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

IF 1.5 Q3 REHABILITATION European Journal of Physiotherapy Pub Date : 2023-03-04 DOI:10.1080/21679169.2023.2187971
T. Rebbeck
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Abstract

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?
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理疗是否愿意、准备好并能够实施不同的护理模式?
物理治疗作为一种职业在过去的20年里有了指数级的发展。就肌肉骨骼物理治疗而言,该行业已经从主要提供以治疗师为中心的被动治疗(例如手工治疗和电疗)转变为更积极和以患者为中心的护理方法。这种范式转变是在20世纪90年代初引入循证实践之后发生的。临床医生被鼓励实施这些证据,并改变他们通常的做法(例如电疗的主导地位),以提供不同的做法(例如有针对性的建议/锻炼)。物理治疗已经接受了这些变化,并在实施其他方面的同时取消了一些护理方面的实施。随着不同的护理模式的出现,我们进入下一个范式,我发现要回答的问题是物理治疗是否愿意,准备好并且能够实施不同的护理模式。以颈部扭伤等肌肉骨骼疾病为例,这一过程使我们考虑了分层护理,但实施起来仍然存在障碍。在这篇社论中,提出了理想的研究设计和需要解决的主要障碍作为前进的方向。循证护理的范例使我们认为随机对照试验(及其综合(系统评价或临床指南))成为我们实践所依据的最高形式的证据。然而,许多试验表明,研究的新干预措施与常规护理的效果模棱两可,并且无法确定干预措施的应答者。一个例子是我们自己的试验,在慢性鞭扭伤患者中,单次“建议”提供的结果与综合物理治疗锻炼计划相似。作为一个临床研究者,我的“研究者”理解这个结果,然而,我的“临床医生”的经验是非常不同的。我们发现,实际上对综合练习有“反应”的人比没有反应的人要多。人们告诉我们很多事情,包括“如果运动能立即减轻疼痛,我更有可能做出反应”,以及“试验测量的恢复情况与患者测量的恢复情况不一致”。这让我们明白,随机对照试验是最纯粹的形式,可能无法回答诸如谁需要更少的照顾,谁需要更多的照顾以及我们应该如何衡量成功等问题。基于预后不良风险的分层护理是检验这种护理模式的一种方法,然而,迄今为止,在肌肉骨骼疾病中进行测试时,结果好坏参半[4,5]。我们曾希望这可能对扭伤患者有益,然而,分层和非分层护理方法的疼痛和残疾结果相似[10]。然而,作为一种职业,我们确实有责任在不需要的时候减少护理(去实施),并在需要的时候认识到谁需要更全面的护理,并提供更早获得这种护理的机会(实施)。我们有能力做到这一点,因为我们已经取消了之前的一些实践,但是下一步应该采取什么方法呢?
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29
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