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The Extended Role of a Physiotherapist in an Out-patient Orthopaedic Clinic
281
TREATMENT REPORT
The Extended Role of a Physiotherapist in an Out-patient Orthopaedic Clinic Julie Hockin Gordon Bannister Key Words Physiotherapy, orthopaedics, out-patients, orthotics, steroid injection.
Summary A physiotherapist with extended training in orthotics and local steroid injection was able to manage 85% of selected orthopaedic out-patients independently. The final treatment selected by the physiotherapist was advice in 12% of cases, manipulation or electrophysiotherapy in 31%, orthoses in 20% and local steroid injection in 22%. 10Vo of patients required surgery and 5% referral to other medical specialties. Of patients treated independently by the physiotherapist, 21% estimated that they had improved by less than 40%, 46% by between 40% and 80% and 33% by more than 80%. Altogether 89% of patients and 95% of general practitioners were satisfied with the treatment received.
Introduction Surveys of out-patient work reported in the literature imply that a proportion of orthopaedic out-patient referrals could be managed efficiently and effectively with consultant support but without direct consultant intervention. Roland et al (1991) opined that 43% of general practitioner (GP) orthopaedic out-patient referrals were inappropriate, but recorded that 83% of patients felt that they derived benefit from their attendance. West and McKibbin (1982) noted that 33%, of patients failed to keep their appointments, implying that the disorders referred were self-limiting. Ross et a1 (1983)found that 3 3 4 of orthopaedic out-patient referrals required specialist treatment and that 27%, were ultimately managed by physiotherapy. Physiotherapists already manage a significant proportion of orthopaedic out-patients, have special experience in the treatment of self-limiting disorders, and know more than doctors of the conditions that respond to physiotherapy skills. Byles and Ling (1989) demonstrated that between 60% to 80% of orthopaedic out-patient referrals could be safely treated by a physiotherapist practising independently. Mrs Byles achieved these results using conventional physiotherapy techniques, but a number of factors suggest that this therapeutic armentarium could profitably be extended. The introduction of gait assessment, and temporary then permanent foot orthoses by the physiotherapy department a t Southmead Hospital, Bristol, had significantly reduced the need for foot surgery in the orthopaedic surgeon author’s practice. The hospital superintendent physiotherapist had requested a rapid-access local steroid injection service for lateral
epicondylitis, which was proving refractory to manipulative and electrophysiotherapeutic interventions. Patients had presented to t h e surgeon author, demonstrating excellent results from local steroid injection administered by a n experienced phyiotherapist practising privately within the city. As a significant proportion of orthopaedic out-patient disorders can be successfully managed by orthotics or local steroid injection (Dixon et al, 19721, and physiotherapists were already practising these techniques, it seemed possible that a physiotherapist with these combined skills might be able to treat a greater number of out-patient referrals than by manipulation and electrophysiotherapy alone. The aim of this study was to assess effectiveness of the physiotherapist with additional training in orthotics and local steroid injection, with available consultant support, in treating general practitioner out-patient orthopaedic referrals primarily. The physiotherapist clinical assistant had the opportunity of attending significantly more postgraduate courses than is generally the case. Maitland training was of especial value in general assessment and Langer in gait. It took some ten months to train the physiotherapist clinical assistant to administer steroid injections consistently. In order to undertake this new treatment, the physiotherapist had to feel confident of supervision and support which was available on demand. Particular difficulties were encountered by the physiotherapist in injecting the acromioclavicularjoint, but in general, injection skills improved in direct proportion to exposure. As skills in injecting were acquired, fewer patients were referred primarily for out-patient physiotherapy and more treated by local steroids.
Material and Methods Patient Selection General practitioners were advised of the availability of appointments to see a physiotherapist clinical assistant. Family practitioners could refer directly to this clinic, but all referral letters, both to the physiotherapist and to the orthopaedic surgeon, were reviewed by the latter, and referrals unlikely to benefit from surgery directed to the physiotherapist. The conditions referred to the physiotherapist included mechanical low back pain, shoulder disorders other than recurrent dislocation, knee disorders other than severe arthritis requiring joint replacement or locked knees, and all foot and ankle disorders. Any condition that could potentially benefit from physiotherapy, orthotics or local steroid injection was seen initially by the physiotherapist clinical assistant. Arthritis, requiring joint replacement, root compression and masses were seen by the surgeon, regardless of to whom the referral was made.
Physiotherapy, May 1994, vol80, no 5
282
staff
Results
The physiotherapist had qualified six years previously and had supplemented her training with MACP Maitland courses in spinal and peripheral joints, Langer biomechanics and gait analysis and adverse mechanical tension. In three clinics the surgeon and t h e physiotherapist saw new patients together to establish common ground, whereafter the physiotherapist consulted in a room adjacent to that of the orthopaedic surgeon. Before attending, patients completed a questionnaire with a body chart and pain analogue score in which previous medical history, occupation, recreation and functional activities were recorded (Byles and Ling, 1989). This alerted t h e physiotherapist clinical assistant to the principal complaints, saved time taking a history, and allowed physical examination to be more accurately focused. Twenty minutes were allowed for each new patient and ten minutes for each follow-up.
Over a ten-month period, 291 patients attended for initial consultation. Treatment was completed i n 236, of whom 47 failed to attend their follow-up appointments, leaving 189 available for study. The presenting disorders affected the lumbar spine, krtee, foot and ankle, neck, shoulder and elbow in that order. The proportion of patients defaulting follow-up appointments varied from 25% in anterior knee pain to 11% for elbow disorders, with a mean of 19%failing to complete their course of treatment (table 1).
Treatment The treatment options available to the physiotherapist were:
1. Advice and self-management exercises. 2. Referral to out-patient physiotherapy.
3. Local steroid injection to the acromioclavicular and gleno-humeral joints and subacromial space, osteoarthritic knees and inflamed tendons, epicondylitis of the elbow and Cyriax facet blocks for mechanical low back pain. 4. Orthotics in t h e form of Langer orthoses for feet,
lumbar corsets and cervical collars. 5 . Immediate consultant opinion with the option of surgery or plaster of Paris immobilisation.
Investigations Plain X-ray for degenerative changes, computer axial tomography scan for suspected disc protrusion, acute phase proteins and auto-immune profiles for chronic i n f l a m m a t o r y disease, were requested by t h e physiotherapist as deemed necessary with consultant advice on demand.
Measurement of Outcome Outcome was measured on conclusion of treatment by patient perception of improvement and subjective satisfaction by postal questionnaire or telephone contact six to 12 months after discharge. Improvement was subjectively recorded by the patients with a slight modification of t h e six grades used by Byles and Ling (1989).These grades were: deteriorated, same, improved less than 40%, improved 40% to 80%, improved more than 80% and problem resolved. Satisfaction with t h e consultation was likewise recorded; a patient could fail to improve, but still express satisfaction wit,h the treatment received.
Table 1: Presentation by anatomical regions Anatomical site
Completing treatment
Physlotherapy, May 1994, vol80, no 5
Total
NO
Yo
No
940
No
Oh
66
78
19
22
85
36
39
75
13
25
52
23
38
88
5
12
43
18
23
72
5
18
28
12
15
88
2
12
17
7
Elbow
8
89
1
11
9
4
Totals
189
81
45
19
234
100
Lumbar spine Anterior knee pain Foot and ankle Neck Shoulder
Table 2: Outcome after final treatment Improvement (%)
Anterior Lumbar Elbow Shoulder knee pain spine
Neck
Fooland ankie
Tolais
Advice alone
< 40 40-80 > 80
1
-
6 6 2
-
1 3 -
9
11 2 12%
Manipulation or electrophysiotherapy
< 40 40-80 > 80
Orthoses < 40 40-80 > 80
2 11 14
1
1 7 2
12 28 18 31O/o
2 6 4
4 11 22 20 010
Steroid injection
< 40 40-80 > 80
1 2
-
3 11 3
8 23 11 220/0
Surgery
< 40 40-80 > 80
3 1 1
2 2 3
11
5 4
1000
Statistical Analysis Data were retrieved and collated by Ian Chadwell, statistician to the medical information department of Southmead Hospital, Bristol. Numbers are expressed in crude form in table 2, but percentages are used in the text to allow proportional comparison. The sole outcome comparison was performed using a chi squared test.
Defaulting
Other specialties
< 40 40-80 > 80
2
-
5 1
-
7
10 5Oo
Totals
39
66
189
Lumbar Spine (table 21 Diagnosis Of the 88 referrals, 22% presented with root imtation, 72% with mechanical low back pain and 6% with spondylolisthesis. lkatment 21% of cases were managed by advice, 15% by physiotherapy, 25% by local anaesthetic and steroid iqjection, 18% by corsets and 11% by surgery.
Outcome Overall, 29% of patients were unchanged or improvedby less than 40%, and 50% improved by between 40% and 80%, with 21% improved by more than 80%. Of all patienta who started treatment, 22% failed to complete the course The outcome of both outpatient physiotheraw and local anaesthetic and steroid iqiections was comparable.
Anterior Knee Pain (table 2) Diagnosis Anterior knee pain was predominantly diagnoeed as lateral tracking. Treatment all the patients, 69% were treated by the McConnell regimen (McConnell, 19841, 3% by advice, 3% by foot orthoses, 8% by local anaesthetic and steroid injection, 13% by surgery and 5% by referral to other m . d i e l specialists. Of
Outcome Overall, 15% of patients remained unchanged, or improved by less than 40%; 41% improved by between 40% and 80% and 44% improved by more than 80%. Of patients treated by the McConnell regimen, 52% were improved by more than 40% and 25% defaulted from follow-up.
Ankles, Feet and Toes (table 2) Diagnosis Mobile and functional deformities constituted the majority of referrals. lkeatment The majority, 56%, were managed by orthoses, 15% by local anaesthetic and steroid injection, 13% by conventional physiotherapy, 10% by surgery and 3% by advice. Outcome Of these patients, 18% were unchanged, or improved by less than 40% 34% improved by between 40% and 80%, and 48%by over 80%. The greatest succesa was recorded by patients treated by orthoses and the least by surgery. There were 12% who defaulted from follow-up
advice, orthosee or local anaesthetic and steroid w o n in equal proportions.
outwme The mqjority, a%, were unchanged,or improved by lese than 40%. 30% improved by between 40% and 80%;and 5% by more than 80%. Of these patienta, 18% failed to keep their follow-up appointmenta
Shoulder (table 2) Dicrgnosis Acromioclavidar degeneration, supraspinatus impingement and gleno-humeral c a p d i t i e were the most common presenting disorders.
!hatment The W r i t y , 6096, were treated by steroid iajection, 27% by advice and 13% by surgery. Outcome O f these patients, 13% were unchanged; 67% were
improved by between 40% and W,and 20% either remitted completely, or improved by more than 80%. All patients treated by local anaesthetic and steroid iqjection were improved by more than 40%. There were 12% who deSaulted from follow-up
Elbow (table 2) Dicrgnosie , The mqjority of patients with elbow dieordew presented with lateral or medial epicondylitia Tkeatment "he majority, 6346, were treated by steroid iqiection and the remainder by manipulation or electrophyeiotherapy, surgery or referral to other specialties in equal proportions. Outcome O f all those treated by steroid i-ion,
80% were
improved by more than 80%.
Overall Tmatment Manipulation or electrophysiotherapy wns the initial management for 50% of patients and the final treatment for 31%. Of the 31 patients who received physiotherapy as their final treatment, 79% were improved by 40% or mom Significantly gmater numbera of patienta in whom the final treatment was orthotice or local anaesthetic and steroid i m i o n reported impravement of over 8096,than of those who received advice and physiotherapy (chi squared equals 4.5 p < o.o~), pr surgery and referrals to other medical specialties (chi squared equals 4.5 p < 0.001).
Outcome at End of Weatment A total of 21% of patients were unchanged, 8% had
Cervical Spine (table 2)
improved by less than 40% 42% by between 40% and 80%; 21% by more than 80%; and in 8% the problem
Diagnosis The majority of the 28 patients presented with cervical spondylosis with mild root irritation.
resolved.
Deatment all the patients seen for cervical spine disorders, 68% were treated with physiotherapy and the remainder by
Ofthe 189 patienta who completed treatment, 89% were satisfied. Of general practitioners who could recollect the referral, 95% were satiefied by the treatment received.
Of
Patient and GP Satisfaction
Phydothenpy,M y 19B4,vol80, no 6
284
Discussion The demand for orthopaedic out-patient appointments exceeds provision and in this city is one of the principal causes of disenchantment with hospital services (Hicks and Baker, 1991). During the study period, some 50%of cases referred to the orthopaedic surgeon author were seen by the physiotherapist clinical assistant. The exercise both increased provision in the orthopaedic outpatient department and brought experience of t h e potential of additional treatment modalities to the outpatient physiotherapy unit where the clinical assistant was superintendent, targeting resources there more accurately. In a case control study (Weale et a2, 1993) comparable results, but a higher level of patient satisfaction, were achieved by a physiotherapist in this role t h a n staff grade orthopaedic surgeons, particularly in t h e management of low back pain. As physiotherapists have greater familiarity with instruction in self-help and t h e treatment of chronic conditions than orthopaedic surgeons, who are oriented towards operative intervention, it seems t h a t this population might be better served by physiotherapists t h a n by surgeons. I n considering t h e alternative in managing this group of patients, it is interesting to compare the four possible courses of action.
1. No treatment. 2. All patients seen by a physiotherapist, without extended training.
and consultant support, was able to assess all patients, treat 85% of them independently and achieve 40% improvement or more in 79%. While this paper principally addresses the additional options provided by local anaesthetic and steroid and orthotics to a physiotherapist, it is a descriptive audit, does not randomise conditions into treatment modalities and cannot strictly compare their merits. Physiotherapists are working in this capacity in a number of units throughout the United Kingdom. The cost of training physiotherapists is very much less t h a n for orthopaedic surgeons and if, as preliminary studies suggest, physiotherapists are at least as effective as medically qualified personnel in out-patient departments, there is likely to be a n expansion of this role.
Two further areas could be addressed profitably in the future. Controlled trials, involving random allocation of patients with comparable histories to medical and physiotherapy staff, would accurately establish the respective roles of each type of personnel. In addition, we obtained detailed questionnaires from patients with pain maps. We used these to help in history taking, but not to predict patients who could benefit most from outpatient treatment. There were 19% of patients who failed to keep appointments and 21% were not helped at ali. The resources utilised on this population could have been better targeted to those more likely to benefit.
3. Management by a general practitioner. 4. An additional consultant clinic.
If no treatment had been offered and the patients had remained on the waiting list, 10% of patients requiring surgery and t h e 79% who benefited from conservative management would not have been helped. Identifying t h e 10% who required surgery was not possible from t h e G P referral letters. Of 88 referrals for back disorder, 19 patients had signs of root irritation of whom 50% were surgically decompressed. Lumbar nerve root decompression was one of the more successful surgical interventions undertaken. Advice, or manipulation and electrophysiotherapy, was the final treatment chosen by a n experienced physiotherapist in 31% of cases. Had all these patients been sent to a n out-patient physiotherapy department, waiting times would have increased and t h e therapeutic endeavours of t h a t department would have been optimally targeted in fewer than one-third of cases.
Authors Julie Hockin MCSP is a superintendent physiotherapist and Gordon Bannister MD MChOrth FRCS is a consultant orthopaedic
surgeon at Southmead Hospital, Westbury on Trym.
Address for Correspondence Mr G Bannister FRCS, Consultant Orthopaedic Surgeon, Southmead Hospital, Westbury on Trym, Bristol BSlO 5NB. References Byles, S E and Ling, R S M (1989). ‘Orthopaedicout-patients a fresh approach‘, Physiotherapy, 7, 435-437. Dixon, A St J, Cosh, J A and Kersley, G D (1972). ‘Local corticosteroid therapy for painful rheumatic states’, Clinical Rials Journal, 3, 14-18. Hicks, N R and Baker, I A (1991).‘Generalpractitioners’ opinions of health services available to their patients’, British Medical Journal, 302, 991-993. McConnell, J (1984). ‘The management of chondromalacia patellae: A long-term solution’,Australian Journal of Physiotherapy, 32, 4, 215-222. Roland, M 0, Porter, R W, Matthews, J G , Redden, J F, Simonds, G Wand Bewley, B (1991).‘Improving care: A study of orthopaedic out-patient referrals’, British Medical Journal, 302, 1124-28. ROSS, A K, Davis, W A, Horn, G and Williams, R (1983).‘General practice orthopaedic out-patient referrals in North Staffordshire’, British Medical Journal, 247, 1439-41.
The G P could have offered advice, referred to physiotherapy and administered local anaesthetic a n d steroid injection. Postgraduate orthopaedic training is not formally included in most G P rotations and a high proportion of GP referrals are considered inappropriate (Roland et al, 1991). Local anaesthetic and steroid injection can be technically demanding and many GPs cannot differentiate appropriate sites. Assuming the GPs had orthopaedic experience and were competent in steroid injection, 65% of patients could have been treated by the family practitioner services of whom 76% would have shown a n improvement by 40% or more.
Surgery, 750, 1, 43.
By contrast, a physiotherapist, with extended skills in orthotics and local anaesthetic and steroid injection
West, R R and McKibbin. B (1982). ‘Shortening waiting lists in orthopaedic surgery out-patientclinics’,British Medical Journal. 284, 728-730.
Physiotherapy, May 1994, vol80, no 5
Weale, A E, Hockin, J and Bannister, G C (1993).‘Physiotherapist or surgeon in orthopaedic out-patients?’Journal of Bone and Joint
TREATMENT REPORT
The Extended Role of a Physiotherapist in an Out-patient Orthopaedic Clinic Julie Hockin Gordon Bannister Key Words Physiotherapy, orthopaedics, out-patients, orthotics, steroid injection.
Summary A physiotherapist with extended training in orthotics and local steroid injection was able to manage 85% of selected orthopaedic out-patients independently. The final treatment selected by the physiotherapist was advice in 12% of cases, manipulation or electrophysiotherapy in 31%, orthoses in 20% and local steroid injection in 22%. 10Vo of patients required surgery and 5% referral to other medical specialties. Of patients treated independently by the physiotherapist, 21% estimated that they had improved by less than 40%, 46% by between 40% and 80% and 33% by more than 80%. Altogether 89% of patients and 95% of general practitioners were satisfied with the treatment received.
Introduction Surveys of out-patient work reported in the literature imply that a proportion of orthopaedic out-patient referrals could be managed efficiently and effectively with consultant support but without direct consultant intervention. Roland et al (1991) opined that 43% of general practitioner (GP) orthopaedic out-patient referrals were inappropriate, but recorded that 83% of patients felt that they derived benefit from their attendance. West and McKibbin (1982) noted that 33%, of patients failed to keep their appointments, implying that the disorders referred were self-limiting. Ross et a1 (1983)found that 3 3 4 of orthopaedic out-patient referrals required specialist treatment and that 27%, were ultimately managed by physiotherapy. Physiotherapists already manage a significant proportion of orthopaedic out-patients, have special experience in the treatment of self-limiting disorders, and know more than doctors of the conditions that respond to physiotherapy skills. Byles and Ling (1989) demonstrated that between 60% to 80% of orthopaedic out-patient referrals could be safely treated by a physiotherapist practising independently. Mrs Byles achieved these results using conventional physiotherapy techniques, but a number of factors suggest that this therapeutic armentarium could profitably be extended. The introduction of gait assessment, and temporary then permanent foot orthoses by the physiotherapy department a t Southmead Hospital, Bristol, had significantly reduced the need for foot surgery in the orthopaedic surgeon author’s practice. The hospital superintendent physiotherapist had requested a rapid-access local steroid injection service for lateral
epicondylitis, which was proving refractory to manipulative and electrophysiotherapeutic interventions. Patients had presented to t h e surgeon author, demonstrating excellent results from local steroid injection administered by a n experienced phyiotherapist practising privately within the city. As a significant proportion of orthopaedic out-patient disorders can be successfully managed by orthotics or local steroid injection (Dixon et al, 19721, and physiotherapists were already practising these techniques, it seemed possible that a physiotherapist with these combined skills might be able to treat a greater number of out-patient referrals than by manipulation and electrophysiotherapy alone. The aim of this study was to assess effectiveness of the physiotherapist with additional training in orthotics and local steroid injection, with available consultant support, in treating general practitioner out-patient orthopaedic referrals primarily. The physiotherapist clinical assistant had the opportunity of attending significantly more postgraduate courses than is generally the case. Maitland training was of especial value in general assessment and Langer in gait. It took some ten months to train the physiotherapist clinical assistant to administer steroid injections consistently. In order to undertake this new treatment, the physiotherapist had to feel confident of supervision and support which was available on demand. Particular difficulties were encountered by the physiotherapist in injecting the acromioclavicularjoint, but in general, injection skills improved in direct proportion to exposure. As skills in injecting were acquired, fewer patients were referred primarily for out-patient physiotherapy and more treated by local steroids.
Material and Methods Patient Selection General practitioners were advised of the availability of appointments to see a physiotherapist clinical assistant. Family practitioners could refer directly to this clinic, but all referral letters, both to the physiotherapist and to the orthopaedic surgeon, were reviewed by the latter, and referrals unlikely to benefit from surgery directed to the physiotherapist. The conditions referred to the physiotherapist included mechanical low back pain, shoulder disorders other than recurrent dislocation, knee disorders other than severe arthritis requiring joint replacement or locked knees, and all foot and ankle disorders. Any condition that could potentially benefit from physiotherapy, orthotics or local steroid injection was seen initially by the physiotherapist clinical assistant. Arthritis, requiring joint replacement, root compression and masses were seen by the surgeon, regardless of to whom the referral was made.
Physiotherapy, May 1994, vol80, no 5
282
staff
Results
The physiotherapist had qualified six years previously and had supplemented her training with MACP Maitland courses in spinal and peripheral joints, Langer biomechanics and gait analysis and adverse mechanical tension. In three clinics the surgeon and t h e physiotherapist saw new patients together to establish common ground, whereafter the physiotherapist consulted in a room adjacent to that of the orthopaedic surgeon. Before attending, patients completed a questionnaire with a body chart and pain analogue score in which previous medical history, occupation, recreation and functional activities were recorded (Byles and Ling, 1989). This alerted t h e physiotherapist clinical assistant to the principal complaints, saved time taking a history, and allowed physical examination to be more accurately focused. Twenty minutes were allowed for each new patient and ten minutes for each follow-up.
Over a ten-month period, 291 patients attended for initial consultation. Treatment was completed i n 236, of whom 47 failed to attend their follow-up appointments, leaving 189 available for study. The presenting disorders affected the lumbar spine, krtee, foot and ankle, neck, shoulder and elbow in that order. The proportion of patients defaulting follow-up appointments varied from 25% in anterior knee pain to 11% for elbow disorders, with a mean of 19%failing to complete their course of treatment (table 1).
Treatment The treatment options available to the physiotherapist were:
1. Advice and self-management exercises. 2. Referral to out-patient physiotherapy.
3. Local steroid injection to the acromioclavicular and gleno-humeral joints and subacromial space, osteoarthritic knees and inflamed tendons, epicondylitis of the elbow and Cyriax facet blocks for mechanical low back pain. 4. Orthotics in t h e form of Langer orthoses for feet,
lumbar corsets and cervical collars. 5 . Immediate consultant opinion with the option of surgery or plaster of Paris immobilisation.
Investigations Plain X-ray for degenerative changes, computer axial tomography scan for suspected disc protrusion, acute phase proteins and auto-immune profiles for chronic i n f l a m m a t o r y disease, were requested by t h e physiotherapist as deemed necessary with consultant advice on demand.
Measurement of Outcome Outcome was measured on conclusion of treatment by patient perception of improvement and subjective satisfaction by postal questionnaire or telephone contact six to 12 months after discharge. Improvement was subjectively recorded by the patients with a slight modification of t h e six grades used by Byles and Ling (1989).These grades were: deteriorated, same, improved less than 40%, improved 40% to 80%, improved more than 80% and problem resolved. Satisfaction with t h e consultation was likewise recorded; a patient could fail to improve, but still express satisfaction wit,h the treatment received.
Table 1: Presentation by anatomical regions Anatomical site
Completing treatment
Physlotherapy, May 1994, vol80, no 5
Total
NO
Yo
No
940
No
Oh
66
78
19
22
85
36
39
75
13
25
52
23
38
88
5
12
43
18
23
72
5
18
28
12
15
88
2
12
17
7
Elbow
8
89
1
11
9
4
Totals
189
81
45
19
234
100
Lumbar spine Anterior knee pain Foot and ankle Neck Shoulder
Table 2: Outcome after final treatment Improvement (%)
Anterior Lumbar Elbow Shoulder knee pain spine
Neck
Fooland ankie
Tolais
Advice alone
< 40 40-80 > 80
1
-
6 6 2
-
1 3 -
9
11 2 12%
Manipulation or electrophysiotherapy
< 40 40-80 > 80
Orthoses < 40 40-80 > 80
2 11 14
1
1 7 2
12 28 18 31O/o
2 6 4
4 11 22 20 010
Steroid injection
< 40 40-80 > 80
1 2
-
3 11 3
8 23 11 220/0
Surgery
< 40 40-80 > 80
3 1 1
2 2 3
11
5 4
1000
Statistical Analysis Data were retrieved and collated by Ian Chadwell, statistician to the medical information department of Southmead Hospital, Bristol. Numbers are expressed in crude form in table 2, but percentages are used in the text to allow proportional comparison. The sole outcome comparison was performed using a chi squared test.
Defaulting
Other specialties
< 40 40-80 > 80
2
-
5 1
-
7
10 5Oo
Totals
39
66
189
Lumbar Spine (table 21 Diagnosis Of the 88 referrals, 22% presented with root imtation, 72% with mechanical low back pain and 6% with spondylolisthesis. lkatment 21% of cases were managed by advice, 15% by physiotherapy, 25% by local anaesthetic and steroid iqjection, 18% by corsets and 11% by surgery.
Outcome Overall, 29% of patients were unchanged or improvedby less than 40%, and 50% improved by between 40% and 80%, with 21% improved by more than 80%. Of all patienta who started treatment, 22% failed to complete the course The outcome of both outpatient physiotheraw and local anaesthetic and steroid iqiections was comparable.
Anterior Knee Pain (table 2) Diagnosis Anterior knee pain was predominantly diagnoeed as lateral tracking. Treatment all the patients, 69% were treated by the McConnell regimen (McConnell, 19841, 3% by advice, 3% by foot orthoses, 8% by local anaesthetic and steroid injection, 13% by surgery and 5% by referral to other m . d i e l specialists. Of
Outcome Overall, 15% of patients remained unchanged, or improved by less than 40%; 41% improved by between 40% and 80% and 44% improved by more than 80%. Of patients treated by the McConnell regimen, 52% were improved by more than 40% and 25% defaulted from follow-up.
Ankles, Feet and Toes (table 2) Diagnosis Mobile and functional deformities constituted the majority of referrals. lkeatment The majority, 56%, were managed by orthoses, 15% by local anaesthetic and steroid injection, 13% by conventional physiotherapy, 10% by surgery and 3% by advice. Outcome Of these patients, 18% were unchanged, or improved by less than 40% 34% improved by between 40% and 80%, and 48%by over 80%. The greatest succesa was recorded by patients treated by orthoses and the least by surgery. There were 12% who defaulted from follow-up
advice, orthosee or local anaesthetic and steroid w o n in equal proportions.
outwme The mqjority, a%, were unchanged,or improved by lese than 40%. 30% improved by between 40% and 80%;and 5% by more than 80%. Of these patienta, 18% failed to keep their follow-up appointmenta
Shoulder (table 2) Dicrgnosis Acromioclavidar degeneration, supraspinatus impingement and gleno-humeral c a p d i t i e were the most common presenting disorders.
!hatment The W r i t y , 6096, were treated by steroid iajection, 27% by advice and 13% by surgery. Outcome O f these patients, 13% were unchanged; 67% were
improved by between 40% and W,and 20% either remitted completely, or improved by more than 80%. All patients treated by local anaesthetic and steroid iqjection were improved by more than 40%. There were 12% who deSaulted from follow-up
Elbow (table 2) Dicrgnosie , The mqjority of patients with elbow dieordew presented with lateral or medial epicondylitia Tkeatment "he majority, 6346, were treated by steroid iqiection and the remainder by manipulation or electrophyeiotherapy, surgery or referral to other specialties in equal proportions. Outcome O f all those treated by steroid i-ion,
80% were
improved by more than 80%.
Overall Tmatment Manipulation or electrophysiotherapy wns the initial management for 50% of patients and the final treatment for 31%. Of the 31 patients who received physiotherapy as their final treatment, 79% were improved by 40% or mom Significantly gmater numbera of patienta in whom the final treatment was orthotice or local anaesthetic and steroid i m i o n reported impravement of over 8096,than of those who received advice and physiotherapy (chi squared equals 4.5 p < o.o~), pr surgery and referrals to other medical specialties (chi squared equals 4.5 p < 0.001).
Outcome at End of Weatment A total of 21% of patients were unchanged, 8% had
Cervical Spine (table 2)
improved by less than 40% 42% by between 40% and 80%; 21% by more than 80%; and in 8% the problem
Diagnosis The majority of the 28 patients presented with cervical spondylosis with mild root irritation.
resolved.
Deatment all the patients seen for cervical spine disorders, 68% were treated with physiotherapy and the remainder by
Ofthe 189 patienta who completed treatment, 89% were satisfied. Of general practitioners who could recollect the referral, 95% were satiefied by the treatment received.
Of
Patient and GP Satisfaction
Phydothenpy,M y 19B4,vol80, no 6
284
Discussion The demand for orthopaedic out-patient appointments exceeds provision and in this city is one of the principal causes of disenchantment with hospital services (Hicks and Baker, 1991). During the study period, some 50%of cases referred to the orthopaedic surgeon author were seen by the physiotherapist clinical assistant. The exercise both increased provision in the orthopaedic outpatient department and brought experience of t h e potential of additional treatment modalities to the outpatient physiotherapy unit where the clinical assistant was superintendent, targeting resources there more accurately. In a case control study (Weale et a2, 1993) comparable results, but a higher level of patient satisfaction, were achieved by a physiotherapist in this role t h a n staff grade orthopaedic surgeons, particularly in t h e management of low back pain. As physiotherapists have greater familiarity with instruction in self-help and t h e treatment of chronic conditions than orthopaedic surgeons, who are oriented towards operative intervention, it seems t h a t this population might be better served by physiotherapists t h a n by surgeons. I n considering t h e alternative in managing this group of patients, it is interesting to compare the four possible courses of action.
1. No treatment. 2. All patients seen by a physiotherapist, without extended training.
and consultant support, was able to assess all patients, treat 85% of them independently and achieve 40% improvement or more in 79%. While this paper principally addresses the additional options provided by local anaesthetic and steroid and orthotics to a physiotherapist, it is a descriptive audit, does not randomise conditions into treatment modalities and cannot strictly compare their merits. Physiotherapists are working in this capacity in a number of units throughout the United Kingdom. The cost of training physiotherapists is very much less t h a n for orthopaedic surgeons and if, as preliminary studies suggest, physiotherapists are at least as effective as medically qualified personnel in out-patient departments, there is likely to be a n expansion of this role.
Two further areas could be addressed profitably in the future. Controlled trials, involving random allocation of patients with comparable histories to medical and physiotherapy staff, would accurately establish the respective roles of each type of personnel. In addition, we obtained detailed questionnaires from patients with pain maps. We used these to help in history taking, but not to predict patients who could benefit most from outpatient treatment. There were 19% of patients who failed to keep appointments and 21% were not helped at ali. The resources utilised on this population could have been better targeted to those more likely to benefit.
3. Management by a general practitioner. 4. An additional consultant clinic.
If no treatment had been offered and the patients had remained on the waiting list, 10% of patients requiring surgery and t h e 79% who benefited from conservative management would not have been helped. Identifying t h e 10% who required surgery was not possible from t h e G P referral letters. Of 88 referrals for back disorder, 19 patients had signs of root irritation of whom 50% were surgically decompressed. Lumbar nerve root decompression was one of the more successful surgical interventions undertaken. Advice, or manipulation and electrophysiotherapy, was the final treatment chosen by a n experienced physiotherapist in 31% of cases. Had all these patients been sent to a n out-patient physiotherapy department, waiting times would have increased and t h e therapeutic endeavours of t h a t department would have been optimally targeted in fewer than one-third of cases.
Authors Julie Hockin MCSP is a superintendent physiotherapist and Gordon Bannister MD MChOrth FRCS is a consultant orthopaedic
surgeon at Southmead Hospital, Westbury on Trym.
Address for Correspondence Mr G Bannister FRCS, Consultant Orthopaedic Surgeon, Southmead Hospital, Westbury on Trym, Bristol BSlO 5NB. References Byles, S E and Ling, R S M (1989). ‘Orthopaedicout-patients a fresh approach‘, Physiotherapy, 7, 435-437. Dixon, A St J, Cosh, J A and Kersley, G D (1972). ‘Local corticosteroid therapy for painful rheumatic states’, Clinical Rials Journal, 3, 14-18. Hicks, N R and Baker, I A (1991).‘Generalpractitioners’ opinions of health services available to their patients’, British Medical Journal, 302, 991-993. McConnell, J (1984). ‘The management of chondromalacia patellae: A long-term solution’,Australian Journal of Physiotherapy, 32, 4, 215-222. Roland, M 0, Porter, R W, Matthews, J G , Redden, J F, Simonds, G Wand Bewley, B (1991).‘Improving care: A study of orthopaedic out-patient referrals’, British Medical Journal, 302, 1124-28. ROSS, A K, Davis, W A, Horn, G and Williams, R (1983).‘General practice orthopaedic out-patient referrals in North Staffordshire’, British Medical Journal, 247, 1439-41.
The G P could have offered advice, referred to physiotherapy and administered local anaesthetic a n d steroid injection. Postgraduate orthopaedic training is not formally included in most G P rotations and a high proportion of GP referrals are considered inappropriate (Roland et al, 1991). Local anaesthetic and steroid injection can be technically demanding and many GPs cannot differentiate appropriate sites. Assuming the GPs had orthopaedic experience and were competent in steroid injection, 65% of patients could have been treated by the family practitioner services of whom 76% would have shown a n improvement by 40% or more.
Surgery, 750, 1, 43.
By contrast, a physiotherapist, with extended skills in orthotics and local anaesthetic and steroid injection
West, R R and McKibbin. B (1982). ‘Shortening waiting lists in orthopaedic surgery out-patientclinics’,British Medical Journal. 284, 728-730.
Physiotherapy, May 1994, vol80, no 5
Weale, A E, Hockin, J and Bannister, G C (1993).‘Physiotherapist or surgeon in orthopaedic out-patients?’Journal of Bone and Joint