Is physiotherapy willing, ready and able to implement different models of care?

Physiotherapy as a profession has exponentially evolved over the past 20 years. In the case of musculoskeletal physiotherapy, the profession has moved from providing largely passive therapy (e.g. manual therapy and electrotherapy) that was therapist-centred to one where the approach to care is more active and patient-centred. This paradigm shift followed the introduction of evidence-based practice in the early 1990s. Clinicians were encouraged to implement the evidence, and change behaviour from their usual practice (e.g. dominance of electrotherapy) to provide different practices (e.g. targeted advice/exercise). Physiotherapy has embraced these changes and de-implemented some aspects of care while implementing others. As different models of care emerge, and we enter the next paradigm, I find that the question to answer is whether physiotherapy is willing, ready and able to implement different models of care.

Using musculoskeletal conditions such as whiplash as an example, the journey has taken us to consider stratified care, yet there are still barriers to implementation. In this editorial, the ideal research design, and key barriers to address are suggested as ways forward. The paradigm of evidence-based care led us to consider that randomised controlled trials (and their synthesis (systematic reviews or clinical guidelines) became the highest form of evidence on which to base our practice. Yet many trials show equivocal effects for the new intervention studied vs usual care and are unable to identify responders to the intervention. An example was our very own trial where a single session of “advice” provided similar outcomes to a comprehensive physiotherapy exercise programme in people with chronic whiplash [1]. As a clinician–researcher, my “researcher” hat understands this result, however, my “clinician” hat’s experience is very different. We found that more people did in fact “respond” to the comprehensive exercise than did not. People told us many things, including “I’m more likely to respond if the exercise reduces pain immediately [2] and that trial measures of recovery did not agree with patient-measured recovery [3]. This led us to understand that the RCT is in its purest form and may not answer the questions such as who needs less and who needs more care and how should we measure success.

Stratified care based on the risk of poor prognosis is one way to test this model of care, however, has mixed results to date when tested in musculoskeletal conditions [4,5]. We had hoped that this may show a benefit in people with whiplash, however, both pain and disability outcomes were similar between a stratified and non-stratified care approach [6]. However, as a profession, we do have a responsibility to reduce care when not needed (de-implementation) and recognise who needs more comprehensive care when needed and provide earlier access to this care (implementation). We are capable of doing this, given we have de-implemented some of our practice previously, but what approach should be next?

1. Implement clinician-patient-led individualised care? As a clinician, stratified care is implemented every day, only on an individual basis. An “individual” is assessed and targeted care is provided based on individual needs. Sometimes these may be biological, psychological, physical (eg addressing movement, strength or sensorimotor impairments) and/or social. Given each person experiences their condition with a different combination of these factors present, how do we truly design a trial to test individualised care? In reflecting on this with respect to whiplash populations and what our patients tell us, should we consider a clinician-led treatment-responsiveness stratified care approach? For example, the clinician and patient determine whether the patient may respond to any given approach early after a presentation (e.g. test an exercise and look for an immediate response). This would however mean that the “stratified care” subgroups become an “n of 1”. The suggestion therefore may be that alternate research designs (eg n of 1 trial) may be more appropriate to test new models of care than expensive RCT’s.

2. Using our emerging roles in models of care. One consistent finding amongst stratified care is the high level of trust and confidence people have in physiotherapists in managing musculoskeletal conditions. Yet if we continue care that does not improve health outcomes, patients lose confidence. Our common practice is to refer outside the profession, yet this may result in unnecessary more expensive care (eg injections, surgery). Key to stratified care approaches has been utilising our own experts in emerging models of care for certain “sub-groups” of patients. That is, for example, referring patients with complex presentations outside our own experience to our peers with specialised expertise in that area (yet within scope). Whilst common in medicine, there are still barriers to this approach within our profession [7] such as fear of losing the patients or feeling inadequate. The experience of patients however is often the opposite, where they express both satisfaction and confidence in their referring physiotherapist for recognising the need early. The question, therefore, is whilst we have worked towards emerging new roles in physiotherapy, are we ready as a profession to overcome the barriers to truly and successfully implement new models of care?

I am looking forward to 2023 when new innovative models of care will be tested and we evolve as a profession not only in what but how we conduct both research and clinical practice.

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Funding

The author(s) reported there is no funding associated with the work featured in this article.