Background:
The National Musculoskeletal (MSK) Triage Initiative was introduced in Ireland in 2011 to improve patient care and reduce waiting times for secondary care orthopaedics and rheumatology. However, patients often face lengthy waiting times and difficulties accessing quality MSK care pre and post MSK triage attendance. To address this, outreach clinics located at the interface between primary and secondary care are being rolled out nationally to improve MSK pathways. The perspectives of clinical specialist physiotherapists working in MSK-triage are critical to understand the acceptability of the current model of care and its expansion into interface clinics in community settings.

Purpose:
To explore MSK-triage CSPs' perspectives on the patient journey from primary to secondary care orthopaedics/rheumatology and following MSK-triage attendance. A secondary aim was to examine MSK-triage CSPs’ perspectives on the acceptability of implementing MSK triage in interface clinics in the Republic of Ireland.

Methods: Focus groups were conducted with 13 MSK triage clinical specialist physiotherapists (CSPs) from 8 urban and regional hospitals. A two-stage analysis framework was utilised. Data were analysed thematically by two independent reviewers, and resultant findings were explored using Normalisation Process Theory (NPT).

Results:
Four themes emerged: development of MSK pathways; clinical governance; implementation of interface clinics; physiotherapy role and identity. The current patient journey through musculoskeletal services in Ireland lacks structure and a stepped care approach, partly influenced by delays accessing allied therapy services in primary care, thus impacting GP referral behaviour. Whilst the implementation of interface clinics is viewed positively, with patients receiving specialist MSK care in primary care settings, delays for investigations and access to allied therapy services following MSK triage at interface was considered a limitation of the service by CSPs. Interface clinics achieved some degree of ‘coherence’ for CSPs with the expectation of patients receiving expert MSK care earlier in their journey. However, this was less ‘beneficial’ to some CSPs if clinics were held in community hospitals located close to the secondary care hospital versus primary care centres closer to patients’ homes, which would enable relationship building with primary care colleagues. CSPs conveyed strong recommendations on ‘collective action’ with IT infrastructure (establishment of a national Electronic Patient Record and modernisation of appointment booking systems) ability to order investigations (e.g., MRI, x-ray) and enhancing relationships with GP and primary care allied therapy colleagues essential for successful implementation of interface clinics in primary care.

Conclusions:
These findings contribute new knowledge about MSK triage CSPs’ perspectives on the patient journey through musculoskeletal pathways in Ireland and provide insights to inform the future implementation of MSK triage interface clinics in primary care.

Implications:
This research highlights the challenges MSK triage CSPs encounter in the patient journey through musculoskeletal services in the Republic of Ireland and the need for collective action in the implementation process of interface MSK triage clinics.

Background
Chronic pain contribute significantly to the years lived with disability globally. There is a growing body of evidence about interventions and approaches to address chronic pain and its concurrent burden. The implementation of evidence-based interventions for chronic pain can positively impact patient and healthcare system outcomes. However, there is a gap between the availability of evidence and its uptake in clinical practice, implying that there may be complex barriers to evidence uptake. There is a need to develop and evaluate implementation strategies for chronic pain management in primary health care (PHC) to optimize care.
Purpose:
The purpose of the scoping review was to systematically identify published literature on implementation of multi/interdisciplinary models for care for the PHC of chronic pain; and to synthesize information on the content, format, outcomes and factors affecting the implementation of the models of care.
Methods:
The review was conducted according to the guidelines of the Joanna Briggs Institute methodology of scoping reviews. Any qualitative, quantitative or mixed methods studies reporting on implementation of multi/interdisciplinary models for chronic pain management in adults in PHC settings, published since 1990 were eligible for inclusion. A systematic search was conducted using eight electronic databases and a set of keywords. Eligible studies were screened for inclusion. Data extracted comprised: bibliographic and characteristics of studies, characteristics of the implementation intervention, factors influencing implementation and outcomes of the implementation. Data was mapped and summarised.

Results:
The search strategy yielded 1061 citations. After screening 1047 titles and 53 abstracts, 15 manuscripts were included in the analysis. Most included studies were conducted in North America, and none were conducted in low-and-middle income countries. Nine studies were qualitative and two were mixed methods. There was a lack of use of implementation frameworks to guide implementation. All studies were interdisciplinary or multidisciplinary, however there was a low representation of rehabilitation in the models of care. The included studies reported variably on factors that influence implementation. There was little attention on reporting on patient factors that influence implementation. Studies reported on patient outcomes, health care system outcomes, cost effectiveness, process related outcomes and changes in practice patterns.

Conclusion(s):
The findings of the review indicate a need for more compressive reporting of implementation strategies and processes to facilitate the uptake of evidence-based models for PHC of adults with chronic pain. The lack of representation of rehabilitation professionals (including physiotherapists), may indicate that rehabilitation options for chronic pain management are not sufficiently incorporated in chronic pain management, despite evidence for its effectiveness. Further studies can focus on a qualitative evidence synthesis for context factors affecting implementation.

Implications:
Contextually relevant models of care may play an important role in healthcare reform and the operationalization of evidence-informed practice. Physiotherapists are an important part of the interdisciplinary team to empower patients regarding chronic pain management.

Background: Musculoskeletal (MSK) conditions represent the leading cause of disability globally, with those living with these conditions requiring the greatest need for rehabilitation services. These disorders often reflect a complex interplay of risk factors, such as low physical activity, overweight, obesity, and older age, together with related co-morbidities, such as cardiovascular disease, diabetes, hypertension, and depression. However, to date, the responses of MSK services to strengthen systems to meet this challenge appear lacking. With this increasing burden, there is a need to deliver more effective, person-centred MSK health care. Purpose: The primary purpose of this community-based service development was to trial a new way to support the local population with MSK conditions in what matters most to them and to help them take an active role in their care; and secondly, to provide staff the opportunity to work together outside of their normal setting and join with other community service providers to help patients beyond their presenting MSK condition. Methods: Following discussions with key stakeholders to ensure a co-creative solution, two Community Appointment Days were planned. Patients on a routine waiting list for MSK rehabilitation services were invited to have their appointment in a local community centre. On arrival, patients had a ‘What Matters To You?’ conversation to determine what they felt they needed in their care and to discuss their care pathway options. In partnership with a staff member, patients could determine their plan to support them with options that patients could access including one or more of the following: a one-to-one assessment, advice and guidance, exercise rehabilitation, and a community hub of local services, including weight management, talking therapies, and wellbeing services, amongst others. Feedback was collected from patients using CollaboRATE, a three item questionnaire (scored between 0 – 15) with higher scores indicating greater patient satisfaction and feelings of shared decision-making. Patients and staff were also asked to reflect on their experience of the day. Results: Over the two separate days, 550 patients accepted and attended their appointment (272 and 278 at each location, respectively). CollaboRATE scores were 11.1 +/- 1.8 (range 3 – 15) indicating increased satisfaction with their experience. Common themes patients reported were that they valued having everything they needed in the same place and having different people and options together with staff that listened to what they needed. Approximately half of the patients over the two days (49.6 % and 51.8%, respectively) were discharged with the option of a follow-up within a year. Staff reported that they enjoyed working with others as a team to support patients and stepping out of their normal work setting. Conclusions: This innovative MSK service development allowed patients to have access to multiple services and help them determine their own care pathway. Having everything in one place rather than separate appointments allowed for 50% of those patients to be discharged on the day. Implications: Future MSK services should look beyond the one-to-one setting and the individual’s MSK condition to result in better person-centred care and patient satisfaction.

Background: Healthcare systems are struggling to deliver high-quality care for low back pain (LBP), which remains a substantial global health challenge and the primary cause of years lived with disability. In 2012 specialist physiotherapist-led musculoskeletal (MSK) triage services were introduced in Irish hospitals to expedite patient care and alleviate pressure on elective orthopaedic and rheumatology consultant clinics and are in the process of expanding to include community locations. Specialist physiotherapists have expertise to inform the planning, delivery and implementation of health service reform in line with best practice guidelines, but clinicians are often not sufficiently consulted to meaningfully influence healthcare development in Ireland and internationally.

Purpose: To 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.

Methods: This study employed a cross-sectional observational study design using an anonymous electronic survey of 34 clinical specialist physiotherapists working in Irish MSK triage services. Qualitative analysis of response data from open-ended questions was underpinned by thematic framework analysis.

Results: Thematic analysis resulted in six overarching themes, grouped into two categories. Category A, LBP healthcare in Ireland, included 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. Category B, Development of community-based MSK interface services, with the following themes: 4) Concern regarding isolation from secondary care services; 5) Unrealistic expectations of MSK triage; 6) Improved communication and collaboration with primary care services.

Conclusion: Clinical specialist physiotherapists identified the persistence of a biomedical model of LBP healthcare in Ireland that is over-reliant on secondary care services. They advocated for investment in comprehensive multidisciplinary primary care teams to enable best practice, enhanced integration across primary and secondary care services, the development of a national clinical pathway to foster equitable evidence-informed care, and a multisectoral approach to address the complexity of LBP-associated disability. Clinical specialist physiotherapists recognised that community-based MSK triage clinics should augment primary and secondary care collaboration, but identified concerns that hinder successful implementation and efficient patient care, including infrastructure challenges, alienation from hospital consultant teams and access to clinical imaging.

Implications: 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. Specialist physiotherapists have valuable insights into the design, development and implementation of MSK health service quality improvement, which through meaningful clinical engagement may be used to effect positive change at clinician, organisation and systems levels to ensure best care for patients.

Background
The majority of musculoskeletal conditions that present to physiotherapy in New Zealand are treated in the private practice setting and are funded by a single government accident insurer, the Accident Compensation Corporation (ACC). In 2019 ACC initiated a series of pilot programmes named Escalated Care Pathways (ECP) to improve the pathway of people with knee, shoulder and spinal injuries. These body sites incur the greatest cost to ACC in terms of surgery, workers compensation and rehabilitation. The pilots were aimed to improve four key areas: Faster return to work, improved utilisation of services, more timely access to surgery and rehabilitation and improved equity and access for Māori and Pacific peoples. Careway, based in Auckland, was one of the five successful pilot groups and was an inclusive model to join physiotherapists and specialists.
Purpose:
The purpose of this project was to improve the systems of delivery to a high value health care system. The introduction of clear evidence based clinical pathways, patients reported outcome measures, functional measures, inter disciplinary team, improved access to care at less cost and improved support for return to work were tested in this pilot. To date the Careway education packages have engaged over 84 orthopaedic surgeons and sports medicine specialists, over 30 vocational therapists and over 700 physiotherapists across Auckland and Northland
Methods:
A quantitative methodology was used. Data were analysed using descriptive statistics Frequencies and percentages are presented.
Results:.
From March 2020 to June 2023, 8,400 patients have entered the Careway programme and 2,700 have successfully met the exit criteria with 5,600 still in active care. 89 % of patients are European and 11 % are Māori. Large datasets are showing good results for patient outcomes, engagement with ACC and other stakeholders.
The majority of surgeries are Knee (ACL) (65%), Shoulder (rotator cuff repair)(25%) and Spine (discectomy)(10%).
Quicker recovery rates following injury, return to work and lower surgical failure rates are currently tracking 77% ahead of target costs, with post-surgery reinjury rates for knee ACL injuries alone 283% ahead of target, indicating successful exits from rehabilitation pathways.
Conclusion(s):
This has been the most significant system change implemented in the private musculoskeletal rehabilitation setting NZ since ACC inception in 1974. The results of the pilot show improved rehabilitation goals, improved return to work rates, reduced reinjury rates especially in the knee. The visibility of the effects of physiotherapy rehabilitation have been enhanced by clear use of outcome measures (PROMS and function) and the use of evidence-based pathways and improved provider collaboration. The roll out for these new systems to become a nationwide programme has now been approved by ACC for 2024.
Implications:
Health care system changes that deliver high value, evidence based, patient focussed outcomes have demonstrated a significant improvement in surgery and rehabilitation for more patients presenting with key MSK conditions. These system changes could be useful to consider in other settings and countries.

Background: People with chronic pain who engage in regular physical activity have better outcomes than those who live a sedentary lifestyle; however, physical inactivity is common in people with chronic pain. Providing general advice to keep active is insufficient to motivate people with chronic pain to engage in physical activity. Health coaching is a behaviour change intervention that has been shown to increase physical activity in several populations.

Purpose: Despite increasing research investigating the effects of health coaching on physical activity in people with chronic pain, current evidence is still conflicting. Our purpose was to summarise the current evidence about health coaching for chronic pain.

Methods: We conducted a systematic review and meta-analysis of randomised controlled trials to investigate the effect of health coaching on physical activity, disability, pain and quality of life in adults with chronic pain. Six research databases were searched from inception to November 2023. We included randomised controlled trials of health coaching interventions designed to increase physical activity in adults with chronic pain (e.g. chronic back pain, knee osteoarthritis) compared to a control group. Physical activity was the primary outcome. Secondary outcomes included disability, pain and quality of life. Evidence was synthesised as standardised mean differences (SMDs) with 95% confidence intervals using random-effect modelling. Risk of bias was assessed using the revised Cochrane risk of bias tool. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to determine evidence certainty.

Results: Twenty-six randomised trials (n = 4,403) were included. Trials had moderate to high risk of bias. Health coaching had a trivial to small effect on improving physical activity compared with control (15 trials; SMD 0.21, 95% CI 0.07 to 0.35; low certainty evidence). Health coaching had a small effect on improving disability (19 trials; SMD 0.25, 95% CI 0.17 to 0.32; moderate certainty evidence) and pain (19 trials; SMD 0.31, 95% CI 0.18 to 0.43; very low certainty evidence) compared with control. The effect of health coaching on quality of life was unclear due to significant imprecision in the effect estimate (five trials; SMD 0.19, 95% CI –0.14 to 0.53; moderate certainty evidence).

Conclusions: Health coaching promotes a trivial to small improvement in physical activity and small improvements in disability and pain in adults with chronic non-cancer pain. The effect of health coaching on quality of life remains unclear.

Implications: Although this review identified only low certainty evidence of a trivial to small effect of health coaching on physical activity, this finding should be considered in light of the practicality, safety and cost of the intervention. Health coaching is a strategy that clinicians and people living with chronic pain can easily add to their management toolkits. There is a growing number of government-funded health coaching services that clinicians can refer their patients to or make their patients aware of. Alternatively, primary healthcare providers themselves are often well-placed to learn the skills of and implement evidence-based health coaching.

Background
Standards for the delivery of high quality musculoskeletal services were set by the Chartered Society of Physiotherapy (CSP) in 2021. The standards outline eight quality standards that support the development and delivery of musculoskeletal physiotherapy, allowing services to demonstrate the value of MSK physiotherapy and drive continuous quality improvement.
This service is set in a National Health Service district general hospital in southeast England. Significant service changes occurred from 2019- 2023 due to the pandemic, the introduction of digital innovation and changing characteristics of our patient group. We undertook an audit of the musculoskeletal service using the CSP service standards from March to July 2023.
Purpose:
This project aimed to benchmark our current quality of service and identify actionable improvement initiatives.

Methods:
This service audit used the CSP musculoskeletal service standards, split into ‘Process’ and ‘Structure’ measures. The Process measures are based on auditing patient notes. The Structure measures are based on a survey of the service management. The outputs are scored using a Red-Amber-Green (RAG) rating; Red indicates a standard is met less than 20% of the time, Green indicates greater than 80% of the time.
Results:
A random sample of two hundred sets of notes were reviewed. Under Process measures, the service scored Green for 2 of the standards; documented self-management plan and staff received communication training. The service scored Red for 2 standards; advice about health behaviour and collecting patient reported outcome and experience measures. All other standards were rated Amber. Patient reported outcomes and experience measures are collected for the service, but at NHS trust level, with limited access to the outputs by staff conducting the audit.
In Structure measures, the service scored 5/8. The Structure measures that require improvement are; using a shared decision-making approach, using a making every contact count approach and arrangements for co-creating self-management plans.
Conclusion(s):
Documentation of patient plans and communication with patients is of high quality. Priorities for service development are: recording a shared decision-making approach with patients, accessing patient reported measures and making every contact count.
A cohort of staff have started a shared decision-making training course, and will conduct a quality improvement initiative, developing a shared decision-making across the service. The department has implemented a digital patient reported outcome and experience measure because of this audit. The physiotherapy team plan to use the implementation guidelines for making every contact count, including changing our clinical notes paperwork to facilitate and support staff in taking a wider health-based approach. The team will undertake a re-audit in one year to assess the outcomes of these initiatives against the CSP musculoskeletal service standards.
Implications:
This audit has highlighted areas where the musculoskeletal service is delivering high quality physiotherapy to patients, and areas which are currently underserved both on a structural level and operational level. With the implementation of our shared decision-making and making every contact count initiatives, patients can expect to receive a higher standard of care, be included in their healthcare decisions and receive information about their wider health needs.

Background
We developed a computerised decision support system (CDSS) based on methods from artificial intelligence to support physiotherapists and their patients in the process of managing musculoskeletal pain. This is the first study to investigate the effectiveness of an AI-based CDSS in primary care physiotherapy.
Methods
In a cluster-randomised multicentre controlled trial, we randomised 44 physiotherapists from primary care in Norway in a 1:1 ratio to expose their patients to the CDSS in addition to usual care versus usual care only. The CDSS gives personalised treatment recommendations for a new patient based on knowledge of the most similar successful patients from the past. We enrolled patients with pain in the neck, shoulder, back, hip, knee or with complex pain from February to November 2021. Primary outcomes were assessed at 12 weeks by Global perceived effect (GPE) and clinically important improvement in function by the Patient Specific Functional Scale (PSFS). The outcomes were analysed by intention to treat using three-level mixed logistic regression models. Trial registration: ISRCTN1797832.
Results
A total of 724 patients were included. The mean age (SD) was 48.4 years (SD 15.1), and the majority were women (64.1%). At 12 weeks, 176/321 (55%) patients in the control group and 165/298 (55%) in the intervention group reported success in GPE (OR 1.18, CI 0.50 to 2.78) for improvement in the intervention group compared with the control group. For PSFS, 218/310 (70%) in control and 173/290 (60%) in intervention reported clinically important improvement in function (OR 0.41, CI 0.20 to 0.85), favouring the control group.
Conclusions
We did not find differences between groups for GPE. For PSFS, there was a difference between groups favouring the control group. However, the difference was less than the prespecified between-group difference of 15% we aimed for. The clinical importance of this finding is therefore uncertain. Further research to explore use of AI in musculoskeletal pain is however encouraged.