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1.  A qualitative study of the consequences of knee symptoms: ‘It's like you're an athlete and you go to a couch potato’ 
BMJ Open  2014;4(10):e006006.
Objectives
To explore the perceived consequences of knee symptoms on the lives of people aged 35–65 years who had diagnosed osteoarthritis (OA) or OA-like symptoms.
Design
A qualitative study with six focus groups and 10 one-on-one interviews. Constructivist grounded theory guided data collection and analysis. Data were analysed using the constant comparative method.
Setting
Toronto, Canada.
Participants
51 participants (median age 49; 61% female) who self-reported knee OA or reported knee pain, aching or stiffness on most days of the past month participated in the study.
Results
The core finding, disruption and change, illustrates the range of perceived consequences of knee symptoms in peoples’ lives. Participants described the consequences of symptoms on their physical activity (giving up high-level activities or changing how or how much they performed activities), social life (leisure, family and work) and emotional life. Knee symptoms also altered the way participants thought about their bodies and themselves. They reported that they had a new awareness of their knee and that they no longer trusted their knee. They also conveyed that their sense of self was altered.
Conclusions
This study illuminates the significant and varied consequences that mild to moderate knee symptoms have on the lives of adults age 35–65 years. Findings highlight the need for clinicians to tailor advice and support to the individual's needs considering their symptoms, the consequences of symptoms on their lives and their personal context.
doi:10.1136/bmjopen-2014-006006
PMCID: PMC4202017  PMID: 25324325
HEALTH SERVICES ADMINISTRATION & MANAGEMENT; QUALITATIVE RESEARCH; RHEUMATOLOGY
2.  Surgery or Consultation: A Population-Based Cohort Study of Use of Orthopaedic Surgeon Services 
PLoS ONE  2013;8(6):e65560.
Background
This population-based cohort study has the objective to understand the sociodemographic characteristics and health conditions of patients who do not receive surgery within 18 months following an ambulatory visit to an orthopaedic surgeon.
Methods
Administrative healthcare databases in Ontario, Canada were linked to identify all patients making an initial ambulatory visit to orthopaedic surgeons between October 1st, 2004 and September 30th, 2005. Logistic regression was used to examine predictors of not receiving surgery within 18 months.
Results
Of the 477,945 patients in the cohort 49% visited orthopaedic surgeons for injury, and 24% for arthritis. Overall, 79.3% did not receive surgery within 18 months of the initial visit, which varied somewhat by diagnosis at first visit (84.5% for injury and 73.0% for arthritis) with highest proportions in the 0–24 and 25–44 age groups. The distribution by income quintile of patients visiting was skewed towards higher incomes. Regression analysis for each diagnostic group showed that younger patients were significantly more likely to be non-surgical than those aged 65+ years (age 0–24: OR 3.45 95%CI 3.33–3.57; age 25–44: OR 1.30 95%CI 1.27–1.33). The odds of not getting surgery were significantly higher for women than men for injury and other conditions; the opposite was true for arthritis and bone conditions.
Conclusion
A substantial proportion of referrals were for expert diagnosis or advice on management and treatment. The findings also suggest socioeconomic inequalities in access to orthopaedic care. Further research is needed to investigate whether the high caseload of non-surgical cases affects waiting times to see a surgeon. This paper contributes to the development of evidence-based strategies to streamline access to surgery, and to develop models of care for non-surgical patients to optimize the use of scarce orthopaedic surgeon resources and to enhance the management of musculoskeletal disorders across the care continuum.
doi:10.1371/journal.pone.0065560
PMCID: PMC3672140  PMID: 23750266
3.  A single group follow-up study of non-surgical patients seen by physiotherapists working in expanded roles in orthopaedic departments: recall of recommendations, change in exercise and self-efficacy 
BMC Research Notes  2012;5:669.
Background
Specially trained physiotherapists (advanced practice physiotherapists (APP)) are working in orthopaedic clinics to improve access to orthopaedic services and support chronic disease management. Little attention has been paid to the impact APPs may have on non-surgical patients. In non-surgical patients with hip or knee arthritis consulting an APP in an orthopaedic clinic, the objectives were to: 1) describe patients’ recall of APP recommendations, use of self-management strategies, and barriers to management six weeks following consultation; and, 2) compare exercise behaviour and self-efficacy at baseline and six weeks.
Findings
This was a single group pre-and post-intervention study of patients who saw an APP when consulting the orthopaedic departments of two hospitals. At baseline and six weeks participants completed the adapted Stanford Exercise Behaviour Scale (response options: none, < 60 minutes/week, 1–3 hours/week or > 3 hours/week), and the Chronic Disease Self-efficacy Scale (range 1–10; higher scores indicate higher self-efficacy). At follow-up participants completed questions on recall of APP recommendations, use of self-management strategies and barriers to management. Seventy three non-surgical patients with hip or knee arthritis participated, a response rate of 89% at follow-up. Seventy one percent of patients reported that the APP recommended exercise, of whom 83% reported exercising to manage their arthritis since the visit. Almost 50% reported an increase in time spent stretching; over 40% reported an increase in time spent walking or doing strengthening exercises at follow-up. Common barriers to arthritis management were time, cost and other health problems. Mean chronic disease self-efficacy scores significantly improved from 6.3 to 7.2 (p < 0.001). The mean difference was 0.95 (95% CI 0.43, 1.62); the effect size was 0.51.
Conclusions
This pilot study of an APP intervention for non-surgical patients referred for orthopaedic consultation showed promising results, particularly for enhancing use of conservative management strategies such as exercise.
doi:10.1186/1756-0500-5-669
PMCID: PMC3538671  PMID: 23206311
Arthritis; Physiotherapists; Advanced practice; Non-surgical; Self-management behaviours; Orthopaedics
4.  Arthritis Extended-Role Practitioners: Impact on Community Practice (An Exploratory Study) 
Physiotherapy Canada  2011;63(4):434-442.
ABSTRACT
Purpose: We compared practice of extended role practitioners and experienced therapists without extended practice training to determine differences in assessment and management of clients with inflammatory arthritis, in preparation for a randomized controlled trial.
Methods: Retrospective review of randomly selected charts of extended-role trained occupational therapists or physiotherapists and from experienced therapists matched on therapist discipline, geographical location, and time of referral. Three trained reviewers used standardized forms to extract data independently.
Results: We reviewed 58 charts of adult clients with inflammatory arthritis. Compared with experienced therapists, extended-role practitioners were more likely to receive referrals specifically for assessments (52% vs. 14%); to treat clients with undifferentiated arthritis (48% vs. 10%); to document comorbidities (90% vs. 66%); to advocate on behalf of the client with the client's family, physician, or specialist (52% vs. 21%); to recommend or provide exercise or physical activity (86% vs. 62%); to educate clients about pain management (41% vs. 28%), energy conservation (24% vs. 14%), and posture (21% vs. 7%); to recommend splints (41% vs. 31%); and to refer for or recommend radiologic or laboratory assessments (14% vs. 3%). Experienced therapists were more likely to provide education about joint protection (41% vs. 31%), community resources (31% vs. 7%), and assistive devices (45% vs. 21%).
Conclusions: We identified possible differences in practice between extended-role practitioners and experienced therapists without training for extended practice. Capturing these details in future studies evaluating the efficacy of extended role practitioner interventions will be important.
doi:10.3138/ptc.2010-33
PMCID: PMC3207983  PMID: 22942521
arthritis; health manpower; education; professional; role; occupational therapy; arthrite inflammatoire; collaboration interprofessionnelle; examen rétrospectif des dossiers; formation postdiplôme; modèles de soins; professionnels à responsabilités étendues; ressources humaines en santé; traitement de l'arthrite
5.  Magnitude of impact and healthcare use for musculoskeletal disorders in the paediaric: a population-based study 
Background
Although musculoskeletal disorders (MSD) are among the most prevalent chronic conditions, minimal attention has been paid to the paediatric population. The aim of this study is to describe the annual prevalence of healthcare contacts for MSD by children and youth age 0-19 years, including type of MSD, care delivery setting and the specialty of the physician consulted.
Methods
Analysis of data on all children with healthcare contacts for MSD in Ontario, Canada using data from universal health insurance databases on ambulatory physician and emergency department (ED) visits, same-day outpatient surgery, and in-patient admissions for the fiscal year 2006/07. The proportion of children and youth seeing different physician specialties was calculated for each physician and condition grouping. Census data for the 2006 Ontario population was used to calculate person visit rates.
Results
122.1 per 1,000 children and youth made visits for MSD. The majority visited for injury and related conditions (63.2 per 1,000), followed by unspecified MSD complaints (33.0 per 1,000), arthritis and related conditions (27.7 per 1,000), bone and spinal conditions (14.2 per 1,000), and congenital anomalies (3 per 1,000). Injury was the most common reason for ED visits and in-patient admissions, and arthritis and related conditions for day-surgery. The majority of children presented to primary care physicians (74.4%), surgeons (22.3%), and paediatricians (10.1%). Paediatricians were more likely to see younger children and those with congenital anomalies or arthritis and related conditions.
Conclusion
One in eight children and youth make physician visits for MSD in a year, suggesting that the prevalence of MSD in children may have been previously underestimated. Although most children may have self-limiting conditions, it is unknown to what extent these may deter involvement in physical activity, or be indicators of serious and potentially life-threatening conditions. Given deficiencies in medical education, particularly of primary care physicians and paediatricians, it is important that training programs devote an appropriate amount of time to paediatric MSD.
doi:10.1186/1471-2474-13-98
PMCID: PMC3493363  PMID: 22691633
6.  Educational Needs of Patients Undergoing Total Joint Arthroplasty 
Physiotherapy Canada  2010;62(3):206-214.
ABSTRACT
Purpose: To identify the educational needs of adults who undergo total hip and total knee replacement surgery.
Methods: A qualitative research design using a semi-standardized interviewing method was employed. A purposive sampling technique was used to recruit participants, who were eligible if they were scheduled to undergo total hip or total knee replacement or had undergone total hip or total knee replacement in the previous 3 to 6 months. A comparative contrast method of analysis was used.
Results: Of 22 potential participants who were approached, 15 participated. Five were booked for upcoming total hip or total knee replacement and 10 had undergone at least one total hip or total knee replacement in the previous 3 to 6 months. Several themes related to specific educational needs and factors affecting educational needs, including access, preoperative phase, surgery and medical recovery, rehabilitation process and functional recovery, fears, and expectations counterbalanced with responsibility, emerged from the interviews.
Conclusions: Educational needs of adults who undergo total hip and knee replacement surgery encompass a broad range of topics, confirming the importance of offering an all-inclusive information package regarding total hip and total knee replacement.
doi:10.3138/physio.62.3.206
PMCID: PMC2909857  PMID: 21629598
educational needs; patient education; qualitative research; total hip arthroplasty; total knee arthroplasty; arthroplastie totale de la hanche; arthroplastie totale du genou; besoins éducatifs; éducation des patients; recherche qualitative
7.  A population-based study of ambulatory and surgical services provided by orthopaedic surgeons for musculoskeletal conditions 
Background
The ongoing process of population aging is associated with an increase in prevalence of musculoskeletal conditions with a concomitant increase in the demand of orthopaedic services. Shortages of orthopaedic services have been documented in Canada and elsewhere. This population-based study describes the number of patients seen by orthopaedic surgeons in office and hospital settings to set the scene for the development of strategies that could maximize the availability of orthopaedic resources.
Methods
Administrative data from the Ontario Health Insurance Plan and Canadian Institute for Health Information hospital separation databases for the 2005/06 fiscal year were used to identify individuals accessing orthopaedic services in Ontario, Canada. The number of patients with encounters with orthopaedic surgeons, the number of encounters and the number of surgeries carried out by orthopaedic surgeons were estimated according to condition groups, service location, patient's age and sex.
Results
In 2005/06, over 520,000 Ontarians (41 per 1,000 population) had over 1.3 million encounters with orthopaedic surgeons. Of those 86% were ambulatory encounters and 14% were in hospital encounters. The majority of ambulatory encounters were for an injury or related condition (44%) followed by arthritis and related conditions (37%). Osteoarthritis accounted for 16% of all ambulatory encounters. Orthopaedic surgeons carried out over 140,000 surgeries in 2005/06: joint replacement accounted for 25% of all orthopaedic surgeries, whereas closed repair accounted for 16% and reductions accounted for 21%. Half of the orthopaedic surgeries were for arthritis and related conditions.
Conclusion
The large volume of ambulatory care points to the significant contribution of orthopaedic surgeons to the medical management of chronic musculoskeletal conditions including arthritis and injuries. The findings highlight that surgery is only one component of the work of orthopaedic surgeons in the management of these conditions. Policy makers and orthopaedic surgeons need to be creative in developing strategies to accommodate the growing workload of orthopaedic surgeons without sacrificing quality of care of patients with musculoskeletal conditions.
doi:10.1186/1472-6963-9-56
PMCID: PMC2682488  PMID: 19335904
8.  Characteristics of evolving models of care for arthritis: A key informant study 
Background
The burden of arthritis is increasing in the face of diminishing health human resources to deliver care. In response, innovative models of care delivery are developing to facilitate access to quality care. Most models have developed in response to local needs with limited evaluation. The primary objective of this study is to a) examine the range of models of care that deliver specialist services using a medical/surgical specialist and at least one other health care provider and b) document the strengths and challenges of the identified models. A secondary objective is to identify key elements of best practice models of care for arthritis.
Methods
Semi-structured interviews were conducted with a sample of key informants with expertise in arthritis from jurisdictions with primarily publicly-funded health care systems. Qualitative data were analyzed using a constant comparative approach to identify common types of models of care, strengths and challenges of models, and key components of arthritis care.
Results
Seventy-four key informants were interviewed from six countries. Five main types of models of care emerged. 1) Specialized arthritis programs deliver comprehensive, multidisciplinary team care for arthritis. Two models were identified using health care providers (e.g. nurses or physiotherapists) in expanded clinical roles: 2) triage of patients with musculoskeletal conditions to the appropriate services including specialists; and 3) ongoing management in collaboration with a specialist. Two models promoting rural access were 4) rural consultation support and 5) telemedicine. Key informants described important components of models of care including knowledgeable health professionals and patients.
Conclusion
A range of models of care for arthritis have been developed. This classification can be used as a framework for discussing care delivery. Areas for development include integration of care across the continuum, including primary care.
doi:10.1186/1472-6963-8-147
PMCID: PMC2491608  PMID: 18625070

Results 1-8 (8)