patients (8.9%) were seen within 3 weeks of being referred and 5 patients (7%) started DMARD therapy within 6 weeks of referral. On average, patients waited 66 days (range: 5-138) to be seen and diagnosed, and if sent for investigations on average a further 50 days (range: 37-69) to diagnosis. There was an additional wait for drug education, with patients waiting a mean of 25 days and 39 days if they had been sent for investigations to confirm diagnosis. Prior to starting DMARD therapy 65 (90%) patients were given bridging steroids. Sixty-five (92%) patients started DMARDs, and in those that didn’t there was justification. A higher proportion of patients >65years started DMARD monotherapy in sero-positive patients and those with a high DAS28 we found more use of combination DMARD therapy. Process mapping and driver diagrams highlighted areas for improvement, both clinician and patient in origin. Regarding QS2 these include developing referral guidelines for primary care, increasing triage capacity, simplifying the booking process, increasing new appointment capacity (additional consultant, upskilling extended scope practitioner and specialist nurse) and introducing text reminders. In relation to QS3 these include: one-stop clinic with access to ultrasound, increasing drug education and monitoring clinic capacity, improve sign-posting to National Rheumatoid Arthritis Society. Conclusion The NEIAA has provided detailed information about the patient pathway which has enabled the team to identify priority areas for improvement. The prospective nature of the audit will allow the team to determine if changes are improving performance. Disclosures J. Loh None. J. Withers None. S. FIsh None. E. MacPhie Other; EM is the secretary of the North West Rheumatology Club; meetings are supported by an unrestricted educational grant from UCB.

New Model Foot and Ankle Service Pathway: Pilot Results 2 Years

Category:Service improvementIntroduction/Purpose:The foot and ankle services at NUTH incorporates both elective and trauma services. The elective service carries out on average 10,500- 11,000 review appointments/ year and 4000-4500 new patient appointments/year. The waiting times for new out-patient appointments were 8-14 weeks. A new pathway was designed with the aim to improve 18 week national target compliance, improve departmental efficiency, and improve patient satisfaction.Methods:A new initial assessment clinic pathways was designed were all new patients are seen in a one hour slot one stop clinic by a dedicated Extended Scope Practitioner. History and clinical examination are taken as well as initial Proms questionnaire, x-ray assessment followed by gate analysis including pain map, treadmill assessment and plantar pressure analysis. A consultant led MDT review of the finding is performed the same week where plan for treatment or further investigations is formulated.Results:A total of 1792 patients had the initial assessment through the new clinic pathway between March 2016 and March 2018. The average waiting time for the initial assessment has been gradually reduced from 14 to 3 weeks. We obtained over 96% patient satisfaction in enhancing patient experience.Conclusion:Our new clinic model has shown to improve efficiency, patient satisfaction and reduce waiting times.

Extended scope practitioner (physiotherapist) as first point of contact for musculoskeletal conditions in primary care

Extended scope practitioner (physiotherapist) as first point of contact for musculoskeletal conditions in primary care

266 Pilot of a rheumatology extended scope practitioner to improve the triage process andassess patients with non-inflammatory conditions

266 Pilot of a rheumatology extended scope practitioner to improve the triage process andassess patients with non-inflammatory conditions

Proof of Concept trial of diagnostic ultrasound in the orthopaedic triage setting.

Purpose: This study aims to investigate the benefits of Point of Care (POC) ultrasound and Scheduled Ultrasound Clinics using a Proof of Concept approach in the orthopaedic triage setting.Materials and Methods: The trial ran for a six week period sourcing all patients referred to the orthopaedic triage service. The trial collected three measurable outcomes i.e. two Patient Reported Outcome Measures: MSK-HQ and The Care Measure, and a Proof of Concept clinician survey via Survey Monkey. These were completed by the clinicians and patient cohort during the scheduled clinic and POC clinical contact.Results: A total of 135 patients received a diagnostic ultrasound scan over the six week trial period. 34 patients received a diagnostic ultrasound scan from the Extended Scope Practitioner (ESP) Physiotherapist in a Scheduled Care setting. 101 patients received a diagnostic ultrasound scan from the ESP Podiatrist in orthopaedic triage over the six week period (74 in Scheduled care clinics and 27 at Point of Care). The outcome measure suggest that patients recieved a rapid diagnosis (n.135), implementation of appropriate treatment pathway (86.36%), a positive impact on Referral to Treatment (88.55%), appropriate implementation of conservative treatment (91.11%) and had excellent co-production during the trial with an 88% average CARE Measure Score. The MSK-HQ results suggested a wide variety of muscuoskeletal conditions were asseessed during the trial with a mean MSK-HQ score of 27.6 with a Standard Deviation of 12.Conclusion: Results from clinician sourced Survey Monkey data, The CARE Measure and MSK HQ suggest that POC ultrasound and Scheduled care clinics offer a positive benefit for the patient’s care pathway, are beneficial clinically and suggest adequate demand for the service.

Clinical- and cost-effectiveness of the STAR care pathway compared to usual care for patients with chronic pain after total knee replacement: study protocol for a UK randomised controlled trial

BackgroundApproximately 20% of patients experience chronic pain after total knee replacement. There is little evidence for effective interventions for the management of this pain, and current healthcare provision is patchy and inconsistent. Given the complexity of this condition, multimodal and individualised interventions matched to pain characteristics are needed. We have undertaken a comprehensive programme of work to develop a care pathway for patients with chronic pain after total knee replacement. This protocol describes the design of a randomised controlled trial to evaluate the clinical- and cost-effectiveness of a complex intervention care pathway compared with usual care.MethodsThis is a pragmatic two-armed, open, multi-centred randomised controlled trial conducted within secondary care in the UK. Patients will be screened at 2 months after total knee replacement and 381 patients with chronic pain at 3 months postoperatively will be recruited. Recruitment processes will be optimised through qualitative research during a 6-month internal pilot phase. Patients are randomised using a 2:1 intervention:control allocation ratio. All participants receive usual care as provided by their hospital. The intervention comprises an assessment clinic appointment at 3 months postoperatively with an Extended Scope Practitioner and up to six telephone follow-up calls over 12 months. In the assessment clinic, a standardised protocol is followed to identify potential underlying causes for the chronic pain and enable appropriate onward referrals to existing services for targeted and individualised treatment. Outcomes are assessed by questionnaires at 6 and 12 months after randomisation. The co-primary outcomes are pain severity and pain interference assessed using the Brief Pain Inventory at 12 months after randomisation. Secondary outcomes relate to resource use, function, neuropathic pain, mental well-being, use of pain medications, satisfaction with pain relief, pain frequency, capability, health-related quality of life and bodily pain. After trial completion, up to 30 patients in the intervention group will be interviewed about their experiences of the care pathway.DiscussionIf shown to be clinically and cost-effective, this care pathway intervention could improve the management of chronic pain after total knee replacement.Trial registrationISRCTN registry (ISRCTN92545361), prospectively registered on 30 August 2016.

Concordance Between Clinical Examination and MRI Findings, and Its Effect on Surgical Outcome in Patients with Lumbosacral Radiculopathy

1. Abstract 1.1. Background: Lumbosacral radiculopathy is a common cause of pain and disability. Surgical intervention improves pain and quality of life in patients who do not respond to conservative treatment. A proportion of patients experience their symptoms in a different dermatomal distribution to what might be expected from abnormalities seen on MRI. Previous investigators have concluded that clinical examination and dermatomal maps are inaccurate in this group, and that anatomical variability exists. This study investigates clinical outcome following surgical treatment of this patient cohort. 1.2. Materials and Methods: Surgical outcome data from 137 spinal surgery patients at a teaching hospital over 6 years were analysed retrospectively. Patients were divided into two groups - those whose examination findings were concordant with their MRI findings, and those whose findings were non-concordant. Improvements in validated surgical outcome measures were compared between the two groups. 1.3. Results: The concordant group (n = 100) improved significantly (P < 0.05) across 9 out of 10 measures. The non-concordant group (n = 37) improved significantly across 8 out of 10 measures. The difference in improvement between the two groups was not significant. 1.4. Conclusion: The non-concordant group appeared to have surgical outcomes as good as the concordant group. This suggests that the pathology seen on MRI is the source of the patient’s symptoms, and is in keeping with previous research suggesting that dermatomal innervation is variable, and clinical examination using dermatome maps can be inaccurate. The study is limited by its size and its retrospective nature. A larger, prospective study could confirm these results. 2. Abbreviations: MRI : Magnetic Resonance Imaging CT : Computed Tomography ESP : Extended Scope Practitioner LBOS : Low-Back Outcome Score ODI : Oswestry Disability Index MSPQ : Modified Somatic Perception Questionnaire VAS : Visual Analogue Scale ADL : Activities of Daily Living SD : Standard Deviation MRC : Medical Research Council

How Knowledge Relates to Confidence in Orthopedics and Emergency Medicine Regarding Return to Sport and Rehabilitation in Foot and Ankle Trauma

The aim of this study was to survey the knowledge of registrars in emergency medicine and orthopedics on 5 common injuries to the foot and ankle and compare this knowledge, and self-reported confidence in giving it, with that of consultants and physiotherapists of various levels of experience. An online survey was used to gather the information using scenario-based open and closed questions. A total of 102 health care professionals, who regularly deal with sports injuries, were recruited. These included consultant orthopedic surgeons with a subspecialty interest in foot and ankle surgery, orthopedic surgeons in other specialties, extended scope physiotherapy practitioners (ESPs) in foot and ankle and general musculoskeletal practice, emergency medicine consultants, emergency medicine registrars, orthopedic registrars, senior physiotherapists, and junior physiotherapists. The participants were drawn from various health care institutions in the North East of England. Consultant foot and ankle surgeons and extended scope practitioners in foot and ankle both scored significantly on knowledge of rehabilitation program design than either set of registrars. For 2 of the case scenarios, there was a significant difference in scores between either orthopedic consultants or ESPs and registrars (p < 0.05). For total score, there was a trend for extended scope practitioners to score higher than both sets of registrars, but this did not reach significance. Correlation coefficients for knowledge and self-reported confidence ranged between 0.009 and 0.33, demonstrating only weak positive linear correlation between scenario score and reported confidence in advice given. The most significant area of gaps in knowledge among the 2 groups of registrars was in the specifics of rehabilitation programs. There was markedly higher confidence with greater seniority. Registrars in emergency medicine and orthopedics are likely to benefit from case-based teaching in sports injury rehabilitation.

How Knowledge Relates to Confidence in Orthopaedics and Emergency Medicine Regarding Rehabilitation in Foot and Ankle Trauma

Category: Sports Introduction/Purpose: The aim of this study was to survey the knowledge of registrars in emergency medicine and orthopaedics on five common injuries to the foot and ankle and compare this knowledge, and self-reported confidence in giving it, with that of consultants and physiotherapists of various levels of experience. Methods: An online survey was used to gather the information using scenario based open and closed questions. A total of 102 healthcare professionals, who regularly deal with sports injuries, were recruited. This included consultant orthopaedic surgeons with a subspecialty interest in foot and ankle surgery,. orthopaedic surgeons in other specialties, extended scope physiotherapy practitioners (ESPs) in foot and ankle and general musculoskeletal practice, emergency medicine consultants, emergency medicine registrars, orthopaedic registrars, senior physiotherapists and junior physiotherapists. The participants were drawn from the various healthcare institutions in the North East of England. Results: Consultant foot and ankle surgeons and extended scope practitioners in foot and ankle both scored significantly on knowledge of rehabilitation programme design than either set of registrars. For two of the case scenarios there was a significant difference in scores between either orthopaedic consultants or ESPs and registrars (p &lt; 0.05). For total score there was a trend for extended scope practitioners to score higher than both sets of registrars but this did not reach significance. Correlation coefficients for knowledge and self-reported confidence ranged between 0.009 and 0.33, demonstrating only weak positive linear correlation between scenario score and reported confidence in advice given. Conclusion: The most significant area of gaps in knowledge amongst the two groups of registrars was in the specifics of rehabilitation programmes. There was markedly higher confidence with greater seniority, which correlated poorly with differences in specific knowledge. Registrars in emergency medicine and orthopaedics are likely to benefit from case based teaching in sports injury rehabilitation.

The Role of Physiotherapy Extended Scope Practitioners in Musculoskeletal care with Focus on Decision Making and Clinical Outcomes: A Systematic Review of Quantitative and Qualitative Research.

Physiotherapy extended scope practitioner (ESP) roles are widely utilized in the management of musculoskeletal conditions. The present article reviews the current literature, with particular emphasis on the decision-making process, patient/clinician interaction and clinical outcomes. A systematic review of musculoskeletal extended scope practice was carried out. The review focused on the outcome of interventions, and the interactions and decision-making processes between ESPs and their patients. A wide search strategy was employed, through multiple databases, grey literature and experts in the field. Qualitative and quantitative studies alike were included and a mixed-methods synthesis approach was undertaken in analysing the findings of included studies. A total of 476 articles were identified for inclusion, 25 of which (22 quantitative and three qualitative) meeting the criteria for full quality appraisal and synthesis. It was not possible to conduct a meta-analysis owing to data heterogeneity. The results showed high patient satisfaction with the ESP role, support for ESP staff listing patients for orthopaedic surgery, a high positive correlation of decision making between ESPs and orthopaedic surgeons and evidence of a positive impact on patient outcomes. Qualitative themes reflected the importance of ESP clinical decision making and interpersonal skills and their role in patient education. There is broad support for the physiotherapy ESP role and evidence of favourable outcomes from ESP intervention. Clinical decisions made by ESPs correlate well with those of medical colleagues, although there is a lack of detail explaining the ESP decision-making process itself and the influences and mechanisms by which this occurs. Copyright © 2016 John Wiley & Sons, Ltd.

Development of a toolkit for early identification of cauda equina syndrome.

CES is a rare condition which can be very challenging to identify in a generalist medical setting. A three phase iterative design with two stake holder groups; extended scope practitioners experienced in managing CES patients and CES sufferers. Toolkit development Synthesis of existing CES literature with CES patient data generated from in depth interviews. Toolkit validation Content validation of the draft toolkit with CES patients. Toolkit validation Content validation of the draft toolkit with extended scope physiotherapists. Findings A three arm toolkit has been developed for use with patients considered by the clinician as at risk of developing CES (eg, worsening low back pain with symptoms/signs of progressive sensory-motor deficit in the lower limbs); patient expertise, clinical expertise, research and pathways. Uniquely, the toolkit drew upon the lived experiences of patients suffering from CES to inform the content.