Beruflich Dokumente
Kultur Dokumente
Manual Therapy
journal homepage: www.elsevier.com/math
Original article
Department of Clinical Neuroscience and Rehabilitation, The Sahlgrenska Academy, Gothenburg University, Box 430, 405 30 Gothenburg, Sweden
rhalsan Tjo
stra Go
g 1, 471 94 Klleka
rr, Sweden
rn Rehabilitation Clinic, Primary Healthcare, Region Va
taland, Syster Ebbas va
Na
rhalsan Research and Development, Primary Healthcare, Region Va
stra Go
taland, Kungsgatan 12, level 6 411 18 Gothenburg, Sweden
Na
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 20 December 2013
Received in revised form
9 May 2014
Accepted 24 June 2014
Introduction: The literature indicates that physiotherapy triage assessment can be efcient for patients
referred for orthopaedic consultation, however long-term follow up of patient reported outcome measures are not available.
Aim: To report a long-term evaluation of patient-reported health-related quality of life, pain-related
disability, and sick leave after a physiotherapy triage assessment of patients referred for orthopaedic
consultation compared with standard practice.
Methods: Patients referred for orthopaedic consultation (n 208) were randomised to physiotherapy
triage assessment or standard practice. The randomised cohort was analysed on an intention-to-treat
(ITT) basis. The patient reported outcome measures EuroQol VAS (self-reported health-state), EuroQol
5D-3L (EQ-5D) and Pain Disability Index (PDI) were assessed at baseline and after 3, 6 and 12 months. EQ
VAS was analysed using a repeated measure ANOVA. PDI and EQ-5D were analysed using a marginal
logistic regression model. Sick leave was analysed for the 12 months following consultation using a Mann
eWhitney U-test.
Results: The patients rated a signicantly better health-state at 3 after physiotherapy triage assessment
[mean difference 5.7 (95% CI 11.1; 0.2); p 0.04]. There were no other statistically signicant differences in perceived health-related quality of life or pain related disability between the groups at any of
the follow-ups, or sick leave.
Conclusion: This study reports that the long-term follow up of the patient related outcome measures
health-related quality of life, pain-related disability and sick leave after physiotherapy triage assessment did
not differ from standard practice, indicating the possible benets of implementation of this model of care.
2014 Elsevier Ltd. All rights reserved.
Keywords:
Randomised controlled trial
Primary care
EQ-5D
PDI
1. Introduction
Musculoskeletal pain often results in functional limitations in
rnsdo
ttir et al., 2013) and
daily life (Bingefors and Isacson, 2004; Bjo
many patients with persistent pain experience a high level of
disability, affecting work capacity (Gureje et al., 2001; Gerdle et al.,
2004; Landmark et al., 2013). Persistent pain has also been found to
negatively inuence quality of life (Kroenke et al., 2013; Landmark,
et al., 2013). Studies show that between 45% and 74% of the
rhalsan Tjo
rn Rehabilitation Clinic, Syster Ebbas v. 1,
* Corresponding author. Na
47194 Kllek
arr, Sweden. Tel.: 46 707 5262604; fax: 46 304 660342.
E-mail addresses: karin.samsson@vgregion.se, karin.samsson@gmail.com
(K.S. Samsson).
http://dx.doi.org/10.1016/j.math.2014.06.009
1356-689X/ 2014 Elsevier Ltd. All rights reserved.
39
40
3.1. Participants
The inclusion process and follow-up is presented in Fig. 1. There
were no statistically signicant differences between the two groups
regarding patient demographics at baseline (Table 1).
3.2. Health-related quality of life
The patients in the physiotherapy triage assessment group rated
a signicantly better health state at 3 months following consultation compared with the standard practice group [mean difference
5.7 (95% CI 11.1; 0.2); p 0.04]. No statistically signicant
differences were found between the groups at baseline (p 0.11) or
after 6 (p 0.06) or 12 months (p 0.14) (Fig. 2). There were no
statistically signicant differences between the groups in odds ratios for reporting no problemsin the EQ-5D at baseline or after 3, 6
and 12 months (Table 2).
3.3. Pain-related disability
We found no statistically signicant differences between the
groups in odds ratios for reporting baseline or below in the PDI at
baseline or after 3, 6 and 12 months (Table 3).
3.4. Sick leave
A small number of patients were on sick leave during the 12
months following consultation; seven in the physiotherapy triage
assessment group [mean days 146, (SD 128)] and 15 in the standard
practice group [mean days 72, (SD 81)]. No statistically signicant
difference between the groups was found (p 0.113).
3.5. Missing data analysis
The patients in the physiotherapy triage assessment group who
responded to EQ VAS at 3 months reported a statistically signicantly better health state at baseline, compared with the patients in
the standard practice group (difference in mean score 7.2, 95%
CI 13.6; 0.8). This means that the statistically signicant ndings
in the main analysis for EQ VAS must be interpreted with caution.
There were similar ndings of signicant differences for self care
(difference in mean score 6.2, 95% CI 12.2; 0.1), anxiety
(difference in mean score 6.2, 95% CI 12.2; 0.1) and mobility
(difference in mean score 6.5, 95% CI 12.6; 0.5) at 3 months.
41
Fig. 1. CONSORT ow chart of the patients through the study. PT physiotherapy, m months, EQ VAS EuroQol VAS (Self-reported health-state), EQ-5D EuroQol-5D,
PDI Pain Disability Index.
However, the ndings in the main analysis for these items were not
statistically signicant.
4. Discussion
The ndings in this study show that patients in the physiotherapy triage assessment group perceived better self-rated health
state (EQ VAS) after 3 months compared with patients in the
standard practice group. However, this nding must be interpreted
with caution since the missing data analysis showed a betweengroup difference for the respondents self-reported health state at
baseline. The study also shows that health-related quality of life,
pain-related disability and sick leave after physiotherapy triage
assessment did not differ from standard practice at the long-term
follow-up. We have earlier demonstrated that physiotherapy
triage assessment of patients referred for an orthopaedic consultation in primary healthcare can reduce referrals for orthopaedic
consultation, result in more appropriate referrals, as well as shorter
waiting times (Samsson and Larsson, 2015). By analysing long term
patient-related outcomes, yet another dimension is added, and our
ndings, in combination with the existing scientic evidence,
suggest that a model using physiotherapy triage assessment of
patients referred for orthopaedic consultation could be suitable for
42
Table 1
Demographic characteristics of the participants at baseline.
Age
Min
Max
Mean
SD
Sex (%)
Male
Female
Civil status (%)
Married/living
together
Single/living alone
Missing
Birth country (%)
Sweden
Other
Missing
Education (%)
Elementary School
Upper secondary
school
University
Missing
Occupation (%)
Working
Student
Other
Missing
Anatomic region (%)
Spinal
Cervical
Thoracic
Lumbar
Upper extremity
Shoulder
Arm/Wrist/Hand
Lower extremity
Hip
Knee
Leg/Ankle/Foot
Other
Duration of symptoms
Subachute
Chronic
Missing
PT triage assessment
(n 102)
Standard practice
(n 101)
18
67
51
13
21
67
53
12
45 (44)
57 (56)
45 (45)
56 (55)
82 (80)
86 (85)
16 (16)
4 (4)
14 (14)
1 (1)
93 (91)
5 (5)
4 (4)
92 (91)
8 (8)
1 (1)
11 (11)
48 (47)
23 (22)
47 (47)
39 (38)
4 (4)
30 (30)
1 (1)
71 (70)
2 (2)
25 (24)
4 (4)
70 (69)
3 (3)
27 (27)
1 (1)
7 (7)
2 (2)
18 (17)
8 (8)
0
15 (15)
13 (13)
12 (12)
14 (14)
16 (16)
12 (12)
21 (20)
15 (15)
2 (2)
(%)
18 (18)
75 (73)
9 (9)
9 (9)
30 (30)
6 (6)
3 (3)
14 (14)
70 (69)
17 (17)
Fig. 2. Long-term follow up for self-rated health state (EQ VAS) (predicted means,
standard errors); physiotherapy triage assessment (PT) versus standard practice (SP).
Analysis was made using an ANOVA. * A statistically signicant difference between
the groups [mean difference 5.7 (95% CI 11.1; 0.2); p 0.04].
43
Table 2
Health-related quality of life; Odds ratios (OR) and condence intervals (95% CI) for rating no problems in the physiotherapy triage assessment group.
EQ-5D
Activity
Anxiety
Mobility
Pain
Self care
Group
PT
SP
PT
SP
PT
SP
PT
SP
PT
SP
Baseline
3 months
6 months
12 months
OR
95% CI
OR
95% CI
OR
95% CI
OR
95% CI
101
99
101
97
99
96
101
97
101
96
1.4
Ref
1.4
Ref
1.2
Ref
0.7
Ref
4.1
Ref
0.8; 2.4
80
75
80
76
80
75
80
75
80
76
1.1
ref
0.9
Ref
1.8
Ref
0.8
Ref
1.5
Ref
0.3; 4.0
78
68
79
67
79
68
77
65
78
68
1.1
Ref
1.9
Ref
1.2
Ref
0.9
Ref
4.6
Ref
0.3; 3.8
82
79
83
79
83
78
84
78
83
79
1.8
Ref
1.6
Ref
1.0
Ref
0.7
Ref
1.6
Ref
0.5; 6.3
0.8; 2.4
0.7; 2.0
0.2; 3.3
0.8; 19.9
0.3; 3.1
0.5; 5.8
0.0; 21.1
0.1; 36.4
0.5; 8.1
0.3; 4.2
0.0; 2.1
0.2; 1215.3
0.5; 5.2
0.3; 3.9
0.0; 16.5
0.0; 59.0
The number of respondents in each group varied (65e101) because of incomplete data.
Analysis was made using a marginal logistic regression model.
EQ-5D EuroQol 5D, PT Physiotherapy triage assessment group, SP Standard practice group, Ref reference group for analysis.
Table 3
Pain-related Disability; Odds ratios (OR) and condence intervals (95% CI) for rating median or below in the physiotherapy triage assessment group.
PDI
Family/home responsibility
Recreational
Social activity
Occupation
Sexual behaviour
Self Care
Life-support activity
Group
PT
SP
PT
SP
PT
SP
PT
SP
PT
SP
PT
SP
PT
SP
Baseline
3 months
6 months
12 months
OR
95% CI
OR
95% CI
OR
95% CI
OR
95% CI
98
94
99
96
100
97
99
94
96
94
100
98
100
96
1.5
Ref
1.2
Ref
1.3
Ref
1.4
Ref
1.6
Ref
1.1
Ref
1.1
Ref
0.8; 2.6
80
75
80
74
80
75
78
75
75
73
79
74
79
75
1.0
Ref
1.4
Ref
1.4
Ref
1.8
Ref
1.4
Ref
1.4
Ref
1.0
Ref
0.3; 3.8
77
66
77
64
78
65
78
65
76
63
78
66
79
65
1.5
Ref
1.5
Ref
1.7
Ref
1.8
Ref
2.0
Ref
3.1
Ref
1.4
Ref
0.4; 5.8
82
76
82
75
82
78
83
75
80
73
81
75
81
76
1.3
Ref
1.2
Ref
1.4
Ref
1.1
Ref
1.3
Ref
1.5
Ref
1.2
Ref
0.3; 5.0
0.7; 2.1
0.7; 2.3
0.8; 2.5
0.9; 2.8
0.6; 1.9
0.6; 1.8
0.4; 5.1
0.4; 4.4
0.5; 6.5
0.5; 3.9
0.4; 4.7
0.3; 3.5
0.4; 5.3
0.5; 4.7
0.5; 5.2
0.6; 5.5
0.8; 14.6
0.4; 5.2
The number of respondents in each group varied (63e100) because of incomplete data.
Analysis was made using a marginal logistic regression model.
PDI Pain Disability Index, PT Physiotherapy triage assesment group, SP Standard practice group, Ref reference group for analysis.
0.3; 4.4
0.4; 4.6
0.3; 3.8
0.4; 4.3
0.4; 5.3
0.3; 4.0
44
Department of Health. The musculoskeletal services Framework e a Joint responsibility: Doing it differently; 2006. Available at, http://webarchive.
nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_
consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_
4138412.pdf. accessed 21.11.13.
Desmeules F, Roy JS, Macdermid JC, Champagne F, Hinse O, Woodhouse LJ.
Advanced practice physiotherapy in patients with musculoskeletal disorders: a
systematic review. BMC Musculoskelet Disord 2012;13:107.
Devine J, Norvell DC, Ecker E, Fourney DR, Vaccaro A, Wang J, et al. Evaluating the
correlation and responsiveness of patient-reported pain with function and
quality-of-life outcomes after spine surgery. Spine 2011;36:S69e74.
Edwards SJL, Lilford RJ, Braunholtz DA, Jackson JC, Hewison J, Thornton J. Ethical
issues in the design and conduct of randomised controlled trials. Health
Technol Assess 1998;2. v-76.
EuroQol. Available at http://www.euroqol.org/home.html. accessed 18.11.13.
EuroQol Group. EuroQolea new facility for the measurement of health-related
quality of life. Health Policy 1990;16:199e208.
Fitzpatrick R, Davey C, Buxton MJ, Jones DR. Evaluating patient-based outcome
measures for use in clinical trials. Health Technol Assess 1998;2. i-74.
Fritz JM, Childs JD, Wainner RS, Flynn TW. Primary care referral of patients with low
back pain to physical therapy: Impact on future health care utilization and
costs. Spine 2012;37:2114e21.
Gerdle B, Bjork J, Henriksson C, Bengtsson A. Prevalence of current and chronic pain
and their inuences upon work and healthcare-seeking: population study.
J Rheumatol 2004;31:1399e406.
Grimby-Ekman A, Andersson EM, Hagberg M. Analyzing musculoskeletal neck pain,
measured as present pain and periods of pain, with three different regression
models: a cohort study. BMC Musculoskelet Disord 2009;10.
Gureje O, Simon G, Von Korff M. A cross-national study of the course of persistent
pain in primary care. Pain 2001;92:195e200.
Hosmer DW, Lemeshow S. Applied logistic regression. 2nd ed. Hoboken, NJ, USA:
John Wiley & Sons, Inc; 2005.
Jordan KP, Kadam UT, Hayward R, Porcheret M, Young C, Croft P. Annual consultation prevalence of regional musculoskeletal problems in primary care: an
observational study. BMC Musculoskelet Disord 2010;11.
Kersten P, McPherson K, Lattimer V, George S, Breton A, Ellis B. Physiotherapy
extended scope of practice e who is doing what and why? Physiotherapy
2007;93:235e42.
Kroenke K, Outcalt S, Krebs E, Bair MJ, Wu J, Chumbler N, et al. Association between
anxiety, health-related quality of life and functional impairment in primary care
patients with chronic pain. Gen Hosp Psychiatry 2013;35:359e65.
Landmark T, Romundstad P, Dale O, Borchgrevink PC, Vatten L, Kaasa S. Chronic
pain: one year prevalence and associated characteristics (the HUNT pain study).
Scand J Pain 2013;4:182e7.
MacKay C, Canizares M, Davis AM, Badley EM. Health care utilization for musculoskeletal disorders. Arthritis Care Res 2010;62:161e9.
Maddison P, Jones J, Breslin A, Barton C, Fleur J, Lewis R, et al. Improved access and
targeting of musculoskeletal services in northwest Wales: targeted early access to musculoskeletal services (TEAMS) programme. Br Med J 2004;329:
1325e7.
rkelund C. Reasons for encounters, inMnsson J, Nilsson G, Strender LE, Bjo
vestigations, referrals, diagnoses and treatments in general practice in Swedena multicentre pilot study using electronic patient records. Eur J Gen Pract
2011;17:87e94.
McHugh GA, Campbell M, Luker KA. GP referral of patients with osteoarthritis for
consideration of total joint replacement: a longitudinal study. Br J Gen Pract
2011;61:459e68.
Menzies RD, Young RA. Referrals from a primary care-based sports medicine
department to an orthopaedic department: a retrospective cohort study. Br J
Sports Med 2012;45:1064e7.
hler E. What is normal
Mewes R, Rief W, Stenzel N, Glaesmer H, Martin A, Bra
disability? An investigation of disability in the general population. Pain
2009;142:36e41.
Morris J, Grimmer-Somers K, Kumar S, Murphy K, Gilmore L, Ashman B, et al.
Effectiveness of a physiotherapy-initiated telephone triage of orthopedic
waitlist patients. Patient Relat Outcome Meas 2011;2:151e9.
Picavet HSJ, Schouten JSAG. Musculoskeletal pain in the Netherlands: prevalences,
consequences and risk groups, the DMC(3)-study. Pain 2003;102:167e78.
Rabey M, Morgans S, Barrett C. Orthopaedic physiotherapy practitioners: surgical
and radiological referral rates. Clin Gov Int J 2009;14:15e9.
Richardson B, Shepstone L, Poland F, Mugford M, Finlayson B, Clemence N. Randomised controlled trial and cost consequences study comparing initial physiotherapy assessment and management with routine practice for selected
patients in an accident and emergency department of an acute hospital. Emerg
Med J 2005;22:87e92.
Robarts S, Kennedy D, MacLeod AM, Findlay H, Gollish J. A framework for the
development and implementation of an advanced practice role for physiotherapists that improves access and quality of care for patients. Healthc Q
2008;11:67e75.
Samsson K, Larsson MEH. Physiotherapy screening of patients referred for orthopaedic consultation in primary healthcare e a randomised controlled trial. Man
Ther 2015;19(5):386e91.
Sephton R, Hough E, Roberts SA, Oldham J. Evaluation of a primary care musculoskeletal clinical assessment service: a preliminary study. Physiotherapy
2010;96:296e302.
45