The Advanced Practice Physiotherapist in Orthopaedic Care
Alice B. Aiken, PhD, PT
School of Rehabilitation Therapy
Care for persons with orthopaedic problems can be complex. Usually the first health care contact for such a condition is the family physician. More than 60% of the people who suffer from orthopaedic problems will seek attention from their family physician1 who will typically treat the patient with anti-inflammatory medications and advice on rest2. However, family physicians may lack the background knowledge and sufficient contact time to comprehensively manage orthopaedic conditions, and patients may not respond to conservative treatment, leaving referral to a specialist as the typical course of action.
In order to address access to care issues, many countries, including Canada, have begun to examine multidisciplinary collaborative models of care. Improved use of non-physician health care providers can have a positive impact on the cost of health care3, on efficiency of the health care system in terms of human resources4,5, on patient satisfaction with care6,7, and on physician productivity and satisfaction with the work environment8-10.
In the Canadian health care system, the most obvious choice for collaborative care in the management of orthopaedic problems is the physiotherapist because they are experts in the conservative management of these conditions11. Using physiotherapists to manage non-surgical orthopaedic patients in a front-line, clinic setting is not new. The model of care in which a physiotherapist assesses, triages and manages orthopaedic patients has been successfully implemented in other countries12-19.
The new trend in Ontario, particularly in hip and knee arthroplasty clinics, is for advance practice physiotherapists (APPs) to assess and triage patients for orthopaedic surgical assessment, and to manage those patients who require conservative care with appropriate advice, or by referring them for other management, such as a dietician. Patients who do require a consultation with the surgeon are then prioritized for a visit within one, three or six months, allowing the surgeon to deal with the more urgent cases first. APPs can also perform regular check-ups of those patients who have been referred for arthroplasty but who have been deemed by the surgeon as inappropriate at the current time, thereby taking the patient off the surgeon's wait list. In addition, these APPs are able to manage postoperative arthroplasty patients, especially for the six- and 12-month follow-up visits. This again serves to reduce the number of clinic patients that orthopaedic surgeons are required to see20.
These APPs work in hospitals and have delegated acts that allow them to order X-rays, blood work and other necessary tests in order to make appropriate care decisions about patients. They will typically work with the surgeons for a period of time before starting their own clinics in order to learn the criteria that each surgeon uses to judge the necessity for surgery, and to learn additional radiographic diagnostic skills. This period of time also familiarizes the surgeon with the capabilities of the APP so the surgeon can be confident in the abilities of the person with whom they will work collaboratively.
Although the training for APPs is not standardized, several hospitals have developed training programmes, and one Ontario university has implemented a Masters programme in advanced practice. Typically the training will still be done on site in a similar format to that of a resident.
APPs can see patients in a timely manner and are able to identify those who require conservative management or who need to see the surgeon. This allows the orthopaedic surgeons to care for patients with conditions more amenable to surgical intervention. This collaborative model of care between physicians and physiotherapists has been shown to: a) increase the number of patients seen in the out-patient orthopaedic clinics since only those who may require surgery see the surgeon; b) improve patient and physician satisfaction by easing the burden of excessive wait times on both; and c) may ultimately improve publicly-funded access to the appropriate care for orthopaedic problems 20.
Further information about APPs could be found on the Ontario Physiotherapy Association's web site: http://www.opa.on.ca/
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