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A Description of Physical Therapists’ Knowledge in Managing Musculoskeletal Conditions

BMC Musculoskeletal Disorders

February 2005
6(1):32

DOI:10.1186/1471-2474-6-32

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PubMed

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CC BY 4.0

Authors:

John D Childs

Evidence in Motion

Julie M Whitman

Evidence in Motion

Phillip S Sizer

Texas Tech University Health Sciences Center

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Physical therapists increasingly provide direct access services to patients with musculoskeletal conditions, and growing evidence supports the cost-effectiveness of this mode of healthcare delivery. However, further evidence is needed to determine if physical therapists have the requisite knowledge necessary to manage musculoskeletal conditions. Therefore, the purpose of this study was to describe physical therapists' knowledge in managing musculoskeletal conditions. This study utilized a cross-sectional design in which 174 physical therapist students from randomly selected educational programs and 182 experienced physical therapists completed a standardized examination assessing knowledge in managing musculoskeletal conditions. This same examination has been previously been used to assess knowledge in musculoskeletal medicine among medical students, physician interns and residents, and across a variety of physician specialties. Experienced physical therapists had higher levels of knowledge in managing musculoskeletal conditions than medical students, physician interns and residents, and all physician specialists except for orthopaedists. Physical therapist students enrolled in doctoral degree educational programs achieved significantly higher scores than their peers enrolled in master's degree programs. Furthermore, experienced physical therapists who were board-certified in orthopaedic or sports physical therapy achieved significantly higher scores and passing rates than their non board-certified colleagues. The results of this study may have implications for health and public policy decisions regarding the suitability of utilizing physical therapists to provide direct access care for patients with musculoskeletal conditions.

Overall scores on the musculoskeletal knowledge examination among physical therapist students, licensed physical therapists, and previous data using the same examination among physicians. All physician-related data was derived from Matzkin et al,[12] except data for the subgroup of physician interns, which was derived from Freedman and Bernstein[7]. PT = physical therapist, Phys = physician, OCS = Orthopaedic Clinical Specialist, SCS = Sports Clinical Specialist, DPT = doctoral physical therapy program, MPT = master's physical therapy program, Ortho = orthopaedics, Other = anesthesia, emergency medicine. ophthalmology, radiology, and transitional, FP = family practice, GS = general surgery, Res = Resident, Peds = Pediatrics, Med = internal medicine, Med stu = medical student, OB = obstetrics-gynecology, and Psy = psychiatry

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BioMed Central

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BMC Musculoskeletal Disorders

Open Access

Research article

A description of physical therapists' knowledge in managing

musculoskeletal conditions

John D Childs

†1

, Julie M Whitman

†2

, Phillip S Sizer*

†3

, Maria L Pugia

†4

Timothy W Flynn

†2

and Anthony Delitto

†5

Address:

US Army-Baylor University Doctoral Program in Physical Therapy, Fort Sam Houston, San Antonio, TX, USA,

Department of Physical

Therapy, Regis University, Denver, CO, USA,

Department of Physical Therapy, Texas Tech University, Lubbock, TX, USA,

Department of Physical

Therapy, Los Angeles Air Force Base, Los Angeles, CA, USA and

Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA

Email: John D Childs - childsjd@sbcglobal.net; Julie M Whitman - jwitman55@comcast.net; Phillip S Sizer* - phil.sizer@ttuhsc.edu;

Maria L Pugia - maria.pugia@losangeles.af.mil; Timothy W Flynn - tflynn@regis.edu; Anthony Delitto - delittoa@upmc.edu

* Corresponding author †Equal contributors

Abstract

Background: Physical therapists increasingly provide direct access services to patients with

musculoskeletal conditions, and growing evidence supports the cost-effectiveness of this mode of

healthcare delivery. However, further evidence is needed to determine if physical therapists have

the requisite knowledge necessary to manage musculoskeletal conditions. Therefore, the purpose

of this study was to describe physical therapists' knowledge in managing musculoskeletal conditions.

Methods: This study utilized a cross-sectional design in which 174 physical therapist students from

randomly selected educational programs and 182 experienced physical therapists completed a

standardized examination assessing knowledge in managing musculoskeletal conditions. This same

examination has been previously been used to assess knowledge in musculoskeletal medicine

among medical students, physician interns and residents, and across a variety of physician

specialties.

Results: Experienced physical therapists had higher levels of knowledge in managing

musculoskeletal conditions than medical students, physician interns and residents, and all physician

specialists except for orthopaedists. Physical therapist students enrolled in doctoral degree

educational programs achieved significantly higher scores than their peers enrolled in master's

degree programs. Furthermore, experienced physical therapists who were board-certified in

orthopaedic or sports physical therapy achieved significantly higher scores and passing rates than

their non board-certified colleagues.

Conclusion: The results of this study may have implications for health and public policy decisions

regarding the suitability of utilizing physical therapists to provide direct access care for patients with

musculoskeletal conditions.

Published: 17 June 2005

BMC Musculoskeletal Disorders 2005, 6:32 doi:10.1186/1471-2474-6-32

Received: 22 November 2004

Accepted: 17 June 2005

This article is available from: http://www.biomedcentral.com/1471-2474/6/32

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

BMC Musculoskeletal Disorders 2005, 6:32 http://www.biomedcentral.com/1471-2474/6/32

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Background

Musculoskeletal conditions account for roughly 25% of

patient complaints in the primary care setting[1]. How-

ever, physicians have been shown to lack confidence in

their evaluation and treatment skills of these patients [2-

6]. Although its de-emphasis in medical school curricula

has been repeatedly implicated,[1,5,7-9] almost half of

American medical schools still do not require any formal

training in musculoskeletal medicine[10]. This lack of

confidence is reflected by poor performance on formal

assessments of knowledge in musculoskeletal medi-

cine[7] and less than optimal practice patterns for patients

with musculoskeletal conditions[11]. Freedman and

Bernstein[7] assessed knowledge in musculoskeletal med-

icine among 85 physicians during their first week of their

internship following graduation from medical school

using a standardized examination. The mean score was

just under 60%, with only 18% of physicians scoring

above a level determined orthopaedic program directors

as the minimum threshold necessary to establish compe-

tency in musculoskeletal medicine in the primary care set-

ting[7]. Matzkin et al[12] recently demonstrated similar

suboptimal levels of knowledge in musculoskeletal medi-

cine among medical students and residents. Except for

orthopaedists, they also found that experienced physi-

cians across a variety of specialties demonstrated less than

adequate knowledge related to musculoskeletal medicine.

The authors concluded that training in both medical

school and non-orthopaedic residency training programs

was inadequate, a sentiment that has been echoed

elsewhere[13].

Considerable evidence supports the benefits of early

access to physical therapy care [14-18]. In particular, phys-

ical therapists increasingly provide their services without

physician referral (ie, direct access). Seventy percent of the

public reports they would seek care from a physical thera-

pist without physician referral for musculoskeletal condi-

tions, [19] with 39 states having passed legislation

supporting this mode of healthcare delivery [20]. Multiple

studies have demonstrated that physical therapists can

provide safe and cost-effective care for patients with mus-

culoskeletal conditions in direct access practice settings,

supporting the expansion of direct access physical therapy

services [21-26]. For example, physician referral episodes

of care reportedly increased physical therapy claims by

67%, office visits by 60%, and costs by 123% than when

patients directly accessed physical therapy without physi-

cian referral[24].

Despite the curricular emphasis placed on the manage-

ment of musculoskeletal conditions in physical therapy

programs, to date few studies have described physical

therapists' knowledge of the skills necessary to manage

these patients in a direct access setting. A musculoskeletal

written examination has been developed and validated for

this purpose[7,27]. The examination has been adminis-

tered to physician interns,[7] medical students and resi-

dents,[12] and a variety of physician specialists,[12]

making it a pragmatic reference standard for the initial

assessment of knowledge in managing musculoskeletal

conditions among physical therapist students and

licensed physical therapists. Therefore, the purpose of this

study was to describe physical therapists' knowledge in

managing musculoskeletal conditions using this examina-

tion. These data combined with clinical studies demon-

strating the benefits of direct access physical therapy [21-

26] may further clarify the role of physical therapists in

direct access environments.

Methods

We used a cross-sectional design to describe knowledge in

managing musculoskeletal conditions among physical

therapist students and licensed physical therapists in the

uniformed services. The study was approved by the Insti-

tutional Review Boards at Wilford Hall Medical Center in

San Antonio, TX and at Texas Tech University in Lubbock,

TX before subject recruitment and data collection began.

All subjects provided informed consent prior to

participation.

Based on an a priori sample size estimation, a total of 26

first-professional physical therapy programs accredited by

the Commission for Accreditation of Physical Therapy

Education were randomly selected for participation. Edu-

cational programs are rapidly transitioning to doctoral

programs, with approximately 80% of programs having

completed the transition to the Doctor of Physical Ther-

apy degree or in the transitioning process at the time of

the study [28]. Therefore, randomization was blocked by

the degree to be conferred upon graduation: master's (n =

13) vs. doctoral (n = 13) to permit comparisons based on

degree status. Program directors were contacted initially

by email to inform them of their program's selection,

describe the study procedures, and invite the program's

participation. Students in these programs were in the ter-

minal phase of their program's curriculum, defined as

having completed substantial portions of the didactic cur-

riculum and clinical affiliations. All licensed physical ther-

apists in the four uniformed health services (U.S. Air

Force, U.S. Army, U.S. Navy, and U.S. Public Health Serv-

ice) with at least one year of clinical experience were also

invited to participate.

Participants completed the identical examination origi-

nally developed by Freedman and Bernstein to assess

knowledge in musculoskeletal medicine among physician

interns, [7] and more recently administered to medical

students, residents, and a variety of physician specialists

[12]. The examination consists of 25 open-ended

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questions that were selected based on commonly encoun-

tered musculoskeletal diagnoses encountered in the pri-

mary care setting (ie, fractures and dislocations, low back

pain, sciatica, and arthritis) and consideration of ortho-

paedic emergencies that warrant immediate referral to an

orthopaedic surgeon or the emergency department (ie,

compartment syndrome, hip dislocation, etc.) [7]. Addi-

tional details related to the development and validation of

the examination are reported elsewhere [7,27].

The examination was administered in a web-based format

using Web Surveyor, version 3.6 (Web Surveyor Corpora-

tion, Herndon, VA). No time limit was imposed to be con-

sistent with previous methodology [7,12]. Subject

confidentiality was strictly maintained through assign-

ment of a unique computer-generated code. Administra-

tion of the examination was preceded by a brief

demographic survey that queried patients as to their edu-

cational background, board-certification status (Ortho-

paedic and/or Sports Clinical Specialist designation via

the American Board of Physical Therapy Specialties),

experience in different practice settings, and familiarity

with the studies by Freedman and Bernstein [7,27]. Data

from any therapists familiar with the studies by Freedman

and Bernstein [7,27] were excluded from analysis because

the examination questions and answer key were pub-

lished verbatim in these manuscripts.

Educational programs were requested to have participants

complete the study in a group setting with a proctor

present (eg, a computer lab) when possible. This would

insure that participants did not use any outside resources

(ie, textbooks, information available on the internet, per-

sonal communication, etc.) to assist them in answering

the questions. To maximize participation, however, pro-

grams were alternatively given the option to have partici-

pants complete the study on their own if a computer lab

or similar arrangement was unavailable, or if a participant

was not available at the designated time. Licensed physi-

cal therapists were also asked to complete the study in a

proctored setting. All participants were queried at the end

of the study as to whether they used any outside resources

to assist them in the completion of the examination. The

results of the demographic survey and content of the

examination were stored in a secure, password-protected

centralized database for subsequent analysis.

Data analysis

A total of 6 judges, blinded to the demographic survey

results and whether the participant was a physical thera-

pist student or licensed physical therapist scored blocks of

4–6 questions, resulting in each question being scored by

two raters. Judges were physical therapist faculty with con-

siderable experience in providing direct access care for

patients with musculoskeletal conditions. Each rater was

also trained in the scoring procedures by one of the inves-

tigators. An overall score and passing rate were deter-

mined using identical procedures as those described by

Freedman and Bernstein,[7] however a brief review is pro-

vided here. Each question was assigned a maximum pos-

sible of 1 point. Partial credit was assigned based on the

criteria for partial credit outlined in the answer key [7].

Scores were not penalized for incorrect spelling. Sums of

individual scores represented the overall score, which was

multiplied by 4 to obtain a percentage score. Inter-rater

reliability of the overall score was examined using the

intraclass correlation coefficient (ICC), equation 3,1 [29].

The ICC and associated 95% confidence interval was 0.91

(0.89, 0.92). Given a sufficiently high reliability coeffi-

cient, only data from the first rater were used in the anal-

ysis. Using the results from a single rater is also consistent

with the procedures utilized by Freedman and Bernstein

[7]. Participants were judged to have passed the examina-

tion if their score exceeded the previously established

threshold of 73.1% [7].

Descriptive statistics, including frequency counts for cate-

gorical variables and measures of central tendency and

dispersion for continuous variables were calculated to

summarize the data using SPSS for Windows 11.0.1 (Chi-

cago, IL). Independent sample t-tests were used to directly

compare differences in knowledge between educational

programs conferring the doctoral versus master's degree

and between licensed physical therapists who were board-

certified and those who were not. Differences in the pass-

ing rates among the physical therapist subgroups were

examined using the Pearson chi-square statistic. The

alpha-level was established a priori to be 0.05 utilizing a

two-tailed test.

Results

174 physical therapist students across 12 out of the 26

(46%) randomly selected programs volunteered and com-

pleted the study, representing 52% of students within

these programs. The mean age of physical therapist stu-

dent participants was 26.7 (3.3) (range = 22–40). Ninety-

two percent of physical therapist student participants (n =

160) completed the study in a proctored setting. 63.8% of

physical therapist students (n = 111) were enrolled in doc-

toral degree programs. 182 licensed physical therapists in

the uniformed services completed the study, representing

44% of uniformed physical therapists. The mean age of

the licensed physical therapist participants was 37.7 (6.7)

(range = 25–55). The average years of experience was 8.7

(6.3) (range = 1–30) and 28.6% (n = 52) of licensed phys-

ical therapists were board-certified.

No participant reported having received assistance to

complete the examination. One licensed physical thera-

pist reported being familiar with the Freedman and

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Bernstein studies, [7,27] thus these data were removed

from the analysis. No differences in performance on the

examination were observed between participants who

completed the examination in a proctored versus an un-

proctored setting (p = 0.465). Therefore, all responses

were included in the analyses.

Overall scores among the physical therapist students and

licensed physical therapists are reported in Figure 1. We

did not directly compare the results between physical

therapists and physicians using inferential statistics

because the data from these groups were derived from

unrelated studies. However, the identical examination

and similar procedures were used in these studies, thus it

is reasonable to discuss our findings in relation to the pre-

vious data among physicians. To facilitate this discussion,

we superimpose the overall scores among the different

physician subgroups with those of the different physical

therapist subgroups. This provides a frame of reference for

visualizing possible differences in knowledge related to

managing musculoskeletal conditions between physical

therapists and physicians (Figure 1).

Licensed physical therapists (n = 182) achieved an average

score of 75.9%, with an overall passing rate of 67%.

Licensed physical therapists who were board-certified

achieved significantly higher scores and passing rates than

their non board-certified colleagues (Table 2). Physical

therapist students (n = 174) achieved an average score of

66.2%, with an overall passing rate of 24%, versus a 19%

Overall scores on the musculoskeletal knowledge examination among physical therapist students, licensed physical therapists, and previous data using the same examination among physiciansFigure 1

Overall scores on the musculoskeletal knowledge examination among physical therapist students, licensed physical therapists,

and previous data using the same examination among physicians. All physician-related data was derived from Matzkin et al,[12]

except data for the subgroup of physician interns, which was derived from Freedman and Bernstein[7]. PT = physical therapist,

Phys = physician, OCS = Orthopaedic Clinical Specialist, SCS = Sports Clinical Specialist, DPT = doctoral physical therapy pro-

gram, MPT = master's physical therapy program, Ortho = orthopaedics, Other = anesthesia, emergency medicine. ophthalmol-

ogy, radiology, and transitional, FP = family practice, GS = general surgery, Res = Resident, Peds = Pediatrics, Med = internal

medicine, Med stu = medical student, OB = obstetrics-gynecology, and Psy = psychiatry

100

ys (O

)

PT (OCS/S

no OC

PT stu

ts (

DPT)

PT students (Masters)

ys (

)

Phys (Intern

)

hys (GS)

ys (Re

Phys (Peds)

hys (

ys (Me

stu)

Phys (OB)

ys (

Psy)

Overall score

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passing rate among physician interns [7]. Physical

therapist students enrolled in programs conferring the

doctoral degree achieved significantly higher scores than

students enrolled in programs conferring the master's

degree, although passing rates were statistically similar

(Table 1).

Discussion

Physicians assessed in the study by Freedman and Bern-

stein had just begun their internship year, [7] and Matzkin

et al [12] reported data from medical students, residents,

and a variety of physician specialists. Given the spectrum

of physician experience levels and specialties represented

in previous studies, [7,12] these data offer a compelling

reference standard for at least a preliminary discussion

related to the preparation of physical therapists versus

physicians with respect to managing musculoskeletal con-

ditions. It also seems reasonable to make preliminary gen-

eral observations about possible differences between

physical therapists and physicians since we used the iden-

tical examination and administered the examination

using similar procedures as those used in the previous

studies [7,12].

Figure 1 reveals that both physical therapist students and

licensed physical therapists tended to have higher levels of

knowledge in managing musculoskeletal conditions than

medical students, physician interns and residents, and all

physician specialists except for orthopaedists. This trend

may seem somewhat intuitive since topics related to man-

aging musculoskeletal conditions are emphasized in

physical therapy curricula. However, data were previously

lacking to support this contention. It is important to con-

sider that the physician data were derived from unrelated

studies, [7,12] thus we discuss our results in general terms

in relation to the previous studies among physicians

[7,12]. The implication that physical therapists have

higher levels of knowledge in managing musculoskeletal

conditions than physicians provide impetus for further

prospective research in this area.

It could be argued that performance among physical ther-

apist students remains suboptimal, supported by the fact

that physical therapist students overall achieved an aver-

age score of 66.2%. However, the average score among

medical students and interns (the most comparable phy-

sician group) was 49% [12] and 60%, [7] respectively.

One of the primary curricular areas more heavily empha-

sized in doctoral physical therapy educational programs is

the differential diagnosis of these conditions, a profi-

ciency necessary for competence in more autonomous

practice settings such as primary care [30]. Although pass-

ing rates were statistically similar, overall scores among

physical therapists enrolled in doctoral programs was sig-

nificantly higher than for master's programs (Table 1).

These data provide preliminary evidence that an increased

focus on the diagnosis of commonly encountered muscu-

loskeletal conditions and orthopaedic emergencies is

occurring in the curricula of doctoral physical therapy

programs. However, a threshold of 73.1% was established

by orthopaedic program directors as a minimum level of

knowledge necessary for competency in musculoskeletal

medicine. Given similar passing rates, and in light of

increasing availability of direct access care for patients

with musculoskeletal conditions, orthopaedic curricula

among doctoral physical therapy programs should con-

tinue to be enhanced.

Both physicians and physical therapists are at a relative

early juncture in their clinical education upon graduation

Table 1: Performance on the musculoskeletal knowledge examination between physical therapists enrolled in a program that confers

a master's vs. a doctoral degree. (Participants were judged to have passed if their score exceeded 73.1%[7].)

Degree Status (n = 174) Master's (n = 63) (95% CI) Doctoral (n = 111) (95% CI) p-value

Overall score 63.6 (60.6, 66.6) 67.6 (65.6, 69.6) .022

Passing rate (Overall score >.731) .21 (.11, .31) .26 (.18, .34) .416

Table 2: Performance on the musculoskeletal knowledge examination based on board-certification status. (Participants were judged

to have passed if their score exceeded 73.1%[7].)

Board-certification (OCS and/or SCS) (n = 182) Yes (n = 52) (95% CI) No (n = 130) (95% CI) p-value

Overall score 81.3 (79.2, 83.4) 73.7 (71.9, 75.5) <.001

Passing rate .88 (.80, .97) .58 (.50, .67) <.001

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from medical school or physical therapy school, thus they

might be expected to have scores below the level estab-

lished by residency program directors. However, the

licensed physical therapists in this study demonstrated

higher levels of knowledge in managing musculoskeletal

conditions than physical therapist students and all physi-

cian subgroups, except for orthopaedists (Figure 1).

Licensed physical therapists achieved an average score of

75.9% and an overall passing rate of 67%. This seems to

be markedly improved compared to the passing rate

amongst all physician subgroups except orthopaedists

[12]. Furthermore, most physicians, and with increasing

frequency physical therapists, receive graduate medical

education in the form of clinical residencies which lead to

board certification. In fact, board certification in ortho-

paedic physical therapy represents the largest area of spe-

cialization by physical therapists [31]. One of the key

findings from this study was that performance among

licensed physical therapists who were board-certified was

significantly better when compared to their non board-

certified colleagues, lending further credibility to the

physical therapist board-certification process, which was

not initiated until the 1980s.

Several limitations should be considered. Similar to med-

ical education, physical therapy educational programs do

not utilize standardized curricula, thus exposure to didac-

tic and clinical education experiences related to the man-

agement of musculoskeletal conditions differs. Physical

therapists with a stronger background in this area may

have achieved higher scores than with less exposure to an

orthopaedic curricula. Content of the examination was

also primarily focused on the differential diagnosis of

commonly encountered musculoskeletal diagnoses in a

primary care setting (ie, fractures and dislocations, low

back pain, sciatica, and arthritis) and orthopaedic emer-

gencies that warrant immediate referral to an orthopaedic

surgeon or the emergency department (ie, compartment

syndrome, hip dislocation, etc.) [7]. Therefore, these data

may not be generalizable to other physical therapy prac-

tice settings. We invited volunteer physical therapist stu-

dents and licensed physical therapists to participate, thus

the potential for selection bias cannot be excluded. How-

ever, physician participants in the study by Matzkin et al

[12] were also volunteers, posing a similar limitation that

likely mitigates any potential bias in discussing our results

in relation to this study. Furthermore, although the exam-

ination in the Freedman and Bernstein study [7] was

apparently completed by all physicians in the intern class,

the examination was only administered to one class [7].

The fact that physical therapist students from a wide vari-

ety of programs and licensed physical therapists in geo-

graphical locations throughout the country participated

in this study increases the generalizability of the findings.

Future research could be performed to determine if the

results demonstrated among licensed physical therapists

in the uniformed services who participated in this study

would be similar to the results among a group of civilian

physical therapists.

Conclusion

The results of this study corroborate existing clinical stud-

ies demonstrating that physical therapists can provide safe

and effective care for patients with musculoskeletal condi-

tions in a direct access setting [21-26]. In comparison to

previous studies among physicians, [7,12] physical thera-

pists demonstrated higher levels of knowledge in manag-

ing musculoskeletal conditions than medical students,

physician interns and residents, and most physician spe-

cialists except for orthopaedists. Physical therapist stu-

dents enrolled in educational programs conferring the

doctoral degree achieved higher scores than their peers

enrolled in programs conferring the master's degree. Fur-

thermore, licensed physical therapists who were board-

certified achieved higher scores and passing rates than

their colleagues who were not board-certified. Neverthe-

less, despite the benefits of early access to physical therapy

[14-17] and favorable legislation in most states, [20] the

primary barrier to patients receiving physical therapy serv-

ices without physician referral is that claims are infre-

quently reimbursed by third party payers. Combined with

existing evidence demonstrating that physical therapists

are capable of providing safe and effective care for patients

with musculoskeletal conditions in a direct access setting

at a reduced cost to the healthcare system and employers,

the results of this study may have implications for health

and public policy decisions regarding the care of patients

with musculoskeletal conditions.

Competing interests

None of the authors of this manuscript have any relevant

conflict of interest, financial or otherwise. This study was

supported by a grant from the Sports Physical Therapy

Section of the American Physical Therapy Association,

Inc. The funding organization had no role in the design

and conduct of the study, to include data collection; man-

agement, analysis, or interpretation of the data. The fund-

ing organization was also not involved in the preparation

of this manuscript, nor has it been asked to review and/or

approve this submission.

Authors' contributions

JC designed and coordinated the study, performed the sta-

tistical analysis, and drafted the manuscript. JW assisted

with the study design and drafting of the manuscript. PS

developed the web survey instrument and provided over-

sight for the technical aspects of the survey administra-

tion. MP coordinated with the first-professional programs

and assisted in the data analysis. TF conceived the idea

and assisted with study design and analysis. AD assisted

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BMC Musculoskeletal Disorders 2005, 6:32 http://www.biomedcentral.com/1471-2474/6/32

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with the study design and acted as a liaison to the program

directors. All authors read and approved the final

manuscript.

Disclaimer

The opinions or assertions contained herein are the pri-

vate views of the authors and are not to be construed as

official or as reflecting the views of the U.S. Air Force or

Department of Defense.

Acknowledgements

None

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Pre-publication history

The pre-publication history for this paper can be accessed

here:

http://www.biomedcentral.com/1471-2474/6/32/prepub

Physiotherapy awareness among clinical doctors in Nepal

Article

Full-text available

Aug 2011

Introduction: Physiotherapy as a profession has come a long way over the years. As the treatment of injuries and illness has developed over the decades, the practice has evolved and grown from general forms of physical therapies to specialized physiotherapy services in healthcare settings. Despite the recognition and advances gained worldwide in physiotherapy, yet there is lack of research study in Nepal to evaluate the awareness of physiotherapy among clinical doctors of Nepal. Objective of this study is to investigate the awareness of physiotherapy among clinical doctors working in various hospitals of Nepal. Methods: A cross sectional survey was conducted among the clinical doctors working in various hospitals of Nepal. A questionnaire was randomly distributed among 200 doctors. It comprised of 13 questions related to physiotherapy awareness. Data were collected and statistically analyzed. Results: Among 115 respondents, 98.3% were aware of physiotherapy and 87.8 % of the doctors reported to have physiotherapy services in their hospital. Referral to physiotherapy was found to be 94.8 %. With respect to referrals to physiotherapy in preoperative cases, it was found that 63% of the clinical doctors agreed to refer their patients to physiotherapists. The study also found that 93% of the clinical doctors agreed to refer their patients to physiotherapy post-operatively. Referrals to ICU were agreed by 88% of the doctors involved in this study. Among the clinical doctors surveyed physiotherapy in orthopedic conditions has the maximum awareness (94.8%). The study found that a very small percent of the clinical doctors knew about physiotherapy education in Nepal (39.1%) and Nepal Physiotherapy Association (NEPTA) (33%). Conclusions: The study concluded that the clinical doctors had a good awareness about physiotherapy profession. But awareness needs to be accelerated in terms of referrals and specialized services provided by the physiotherapists for potential benefits of the patients. Physiotherapists as a part of the health care team plays an essential role in reducing the hospital stay, quick recovery and in rehabilitation for a better quality life.

The ability of Austrian registered physiotherapists to recognize serious pathology

Article

Full-text available

Oct 2024

Background Serious pathology masking as musculoskeletal conditions is rare, still it is pertinent that physiotherapists can recognise it. This ability has been investigated internationally, however the decision-making skills of registered Austrian physiotherapists has not been examined. The aim of this study was to assess the ability of registered Austrian physiotherapists to make accurate keep-refer decisions based on clinical vignettes. Methods In this national survey registered Austrian (self-)employed physiotherapists were recruited and completed 12 clinical vignettes. Correctly answered vignettes were listed as percentages. Results 479 physiotherapists participated in the study. The response rate of the self-employed physiotherapists was 8.0%. On average participants classified 70.5% of the musculoskeletal cases, 79.4% of the non-critical medical cases, and 53.3% of the critical medical cases correctly. Conclusion This study suggests that, despite the limitations of using written clinical vignettes, registered Austrian physiotherapists welcome additional training to improve their skills in identifying serious pathology. Targeted training and educational programs including new and more detailed educational clinical vignettes relevant for non-direct access countries are needed to enhance physiotherapists’ diagnostic skills and decision-making processes.

Confidence in Providing Primary Care to Patients with Low Back Pain among Physiotherapists

Preprint

Full-text available

Jul 2024

Background Low back pain (LBP) is a common musculoskeletal disorder with distinct clinical features. Direct access to physiotherapy (PT), with PTs acting as primary care providers, can improve the management of individuals with LBP. However, the success of these treatments is related to clinician confidence. The objectives of this study were to develop the Primary Care Confidence Scale (PCCS) and to describe the confidence of PTs in treating LBP in primary care. Methods The PCCS questionnaire was developed through a seven-stage Delphi process involving experts who modified an existing self-confidence scale. The questionnaire was completed by 314 PTs, 140 of whom completed it again after 2 weeks. Structural validity was evaluated using exploratory and confirmatory factor analysis. Reliability was assessed with Cronbach’s alpha for internal consistency and intraclass correlation coefficients (ICC) for test-retest reliability. Spearman tests assessed correlations between background characteristics and PCCS scores. Two independent t-tests estimated the effects of gender and post-graduate education. One-way ANOVA was used to evaluate the impact of the workplace. Results The PCCS had a multidimensional structure with three factors demonstrating an acceptable model fit and good reliability (α = 0.83, ICC = 0.78). The mean level of confidence was 75% (PCCS = 45 ± 6/60), with moderate positive correlations between age and years of experience (r = 0.33) and PCCS scores (r = 0.42, p < 0.001( for both. PTs working in public or private outpatient clinics had significantly higher scores (PCCS = 45.3 and 47.0, respectively) compared to PTs working in an inpatient hospital or in rehabilitation centers (PCCS = 40.6 and 40.3, respectively, p < 0.009). Conclusions The newly developed PCCS demonstrated adequate validity and high reliability, suggesting that it is suitable for measuring confidence in treating patients with LBP in primary care settings. PTs showed similar confidence levels to other healthcare professionals treating patients in primary care, which could support direct access to PT. Health policy makers and educators could incorporate the PCCS into training and evaluation programs to assess the readiness and competence of clinicians to treat LBP in primary care.

Capacidade da tomada de decisão dos fisioterapeutas brasileiros para pacientes com bandeiras vermelhas

Article

Full-text available

Jan 2024

JUSTIFICATIVA E OBJETIVOS: O objetivo da triagem de bandeiras vermelhas é garantir que sinais e sintomas que levantam suspeitas de doenças graves sejam considerados durante a avaliação, auxiliando os fisioterapeutas no seu processo de decisão clínica. Os fisioterapeutas brasileiros são autônomos e podem atuar como profissionais de primeiro contato no manejo de distúrbios musculoesqueléticos, portanto, precisam saber reconhecer, rastrear e encaminhar pacientes com bandeiras vermelhas para melhor manejo terapêutico. Os objetivos deste estudo foram verificar se os fisioterapeutas brasileiros conseguem reconhecer e tratar pacientes que apresentavam bandeiras vermelhas, comparar as habilidades dos profissionais com diferentes níveis de formação acadêmica e experiência clínica e identificar quais fatores podem influenciar os resultados. MÉTODOS: Uma pesquisa transversal e quantitativa foi realizada, coletada através de um questionário online. O público-alvo consistiu em fisioterapeutas brasileiros com experiência clínica no manejo de pacientes com disfunções musculoesqueléticas. Os participantes preencheram dados demográficos e tomaram decisões clínicas com base em seis casos clínicos criados pelos autores, com base na literatura, e revisados por três especialistas. Os dados foram analisados por estatísticas descritivas,pelo teste qui-quadrado de independência e por regressão logística. RESULTADOS: Foram analisadas 384 respostas de fisioterapeutas brasileiros com experiência clínica em disfunções musculoesqueléticas. Os fisioterapeutas brasileiros, em geral, não demonstraram ser capazes de reconhecer e manejar adequadamente os casos clínicos que envolvem bandeiras vermelhas, com 23,2% da amostra realizando manejo adequado para condições médicas, 53,9% para condições de emergência e 61,8% para condições médicas com disfunção musculoesquelética associada. Mais anos de experiência clínica e educação pós-profissional não influenciaram positivamente os resultados. Graus acadêmicos mais elevados (Doutorado) podem influenciar positivamente no manejo de condições médicas não emergenciais. CONCLUSÃO: Fisioterapeutas brasileiros que atuam com pacientes com disfunções musculoesqueléticas apresentam um mau desempenho na identificação de bandeiras vermelhas em casos clínicos hipotéticos.Descritores: Assistência ambulatorial, Atenção primária à Saúde, Diagnóstico diferencial. Encaminhamento e consulta, Tomada de decisões.

The decision-making skills of Brazilian physical therapists for patients with red flags

Article

Full-text available

Mar 2024

BACKGROUND AND OBJECTIVES The red flags screening purpose is to ensure that signs and symptoms that raise suspicion of serious diseases are being considered during the assessment, assisting physical therapists in their clinical decision process. Brazilian physical therapists are autonomous and can act as first contact professionals in the management of musculoskeletal disorders, therefore, they need to know how to recognize, screen and refer patients with red flags for better therapeutic management. The objectives of this study were to verify whether Brazilian physical therapists can recognize and manage patients who presented red flags, compare professionals’ skills regarding different academic degree levels and clinical experience and identify which factors can influence the results. METHODS A cross-sectional and quantitative research was conducted, collected from an online questionnaire. The target audience consisted of Brazilian physical therapists who have clinical experience in the management of patients with musculoskeletal disorders. Participants filled demographic data and made clinical decisions based on six clinical cases created by the authors, based on the literature, and reviewed by three experts. Data were analyzed using descriptive statistics, the Chi-square test of independence and logistic regression. RESULTS The study analyzed 384 answers from Brazilian physical therapists with clinical experience in musculoskeletal conditions. Brazilian physical therapists, in general, have not shown to be able to properly recognize and manage the clinical cases involving red flags, with 23.2% of the sample performing appropriate management for medical conditions, 53.9% for emergency conditions and 61.8% for medical conditions with associated musculoskeletal dysfunction. More years of clinical experience and post-professional education did not positively influence the outcomes. Higher academic degrees (Doctorate) can influence positively on the management of non-emergency medical conditions. CONCLUSION Brazilian physical therapists who work with patients with musculoskeletal disorders perform poorly in identifying red flags in hypothetical clinical cases. Keywords: Ambulatory care; Decision making; Differential diagnosis; Primary Health Care; Referral and consultation

Article

Aug 2023

Aim: To find out the work related musculoskeletal complications experienced by the physical therapists in Pakistan. Methods: This cross sectional study was conducted on 98 physiotherapists. To gather precise data and address challenges, a self-administered questionnaire was created for demographics. A modified version of the Nordic Questionnaire was used and to locate pain or unpleasant feelings in nine different areas of the body, including the neck, shoulders, elbows, wrists, upper back, lumbar, thighs, knees, and ankles. Utilising a non-probability convenient sampling strategy, the sample size was determined. The Lahore hospitals will be asked for written consent. Data will be gathered from various hospitals in Lahore, including Jinnah Hospital and the UOL teaching hospital. Results: 52% reported that they have feeling trouble in neck during last 7 days. 52% have been feeling any trouble in shoulders. 47.9% have been feeling any trouble in upper back. 41.8% have been feeling any trouble in elbows. 41.8% have been feeling any trouble in wrist/ hands. 60.2% have been feeling any trouble in lower back. 29.5% have been feeling any trouble in hips/thighs. 26.5% have been feeling any trouble in knees. 30.6% have been feeling any trouble in ankles/feet. Conclusion:Physical therapists from Pakistan frequently suffered from work-related musculoskeletal conditions, particularly in the neck, shoulders, wrist, and lower back. Keywords: Physiotherapist, Musculoskeletal, Complications

Test-Retest Reliability and Concurrent Validity of the Health Leads Screening Tool in Outpatient Orthopedic Physical Therapy Patients

Article

Oct 2024

OBJECTIVE: To determine the test-retest reliability and concurrent validity of the Health Leads Screening Tool. DESIGN: Primary survey data collected between September 2021 and May 2022 with participants who received outpatient orthopedic physical therapy in a public hospital system. Participants completed the Health Leads Screening Tool (HLST) and the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) at 1 physical therapy visit to examine the concurrent validity of the HLST. They completed the HLST again at a follow-up visit to examine its test-retest reliability. METHODS: Paper surveys were used to collect information from participants who were over 18 years of age, spoke and read English or Spanish, and were receiving outpatient orthopedic physical therapy. Fifty-two participants completed the surveys to examine concurrent validity and 50 participants completed the surveys for test-retest reliability. Cohen’s kappa statistics were used to examine agreement. RESULTS: The HLST had excellent test-retest reliability for all 9 domains, with kappa values ranging from 0.91 to 1.00. It had greater than moderate concurrent validity (k>0.6) with the PRAPARE for 6 of 9 domains, including food, utilities, health care, transportation, employment, and mental health. CONCLUSIONS: The Health Leads Screening Tool demonstrated excellent test-retest reliability and moderate concurrent validity for 6 out of 9 domains and, thus, could be a feasible social needs screening tool in outpatient orthopedic physical therapy settings. JOSPT Open 2024;2(4):1-8. Epub 24 May 2024. doi:10.2519/josptopen.2024.1241

Physical Therapist Identification of an Undetected Rotator Cuff Tear via a Telehealth Evaluation: A Case Report

Article

Feb 2021

Background The COVID-19 pandemic has highlighted the need to explore alternative methods of health care delivery, including telehealth. Minimal evidence is available regarding telehealth as a diagnostic tool for suspected orthopaedic pathology. Case Presentation A self-referred 66-year-old man presented with left shoulder pain that had been present for 6 weeks. Mechanism of injury included 2 falls 2 weeks apart. His physician diagnosed him with adhesive capsulitis and referred him to a physical therapist near his home. No imaging studies were performed. Initial management did not improve his status, so the patient requested a second opinion. A telehealth evaluation was chosen, as he resides 220 miles away. Live 2-way video conferencing was utilized throughout the evaluation. Visual motion observation noted marked active, but not passive, limitations. Pain in active external rotation was 8/10. Special testing noted positive drop arm test and impairments in external rotation. Outcome and Follow-Up A rotator cuff tear was suspected and the patient was referred for a surgical consultation, with subsequent surgery completed for a full-thickness supraspinatus tear. During follow-up 3 months after surgery, the patient reported that the telehealth visits were very convenient and more effective than prior management. Discussion A telehealth evaluation performed by a physical therapist was able to identify and manage, via referral, an undetected full-thickness rotator cuff tear. JOSPT Cases 2021;1(1):29–33. doi:10.2519/josptcases.2021.9990

A Quantitative Review of Certified Burn Therapist's Involvement in the JBCR Publications and ABA Leadership

Article

Jul 2024
J BURN CARE RES

The Burn Therapist Certification (BT-C) was introduced in 2018 to acknowledge occupational and physical therapists with specialized knowledge, skill, and experience in promotion of quality burn rehabilitation. Currently, BT-Cs make up 11.7% of therapists working in burn rehabilitation (n=39/333). The purpose of this review is to report on contributions of BT-Cs to organizational leadership of the American Burn Association (ABA) and in the generation of new knowledge through peer-reviewed publications. Despite the small percentage of burn therapists who are certified, they have a disproportionately large involvement in leadership within the ABA and burn research in the Journal of Burn Care and Rehabilitation (JBCR). From 2018-2023, BT-Cs have contributed to nearly one-half (n=26/56) of therapy authored publications in the JBCR and almost one-third (n=65/202) of accepted abstracts at the ABA annual meeting. Certified burn therapists demonstrate substantial involvement throughout the ABA including maintaining an 85% membership rate and on average serve in 53% (n=31/59) of the therapy allotted committee positions. Therapist pursuit of certification can have a profound impact on the burn community through publication, leadership, and development of care standards. Although therapists have indicated a desire to pursue certification, barriers related to a lack of association and center support have been identified. The burn community has endorsed certification as a mark of excellence for nurses and physicians. Maximizing the value of a transdisciplinary approach to burn care is also dependent on excellence from therapies. If the burn community desires improved engagement and contribution from therapies, it should support therapist certification.

Reliability of a Musculoskeletal Imaging Competency Examination for Physical Therapists

Article

Jan 2024

Introduction The Burley Readiness Examination (BRE) for Musculoskeletal (MSK) Imaging Competency assesses physical therapists' baseline MSK imaging competency. Establishing its reliability is essential to its value in determining MSK imaging competency. The purpose of this study was to test the reliability of the BRE for MSK Imaging Competency among physical therapists (PTs) with varying levels of training and education. Review of Literature Previous literature supports PTs' utility concerning diagnostic imaging; however, no studies directly measure their competency. With PTs expanding their practice scope and professional PT education programs, increasing their MSK imaging instruction, assessing competency becomes strategic in determining the future of MSK education and training. Subjects One hundred twenty-three United States licensed PTs completed the BRE. Methods Physical therapists completed the BRE through an online survey platform. Point biserial correlation (r pb ) was calculated for each examination question. Final analyses were based on 140 examination questions. Examination scores were compared using independent sample t -test and one-way analysis of variance. Chi-square tests and odds ratios (ORs) assessed the relationship of a passing examination score (≥75%) and the type of training. Reliability of the BRE was assessed using Cronbach's alpha (α). Results Mean overall examination score was 75.89 ± 8.56%. Seventy PTs (56.9%) obtained a passing score. Physical therapists with additional MSK imaging training, board certification, and residency or fellowship training scored significantly higher ( P < .001) compared with those with only entry-level PT program education. Physical therapists with additional MSK imaging training scored significantly higher (x̄ = 81.07% ± 8.93%) and were almost 5 times (OR = 4.74, 95% CI [1.95–11.50]) as likely to achieve a passing score than those without. The BRE demonstrated strong internal consistency (Cronbach's α = 0.874). Discussion and Conclusions The BRE was reliable, consistently identifying higher examination scores among those with increased MSK imaging training. Training in MSK imaging influenced competency more than other factors. The BRE may be of analytical value to PT professional and postprofessional programs.

A randomised controlled trial. Shifting boundaries of doctors and physiotherapists in Orthopaedic Outpatient Departments

Article

Full-text available

Oct 1999

To evaluate the effectiveness and cost effectiveness of specially trained physiotherapists in the assessment and management of defined referrals to hospital orthopaedic departments. Randomised controlled trial. Orthopaedic outpatient departments in two hospitals. 481 patients with musculoskeletal problems referred for specialist orthopaedic opinion. Initial assessment and management undertaken by post-Fellowship junior orthopaedic surgeons, or by specially trained physiotherapists working in an extended role (orthopaedic physiotherapy specialists). Patient centred measures of pain, functional disability and perceived handicap. A total of 654 patients were eligible to join the trial, 481 (73.6%) gave their consent to be randomised. The two arms (doctor n = 244, physiotherapist n = 237) were similar at baseline. Baseline and follow up questionnaires were completed by 383 patients (79.6%). The mean time to follow up was 5.6 months after randomisation, with similar distributions of intervals to follow up in both arms. The only outcome for which there was a statistically or clinically important difference between arms was in a measure of patient satisfaction, which favoured the physiotherapist arm. A cost minimisation analysis showed no significant differences in direct costs to the patient or NHS primary care costs. Direct hospital costs were lower (p < 0.00001) in the physiotherapist arm (mean cost per patient = 256 Pounds, n = 232), as they were less likely to order radiographs and to refer patients for orthopaedic surgery than were the junior doctors (mean cost per patient in arm = 498 Pounds, n = 238). On the basis of the patient centred outcomes measured in this randomised trial, orthopaedic physiotherapy specialists are as effective as post-Fellowship junior staff and clinical assistant orthopaedic surgeons in the initial assessment and management of new referrals to outpatient orthopaedic departments, and generate lower initial direct hospital costs.

Intraclass correlations: Uses in assessing rater reliability

Article

Full-text available

Mar 1979

Reliability coefficients often take the form of intraclass correlation coefficients. In this article, guidelines are given for choosing among 6 different forms of the intraclass correlation for reliability studies in which n targets are rated by k judges. Relevant to the choice of the coefficient are the appropriate statistical model for the reliability study and the applications to be made of the reliability results. Confidence intervals for each of the forms are reviewed. (23 ref) (PsycINFO Database Record (c) 2006 APA, all rights reserved).

Physical Therapy Care for Low Back Pain Monitored Program of First-Contact Nonphysician Care

Article

Full-text available

Mar 1988

We studied the process and outcomes of physical therapist management of 107 patients with low back pain at a walk-in clinic. Sixty-seven patients with low back pain concurrently were assigned randomly to internists at the clinic. Physicians and physical therapists recorded baseline clinical data and management plans on standard check lists. Physical therapists used a validated algorithm that directed diagnostic evaluations and physician consultations, but all other physical therapist treatment decisions were unconstrained. Patients in the physical therapist and physician groups did not differ significantly. Physical therapists referred more patients to the physical therapy department than did physicians but recommended muscle relaxants, prescription analgesics, and bed rest less frequently. The occurrence of new symptoms, duration of symptoms, and duration of activity limitations were similar between the physician and physical therapy patient groups at a one-month follow-up examination. Physical therapist-managed patients expressed greater satisfaction than physician-managed patients with several aspects of their care. The percentage of functional improvement for highly dysfunctional patients was significantly greater for the physical therapist-managed patients than for the physician-managed patients. The implications of a physical therapist first-contact care program for health service organizations, health care policy, physical therapist training, and credentialing are discussed.

Pediatric Residency as Preparation for Primary Care Practice

Article

Jan 1997
Arch Pediatr Adolesc Med

Bonnie W. Camp

Objectives: To assess the effectiveness of pediatric residency training as preparation for primary care and make recommendations for improving residency training. Method: Two surveys were sent to graduates of the pediatric residency at the University of Colorado from 1984 to 1991. The first survey requested information about practice patterns and ratings of preparedness in 45 areas important for primary care. The second survey requested ratings of importance for increasing training time in 25 areas judged as inadequate in the first survey. Results: Of 147 surveys mailed, 103 graduates responded and rated themselves as less than adequately trained in 25 of 45 areas selected for relevance to primary care. Graduates of the primary care track rated themselves as significantly better trained than graduates of non-primary care tracks in 10 of 45 areas; nonprimary care graduates had higher ratings in 2 of 45 areas. The second survey (completed by 70 of the 103 initial responders) indicated that the top 5 areas needing increased time in residency training were, in descending order, orthopedics, developmental and behavioral problems, learning disability, attention-deficit hyperactivity disorder, and school difficulty. Graduates of the primary care track rated themselves as adequately trained in developmental and behavioral problems and attention-deficit hyperactivity disorder, but they and nonprimary care graduates felt inadequately prepared in the other 3 areas. Conclusion: Implications of these results change with different content areas, suggesting the need to improve training for all residents in some areas and extending to all residents some of the curriculum already implemented in the primary care track.Arch Pediatr Adolesc Med. 1997;151:78-83

Orthopaedic Out-patients — A Fresh Approach

Article

Jul 1989

A pilot study was set up by Exeter Health Authority to examine the extent to which patients referred to orthopaedic out-patient clinics could be managed by a physiotherapist. The results of the study indicate that an experienced physiotherapist can manage between 40-60% of the referrals safely and to the satisfaction of 89% of the patients. The vast majority of referring doctors supported the scheme fully.

The musculo-skeletal examination: A neglected clinical skill

Article

Jul 1991
Aust New Zeal J Med

One hundred and sixty‐six patients admitted to general medical wards of a teaching hospital were examined on the day of discharge to determine whether they had been assessed for musculoskeletal disorders during their admission. Of these patients, 54.8% had musculo‐skeletal symptoms with 17.5% having a significant rheumatological disorder which had been ignored. A history of musculo‐skeletal symptoms was recorded in 40.4% of all patients and the examination in only 14.5%. This contrasted with the documentation of the cardiovascular (99.4%), respiratory (100%), gastrointestinal (97.6%) and central nervous (53%) systems' examination. Eighty per cent of symptomatic patients received either no treatment for their rheumatic disorder, or treatment that we regarded as suboptimal or inappropriate. Musculo‐skeletal symptoms are common in patients admitted to medical wards, but are being inadequately assessed or at worst ignored. The omission of the musculo‐skeletal system examination, in contrast to the almost universal inclusion of other systems' examination, demands correction. Undergraduate and postgraduate training programmes require re‐evaluation. The implications of these findings are discussed.

Who should see orthopaedic outpatients – Physiotherapists or surgeons?

Article

Apr 1995

Orthopaedic outpatient waiting lists are long and the majority of referrals are for conditions that do not respond to surgical intervention. Many of these patients are best managed by physiotherapy, orthotics or steroid injections, which can be administered by an appropriately trained physiotherapist. The effectiveness of a physiotherapist with extended training in orthotics and steroid injection was compared with staff grade orthopaedic surgeons in the management of orthopaedic outpatients judged unlikely to require surgery from the general practitioner's referral letter. Some 221 patients with mechanical low back pain and foot and shoulder disorders were seen by a physiotherapist and 97 by staff grade surgeons over a 10-month period. Outcome was assessed by postal questionnaire or telephone contact 6-12 months following discharge. Outcome was satisfactory in 80 per cent of patients overall, 65 per cent of low back and 69 per cent of neck pain, 80 per cent of foot and 83 per cent of shoulder disorders. An appropriately trained physiotherapist is as effective as staff grade surgeons in managing orthopaedic outpatients unlikely to benefit from surgical intervention. This has implications both in reduction of outpatient waiting lists and hospital doctor hours of work.

Opioid hyperexcitability: The application of alternate opioid therapy

Article

Jul 1993

Three cases are reported where patients experienced severe central nervous system adverse effects on high-dose hydromorphone. These effects were rapidly alleviated following a change in therapy to morphine at 20-25% of the usually accepted potency equivalent dose. We recommend caution in using equivalent dose tables when changing opioid therapy in patients receiving high-dose opioid treatment.

A controlled study of the effects of an early intervention on acute musculoskeletal pain problems

Article

Oct 1993

Current conceptions of chronic pain clearly suggest that proper care at the acute stage should prevent the development of chronic problems. Patients (198) seeking help for acute musculoskeletal pain (MSP), e.g., back and neck pain participated in two studies of the effects of an Early Active intervention which underscored 'well' behavior and function compared to a Treatment as usual control group. The quantity of the Early Active treatment was a median of 1 doctor's appointment and 3 meetings with a physical therapist. Study I concerned patients with a prior history of sick-listing for MSP, while study II involved patients with no prior history of MSP. Treatment satisfaction, pain experience, activities and sickness absenteeism were assessed before, after and at a 12-month follow-up. In study I (patients with a history of MSP), the results showed significant improvements for both groups, but virtually no differences between the groups. Similarly, in study II (no history of MSP) both groups demonstrated significant improvements, e.g., for pain intensity and activity levels. However, the Early Active treatment resulted in significantly less sick-listing relative to the control group. Moreover, the risk of developing chronic (> 200 sick days) pain was 8 times lower for the Early Activation group. This investigation shows that relatively simple changes in treatment result in reduced sickness absenteeism for 'first-time' sufferers only. Consequently, the content and timing of treatment for pain appear to be crucial. Properly administered early intervention may therefore decrease sick leave and prevent chronic problems, thus saving considerable resources.

Physician Referral to Physical Therapy in a Cohort of Workers Compensated for Low Back Pain

Article

Mar 1996

This study described the physical therapy referral of workers compensated for back injury; characterized physical therapy by duration and choice of therapeutic techniques; and compared workers who were and were not referred for physical therapy in terms of age, gender, diagnosis, and absence from work. A cohort of 2,147 subjects were randomly selected from 54,401 workers compensated for back injuries in 1988. Each subject was followed for 2 years from date of entry into the study. Data were obtained from the Quebec Worker's Compensation Board computerized files, medical files, and initial reports completed by physical therapists. Of the cohort, 389 subjects (18%) had received physical therapy after referral by their physician. Exercise, heat, ultrasound, back education, manipulation, and transcutaneous electrical nerve stimulation were the most frequently selected treatments. Implementation of physical therapy within 1 month of back injury had a strong protective effect on return to work within 60 days. Female gender and presence of a specific diagnosis were predictors for greater than 60 days' absence. This study demonstrated that physicians request physical therapy services based on certain patient characteristics. Patients who were referred earlier tended to return to work sooner than those who were referred later, which indicates that timing of physical therapy is an important factor in the rehabilitation of workers with low back pain.