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Outcomes of a consultant physiotherapy upper limb clinic: reducing the patient journey through early access to specialist care

02 April 2024
Volume 2 · Issue 2

Abstract

Background:

Many patients referred into secondary care for a ‘surgical opinion’ do not have a surgical target.

Aims:

An intermediate care consultant physiotherapy upper limb clinic was set up to reduce the patient journey and deliver the right advice/treatment at the first point of assessment.

Method:

A clinic was set up to: enable an expert clinical assessment; deliver education to the patient regarding diagnosis, treatment options and likely outcomes; arrange appropriate imaging; and deliver care on the day (advice, specialist physiotherapy, injection or splinting). This creates a proactive approach to waiting list management and ensures early management for patients.

Results:

Complete data from the first 173 patients seen are presented. A total of 99.5% had treatment delivered on the day. Waiting times were reduced by a mean of 3.5 months for appointment, and 27 weeks for physiotherapy input. All received on-the-day expert physiotherapy advice, exercise programmes and progression advice. Oxford Shoulder Score improved by 17.5 (mean). QuickDASH scores improved by 34.72 (mean). Patient satisfaction was extremely positive.

Conclusion:

The clinic has been successful at shortening the patient journey, reducing the burden on secondary care and delivering best care in a timely manner.

Following the COVID-19 pandemic, waiting times for elective orthopaedic clinics increased significantly. It was identified that many patients being referred into secondary care for a ‘surgical opinion’ did not have a surgical target. Locally, it was identified that around 13% of patients in shoulder clinics were proceeding to surgery. However, it is difficult for those in primary care to manage patients who are still struggling with symptoms once they have exhausted the available options.

Within upper limb orthopaedic clinics, many patients require specialist physiotherapy input, as opposed to surgical intervention. They often need the reassurance of an expert assessment, appropriate imaging and the judicious use of steroid injections for pain relief, which facilitates engagement in physiotherapy. A comprehensive package of assessment and treatment is ideally managed by a consultant or high-level advanced physiotherapist. Advanced practice is defined by the multi-professional framework for advanced clinical practice in England as ‘care delivered by experienced, registered health and care practitioners’ (Health Education England (HEE), 2017). It is a level of practice characterised by a high degree of autonomy and complex decision-making, underpinned by a master's-level award or equivalent that encompasses the four pillars of clinical practice, leadership and management, education and research, with demonstration of core capabilities and area-specific clinical competence (HEE, 2017). Consultant practice involves expertise across the four domains of: 1) expert practice; 2) learning, developing and improving across the system; 3) strategic, enabling leadership; and 4) research and innovation (HEE, 2023). Expert practice is needed to deliver the service, and the practitioner must work with a high degree of autonomy, using complex decision-making skills and working across pathways/services. The set-up of this clinic involved enhanced leadership skills, to create an opportunity to have maximum impact on practice, adding and sustaining capacity and capability. By working across systems to incorporate a clinic setting where communication between imaging, surgeons and therapists was optimal, an environment was created where the patient is at the centre.

In the UK, one in six people lives with pain, fatigue, lack of mobility and dexterity, and around one-third of the population has a musculoskeletal (MSK) condition (Public Health England, 2022). This creates a burden on secondary care appointments, with patients seeking help to improve their pain or function. Patient-centred care can be promoted through a patient's education regarding their diagnosis, treatment options and likely outcomes. There is enhanced opportunity to engage patients in relevant shared decision-making. Shared decision-making ensures that individuals are supported to make decisions that are right for them. It is a collaborative process through which a clinician supports a patient to reach a decision about their treatment (Joseph-Williams et al, 2017).

One-stop shoulder clinics have been effectively used elsewhere (Gwilym et al, 2007; Patel et al, 2023); however, the emphasis has been on the use of ultrasound scans for diagnosis and delivery of guided injections. The GRASP trial (Hopewell et al, 2017) found that a one-off best advice session of physiotherapy (plus or minus a steroid injection) can be as effective as a course of treatment. This supports the value of a physiotherapist-led specialist one-stop clinic to deliver best advice and provide a complete package of assessment and management within the first appointment.

To deliver this service, a consultant physiotherapist-led intermediate care upper limb clinic was set up. This innovative and creative approach to waiting list management ensures early, appropriate treatment and management for patients, avoiding mixed messages regarding diagnoses, treatment options and likely outcomes. Patients often receive mixed messages when seeking advice and seeing multiple clinicians, which can reinforce negative beliefs about their pain or disability around doing harm, the body needing protection and about vulnerability of the painful body part (Caneiro et al, 2021). This is in line with the Getting It Right First Time (GIRFT) approach, which aims to bring about higher-quality care in hospitals, at lower cost, by reducing unwanted variations in services and practices (Kings Fund, 2017).

Aims

The main aims of the clinic are to:

  • Demonstrate a reduction in waiting times from referral to meaningful treatment for patients
  • Demonstrate enhanced quality of care outcomes and patient satisfaction
  • Demonstrate the value of advanced practice physiotherapy in MSK disorders.
  • There were several additional aims to support the efficacy of the clinic:

  • Monitor appropriateness of referral into clinic
  • Monitor clinic activity in terms of referral diagnoses
  • Evaluate referrals to radiology (including imaging completed on the same day and those requiring further referral)
  • Register the number of injections performed
  • Register the number of patients commencing meaningful management on the same day
  • Define those who still required listing for surgery.
  • Method

    A specialist intermediate care clinic was set up to enable an expert clinical assessment, arrange appropriate imaging, discuss treatment options and deliver care on the day in the form of advice, specialist physiotherapy, injection or splinting. Patient referrals were:

  • Patients on orthopaedic waiting lists who appeared to not have a surgical target from their referral were screened and offered an earlier appointment
  • Patients from first contact practitioners or from physiotherapists who felt patients had plateaued, needed further investigation/assessment/injection. This has helped promote and highlight MSK pathways from primary care.
  • An appropriate length of appointment time (30 minutes) was set up to enable patients to have an expert assessment and to ensure the right care was delivered (in line with the GIRFT approach). This would allow the delivery of specialist physiotherapy on the day (rather than further referral) and for delivery of an injection (if appropriate), rather than taking up an orthopaedic clinic appointment.

    If patients needed onward imaging, this could be arranged. With strong links and trusted expertise in secondary care, mentorship/support could be sought from surgical colleagues; if patients required surgery, they could be listed directly from the clinic. This avoided further delay and increased overall efficiency.

    Data collected included patient satisfaction; patient-reported outcome measures (Oxford Shoulder Score and QuickDASH); referral-to-treatment time; number of patients commencing treatment on the day; definitive treatment; number of injections performed; radiology referrals; and diagnoses made.

    Findings

    The clinic was structured to include three new patient appointments, two face-to-face follow-ups and two telephone follow-ups per session (half day/3.5 hours). Complete data are presented for the first 173 patients who attended the clinic.

    Upper limb consultant clinic referral wait times were reduced by a mean of 3.5 months compared to those who continued to wait on orthopaedic waiting lists. Wait time for this clinic stands at 1 month, which is a vast improvement on orthopaedic waiting times, especially for those patients directed in from physiotherapy whose journey would have been prolonged by waiting to see GP and then referred, sometimes delayed further by unnecessary investigations. Physiotherapy is commenced on the day, which avoids an unnecessary delay waiting on the physiotherapy waiting list, which, at its peak, has been up to 27 weeks.

    Treatment was delivered on the day in 99.5% of patients, with only one referral being inappropriate and therefore directed on to the appropriate service. Definitive treatment was delivered in 88.4% of cases; 11.6% did proceed to surgical intervention, but were able to proceed straight to orthopaedic waiting list under mentor surgeons, without needing a further appointment or incurring any delay. All received on-the-day expert physiotherapy advice, exercise programmes and progression advice. Some 37.0% (n=64) were treated with a steroid injection, but also received advice to commence physiotherapy exercises on the day. Follow-up for the majority (79.8%/n=138) was as a telephone call; 71% (n=123) were managed with an open appointment or patient-initiated follow-up (PIFU). Patients who required specialist physiotherapy input were managed in-house in the face-to-face follow-up slots.

    Shoulders were the most common anatomical region seen (68.6%) (Table 1); the most common diagnoses were: subacromial impingement/acromioclavicular joint symptoms (n=43), followed by rotator cuff tear (degenerative primarily) (n=27), frozen shoulder (n=23), instability (n=17), glenohumeral osteoarthritis (n=4), proximal humerus fractures (chronic) (n=2), thoracic outlet syndrome (neurogenic) (n=1) and complex regional pain syndrome (n=1).


    Variable n (%)
    Review of referral diagnoses Shoulder 118 (68.6)
    Hands 37 (21.4)
    Elbow 17 (9.8)
    Neck 1 (0.6)
    Radiology/investigation referrals and type X-ray 50 (28.9)
    Ultrasound scanning 14 (8.1)
    Magnetic resonance imaging (MRI) 6 (3.5)
    Computed tomography (CT) 4 (2.3)
    Magnetic resonance angiography (MRA) 2 (1.6)
    Nerve conduction study (NCS) 13 (7.5)
    Bloods 7 (4)

    For hands, the most common diagnoses were: first carpometacarpal joint osteoarthritis (n=21), trigger finger (n=8), De Quervain's (n=3), carpal tunnel syndrome (n=2), complex regional pain syndrome (n=1), extensor carpi ulnaris subluxation (n=1) and chronic ulnar collateral ligament injury (thumb metacarpophalangeal joint) (n=1). For elbows, the most common diagnoses were cubital tunnel syndrome (n=8), instability (n=5), tennis/golfer's elbow (n=2) and olecranon bursitis (n=2).

    To ensure that a significant improvement is being made for the patients that have attended the clinic, patient-rated outcome measures (PROMs) were collected prior to assessment, and also at follow-up (after treatment commenced).

    For the shoulder, the Oxford Shoulder Score was used, a functional self-reported questionnaire that results in a score between 0–48, with 0 being the worst score, indicating significant pain and poor function, to 48 as the best score. The Oxford Shoulder Score is one of the most commonly used validated outcome measures deployed by shoulder surgeons in the NHS and enables assessment on the quality of care from the patient's perspective (Varghese et al, 2014). Minimal clinically important change is considered an improvement of 6 points (Christiansen et al, 2015).

    For the elbow and hand, QuickDASH was used, an 11-item self-reported questionnaire that measures disabilities of the arm, shoulder and hand. This is a scale ranging from 0–100, where 0 represents no disability and 100 represents total disability. QuickDASH is a short, reliable and valid measure of physical function and symptoms related to upper limb MSK disorders (Beaton et al, 2005). Minimal clinically important change is considered an improvement of 15.91 (Franchignoni et al, 2014).

    Oxford Shoulder Scores improved from a mean of 24.7 (SD 8.3) to 42.2 (SD 5.4), a mean improvement of 17.5. QuickDASH scores improved from a mean of 53.7 (SD 22.2) to 18.98 (SD 18.78), a mean improvement of 34.72. Therefore, both scores represented clinically significant functional improvements, with all patients showing a meaningful level of improvement throughout.

    Investigations ordered are displayed in Table 1; the majority of these were X-rays (28.9%) and were performed on the day. More specialist investigations (ie those traditionally ordered by orthopaedic doctors) were ordered by the physiotherapist, preventing further delays. Patients could still commence treatment (mainly in the form of physiotherapy) while awaiting imaging, to prevent delays in all cases.

    Did not attend (DNA) follow-up rate was low (2%), and these were either being unable to contact patients for a telephone call or for face-to-face follow-ups. Letters were sent to patients, inviting them to get in contact if they had ongoing problems, and no contact was made.

    Satisfaction data were collected for the first 50 patients attending, gathered using an anonymised paper survey completed after their first appointment. Patient satisfaction was extremely positive (Figure 1). All of the patients agreed or strongly agreed that the appointment was helpful and were satisfied with the information they received about their condition. Comments from patients included:

    ‘Great clinic, helpful and very informative.’

    ‘To be seen personally has been the key for me today, so nothing to improve.’

    FIGURE 1. Survey responses

    Feedback was also gained from physiotherapists who have referred into the clinic (Box 1). Key comments included:

    ‘Fantastic service to patients […] patient able to be assessed, investigated, management plan in 1 appointment […] patient extremely satisfied when offered this service.’

    ‘Able to clinically reason with the consultant physiotherapist and gain understanding of appropriate patients for the clinic.’

    ‘Creates a learning opportunity for physiotherapists referring into the clinic.’

    BENEFITS FOR PHYSIOTHERAPY STAFF

    Able to clinically reason between patients and consultant physiotherapists (CPs), and gain an understanding of which patients are appropriate for the clinic

    Can provide high-quality services to patients

    Can keep waiting times short, which allows minimal disruption to patient's recovery time and increases satisfaction

    Able to refer patients with a variety of upper limb conditions, which helps their functional rehabilitation

    Able to see patients quickly after their interventions

    Able to consult with the CP to understand how best to manage patients

    Able to help patients manage their expectations

    Help maintain assessment and treatment continuity

    Able to provide specialist direction to patients and improve their confidence/engagement.

    Conclusions

    The outcomes of the specialist intermediate care clinic demonstrate an effective way to manage patients with upper limb disorders, negating the need for secondary care orthopaedic appointments. The outcomes include reduced time to treatment, high satisfaction rates and the ability to provide a comprehensive package of assessment and treatment. Successful functional improvements have been demonstrated, with reduced need for ongoing intervention. The emphasis of this clinic has been the use of expert assessment and the ability to deliver specialist physiotherapy, along with open discussions around treatment options. It must be emphasised that the physiotherapist leading the clinic has many years of experience working alongside consultants in secondary care, and continues to work with consultant mentors to ensure evidence-based practice and contribute to the success of the clinic. While this clinic was set up within the UK to address waiting times, a similar model could be adopted across any healthcare setting with appropriately skilled physiotherapists.

    There may be scope for further improvement if the clinic can provide point-of-care ultrasound imaging, guided injections or suprascapular nerve blocks. If these adjuncts were available, it would increase the scope of the clinic and reduce pressure on radiology and pain clinics. At present, the clinic is only available in one location, which limits patient access; in the future, introducing similar clinics with the same ethos within the integrated care system in multiple locations would be beneficial.

    KEY POINTS

  • Consultant and advanced practice physiotherapists are well-suited to provide intermediate care services
  • Consultant- and advanced practice-led physiotherapy clinics can shorten the patient journey and reduce the burden on secondary care services
  • Patient-reported outcome measures show a consultant-led physiotherapy clinic can be an effective way to manage upper limb patients without a surgical target.
  • CPD / Reflective Questions

  • Should patients be reviewed by specialist advanced physiotherapists prior to surgical consideration?
  • If patients are given effective advice earlier in their pathway, does this reduce the likelihood of surgical intervention being required?
  • If the burden on secondary care clinics was reduced, would overall waiting times for surgery in turn be reduced?