Ep 204: Expanding roles for musculoskeletal rehabilitation clinicians, with Dr Simon Lafrance

[00:00:04] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the Editor-in-Chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today.

[00:00:22] Ballooning wait times, overworked and burnt out staff, I'm sure you're only too familiar with the signs of a health system under serious strain. And not just since the COVID pandemic.

[00:00:33] Today, Simon Lafrance, physiotherapist and researcher from the University of Montreal joins us.

[00:00:39] Simon explains musculoskeletal care models that flip the traditional medical model of the doctor as the first contact point a patient has with the health system.

[00:00:48] To a musculoskeletal specialist, like a physical therapist leading instead.

[00:00:53] These advanced practitioner roles are slowly appearing in different health services around the world, and today we look at the evidence.

[00:01:01] Are advanced musculoskeletal practice models a viable way of providing high-value musculoskeletal health care?

[00:01:08] What do patients and providers think?

[00:01:10] We explore the specific example of providing care for people with spine pain to make a compelling case.

[00:01:17] Dr Simon Lafrance, welcome to JOSPT Insights.

[00:01:21] Hi, pretty happy to be here.

[00:01:23] Your research has a really strong focus on ways to boost people's access to high-value musculoskeletal health care.

[00:01:30] Now, it's always challenging when we're speaking with a global audience to narrow down specific issues because everyone's health context is a little bit different.

[00:01:39] The best that you can, what do you see as the main issues with access for patients to specialist musculoskeletal health care right now?

[00:01:47] Well, actually, when we look at global data around the world, in most of the OCD countries, we've seen that over the past few decades, the amount of time between a general practitioner referral to a specialist in the treatment provided, these times have increased and increased over the years.

[00:02:06] So, this is a big problem that we have globally because the healthcare access that we had back in the 90s is not there anymore.

[00:02:15] And when we look especially like at the musculoskeletal care, these waiting times are even longer.

[00:02:21] So, for example, in Canada, in the early 90s, the amount of time between a GP referral to a treatment by a specialist was about nine weeks.

[00:02:32] Now, it's around 27 weeks.

[00:02:35] And when we look at orthopedic care and neurosurgery care, that's more close to like a year in median.

[00:02:42] So, that kind of like means that a lot of these countries with universal healthcare access are kind of like not providing anymore that timely access to care to the patients.

[00:02:55] We can also ask the question, is being placed on a waiting list really having access to care?

[00:03:02] So, we kind of like have to find some solutions to improve that healthcare access.

[00:03:06] And one of these solutions is actually to bring advanced practice physiotherapy models of care.

[00:03:13] Well, at least for musculoskeletal disorders.

[00:03:15] So, in these models, we give kind of like more autonomy, more responsibilities to these physiotherapists.

[00:03:23] And they kind of like take like some roles, some tasks that are traditionally taken by medical doctors,

[00:03:30] such as assessing, diagnosing, triaging those potential surgical candidates.

[00:03:37] And we've seen actually in many countries, like in Canada, that have implemented these models,

[00:03:43] the healthcare access has dramatically improved, both for first consultations and also to see a specialist if needed.

[00:03:51] So, kind of like our research now that we are conducting is actually to study these models and to really have a more broad overview of what they can do to improve healthcare access,

[00:04:04] provide high quality of care to the patients, and also to decrease the cost for healthcare.

[00:04:11] We know that in the global situations, cost to healthcare is kind of like increasing.

[00:04:16] So, we need also to find solutions that provide timely access, high quality of care, and also to minimize the healthcare costs.

[00:04:25] And for muscle school care, advanced practice physiotherapy is definitely a great solution that needs to be taken to be implemented in many countries.

[00:04:34] Now, Simon, this is a problem that has been going since well before the pandemic.

[00:04:40] So, what's driving the decline in people's access to high-value musculoskeletal healthcare?

[00:04:45] Of course, the pandemics made the situation even worse, but that problems exist much before the pandemics.

[00:04:52] And even if we go back to the 70s, during the Vietnam War, the American army had that kind of like issue

[00:05:00] with an increase in the amount of soldiers that had musculoskeletal injuries.

[00:05:05] And at that time, the orthopedic surgeons were not able to assess and to triage these soldiers in a timely access.

[00:05:14] So, they kind of like trained, they had a great idea to train the physical parapets into these advanced roles.

[00:05:22] And that kind of like found a solution for their problems of healthcare access at that time.

[00:05:28] So, it's actually at that time that advanced practice physiotherapy was born.

[00:05:33] And then when we look more at Canadian data, the issue with healthcare access was, of course, present much before the pandemics.

[00:05:44] In the 90s, the median wait time for consultation with a specialist was about nine weeks.

[00:05:49] But it grew up to about 21 weeks just before the pandemics.

[00:05:53] And it got even worse after at around 27 weeks.

[00:05:57] So, it's not a problem that exists since the pandemics.

[00:06:01] It exists since a much longer time.

[00:06:03] And one of the drivers for that problem is just like what they had with the military, with the American army.

[00:06:11] It's an increase in prevalence of people with musculoskeletal disorders.

[00:06:16] There's much more people that need care.

[00:06:19] And the cares also are getting more and more specialized.

[00:06:22] The current model that we have is not working anymore to offer timely access.

[00:06:28] Now, you mentioned advanced practice physiotherapy.

[00:06:32] And I think some listeners will probably feel more familiar with nurse practitioners and some of the other advanced practice roles rather than having a PT in those roles.

[00:06:46] One of the criticisms I hear of this model is that, oh, all it's going to do is put people on a conveyor belt to specialist care and it's going to increase people seeking specialist care.

[00:06:59] In our musculoskeletal context, I think often people are thinking that everyone's going to want to go to the orthopedic surgeon.

[00:07:07] What would you say to those criticisms?

[00:07:10] Well, first of all, advanced practice is not only something that we will see in secondary medical care.

[00:07:16] So, for example, we can develop these models also in primary care.

[00:07:22] So, in an ideal world, we will have advanced practice physiotherapists also in primary care, just like we have also nurse practitioner in primary care in many clinics.

[00:07:33] So, someone with, let's say, like a muscle skeletal disorders, a spine muscle skeletal disorders could be seen, could be assessed in primary care by an advanced practice physiotherapist.

[00:07:46] And this will actually help to reduce the amount of people that are referred to specialized spine surgeries.

[00:07:53] Because the current data that we have is there's about like seven to eight out of 10 referrals that the patients are actually non-surgicals to these models.

[00:08:07] So, we know that like most of those referrals to spine surgery, they shouldn't have been made, actually.

[00:08:14] These patients should have been taken care in primary care.

[00:08:18] So, developing these models both in primary care and in specialized medical care will actually help a lot with access to care.

[00:08:28] And these models could also be developed in emergency departments to improve access and to decrease the amount of time that we spent when we need to consult in these services.

[00:08:40] And there are a few examples of advanced practice PT being implemented in emergency departments.

[00:08:46] I'm aware of some of those models in Australia.

[00:08:49] There's some in Canada.

[00:08:50] So, it's definitely happening around the world in relatively small instances.

[00:08:56] How does advanced practice physiotherapy or physical therapy differ from regular musculoskeletal physiotherapy?

[00:09:04] Really?

[00:09:05] Like when we say the word advanced practice, which, as you mentioned, is not only limited to physical therapy.

[00:09:12] We can have advanced practitioner in nurse, in nursing, in pharmacy with various other professionals.

[00:09:19] It's really when we push the professional boundaries.

[00:09:23] So, we kind of like go a little bit beyond our traditional scope.

[00:09:28] So, for example, a physiotherapist that works in an advanced practice role in spine surgery will kind of like take some roles that are traditionally taken by medical doctors.

[00:09:39] Like doing the assessment, diagnosis, triaging those patients that will normally be seen by the spine surgeons.

[00:09:48] So, there could also be some medical doctors that are delegated, such as prescribing imaging tests, some medications.

[00:10:01] And, of course, it could be challenging to write the exact definitions, especially because the scope of physical therapy is not the same around the world.

[00:10:11] So, for example, the current scope in Australia, in the UK, could be different than the one in Canada, which is also different than the one in France or in African countries.

[00:10:23] So, yes, there's challenges with the exact definitions.

[00:10:27] But to make it simple, it's really when we push the professional boundaries and we kind of like go really at the max of our scope.

[00:10:37] In most of these models, since the main goal is to improve healthcare access, to provide efficient triaging of these patients,

[00:10:47] most of the times it's the care is provided within a single session or with very minimal follow-ups with the patients.

[00:10:55] Because, again, main goal is really like to improve the healthcare access.

[00:11:01] Is that management adequate?

[00:11:04] Because we see that in more like traditional physical therapy managements, we tend to give like a few follow-up sessions to reassess our patients,

[00:11:14] provide more educations, maybe change a few of the components of the exercise programs.

[00:11:19] And when indicated to provide also like other like physical therapy modalities like manual therapy, dry needlings and many others.

[00:11:29] So, one of the big questions we add is, should we actually have follow-ups with the patients in these models to make sure that we provide a good quality of care to these patients?

[00:11:42] So, Simon, this is the perfect lead-in to talking about a trial that you've led and we've recently published in JOSPT.

[00:11:51] This new trial is comparing two different approaches to managing spine pain in adults.

[00:11:56] So, tell us about what these interventions were.

[00:11:58] Yes, actually, we were working in collaborations with the models and models that's implemented in Montreal.

[00:12:07] And kind of like the knowledge users, the people working in this model had the same questions.

[00:12:14] They knew like from previous studies we've made with them that the model was improving access.

[00:12:19] This diagnosis was as accurate as the one made by the surgeons.

[00:12:24] But the big questions remains for those like 75% of the patients that are considered as non-surgicals.

[00:12:33] Are they receiving adequate and high-value care?

[00:12:37] Because that was within a single session.

[00:12:40] What we've done is we conducted a pragmatic randomized control trial.

[00:12:44] So, when we say pragmatic, it's really because we wanted to capture more real-world situation data.

[00:12:51] So, the only thing that we controlled within the trial was the amount of sessions.

[00:12:58] So, patients either receiving a single session with the advanced practice physiotherapist or five additional sessions or a total of six.

[00:13:07] The physical therapists, they add the freedom to really provide the interventions that they considered adequate based on their clinical reasoning.

[00:13:18] So, when we look more in details at the interventions, the people that receive the single sessions,

[00:13:25] they receive educations on their conditions, advice about some activities that they can do,

[00:13:32] stuff that maybe they should try to limit, and also an exercise program that was really like patient-centered.

[00:13:40] So, those patients receive, for example, some of them receive more directional preference exercise, like the McKinsey approach.

[00:13:48] Some receive stretching, motor control, strengthening of the core, really was specific to each patient.

[00:13:56] In comparisons, the people in the multiple session arm receive the same type of educations, same type of exercise,

[00:14:06] but again, really patient-centered with follow-ups.

[00:14:11] So, with some like a modification of the exercise program when needed,

[00:14:14] and also some of them receive passive, an addition of passive physical therapy modalities.

[00:14:21] So, 70% of the patients also receive manual therapy, 17% receive dry needling,

[00:14:28] and there was like a minority of patients that receive other interventions,

[00:14:33] like thermal therapies and taping and other stuff like that.

[00:14:37] And what did you find, Simon?

[00:14:39] At the start, our hypothesis was that there will be like some like minor benefit of the addition of multiple sessions,

[00:14:47] but we actually found there wasn't much of a difference between the two interventions in regards of the clinical outcomes.

[00:14:55] So, the only mild difference was a statistically significant difference for one of the outcomes

[00:15:01] related to the impact of pain on functions, but only at six weeks.

[00:15:06] So, if we really go like in a summary, both programs were effective to improve,

[00:15:12] to decrease pain, to improve functions, quality of life of the patients,

[00:15:16] but there wasn't one that was superior than the other one.

[00:15:20] But then what is also interesting is we also look at other outcomes,

[00:15:24] such as satisfaction with care.

[00:15:27] And the patients that got the multiple sessions in the multiple session group

[00:15:32] actually add higher satisfaction with care with various outcomes that we use, various questionnaires.

[00:15:40] Then we also conduct a few interviews with a subgroup of patients and with the physical therapists

[00:15:46] to really go more in deep about that questions.

[00:15:49] And that's also something that both the patients and the physical therapists report.

[00:15:54] Patients actually add higher satisfactions because they felt more supportive when they had the follow-up sessions.

[00:16:01] They kind of like felt that the physical therapist was there really to help them,

[00:16:07] to really provide them the highest quality of care and to make some change if needed.

[00:16:13] One of the questions that we're kind of like having now is what should we do next?

[00:16:19] What should be the recommendations that we give to both consider to have like high value of care,

[00:16:28] but also like to make sure patients and physical therapists are satisfied with the care provided.

[00:16:34] So basically what we think a group of researchers will be a great approach is,

[00:16:40] of course, to focus on educations, on advice, on exercise prescriptions that, of course, needs to be centered to the patients.

[00:16:51] But maybe we need to offer at least potential follow-up sessions.

[00:16:55] So the patients don't feel that after a session, it's done.

[00:17:01] And that they feel they can also be consult if needed.

[00:17:05] They can have like some supports from the physical therapist.

[00:17:07] The data shows that having like systematic follow-up sessions for patients is probably not providing high value of care.

[00:17:17] There's minimal value for the additions of many follow-up sessions for most of the patients.

[00:17:24] And we can see that as kind of like a challenge because for professions,

[00:17:31] we are providing more care might not lead to more favorable outcomes.

[00:17:36] But I see it more as an opportunity because if we want to integrate more the public systems,

[00:17:44] if we want to place physical therapists in these more advanced roles,

[00:17:49] that's either in primary care, emergency departments, or in specialized medical care,

[00:17:54] we need also to prove that we are effective, that we're efficient,

[00:17:59] that we're able to treat these patients in a timely manner.

[00:18:04] And these data are actually like kind of like supporting that.

[00:18:09] And it brings me back to earlier on in our discussion where you talked about generally,

[00:18:16] these advanced practice roles can save the healthcare system money.

[00:18:20] And I think it's challenging to square this idea that the single session and the multiple session had essentially the same outcomes.

[00:18:29] The multiple session approach is clearly going to cost more money.

[00:18:32] So I guess how do you square the challenge of the cost of health,

[00:18:37] of different models of care to the healthcare system?

[00:18:40] And maybe you can wrap that up in a bigger discussion about cost generally.

[00:18:46] I'll answer that in two parts.

[00:18:49] First of all, when we look at advanced practice physiotherapy models of care compared to more like the standard models of care,

[00:18:57] where it's mainly like medical doctors that are the lead professionals,

[00:19:02] we see that the advanced practice physiotherapy models of care is probably saving monies.

[00:19:08] And I see probably it's because we also have to be very careful when we do these assessments,

[00:19:14] because it's very dependent on the context.

[00:19:17] So the data from Canada might not be generalizable to another country, for example.

[00:19:24] But what we're seeing is that in these models,

[00:19:28] there's a trend to have a fewer amount of the patients that end up having a surgery.

[00:19:33] And we know that surgeries are very, very costly for the system.

[00:19:39] Then there's also like a fewer amount of medication that are prescribed,

[00:19:43] fewer amount of imaging tests that are prescribed.

[00:19:47] So these are also possibility to save money.

[00:19:51] This is not a comparison between physical therapists and medical doctors.

[00:19:55] Medical doctors are also involved in the advanced practice physiotherapy models of care.

[00:20:00] They're just not the lead providers.

[00:20:03] And that just makes sense because we keep, for example,

[00:20:07] the real specialty of a surgeon for the few patients that really need them.

[00:20:12] So these models are really about providing the right care to the right patients at the right times.

[00:20:19] When we look at within the system to compare one sessions to multiple sessions,

[00:20:26] well, we haven't studied that yet.

[00:20:29] We're currently looking at data for the economic impact.

[00:20:33] But there's at least a good hypothesis that the single sessions will cost less.

[00:20:39] I don't see that as a challenge if it's the case.

[00:20:41] I see that as an opportunity for us to have a look at the interventions that we're providing

[00:20:47] and to try really to optimize the value of the care that we're providing.

[00:20:52] And that doesn't mean, for example, to stop to do manual therapy.

[00:20:56] But maybe we need to explain the potential impact of manual therapy to the patients a little bit more,

[00:21:04] to really select the patients that we want to provide manual therapy and other passive modalities,

[00:21:10] and maybe to do it a little bit less or not to do it as systematically as we tend to do.

[00:21:17] And to really focus on the high value of care interventions that we have,

[00:21:22] which are patient-centered educations, advice, and exercise prescriptions.

[00:21:29] Simon, I really like this emphasis on high value health care.

[00:21:34] And I can't help but pause here and take the view of someone who's listening in who's not a PT,

[00:21:41] who might think, oh, this is a bunch of physios talking amongst themselves about how great they are.

[00:21:48] What's your pitch to people who are a bit skeptical or who might think that we're very biased in pushing our own agenda

[00:21:56] for the physical therapy, physiotherapy profession here?

[00:22:00] How do you make the case for changing the way that we think about delivering health care?

[00:22:07] Actually, if we go back to the big picture,

[00:22:09] the issue is the lack of health care access that we have for the populations.

[00:22:15] Canadian populations and populations in many other countries don't have health care access,

[00:22:21] don't have the health care access that they deserve.

[00:22:23] So we need to find solutions to kind of like solve that issues.

[00:22:30] And one of these solutions is really to change the approach with the current model of care.

[00:22:35] Now we're more in a physician-centric models of care,

[00:22:38] but we need to change that with more an health care provider-centric models of care.

[00:22:44] That could be with nurse practitioner in primary care for various medical disorders.

[00:22:49] That could be with giving more role autonomy to pharmacists,

[00:22:54] psychologists for mental health disorders,

[00:22:57] dieticians for issues with the gastric systems,

[00:23:00] and also with physical therapists for the musculoskeletal disorders.

[00:23:05] So when we look really at the big picture as changing who's the lead providers for various disorders,

[00:23:13] providing the right care at the right time to the right patients,

[00:23:17] and also to reserve more the expertise of the physicians,

[00:23:21] of the specialists for those few cases that really needs that expertise,

[00:23:28] that amount of that level of care.

[00:23:31] I think that's a great place for us to finish our chat today.

[00:23:34] Right care at the right time, Simon, is a good thing for us all to aspire to, I reckon.

[00:23:39] So Dr Simon LaFrance, thank you for joining me on JOSPT Insights today.

[00:23:44] Thank you very much, Claire.

[00:23:50] Thanks for listening to this episode of JOSPT Insights.

[00:23:53] For more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice,

[00:23:58] subscribe to JOSPT Insights on Apple Podcasts, Spotify, TuneIn, Stitcher, Google,

[00:24:05] or your favourite podcast app.

[00:24:07] If you like JOSPT Insights, help others find us.

[00:24:11] Tell your friends and colleagues and rate and review us.

[00:24:13] To keep up to date with all the latest JOSPT content, be sure to follow us on Twitter,

[00:24:18] we're at JOSPT, and Facebook, we're JOSPT Official.

[00:24:23] Talk with you next time.