1. Advanced practice physiotherapy roles require high levels of clinical expertise

Advanced practice physiotherapists independently manage simple fractures and dislocations, spinal pain and soft tissue injuries in emergency departments. 

Advanced practice physiotherapy roles have existed in Australia for almost 20 years, primarily in the musculoskeletal area in public health settings.

Advanced practice physiotherapists use high levels of clinical expertise and experience to assess and independently manage a specific cohort of patients, often with complex presentations.

Advanced musculoskeletal physiotherapists work in emergency departments across Australia, independently managing simple fractures and dislocations, spinal pain and soft tissue injuries.

They also work alongside medical specialists and surgeons, assessing patients on public health waiting lists in areas such as neurosurgery, orthopaedics and rheumatology.

Many roles across the country have been established for more than 10 years and are embedded as first-line options for patient care.

Advanced practice roles can exist in almost any area of physiotherapy, including women’s and men’s health, paediatrics, cardiothoracic surgery, neurology and pain, and are distinct from standard physiotherapy practice due to the high-level decision-making and risk management required and the unique environments in which advanced practice physiotherapists typically work.

2. First contact physiotherapy practitioners can manage musculoskeletal conditions effectively to reduce the load on primary care

Emerging evidence from the UK demonstrates the effective use of advanced physiotherapy practitioners for the management of musculoskeletal conditions in a primary healthcare setting.

Musculoskeletal disorders are the second largest cause of disability and the progression of chronic conditions in an ageing population is expected to increase the healthcare burden in public healthcare settings (Marks et al 2017).

The ability to redirect a portion of this patient load to physiotherapists has been shown to reduce the musculoskeletal case load for medical staff in primary healthcare.

Importantly, it has also been shown that physiotherapists are able to consistently identify and refer patients presenting with serious pathologies, while also reducing the number of referrals to specialist services such as orthopaedics.

This demonstrably reduces waiting lists and waiting times for specialist care.

Patient satisfaction with physiotherapy-led services remains high, with patients as satisfied or more satisfied with first contact physiotherapy care as with other primary healthcare (Downie et al 2019).

3. Advanced practice physiotherapists have high diagnostic agreement with specialists

There is a high degree of diagnostic agreement between advanced practice physiotherapists and specialists such as orthopaedic surgeons. 

Advanced practice physiotherapists have high levels of diagnostic agreement with a variety of specialists.

Physiotherapy-led musculoskeletal clinics have been shown to be safe and effective in a primary contact setting, such as general practitioner clinics, with high patient satisfaction (Ludvigsson & Enthoven 2012).

In a systematic review of randomised controlled trials and observational studies conducted by Trøstrup et al (2020), advanced practice physiotherapists were shown to be as effective as orthopaedic surgeons in the diagnosis of musculoskeletal conditions.

The study also reported high agreement when comparing the diagnosis made by an advanced practice physiotherapist with surgical findings or medical imaging.

Furthermore, Mír et al (2018) concluded that advanced practice physiotherapists had high diagnostic agreement with paediatric orthopaedic specialists.

Similarly high levels of diagnostic agreement have also been shown for advanced practice physiotherapists and neurosurgeons in physiotherapy-led low back pain triage clinics (Robarts et al 2017).

As part of a longitudinal randomised controlled trial, Samsson and Larsson (2015) showed that advanced practice physiotherapy-led musculoskeletal triage clinics were as effective as normal care when measuring self-reported, health-related outcomes in the short, immediate and long term.

4. Advanced practice physiotherapists effectively manage simple fractures in virtual fracture clinics

Mackenzie et al (2018) demonstrated that common fractures can be effectively managed with braces (rather than plasters) and minimal follow-up.

Virtual fracture clinics have been shown to reduce footfall in hospitals, reduce costs (via fewer appointments and X-rays) and provide both high patient satisfaction and good outcomes (Khan et al 2020).

A physiotherapist-led orthopaedic trauma telehealth clinic (virtual fracture clinic) has been run out of Fiona Stanley Hospital in Perth since May 2020.

The clinic is staffed by advanced practice physiotherapists, who also work in the emergency department. 

Common injuries routinely managed include clavicle, radial head, metacarpal, metatarsal and toe fractures.

As the advanced practice physiotherapy workforce is involved in both acute (emergency department) and ongoing (orthopaedics) care, it is well positioned to develop cost-effective, evidence-based care that sets patients up to succeed through telehealth follow-up.

To give an example of virtual fracture clinic care, patients with fifth metacarpal fractures are now buddy taped in the emergency department and given range-of-motion exercises.

Previously, they were put in plaster for up to six weeks.

Patients may return to work within a week and typically get very good functional outcomes, with savings of approximately $800 per patient.

5. Advanced practice emergency department physiotherapists provide high-quality emergency care

Patients seen by advanced practice physiotherapists in emergency departments have a shorter length of stay, improved pain control and reduced disability in the short term. 

Studies reveal that patients seen by primary care physiotherapists in emergency departments had a significant reduction in length of stay and wait time compared to usual care, with length-of-stay targets met in 95 per cent of patients (de Gruchy et al 2015, Alkhouri et al 2019, Bird et al 2016, Taylor et al 2011, Coombs et al 2021, Jibuike 2003).

There is also evidence of improved pain control (Schulz et al 2016, Kilner 2011, Lau et al 2008) with reduced opioid use (Lau et al 2008) and reduced time to first analgesia (Alkhouri 2019).

Patients managed by primary care physiotherapists were more likely to be discharged directly from emergency departments, with minimal or no misdiagnoses or adverse effects and reduced disability in the short term (Bird et al 2016, Taylor et al 2011, Kilner 2011, Maka et al 2021).

One study found that almost 50 per cent of clients were managed independently, without medical officer support (de Gruchy et al 2015).

Advanced musculoskeletal physiotherapists are less likely to order imaging (Schulz et al 2016) and were found to have high accuracy in clinical assessment (Jibuike 2003).

Emergency department staff and patients reported high levels of satisfaction with the primary care physiotherapy role (Bird et al 2016, Schulz et al 2016, Lau et al 2008).

Click here for an infographic poster version of this article. 

>> Wendy Milway APAM is an emergency physiotherapy practitioner at Caboolture Hospital in Queensland and the Queensland Chair of the Advanced Practice (including Emergency Department) national group.

>> Rowena Charteris APAM is the senior physiotherapist working in the emergency department at Concord Repatriation General Hospital in Sydney.

>> Piers Truter APAM is an advanced scope physiotherapist and data analyst working at Fiona Stanley Hospital in Perth. He is the team lead of the virtual fracture clinic and is currently completing his PhD in the area.

>> Mark Cruickshank APAM is a senior physiotherapist working in the emergency department at Flinders Medical Centre in Adelaide and an APA Musculoskeletal Physiotherapist.

>> Caitlin Farmer APAM MACP is the National Chair of the Advanced Practice (including Emergency Department) group, the Clinical Lead for Advanced Practice at Royal Melbourne Hospital and an APA Musculoskeletal Physiotherapist.

References

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2.            Downie F, McRitchie C, Monteith W, Turner H. Physiotherapist as an alternative to a GP for musculoskeletal conditions: a 2-year service evaluation of UK primary care data. Br J Gen Pract. 2019;69(682):e314-e320.

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4.            Trostrup J, Juhl CB, Mikkelsen LR. Effect of extended scope physiotherapists assessments in orthopaedic diagnostic setting: a systematic review. Physiotherapy. 2020;108:120-128.

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6.            Robarts S, Stratford P, Kennedy D, Malcolm B, Finkelstein J. Evaluation of an advanced-practice physiotherapist in triaging patients with lumbar spine pain: surgeon-physiotherapist level of agreement and patient satisfaction. Can J Surg. 2017;60(4):266-272.

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