THE EFFECTIVENESS OF OUTPATIENT MUSCULOSKELETAL PHYSIOTHERAPY FOR THE UPPER LIMB: A SERVICE EVALUATION

T. Rhodes-Jones¹, R. Charnley¹, C. Newton¹, S. Palmer²

¹University Hospitals Coventry & Warwickshire NHS Trust, Physiotherapy, Coventry, United Kingdom, ²Coventry University and University Hospitals Coventry & Warwickshire NHS Trust, Centre for Care Excellence, Coventry, United Kingdom

Background: The Quick Disability of the Arm, Shoulder and Hand questionnaire (QuickDASH) is an 11-item patient-reported outcome measure assessing upper limb symptom severity and function (Gummesson et al 2006). Each item uses a 5-point Likert scale (Matheson et al 2006). Scores for individual items are summed and converted to a total score out of 100, with higher scores representing greater disability (Beaton et al 2001). It is more clinically acceptable than the original 30-item DASH (Beaton et al 2005), is slightly more responsive (Gummeson et al 2006) and has strong reliability (Mintken et al 2009) and validity (Beaton et al 2005). We were interested to see if it could be used to evaluate outpatient physiotherapy services for a diverse range of upper limb conditions.

Purpose: To evaluate the effectiveness of outpatient musculoskeletal services for upper limb conditions.

Methods: Patients at the Hospital of St Cross, Rugby, UK completed the QuickDASH at the beginning and end of their physiotherapy management. Patients with incomplete data were excluded from analysis. Data was collected between August 2020 and November 2021. Upper limb conditions included a wide range of rheumatological and orthopaedic conditions, soft tissue trauma, bony fractures, and urgent and elective surgery. The number and type of sessions (face to face, video or telephone) were recorded, but other details of physiotherapy management were not. Management was left to the discretion of the treating therapist. Descriptive analysis (mean ± SD) was used to identify changes in QuickDASH scores from baseline to post-treatment. The Standardised Mean Difference (SMD) (Cohen’s d) and associated 95% confidence Interval (CI) was calculated. Accepted cut-offs of d=0.2 (‘small’), 0.5 (‘medium’) and 0.8 (‘large’) were used to interpret the SMD values (Cohen 1988). The minimum clinically important difference (MCID) was set at 16 points (Franchinogni et al., 2014).

Results: 239 patients provided a QuickDASH score at baseline. Of these, 74.9% (179/239) also provided a QuickDASH score at discharge and were included in analysis. Patients were 56.6% female and had a mean ± standard deviation age of 56.07 ± 17.04 years (range 12 to 89 years). The mean QuickDASH score at baseline was 53.26 ± 22.91 and at discharge was 12.94 ± 13.34, representing a mean improvement of -40.32 ± 23.47. The SMD was 3.83 (95% CI 3.47, 4.17), representing a ‘large’ improvement. 83.2% (149/179) of patients met or exceeded the MCID of 16 points. A median of 5 physiotherapy sessions were received by patients. The latest published NHS unit cost for outpatient physiotherapy is £63 (Based on Grade 7 hospital physiotherapist, NHS England, 2020-21), equating to a median cost of £315 per patient.

Conclusions: This physiotherapy service evaluation has demonstrated large improvements in the QuickDASH for people with upper limb conditions. The magnitude of improvements far exceeded the MCID, with even the lower boundary of the 95% confidence interval for the SMD approaching 3.5 (a ‘large’ improvement). The vast majority of patients reached the MCID.

Implications: The QuickDASH data suggests a very effective service for patients with upper limb disorders.

Funding acknowledgements: This work was unfunded

Keywords:
Upper limb
QuickDASH
Service evaluation

Topics:
Musculoskeletal: upper limb
Service delivery/emerging roles

Did this work require ethics approval? No

Reason: This service evaluation did not meet the Health Research Authority’s definition of research and was therefore exempt from ethical approval.