Musculoskeletal Triage 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.

CSP2023: 145 - Case report: Digital Musculoskeletal triage and rehabilitation tools enhance accessibility, user experience and outcomes in mechanical knee pain

CSP2023: 145 - Case report: Digital Musculoskeletal triage and rehabilitation tools enhance accessibility, user experience and outcomes in mechanical knee pain

CSP2023: 132 - A Case Report: Digital Musculoskeletal Triage and Rehabilitation Tools Improve Outcomes and Offer a Positive Experience for Lower Back Pain

CSP2023: 132 - A Case Report: Digital Musculoskeletal Triage and Rehabilitation Tools Improve Outcomes and Offer a Positive Experience for Lower Back Pain

‘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.

ADvAnced PhysioTherapy in MuSculosKeletal Triage: Investigating prognostic factors, healthcare utilisation and clinical outcomes (ADAPT MSK) - a cohort study protocol.

Clinical specialist physiotherapist-led musculoskeletal triage clinics were introduced nationally in Ireland in 2011 to improve patient care and reduce waiting times for secondary care orthopaedics and rheumatology. Evidence has shown them to be effective in reducing waiting lists, however there are currently no data on longitudinal patient outcomes following clinic attendance. The primary aim of this cohort study is to identify predictors of pain and function outcomes up to one year following musculoskeletal triage review. Secondary aims include measuring self-reported use of healthcare resources over the 12-month follow-up period and to explore musculoskeletal phenotypes based on established prognostic factors for musculoskeletal pain. This is a prospective cohort study. ADvAnced PhysioTherapy in MuSculosKeletal Triage (ADAPT MSK) will recruit a cohort of 252 adults through musculoskeletal triage clinics across five secondary care sites in Ireland. The STrengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines will be adhered to for future reporting. Adults (≥ 18 years old) attending physiotherapist-led musculoskeletal triage clinics with musculoskeletal pain, who do not require surgical or consultant-led medical care will be considered for participation. Participant demographics, health literacy, healthcare utilisation, and self-report questionnaires on pain, function, musculoskeletal health, musculoskeletal risk stratification, fear of movement, and psychological distress will be obtained at baseline, with follow-ups at three, six, and 12 months. Primary outcomes are pain intensity and function. Secondary outcomes include musculoskeletal risk stratification status, musculoskeletal health, healthcare utilisation, and work-related factors. Descriptive statistics will be used to profile the participants and predictors of outcome will be assessed using multivariable linear regression. Musculoskeletal phenotypes will be explored using latent class analysis. Results will be disseminated via peer-reviewed journal publication and presentation at national and international conferences. Engagement with a public patient involvement (PPI) panel will explore dissemination strategies for public and service user engagement.

Diagnosing knee osteoarthritis in patients, differences between general practitioners and orthopedic surgeons: a retrospective cohort study

Backgroundknee complaints are one of the most common reasons to consult the general practitioners in the Netherlands and contribute to the increasing burden on general practitioners. A proportion of patients that are referred to orthopedic outpatient clinics are potentially referred unnecessarily. We believe osteoarthritis is not always considered by general practitioners as the cause of atraumatic knee complaints. This may impede early recognition and timely care of osteoarthritis complaints and lead to unnecessary referrals.Methodsthe aim of this study was to compare the frequency of (differential) diagnosis of osteoarthritis mentioned in referral letters of general practitioners with the frequency of osteoarthritis mentioned as orthopedic diagnosis at the outpatient clinic. Therefore we conducted a retrospective cohort study based on data collected from referral letters and the corresponding outpatient clinic reports of patients with atraumatic knee complaints of 45 years or older referred to a regional hospital in Nijmegen, The Netherlands in the period from 1-6-2019 until 1-01-2020.Resultsa total of 292 referral letters were included. In the younger aged patients (45–54 years) osteoarthritis was mentioned less frequent and meniscal lesions were mentioned more frequent in referral letters when compared to diagnoses made at the outpatient clinic. Differences in differential diagnosis of osteoarthritis as well as meniscal lesions between orthopedic surgeon and general practitioners were found (both p < 0.001, McNemar). Matching diagnoses were present in 58.2% when all referral letters were analyzed (n = 292) and 75.2% when only referrals containing a differential diagnosis were analyzed (n = 226). Matching diagnoses were present in 31.6% in the younger age categories (45–54 years). A linear trend showing fewer matching diagnoses in younger patient categories was observed (p < 0.001).ConclusionsOsteoarthritis was less frequently mentioned in general practitioner referral letters among the differential diagnosis then it was diagnosed at the outpatient clinic, especially in younger patients (45–54 years). Also matching diagnoses in younger patients were evidently lower than in older patients, partly explained by underdiagnosing of osteoarthritis in younger patients in this cohort. Better recognition of osteoarthritis in younger patients and changing the diagnostic approach of general practitioners might improve efficacy in knee care. Future research should focus on the effectiveness of musculoskeletal triage, the need for multidisciplinary educational programs for patients and promotion of conservative treatment modalities among general practitioners.

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.

Musculoskeletal triage: Do advanced practitioners agree on referral allocation?

Musculoskeletal triage: Do advanced practitioners agree on referral allocation?

A systematic review and evidence synthesis of non-medical triage, self-referral and direct access services for patients with musculoskeletal pain.

The demand for musculoskeletal (MSK) care is rising, and is a growing challenge for general practice. Direct access to physiotherapy and other healthcare services may offer appropriate care for MSK pain patients but there is uncertainty regarding the effectiveness or efficiency of this approach in practice. This study aimed to review the evidence regarding characteristics, outcomes, barriers and facilitators of MSK triage and direct access services. A comprehensive search of eight databases (including MEDLINE, EMBASE, and Cochrane library) up to February 2018 was conducted to identify studies (trials, cohorts and qualitative evidence) on direct access services for MSK in primary care settings. Using predefined inclusion and exclusion criteria, titles, abstracts, and subsequent full texts were independently screened by reviewers. Methodological quality of eligible studies was assessed using the mixed methods appraisal tool, and extracted data regarding study characteristics and results were independently reviewed. A narrative synthesis and grading of evidence was undertaken. Approaches to MSK triage and direct access were profiled along with their respective outcomes of care relating to patient-oriented and socioeconomic outcomes. Barriers and facilitators of each model of direct access services were also highlighted. 9010 unique citations were screened, of which 26 studies were eligible. Three approaches (open access, combination and service pathway models) to MSK triage and direct access shared similar goals but were heterogeneous in application. MSK patients using direct access showed largely similar characteristics (age, sex and duration of symptoms) compared to GP-led care, although they were often younger, slightly more educated and with better socio-economic status than patients seen through GP-led care. Although many studies showed limitations in design or methods, outcomes of care (patient oriented outcomes of pain, and disability) did not show large differences between direct access and GP-led care. In most studies direct access patients were reported to have lower healthcare utilisation (fewer physiotherapy or GP consultations, analgesics or muscle relaxants prescriptions, or imaging procedures) and less time off work compared to GP-led care. This study provides insight into the current state of evidence regarding MSK triage and direct access services and highlights potential implications for future research, healthcare services planning, resource utilisation and organising care for MSK patients in primary care. There is consistent, although limited, evidence to suggest that MSK triage and direct access services lead to comparable clinical outcomes with lower healthcare consumption, and can help to manage GP workload. However, due to the paucity of strong empirical data from methodologically robust studies, a scale up and widespread roll out of direct access services cannot as yet be assumed to result in long term health and socio-economic gains. PROSPERO-ID: CRD42018085978.

Paediatric musculoskeletal (MSK) triage in the community - RightPath - a pilot study

Purpose: We have developed children and young people (CYP) community-based triage (called RightPath) based on a validated adult MSK model developed by Pennine MSK Partnership Ltd (PMSKP). RightPath aims to use paediatric physiotherapists to identify CYP with MSK pathology and triage them to the appropriate service (rheumatology, orthopaedics, or urgent care), managing those who do not need specialist referral appropriately within the community (by physiotherapists and podiatrists). Triage and referral guidance was developed in partnership with MSK specialists and primary care. The pilot tested safety, feasibility, acceptability, and transferability of triage in the community in two UK localities with emphasis on the educational requirements of the triage guidance for healthcare professionals who may not be expert in CYP MSK disease.

The implementation of a ́One Stop Shoṕ shoulder clinic within a musculoskeletal triage service: assessment, diagnostic ultrasound & guided injections

The implementation of a ́One Stop Shoṕ shoulder clinic within a musculoskeletal triage service: assessment, diagnostic ultrasound & guided injections

The outcomes of triaging rheumatology referrals at a single point of access

BackgroundEast Surrey Clinical Commissioning Group established a musculoskeletal triage service for primary care referrals in December 2017 in order to reduce pressure on secondary care.AimTo analyse the processing of rheumatology referrals through the single point of access.MethodA total of 158 referrals over an 8-month period were triaged, 50 of which had available final outcome data. Using a standardised form for GPs, data including initial GP diagnosis, appropriateness for secondary care, any requirement for additional information, relevant blood tests needed before the appointment, and if the patient could be seen by a GP with an extended role in rheumatology were recorded. The resultant rheumatological diagnosis from secondary care was recorded.ResultsOf 158 referrals, 86% were triaged to secondary care, the remainder were referred back to primary care or an alternative healthcare professional. Additional information from the EMIS record was added to 67% of all referrals and additional blood tests were requested in 26%. Of the 50 patients with outcome data, 40% were thought to have non-inflammatory conditions and could be seen in the community setting; this was confirmed in 85% after rheumatology assessment. The most frequent diagnosis in this group was fibromyalgia. Where an inflammatory condition was suspected by the referrer this was confirmed in 68%.ConclusionA significant number of referrals could be seen by a specialist GP in a community setting, the biggest single sub-set of these patients have chronic non-inflammatory pain. The provision of community GP-led rheumatology clinics could improve patient experience, reduce costs, and reduce the burden on secondary care.

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.

316 Paediatric musculoskeletal (MSK) triage in the community: Rightpath a pilot study

316 Paediatric musculoskeletal (MSK) triage in the community: Rightpath a pilot study

Development of Hip/Knee Pathway between Primary and Secondary Care

Introduction: Hip and Knee referrals are the most common General Practioner (GP) referral to the Musculoskeletal (MSK) Triage service in Tallaght hospital. Between 2012-2014, 74% of patients with hip and knee pathology were discharged at their MSK Triage clinic visit and 59% were referred to physiotherapy. Therefore, the need for these patients to be referred to secondary care is questionable. Physiotherapy is recommended for non-traumatic hip and knee pathology prior to considering invasive intervention1,2. The objective was toestablish a care pathway for patients with non-traumatic hip and knee conditions between primary and secondary care. The aims of this pathway was to: 1) Provide timely access to physiotherapy for patients; 2) Improve access for patients requiring further investigations or specialist opinion; 3) Improve communication and streamline care between primary and secondary care services. All patientsresiding in Dublin South West (DSW) are eligible for referral to this pathway. GPs in DSW were encouraged to refer patients with any non-traumatic hip or knee pathology to PCCC physiotherapy in the first instance, who will then refer onto MSK Triage Clinics where appropriate. Any patients who the PCCC physiotherapist deems appropriate for onward referral will be seen at the MSK Triage Clinic within one month of referral. Methods: In November 2015 a care pathway for patients presenting to GPs with non-traumatic hip or knee pain was established between the MSK Triage Service in Tallaght Hospital, GPs and DSW physiotherapy department.The total number of hip and knee referrals received to the MSK Triage service were compared between January-June 2015 and 2016. As the pathway was in DSW, the number of referrals from DSW GPs only was compared between May-July 2015 and 2016. The number of DSW physiotherapy referrals from GPs was also reviewed. Results: The number of referrals from all GPs to the MSK Triage Service for January-June 2015: Hip: 86; Knee: 253 compared to January-June 2016: Hip: 106; Knee: 244. The percentage of referrals to the MSK Triage Service from DSW GPs reduced from May-July 2015 (41% of total referrals) compared with May-July 2016 (34% of total referrals). The percentage of hip and knee referrals from DSW GPs to DSW increased from 33% of total referrals to 63% of total referrals. Discussions/Conclusions: This initial data shows promising results that GPs in DSW are increasing their utilisation of physiotherapy services in primary care. Results demonstrate that there is the need for further promotion and dissemination of the pathway with GPs in DSW and although there is an increased referral to physiotherapy, they need to be encouraged not to send a duplicate referral to secondary care. Results demonstrate that the number of referrals to the MSK Triage service has not changed in the first six months following the introduction of the pathway. However, these figures include referrals from all GPs rather than just DSW. Future developments include introducing this pathway to other primary care areas.

Streamlining the patient journey in musculoskeletal medicine

Introduction: Orthopaedic ICATS was established in the NHS in Northern Ireland in 2006. The founding principle of this service was to provide specialist musculoskeletal assessment and triage for patients whose musculoskeletal complaints had not resolved with GP, physiotherapy or podiatry care. The service forms part of the pathway for referral to Orthopaedic Surgery. An element of its remit involves appropriate investigation prior to surgical consultation and provision of treatment to ensure optimum conservative management has been achieved. When surgery is not advocated, Orthopaedic ICATS manages these patients by signposting them to the most appropriate service which can better address their condition. As a result direct referrals are made to pain clinics, neurology, neurosurgery, core physiotherapy and podiatry services. Problem statement, Targeted population/stakeholders: The musculoskeletal patient journey can be a complicated one. Patients may require input from a number of services in order to resolve their complaint. Previously Physiotherapists and Podiatrists, who recognised the need for further management in their patients, had to refer back to a GP in order to initiate a referral to Orthopaedic ICATS. This process significantly increased the patients waiting time for essential assessment and treatment. The backward step to GP did not easily facilitate good transmission of patient assessment and management data to the ICATS team, often useful clinical information may have been lost in the indirect handover. In addition it added to the burden for already stretched GP services. Aim and Theory of Change: The aim behind the changes in the Southern Trust was to clarify the roles and remits of all stakeholders and to streamline the patient journey by establishing a direct referral pathway thus removing the need for core Physiotherapists and Podiatrists to refer back to the GP in order to gain access to ICATS for their patients. The theory underpinning the concept was that the patient should get the right treatment from the right clinician at the right time. This small practice change had wider financial implications in terms of cost saving by reducing unnecessary appointments. Timeline: The ICATS team started working in conjunction with the team leads in Core Podiatry and Physiotherapy to establish a pathway for direct transfer of patients from their initial musculoskeletal management in physiotherapy and podiatry to Orthopaedic ICATS. The system was implemented initially with defining roles and responsibilities and then producing clear guidelines to aid staff in deciding appropriate patients to refer. Highlights innovation, impact and Outcomes: The system is simple but it opens a pathway which for many years was unnecessarily complicated. It improves dialogue between services and therefore enhances overall management. Closer collaboration between services, with the patient experience as its focus, will ensure innovative service improvement. With the negative publicity that waiting times attract, speeding up the patient journey is a welcomed improvement. Sustainability and Transferability: The system has been in operation in physiotherapy for a number of years, all referrals are triaged in the ICATS service and with the guidance in place referrals have been appropriate. The system has more recently opened up for the referral of musculoskeletal podiatry patients and has been welcomed trust wide as a means of optimising patient flow. The initiative has also been taken up and is gradually being implemented in other ICATS services throughout the region. Conclusion, Discussions, Lessons learned: Streamlining a referral pathway can be viewed as a small change, but this simple step has had a major impact on patient flow and reduced waiting times. It has wider reaching implications helping reduce burdens on GP time. Staff also reap benefits as the new referral pathway has improved dialogue and working relationships between services who are all striving to provide the best possible outcomes, in a timely fashion for the management of those in our care.

05. Paediatric Musculoskeletal Triage in the Community: Rightpath – A Pilot Study

05. Paediatric Musculoskeletal Triage in the Community: Rightpath – A Pilot Study

Review and advances in avian orthopaedic surgery: part 1 — introduction

Orthopaedic conditions, particularly (comminuted) fractures, are a common pathology in avian practice. This first article provides an introduction including considerations of avian musculoskeletal anatomy, patient assessment, triage and initial stabilisation. Although the principles of fracture management in birds are similar to those in human or small animal orthopaedics, there are some significant differences. The principal objectives in the management of avian orthopaedic conditions are to restore and maintain the longitudinal, lateral and rotational alignment of the bones, while causing the minimum iatrogenic damage. The clinician should always aim for a result as close as possible to normal functional anatomy. The degree of perfection required for postoperative return to normal function will be dictated by the species and initial life style of the patient. Avian bone cortices are significantly thinner compared with mammalian patients and are inherently brittle, providing less holding capacity to fixation elements. The objectives of patient stabilisation are to maintain circulation and oxygen exchange and provide analgesia, as well as to prevent any further damage or desiccation to traumatised tissues.

Musculoskeletal triage: The experiences of advanced practice physiotherapists in Ireland

Musculoskeletal triage: The experiences of advanced practice physiotherapists in Ireland

Physiotherapists and General Practitioners attitudes towards ‘Physio Direct’ phone based musculoskeletal Physiotherapy services: a national survey

ObjectivesPhysiotherapy phone based, “Physio Direct” (PD) musculoskeletal triage and treat services are a relatively new phenomena. This study explored Physiotherapist and GP attitudes towards PD services. DesignOnline national survey via cascade e-mail initiated by study leads. Participants488 Physiotherapists and 68 GPs completed the survey. Outcome measuresThe survey asked three negatively worded and three positively worded Likert scale questions regarding PD services. It also collected demographic data and more global attitudes including a version of the friends and family test. ResultsOverall both Physiotherapists and GP’s have positive attitudes towards PD services. There was global agreement that PD triage was a good idea but in both groups the majority of respondents who expressed a definite opinion thought that patients would still eventually need to be seen face to face. The vast majority of all respondents also thought patients should be given a choice about first accessing PD services. Physiotherapists with experience of PD services had more positive and less negative attitudes than those without experience. More detailed results are discussed. ConclusionsRelevant clinical stakeholders have generally positive attitudes towards PD services, but more so when they have experience of them. Counter to research findings significant proportions of respondents believe patients accessing PD services will still need to be seen face to face. The significant majority of respondents believe patients should be given a choice whether they access PD services in the first instance or not.