Background
People with musculoskeletal conditions often seek treatment from allied health and medical practitioners in primary care. Clinical practice guidelines recommend that those people at risk of poor outcomes may benefit from interprofessional collaboration and multidisciplinary care including early referral to specialist musculoskeletal physiotherapists. Despite this recommendation, recent studies suggest that early referral and interprofessional collaboration between allied health and medical practitioners may not be occurring in practice. Inefficiencies in the delivery of health services to manage musculoskeletal disorders, including inappropriate referrals for imaging and/or surgery are the single highest contributor to total health expenditure in Australia. Therefore, greater clarity is needed regarding when, why, and to whom people with musculoskeletal conditions are, or should be referred in primary care as well as the barriers and facilitators of early referral to specialist physiotherapists.
Aim: (i) explore factors influencing referral practices of Australian allied health and medical practitioners managing people with musculoskeletal conditions in primary care and (ii) investigate practitioners’ perceptions of the barriers and facilitators of early referral to specialist musculoskeletal physiotherapists within a proposed clinical pathway of care (PACE MSK).
Methods
Semi-structured interviews were conducted with 58 Australian health professionals currently managing people with musculoskeletal pain in primary care: 38 allied health practitioners (physiotherapists, psychologists, exercise physiologists), and 20 medical practitioners (general practitioners, pain physicians, rheumatologists, rehabilitation physicians, sports and exercise physicians, orthopaedic surgeons, neurosurgeons). Perspectives on participants’ current referral practices (to whom, when, and why they referred) were sought. Participants were also presented with a proposed clinical pathway of care (PACE MSK) and asked their thoughts on the barriers and facilitators of referral to specialist musculoskeletal physiotherapists for people at risk of poor outcome. Interviews were recorded and transcribed verbatim prior to a qualitative analysis. Data collection and thematic analysis were conducted iteratively.
Results
Key themes were grouped under (i) patient-related factors (specific pathoanatomical or clinical presentations, psychosocial factors, lack of improvement, patient preferences) (ii) practitioner-related factors (trusted professional networks, expertise hierarchy, access to services), and (iii) external/system-related factors (financial impact, referring rights). Trust in professional networks, location of services and financial impact on patients and practitioners were key factors influencing referral practices for all participants. Trust was underpinned by three factors: good communication, mutual respect for professional roles, and positive patient feedback. AHPs and MPs but not surgeons expressed preferences for multidisciplinary, co-located care.
Early referral of people at high risk of poor outcomes was acceptable to all participants. Barriers to implementation included lack of awareness of specialist roles and financial disincentives. Establishing interprofessional trust and clear referral guidelines were identified as facilitators of optimal care pathways.
Conclusions
Referral decisions of allied health and medical practitioners are not only influenced by patients' clinical presentation, but also by trusted professional networks established amongst practitioners. Discordant perceptions of roles, funding disincentives and lack of communication amongst and between professional groups may be a barrier to implementing optimal care pathways for people presenting with musculoskeletal conditions in primary care in Australia.

Background

Delay to diagnosis and treatment of Degenerative Cervical Myelopathy (DCM) is a well-documented phenomenon, with surgical timing an important consideration, as individuals with DCM typically deteriorate if left untreated. However, no clinical guidelines currently exist to differentiate when emergency or elective surgery is indicated. Historically, those with DCM were evaluated prior to surgical listing by Spinal Surgeons. However, with lengthy waits for Spinal Surgeon review, at our tertiary centre, patients with DCM are assessed by Advanced Practice Physiotherapists (APPs) within two weeks from referral, before multi-disciplinary team discussion for listing. Those agreed for surgery are either admitted directly to our spinal ward for emergency intervention ‘Priority 1 (P1)’ or listed for urgent elective surgery ‘Priority 2 (P2)’.

Purpose

To evaluate current surgical listing practices following APP assessment for those with DCM at our tertiary spinal centre. To establish whether any statistically significant factors differentiated emergency from electively listed patients. This project aims to provide evidence for establishing a standardised listing pathway for DCM patients assessed by APPs at our centre.

Methods

This retrospective analysis collated patients with DCM listed for either P1 or P2 surgery over a 24 month period (September 2021-2023) through the APP pathway. Extracted data from medical records included: demographic variables, patient history factors such as symptom onset and deterioration, Modified Japanese Orthopaedic Association (MJOA) score, Neurological examination findings and radiological variables such as cord signal change, type of anatomical pathology and number of spinal segments with cord compression. This data was then analysed using multi-variate regression analysis.

Results

Overall, 184 patients were listed for surgery. Sixty-four as P1, including 11 that converted from P2 due to acute deterioration. There was a statistically significant difference in MJOA score between groups using binary logistic regression model with P1 having a lower MJOA (mean=10.42) compared with P2 (mean=12.55) (95% CI [0.43, 0.85]). Patients with severe MJOA scores were more likely to be listed for emergency intervention compared to those with moderate or mild scores. P1 patients were statistically more likely to have had recent deterioration in symptoms within the last month (95% CI [0.18, 0.48]). Patients below the age of 60 were also more likely to be P1 listed (95% CI [0.05, 0.87]). There were no other statistically significant factors between groups when accounting for control variables.

Conclusions

These data suggest a clinically important difference between P1 and P2 cases using multi-variate regression analysis. This will inform the implementation of a standardised surgical listing pathway for DCM patients at our tertiary hospital.
The number of patients listed for surgery following APP assessment over this period could indicate that APPs with sufficient knowledge and training can appropriately triage those with DCM.

Introduction
Advanced practice physiotherapists (APPs) manage the national low back and radicular pain pathway across the UK. In Nottingham, a novel APP-led spinal same-day emergency care (SDEC) pathway, accepts referrals from community services and the emergency department (ED). Low back pain is generally considered to be predominantly non-specific, with < 1% of all presentations in primary care due to serious pathology. Patients may attend ED with spinal pain in the belief their pain is due to a serious underlying cause. An Australian study quantified the prevalence of serious spinal pathology in patients admitted from the emergency department with non-specific low back pain (NSLBP) and found a significantly higher proportion of serious pathology than is reported in primary care data. Little data exists on prevalence of serious pathologies in a spinal pain cohort within a secondary care setting in the UK. This paper aims to review the number of serious pathologies identified by APP’s on a same-day emergency care pathway.
Methods
Retrospective data from 2 years (2021-2022) of routinely collected information was extracted and analysed by two APPs. Counts were reported as a percentage of total patients seen on the SDEC unit and compared to nationally reported figures. A total of 4244 patients referred with spinal +/- radicular pain, were assessed over the two year period. 416 (9.8%) had serious spinal or serious pathology beyond the spine identified.
Patients were classified into type of serious pathology (n, % of serious pathology): fractures (121, 29.1%), cauda equina compression (77, 18.5%), infection (54, 12.9%)[ including discitis, sepsis and wound infections], cancers (58, 13.9%)[including metastases, metastatic spinal cord compression, nerve sheath tumours and intradural tumours], acute or deteriorating myelopathy (54, 13.0%), neurological conditions (21, 5.0%)[including transverse myelitis, multiple sclerosis, guillan barre syndrome, demyelinating or inflammatory neuropathy and strokes] and other (31, 7.5%) serious pathology [including for example venous thrombosis, renal colic, intramedullary tumours, syrinx, arteriovenous malformations, acute foot drop].
Conclusion
Prevalence of serious spinal pathologies appears higher on an ED pathway compared to the reported prevalence in primary care settings. Most patients visiting ED or SDEC areas with spinal pain will have a benign self-limiting cause. However, from our data, around 10% of patients will have a serious pathology that, if not rapidly diagnosed and treated, could result in poor outcome and permeant neurologic impairment. The most common include fractures, cord or cauda equina compression, infection and cancers. The role of the APP working on an emergency pathway is to identify this subset in a timely fashion. Knowledge and training to identify serious pathology, robust escalation pathways and close multidisciplinary team working are essential in support of APP roles. Clear escalation pathways alongside training to identify common masquerade pathologies are necessary to support APPs working in secondary or emergency care settings.

Background: Diagnosis is a fundamental concept in clinical reasoning. Compared to physical examination alone, a more conclusive pathoanatomical diagnosis of a patient's presentation can be made with ultrasound imaging (USI). USI is expanding in point-of-care applications to augment the physical examination in physical therapy (PT) practice. Early PT adopters provide unique perspectives on PT-specific applications and decision-making.

Purpose: To highlight an innovative model of integrating USI into the physical therapist clinical examination and assess the clinical decision-making process.

Methods: Summary of two studies. The first study was a mixed methods longitudinal, observational design that evaluated the clinical application of USI of sixteen PT’s certified as registered musculoskeletal sonographers (RMSK) in practice across the United States. Demographic data and weekly reflective journals were collected over three months using REDcap™. Journal data included patient cases significant to clinician learning. Demographic data were summarized using descriptive statistics. Significant case data were analyzed thematically. The second study reviewed published case reports of USI in PT practice. Papers were categorized based on indications for imaging.

Results: In study one, PTs reported that 93% of the weekly musculoskeletal USI exams were performed for diagnostic purposes, the remaining 7% were for intervention, biofeedback and/or research. Of these diagnostic exams, participants reported USI contributed significant information very often (75%) and often (25%) to the PT evaluation. Seventy-three significant cases were reported, USI indications were qualitatively analyzed resulting in three themes. Theme 1: USI augments the clinical evaluation, subthemes included comparing patient symptoms and functional limitations with tissue changes, confirming an inconclusive clinical exam, and narrowing potential differential diagnoses. Theme 2: Support clinical decision-making, subthemes included changes in diagnosis, treatment or supporting a referral. Theme 3: Metacognition/ reflection on diagnostic strategies, subthemes included avoiding confirmation bias and considering too few hypotheses. In the second study, 44 published case studies were identified. Cases often included more than one indication for USI. The two most common reasons were to aid in differential diagnosis and identify serious pathologies. Thirty-three cases (77%) resulted in confirmation of a diagnosis. Twenty-five cases (63%) resulted in referrals. The third indication was to support the evaluation outcome; 29 cases (67%) documented significant changes in PT intervention strategies due to USI findings.

Conclusions: The qualitative study of RMSK-credentialed PTs demonstrated consistency with the clinical impact illustrated by published case reports. Integrating USI into the evaluation process directly influenced clinical reasoning by informing the diagnostic process, treatment plan, and ensuring appropriate and timely care. USI clarified potential red flags, tissue healing status, and ambiguous clinical findings, in addition to providing the clinician an opportunity for reflection. Further investigation is needed to "cross the bridge" and define when and how PTs use USI and the impact on patient outcomes.

Implications: USI offers a visual perspective of anatomy and pathology that increases confidence related to diagnosis, treatment choice, progressions, patient education, and referral. Recent advancements in technology and more affordable devices make this the ideal time to explore the value of USI to supplement a PTs physical examination for future practice.

RESEARCH QUESTION: What is the diagnostic accuracy of the IFOMPT framework to assess the risk of vascular complications in patients with neck pain and/or headache?
DESIGN: Cross-sectional diagnostic accuracy study. Participants: One hundred and fifty patients seeking physiotherapy for neck pain and/or headache in primary care.
METHODS: The index test was performed according to the IFOMPT framework by nineteen physiotherapists. Patients were classified as having a high, intermediate, or low risk for vascular complications, following manual therapy and/or exercise, derived from the estimated risk for the presence of vascular pathology. The reference test was a consensus medical decision reached by a vascular neurologist and an interventional neurologist, with input from a neuro-radiologist. The neurologists had access to clinical data, magnetic resonance imaging of the cervical spine, including an angiogram of the cervical arteries. Outcome measures: Diagnostic accuracy measures were calculated for ‘no contra-indication’ (ie, the low-risk category) and ‘contra-indication’ (ie, the high and intermediate-risk categories) for manual therapy and/or exercise. Sensitivity, specificity, predictive values, likelihood ratios, and the area under the curve were calculated.
RESULTS: Manual therapy and/or exercise were contra-indicated in 54.7% of the patients. The sensitivity of the IFOMPT framework was low (0.50, 95% CI 0.39 to 0.61) and its specificity was moderate (0.63, 95% CI 0.51 to 0.75). The positive and negative likelihood ratios were weak at 1.36 (95% CI 0.93 to 1.99) and 0.79 (95% CI 0.60 to 1.05), respectively. The area under the curve was poor (0.57, 95% CI 0.49 to 0.65).
CONCLUSION: The IFOMPT framework has poor diagnostic accuracy when compared to a reference standard consisting of a consensus medical decision.
 

Background
Emergency Department (ED) crowding is a significant issue in many countries. Hospital EDs are under considerable work pressures that were further exacerbated by the COVID-19 pandemic response. The pandemic has also impacted primary care delivery and costs to patients. Thus, we are facing yearly increases in presentations to Emergency Departments.

A significant proportion of patients who attend ED, including patients with some MSK pain conditions, could be treated in non-emergency settings. Providing care to this cohort of patients in ED is expensive and novel models of care, that engage a non-medical workforce, have potential to provide cost effective alternative access to care.

Purpose:
To establish a physiotherapy-led clinic to divert suitable patients with MSK conditions away from ED and to examine the feasibility, patient and health service outcomes of this new service compared to usual ED care

Methods:
This was a prospective non-randomised cohort study comparing the ASP outpatient diversion clinic with usual care in the ED and describing characteristics of patients considered suitable and not suitable for diversion.

Patients with MSK conditions were triaged by an advanced scope physiotherapist (ASP) in the ED waiting room and diverted directly from the ED to a physiotherapy diversion clinic. The clinic was staffed ASPs, supported by senior physiotherapists with outpatient and ED experience. Physiotherapy care was provided for people with musculoskeletal conditions, including plastering and thermoplastic splinting for fractures.

Patients aged 8-65 were diverted from May 2022 to December 2022 at a secondary hospital ED in Perth, Australia. A REDCap database captured clinical encounter data, tracked ED metrics and surveyed patients for clinical outcomes and satisfaction. The clinic was piloted by experienced ED ASPs, but after recruitment and training, transitioned to running with clinicians primarily recruited from existing hospital senior staff.

Results:
Data from the pilot project covers 1099 patients diverted from ED. Most diverted patients were low acuity (Australasian triage category 4) (74%) and 97% were satisfied with the care they received. Median ED LOS was 64 mins for diverted patients, 110 minutes (95% CI 99-120 mins) less than similar patients receiving care in the ED. The clinic connected 71% of patients to ongoing care in orthopaedics, hand surgery or physiotherapy outpatients. 3.2% of patients re-presented to the ED with the same condition within 28 days (compared to 3.7% of patients seen in the ED). The main reasons that patients were deemed not suitable for diversion to outpatients were that they had a differential diagnosis that encompassed non-MSK diagnoses, met exclusion criteria (e.g. open fracture) or required multi-disciplinary care.

Conclusion(s):
Based on the pilot project, this diversion clinic model of care appears promising as a safe and efficient way to increase ED capacity using a non-medical workforce.

Implications:
The South Metropolitan Health Service ED musculoskeletal diversion clinic has been permanently funded at Rockingham Hospital. This pilot project adds to a body of evidence supporting physiotherapy-led care for patients attending EDs. Models of care such as this should be explored internationally to reduce the burden on EDs.

Background: To face the rising number of patients presenting themselves to the emergency department a new scheme was established at a Swiss university hospital. “Physiotherapy in the emergency department” involves a physiotherapist (PT) treating patients with musculoskeletal disorders from the beginning of their journey.

Purpose: This study presented here was part of the scientific monitoring of the new scheme and was intended to fill knowledge gaps in the area of red flag screening by PTs. Furthermore, it explored the skills required by a PT to work in such an advanced practice role and the level of academic education and/or further training in which a physiotherapist can acquire these skills.

Methods: This study was designed as a retrospective observational study. The clinical records of patients treated in the emergency department under the new scheme were analysed to describe the number and kind of red flags screened by PTs and medical doctors (MDs). All patients treated by a PT within a period of 5 months were included.
To evaluate the aspect of physiotherapeutic education, a questionnaire on training of red flag screening was sent to 24 providers of educational programmes at different levels.

Results: The cohort consisted of 146 patients. Mean age of the population was 44 years (SD ±17.6), the lumbar spine (61%) was the most common area of complaint. PTs did additional screening in 78% of cases, mainly neurological tests (38%) followed by manual provocation testing (31%), pressure dolence (17%) and safety questions (15%). Their screening tools were largely consistent with those used by the MDs who had seen the patients before.
16 of 24 educational institutions answered the questionnaire. Screening tools similar to those used by the PTs are taught in basic training, in advanced courses/programmes mainly with a focus on manual/musculoskeletal therapy and in a specific postgraduate screening course.

Conclusion(s): The red flag screening of PTs in patients presenting to the emergency department for musculoskeletal disorders may be sufficiently comprehensive and comparable to that of MDs. On an educational level, first hints of a possible correlation between content of educational and training programmes and screened red flags in practice were found.

Implications: As advanced practice roles in physiotherapy are still in the early stages in Switzerland, studies on this topic are not only of (inter-)professional, but also of political relevance. Monitoring and evaluating the implementation of the new physiotherapeutic scheme in the emergency department is needed to ensure high quality of health care. Furthermore, it might stimulate similar approaches in other hospitals or other clinical settings.

Background: Unhelpful back beliefs (UBBs) are very frequent and play a critical role in the management of low back pain (LBP). Media campaigns promoting scientifically backed content could mitigate the level of UBBs. However, the impact of short educational videos on changing specific beliefs remains to be elucidated to design efficient educational strategies for the public.
Purpose: To evaluate the effect of a short educational video on back beliefs. The primary objective was to assess the effect of the video on the vulnerability theme of the 10-item Back Pain Attitude Questionnaire (Back-PAQ10). The secondary objective was to assess the effect on the total score of the Back-PAQ10.
Methods: The design of the study was a two-group randomized controlled trial with one intervention (n=113) and one control (n=109) group. The general adult population of German-speaking Switzerland, with or without back pain, was included in the study. The intervention consisted of a 3-minute video, targeting misconceptions about back vulnerability and needs for its protection. The control group was provided with an anatomical video about the back. Back beliefs were quantified pre and post intervention, using the Back-PAQ10 which included questions related to back vulnerability, injury, activity, and recovery. The scores of the Back-PAQ10 ranged between -2 and 2 where negative and positive values indicated the absence and presence of UBBs, respectively.
Results: The survey was completed by 222 participants (mean age: 46.14±17.17, male/female: 74/148). Prior to the intervention, the mean score for back vulnerability was 0.88±1.05 for the intervention and 1.1±0.85 for the control group (p=0.27), whereas the mean Back-PAQ10 total score was -0.42±0.56 and -0.29±0.53 for the intervention and control group, respectively (p=0.08). After the intervention, the back vulnerability mean score was -0.5±1.28 and 0.58±1.18 for the intervention and control group, respectively, showing a significant between group difference (p < 0.0001). Concurrently, the mean Back-PAQ10 total score was -1.1±0.64 and -0.4±0.65 for the intervention and control group, respectively (p < 0.0001).
Conclusions: Educational videos based on current scientific findings are an effective method to reduce UBBs. The German speaking general population of Switzerland has high levels of UBBs regarding the vulnerability of the back, which could be targeted with media campaigns. Future research should evaluate the long-term effects of similar educational content and the combination of educational videos with physiotherapy interventions.
Implications: Our data suggest that video education with proper evidence-based content could be used in mass-media campaigns to improve the frequent unhelpful beliefs about the back, found in this population.