Crystal MacKay

Expanding roles in orthopaedic care: a comparison of physiotherapist and orthopaedic surgeon recommendations for triage

RATIONALE, AIMS AND OBJECTIVES Innovative service delivery models are emerging using physiotherapists in the assessment and management of patients referred for orthopaedic consultation. The primary objective of this study was to compare the clinical recommendations of specially trained physiotherapists with those of an orthopaedic surgeon on: (1) appropriateness to be seen by an orthopaedic surgeon; and (2) candidacy and willingness to undergo total joint replacement (TJR) for patients with hip or knee problems. A secondary objective was to examine their recommendations for non-surgical management and agreement on clinical diagnosis. METHODS Physiotherapists and orthopaedic surgeons independently assessed patients with hip and knee problems referred for consideration for TJR and completed a standardized form on treatment recommendations. Agreement between providers was determined using the kappa coefficient and per cent agreement. RESULTS Two physiotherapists and three orthopaedic surgeons participated in the study that included 45 and 17 patients with knee and hip problems respectively. In 91.8% (56/61) of cases, physiotherapists and orthopaedic surgeons agreed on the recommendation of appropriateness for the patient to see a surgeon (kappa 0.69). In discordant cases, the physiotherapists tended to refer for consultation. There was 85.5% (53/62) agreement on whether a patient was a candidate and willing to have TJR (kappa 0.70). The physiotherapists commonly recommended exercise and education for non-surgical patients. Orthopaedic surgeons most commonly referred patients to rehabilitation services. CONCLUSIONS Patients with hip or knee pain referred to orthopaedic surgeons can be appropriately referred for orthopaedic consultation by physiotherapists working in extended roles. Further research is required to evaluate the value-added and the most appropriate use of extended role physiotherapists.

Health care utilization for musculoskeletal disorders

To examine patterns of ambulatory care and hospital utilization for people with musculoskeletal disorders (MSDs), including arthritis and related conditions, bone and spinal conditions, trauma and related conditions, and unspecified MSDs.

Educational needs of patients undergoing total joint arthroplasty.

PURPOSE To identify the educational needs of adults who undergo total hip and total knee replacement surgery. METHODS A qualitative research design using a semi-standardized interviewing method was employed. A purposive sampling technique was used to recruit participants, who were eligible if they were scheduled to undergo total hip or total knee replacement or had undergone total hip or total knee replacement in the previous 3 to 6 months. A comparative contrast method of analysis was used. RESULTS Of 22 potential participants who were approached, 15 participated. Five were booked for upcoming total hip or total knee replacement and 10 had undergone at least one total hip or total knee replacement in the previous 3 to 6 months. Several themes related to specific educational needs and factors affecting educational needs, including access, preoperative phase, surgery and medical recovery, rehabilitation process and functional recovery, fears, and expectations counterbalanced with responsibility, emerged from the interviews. CONCLUSIONS Educational needs of adults who undergo total hip and knee replacement surgery encompass a broad range of topics, confirming the importance of offering an all-inclusive information package regarding total hip and total knee replacement.

An evidence‐informed, integrated framework for rheumatoid arthritis care

Introduction Providing adequate care for persons with rheumatoid arthritis (RA) is an ongoing challenge. Although the current evidence supports the use of disease-modifying antirheumatic drugs (DMARDs) within the first 3 months of symptoms appearing (1–3), delay in DMARD use and other gaps in care have been reported across communities (4–9). The situation has worsened due to the shortage of specialists (10). The process of seeking medical treatment begins with the person’s recognition of the symptoms and the action of visiting a family physician (FP) (Figure 1, levels A and B). The FP then performs the appropriate investigations, and if RA is suspected, the FP refers the person to a rheumatologist (levels B and C) who then conducts further tests, provides a diagnosis, and prescribes DMARDs and other appropriate medications (level D). Next, the person may be referred to the available community resources and/or rehabilitation programs that enable self-management (levels E1–E4), and will be periodically assessed by a rheumatologist (level F). Successful delivery of these interventions is largely dependent on the availability of local programs and the coordination among the rheumatologist, the FP, and other health professionals. In the case of severe joint damage, the person is referred for an orthopedic consultation and surgery may be considered (levels G1–G4). Moving from one level to the next involves a potential wait period, which may be caused by, for example, delays in patients’ and health professionals’ recognition of RA symptoms, delays in referral to rheumatologists, lack of access to specialist care or community resources, or patients’ own choices. Delays may occur at any of the following periods (Figure 1): Wait 1: the time between a person’s development and awareness of the seriousness of the symptoms and the first visit with an FP; Wait 2: the time between the first visit with an FP and the first visit with a rheumatologist; Wait 3: from the first rheumatology visit to the date the patient starts the appropriate therapy; Wait 4: from a patient starting medication to the date when he or she has access to adequate resources that enable self-management; andWait 5: from the decision date for an orthopedic consultation to the date of the patient’s first visit with a surgeon and, subsequently, the date of surgery. The delay between symptom onset and DMARD prescription for individuals with RA is a problem across countries (Waits 1–3), with a median lag time ranging from 6.5 to 19 months (5–9). A few studies have attempted to estimate the length of Wait 1, but the findings are inconsistent. Two studies, a retrospective cohort from the US (11) and a prospective study from Norway (12), estimated a median delay of 4 weeks for the first FP visit. However, more recent research from the UK estimated 12 weeks (13), with 38% of people waiting more than 3 months before seeing an FP (14). The lag time from FP visit to rheumatologist consultation is believed to be a major source of the delay (Wait 2). In a UK study, 44% waited more than 3 months for a specialist referral (14). Recent research from Canada also found a median lag time of 79 days between the FP visit and the first rheumatologist visit (15). In contrast, the Linda C. Li, PT, PhD: University of British Columbia and Arthritis Research Centre of Canada, Vancouver, British Columbia, Canada; Elizabeth M. Badley, DPhil: Arthritis Community Research and Evaluation Unit, Toronto Western Research Institute and University of Toronto, Toronto, Ontario, Canada; Crystal MacKay, PT, MHSc: Arthritis Community Research and Evaluation Unit, Toronto Western Research Institute, Toronto, Ontario, Canada; Dianne Mosher, MD, FRCP(C): Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada; Shahin (Walji) Jamal, MD, FRCP(C): St. Michael’s Hospital and University of Toronto, Toronto, Ontario, Canada; Anamaria Jones, PT, PhD(Candidate): Arthritis Research Centre of Canada, Vancouver, British Columbia, Canada, and Federal University of Sao Paulo, Sao Paulo, Brazil; Claire Bombardier, MD, FRCP(C): University Health Network, University of Toronto, Institute for Work & Health, and Mount Sinai Hospital, Toronto, Ontario, Canada. Dr. Mosher has received honoraria (less than

Characteristics of evolving models of care for arthritis: A key informant study

10,000) from serving on the advisory board for Pfizer, and has received speaking fees (less than

Osteoarthritis year in review: outcome of rehabilitation

10,000 each) from Schering, Amgen, and Wyeth. Address correspondence to Linda C. Li, PT, PhD, Arthritis Research Centre of Canada, 895 West 10th Avenue, Room 324, Vancouver, British Columbia V5Z 1L7, Canada. E-mail: lli@arthritisresearch.ca. Submitted for publication December 27, 2007; accepted in revised form April 22, 2008. Arthritis & Rheumatism (Arthritis Care & Research) Vol. 59, No. 8, August 15, 2008, pp 1171–1183 DOI 10.1002/art.23931

Magnitude of impact and healthcare use for musculoskeletal disorders in the paediaric: a population-based study

BackgroundThe burden of arthritis is increasing in the face of diminishing health human resources to deliver care. In response, innovative models of care delivery are developing to facilitate access to quality care. Most models have developed in response to local needs with limited evaluation. The primary objective of this study is to a) examine the range of models of care that deliver specialist services using a medical/surgical specialist and at least one other health care provider and b) document the strengths and challenges of the identified models. A secondary objective is to identify key elements of best practice models of care for arthritis.MethodsSemi-structured interviews were conducted with a sample of key informants with expertise in arthritis from jurisdictions with primarily publicly-funded health care systems. Qualitative data were analyzed using a constant comparative approach to identify common types of models of care, strengths and challenges of models, and key components of arthritis care.ResultsSeventy-four key informants were interviewed from six countries. Five main types of models of care emerged. 1) Specialized arthritis programs deliver comprehensive, multidisciplinary team care for arthritis. Two models were identified using health care providers (e.g. nurses or physiotherapists) in expanded clinical roles: 2) triage of patients with musculoskeletal conditions to the appropriate services including specialists; and 3) ongoing management in collaboration with a specialist. Two models promoting rural access were 4) rural consultation support and 5) telemedicine. Key informants described important components of models of care including knowledgeable health professionals and patients.ConclusionA range of models of care for arthritis have been developed. This classification can be used as a framework for discussing care delivery. Areas for development include integration of care across the continuum, including primary care.

A population-based study of ambulatory and surgical services provided by orthopaedic surgeons for musculoskeletal conditions

PURPOSE This review highlights seminal publications of rehabilitation interventions for osteoarthritis (OA) since April 2012. METHODS Medline in process, Embase, CINAHL and Cochrane databases were searched from April 2012 through February 2013 for English language publications using key words osteoarthritis, rehabilitation, physiotherapy, physical therapy, and exercise. Rehabilitation intervention studies included randomized trials or systematic reviews/meta-analyses or pre-post studies. Pilot randomized trials, feasibility studies and studies of surgical interventions unless they included evaluation of a rehabilitation intervention were excluded. RESULTS Twenty-five studies were identified for inclusion and grouped thematically. The short-term benefits (i.e., to 3 months) of variable types and dosages of exercise were demonstrated for a number of outcomes including pain, stiffness, function, balance, biomarkers, and executive function and dual task performance (related to falling) in people with knee OA. Modalities such as 890-nm radiation, interferential current, short wave diathermy, ultrasound and neuromuscular functional electrical stimulation did not demonstrate benefit over sham controls in those with knee OA. Spa therapy improved pain over the period of treatment in those with knee and hand OA. Supervised self-management based on cognitive therapy principles resulted in improved outcomes for people with knee OA. Shock absorbing insoles compared to normal footwear minimally improved knee pain and but not function and did not decrease knee load. Neuromuscular and motor training improved function in those with total hip replacement. Accelerated weight-bearing and rehabilitation (8 versus 11 weeks) was demonstrated to be safe and effective at 5 years following matrix autologous chondrocyte implantation for cartilage defects in the knee. CONCLUSIONS Exercise remains a mainstay of conservative management although most studies report only short-term outcomes. Self-management strategies also are beneficial in knee OA. There seems to be a placebo effect with most trials of physical modalities although spa therapy demonstrated very short-term effects.

A qualitative study of the consequences of knee symptoms: ‘It's like you're an athlete and you go to a couch potato’

BackgroundAlthough musculoskeletal disorders (MSD) are among the most prevalent chronic conditions, minimal attention has been paid to the paediatric population. The aim of this study is to describe the annual prevalence of healthcare contacts for MSD by children and youth age 0-19 years, including type of MSD, care delivery setting and the specialty of the physician consulted.MethodsAnalysis of data on all children with healthcare contacts for MSD in Ontario, Canada using data from universal health insurance databases on ambulatory physician and emergency department (ED) visits, same-day outpatient surgery, and in-patient admissions for the fiscal year 2006/07. The proportion of children and youth seeing different physician specialties was calculated for each physician and condition grouping. Census data for the 2006 Ontario population was used to calculate person visit rates.Results122.1 per 1,000 children and youth made visits for MSD. The majority visited for injury and related conditions (63.2 per 1,000), followed by unspecified MSD complaints (33.0 per 1,000), arthritis and related conditions (27.7 per 1,000), bone and spinal conditions (14.2 per 1,000), and congenital anomalies (3 per 1,000). Injury was the most common reason for ED visits and in-patient admissions, and arthritis and related conditions for day-surgery. The majority of children presented to primary care physicians (74.4%), surgeons (22.3%), and paediatricians (10.1%). Paediatricians were more likely to see younger children and those with congenital anomalies or arthritis and related conditions.ConclusionOne in eight children and youth make physician visits for MSD in a year, suggesting that the prevalence of MSD in children may have been previously underestimated. Although most children may have self-limiting conditions, it is unknown to what extent these may deter involvement in physical activity, or be indicators of serious and potentially life-threatening conditions. Given deficiencies in medical education, particularly of primary care physicians and paediatricians, it is important that training programs devote an appropriate amount of time to paediatric MSD.

“We're All Looking for Solutions”: A Qualitative Study of the Management of Knee Symptoms

BackgroundThe ongoing process of population aging is associated with an increase in prevalence of musculoskeletal conditions with a concomitant increase in the demand of orthopaedic services. Shortages of orthopaedic services have been documented in Canada and elsewhere. This population-based study describes the number of patients seen by orthopaedic surgeons in office and hospital settings to set the scene for the development of strategies that could maximize the availability of orthopaedic resources.MethodsAdministrative data from the Ontario Health Insurance Plan and Canadian Institute for Health Information hospital separation databases for the 2005/06 fiscal year were used to identify individuals accessing orthopaedic services in Ontario, Canada. The number of patients with encounters with orthopaedic surgeons, the number of encounters and the number of surgeries carried out by orthopaedic surgeons were estimated according to condition groups, service location, patients age and sex.ResultsIn 2005/06, over 520,000 Ontarians (41 per 1,000 population) had over 1.3 million encounters with orthopaedic surgeons. Of those 86% were ambulatory encounters and 14% were in hospital encounters. The majority of ambulatory encounters were for an injury or related condition (44%) followed by arthritis and related conditions (37%). Osteoarthritis accounted for 16% of all ambulatory encounters. Orthopaedic surgeons carried out over 140,000 surgeries in 2005/06: joint replacement accounted for 25% of all orthopaedic surgeries, whereas closed repair accounted for 16% and reductions accounted for 21%. Half of the orthopaedic surgeries were for arthritis and related conditions.ConclusionThe large volume of ambulatory care points to the significant contribution of orthopaedic surgeons to the medical management of chronic musculoskeletal conditions including arthritis and injuries. The findings highlight that surgery is only one component of the work of orthopaedic surgeons in the management of these conditions. Policy makers and orthopaedic surgeons need to be creative in developing strategies to accommodate the growing workload of orthopaedic surgeons without sacrificing quality of care of patients with musculoskeletal conditions.