The impact of home-based physiotherapy interventions on breathlessness during activities of daily living in severe COPD: A systematic review

Objectives

To conduct a systematic review and meta-analysis to determine the impact of home-based physiotherapy interventions on breathlessness during activities of daily living (ADL) in severe chronic obstructive disease (COPD).

Data sources

The electronic databases AMED, CINAHL, Cochrane Central Register of Controlled Trials, Embase, Medline and Physiotherapy Evidence Database (PEDro) were searched from their inception to Week 20 2008. Bibliographies of all potentially relevant retrieved studies, identified relevant systematic reviews and international guidelines were searched by hand.

Review methods

Inclusion criteria consisted of individuals over 18 years of age with severe COPD (defined as forced expiratory volume in 1 second ≤50% predicted) without cardiovascular co-morbidities, home-based interventions and valid, reliable breathlessness ADL outcome measures. The PEDro scale assessed methodological quality. Data extraction included baseline characteristics, treatment intervention, frequency of training, level of supervision, breathlessness ADL outcome measure and results. Where possible, a random-effects meta-analysis was applied to appropriate trial data to produce overall quantitative results.

Results

Seven studies, providing nine data sets, met the inclusion criteria. Trial PEDro scores ranged from 4 to 7 out of 10. Studies were homogenous at baseline regarding age and COPD severity, although subjects were predominantly male. Five studies investigated inspiratory or expiratory muscle training, and two studies investigated exercises. Statistically significant breathlessness ADL outcome improvements were reported for all interventions except expiratory muscle training. Five studies demonstrated clinical significance (four for inspiratory muscle training and one for exercise). However, due to heterogeneity among study interventions and outcomes, meta-analysis was only considered clinically appropriate on one occasion to pool three inspiratory muscle training studies in relation to breathlessness score. The random-effects meta-analysis indicated that, on average, inspiratory muscle training improved the breathlessness score significantly by 2.36 (95% confidence interval 0.76 to 3.96) compared with controls.

Conclusion

Inspiratory muscle training and exercise are home-based physiotherapy interventions that may improve breathlessness during ADL in severe COPD. Administration can only be advocated tentatively in outpatient services and primary care at this stage because further higher quality, more homogeneous research with larger sample sizes is required to substantiate the current findings.     

Chest physiotherapy for patients admitted to hospital with an acute exacerbation of chronic obstructive pulmonary disease (COPD): a systematic review

Objectives

To examine the effectiveness of chest physiotherapy for patients admitted to hospital with an acute exacerbation of chronic obstructive pulmonary disease (COPD).

Data source

CINAHL, MEDLINE, Embase, Cochrane, Expanded Academic Index, Clinical Evidence, PEDro, Pubmed, Web of Knowledge and Proquest were searched from the earliest available time to September 2007, using the key elements of COPD, acute exacerbation and chest physiotherapy interventions.

Review methods

To be included, trials had to investigate patients during admission to hospital with an acute exacerbation of COPD, and to evaluate at least one physiotherapy intervention. Two reviewers independently applied the inclusion criteria, and assessed trial quality using the PEDro scale. Results were expressed as standardised mean differences and analysed qualitatively with a best-evidence synthesis.

Results

Thirteen trials were identified. There was moderate evidence that intermittent positive pressure ventilation and positive expiratory pressure were effective in improving sputum expectoration. In addition, there was moderate evidence that walking programmes led to benefits in arterial blood gases, lung function, dyspnoea and quality of life. No evidence was found supporting the use of any other chest physiotherapy techniques to change lung function, arterial blood gases, perceived level of dyspnoea or quality of life.

Conclusions

Chest physiotherapy techniques such as intermittent positive pressure ventilation and positive expiratory pressure may benefit patients with COPD requiring assistance with sputum clearance, while walking programmes may have wider benefits for patients admitted with an exacerbation of COPD. Chest physiotherapy techniques other than percussion are safe for administration to this patient population.     

Does the pulse frequency of transcutaneous electrical nerve stimulation (TENS) influence hypoalgesia?: A systematic review of studies using experimental pain and healthy human participants

Objectives

To determine the hypoalgesic effect of pulse frequency of transcutaneous electrical nerve stimulation (TENS) when all other TENS parameters are held constant.

Data sources

Systematic review of studies using experimentally induced pain on healthy participants where there was a head-to-head comparison of different pulse frequencies. AMED, CINAHL, EMBASE, Inspec, PEDro, Pre-CINAHL, PsycARTICLES, PubMed, SPORTDiscus were searched in September 2006.

Review methods

Inclusion criteria were studies that directly compared two or more pulse frequencies head-to-head and recorded outcome as change in pain threshold or pain intensity. Studies were excluded if pulse intensity, pulse pattern, or pulse duration of TENS were not standardized between groups. Two reviewers judged the trial outcome independently. Primary outcome was a report of a statistically significant difference between pulse frequencies for pain threshold or intensity at any time point through the experiment.

Results

Twenty studies were identified, of which 13 experimental studies from 12 published reports were included for review. Ten studies found no statistically significant differences in hypoalgesia between pulse frequencies. Of the three studies judged as positive outcome, one reported that 100 pulses per second (pps) was superior to 10 pps; one that 4 pps was superior to 100 pps; and one that 5 pps and 80 pps were superior to 2 pps.

Conclusion

Evidence from experimental pain studies suggests that TENS pulse frequency does not influence hypolagesia when its pulse intensity, pulse pattern, and pulse duration are kept constant. Inadequate sample sizes may have generated false negative findings in some studies.     

Reliability of physical examination tests used in the assessment of patients with shoulder problems: a systematic review

Background

Shoulder pain is a common clinical problem, and numerous tests are used to diagnose structural pathology.

Objectives

To systematically review the reliability of physical examination procedures used in the clinical examination of patients with shoulder pain.

Data sources

MEDLINE, PEDro, AMED, PsychInfo, Cochrane Library (2009) and CINAHL were searched from the earliest record on the database to June 2009.

Study eligibility criteria

Reliability studies that included any patients with shoulder pain were analysed for their quality and reliability results.

Study appraisal and synthesis methods

Pre-established criteria were used to judge the quality of the studies (high quality >60% methods score) and satisfactory levels of reliability (kappa or intraclass correlation coefficient ≥0.85, sensitivity analysis 0.70). A qualitative synthesis was performed based on levels of evidence.

Results

Thirty-six studies were included with a mean methods score of 57%. Seventeen studies were deemed to be of high quality; high-quality studies were less likely to meet the pre-agreed level of reliability. The majority of studies indicated poor reliability for all procedures investigated.

Limitations

Overall, the evidence regarding reliability was contradictory.

Conclusions and implications

There is no consistent evidence that any examination procedure used in shoulder assessments has acceptable levels of reliability. Alternate methods of classification which are reliable should be used to classify patients with shoulder problems.     

A systematic review of bracing following reconstruction of the anterior cruciate ligament

Objectives

To determine whether the use of a postoperative knee brace following reconstruction of the anterior cruciate ligament (ACL) affects clinical outcomes.

Data sources

The electronic databases AMED, Cinahl, Cochrane database, Embase, Medline (via Ovid), Physiotherapy Evidence Database (PEDro) and Pubmed were searched from their inception to August 2006. A manual search of pertinent specialist journals and the reference lists of identified articles was also performed.

Review methods

All English-language, human subject, controlled clinical trials that compared the effects of wearing a knee brace with not wearing a brace for 1 day to 3 months following ACL reconstruction were included. Two reviewers extracted the data independently from the included studies, and assessed the methodological quality of the literature using the PEDro scoring system.

Results

Seven papers comprising of 390 ACL reconstructions were included. There were no significant longer-term differences in outcomes between patients who wore knee braces and those who did not. The methodological assessment of the literature revealed a number of limitations, including not blinding assessors, not performing a power calculation to determine the sample size, and not concealing subject allocation.

Conclusions

There appeared to be no significant longer-term differences in clinical outcomes between patients who wore postoperative knee braces and those who did not. Areas for further study are suggested, most notably to assess this topic using more rigorous randomised controlled trial methodologies.     

Early rehabilitation following less invasive surgical stabilisation plate fixation for distal femoral fractures

Objective

The less invasive surgical stabilisation (LISS) plate fixation method is an orthopaedic procedure for the fixation of distal femoral fractures. Early physiotherapy treatments of motion and mobilisation have been advocated following this procedure. This article critically appraises the evidence base assessing the early rehabilitation of patients following LISS fixation for distal femoral fractures.

Data sources

A review of EMBASE, Medline, CINAHL and AMED, and a hand search were undertaken.

Review methods

Two independent reviewers identified all eligible articles. Two reviewers extracted the data, which were verified by a third reviewer. All included articles were critically appraised by two independent reviewers using the Critical Appraisal Skills Programme tool.

Results

Seventeen case series assessing 508 patients with 535 fractures were reviewed. No clinical trials comparing physiotherapy programmes were identified. The review identified that following LISS fixation for distal femoral fractures, patients begin range-of-motion exercises immediately and are initially required to restrict weight-bearing following surgery. It remains unclear whether casts, braces or immobilisation aids are applied during the initial postoperative period.

Conclusion

The efficacy of different physiotherapy protocols following LISS fixation for distal femoral fractures remains unclear. Further well-designed randomised controlled trials are required to compare different postoperative physiotherapy rehabilitation programmes for patients following LISS fixation of distal femoral fractures in order to determine the optimal postoperative management for this complex patient group.     

Parents’ and health professionals’ perceptions of family centred care for children in hospital, in developed and developing countries: A review of the literature

Background

In paediatrics family centred care (FCC) is a widely used model of care that is believed to help meet the emotional, psychological and developmental needs of the hospitalized child. However, perceptions of the effectiveness of the operationalization of FCC in terms of meeting family needs are varied.

Objectives

The aim of this review was to explore the attitudes towards and experiences of FCC by healthcare professionals and parents during the hospitalization of a child.

Design

A comprehensive search of the literature was undertaken drawing principally on key electronic databases of the health literature, augmented with reference list searching.

Data sources

: English language publications indexed in CINAHL, EMBASE, The Cochrane Database of Systematic Reviews, AMED, MEDLINE and PsycINFO published from 1997 to 2009.

Review methods

: Two review authors independently undertook the searches and two to three authors independently assessed trial quality, family centeredness, data extraction and thematic synthesis. Fifteen studies were reviewed.

Results

Four themes emerged from the literature on communication, healthcare professional and parent relationships, caring for parents and available resources. The differences, similarities and interpretation between healthcare professionals’ and parents’ perspectives on these themes are reported.

Conclusion

The effectiveness of FCC can often depend on individual demographic characteristics of the child, parent and healthcare professional. A broad spectrum of variability exists in the perceptions of healthcare professionals and parents on parental needs and FCC within a hospital context.     

Assessing the effect of sample size, methodological quality and statistical rigour on outcomes of randomised controlled trials on mobilisation, manipulation and massage for low back pain of at least 6 weeks duration

Objectives

To assess the effect of sample size, methodological quality and statistical rigour on outcomes of randomised controlled trials (RCTs) on manual therapy (i.e. manipulation, mobilisation and/or massage) for non-specific low back pain (LBP) of at least 6 weeks duration, and to report results from RCTs with adequate sample size, methodological quality and statistical rigour.

Data sources

MedLine, EMBASE, CINAHL, AMED, Cochrane, PEDro and the library collection of the Chartered Society of Physiotherapy.

Review methods

RCTs were identified that compared manual therapy with a control or alternative intervention in adults with non-specific LBP of at least 6 weeks duration. The sample size, methodological quality (adapted 10-point van Tulder scale) and statistical rigour were then assessed. RCTs were regarded as higher quality if they fulfilled the following three criteria: (a) >40 subjects in the manual therapy group; (b) scoring >5/10 on the Van Tulder scale; and (c) reporting statistical tests that compared the change in the intervention group with the change in the control group.

Results

Ten RCTs were included in the review but only two qualified as higher quality RCTs. Results from smaller trials and lower quality RCTs showed more variation in differences between the intervention and control groups than larger or higher quality trials. Evidence from large, high-quality RCTs with adequate statistical analyses showed that, for improvement in pain and function, a mobilisation/manipulation package is an effective intervention [compared with general practitioner (GP) care], whilst manipulation used in isolation showed no real benefits over sham manipulation or an alternative intervention. No higher quality evidence considering massage was identified.

Conclusions

Many RCTs in the area of manual therapy for LBP have shortcomings in sample size, methodological quality and/or statistical rigour, but there remains evidence from higher quality RCTs to support the use of a manual therapy package, compared with GP care, for non-specific LBP of at least 6 weeks duration.     

Are physiotherapy students adequately prepared to successfully gain employment?

Objectives

To explore the preparedness of final-year physiotherapy students for their progression into employment, and identify what universities can do to facilitate a smooth transition.

Design

A single-cohort study, utilising a qualitative design incorporating a survey followed by transcribed and coded semi-structured interviews.

Setting

Interviews were held in the Placement and Careers Centre at Brunel University, London.

Participants

Sixty final-year full- and part-time students participated in the survey, and 12 final-year full- and part-time students participated in the semi-structured interviews.

Methods

Sixty students completed a questionnaire which explored their preparedness for employment. Questions related to the current job situation, the application process and the student's ideal first post. Responses from the questionnaire were analysed and discussed further through a digitally recorded interview. Twelve students were interviewed by an experienced interviewer from a non-physiotherapy background.

Results

Students felt unprepared for employment. Forty-seven per cent wanted a rotational post, but 26% would only spend 6 months and 39% would only spend 1 year looking for a job. Seventy-one percent would change career and 99% would work abroad if they were unable to secure a post in the UK. Most importantly, students could not identify transferable skills required by potential employers; only 25% cited effective communications, and 10% cited flexible working as a transferable skill. Self-management skills (e.g. prioritisation, time management and documentation) were not perceived as essential for employment.

Conclusions

The job market requires physiotherapy graduates to possess transferable skills which can be applied to any situation. Many are integral to the profession and the undergraduate curriculum; however, analysis and assimilation of these skills cannot be assumed. Universities should reflect on their curriculum delivery to produce graduates who meet employers’ expectations and make a smooth transition into the workplace.     

Stabilisation exercises for low back pain: a systematic review

Objectives

To examine the literature to determine if stabilisation exercises are effective for the treatment of pain and dysfunction in patients with low back pain.

Data sources

PubMed (MEDLINE), CINAHL, AMED, PEDro and the Cochrane Library were searched up to October 2006.

Review methods

Inclusion criteria were: randomised clinical trials; in English; full publications; subjects were adults with low back pain; one group received specific stabilisation exercises as the primary intervention; and outcome measures included some measure of pain and/or function. Following a systematic search of major databases, articles were scored according to the PEDro criteria for quality. Due to heterogeneity of specific interventions, control groups, duration of follow-up, outcome measures and study population, a meta-analysis was not conducted. A qualitative review was undertaken that focused on study quality, study population and type of control group.

Results

In total, 18 trials were included in the review; a large number of trials were excluded. There was little evidence to support the use of stabilisation exercises for acute low back pain. There was some evidence to support the use of stabilisation exercises in chronic back pain, with the majority of high-quality trials showing a significant difference in favour of stabilisation exercises. Overall, however, the evidence was conflicting, and significant differences favouring stabilisation exercises were less likely when they were compared with active treatment control groups rather than inactive control groups.

Conclusions

There may be a role for specific stabilisation exercises in some patients with chronic low back pain, but these are no more effective than other active interventions.     

Chest physiotherapy using the expiratory flow increase procedure in ventilated newborns: a pilot study

Objectives

To evaluate the incidence of post-extubation atelectasia (PEA) and brain injury in newborns treated with the expiratory flow increase (EFI) method of chest physiotherapy, the most common chest physiotherapy technique in France.

Design

Retrospective study.

Setting

A large level-3 regional neonatal intensive care unit.

Population

A cohort of all consecutive neonates admitted over a 17-month period who developed acute or chronic lung disease and required conventional mechanical ventilation.

Intervention

Chest physiotherapy using the EFI technique, initiated early after birth, and performed three times daily until at least 24 hours after extubation.

Outcome measures

PEA and brain lesions (intraventricular haemorrhage and cystic periventricular leukomalacia). Chest X-rays were taken 24 hours after extubation and routine head ultrasounds were performed during the course of hospitalization.

Results

Among the 362 infants submitted to chest physiotherapy, nine developed PEA (2%; 95% CI = 1-4.0%). PEA was highly predictive of extubation failure since six of the nine infants with PEA were reintubated (67%), whereas only 33 among the 353 infants without PEA required reintubation (9%). Intraventricular haemorrhage and cystic periventricular leukomalacia were documented in 59 (16%) and 5 (1%) infants, respectively. In 54 of the 59 infants (92%) with intraventricular haemorrhage and all infants with periventricular leukomalacia, brain lesions existed prior to the initiation of chest physiotherapy.

Conclusion

The incidence of PEA in babies treated with the EFI technique is low and chest physiotherapy does not appear to increase the incidence of brain lesions above the percentage normally seen in newborns with respiratory failure. A randomized controlled trial is urgently needed to further study the efficacy and safety of the EFI method in the prevention of neonatal post-extubation atelectasis and extubation failure.     

Evolution of the concept of self-care and implications for nurses: A literature review

Background

Worldwide, the increasing prevalence of chronic disease evokes concern on a number of levels, including quality of life, health care costs and workforce issues to meet increasing demands on services. One response has been a shift in governmental health policy to encourage greater involvement of the chronically ill individual in their health care through participation in self-management programmes. Embedded in self-management programmes is the underlying concept of self-care, a complex and multidimensional phenomenon.

Objective

This paper explores the development of the concept of self-care through health related literature and reviews the factors that have shaped the concept.

Design

A comprehensive search of the literature was undertaken drawing principally on key electronic databases of the health literature, augmented with reference list searching.

Data sources

English language publications indexed in CINAHL, EMBASE, AMED, MEDLINE and PsycInfo with no limit on date of publication.

Review methods

Abstracts were reviewed against the inclusion criteria and quality appraisal undertaken. Twenty-two studies were reviewed.

Results

Many definitions of self-care exist and a consensual definition has not been reached. The current concept of self-care has been shaped by many different social, economic and political factors and is embedded in diverse theoretical perspectives and paradigms.

Conclusion

An understanding of the underlying theoretical perspectives and paradigms embedded within acute and chronic disease management will facilitate nurses’ engagement in the debate, practice within appropriate ethical boundaries and support individuals, families and communities more effectively in managing chronic disease.     

What are the costs to NHS Scotland of self-referral to physiotherapy? Results of a national trial

Background

Recent healthcare policies have encouraged increasing interest in the concept of patient self-referral, specifically with regard to physiotherapy. However, what has not been known until recently is the efficacy of this mode of access within the National Health Service (NHS), including the cost implications on which to reliably base the provision of future service models.

Aim

To establish the costs to National Health Service (NHS) Scotland of differing modes of access to physiotherapy in primary care.

Design

Cost-minimisation analysis, multi-centred national trial.

Setting

Twenty-six general practices throughout Scotland.

Participants

Three-thousand and ten patients.

Method

Self-referral was introduced in each site in parallel with referral by a general practitioner (GP). NHS-associated cost data were collated over a full year by referral type, i.e. self-referral, GP-suggested and GP-referral groups. A cost-minimisation analysis was performed and the main outcome measures were the number of GP and physiotherapy contacts, prescribing of non-steroidal anti-inflammatory drugs and analgesics, and referral for X-ray, magnetic resonance imaging and/or secondary care. Costs were established for 2004.

Results

The data from 3010 patients identified significant associations between referral group and prescribing, referral for X-ray and to secondary care, and GP and physiotherapy contacts (P < 0.001). The average cost of an episode of care was established as £66.31 for a self-referral, £79.50 for a GP-suggested referral and £88.99 for a GP referral. Extrapolated to identify national implications, the average cost benefit to NHS Scotland was identified as being approximately £2 million per annum.

Conclusion

There are significant positive implications associated with self-referral to physiotherapy that represent added value for NHS Scotland. These implications are also of relevance to the rest of the NHS in the UK.     

An under-used yet easily understood statistic: the number needed to treat (NNT)

Objectives

Interpretation of the research literature can be difficult, yet it is essential in order for physiotherapists to convey the details of risks and benefits associated with therapeutic interventions to patients. The number needed to treat (NNT) statistic is one such statistic that is easily interpretable. Using several examples from the physiotherapy literature representing a range of conditions, this article demonstrates how to convert more commonly used statistics into the NNT statistic. The purpose of this is to show how the NNT can help clinicians to converse with patients to convey details about the likelihood of benefit with treatment and/or the likelihood of risk, in order that a decision may be made with respect to therapy.

Design

The Australian Physiotherapy Evidence Database (PEDro) was searched in order to locate a selection of physiotherapy research articles that reported various dichotomous outcomes that could be converted to the NNT statistic for the purpose of this analysis.

Results

The NNT statistic for nine studies with a PEDro score ≥6 was calculated using the Internet-based downloadable spreadsheet on the PEDro website. For six studies, the NNT point estimates ranged from 2 to 4 (95% confidence interval 1-10). One study had a NNT of 8, while two other studies produced number needed to harm values.

Conclusion

The NNT can be calculated quickly and efficiently using Internet-based calculators and/or other decision-making tools, and may be an alternative that provides readily interpretable information to assist in conveying the likely benefits (and/or risks) of treatment to patients.     

Predictors of Success for Physiotherapy Treatment in Women With Persistent Postpartum Stress Urinary Incontinence

Dumoulin C, Bourbonnais D, Morin M, Gravel D, Lemieux M-C. Predictors of success for physiotherapy treatment in women with persistent postpartum stress urinary incontinence.

Objective

To identify predictors of success for physiotherapy treatment in women with persistent postpartum stress urinary incontinence (SUI).

Design

Secondary analysis of data from a single-blind randomized controlled trial comparing 2 physiotherapy intervention programs for persistent SUI in postpartum women.

Setting

Obstetric clinic of a mother and children's university hospital.

Participants

Women, ages 23 to 39 (N=57), were randomized to 1 of 2 pelvic floor muscle (PFM) training programs, 1 with and 1 without abdominal muscle training.

Intervention

Over 8 weeks, participants in each group followed a specific home exercise program once a day, 5 days a week. In addition, participants attended individual weekly physiotherapy sessions throughout the 8-week program.

Main Outcome Measures

Treatment success was defined as a pad weight gain of less than 2g on a 20-minute pad test with standardized bladder volume after 8 weeks' treatment. The relationship between potential predictive PFM function variables as measured by a PFM dynamometer and success of physiotherapy was studied using forward stepwise multivariate logistic regression analyses.

Results

Forty-two women (74%) were classified as treatment successes, and 15 (26%) were not. Treatment success was associated with lower pretreatment PFM passive force and greater PFM endurance pretreatment, but the latter association was barely statistically significant. This model explained between 23% (Cox and Snell R²) and 34% (Nagelkerke R²) of the outcome variability.

Conclusions

The results contribute new information on predictors of success for physiotherapy treatment in women with persistent postpartum SUI.     

Constraint-induced movement therapy: a narrative review

Objectives

To identify factors relevant to implementing constraint-induced movement therapy (CIMT) within the clinical setting.

Data sources

AMED (1995-January 2007), CINHAL (1982-January 2007), Medline (1996-January 2007) and EMBASE (1996-January 2007) were searched to identify relevant studies.

Review methods

Criteria for inclusion of trials in this study were that trial participants were over 18 years of age, had had a stroke, and CIMT or modified CIMT was compared with either no intervention, modified CIMT or alternative treatment. Modified CIMT had to include both constraint and training components. The study design was either a quasi-randomised controlled trial or a randomised controlled trial. Trials had to be published in English and score 4 or more on the PEDro scale.

Results

Twelve eligible studies were identified. The quality of the studies varied, although there was evidence that this improved with more recent studies achieving higher PEDro scores. Patient selection criteria and the components related to the delivery of CIMT were identified as relevant factors. Thirteen different patient selection criteria were identified: age; length of time post stroke; specified side of hemiplegia; hand dominance; spasticity; pain; balance and mobility; hand function; range of active and passive movement; cognitive impairment; perception; sensation; and communication. Ten components were identified as being relevant to the actual delivery of CIMT: type of CIMT; type of constraint; constraint wear time; excluded activities; shaping; shaping dosage; group versus individual treatment; environment; potential harms of CIMT; and compliance. A third relevant consideration was the selection of outcome measures. Significant variability was identified in many aspects of CIMT, although there was evidence of greater standardisation in more recent studies.

Conclusion

The development of CIMT for stroke patients has provided clinicians with a treatment technique for a defined patient group that is now supported by a considerable evidence base. CIMT is a complex intervention and the optimum intensity and length of treatment remains unknown. Transferring CIMT into the clinical environment has been hampered by the lack of standardisation in many aspects of the intervention. However, there is evidence that this is improving. Implementation and evaluation in the clinical environment would strengthen the evidence base.     

Self-referral, access and physiotherapy: patients’ knowledge and attitudes—results of a national trial

Objectives

To identify service users’ views and attitudes to access, physiotherapy and patient-autonomous health-seeking behaviours.

Study design

Mixed qualitative and quantitative questionnaire.

Setting

Twenty-six locations representing a range of socio-economic and geographical settings throughout Scotland.

Participants

Three thousand and ten patients over 16 years of age.

Methods

Postal questionnaires containing a mix of open and closed questions, attitude statements and free text for comments were sent to all consenting patients 4 weeks after discharge from physiotherapy. Responses were analysed by referral group: self-referred patients; patients referred by their general practitioner (GP); and patients referred at the suggestion of their GP.

Results

A response rate of 72% (2177/3010) was achieved. Males, females and all age groups were represented. Strong support for the effectiveness of physiotherapy was reported by all groups (>90%). Despite more than 80% of respondents claiming that they were able to confidently predict when they needed physiotherapy, less than 23% reported being knowledgeable or very knowledgeable about physiotherapy, with no significant association between level of knowledge and referral group (P = 0.129). Self-referred patients were more satisfied (P < 0.001), more supportive of being able to self-refer (83% vs 69% of GP-referred patients and 71% of patients referred at the suggestion of their GP), and more supportive of physiotherapists making decisions about their fitness for work or activities (59% vs 53% of GP-referred patients and 53% of patients referred at the suggestion of their GP).

Conclusions

Physiotherapy was regarded positively by all referral groups, particularly by self-referred patients, despite there being a distinct lack of knowledge about the profession. There is a clear need to raise awareness and knowledge of physiotherapy if autonomous health-seeking behaviours are to be encouraged and self-referral schemes progressed appropriately.     

Primary contact physiotherapy in emergency departments can reduce length of stay for patients with peripheral musculoskeletal injuries compared with secondary contact physiotherapy: a prospective non-randomised controlled trial

Objective

To evaluate if direct physiotherapy assessment and management of patients presenting to emergency departments with musculoskeletal injuries (primary contact physiotherapy) results in reduced length of stay without any increase in adverse effects compared with secondary contact physiotherapy, where patients are seen by a physiotherapist after initial assessment by a doctor.

Design

Prospective non-randomised controlled trial.

Setting

Three metropolitan emergency departments.

Participants

Adults (n = 315) presenting to emergency departments with peripheral musculoskeletal injuries were allocated to primary or secondary contact physiotherapy; 306 participants completed the study. Patients with serious pathology, open fractures and spinal pain were excluded.

Intervention

A single episode of physiotherapy.

Main outcome measures

Primary outcome measures were patient length of stay, waiting time and treatment time. Secondary outcome measures were re-presentations to the emergency department, imaging referrals, patient satisfaction and emergency department staff acceptance.

Results

Primary contact physiotherapy resulted in a reduction in length of stay of 59.5 minutes [95% confidence interval (CI) 38.4 to 80.6] compared with secondary contact physiotherapy, with a reduced waiting time of 25.0 minutes (95%CI 12.1 to 38.0) and a reduced treatment time of 34.9 minutes (95%CI 16.2 to 53.6). There were no differences between the groups in imaging referrals or re-presentations. Patients strongly agreed (≥82%) that they were satisfied with their management, and 96% of emergency department staff agreed that primary contact physiotherapists had appropriate skills and knowledge to provide emergency care.

Conclusion

Experienced musculoskeletal physiotherapists working in emergency departments can be the first point of contact for patients with simple, semi-urgent and non-urgent peripheral musculoskeletal injuries, resulting in decreased waiting times and length of stay for patients without any adverse effects.     

Patient-centredness in physiotherapy from the perspective of the chronic low back pain patient

Objective

To define patient-centredness from the patient's perspective in the context of physiotherapy for chronic low back pain (CLBP).

Design

Qualitative study using semi-structured interviews to explore perceptions of various aspects of physiotherapy management of CLBP.

Setting

Physiotherapy departments in one geographical area of the UK National Health Service.

Participants

Twenty-five individuals who had received physiotherapy for CLBP within the previous 6 months.

Results

Six key themes emerged as the dimensions that the participants perceived to be important for patient-centred physiotherapy: communication; individual care; decision-making; information; the physiotherapist; and organisation of care. Communication was the most important dimension, underpinning the five other dimensions as well as being a distinct dimension of patient-centred physiotherapy.

Conclusions

Physiotherapists should have an understanding of the six dimensions of patient-centred physiotherapy for CLBP. Improving physiotherapists’ communication skills may better facilitate patient-centred physiotherapy, and therefore enhance the experience of physiotherapy for this client group.