Open Access Highly Accessed Research article

Validation of an advanced practice physiotherapy model of care in an orthopaedic outpatient clinic

François Desmeules12*, Panagiota Toliopoulos2, Jean-Sébastien Roy34, Linda June Woodhouse56, Marc Lacelle7, Manon Leroux7, Steven Girard2, Debbie E Feldman189 and Julio C Fernandes1011

Author Affiliations

1 School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, QC, Canada

2 Orthopaedic clinical research unit, Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montreal, QC, Canada

3 Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, QC, Canada

4 Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec City, QC, Canada

5 Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada

6 McCaig Institute for Bone and Joint Health, Calgary, AB, Canada

7 Department of Physiotherapy, Sacré-Coeur Hospital, University of Montreal, Montreal, QC, Canada

8 Centre for Interdisciplinary Research in Rehabilitation, Montreal, QC, Canada

9 Institute of Public Health Research of the University of Montreal, Montreal, QC, Canada

10 Orthopaedics Research Laboratory, Research Center, Sacré-Coeur Hospital, University of Montreal, Montreal, QC, Canada

11 Department of Surgery, Faculty of Medicine, University of Montreal, Montreal, QC, Canada

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BMC Musculoskeletal Disorders 2013, 14:162  doi:10.1186/1471-2474-14-162

Published: 8 May 2013



In Canada, new models of orthopaedic care involving advanced practice physiotherapists (APP) are being implemented. In these new models, aimed at improving the efficiency of care for patients with musculoskeletal disorders, APPs diagnose, triage and conservatively treat patients. Formal validation of the efficiency and appropriateness of these emerging models is scarce. The purpose of this study is to assess the diagnostic agreement of an APP compared to orthopaedic surgeons as well as to assess treatment concordance, healthcare resource use, and patient satisfaction in this new model.


120 patients presenting for an initial consult for hip or knee complaints in an outpatient orthopaedic hospital clinic in Montreal, Canada, were independently assessed by an APP and by one of three participating orthopaedic surgeons. Each health care provider independently diagnosed the patients and provided triage recommendations (conservative or surgical management). Proportion of raw agreement and Cohen’s kappa were used to assess inter-rater agreement for diagnosis, triage, treatment recommendations and imaging tests ordered. Chi-Square tests were done in order to compare the type of conservative treatment recommendations made by the APP and the surgeons and Student t-tests to compare patient satisfaction between the two types of care.


The majority of patients assessed were female (54%), mean age was 54.1 years and 91% consulted for a knee complaint. The raw agreement proportion for diagnosis was 88% and diagnostic inter-rater agreement was very high (κ=0.86; 95% CI: 0.80-0.93). The triage recommendations (conservative or surgical management) raw agreement proportion was found to be 88% and inter-rater agreement for triage recommendation was high (κ=0.77; 95% CI: 0.65-0.88). No differences were found between providers with respect to imaging tests ordered (p≥0.05). In terms of conservative treatment recommendations made, the APP gave significantly more education and prescribed more NSAIDs, joint injections, exercises and supervised physiotherapy (p<0.05). Patient satisfaction was significantly higher for APP care than for the surgeons care (p<0.05).


The diagnoses and triage recommendations for patients with hip and knee disorders made by the APP were similar to the orthopaedic surgeons. These results provide evidence supporting the APP model for orthopaedic care.

Physiotherapist; Healthcare service research; Musculoskeletal diseases and professional autonomy