Health effects of direct triaging to physiotherapists in primary care for patients with musculoskeletal disorders: a pragmatic randomized controlled trial
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Maria EH Larsson
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Received 2018 Jul 9; Accepted 2019 Jan 9.
Copyright © The Author(s), 2019
This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( http://www.creativecommons.org/licenses/by-nc/4.0/ ) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage ).
Supplemental material, Supplementary_data for Health effects of direct triaging to physiotherapists in primary care for patients with musculoskeletal disorders: a pragmatic randomized controlled trial by Lena Bornhöft, Maria EH Larsson, Lena Nordeman, Robert Eggertsen and Jörgen Thorn in Therapeutic Advances in Musculoskeletal Disease
Physiotherapists and general practitioners (GPs) both act as primary assessors for patients with musculoskeletal disorders in primary care. Previous studies have shown that initial triaging to physiotherapists at primary healthcare centres has advantages regarding efficiency in the work environment and utilization of healthcare. In this study, we aimed primarily to determine whether triaging to physiotherapists affects the progression of health aspects over time differently than traditional management with initial GP assessment. The secondary aim was to determine whether triaging to physiotherapists affects patients’ attitudes of responsibility for musculoskeletal disorders.
This was a pragmatic trial where both recruitment and treatment strategies were determined by clinical, not study-related parameters, and was initiated at three primary care centres in Sweden. Working-age patients of both sexes seeking primary care for musculoskeletal disorders and nurse assessed as suitable for triaging to physiotherapists were randomized to initial consultations with either physiotherapists or GPs. They received self-assessment questionnaires before the initial consultation and were followed up at 2, 12, 26 and 52 weeks with the same questionnaires. Outcome measures were current and mean (3 months) pain intensities, functional disability, risk for developing chronic musculoskeletal pain, health-related quality of life and attitudes of responsibility for musculoskeletal conditions. Trends over time were analysed with a regression model for repeated measurements.
The physiotherapist-triaged group showed significant improvement for health-related quality of life at 26 weeks and showed consistent but nonsignificant tendencies to greater reductions of current pain, mean pain in the latest 3 months, functional disability and risk for developing chronic pain compared with traditional management. The triage model did not consistently affect patients’ attitudes of responsibility for musculoskeletal disorders.
Triaging to physiotherapists for primary assessment in primary care leads to at least as positive health effects as primary assessment by GPs and can be recommended as an alternative management pathway for patients with musculoskeletal disorders.
Keywords: musculoskeletal disorders, physiotherapy, primary care, RCT, triage
Worldwide, the prevalence of musculoskeletal disorders (MSDs) has been steadily increasing for many years, leading to an approximate 20% increase in years lived with disability from 2006 to 2016. 1 MSDs seen in primary care include a wide range of conditions and account for 14–17% of primary care consultations. 2 , 3 While self-management may suffice for some disorders, others require treatment and some develop over time into chronic conditions which impede daily activities and reduce quality of life in the long term. 4 Standard management in primary care traditionally involves primary assessment by general practitioners (GPs). Physiotherapists also see this group of patients, either as primary assessors or after referrals from physicians. 5
Primary care in Sweden is generally provided at primary healthcare centres (PHCCs) with several practising GPs and other healthcare professionals. Patients are usually required to register themselves at a PHCC that will assume responsibility for providing first-line medical care which does not require emergency services or hospital resources. Rehabilitation services are organized and financed separately and are often located at separate premises from the PHCCs. There is no need for physician referrals to see physiotherapists in Sweden and referrals do not affect treatment costs. Sweden differs, in this way, from many countries where access to physiotherapists is limited by healthcare regulations or by financial incentives and barriers. However, even in Sweden, patients frequently turn to their PHCC first for all medical issues, even when they could easily consult a physiotherapist directly for certain types of health problems. 3
In attempts to improve the management of MSDs in primary care, efforts have been made to include physiotherapists as early as possible in the care of these patients. 6 , 7 Several Swedish PHCCs have implemented a triage model in which nurses screen all patients seeking care using a specially developed handbook which guides them in their decision making. 6 Those seeking help for musculoskeletal conditions and showing no obvious symptoms of serious disease or injury are, whenever possible, booked directly to a physiotherapist for initial consultation. The model also provides opportunity for the physiotherapists to contact a GP after the initial consultation if the patient is in need of medical services.
Nurses, physiotherapists and GPs all screen for ‘red flag’ symptoms which may indicate serious illness or risk for chronicity. 8 – 10 While GPs have greater competence regarding the treatment of serious illness, it is possible that physiotherapeutic focus on regaining musculoskeletal function and learning how to handle musculoskeletal conditions independently may be better suited to many of the conditions seen in primary care. Physiotherapist competence in managing musculoskeletal disorders has been demonstrated earlier. 11 , 12 If nurses can successfully identify those patients who are in greater need of physiotherapeutic treatment than GP treatment, then savings in terms of patient suffering and waiting times for treatment may be made by enabling patients to receive appropriate care without unnecessary delays.
The triage model has been shown to have several advantages, such as increased efficiency in the work environment at PHCCs and reduced utilization of GP visits and services over time. 6 , 13 Other models for musculoskeletal triage in Sweden, Canada, Australia, the United States and the United Kingdom have also shown positive results for early physiotherapeutic involvement but studies have been predominantly nonrandomized and have focused on aspects such as selection accuracy, waiting times or personnel and patient satisfaction. 14 , 15 In a cohort study, Goodwin and Hendrick found health improvements for patients with MSD who chose physiotherapist over GP as first-line contact. 16 The effects of direct triaging to physiotherapists on patients’ health and function have not, to our knowledge, been studied previously with randomised methodology.
Research concerning early initiation of physiotherapy has concentrated on low back pain, with early treatment showing advantages over later onset. 17 If appropriate physiotherapeutic treatment is introduced initially, and immediately when patients seek help for all musculoskeletal conditions at PHCCs, perhaps health benefits may be further increased.
The nature of MSDs varies widely but most lead to pain, impaired function, lower quality of life and, in many cases, to an increased risk for developing chronic conditions. 18 – 20 It is possible that the progression of these aspects over time may be affected by the quality and content of initial management by healthcare.
Physiotherapeutic treatment of MSD is generally oriented to regaining function. Specific advice and assistance on lifestyle, ergonomics and exercise can be combined with manual treatment and nonpharmaceutical pain alleviation techniques. 21 – 23 On the other hand, GPs also give advice in their management of MSDs, and may, in addition, prescribe medication, make referrals for radiological examinations to secondary-care specialists and other professions, and, when necessary, provide sick-leave notes. 10 While all or some of these latter actions may be necessary, they do not require the patient to actively address their disorder in the way physiotherapeutic instructions or exercise may do. It is possible that initial contact with a physiotherapist may increase the focus on other aspects of the health conditions and encourage patients to take more responsibility for their musculoskeletal health.
Pragmatic trials are used to determine the effectiveness of treatments in routine clinical practice. They require the studied population to be as representative as possible and outcome measures to cover a full range of possible health gains and aim to facilitate informed treatment/management choices. 24
The primary aim of the study was to use pragmatic randomized methodology to determine whether direct triaging of patients with musculoskeletal disorders to physiotherapists in primary care affects the health outcomes pain, disability, health-related quality of life (HRQoL) and risk for developing chronic conditions differently than traditional management with initial assessment by GPs. The secondary aim was to determine whether triaging to physiotherapists affects patients’ attitudes of responsibility for musculoskeletal disorders differently than traditional management.
Design and participants
A randomized controlled trial was organized at three PHCCs in Gothenburg, Sweden, where the triage model 6 was well established and physiotherapists integrated into normal practice. The data analyst was blinded to group identification until the preliminary analyses were completed.
One PHCC was situated in an area with low socioeconomic conditions where many of the registered patients were recent immigrants with limited command of either Swedish or English; the second in a more affluent area with primarily Swedish-born-registered patients; and the third in an area with a greater mix of backgrounds and socioeconomic levels. This mix is representative of the urban Swedish population. All triage nurses at the PHCCs were informed of the study and invited to participate in the recruiting process. The managers endorsed the study and encouraged the nurses to participate. The nurses’ role was to recruit participants from those patients whom they normally triaged directly to physiotherapists.
Inclusion criteria: working-age patients, 16–67 years of age, of both sexes seeking help for musculoskeletal conditions at the participating PHCCs who could speak sufficient Swedish or English to complete the questionnaires were included in the study. Exclusion criteria: patients requiring home visits, who primarily needed medical aids, or who had ongoing treatment for the current musculoskeletal disorder with relevant healthcare visits during the preceding month were excluded, as were those seeking help for chronic conditions with unchanged symptoms the latest 3 months and who had already tried physiotherapeutic treatment for the same condition. Sampling was consecutive but was dependent on individual assessment by the triage nurse.
The study was approved by the regional ethical review board in Gothenburg (DNR 358-14). All participants provided informed written consent.
Randomization was prepared in advance by the project leader using a computer-generated sequence in blocks of 10 and sealed opaque envelopes. After giving informed written consent, participants were randomized by a nurse to a first visit with either a physiotherapist or a GP [treatment as usual (TAU)] and received questionnaires to be filled in before the visit. Besides the outcomes listed below, participants were asked about comorbidities and completed the Hospital Anxiety and Depression Scale. 25 The participants were instructed not to divulge to the caregiver that they were participating in the study. The study protocol did not dictate the treatment each patient received. It only determined which profession would make the first assessment. The participants were followed for 1 year from their first visit and received follow-up questionnaires at 2, 12, 26 and 52 weeks in order to discern both short-term and long-term effects.
Primary outcomes Concerning the first aim of the study, several outcomes were examined. With regards to pain, both current pain and mean pain during the latest 3 months were measured using 11-point numeric pain rating scales, with 10 indicating unbearable pain and 0 indicating no pain. 26 The Disability Rating Index (DRI) measured functional disability for 12 different daily activities each on a 100 mm line where the participant marks the difficulty level between the endpoints ‘no difficulty’ and ‘cannot perform’. 27 Higher values indicate higher levels of disability. EuroQol 5 dimensions (EQ5D) measured HRQoL. 28 This is a two-part instrument, with the first giving an index value based on questions concerning mobility, self-care, daily activities, pain and anxiety/depression, and the second part consisting of a visual analogue scale (VAS) from 0-100 where the participants indicate their current health state. Risk for developing chronic musculoskeletal pain was measured with the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ). 29 ÖMPSQ consists of 21 questions concerning present and past pain and ability, as well as expectations for recovery, with possible scores between 3 and 210. Scores < 90 are interpreted as low risk, between 90 and 105 as medium risk, and > 105 as high risk. All of these patient-reported outcome measures have been used extensively in research and clinical environments and have been reliability and validity tested for patients with MSD. 26 , 27 , 30 – 35
Secondary outcome The Attitudes regarding Responsibility for Musculoskeletal disorders scale (ARM) 36 was used to investigate the secondary aim. Higher scores indicate higher degrees of externalization. ARM is divided into four subscales: the Responsibility Employers (RE) subscale investigates the extent to which people place responsibility for musculoskeletal health on employers; the Responsibility Medical Professionals (RMP) subscale examines how much responsibility is placed on medical professionals; the Responsibility Out of my hands (RO) subscale examines the amount of responsibility which is placed on factors not under control of the individual; the Responsibility Self-Active (RSA) subscale examines the extent to which the individual takes own responsibility for musculoskeletal health. The first three subscales can give values between 3 and 18; the fourth, between 6 and 36.
A sample size of 63 participants/group was aimed for, based on a clinically relevant difference between groups of one unit for current pain with power level 80% and p < 0.05.
Mean values with standard deviations were calculated at baseline and at 12 weeks. The Mann–Whitney U test was used to determine differences between groups for dichotomized confounders and Student’s t test for continuous confounders and outcome variables.
Linear regression analyses for repeated measurements were used to study the results using a marginal model with unstructured covariance matrix for residuals. Possible confounders (age, sex, comorbidities, depression, Swedish origin) were tested individually. Those with a statistical significance of p > 0.25 and which had