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Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES

Objective

While strong evidence supports the role of physiotherapy in the co-management of patients with rheumatoid arthritis (RA), it remains unclear what constitutes the essential disease-specific knowledge and clinical skills required by community-based physiotherapists to effectively and safely deliver recommended care. This study aimed to identify essential disease-specific knowledge and skills, link these with evidence from clinical guidelines, and broadly determine the professional development (PD) needs and confidence related to the management of RA among physiotherapists.

Methods

An international Delphi panel of rheumatologists, physiotherapists, and consumers (n = 27) identified essential disease-specific knowledge and clinical skills over 3 rounds. Physiotherapy-relevant recommendations from high-quality, contemporary clinical guidelines were linked to Delphi responses. Finally, an e-survey of PD needs among registered physiotherapists (n = 285) was undertaken.

Results

Overarching themes identified by the Delphi panel across the RA disease stages included the need for excellent communication, the importance of a multidisciplinary team and early referral, adoption of chronic disease management principles, and disease monitoring. Of the essential Delphi themes, 86.7% aligned with clinical guideline recommendations. Up to 77.5% of physiotherapists reported not being confident in managing patients with RA. Across the range of essential knowledge and skills themes, 45.1–93.5% and 71.1–95.2% of respondents, respectively, indicated they would benefit from or definitely need PD.

Conclusion

To effectively manage RA, community-based physiotherapists require excellent communication skills and disease-specific knowledge, including understanding the role of the multidisciplinary team and the principles of early referral, chronic disease management, and monitoring. Physiotherapists identified a need for PD to develop these skills.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES

Rheumatoid arthritis (RA) is associated with a significant personal and societal burden, affecting 0.2–1.1% of the adult population worldwide (1, 2). Data from the 2007–2008 Australian National Health Survey indicate that 2.1% of Australians self-reported a diagnosis of RA (3). Recent projections point to the increasing incidence of RA among women (4), while the prevalence is expected to double in Australia by 2050 (5). These data highlight the need to implement contemporary, evidence-based health policy and clinical practice frameworks to facilitate optimal management of RA, now and in the future.

In Australia, physiotherapy services for patients with RA are predominantly provided through the public hospital system. Although this service model facilitates interprofessional management, significant service access issues exist for patients due to long waiting lists and difficulty accessing public hospitals (6–8). In addressing these issues, governments recognize the importance of improving and expanding community-based primary care services for individuals with chronic health conditions (9, 10). Because the role of physiotherapy in managing RA is substantiated by a strong evidence base (11–21), engaging community-based physiotherapists in management of patients with RA is warranted (8, 22). However, whether the current community-based physiotherapy workforce is capable of meeting the likely growing demand for RA-specific physiotherapy services is unknown.

Patients with RA often present with complex clinical presentations, typically involving diverse and significant comorbidities (23). In many cases, effective management for patients with RA requires a detailed understanding of the complex interactions between associated disease processes, comorbidities, and disability, and the translation of that knowledge to clinical practice. However, what constitutes the essential physiotherapy-specific disease-related knowledge and clinical skills required by community-based physiotherapists to effectively and safely deliver care to patients with RA is unclear. Clinical practice guidelines (CPGs) contain care recommendations; however, their development is time consuming and resource intensive (24), leading to a risk that by the time of CPG publication, it may be out of date due to emergence of recent evidence (25, 26). One way of addressing this limitation is to convene a panel of cross-discipline experts in RA to independently identify the essential disease-related knowledge and the core requisite clinical skills. Combining a review of CPGs with expert consultation harnesses both the comprehensiveness of the CPG process and the up-to-date knowledge of clinical and research leaders in the field. Such information could facilitate the delivery of targeted professional development (PD) to the current and future workforce. The aims of this study were to: 1) establish the essential disease-specific knowledge and clinical skills required by community-based physiotherapists to effectively and safely co-manage patients with RA, 2) identify CPGs underpinning the identified knowledge and skills, and 3) undertake a PD needs assessment among the current physiotherapy workforce in Western Australia (WA) to broadly ascertain their confidence, knowledge, and skills in relation to co-managing patients with RA.

Significance & Innovations

  • An international Delphi panel identified the essential disease-specific knowledge and clinical skills required by community-based physiotherapists to safely and effectively manage patients with rheumatoid arthritis (RA).

  • Delphi responses aligned well with recommendations in RA clinical guidelines.

  • Physiotherapists clearly indicate that they require professional development in order to confidently deliver evidence-based interventions to patients with RA.

  • This study provides a clinically-oriented and consumer-oriented evidence-based framework to enhance the skills of community-based physiotherapists in the safe and effective co-management of RA and represents a direct translation of health policy into practice.

MATERIALS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES

This study used a 4-stage process to address the aims (Figure 1). Institutional human research ethics committee approval was granted for this study.

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Figure 1. Schematic of the 4 stages of the project. RA = rheumatoid arthritis; AGREE = Appraisal of Guidelines for Research and Evaluation; RACGP = Royal Australian College of General Practitioners; PD = professional development; WA = Western Australia.

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Stage 1: Delphi study.

A Delphi panel consisting of 11 rheumatologists, 11 physiotherapists, and 5 consumers was convened to establish consensus regarding the essential disease-specific knowledge and clinical skills required by community-based physiotherapists to safely and effectively co-manage patients with RA. The number of panelists and the method of selection were determined following accepted methods (27, 28). To be included on the panel, rheumatologists and physiotherapists were required to meet ≥3 of the following 4 criteria: 1) experience in research and/or a record of publication in the area of RA, focusing on either health service delivery, primary care, nonpharmacologic management, or multidisciplinary management; 2) research, teaching, or student/trainee supervision in clinical rheumatology; 3) participation in RA-related extracurricular activities such as committee membership and involvement with the development of clinical guidelines or PD resources; and/or 4) experience of ≥2 years managing patients with RA (minimum 25% case load). Inclusion criteria for consumers were having a diagnosis of RA and having received or currently receiving physiotherapy services for their RA. The Delphi process comprised 3 rounds.

In round 1, all of the panelists provided demographic, work, and/or disease history information. They responded to open questions regarding what disease knowledge and clinical skills are required by community-based physiotherapists to safely and effectively co-manage patients with RA during 3 predetermined phases of the disease: prediagnosis, the first few years after diagnosis, and the chronic course (with the chronic course phase divided into knowledge and skills for RA itself and for the comorbid conditions associated with RA). Rheumatologists and physiotherapists were also asked to identify relevant CPGs or resources that supported their responses. Data from this first round were condensed into broad themes for “knowledge” and “skills” across the 3 disease phases. More detailed and specific information provided by the panel supporting each theme was referred to as elements.

The second round refined the first round responses by presenting the synthesized data back to the panel as a composite table of themes and elements for knowledge and skills across each phase of the disease. Panelists were then asked to agree or disagree with, and comment further on, the synthesized data.

In the third round, the panelists were presented with a final synthesis of themes and elements and asked to identify which themes they considered essential disease knowledge and skills requirements for community-based physiotherapists, and to rank the importance of each element within each theme using a 5-point Likert scale (range 1–5, where 1 = not needed and 5 = essential). Consistent with an earlier established framework (29), consensus on essential themes was defined as ≥80% of the panelists rating a theme as essential. Consensus on elements within each essential theme was defined as ≥80% of the panelists ranking an element with a score of 4 or 5 on the Likert scale. During the data analysis, clusters of themes emerged representing broad topics across knowledge and skills and across disease phases. These collective themes are referred to as concepts.

Stage 2: appraisal of CPGs and extraction of physiotherapy-specific recommendations.

CPGs identified by the Delphi panel and a literature review were appraised for quality using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument (30). This instrument consists of 23 items rated on a 4-point Likert scale from which 6 domain scores are derived, each expressed as a percentage. The validity and reliability of the instrument have been established previously (31, 32). Four reviewers (AMB, REF, HS, PB) appraised 8 guidelines (13–20), whereas domain scores for a further 7 guidelines (21, 33–38) were adopted from an earlier appraisal (19). Recommendations relevant to the Australian physiotherapy scope of practice were extracted verbatim by the same 4 reviewers from 6 guidelines (16–21), classified as “recommended” or “strongly recommended” based on domain score thresholds described by the AGREE instrument manual (≥4 domain scores of >30%) and published during 2006–2011.

Stage 3: linking Delphi responses with CPG recommendations.

To examine the alignment between the Delphi panelists' responses and evidence from the RA CPGs, each theme and element derived from the Delphi data was reviewed by the 4 reviewers as a group to reach consensus and, where possible, link with a CPG recommendation(s) by manually comparing Delphi responses with the list of extracted physiotherapy-relevant CPG recommendations.

Stage 4: PD needs assessment survey.

A web-based survey was developed using Qualtrics software (www.qualtrics.com). The survey targeted Australian-registered physiotherapists residing in WA and collected demographic, educational, and professional history data. Self-reported confidence in early detection of RA, knowledge of its typical course, managing RA during its phases, and knowledge of evidence-based treatments were assessed using dichotomous (yes/no) questions. PD needs in the area of RA were assessed for those knowledge and skills themes that ≥80% of Delphi panelists nominated as essential for physiotherapists using nominal response categories (definitely require PD, may benefit from PD, and PD not required). These responses were later collapsed to dichotomous outcomes (PD required and PD not required). There were 12 knowledge themes and 13 skills themes. The participants were also asked to indicate their interest in undertaking PD in RA. The survey was pilot tested among 4 physiotherapists prior to dissemination.

The survey was disseminated by the WA Australian Physiotherapy Association (APA) and the Alumni Office of Curtin University (the main educator of physiotherapists in WA). In 2011, there were 2,600 physiotherapists registered in WA, of which 1,621 (62.3%) were members of the APA; the Alumni Office had contact details for 680 physiotherapy graduates.

Statistical analysis.

Qualitative data from the first and second Delphi rounds were analyzed using an inductive content analysis approach (39) to identify themes that were supported by elements. Inductive content analysis uses detailed text statements to develop broader categories (themes). Open coding was performed while reviewing the panelists' responses to open questions in order to develop a large number of knowledge and skills categories across the predetermined disease phases. After open coding, the number of categories was reduced by collapsing similar categories. Finally, each category was assigned a descriptor to create the theme. Primary data analysis was undertaken by one author (REF), while a second author (AMB) independently reviewed the qualitative responses to ensure accuracy of derived categories and abstraction. Elements have been included in presentation of the data to provide transparency and validity in the creation of themes and to provide sufficient detail for readers to ultimately develop education modules. Responses from Delphi round 3 were interpreted using frequencies. Descriptive statistics were used to analyze responses from the e-survey using PASW Statistics 18.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES

Delphi study.

Characteristics of the Delphi panel are shown in Table 1. Across the 3 Delphi rounds, the response rate was 93–100% (Figure 1). A set of 4 overarching concepts emerged across the 3 RA disease phases and across the knowledge and skills areas, including the need for excellent communication, the importance of utilizing a multidisciplinary team (including early referral to rheumatologist), a commitment to chronic disease management, and disease monitoring.

Table 1. Characteristics of the Delphi panel and the PD survey respondents*
 Delphi panel membersPD survey respondents (n = 285)
Rheumatologists (n = 11)Physiotherapists (n = 11)Consumers (n = 5)
  • *

    PD = professional development; RA = rheumatoid arthritis.

  • Rheumatologists: n = 8 (72.7%), physiotherapists: n = 6 (54.5%), and PD respondents: n = 75 (26.3%).

  • Based on the proportion of respondents who are currently involved in clinical practice (n = 255).

Women, no. (%)7 (64)10 (91)5 (100)200 (70.2)
Age, mean ± SD years44 ± 8.447 ± 6.650 ± 17.236.9 ± 11.8
Primary place of employment, no. (%)    
 Public hospital (tertiary)8 (73)4 (36) 45 (15.8)
 Public hospital (nontertiary)0 (0)0 (0) 31 (10.9)
 Private practice1 (9)1 (9) 127 (44.6)
 University2 (18)4 (36) 22 (7.7)
 Community-based health center0 (0)1 (9) 28 (9.8)
 Other0 (0)1 (9) 32 (11.2)
Secondary place of employment, no. (%)    
 Public hospital (tertiary)2 (18)1 (9) 9 (12.0)
 Public hospital (nontertiary)1 (9)1 (9) 3 (4.0)
 Private practice3 (27)2 (18) 21 (28.0)
 University2 (18)0 (0) 21 (28.0)
 Community-based health center0 (0)1 (9) 2 (2.7)
 Private hospital (tertiary)0 (0)1 (9) 0 (0)
 Other0 (0)0 (0) 19 (25.3)
Overall clinical practice experience, mean ± SD years16 ± 7.126 ± 7.1 12.6 ± 11.1
Rheumatology practice experience, mean ± SD years15 ± 7.314 ± 8.4  
Currently involved in RA research, no. (%)9 (82)5 (46)  
Currently involved in RA clinical practice, no. (%)11 (100)7 (64) 140 (54.9)
Current caseload managing patients with RA, mean ± SD %59 ± 23.420 ± 18.3 4.4 ± 5.9
Currently working, no. (%)11 (100)11 (100)2 (40)285 (100)
Years since diagnosis with RA, mean ± SD  22 ± 12.9 
Years receiving physiotherapy services, mean ± SD  12 ± 10.9 
Essential knowledge and skills themes.

Thirty-nine knowledge themes were identified. General physiotherapeutic principles of treatment for patients with RA (for example, managing inflamed joints, pain relief, joint protection, exercise prescription) was considered an essential knowledge theme (≥80% agreement by the Delphi panel) across all 3 disease phases (Table 2). Being alert to a presentation that may suggest RA and the importance of early referral to a rheumatologist were the only themes considered essential by 100% of the panelists.

Table 2. Disease-specific knowledge themes identified by ≥80% of the Delphi panelists as being essential for community-based physiotherapists and scoring of their elements as 4 (important to know) or 5 (essential to know) by ≥80% of the panelists*
Themes by disease phaseDelphi panelists who considered the theme essential, %ElementsAligns with guidelinesPhysiotherapists' PD needs, % of respondents
Definitely require PDMay benefit from PDPD not required
  • *

    Whether the theme and/or element aligned with a recommendation(s) in the appraised clinical guidelines is indicated with a checkmark (alignment) or an x (nonalignment). The proportion of professional development (PD) survey respondents in each PD category is shown for each theme. Where a theme was included in >1 disease phase, the survey question relating to that theme was only shown once. RA = rheumatoid arthritis; GP = general practitioner.

  • Guidelines classified as recommended or highly recommended after review using the Appraisal of Guidelines for Research and Evaluation instrument (30).

Prediagnosis phase      
 Alert to presentation that may suggest RA100Specific signs and symptoms (e.g., presence of an acutely inflamed joint), typical onset33.153.513.5
 Importance of early referral to a rheumatologist100Understanding importance of early diagnosis, importance of early suppression of inflammation/disease activity, understanding factors that may delay referral25.542.532.0
 Physiotherapeutic principles of treating inflamed joints88Maintenance of function, pain relief, joint protection, inflammation suppression25.853.820.4
Early phase after diagnosis      
 Contraindications to some physiotherapy treatments specific to people with RA96Joint instability in the cervical spine36.744.418.9
 Red flags requiring immediate attention and medical review92Red eye, abrupt loss of vision56.433.89.9
 Features requiring referral back to GP or rheumatologist92Repeated flares, tendon rupture, acute joint effusion, serious medication side effects40.741.517.8
 General physiotherapeutic principles of treating RA84Exercise appropriate to disease status (strength, endurance, mobility), pain relief, strategies to minimize inflammation, management of unaffected joints, joint protection, postural advice, energy conservation and pacing, ergonomics (work place and home)33.853.113.1
 Understanding the importance of good communication84Empathy, understanding, rapport building, and listening to the patient; with the health professional team; advocacy on behalf of the patient6.938.254.9
 Multidisciplinary teamwork80Referral pathways to other health professionals, roles and scope of other health professionals18.553.328.0
Chronic phase of the disease (long-term management of RA)      
 General physiotherapeutic principles of treating RA84Emphasis on maintenance of function and independence and participation in activity and work, knowledge to manage acute issues as they arise, support necessary for ongoing self-management, postoperative physiotherapy intervention, preoperative conditioning principles33.853.113.1
 Importance of monitoring RA disease activity84Knowing what features suggest poorly controlled RA, differentiation between ongoing disease activity and joint damage due to previous disease activity44.049.56.5
       
 Understanding the importance of ongoing good communication84Understanding patients' expectations and requirements of physiotherapist and treatment; fully understand patients' individual priorities, concerns, and changing goals; recognize need for ongoing communication with other health professionals in the team; know what support patient has from family friends and medical team6.938.254.9
 Comprehensive understanding of RA as a chronic disease80Impact both physical and psychological on each patient, work disability and financial implications for each patient14.956.728.4
Chronic phase of the disease (management of comorbidities)      
 Understanding the impact of comorbidities on physiotherapy intervention88Potential need to modify interventions or programs based on status of comorbidities, need for additional advice and education, potential decrease in motivation22.358.519.3

Thirty skills themes were identified. Excellent communication skills and monitoring disease activity were considered essential skills themes (≥80% agreement by the Delphi panel) across all 3 disease phases (Table 3).

Table 3. Disease-specific clinical skills themes identified by ≥80% of the Delphi panelists as being essential for community-based physiotherapists and scoring of their elements as 4 (important to know) or 5 (essential to know) by ≥80% of the panelists*
Theme by disease phaseDelphi panelists who considered the theme essential, %ElementsAligns with guidelinesPhysiotherapists' PD needs, % of respondents
Definitely require PDMay benefit from PDPD not required
  • *

    Whether the theme and/or element aligned with a recommendation(s) in the appraised clinical guidelines is indicated with a checkmark (alignment) or an x (nonalignment). The proportion of professional development (PD) survey respondents in each PD category is shown for each theme. Where a theme was included in >1 disease phase, the survey question relating to that theme was only shown once. RA = rheumatoid arthritis; MCP = metacarpophalangeal; MTP = metatarsophalangeal; GP = general practitioner.

  • Guidelines classified as recommended or highly recommended after review using the Appraisal of Guidelines for Research and Evaluation instrument (30).

Prediagnosis phase      
 Ability to recognize professional limitations specific to management of RA92Confidence in referring people on to more appropriate health professional or resource19.451.628.9
 Ability to conduct and record a thorough musculoskeletal examination specific to RA92Being particularly alert to inflamed joints (swelling, limited range of movement, redness, warmth), squeeze test across MCP and MTP joints, grip strength, comprehensive baseline status recorded56.039.24.8
 Ability to take and record a thorough patient history specific to RA84Being particularly alert to matters of onset, duration, pain presentation, and behavior; joint involvement, risk factors that may suggest RA; global perspective covering patient symptoms, psychological status, general health, medical history, and procedures29.355.315.4
 Ability to implement evidence-based treatments while waiting for a diagnosis to be confirmed84Pain relief modalities, exercise prescription36.649.513.9
 Ability to monitor a patient's progress and outcomes80In particular, noting inflamed joint status39.652.08.4
 Excellent communication skills80To encourage, educate, and support the patient in seeking a medical opinion if RA is suspected; to build rapport with the patient; ability to listen; to advocate for patients18.753.827.5
Early phase after diagnosis      
 Excellent communication skills88To work effectively as part of the RA multidisciplinary team (verbal and written), to develop and demonstrate empathy with patients through listening, to write detailed progress reports to GP and/or rheumatologist, to support self-management, to motivate through changing disease status18.753.827.5
 Identification of potential physical complications of RA84Tendinopathy, tenosynovitis, and tendon rupture; carpal tunnel syndrome; muscle atrophy36.349.514.3
 Ability to provide education80About the role of physiotherapy, the range of different treatment options, about the disease course itself, about the range of education programs available both locally and via the internet44.345.110.6
 Ability to provide self-management support and encouragement80Patient-focused goal setting, behavioral change strategies19.451.628.9
 Ongoing monitoring of disease activity and severity80Ability to recognize the difference between active and inactive disease, recognize a flare (e.g., acutely inflamed joint), monitor for side effects of medication and other treatment (e.g., exercise)49.544.36.2
Chronic phase of the disease (long-term management of RA)      
 Ongoing monitoring and assessment of disease activity and severity88Need to identify potential red flags (e.g., ability to assess for instability of the cervical spine), continue to be able to identify consistently swollen joints that may benefit from steroid injections, ability to assess joint integrity, ability to assess and monitor arches of the feet, recognize indications for consideration of surgery49.544.36.2
 Excellent communication skills88Enabling accessibility for patients during times of need, demonstration of patience with those struggling both emotionally and physically with disease18.753.827.5
 Ability to implement staged treatment strategies in accordance with evidence-based guidelines84Develop maintenance program (range of movement, strength), presurgical preparation and postsurgical management, exercise progression (endurance and strengthening), involvement in group programs suitable to needs and abilities46.945.18.1
 Capacity to be involved with annual multidisciplinary team reviews of patients with RA80Ensuring availability for these tasks24.956.818.3
Chronic phase of the disease (management of comorbidities)      
 Ability to adjust assessment and treatment strategies in accordance with evidence-based guidelines and comorbidities84Balance and falls risk, presence of osteoporosis (may need to avoid strong manual techniques while ensuring inclusion of resistance exercises), reduced cardiovascular fitness (ensure appropriate aerobic exercise), recognize potential for comorbidities to affect patient compliance and functional potential35.553.511.0
Essential themes by the Delphi panel group.

Analysis by the panelist group revealed different trends in both the number of themes achieving 100% consensus (consumers: n = 17, physiotherapists: n = 13, rheumatologists: n = 4) and the content of those themes. Consumers consistently reached 100% agreement on themes associated with communication, the impact of comorbidities, and involvement of a multidisciplinary team. Physiotherapists identified essential themes associated with physiotherapy management, ongoing disease monitoring, and their referral obligations as essential. Rheumatologists reached 100% consensus on essential themes associated with early diagnosis and referral, red flag identification, and musculoskeletal examination skills. Two knowledge themes, general physiotherapeutic principles of treating inflamed joints and contradictions to some physiotherapy treatment techniques, and 1 skill theme, ongoing monitoring of disease activity and severity, achieved 100% agreement across the consumer and physiotherapy groups.

Essential knowledge and skills elements.

One hundred ninety-five elements were identified supporting the themes. Across the entire Delphi panel, 100% consensus was not achieved in any element. The highest agreement, for which 24 (96%) of the 25 panelists gave a score of 5 (essential to know), was achieved in 4 of the 195 elements: importance of identifying features such as repeated flares and ruptured tendons requiring referral for medical review, understanding the importance of early RA diagnosis, recognition of joint instability (especially within the cervical spine), and being alert to the presence of inflamed joints.

Essential elements by the Delphi panel group.

When analyzing element consensus by group, differences were evident between consumers, physiotherapists, and rheumatologists. Consumers reached 100% agreement with scores of 5 on 21 elements, physiotherapists on 12 elements, and rheumatologists on 3 elements. Physiotherapists and consumers together achieved 100% agreement on 5 elements as being essential to know, including understanding the importance of early diagnosis; recognizing repeated flares, ruptured tendon, acute joint effusion, and serious medication side effects; recognizing joint instability, especially in the cervical spine; having confidence in referring people to more appropriate health professionals or resources; and being particularly alert to matters of onset and duration, pain presentation and behavior, joint involvement, and risk factors that may indicate RA. Physiotherapists and rheumatologists achieved 100% agreement on 1 element, being particularly alert to inflamed joints (swelling, limited range of movement, redness, warmth). By contrast, there were no elements agreed on as essential to know by 100% of consumers and rheumatologists.

Appraisal of CPGs and extraction of physiotherapy-specific recommendations.

Table 4 shows scores for each of the AGREE instrument domains derived from the appraisal of the 8 CPGs and the additional scores of 7 CPGs taken from the Royal Australian College of General Practitioners guidelines (19). The 6 CPGs selected for extraction of physiotherapy-relevant recommendations are indicated.

Table 4. Domain scores for each clinical guideline appraised using the AGREE tool*
Clinical guideline, year (ref.)Scope of guidelineAGREE scores, %
Domain 1Domain 2Domain 3Domain 4Domain 5Domain 6
  • *

    Domains include: 1) scope and purpose, 2) stakeholder involvement, 3) rigor of development, 4) clarity and presentation, 5) applicability, and 6) editorial independence. AGREE = Appraisal of Guidelines for Research and Evaluation; BSR/BHPR = British Society of Rheumatology/British Health Professionals in Rheumatology; RA = rheumatoid arthritis; RACGP = Royal Australian College of General Practitioners; RCP/NICE = Royal College of Physicians/National Institute for Health and Clinical Excellence; SIGN = Scottish Intercollegiate Guidelines Network; ACR = American College of Rheumatology; EULAR = European Union League Against Rheumatism.

  • AGREE scores extracted from the RACGP clinical guidelines (19). Selected for extraction of physiotherapy-relevant recommendations.

  • Selected for extraction of physiotherapy-relevant recommendations.

  • §

    AGREE scores extracted from the RACGP clinical guidelines (19).

BSR/BHPR, 2006 (21)Management during the first 2 years of onset of RA in adults726752758392
BSR/BHPR, 2009 (17)Management after the first 2 years of onset of RA in adults785024716750
Forestier et al, 2009 (16)Nondrug management of RA39426983440
RACGP, 2009 (19)Early diagnosis and management (<2 years) in people with RA ages >16 years83698094333
RCP/NICE, 2009 (18)Diagnosis and management of RA in adults896352833383
SIGN 123, 2011 (20)Disease duration of ≤5 years from onset of symptoms835055755058
ACR, 2002 (34)§Management of people with a diagnosis of RA80402233
Emery and Suarez-Almazor, 2003 (36)§Pharmaceutical management of RA64886583366
EULAR, 2007 (38)§Management of early arthritis7225527100
Hennell and Luqmani, 2008 (15)Multidisciplinary management of RA in the first 2 years83632983280
Indian guidelines, 2002 (35)§Diagnosis and management of people with RA11043300
Ottawa Panel evidence-based clinical practice, 2004 (13)Therapeutic exercises in adult patients (ages >18 years) with a diagnosis of RA72716938025
Ottawa Panel evidence-based clinical practice, 2004 (14)Electrotherapy and thermotherapy treatment in adult patients (ages >18 years) with a diagnosis of RA78757167025
SIGN 48, 2000 (33)§Early diagnosis and management (<5 years from onset of symptoms) in people with RA61584075178
South African guidelines, 2003 (37)§Management of RA44582417067

Linking Delphi responses with CPG recommendations.

Comparison between the 30 knowledge and skills themes (supported by their element components) identified as being essential by ≥80% of the Delphi panelists and the recommendations from the RA CPGs demonstrated that 26 (86.7%) of the 30 themes aligned with selected guideline recommendations (Tables 2 and 3).

PD needs assessment survey.

Three hundred forty-eight e-surveys were started online, of which 285 (81.9%) met the selection criteria, representing 10.8% of the registered physiotherapists in WA. Table 1 shows the demographic and work history characteristics of the respondents. Of those physiotherapists who were currently involved in clinical practice (n = 255 [89.5%]), 54.9% currently treated patients with RA. These patients represented a mean ± SD of 4.4% ± 5.9% of their current clinical caseloads. When asked about confidence in managing patients with RA, 41.7% were not confident in their ability to recognize an early presentation of RA, 52.5% were not confident in their knowledge of the typical clinical course of RA, 77.5% were not confident in their knowledge of evidence-based physiotherapy interventions for RA, and 65.6% indicated they had insufficient knowledge to safely and effectively co-manage a patient with RA throughout the disease course. Across the range of essential knowledge and skills themes, 45.1–93.5% and 71.1–95.2% of respondents, respectively, indicated they would benefit from or definitely need PD (Tables 2 and 3). Approximately 70% of respondents reported they would be interested or very interested in accessing PD related to RA.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES

Knowledge and skills relevant to physiotherapy management of RA were identified and aligned with contemporary, evidence-based CPGs. Physiotherapists clearly indicated their PD needs in order to facilitate their evidence-based delivery of services for patients with RA. Significant workforce development may be needed before the transition from hospital-based to community-based services can be realized.

The essential knowledge and skills themes identified in this study consistently align with the core general rheumatology topics proposed by Hewlett et al (29) for UK-based undergraduate health students. Surprisingly, the only themes we identified that did not align with the topics proposed by Hewlett et al (29) were those related to excellent communication. This difference likely reflects the involvement of consumers in our study, but may also reflect a greater emphasis on the importance of communication integral to Australian undergraduate physiotherapy curricula; this may also explain why communication skills was an area of least perceived PD need. Consistent with Hurkmans et al (40), all of the panelists identified the need for promoting physical activity in patients with RA.

The themes considered essential by all of the panelists related exclusively to the prediagnosis phase. These 2 knowledge themes, being alert to a presentation that may suggest RA and the importance of early referral to a rheumatologist, reflect the current medical management of RA, where a narrow window of opportunity exists in the early disease phase to slow or halt joint damage (41). Consequently, it is vital that a community-based physiotherapist is cognizant about the clinical features of early RA, in order to facilitate timely referral to a rheumatologist. At a clinical skills level, physiotherapists need to be proficient in undertaking a clinically-reasoned approach to the musculoskeletal examination of patients with RA, be able to monitor disease activity, and engage in RA-appropriate self-management support. While it might reasonably be expected that practicing physiotherapists would possess general musculoskeletal skills and understand the concepts of self-management support, RA-specific components are likely to require further education for 2 reasons. First, at the undergraduate level, knowledge and skills are generally taught by principle, rather than by specific disease. This aligns with a study of Canadian physiotherapists who identified their undergraduate training in RA to be inadequate (42). Second, the tertiary-oriented service delivery model likely results in depletion of knowledge and skills among those clinicians who practice outside this setting. Findings from the PD survey support this, where a large proportion of respondents indicated a lack of confidence and the need for PD in RA-specific disease knowledge and clinical skills.

Delphi themes relating primarily to the scope of practice for professions other than physiotherapy, such as knowledge of pharmaceutical treatments and skill in identifying psychosocial consequences of RA, did not reach consensus level for “essential” across the different groups. Nonetheless, these themes reinforce the importance of delivering education to both practicing clinicians and trainees in an interprofessional framework. Here, generic knowledge and skills across professions can be complementary while also maintaining domain-specific knowledge and skills. While the concept of Treatment to Target (T2T) is embedded in many areas of clinical medicine, its application to RA is relatively new (43), particularly around nonpharmacologic management. Possibly for this reason, and the fact that the Delphi panelists were not asked specifically about management frameworks, the T2T approach was not identified as an essential knowledge or skill. Nonetheless, with the increased emphasis on T2T, it may be important to embed this management framework within PD initiatives.

Differences were observed in knowledge and skills themes identified as being essential by the 3 panelist groups. Consumers highlighted a greater number of essential themes than either the physiotherapists or rheumatologists, consistent with a consumer expectation for a holistic approach to management and highlighting the need for generic knowledge and skills to enable an integrated team approach to co-care, as emphasized by Woolf (44). Furthermore, consumers' specific theme trends were different from the clinician panel members. Consumers placed greater importance on the effective use of communication strategies to build rapport with patients, educate patients about their disease, and advocate for appropriate care. These findings likely reflect consumers' right and desire to co-manage their RA, consistent with contemporary management approaches for chronic conditions (45, 46). Consumers also emphasized the impact of comorbidities on their general well-being and ongoing management. There was a tendency for physiotherapists to place greater importance on practical skills and for rheumatologists to highlight the need for medical review in the presence of red flags, reflecting the domain-specific orientation of each profession.

The majority of the disease-specific knowledge and clinical skills themes identified as essential by the Delphi panelists were supported by evidence-based, high-quality, contemporary CPGs. Although there were some themes identified by the Delphi panel that did not align with guidelines, these did not reflect recent developments or research evidence that contradict or otherwise alter interpretation of the identified guideline recommendations. Due to CPG variability in the evidence hierarchies, assigning a single level of evidence for each guideline recommendation was impractical. However, aligning these recommendations with the findings of the Delphi process has provided an important link between current expert opinion and evidence. Those themes identified by the panelists that did not link to recommendations in CPGs likely reflect a number of factors, including the medical orientation of the CPGs, an assumption that basic competencies are already held by those professionals to whom the guidelines apply, and that knowledge pertaining to particular skills is assumed. Furthermore, we did not anticipate that all of the CPGs reviewed would encompass all physiotherapy-specific assessment skills. Additionally, CPGs may implicitly assume that health professionals managing people with RA have the necessary skills to identify potential physical complications and red flags associated with RA.

The majority of survey respondents worked in primary care, the workforce group of interest. It is precisely these physiotherapists who could feasibly contribute to the co-management of patients with RA in Australia, since policies and operational aspects of health service delivery promote community-based management for consumers with chronic health conditions, rather than management delivered from tertiary hospitals. The survey data suggest that clinicians in primary care currently lack the confidence to initiate safe and effective management for patients with RA, highlighting the need for PD to ensure that workforce capacity can meet the needs of consumers and health policy directives.

A particular strength of this study lies in the linkage of expert clinical and consumer consensus (Delphi stage) with relevant evidence from high-quality CPGs. Furthermore, the study represents a direct implementation of WA state health policy recommendations surrounding workforce development needs in this clinical area (6). The inclusion of consumer data in the Delphi process presents a unique perspective and emphasizes the need for physiotherapy education to be consumer oriented. A further strength was the use of an international Delphi panel, enabling generalization of findings beyond the Australian health care setting. A potential limitation of the Delphi process was the size of the panel; although smaller than a similar study (29), it met Delphi method recommendations (27, 28).

Although we linked the Delphi responses with evidence-based CPGs, we did not undertake a full systematic guidelines search. Some relevant guidelines therefore may not be identified, although this factor was mitigated by using the Delphi panel to identify key guidelines. A systematic appraisal of CPGs on physiotherapy in RA was published after this study was completed (32). Of the 8 guidelines included in that study, we also appraised 7. Hurkmans et al (32) appraised guidelines published only in scientific journals during 1998–2009; consequently, 8 guidelines we identified were not included. We recommended similar high-quality guidelines to Hurkmans et al (32) within our inclusion criteria (16, 21); however, we appraised 2 as being of lower quality (15, 38).

The majority of participants in this study were women, and a sex bias is therefore possible. We are unable to calculate the exact response rate for the e-survey, since the number of unique survey invitations was unknown. Although the absolute number of e-survey responses received was comparable to a similar study (42), the response rate is likely to be low and represents a limitation to the generalizability of the findings. In order to maintain anonymity of the responses and comply with privacy policies imposed by the APA, Alumni Office, and local ethics committee, we did not have access to responder identities. Therefore, physiotherapists may have received more than 1 invitation to complete the survey. The risk for duplicate responses was minimized by asking the respondents to complete only 1 survey. Furthermore, the Qualtrics platform used browser cookies to block multiple submissions from the same computer.

AUTHOR CONTRIBUTIONS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES

All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be published. Dr. Briggs had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study conception and design. Briggs, Slater, Bragge, Keen, Chan.

Acquisition of data. Briggs, Fary, Slater, Bragge, Chua.

Analysis and interpretation of data. Briggs, Fary, Slater, Bragge.

Acknowledgements

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES

The authors gratefully acknowledge the participation of the Delphi panel members (Ms Susan Archbold, Dr. Sydney Brooks, Dr. Lucie Brousseau, Dr. Graeme Carroll, Dr. Chris Deighton, Mr. Lindsay Dutton, Ms Suzie Edward May, Ms Rebecca Endacott, Ms Maryann Fabling, Ms Camilla Fongen, Dr. Samantha Hider, Dr. Maura Daly Iversen, Dr. Anita Lee, Ms Margaret Lewington, Ms Kerry Mace, Dr. Norma MacIntyre, Ms Maree Munday, Dr. Andrew Ostor, Dr. Zoe Paskins, Ms Kathryn Pickering, Ms Louise Preston, Dr. Susanna Proudman, Dr. Mark Quinn, Dr. Janet Roddy, Dr. Edith Villeneuve, and Ms Alison Wigg) and Dr. Joanne Jordan for qualitative analysis expertise. The Curtin University Alumni Office and the APA (WA office) are acknowledged for their support in disseminating the clinician survey.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. Acknowledgements
  9. REFERENCES
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