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.     

Patients’ perceptions of self-management of chronic low back pain: evidence for enhancing patient education and support

Objectives

To explore the extent to which physiotherapy facilitated chronic low back pain (CLBP) patients to self-manage following discharge, and to explore patients’ perceptions of their need for self-management interventions or support and their preferences in terms of delivery.

Design

Qualitative study using semi-structured interviews to explore patients’ 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 people who had received physiotherapy for CLBP within the previous 6 months.

Results

Adoption of self-management strategies was not achieved consistently in this group of participants. There was a strongly perceived need for self-management support following discharge from physiotherapy. Exercises were reportedly the most common self-management strategy in use. However, it was common for participants to perceive that physiotherapy had little influence on their CLBP management following discharge.

Conclusions

These results suggest that CLBP patients could be better facilitated to manage their condition. Providing self-management education in addition to the patient information and education provided traditionally, and providing self-management support in the form of direct access and/or review appointments or telephone calls is worthy of further investigation in this patient group.     

The effect of a physiotherapy education compared with a non-healthcare education on the attitudes and beliefs of students towards functioning in individuals with back pain: An observational, cross-sectional study

Objectives

To investigate the difference in attitudes: (1) between first and fourth year physiotherapy students towards functioning in individuals with back pain; and (2) between physiotherapy students and non-healthcare students towards functioning in individuals with back pain.

Design

Observational, cross-sectional study.

Setting

Glasgow Caledonian University, Scotland, UK.

Participants

First year physiotherapy (n = 61) and non-healthcare students (n = 61), and fourth year physiotherapy (n = 62) and non-healthcare students (n = 62).

Main outcomes

All participants completed the Health Care Providers’ Pain and Impairment Relationship Scale (range 15 to 105). This questionnaire measures attitudes towards functioning in individuals with back pain.

Results

Fourth year physiotherapy students had more positive attitudes towards functioning in individuals with back pain than first year physiotherapy students [57.4 vs 66.6 (mean difference −9.2, 95% confidence interval −12.2 to −6.1, P < 0.01)]. Similarly, fourth year non-healthcare students had more positive attitudes towards functioning in individuals with back pain compared with first year non-healthcare students [69.2 vs 65.3 (mean difference −3.9, 95% confidence interval −7.2 to −0.5, P = 0.03)]. Physiotherapy students had more positive attitudes than non-healthcare students in the first year [66.6 vs 69.2 (mean difference −2.6, 95% confidence interval −5.5 to 0.4, P = 0.08)] and the fourth year [57.4 vs 65.3 (mean difference −7.9, 95% confidence interval −11.4 to −4.4, P < 0.01)] of study.

Conclusion

These findings suggest that physiotherapy education brings about positive student attitudes towards functioning in individuals with back pain. This may be partly attributable to receiving a university degree education, but would appear to be further enhanced by specifically receiving a physiotherapy degree. This may facilitate students to become more evidence-based practitioners following qualification.     

A national framework for supporting improvements in the physiotherapy assessment and management of low back pain: the Scottish experience

Background

Similar to other countries worldwide, Scotland lacked a national view of whether the quality of the physiotherapy management of low back pain was compliant with national guidelines. Anecdotal evidence suggested that standards of care varied considerably despite the wide availability of clinical guidelines to clinicians.

Aim

To develop a framework that supports National Health Service (NHS) Scotland in providing consistently applied high-quality physiotherapy assessment and management of low back pain in line with guideline recommendations.

Design

Prospective, multicentred national study, data collection and improvement phase.

Setting

All NHS boards in Scotland (n = 14) plus two private provider sites.

Participants

One hundred and eighty-six individual NHS sites and two private providers of services to patients with low back pain.

Method

A national dataset was developed from evidence- and consensus-based guideline sources. All sites collected data (two 5-week periods) over 1 year (2008-2009) using a web-based database. This was interspersed by an improvement phase during which required improvements were considered and implemented. Issues were shared through a national network and national meeting.

Results

Data from 2147 patients showed improvements in the documented physiotherapy management of low back pain over the two cycles. All participants developed and implemented remedial action plans based on the results of the first cycle.

Conclusion

It is possible to implement a framework, which is led nationally but driven and owned locally, supporting physiotherapists in an active programme of locally determined improvement. However, although process and outcome are linked, the direct impact of this initiative on patient outcome is not known.     

A prospective study of patients with chronic back pain randomised to group exercise, physiotherapy or osteopathy

Objective

To investigate the difference in outcome between patients treated with group exercise, physiotherapy or osteopathy.

Design

Prospective study of patients referred at random to one of three treatments, with follow-up 6 weeks after discharge and after 12 months.

Setting

National Health Service physiotherapy department at St Albans City Hospital, part of the West Hertfordshire Musculoskeletal Therapy Service.

Participants

Two hundred and thirty-nine patients aged 18-65 years recruited from referrals to the physiotherapy department with chronic low back pain.

Interventions

Eligible patients were randomised to group exercises led by a physiotherapist, one-to-one predominantly manipulative physiotherapy, or osteopathy.

Main outcomes

Oswestry Disability Index (ODI), EuroQol-5D, shuttle walking test and patients’ subjective responses to pain and treatment.

Results

All three treatments indicated comparable reductions in mean (95% confidence intervals) ODI at 6-week follow-up: group exercise, −4.5 (−0.9 to −8.0); physiotherapy, −4.1 (−1.4 to −6.9); and osteopathy, −5.0 (−1.6 to −8.4). Attendance rates were significantly lower among the group exercise patients. One-to-one therapies provided evidence of greater patient satisfaction.

Conclusion

The study supports the use of a variety of approaches for the treatment of chronic low back pain. Particular attention needs to be given to the problems of attracting enough participants for group sessions, as these can be difficult to schedule in ways that are convenient for different participants.     

Outcome following a physiotherapist-led intervention for chronic low back pain: the important role of cognitive processes

Objectives

To examine whether patients with chronic low back pain exhibit changes in cognitive factors following Interactive Behavioural Modification Therapy (IBMT), delivered by physiotherapists; and to examine the association between pre- to post-treatment changes in cognitive factors (cognitive processes) and pre- to post-treatment changes in pain, disability and depression.

Design

Observational before-after study.

Setting

Outpatient physiotherapy department.

Participants

One hundred and thirty-seven patients with chronic low back pain.

Interventions

IBMT: ‘Work Back to Life’ rehabilitation programme.

Main outcome measures

Pre- to post-treatment changes in pain, disability and a range of cognitive factors.

Results

Patients demonstrated significant favourable changes for a range of cognitive factors. Furthermore, pre- to post-treatment changes in these cognitive factors explained an additional 22%, 17% and 15% of the variance in changes in pain, disability and depression, respectively, after controlling for other important factors.

Conclusions

Changes that emerge in cognitive factors are strongly related to treatment outcome within a physiotherapy treatment context. Specifically, reductions in fear of movement and catastrophising, and increases in functional self-efficacy appear to be particularly important. Modifying these cognitive factors should be seen as a priority when treating patients with chronic low back pain.     

Incentive spirometry following thoracic surgery: what should we be doing?

Background

Thoracic surgery may cause reduced respiratory function and pulmonary complications, with associated increased risk of mortality. Postoperative physiotherapy aims to reverse atelectasis and secretion retention, and may include incentive spirometry.

Objectives

To review the evidence for incentive spirometry, examining the physiological basis, equipment and its use following thoracic surgery.

Data sources

MEDLINE was searched from 1950 to January 2008, EMBASE was searched from 1980 to January 2008, and CINAHL was searched from 1982 to January 2008, all using the OVID interface. The search term was: ‘[incentive spirometry.mp]’. The Cochrane Library was searched using the terms ‘incentive spirometry’ and ‘postoperative physiotherapy’. The Chartered Society of Physiotherapy Resource Centre was also searched, and a hand search was performed to follow-up references from the retrieved studies.

Review method

Non-scientific papers were excluded, as were papers that did not relate to thoracic surgery or the postoperative treatment of patients with incentive spirometry.

Results

Initially, 106 studies were found in MEDLINE, 99 in EMBASE and 42 in CINAHL. Eight references were found in the Cochrane Library and one paper in the Chartered Society of Physiotherapy Resource Centre. Four studies and one systematic review investigating the effects of postoperative physiotherapy and incentive spirometry in thoracic surgery patients were selected and reviewed.

Conclusion

Physiological evidence suggests that incentive spirometry may be appropriate for lung re-expansion following major thoracic surgery. Based on sparse literature, postoperative physiotherapy regimes with, or without, the use of incentive spirometry appear to be effective following thoracic surgery compared with no physiotherapy input.     

Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study

Objective

To investigate the effectiveness of a physiotherapy programme in patients with subacromial impingement syndrome.

Design

Prospective randomised study.

Setting

Orthopaedic department in a district general hospital.

Participants

Eighty-five patients who had been listed for surgery for subacromial impingement syndrome.

Interventions

Patients were allocated at random into one of two groups. One group containing 45 patients received physiotherapy while the other group containing 40 patients acted as controls.

Outcome measures

All patients entering the study underwent Constant score evaluation prior to being allocated to a group. This was repeated at 6 months, prior to surgical intervention.

Results

Seventy-three patients were able to complete the study. In the physiotherapy group, 11 patients no longer required surgery (26%). In this group, all patients improved their Constant score by a mean of 20 (range 4-45). In the control group, all patients required surgery. The mean improvement in the Constant score for the 31 control patients available for review was 0.65 (range −16 to 14).

Conclusion

All patients in this study improved with physiotherapy. Physiotherapy should be thought of as a first-line management for patients with subacromial impingement syndrome.     

Long-term clinical benefits and costs of an integrated rehabilitation programme compared with outpatient physiotherapy for chronic knee pain

Background

Chronic knee pain is a major cause of disability in the elderly. Management guidelines recommend exercise and self-management interventions as effective treatments. The authors previously described a rehabilitation programme integrating exercise and self-management [Enabling Self-management and Coping with Arthritic knee Pain through Exercise (ESCAPE-knee pain)] that produced short-term improvements in pain and physical function, but sustaining these improvements is difficult. Moreover, the programme is untried in clinical environments, where it would ultimately be delivered.

Objectives

To establish the feasibility of ESCAPE-knee pain and compare its clinical effectiveness and costs with outpatient physiotherapy.

Design

Pragmatic, randomised controlled trial.

Setting

Outpatient physiotherapy department and community centre.

Participants

Sixty-four people with chronic knee pain.

Interventions

Outpatient physiotherapy compared with ESCAPE-knee pain.

Outcomes

The primary outcome was physical function assessed using the Western Ontario and McMaster Universities Osteoarthritis Index. Secondary outcomes included pain, objective functional performance, anxiety, depression, exercise-related health beliefs and healthcare utilisation. All outcomes were assessed at baseline and 12 months after completing the interventions (primary endpoint). ANCOVA investigated between-group differences.

Results

Both groups demonstrated similar improvements in clinical outcomes. Outpatient physiotherapy cost £130 per person and the healthcare utilisation costs of participants over 1 year were £583. The ESCAPE-knee pain programme cost £64 per person and the healthcare utilisation costs of participants over 1 year were £320.

Conclusions

ESCAPE-knee pain can be delivered as a community-based integrated rehabilitation programme for people with chronic knee pain. Both ESCAPE-knee pain and outpatient physiotherapy produced sustained physical and psychosocial benefits, but ESCAPE-knee pain cost less and was more cost-effective.Clinical Trial Registration No.: ISRCTN63848242.     

Assessment of undergraduate physiotherapist clinical performance: investigation of educator inter-rater reliability

Objectives

To investigate the inter-rater reliability of physiotherapy educators in awarding clinical placement marks to undergraduate students using a standardised clinical placement assessment form.

Design

Inter-rater reliability study performed over five undergraduate physiotherapy clinical placements.

Setting

Five clinical sites associated with a BSc undergraduate physiotherapy programme.

Participants

Second and final year physiotherapy students who were on clinical placements (n = 86 paired assessments). Two physiotherapy educators (a practice tutor and a practice educator), equally involved in supervising the students over the placement period, marked each student blindly at the end of the placement.

Outcome measure

Marking was performed using a standardised clinical placement assessment form and guidelines. This form was developed by physiotherapy educators, and utilised previously published work in the area.

Results

Eighty-six paired assessment marks were analysed. Practice educators and practice tutors agreed on grades on 74% of occasions. The mean difference in marks (maximum of 100) between educators was −0.5 (95% confidence interval −1.1 to 0.2), and using the limits of agreement method, the results suggested that where two raters mark a student at the end of a clinical placement, the raters will be within 6.2 marks of each other on 95% of occasions. The intraclass correlation coefficient (ICC) for the overall mark was 0.84, indicating almost perfect agreement. Subsections of the form also had substantial agreement (patient management ICC, 0.75; professional development ICC, 0.75; organisation and management ICC, 0.81).

Conclusion

Physiotherapy educators demonstrated a high level of reliability in the assessment and marking of undergraduate physiotherapy student performance using a standardised clinical assessment form. This was evident over several sites and specialities.     

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.     

Indexing of randomised controlled trials of physiotherapy interventions: a comparison of AMED, CENTRAL, CINAHL, EMBASE, Hooked on Evidence, PEDro, PsycINFO and PubMed

Objective

To compare the comprehensiveness of indexing the reports of randomised controlled trials of physiotherapy interventions by eight bibliographic databases (AMED, CENTRAL, CINAHL, EMBASE, Hooked on Evidence, PEDro, PsycINFO and PubMed).

Design

Audit of bibliographic databases.

Methods

Two hundred and eighty-one reports of randomised controlled trials of physiotherapy interventions were identified by screening the reference lists of 30 relevant systematic reviews published in four consecutive issues of the Cochrane Database of Systematic Reviews (Issue 3, 2007 to Issue 2, 2008). AMED, CENTRAL, CINAHL, EMBASE, Hooked on Evidence, PEDro, PsycINFO and PubMed were used to search for the trial reports. The number of trial reports indexed in each database was calculated.

Results

PEDro indexed 99% of the trial reports, CENTRAL indexed 98%, PubMed indexed 91%, EMBASE indexed 82%, CINAHL indexed 61%, Hooked on Evidence indexed 40%, AMED indexed 36% and PsycINFO indexed 17%. Most trial reports (92%) were indexed on four or more of the databases. One trial report was indexed on a single database (PEDro).

Conclusions

Of the eight bibliographic databases examined, PEDro and CENTRAL provide the most comprehensive indexing of reports of randomised trials of physiotherapy interventions.     

An observational study of physiotherapists’ use of cognitive-behavioural principles in the management of patients with back pain and neck pain

Objectives

This study investigated the extent to which physiotherapists collaborating in a randomised trial comparing the McKenzie approach with a Solution Finding Approach (SFA) for back pain or neck pain involved patients in the consultation, and empowered patients to develop self-management strategies. The aims were to develop a tool for this purpose and to identify any observed differences between the consultations in these two approaches.

Design

An observational study, conducted within a randomised trial (McKABI trial).

Setting

Patients referred to seven National Health Service physiotherapy departments in West and East Yorkshire.

Participants

The observational study collected data from 10 of the 28 physiotherapists participating in the McKABI trial.

Main outcome measures

The involvement and empowerment scales of the Involvement and Empowerment of Patients in Physiotherapy Assessment Rating Tool (IMPART).

Results

Although not widely used, physiotherapists employed significantly more patient involvement and empowerment strategies with the SFA compared with the McKenzie approach. The median (interquartile range)/total possible scores were: SFA 19 (18), McKenzie 10 (4.5)/60 for involvement; and SFA 27 (8), McKenzie 11 (10)/64 for empowerment.

Conclusions

Most physiotherapists were able to switch between the two approaches without significant overlap in techniques. Psychosocial questioning and goal-setting were under-utilised by most physiotherapists. Implementing the SFA protocol appeared to be more difficult than the McKenzie approach, possibly because the SFA was less reliant on a structured format. Physiotherapists may have required more training to enable them to deliver the SFA effectively. The IMPART was a reliable measure of physiotherapists’ involvement and empowerment strategies.     

Motivating patients with shoulder and back pain to self-care: can a videotape of exercise support physiotherapy?

Objectives

The National Health Service is developing an ethos of self-care. Patients are being encouraged to become proficient in helping themselves. This has long been a philosophy of the physiotherapy profession, where self-care between consultations has been an integral part of the treatment process through encouraging the uptake of self-care skills training. This study explored how patients with shoulder and back pain perceived videotaped exercises and instructions to support their routine physiotherapy, and how the videotape was used.

Design

A videotape, developed by physiotherapists for patients with musculoskeletal problems, of exercises to view at home was given to patients by their physiotherapists to support their routine physiotherapy consultations. A qualitative methodology was used to examine how patients responded to being given a videotape of exercises and instructions between consultations. Data were collected through semi-structured interviews.

Setting

The study was based in 26 general practices that had access to practice-based physiotherapists in two primary care trusts in the north-west of England.

Participants

Thirty-three patients with shoulder and back pain who received a videotape of exercises and advice were interviewed.

Results

Three themes emerged from the data: finding space for exercise; remembering and doing exercises; and supporting the physiotherapy-patient relationship. Patients discussed aspects of motivation, and described how a videotape of exercises might support or inhibit the performance of exercises prescribed by physiotherapists. Patients identified a range of different ways in which they derived support from the videotape.

Conclusions

The videotape supported patients with a variety of different needs as it enhanced their ability to complete exercises correctly. Videotapes (or DVDs) are useful for patients and could be adopted as a tool to support treatment.     

Work-related musculoskeletal disorders affecting members of the Chartered Society of Physiotherapy

Objective

To estimate the prevalence of work-related musculoskeletal disorders from a snapshot sample of members of the Chartered Society of Physiotherapy (CSP); the trade union, educational and professional body for physiotherapists, physiotherapy assistants and physiotherapy students in the UK. The distribution of musculoskeletal disorders against different variables, including age of therapist, years in practice and clinical specialty, was also investigated. We set out to highlight the job tasks that injured physiotherapists associated with their complaint and to identify any preventive strategies that injured physiotherapists adopted to prevent re-injury.

Design

A self-administered questionnaire was posted to a randomly selected sample taken from the membership database of the CSP.

Participants

Ten percent (n = 3661) of registered physiotherapists, physiotherapy assistants and physiotherapy students on clinical placement.

Main instrument

Questionnaire based on the Standardised Nordic Questionnaire.

Results

Reported career prevalence of work-related musculoskeletal disorders in members of the CSP was 68%. Previous 12-month prevalence was 58%, and 42% reported musculoskeletal symptoms in the last 12 months that lasted for more than 3 days. The low back was the body area identified by 44% of injured respondents as their most significant injury. Nearly one-third (32%) of injured respondents first experienced their worst injury within 5 years of graduation. A greater number of respondents (59%) were aged 30 years or under when their most serious injury occurred. Injured respondents rated ‘performing the same tasks over and over’, ‘working in the same position for long periods’ and ‘treating a large number of patients in 1 day’ as the three most influential job risk factors contributing to injury.

Conclusions

Younger physiotherapists and newly qualified graduates appear to be most in need of intervention services aimed at reducing injury rates. Official action is undermined by injured physiotherapists seeking informal treatment from colleagues rather than reporting injury to their manager, helping to keep work-related injury a hidden problem. Physiotherapists should be encouraged to report workplace injury, and barriers to official reporting should be identified.     

A video analysis of how physiotherapists communicate with patients about errors of performance: insights for practice and policy

Objectives

To describe and elucidate skilled practices by which physiotherapists communicate with patients about problems of ongoing or recent performance of physical treatment activities; to offer a sociological perspective on this area of practice; to examine relations between actual communication practice and official (Chartered Society of Physiotherapy) recommendations; to explore problems associated with formulating standards pertaining to communication and suggest how these might be addressed.

Design

Video recordings of physiotherapy treatment sessions (n = 74) were analysed using conversation analysis—an observational, inductive, social science methodology.

Setting

Inpatient rehabilitation units in four English hospitals.

Participants

Twenty-one stroke patients aged 52-86 years and 10 senior physiotherapists with 3-23 years of postqualification experience.

Results and conclusions

A variety of practices were identified. Managing shortcomings of performance often involves identifying and/or correcting the problem in a manner that deals sensitively with the negative connotations of physical non-competence. Characteristics of these practices include indirectness and ambiguity. As such, they do not conform to some official recommendations. However, good interactional reasons underlie the observed patterns. It is suggested that official guidance should acknowledge the complexity of communication and its measurement. Recommendations should be based upon a thorough understanding of the interactional tasks and practices entailed in physiotherapy. Recommendations should be explicitly tentative and refer to broad principles. By elucidating specific communication strategies, their consequences and the considerations that underlie them, conversation analytic research into physiotherapy communication has the potential to inform guidelines, and provide resources for developing and teaching communication skills.     

What Are the Relations Between Voluntary Postural Sway Measures and Falls-History Status in Community-Dwelling Older Adults?

Tucker MG, Kavanagh JJ, Morrison S, Barrett RS. What are the relations between voluntary postural sway measures and falls-history status in community-dwelling older adults?

Objectives

To determine whether a series of voluntary postural sway tasks could differentiate and accurately identify the falls-history status of older adults, and to examine the relations between voluntary sway measures and falls risk.

Design

Case-control study.

Setting

University biomechanics laboratory.

Participants

Healthy community-dwelling older adults (N=51) aged 65 to 94 years who were divided into nonfaller (n=36), single faller (n=10), and multiple faller (n=5) groups based on a 12-month history of falls.

Interventions

Not applicable.

Main Outcome Measures

Participants underwent a falls-risk assessment using the Physiological Profile Assessment (PPA) and then performed 6 voluntary postural sway tasks. The tasks included maximum static leans, maximum voluntary sway, continuous voluntary sway, rapid initiation of voluntary sway, rapid termination of voluntary sway, and rapid orthogonal switches of voluntary sway between the anterior-posterior and medial-lateral directions. Center of pressure amplitudes and reaction time measures were examined using analysis of covariance, Pearson's correlation, and discriminant function analyses.

Results

Multiple fallers had increased age; increased falls risk; slower initiation, termination, and orthogonal switch reaction times; and reduced center of pressure amplitude during sway initiation and continuous voluntary sway compared with nonfallers. Few differences were observed between the nonfallers and single fallers. Voluntary sway measures were significantly correlated with each other and with PPA score. Two postural reaction time measures and age identified 80% of multiple fallers and 98% of nonmultiple fallers. Similarly, PPA score and age identified 80% of multiple fallers and 100% of nonmultiple fallers.

Conclusions

The slower and less effective balance responses of multiple fallers compared with nonfallers and the comparable sensitivity and specificity of PPA score and reactive voluntary sway measures indicate that postural reaction time is a strong determinant of falls risk.     

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.     

First impressions: an information leaflet for patients attending a musculoskeletal outpatient department

Objective

The purpose of this work was to design and evaluate an information leaflet for new patients attending a physiotherapy outpatient department. This formed part of a wider agenda of improving the patients’ experience and increasing adherence to the Chartered Society of Physiotherapy's core standards.

Design

A needs analysis was undertaken with existing patients to determine the content of the new leaflet. This was then tested for readability, reviewed by physiotherapy staff and evaluated by patients via a questionnaire.

Setting

The musculoskeletal outpatient physiotherapy department at Southampton General Hospital.

Participants

Patients referred to the outpatient physiotherapy service, plus all clinical and support staff employed in the musculoskeletal outpatient team.

Main outcome measures

Numerical Rating Scale and Gunning's Fog Index.

Results

Thirty-seven of 50 patients completed the needs analysis (74%), generating 42 ideas for the leaflet content. The definitive leaflet addressed one core standard and 16 specific criteria, and had a readability of grade 8.3, which is below the recommended maximum limit of grade 9 for health education leaflets. Using an 11-point Numerical Rating Scale, where 0 = of no benefit and 10 = extremely helpful, the mean rating for the leaflet from 29 of 100 patients was 8.6.

Conclusions

This work has produced a patient information leaflet for physiotherapy outpatients, a copy of which is freely available (electronically) from the author. The leaflet forms part of an ongoing commitment to improving the patients’ experience.