Primary Care Physiotherapists Research Articles

What Role Expectations Do Primary Care Physicians in Japan Hold for Physical Therapists Regarding Primary Care?

This study aimed to clarify what primary care physicians (PCPs) in Japan understand of the role of physical therapists (PTs) through the experience of working with PTs in hospitals, and what roles PCPs expect for PTs in future primary care. Semi-structured interviews were conducted individually with 9 purposively sampled PCPs with sufficient experience of collaboration with PTs. Interview data were analyzed by theme analysis focusing on "What does the PCP understand about the role of PTs through the experience of working with PTs in hospitals?" and "What roles and purposes does the PCP wish for PTs in primary care settings?" PCPs viewed PTs as providers of rehabilitation in the traditional medical model, and understood their role as an occupation having a mono-causal viewpoint, namely a specific and well-defined outcome for individual patients, and intervening with patients within a short clinical course with the aim of improvement or maintenance of the patient's condition. With regard to future primary care, PCPs expected that PTs would interpret various factors related to patient lives from the viewpoint of causal interactions; become important stakeholders in the community; and respond flexibly to patients and the environmental factors around them with continued support to the individual. PCPs understood the role of PTs in hospitals as "Rehabilitation in the traditional medical model," and expected the future role of PTs in primary care as "Rehabilitation in integrated community care."

Back2Action: effectiveness of physiotherapy blended with eHealth consisting of pain education and behavioural activation versus physiotherapy alone—protocol for a pragmatic randomised clinical trial for people with subacute or persistent spinal pain

IntroductionPsychosocial factors predict recovery in patients with spinal pain. Several of these factors are modifiable, such as depression and anxiety. However, primary care physiotherapists who typically manage these patients indicate...

Physiotherapists\u2019 experiences of osteoarthritis guidelines in primary health care \u2013 an interview study

BackgroundOsteoarthritis is a common joint disease, globally. Guidelines recommend information, exercise and, if needed, weight reduction as core treatment. There is a gap between evidence-based recommended care for osteoarthritis and clinical practice. To increase compliance to guidelines, implementation was conducted. The aim of the study was to explore physiotherapists’ experiences of osteoarthritis guidelines and their experiences of implementation of the guidelines in primary health care in a region in southern Sweden.MethodsEighteen individual, semi-structured interviews with physiotherapists in primary health care were analysed with inductive qualitative content analysis.ResultsThe analysis resulted in two categories and four subcategories. The physiotherapists were confident in their role as primary assessors for patients with osteoarthritis and the guidelines were aligned with their professional beliefs. The Supported Osteoarthritis Self-Management Programme, that is part of the guidelines, was found to be efficient for the patients. Even though the physiotherapists followed the guidelines they saw room for improvement since all patients with hip and/or knee osteoarthritis did not receive treatment according to the guidelines. Furthermore, the physiotherapists emphasised the need for management’s support and that guidelines should be easy to follow.ConclusionThe physiotherapists believed in the guidelines and were confident in providing first line treatment to patients with osteoarthritis. However, information about the guidelines probably needs to be repeated to all health care providers and management. Data from a national quality register on osteoarthritis could be used to a greater extent in daily clinical work in primary health care to improve quality of care for patients with osteoarthritis.

Primary care physiotherapists ability to make correct management decisions \u2013 is there room for improvement? A mixed method study

BackgroundWith increasing interest in direct access to physiotherapy, it is important to consider the physiotherapists (PTs) ability to make correct management decisions, because identification of differential diagnostic pathologies and timely referral for specialist care is vital for patient safety.The aims of the study were to investigate PTs ability to make correct management decisions in patients presenting with musculoskeletal conditions and to identify explanatory factors associated with this ability. Furthermore, we wanted to explore the PTs views on the identified factors.MethodsThe study was a mixed methods study with an explanatory sequential design consisting of a questionnaire survey and semi-structured interviews. The questionnaire comprised 12 clinical vignettes describing patient scenarios for musculoskeletal conditions, non-critical medical conditions and critical medical conditions. Based on this, the PTs indicated whether the patient should be managed by the PT or were in need of medical referral. Associations between correct decisions and explanatory variables was analyzed by mixed- effects logistic regression. Interviews were performed with nine PTs to explore their reactions to the results. A directed content analysis was performed.ResultsA total of 195 PTs participated in the questionnaire survey and 9 PTs were interviewed. Overall, PTs were more likely to make correct management decisions in the musculoskeletal conditions category, whereas wrong decisions were more often chosen for underlying medical conditions categories. Positive associations between correct management decision in the critical medical category were found for experience: odds ratio (OR) 2.73 (1.33;5.57) and passed quality audit OR 2.90 (1.50;5.58). In the interviews, PTs expressed concerns about the differential diagnostic abilities. They all noted, that experience is immensely important in the clinical reasoning process because the ability to recognise diagnostic patterns evolves over time. Furthermore, the quality audit seems to address and systematize the clinical reasoning process and workflow within the clinics.ConclusionThe lack of ability to make correct management decision in critical medical categories and the uncertainties expressed by PT’s should raise concern, as direct access to physiotherapy is already well-established and the results indicate that patient safety could be at risk. The findings that experience and passed quality audit was associated with correct management decisions highlights the need for ongoing awareness and education into differential diagnostics.

Implementing a Stratified Vocational Advice Intervention for People on Sick Leave with Musculoskeletal Disorders: A Multimethod Process Evaluation

Purpose To perform a process evaluation of a stratified vocational advice intervention (SVAI), delivered by physiotherapists in primary care, for people on sick leave with musculoskeletal disorders participating in a randomised controlled trial. The research questions concerned how the SVAI was delivered, the content of the SVAI and the physiotherapists’ experiences from delivering the SVAI. Methods We used qualitative and quantitative data from 148 intervention logs documenting the follow-up provided to each participant, recordings of 18 intervention sessions and minutes from 20 meetings with the physiotherapists. The log data were analysed with descriptive statistics. A qualitative content analysis was performed of the recordings, and we identified facilitators and barriers for implementation from the minutes. Results Of 170 participants randomised to the SVAI 152 (89%) received the intervention and 148 logs were completed. According to the logs, 131 participants received the correct number of sessions (all by telephone) and 146 action plans were developed. The physiotherapists did not attend any workplace meetings but contacted stakeholders in 37 cases. The main themes from the recorded sessions were: ‘symptom burden’, ‘managing symptoms’, ‘relations with the workplace’ and ‘fear of not being able to manage work’. The physiotherapists felt they were able to build rapport with most participants. However, case management was hindered by the restricted number of sessions permitted according to the protocol. Conclusion Overall, the SVAI was delivered in accordance with the protocol and is therefore likely to be implementable in primary care if it is effective in reducing sick leave.

Coordinating physiotherapy care for persons with haemophilia.

IntroductionPhysiotherapy is highly recommended for persons with haemophilia (PWH), to regain functioning after bleeding and to maintain functioning when dealing with haemophilic arthropathy. However, many PWH live too far from their Haemophilia Comprehensive Care Centre (HCCC) to receive regular treatment at their HCCC. Physiotherapists in primary care may have limited experience with a rare disease like haemophilia.AimTo explore experiences of stakeholders with primary care physiotherapy for PWH and develop recommendations to optimize physiotherapy care coordination.MethodsA RAND approach was used, consisting of a Delphi procedure with e‐mailed questionnaires and a consensus meeting. Included stakeholders were PWH, physiotherapists from HCCC's and primary care physiotherapists. HCCC physiotherapists approached patients from their centre and primary care physiotherapists from their network to fill in the questionnaires. Purposive sampling was used to select participants from the survey sample for the consensus meeting.ResultsNinety‐six primary care physiotherapists, 54 PWH and eight HCCC physiotherapists completed the questionnaire. Subsequently, four PWH, three primary care physiotherapists and four HCCC physiotherapists participated in the consensus meeting. The questionnaires yielded 33 recommendations, merged into a final list of 20 recommendations based on the consensus meeting. The final rank‐order consists of 13 recommendations prioritized by at least one stakeholder.ConclusionCommitment to a formal network is considered not feasible for a rare disease like haemophilia. Development of a practice guideline, easy‐accessible information and contact details, two‐way and open communication between HCCC and primary care and criteria to refer back to the HCCC are recommended.

Extended roles in primary care when physiotherapist-initiated referral to X-ray can save time and reduce costs.

ObjectiveThe objective of this study was to evaluate an extended role for the physiotherapist in primary care in referring patients to plain X-ray.MethodsThis prospective cohort study was set in a single region in Sweden. It included 20 physiotherapists who were educated in a 1-day training in performing referral to X-ray, along with 107 patients with musculoskeletal disorders who were referred to X-ray. We evaluated referral quality and patient and physiotherapist satisfaction and calculated healthcare and patient costs.ResultsAll referrals fulfilled the basic requirements of quality, and 78% were classified as good, fulfilling all criteria. Both patients and physiotherapists were satisfied with the extended role for the physiotherapist that decreased the waiting time to diagnosis and to adequate treatment. Costs were reduced for patients (by €53/patient) and healthcare (by €6286.2/107 patients). The cost to visit a physician was twice that of a physiotherapist visit.ConclusionsAn extended role for physiotherapists in primary care in referring patients to X-ray was effective and safe for patients and reduced costs for patients and for healthcare. Physiotherapists in primary care were able to refer patients to X-ray after a 1 day of training, and the extended role freed up 45 min of physician time for each patient with a musculoskeletal disorder in need of an X-ray.

Surgeons and Administrators Co-creating Value.

Surgeons and Administrators Co-creating Value.

Frailty in renal diseases

Frailty beschreibt einen Zustand reduzierter Belastbarkeit gegenüber Stressfaktoren, welcher u. a. Folge altersbedingter Abbauprozesse verschiedener Organsysteme ist und mit einem erhöhten Risiko für Stürze, Hospitalisationen, funktionelle Einschränkung und Mortalität assoziiert ist. Frailty tritt bei Patienten mit CKD früher und häufiger auf als in der Allgemeinbevölkerung und ist ein wichtiger und potenziell modifizierbarer Risikofaktor für eine erhöhte Sterblichkeit und Hospitalisationsrate sowie eine reduzierte Lebensqualität. Die Erkennung von Frailty bei Patienten mit CKD ermöglicht eine Identifikation von wichtigen und potenziell modifizierbaren Risikofaktoren.Eine frühzeitige nephrologische Beurteilung sowie eine interdisziplinäre Zusammenarbeit mit Geriatern, Allgemeinmedizinern, Physiotherapeuten, Ergotherapeuten und Ernährungsberatung sind essenzielle Bausteine in der Prävention und Therapie von Frailty.Zur Messung von Frailty existieren verschiedene Instrumente, wobei keines in der Erkennung von Frailty bei CKD-Patienten als überlegen identifiziert wurde. Die Auswahl des Screeninginstruments sollte daher unter Berücksichtigung der klinischen Rahmenbedingungen und der verfügbaren Ressourcen erfolgen. In diesem Artikel wird eine Strategie zur frühen Identifikation von gebrechlichen Patienten mit CKD vorgeschlagen, welche auf einer multidiemensionalen und interdisziplinären Einschätzung beruht. Wichtiger als die Methode ist jedoch die Notwendigkeit, Patienten mit Frailty zu identifizieren.

Physical therapy in patients with systemic sclerosis: physical therapists’ perspectives on current delivery and educational needs

Objective: To assess the perspectives of physical therapists treating patients with systemic sclerosis (SSc) on their current practice and educational needs. Method: In July 2019, 405 SSc patients attending a multidisciplinary SSc programme received a survey on physical therapy. Patients who indicated having received physical therapy in the past 2 years were asked to invite their treating physical therapist to complete a questionnaire including sociodemographic characteristics, referral process, content of treatment, perceived knowledge and skills, and educational needs (mostly yes/no answers). Results: Forty-eight of 80 possibly eligible physical therapists treating SSc patients returned the questionnaire [median age 44 years (interquartile range 35–58); 52% female; median number of SSc patients currently treated: 1 (range 1–4)]. Eighty-one per cent (n = 39) of physical therapists had received a referral, with 69% (n = 27/39) judging its content as insufficient. The most often provided types of exercises were range of motion (96%), muscle-strengthening (85%), and aerobic (71%) exercises, followed by hand (42%) and mouth (10%) exercises. Concerning manual treatment, 65% performed either massage or passive mobilization. Regarding competences, 65% indicated feeling capable of treating SSc patients. Nevertheless, 85% expressed the need for an information website on physical therapy in SSc, and 77% for postgraduate education on SSc. Conclusion: Primary care physical therapists treating patients with SSc used a wide range of treatment modalities. Although most stated that they treated very few patients, the majority felt capable of treating SSc patients. Nevertheless, the large majority expressed a need for additional information and educational activities concerning SSc.

The Role of Physiotherapy in the New Treatment Landscape for Haemophilia.

The physiotherapist plays an essential role for people with haemophilia, an inherited bleeding disease responsible for musculoskeletal complications. Yet, with the advent of new and advanced therapies, the medical landscape is changing, and physiotherapy must adapt alongside. This paper considers whether there will still be a need for physiotherapy in the era of advanced therapies, and discusses ways in which services should evolve to complement emerging treatment paradigms for haemostasis in people with haemophilia. Ultimately, physiotherapy will remain an important element of care, even for people with little joint damage and low risks in the era of the new mild phenotype. However, competencies will need to evolve, and physiotherapists in both primary care and specialist treatment centres should work with haematology colleagues to develop more sensitive tools for detecting early joint changes. Physiotherapists will also play a crucial role in counselling and physically coaching, monitoring the musculoskeletal status of people with haemophilia who have transitioned to new treatments.

Are patient reported outcome measures (PROMs) useful in low back pain? Experiences of physiotherapists in primary health care in Sweden

BackgroundPhysiotherapists in primary health care are required to use patient reported outcome measures (PROMs) to manage patients with low back pain (LBP). ObjectiveOur aim was to explore and describe how physiotherapists in primary care managing patients with LBP, experience the use of PROMs with a focus on facilitating and hindering factors. MethodsWe undertook a qualitative study with semi-structured interviews. Fifteen physiotherapists (9 female and 6 male) were included. The interviews were audio-recorded and transcribed verbatim and analysed by inductive manifest content analysis. ResultsOur findings resulted in eight main categories: PROMs give structure and increase patient involvement; Patients' motivations to use PROMs; Time and the physiotherapist's clinical priorities; Physiotherapists' routines steer their use of PROMs; Physiotherapists' competences in using PROMs; Organizations and managers steer the use of PROMs; Prerequisites for future use of PROMs; Using PROMs develops the physiotherapy profession. ConclusionOur findings show that using PROMs gives structure and increases patient involvement, but the patient's motivation to use PROMs needs to be taken into consideration. Time and routines influence the use of PROMs and these factors depend on organizational and managerial levels. Using PROMs is believed to help develop the physiotherapy profession. Prerequisites for future use, such as digitalization and increased competence, need to be fulfilled. Future studies should focus on increasing physiotherapists' knowledge about relevant PROMs, and study implementation in clinical practice, thereby improving the physiotherapy profession's quality of care.

Reliability, validity and discriminability of patient reported outcomes for non-specific low back pain in a nationwide physical therapy registry: A retrospective observational cohort study.

A national clinical registry was established in the Netherlands containing data directly sampled from electronic health record systems of physical therapists (PTs). This registry aims to evaluate the potential of patient reported outcome measures (PROMs) to develop quality indicators (QIs) in physical therapy care. To test to what extent the collected PROM data are reliable, valid and discriminatory between practices in measuring outcomes of patients with non-specific low back pain (NSLBP). In this retrospective cohort study 865 PT practices with 6,560 PTs voluntarily collected PROM data of patients with NSLBP, using the Quebec Back Pain Disability Scale (QBPDS), the Numeric Pain Rating Scale (NPRS) and the Patient Specific Functioning Scale (PSFS). Reliability was determined by analysing the completeness of the dataset, the comparability by using national reference data, and through checking selection bias in the included patients. Validity was tested using the known-groups contrast between patients with (sub)acute vs. chronic NSLBP. To determine discriminative ability of outcomes between PT practices, case-mix corrected hierarchical multilevel analyses were performed. Reliability was sufficient by confirming fifteen of the sixteen hypotheses: 59% of all patients opted in for data analysis, 42% of these included patients showed repeated measurement, comparing with reference data and potential selection bias showed < 5% between group differences, while differences between (sub)acute and chronic NSLB-groups were significantly larger than 5% (less treatment sessions, lager differences in outcomes in (sub)acute NSLB patients). In addition, all nine adjusted hierarchical multilevel models confirm that the collected dataset on outcomes in PT care is able to discriminate between practices using PROM results of patients with NSLBP (ICC-scores range 0.11-0.21). Although we have shown the reliability, validity and discriminative ability of the dataset in the quest to develop QIs, we are aware that reducing missing values in patient records and the selective participation of PTs that belong to the innovators needs attention in the next stages of implementation to avoid bias in the results. PROMs of patients with NSLBP collected in the national clinical registry of KNGF are reliable, valid and able to discriminate between primary care PT practices.

Project ECHO: Enhancing palliative care for primary care occupational therapists and physiotherapists in Ireland.

Project ECHO (Extension for Community Healthcare Outcomes) uses videoconferencing technology to support and train healthcare professionals (HCPs) remotely. A 4-month fortnightly ECHO programme was developed and implemented to enhance palliative care provision by primary care therapists. Teaching and case-based discussions were facilitated by palliative care specialists. A mixed-methods cohort study was used to evaluate the project. ECHO participants completed pre- and post-programme questionnaires regarding their knowledge and skills across key palliative care domains. Focus groups were held before programme commencement to explore participants' attitudes and experiences of palliative care and after programme conclusion to explore their experiences of ECHO. Twenty-six primary care HCPs commenced the ECHO programme. Mean scores in self-rated confidence in knowledge and skill improved significantly(p<.002) following the programme. Twenty-one primary care HCPs completed the post-ECHO surveys and scores of self-rated confidence in knowledge and skills were significantly higher than pre-ECHO scores. Ninety-five percent of participants (n=19) reported ECHO met their learning needs and was an effective format to enhance clinical knowledge. Eighty-five percent of participants (n=17) would recommend ECHO to their colleagues. Project ECHO improved palliative care knowledge and skills of primary care HCPs in Ireland, with potential to address the growing need for integrated palliative care services.

Clinician acceptance of complex clinical decision support systems for treatment allocation of patients with chronic low back pain

BackgroundThe uptake of complex clinical decision support systems (CDSS) in daily practice remains low, despite the proven potential to reduce medical errors and to improve the quality of care. To improve successful implementation of a complex CDSS this study aims to identify the factors that hinder, or alleviate the acceptance of, clinicians toward the use of a complex CDSS for treatment allocation of patients with chronic low back pain.MethodsWe tested a research model in which the intention to use a CDSS by clinicians is influenced by the perceived usefulness; this usefulness, in turn is influenced by the perceived service benefits and perceived service risks. An online survey was created to test our research model and the data was analysed using Partial Least Squares Structural Equation Modelling. The study population consisted of clinicians. The online questionnaire started with demographic questions and continued with a video animation of the complex CDSS followed by the set of measurement items. The online questionnaire ended with two open questions enquiring the reasons to use and not use, a complex CDSS.ResultsNinety-eight participants (46% general practitioners, 25% primary care physical therapists, and 29% clinicians at a rehabilitation centre) fully completed the questionnaire. Fifty-two percent of the respondents were male. The average age was 48 years (SD ± 12.2). The causal model suggests that perceived usefulness is the main factor contributing to the intention to use a complex CDSS. Perceived service benefits and risks are both significant antecedents of perceived usefulness and perceived service risks are affected by the perceived threat to autonomy and trusting beliefs, particularly benevolence and competence.ConclusionsTo improve the acceptance of complex CDSSs it is important to address the risks, but the main focus during the implementation phase should be on the expected improvements in patient outcomes and the overall gain for clinicians. Our results will help the development of complex CDSSs that fit more into the daily clinical practice of clinicians.

Improving mobility and participation of older people with vertigo, dizziness and balance disorders in primary care using a care pathway: feasibility study and process evaluation

BackgroundCommunity-dwelling older people are frequently affected by vertigo, dizziness and balance disorders (VDB). We previously developed a care pathway (CPW) to improve their mobility and participation by offering standardized approaches for general practitioners (GPs) and physical therapists (PTs). We aimed to assess the feasibility of the intervention, its implementation strategy and the study procedures in preparation for the subsequent main trial.MethodsThis 12-week prospective cohort feasibility study was accompanied by a process evaluation designed according to the UK Medical Research Council’s Guidance for developing and evaluating complex interventions. Patients with VDB (≥65 years), GPs and PTs in primary care were included. The intervention consisted of a diagnostic screening checklist for GPs and a guide for PTs. The implementation strategy included specific educational trainings and a telephone helpline. Data for mixed-method process evaluation were collected via standardized questionnaires, field notes and qualitative interviews. Quantitative data were analysed using descriptive statistics, qualitative data using content analysis.ResultsA total of five GP practices (seven single GPs), 10 PT practices and 22 patients were included in the study. The recruitment of GPs and patients was challenging (response rates: GP practices: 28%, PT practices: 39%). Ninety-one percent of the patients and all health professionals completed the study. The health professionals responded well to the educational trainings; the utilization of the telephone helpline was low (one call each from GPs and PTs). Familiarisation with the routine of application of the intervention and positive attitudes were emphasized as facilitators of the implementation of the intervention, whereas a lack of time was mentioned as a barrier. Despite difficulties in the GPs’ adherence to the intervention protocol, the GPs, PTs and patients saw benefit in the intervention. The patients’ treatment adherence to physical therapy was good. There were minor issues in data collection, but no unintended consequences.ConclusionAlthough the process evaluation provided good support for the feasibility of study procedures, the intervention and its implementation strategy, we identified a need for improvement in recruitment of participants, the GP intervention part and the data collection procedures. The findings will inform the main trial to test the interventions effectiveness in a cluster RCT.Trial registrationProjektdatenbank Versorgungsforschung Deutschland (German registry Health Services Research) VfD_MobilE-PHY_17_003910, date of registration: 30.11.2017; Deutsches Register Klinischer Studien (German Clinical Trials Register) DRKS00022918, date of registration: 03.09.2020 (retrospectively registered).

The minimal important change for the seven-item disability of the arm, shoulder, and hand (DASH 7) questionnaire - Assessing shoulder function in patients with subacromial pain.

BackgroundThe DASH 7 is a recently published activity-related 7-item short form of the disability of the arm, shoulder, and hand (DASH) questionnaire developed to assess shoulder function in patients with subacromial pain. Before implementation in both intervention studies and in clinical practice, it is essential to evaluate its responsiveness. The objective of this study was to determine the minimal important change (MIC) in the DASH 7 questionnaire for patients with subacromial pain after a 3 months exercise intervention in a primary care context.MethodsIn this psychometric study the anchor-based MIC-distribution method was used to establish the MIC. The Patient Global Impression of Change (PGIC) was used as external criterion. Data from a clinical implementation study, aimed to implement a specific exercise strategy for patients with subacromial pain among physiotherapists in primary care, were used. Data from 70 patients were included in the analyses.ResultsThe correlation coefficient between Patient Global Impression of Change and the DASH 7 score change was 0.67 and the area under the curve was 0.94 (95% confidence interval: 0.88-1.0). The MICROC for improvement was detected at a mean change in 6.5 points with the sensitivity at 0.98 (98%) and the specificity at 0.78 (78%), and the MIC95% limit for improvement was detected at a mean change of 25.7 points. There were 77% of the patients who reached at least this MICROC and 51% who reached at least the MIC95% limit after 3 months of exercise intervention.ConclusionThe DASH 7 is responsive to change over time and can discriminate between patients considered to be improved and patients considered not improved. These MIC values for patients with subacromial pain in the primary care setting can be used in clinical practice and in intervention studies as an indication on the patients clinically important level of score change for improvement.

The Cardiac Care Bridge randomized trial in high-risk older cardiac patients: A mixed-methods process evaluation.

AimTo evaluate healthcare professionals' performance and treatment fidelity in the Cardiac Care Bridge (CCB) nurse‐coordinated transitional care intervention in older cardiac patients to understand and interpret the study results.DesignA mixed‐methods process evaluation based on the Medical Research Council Process Evaluation framework.MethodsQuantitative data on intervention key elements were collected from 153 logbooks of all intervention patients. Qualitative data were collected using semi‐structured interviews with 19 CCB professionals (cardiac nurses, community nurses and primary care physical therapists), from June 2017 until October 2018. Qualitative data‐analysis is based on thematic analysis and integrated with quantitative key element outcomes. The analysis was blinded to trial outcomes. Fidelity was defined as the level of intervention adherence.ResultsThe overall intervention fidelity was 67%, ranging from severely low fidelity in the consultation of in‐hospital geriatric teams (17%) to maximum fidelity in the comprehensive geriatric assessment (100%). Main themes of influence in the intervention performance that emerged from the interviews are interdisciplinary collaboration, organizational preconditions, confidence in the programme, time management and patient characteristics. In addition to practical issues, the patient's frailty status and limited motivation were barriers to the intervention.ConclusionAlthough involved healthcare professionals expressed their confidence in the intervention, the fidelity rate was suboptimal. This could have influenced the non‐significant effect of the CCB intervention on the primary composite outcome of readmission and mortality 6 months after randomization. Feasibility of intervention key elements should be reconsidered in relation to experienced barriers and the population.ImpactIn addition to insight in effectiveness, insight in intervention fidelity and performance is necessary to understand the mechanism of impact. This study demonstrates that the suboptimal fidelity was subject to a complex interplay of organizational, professionals' and patients' issues. The results support intervention redesign and inform future development of transitional care interventions in older cardiac patients.

Profile of children referred to primary health care physiotherapy: a longitudinal observational study in Norway

BackgroundPhysiotherapy services are an important part of the primary health care services for children, serving a broad spectrum of children referred from different sources and for a variety of reasons. There is limited knowledge about their characteristics and outcome. The aim of this study was to describe the profile, i.e. referral patterns, baseline demographical and clinical characteristics, as well as treatment outcome at follow-up 6 months after baseline, of children receiving physiotherapy in primary health care.MethodsChildren referred to primary health care physiotherapy in a large municipality in Norway were invited to participate in this longitudinal observational study. The children’s demographics, referral sources, causes of referral, functional diagnoses, influence on their daily activities, main goals and planned treatments were registered at baseline. Goal attainment and treatment compliance were registered at follow-up maximum 6 months after baseline.ResultsThe physiotherapists registered baseline characteristics for 148 children. Parent-reported data at baseline were available for 101 (68.2%) of these children. Children were mainly referred from child health care centres (n = 74; 50.0%), hospital (n = 25; 16.9%) and kindergarten (n = 22; 14.9%). The most frequent causes of referral were concerns for motor development (n = 50; 33.8%), asymmetry (n = 40; 27.0%) and orthopaedic conditions (n = 25; 16.9%). Eighty-one (54.7%) children were below the age of 1 year. There was partly agreement between causes of referral and the physiotherapists’ functional diagnoses. Parents of 69 (71.1%) children reported that their child’s daily activities were little to not at all affected by the problem or complaint for which they were referred. Follow-up data were registered for 64 children. The main treatment goal was achieved in 37 (57.8%) and partly achieved in 26 (40.6%) children and the treatment was carried out as planned in 55 (87.3%) children.ConclusionsThe large variation in the profile of children receiving physiotherapy in a primary health care setting in Norway shows how primary health care physiotherapists can contribute to fulfil the broad purpose of the primary health care services.Trial registrationClinicalTrials.gov Identifier: NCT03626389. Registered on August 13th 2018 (retrospectively registered).

Physiotherapy practices in primary health care

Abstract Introduction: Physiotherapy was included in primary health care (PHC) in order to expand access and provide comprehensive care to the population. Objective: To understand the routine and tools used by physiotherapists in primary health care and analyze the determining factors in providing care in a municipality where every basic health unit (BHU) has a physiotherapist. Methods: This is a qualitative study of nineteen physiotherapists conducted in a city of Southern Brazil, using a semistructured interview and a methodological framework for discourse analysis. Results: The main tools routinely used in the physiotherapy service are individual appointments, home visits and group work. Physiotherapy practices are influenced by public health, municipal management and BHU policies, physiotherapy profile in addition to the characteristics of the coverage area and the population being treated. Introducing health promotion measures and implementing relational technologies are the main challenges for physiotherapists, and many of these professionals already recognize their importance in promoting comprehensive care. Conclusion: Physio-therapy practices and the tools used are in line with the Primary Care Family Health Support Center (NASF-AB) model of action recommended by public policies and have been effective for many health conditions. Knowing the routine of PHC physiotherapy services may help professional training and service management, with a view to producing physiotherapy care aimed at the principle of comprehensiveness and consolidating the role of physiotherapists at this level of care.