Musculoskeletal Physiotherapy Services Research Articles

Consolidation of Publicly Funded Outpatient Musculoskeletal Physiotherapy Services in Winnipeg, Manitoba: Effects on Accessibility and Service Delivery

Consolidation of Publicly Funded Outpatient Musculoskeletal Physiotherapy Services in Winnipeg, Manitoba: Effects on Accessibility and Service Delivery

Musculoskeletal patients’ preferences for care from physiotherapists or support workers: a discrete choice experiment

BackgroundDelegation of clinical tasks from physiotherapists to physiotherapy support workers is common yet varies considerably in musculoskeletal outpatient physiotherapy services, leading to variation in patient care. This study aimed to explore patients’ preferences and estimate specific trade-offs patients are willing to make in treatment choices when treated in musculoskeletal outpatient physiotherapy services.MethodsA discrete choice experiment was conducted using an efficient design with 16 choice scenarios, divided into two blocks. Adult patients with musculoskeletal conditions recruited from a physiotherapy service completed a cross-sectional, online questionnaire. Choice data analyses were conducted using a multinomial logit model. The marginal rate of substitution for waiting time to first follow-up physiotherapy appointment and distance from the physiotherapy clinic was calculated and a probability model was built to estimate the probability of choosing between two distinct physiotherapy service options under different scenarios.Results382 patient questionnaires were completed; 302 participants were treated by physiotherapists and 80 by physiotherapists and support workers. There was a significant preference to be seen by a physiotherapist, have more follow-up treatments, to wait less time for the first follow-up appointment, to be seen one-to-one, to see the same clinician, to travel a shorter distance to get to the clinic and to go to clinics with ample parking. Participants treated by support workers did not have a significant preference to be seen by a physiotherapist and it was more likely that they would choose to be seen by a support worker for clinic scenarios where the characteristics of the physiotherapy service were as good or better.ConclusionsFindings highlight that patients treated by support workers are likely to choose to be treated by support workers again if the other service characteristics are as good or better compared to a service where treatment is provided only by physiotherapists. Findings have implications for the design of physiotherapy services to enhance patient experience when patients are treated by support workers. The findings will contribute to the development of “best practice” recommendations to guide physiotherapists in delegating clinical work to physiotherapy support workers for patients with musculoskeletal conditions.

Agreeing priority categories and items for inclusion in a future best practice delegation framework for musculoskeletal outpatient physiotherapy services: A consensus groups study

PurposeDelegation of clinical tasks from physiotherapists to physiotherapy support workers varies considerably in musculoskeletal outpatient physiotherapy services leading to variation in patient care. This study aimed to develop consensus amongst physiotherapists, support workers and managers about what components should be included in a future framework to guide effective and safe delegation of clinical tasks to physiotherapy support workers in United Kingdom's National Health Service musculoskeletal outpatient physiotherapy services. MethodsA consensus study was carried out, using Nominal Group Technique. Seven physiotherapists, ten physiotherapy support workers and ten physiotherapy operational/clinical leads from 13 musculoskeletal physiotherapy services within United Kingdom's National Health Service were recruited through the Chartered Society of Physiotherapy's professional networks and social media. Three separate, role-specific consensus groups were convened, involving participants generating, discussing and rating on a Likert scale, components for inclusion in a future delegation framework. Results32 out of 38 generated items reached consensus of ≥70%, i.e. a mean of ≥4.9 on a 7-point Likert scale, across the three groups. Items were grouped under five main categories: 1) training/Continuous Professional Development for physiotherapists and support workers; 2) need for a clear delegation process; 3) competencies 4) defining the role of support workers and 5) safety net. ConclusionKey stakeholder groups were able to reach consensus on five priority areas which will be developed into a best practice framework to standardise delegation and guide physiotherapists when delegating clinical tasks to support workers.

Anti-TNF (adalimumab) injection for the treatment of adults with frozen shoulder during the pain predominant stage protocol for a multi-centre, randomised, double blind, parallel group, feasibility trial.

The Anti-Freaze-F trial will assess the feasibility of conducting a large randomised controlled trial to assess whether intra-articular injection of anti-TNF (adalimumab) can reduce pain and improve function in people with pain predominant early stage frozen shoulder. We are conducting a multi-centre, randomised feasibility study, with an embedded qualitative sub-study. We will recruit adults ≥18 years with a new episode of shoulder pain attributable to early stage frozen shoulder, recruited from at least five UK NHS musculoskeletal and related physiotherapy services. Participants (n=84) will be randomised (centralised computer generated 1:1 allocation) to receive either: 1) intra-articular injection of anti-TNF (adalimumab 160mg) or 2) placebo injection (saline [0.9% sodium chloride]), both under ultrasound guidance. A second injection of the allocated treatment (adalimumab 80mg) or equivalent volume of placebo will be administered 2-3 weeks later. All participants will receive a physiotherapy advice leaflet providing education and advice about frozen shoulder and pain management. The primary feasibility objectives are: 1) the ability to screen and identify potential participants with pain predominant early stage frozen shoulder; 2) willingness of eligible participants to consent and be randomised to intervention; 3) practicalities of delivering the intervention, including time to first injection and number of participants receiving second injection; 4) standard deviation of the Shoulder Pain and Disability Index (SPADI) score and attrition rate at 3 months (i.e. 12 weeks) post-randomisation in order to estimate the sample size for a definitive trial. We will also assess follow up rates and viability of patient-reported outcome measures and range of shoulder motion for a definitive trial. Research Ethics Committee approval (REC 21/NE/0214). ISRCTN 27075727; EudraCT number: 2021-003509-23; ClinicalTrials.gov NCT05299242.

Developing a best practice framework for musculoskeletal outpatient physiotherapy delegation: the MOPeD mixed-methods research study protocol

IntroductionPhysiotherapy assistants/support workers are an important part of the physiotherapy workforce in the UK. Many of them work in National Health Service (NHS) physiotherapy outpatient services treating patients with musculoskeletal...

Anti-TNF (adalimumab) injection for the treatment of adults with frozen shoulder during the pain predominant stage protocol for a multi-centre, randomised, double blind, parallel group, feasibility trial

Objectives: The Anti-Freaze-F trial will assess the feasibility of conducting a large randomised controlled trial to assess whether intra-articular injection of anti-TNF (adalimumab) can reduce pain and improve function in people with pain predominant early stage frozen shoulder. Methods and analysis: We are conducting a multi-centre, randomised feasibility study, with an embedded qualitative sub-study. We will recruit adults ≥18 years with a new episode of shoulder pain attributable to early stage frozen shoulder, recruited from at least five UK NHS musculoskeletal and related physiotherapy services. Participants (n=84) will be randomised (centralised computer generated 1:1 allocation) to receive either: 1) intra-articular injection of anti-TNF (adalimumab 160mg) or 2) placebo injection (saline [0.9% sodium chloride]), both under ultrasound guidance. A second injection of the allocated treatment (adalimumab 80mg) or equivalent volume of placebo will be administered 2-3 weeks later. All participants will receive a physiotherapy advice leaflet providing education and advice about frozen shoulder and pain management. The primary feasibility objectives are: 1) the ability to screen and identify potential participants with pain predominant early stage frozen shoulder; 2) willingness of eligible participants to consent and be randomised to intervention; 3) practicalities of delivering the intervention, including time to first injection and number of participants receiving second injection; 4) standard deviation of the Shoulder Pain and Disability Index (SPADI) score and attrition rate at 3 months from baseline in order to estimate the sample size for a definitive trial. We will also assess follow up rates and viability of patient-reported outcome measures and range of shoulder motion for a definitive trial. Research Ethics Committee approval (REC 21/NE/0214). Trial registration number: ISRCTN 27075727; EudraCT number: 2021-003509-23; ClinicalTrials.gov NCT05299242.

Staff experience of rapid implementation of telemedicine: informing future service redesign

Background/Aims In response to the COVID-19 pandemic, many services in the NHS suspended face-to-face appointments and transitioned to remote consultations. Best practice advocates for evaluation of what was implemented, and the lessons learned, to guide future service redevelopment. This evaluation explored the experienced of physiotherapy staff, aiming to inform future service development and ensure that the staff perspective is taken into account. Methods A survey was distributed to all staff involved in the initial running of the integrated musculoskeletal physiotherapy service at Guy's and St Thomas' NHS Foundation Trust. Questions consisted of Likert scales, multiple choice questions, scales of 1–100 and open questions. Overall, 22 staff members from the new remote clinic and 10 from the follow-up clinic responded. Content analysis was performed to draw themes from responses. Results Overall, 75% of responses indicated a positive experience of the implementation of telemedicine. However, improvements in training and procedural matters were highlighted as fundamental to supporting staff in these clinics. There was considerable variation between staff in the new patient clinic and those in the follow-up clinic, with the former feeling less confident about running remote patient clinics. Conclusions Remote consultations are an accepted medium for staff to deliver physiotherapy consultations. However, future development of telemedicine services must be informed by this experience and take staff experiences into consideration.

Survey of people with Myalgic Encephalomyelitis (ME) to explore their use and experiences of physiotherapy services in the UK

Purpose: 250,000 people live with Myalgic Encephalitis (ME) in the UK, this compares to 100,000 living with Multiple Sclerosis. In 2019, a survey by MEAction of 1906 people with ME, identified that over 50% of people who attended specialists ME clinics, employing physiotherapists, were unsatisfied with the services. People with ME (PwME) are also seen in regular musculoskeletal, community, neurological and paediatric physiotherapy services but the views of PwME related to these services are not known. The aim of this present survey, therefore, was to identify the experiences of PwME of physiotherapy services throughout all areas of physiotherapy practice.

Shared Decision Making training improves confidence in clinicians to facilitate collaborative decisions in musculoskeletal physiotherapy

Purpose: In collaboration with Making Choices Together (Improvement Cymru), ABUHB Musculoskeletal Physiotherapy service aimed to deliver a training and support package to embed SDM knowledge and skills into practice and evaluate its initial feedback from clinical staff and service users.

Progressive exercise compared with best-practice advice, with or without corticosteroid injection, for rotator cuff disorders: the GRASP factorial RCT.

Rotator cuff-related shoulder pain is very common, but there is uncertainty regarding which modes of exercise delivery are optimal and the long-term benefits of corticosteroid injections. To assess the clinical effectiveness and cost-effectiveness of progressive exercise compared with best-practice physiotherapy advice, with or without corticosteroid injection, in adults with a rotator cuff disorder. This was a pragmatic multicentre superiority randomised controlled trial (with a 2 × 2 factorial design). Twenty NHS primary care-based musculoskeletal and related physiotherapy services. Adults aged ≥ 18 years with a new episode of rotator cuff-related shoulder pain in the previous 6 months. A total of 708 participants were randomised (March 2017-May 2019) by a centralised computer-generated 1 : 1 : 1 : 1 allocation ratio to one of four interventions: (1) progressive exercise (n = 174) (six or fewer physiotherapy sessions), (2) best-practice advice (n = 174) (one physiotherapy session), (3) corticosteroid injection then progressive exercise (n = 182) (six or fewer physiotherapy sessions) or (4) corticosteroid injection then best-practice advice (n = 178) (one physiotherapy session). The primary outcome was Shoulder Pain and Disability Index (SPADI) score over 12 months. Secondary outcomes included SPADI subdomains, the EuroQol 5 Dimensions, five-level version, sleep disturbance, fear avoidance, pain self-efficacy, return to activity, Global Impression of Treatment and health resource use. Outcomes were collected by postal questionnaires at 8 weeks and at 6 and 12 months. A within-trial economic evaluation was also conducted. The primary analysis was intention to treat. Participants had a mean age of 55.5 (standard deviation 13.1) years and 49.3% were female. The mean baseline SPADI score was 54.1 (standard deviation 18.5). Follow-up rates were 91% at 8 weeks and 87% at 6 and 12 months. There was an overall improvement in SPADI score from baseline in each group over time. Over 12 months, there was no evidence of a difference in the SPADI scores between the progressive exercise intervention and the best-practice advice intervention in shoulder pain and function (adjusted mean difference between groups over 12 months -0.66, 99% confidence interval -4.52 to 3.20). There was also no difference in SPADI scores between the progressive exercise intervention and best-practice advice intervention when analysed at the 8-week and 6- and 12-month time points. Injection resulted in improvement in shoulder pain and function at 8 weeks compared with no injection (adjusted mean difference -5.64, 99% confidence interval -9.93 to -1.35), but not when analysed over 12 months (adjusted mean difference -1.11, 99% confidence interval -4.47 to 2.26), or at 6 and 12 months. There were no serious adverse events. In the base-case analysis, adding injection to best-practice advice gained 0.021 quality-adjusted life-years (p = 0.184) and increased the cost by £10 per participant (p = 0.747). Progressive exercise alone was £52 (p = 0.247) more expensive per participant than best-practice advice, and gained 0.019 QALYs (p = 0.220). At a ceiling ratio of £20,000 per quality-adjusted life-year, injection plus best-practice advice had a 54.93% probability of being the most cost-effective treatment. Participants and physiotherapists were not blinded to group allocation. Twelve-month follow-up may be insufficient for identifying all safety concerns. Progressive exercise was not superior to a best-practice advice session with a physiotherapist. Subacromial corticosteroid injection improved shoulder pain and function, but provided only modest short-term benefit. Best-practice advice in combination with corticosteroid injection was expected to be most cost-effective, although there was substantial uncertainty. Longer-term follow-up, including any serious adverse effects of corticosteroid injection. Current Controlled Trials ISRCTN16539266 and EudraCT 2016-002991-28. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 48. See the NIHR Journals Library website for further project information.

The use of a standardised outcome measure (musculoskeletal health questionnaire) within the musculoskeletal physiotherapy services across a trust in Staffordshire

The use of a standardised outcome measure (musculoskeletal health questionnaire) within the musculoskeletal physiotherapy services across a trust in Staffordshire

Quality improvement science can be successfully used to implement an online self referral initiative for an NHS musculoskeletal physiotherapy service

Key-Words: Innovation, Quality Improvement, Patient self referral

Corticosteroid injections in the management of subacromial pain: Experiences and decision making of physiotherapists

BackgroundDespite ongoing debate in the literature regarding their efficacy, corticosteroid injections remain a common treatment intervention for physiotherapists to consider for patients with subacromial pain. Very little is known about what factors and how clinician's experiences inform decision making in this area. ObjectivesTo investigate the experiences and decision making of physiotherapists in relation to the use of corticosteroid injections for subacromial pain. DesignA qualitative study using semi-structured interviews, which were then analysed using thematic analysis. SettingA social enterprise organisation delivering NHS primary care musculo-skeletal physiotherapy services. ParticipantsNine physiotherapists. ResultsThree broad codes were identified: (1) initial management; (2) patient factors; (3) therapist beliefs. Within these three codes, seven sub-themes were identified. Confidence in diagnosis and satisfaction that conservative management had been attempted was important. Features of a patient's presentation were key to decision making, i.e. pain severity, function and effect on sleep. Patient engagement with rehabilitation was also considered important, as was consideration of the effect of psychosocial factors. Therapist beliefs and experiences around the efficacy of corticosteroid injections was also considered influential on decision making. Some dissuasive factors were also discussed. ConclusionSome of the key factors in the decision making of physiotherapists in relation to the use of corticosteroid injections for subacromial pain have been identified, such as patient presentation and engagement, clinician experience and consideration of current literature. Further research is indicated to explore this subject further to enable better understanding around clinical decision making and the use of corticosteroid injections.

Collaborative service delivery to address public health issues within a musculoskeletal setting: evaluation of the Healthy Mind, Healthy Body project

Background/Aims There is a need for greater focus on public health and its impact on musculoskeletal conditions within healthcare delivery. Physiotherapists are well positioned to support this. Outpatient physiotherapy musculoskeletal services traditionally focus on rehabilitation and physical exercise, yet many service users require support to improve both their mental and physical health. This innovative service improvement aimed to embed integrated health promotion within musculoskeletal physiotherapy service delivery. Methods A physiotherapy-led multidisciplinary team introduced patients to other community-based support services to address wider health needs. Results Service evaluation demonstrated a high uptake of self-referral to community services, validating the potential benefit for musculoskeletal condition management. Positive patient feedback indicates that patients valued the service and were well-supported to engage with health improvement. Conclusions Musculoskeletal physiotherapy services need to consider the wider aspects of health, putting public health at the heart of musculoskeletal service delivery.

Advanced musculoskeletal physiotherapy: Barriers and enablers to multi-site implementation.

Advanced musculoskeletal physiotherapy (AMP) services are a safe, effective model of care, but without broad-scale healthcare implementation to date. The aim of the present study was to identify the barriers and enablers to implementation of 12 AMP services from the perspective of clinical staff. In a qualitative study, 12 participants (physiotherapists), from 12 different healthcare networks (seven metropolitan, three regional, two rural), were included. Their departments implemented AMP services (orthopaedic postoperative joint replacement review, n=10; general orthopaedic, n=1; emergency, n=1; and neurosurgery n=1) over a 12-month period. Participants completed a structured survey specifically designed for the study. Thematic analysis was used, with themes mapped to the validated Theoretical Domains Framework. Nine major themes emerged from the data regarding barriers and enablers to the implementation of the AMP services from the perspective of clinical staff. These were: demand/capacity; model of care; the organization; stakeholders; communication; planning and processes; evaluation; workforce; and learning and assessment framework. Important enablers included engagement and buy-in from key stakeholders and medical staff, and well-established AMP learning frameworks for training and operational frameworks. Barriers included competitive funding environment, and issues that hindered effective communication. The knowledge, skills, availability, motivation and experience of the advanced musculoskeletal physiotherapists had a large impact on the implementation. The study identified a number of factors that should be considered for successful implementation of AMP services across healthcare services or wider healthcare networks.

Evaluation of a musculoskeletal physiotherapy service and associated cost benefits

Evaluation of a musculoskeletal physiotherapy service and associated cost benefits

Variations in demand and provision for publicly funded outpatient musculoskeletal physiotherapy services across Quebec, Canada.

The prevalence of musculoskeletal disorders is high and expected to increase in the next decade. Persons suffering from musculoskeletal disorders benefit from early physiotherapy services. However, access to publicly funded physiotherapy services has been shown to be compromised by long waiting times and limited availability of resources in many countries around the world. Decisions on resource allocation may create geographic disparities in provision and access to services, which may result in inequity in access. This study aimed to assess variations in demand and provision of publicly funded outpatient physiotherapy services across the province of Quebec, Canada, as well as to assess the demand to provision relationship. We conducted a secondary analysis of data retrieved from the 2008 Quebec Health Survey and data obtained from a survey of hospitals in the province of Quebec in 2015. We used geographic information systems analyses and descriptive analyses to assess geographic variations and the relationship between demand and provision. Our results indicate substantial variations in the provision and demand for physiotherapy services in the province of Quebec. The variations in service provision did not follow the variations in demand. Long waiting times and insufficient provision of services were found in many regions. The variations in provision of physiotherapy services between regions reported in our study did not correspond to the variations in demand. Such geographic variations and demand to provision mismatches may create inequity in access to services, especially for those unable to afford private services.

Clinical and cost-effectiveness of progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of rotator cuff disorders: protocol for a 2x2 factorial randomised controlled trial (the GRASP trial)

IntroductionShoulder pain is very common, with around 70% of cases due to disorders of the rotator cuff. Despite widespread provision of physiotherapy, there is uncertainty about which type of exercise...

Low Back Pain: Current Patterns of Canadian Physiotherapy Service Delivery.

Purpose: The aim of this study was to describe the current patterns of service delivery of Canadian physiotherapy (PT) professionals working in adult musculoskeletal (MSK) outpatient practice. Methods: A total of 846 Canadian PT professionals working with an adult MSK outpatient clientele participated in an online survey about how they would treat a patient with low back pain (LBP). After reading an online clinical vignette about a fictional patient with varying insurance status, participants answered questions about how they would treat the patient (e.g., wait time, frequency and duration of treatment, time allotted for initial evaluation and treatment), about their actual practice (e.g., number of patients seen per day), and about their work setting. Results: The vignette patients with LBP would typically be seen within 2 weeks, especially in private practice, and most would receive care 2-3 times per week for 1-3 months. Initial evaluations and subsequent treatments would take 31-60 minutes. Two-thirds of participants reported treating 6-15 patients a day in their current practice setting. Differences were found between provinces and territories (with the longest wait time in Quebec), practice settings (with a longer wait time in the public sector), and insurance status (patients covered by workers' compensation are seen more frequently). Conclusion: This study adds to our knowledge of the accessibility of outpatient MSK PT services for patients with LBP in Canada, and it points to potential areas for improvement.

Physiotherapy managers’ perceptions of musculoskeletal physiotherapy services in primary care in the Republic of Ireland: a qualitative study

Physiotherapy managers’ perceptions of musculoskeletal physiotherapy services in primary care in the Republic of Ireland: a qualitative study