Musculoskeletal Disorders In Primary Care Research Articles

Prognostic Factors and Treatment Effect Modifiers for Physical Health, Opioid Prescription, and Health Care Utilization in Patients With Musculoskeletal Disorders in Primary Care: Exploratory Secondary Analysis of the STEMS Randomized Trial of Direct Access to Physical Therapist-Led Care.

The aims of the study were to identify prognostic factors associated with health care outcomes in patients with musculoskeletal conditions in primary care and to determine whether characteristics associated with choice of care modify treatment effects of a direct-access physical therapist-led pathway in addition to general practitioner (GP)-led care compared to GP-led care alone. A secondary analysis of a 2-parallel-arm, cluster randomized controlled trial involving general practices in the United Kingdom was conducted. Practices were randomized to continue offering GP-led care or to also offer a direct-access physical therapist-led pathway. Data from adults with musculoskeletal conditions who completed the 6-month follow-up questionnaire were analyzed. Outcomes included physical health, opioid prescription, and self-reported health care utilization over 6 months. Treatment effect modifiers were selected a priori from associations in observational studies. Multivariable regression models identified potential prognostic factors, and interaction analysis tested for potential treatment effect modifiers. Analysis of 767 participants indicated that baseline pain self-efficacy, pain severity, and having low back pain statistically predicted outcomes at 6 months. Higher pain self-efficacy scores at baseline were associated with improved physical health scores, reduced opioid prescription, and less health care utilization. Higher bodily pain at baseline and having low back pain were associated with worse physical health scores and increased opioid prescription. Main interaction analyses did not reveal that patients' age, level of education, duration of symptoms, or musculoskeletal presentation influenced response to treatment, but visual trends suggested those in the older age group proceeded to fewer opioid prescriptions and utilized less health care when offered direct access to physical therapy. Patients with musculoskeletal conditions with lower levels of pain self-efficacy, higher pain severity, and presenting with low back pain have less favorable clinical and health care outcomes in primary care. Prespecified characteristics did not modify the treatment effect of the offer of a direct-access physical therapist-led pathway compared to GP-led care. Patients with musculoskeletal conditions receiving primary care in the form of direct-access physical therapist-led or GP-led care who have lower levels of self-efficacy, higher pain severity, and low back pain are likely to have a less favorable prognosis. Age and duration of symptoms should be explored as potential patient characteristics that modify the treatment response to a direct-access physical therapist-led model of care.

P101 Understanding First Contact Physiotherapists experiences of remote consultations in primary care

Abstract Background/Aims First Contact Physiotherapists (FCPs) assess, diagnose and manage patients presenting with musculoskeletal disorders in primary care, without the need for prior GP consultation. Prior to COVID-19 almost every consultation was conducted in-person. Since the pandemic, many consultations are now undertaken remotely, a trend that is set to continue in line with the ‘Digital first’ strategy which seeks to enhance patient access to appointments. This aim of this study was to explore FCP views of remote consultations and how this impacted their role satisfaction and wellbeing. Methods This mixed methods two phase study consisted of an online survey investigating distributed via professional networks and through social media. The phase one survey explored consultation methods; levels of training; challenges and benefits; and a stress appraisal. Data were analysed descriptively. Respondents were invited to take part in phase two which included a semi-structured interview to gain an in-depth understanding of FCPs lived experience of remote consultation ways of working. Transcripts were thematically analysed. Results The online survey received n = 109 responses from UK-based FCPs. Data revealed that despite the ‘Digital First’ push for continued remote consultations, the majority of FCPs (62%) used them for less than a quarter of their appointment slots. Whilst recognising that many patients found this format convenient, FCPs highlighted their own stress levels, citing poor efficacy, anxiety of misdiagnosis, feelings of isolation and increased administrative workload. Nearly two thirds (66%) of respondents had not received any training in how to conduct effective remote consultations. Follow-up interviews with n = 16 FCPs highlighted coping strategies including following up with an in-person consultation and directing patients to other community health and wellbeing resources. In areas of high socioeconomic deprivation and poor health literacy additional problems associated with communication difficulties, poor IT access and capability, and digital poverty were all cited. Conclusion Remote consultations may offer a convenient alternative for some patients. FCP responses suggest that the continued offer of remote consultation is decreasing now pandemic restrictions have been lifted, despite the push for continued digital working practices. The perceived lack of efficacy, and fear of missing important diagnostic information means that many FCPs are either returning to in-person consultation or following up with a second face-to-face assessment resulting in potential service inefficiencies. Additional challenges were identified in areas of high deprivation and low health literacy, and the value of this consultation format needs to be considered in this context. Future work should focus on the training and support needs of FCP staff who are engaging with remote working to ensure clinical effectiveness and staff wellbeing. Disclosure N. Walsh: Grants/research support; Walsh is funded by NIHR. B.E. Jones: None. R. Thomas: None. Z. Anchors: None.

Factors associated with referral to physiotherapists for adult patients consulting for musculoskeletal disorders in primary care; an ancillary study to ECOGEN

BackgroundMusculoskeletal disorders (MSD) are multifactorial requiring multidisciplinary treatment including physiotherapy. General practitioners (GP) have a central role in managing MSDs and mostly solicit physiotherapists accounting for 76.1% of physiotherapy referrals in France. Patient, physician, and contextual factors, including healthcare accessibility, can influence physiotherapy referral rates.ObjectiveTo identify patient, physician, and contextual factors associated with physiotherapy referral in adult patients with MSDs in general practice.MethodsThis study is based on the 2011/2012 French cross-sectional ECOGEN study. Analyses included working-age patients consulting their GP for any MSD. Physiotherapy referral was assessed initially, then adjusted multilevel logistic model analysis of patient, physician, geographical area-related factors associated with these referrals was performed.ResultsAmong the 2305 patients included, 456 (19.8%) were referred to a physiotherapist. Following multilevel multivariate analyses, physiotherapist referral was more frequent for female patients (OR 1.28; 95% CI [1.03, 1.59]) with spinal (OR 1.47; 95% CI [1.18, 1.83]) and upper limb disorders (OR 1.66; 95% CI [1.20, 2.29]), and less frequent for patients ≥ 50 years (OR 0.69; 95% CI [0.52, 0.91]), living in deprived geographical areas (OR 0.60; 95% CI [0.40, 0.90]). GPs referred to a physiotherapist less frequently if they were ≥ 50 years (OR 0.50; 95% CI [0.39, 0.63]), had a high number of annual consultations, or were practicing in semi-urban area in a multidisciplinary team.ConclusionThis multilevel analysis identifies factors associated with physiotherapy referral for patients with MSDs, including living in deprived geographical areas. This constitutes an original contribution towards addressing healthcare disparities.

Minimal clinical data sets for spine-related musculoskeletal disorders in primary care and outpatient settings: a scoping review protocol

IntroductionLack of standardised clinical data collection may lead to reduced quality in musculoskeletal (MSK)-related clinical care and research. Little is known about the availability and characteristics of minimal clinical data...

Health effects of direct triaging to physiotherapists in primary care for patients with musculoskeletal disorders: a pragmatic randomized controlled trial.

Background:Physiotherapists and general practitioners (GPs) both act as primary assessors for patients with musculoskeletal disorders in primary care. Previous studies have shown that initial triaging to physiotherapists at primary healthcare centres has advantages regarding efficiency in the work environment and utilization of healthcare. In this study, we aimed primarily to determine whether triaging to physiotherapists affects the progression of health aspects over time differently than traditional management with initial GP assessment. The secondary aim was to determine whether triaging to physiotherapists affects patients’ attitudes of responsibility for musculoskeletal disorders.Methods:This was a pragmatic trial where both recruitment and treatment strategies were determined by clinical, not study-related parameters, and was initiated at three primary care centres in Sweden. Working-age patients of both sexes seeking primary care for musculoskeletal disorders and nurse assessed as suitable for triaging to physiotherapists were randomized to initial consultations with either physiotherapists or GPs. They received self-assessment questionnaires before the initial consultation and were followed up at 2, 12, 26 and 52 weeks with the same questionnaires. Outcome measures were current and mean (3 months) pain intensities, functional disability, risk for developing chronic musculoskeletal pain, health-related quality of life and attitudes of responsibility for musculoskeletal conditions. Trends over time were analysed with a regression model for repeated measurements.Results:The physiotherapist-triaged group showed significant improvement for health-related quality of life at 26 weeks and showed consistent but nonsignificant tendencies to greater reductions of current pain, mean pain in the latest 3 months, functional disability and risk for developing chronic pain compared with traditional management. The triage model did not consistently affect patients’ attitudes of responsibility for musculoskeletal disorders.Conclusions:Triaging to physiotherapists for primary assessment in primary care leads to at least as positive health effects as primary assessment by GPs and can be recommended as an alternative management pathway for patients with musculoskeletal disorders.ClinicalTrials.gov identifier:NCT148611.

Acceptability of physiotherapists as primary care practitioners and advanced practice physiotherapists for care of patients with musculoskeletal disorders: a survey of a university community within the province of Quebec

BackgroundMusculoskeletal (MSK) disorders represent a great burden on the health care system. The use of physiotherapists in their autonomous roles and in advanced practice roles may help increase access to care. Thus, the aim of this survey was to assess the perceptions of a university community sample within the province of Quebec about physiotherapists as primary care practitioners and advanced practice physiotherapists (APPs) for the treatment of patients with musculoskeletal disorders.MethodsAn electronic survey was sent in February 2014 via a web platform to members of the Laval University community (Québec City, Canada). The survey included questions about knowledge and perceptions on current physiotherapists’ autonomous role in primary care and on APP future model of care for patients with MSK disorders. Survey results were synthetized with descriptive statistics. Differences in responses according to demographics, personal characteristics and previous physiotherapy care experience were evaluated using Chi-Square tests.ResultsA total of 513 participants completed the online survey (1 % response rate). The majority of respondents were women (74 %) and aged 18 to 24 (39 % of all respondent). About 90 % of respondents believed that physiotherapists were skilled and competent and 91 % answered that they had trust in physiotherapists for the treatment of MSK disorders in primary care. A total of 90 % of respondents supported the idea of introducing APPs for the treatment of patients with MSK disorders. Over 90 % of respondents were in favour of the delegation of medical acts such as: communicating a medical diagnosis, ordering imaging tests, triaging surgical candidates or prescribing medication such as NSAIDS.ConclusionsRespondents are satisfied and have confidence in physiotherapists as primary care practitioners; they also support the intended new roles of the APPs in the health care system. Caution should be taken in generalizing these results from this particular sample. These results need to be corroborated in the general population.Electronic supplementary materialThe online version of this article (doi:10.1186/s12891-016-1256-8) contains supplementary material, which is available to authorized users.

Costs and Utilities of Manual Therapy and Orthopedic Standard Care for Low-prioritized Orthopedic Outpatients of Working Age

Treatment for musculoskeletal disorders in primary care in Sweden is generally initiated with advice and medication. Second-line therapy is physiotherapy and/or injection and radiography; third-line therapy is referral to an orthopedist. Manual therapy is not routine. It is a challenge to identify patients who benefit from treatment by different specialists. The current referral strategy probably contributes to long waiting lists in orthopedic departments, which is costly and implies prolonged suffering for the patients. The aim of this health economic evaluation was to compare costs and outcomes from naprapathic manual therapy (NMT) with orthopedic standard care for common, low-prioritized, nonsurgical musculoskeletal disorders, after second-line treatment. Diagnose Related Groups were used to define the costs, and the SF-36 was encoded to evaluate the outcomes in cost per quality adjusted life years gained. Results from a 12 months' follow-up showed significantly larger improvement for the NMT than for orthopedic standard care, significantly lower mean cost per patient; 5427 SEK (*Price level 2009; 1 Euro=106,213 SEK; 1 US Dollar=76,457 SEK) (95% confidence interval, 3693-7161) compared to14298 SEK (95% confidence interval, 8322-20,274), and more gains in outcomes in cost per quality adjusted life years per patient (0.066 compared with 0.026). Thus the result is "dominant." It is plausible that improved outcomes and reasonable cost savings for low-prioritized nonsurgical outpatients would be attainable if NMT were available as an additional standard care option in orthopedic outpatient clinics.

Musculoskeletal Disorders in Primary Care

This book is well written by a large number of authors (at least one for each chapter!) who have previous publications and recognized expertise in their particular fields. The editing has given a c...

Evaluation of physiotherapists as primary assessors of patients with musculoskeletal disorders seeking primary health care

ObjectivesTo evaluate primary physiotherapist assessment and management of patients with musculoskeletal disorders in primary care, and to compare patient satisfaction with primary assessment by a physiotherapist or a general practitioner (GP). DesignAn observational, retrospective cohort study reviewing medical records, and a separate consecutive non-randomised study of patient satisfaction. SettingPrimary healthcare centre. ParticipantsFour hundred and thirty-two patients with musculoskeletal disorders, primarily assessed by a physiotherapist. Fifty-one of these patients primarily assessed by a physiotherapist and 42 patients assessed by a GP answered a patient satisfaction questionnaire. InterventionsPrimary assessment and management of patients with musculoskeletal disorders. Main outcome measuresData from medical records within 3-month after the visit, and patient satisfaction questionnaire. ResultsEighty-five percent (367/432) of patients did not need to see a GP. Serious pathologies were found among the 6% (26/432) of patients who were referred to a GP by a physiotherapist, but no serious pathologies were found among the 9% (39/432) of patients who subsequently returned for a GP appointment for the same disorder. Patients assessed by a physiotherapist were more satisfied with the information received about their disorder and self-care than patients assessed by a GP. Patients also had higher confidence in the ability of physiotherapists to assess their disorder (P<0.002). ConclusionPhysiotherapists can be considered primary assessors of patients with musculoskeletal disorders in primary care as few patients needed additional assessment by a GP, patients with confirmed serious pathologies were identified by the physiotherapists, and patients were satisfied with assessment by a physiotherapist.

Improving management of musculoskeletal disorders in primary care: the Joint Adventures Program

Musculoskeletal disorders represent a large and growing clinical challenge to primary care clinicians. Unfortunately, there appears to be a gap in current training and continuing education to meet this challenge. We used script concordance within a continuing medical education program entitled "Joint Adventures" to assist family physicians to acquire the knowledge, skills, and tools they need to improve their management of musculoskeletal disorders. Program workshops were coordinated through a national continuing education program of the College of Family Physicians of Canada. A group of 54 experts in musculoskeletal disorders including family physicians, rheumatologists, and orthopedists developed cases for six areas of management that were identified by family physicians during a needs survey delivered at a national scientific congress in primary care. Script concordance methodology was used in the Joint Adventures workshop to address knowledge gaps or lack of group consensus in the six areas including (1) diagnosis of osteoarthritis, (2) treatment and management of osteoarthritis, (3) treatment and management of rheumatoid arthritis, (4) diagnosis and treatment of back pain, (5) diagnosis and treatment of fibromyalgia and diagnosis, and (6) treatment of shoulder pain. Each workshop session included 5-30 family physicians, a specialist expert, and a family physician facilitator. Before each session, a group needs assessment was conducted to identify which one or two of the six cases would be used. Perceived knowledge and skill acquisition, self-assessed change in practice, and satisfaction with the program were measured at the conclusion of each session and again at 3 months post program. All programs were delivered from March 2003 to September 2005. Six hundred and fifty family physicians from across Canada completed the program. In general, participants reached concordance with each case. Measures of knowledge and skill acquisition and self-assessed change in practice were significantly improved with high rates of program satisfaction. The Joint Adventures program provided family physicians with knowledge and skills that changed their care of musculoskeletal disorders. This was achieved using consensus that was sensitive to local needs. Further use should be evaluated in other areas of medical practice as well.

Relating undergraduate musculoskeletal medicine curricula to the needs of modern practice

International studies have demonstrated significant discrepancies between undergraduate musculoskeletal curricula and the needs of modern medical practice. To determine the prevalence of musculoskeletal disorders in primary care, General Practitioners, assessment of their undergraduate musculoskeletal training and that considered ideal for several clinical skills, and the relative importance of the ability to recognise selected clinical presentations. A postal survey of 200 General Practitioners using a detailed questionnaire. The response rate was 50.5%, with respondents being an average 18.5 years in practice. They saw a mean 140.3 patients/week (range 10-270) of which 17.4% presented with musculoskeletal complaints (range 5-50%). Respondents felt their musculoskeletal education was poor, with a significant difference between it and their ideal (p = 0.007). The most important skill for a graduating doctor was history taking, examination and appropriate investigation of a musculoskeletal problem. The most important clinical presentation was recognition of traumatic quadriplegia. A large proportion of primary care in Ireland is devoted to musculoskeletal complaints, however, there are deficiencies perceived in undergraduate musculoskeletal education. A review of undergraduate musculoskeletal curricula, emphasising the clinically relevant aspects of this discipline is needed.

Physical and psychological health and social relations in patients with prolonged musculoskeletal disorders.

The purpose of this study was to describe and analyse the relationship between physical and psychological health and social relations in patients with prolonged musculoskeletal disorders in primary care. Seventy-eight patients--64 women and 14 men--were included in the study. Data from a semi-structured interview called addiction severity index (ASI), frequently used in psychiatric and drug abuse research and a visual analogue scale (VAS) symptom list as well were analysed using principal component analysis (PCA). The analysis gave a two-dimensional model with four poles of related variables characterizing the whole group. The first dimension consisted of one pole characterized by present psychiatric symptoms and many somatic symptoms. The second pole on this dimension was characterized by well-being, having work and feeling satisfaction with life. One pole on the second dimension was characterized by severe physical problems, related to sick leave and disability pension. The opposite pole on this dimension was characterized by severe psychiatric symptoms earlier in life and present relationship problems with family and other people. The ASI-instrument was considered to be relevant for describing important problem areas in patients with prolonged musculoskeletal disorders.