Brazilian Journal of Pain
https://brjp.org.br/article/doi/10.5935/2595-0118.20240014-en
Brazilian Journal of Pain
Original Article

The decision-making skills of Brazilian physical therapists for patients with red flags

Capacidade da tomada de decisão dos fisioterapeutas brasileiros para pacientes com bandeiras vermelhas

Thayse Cassaniga; Marcelo Pandolfo; Débora Ewelyn Scheidt; Carlos Emílio Ladeira; Clóvis Arlindo de Sousa; Marcelo Anderson Bracht

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Abstract

BACKGROUND AND OBJECTIVES: The red flags screening purpose is to ensure that signs and symptoms that raise suspicion of serious diseases are being considered during the assessment, assisting physical therapists in their clinical decision process. Brazilian physical therapists are autonomous and can act as first contact professionals in the management of musculoskeletal disorders, therefore, they need to know how to recognize, screen and refer patients with red flags for better therapeutic management. The objectives of this study were to verify whether Brazilian physical therapists can recognize and manage patients who presented red flags, compare professionals’ skills regarding different academic degree levels and clinical experience and identify which factors can influence the results.
METHODS: A cross-sectional and quantitative research was conducted, collected from an online questionnaire. The target audience consisted of Brazilian physical therapists who have clinical experience in the management of patients with musculoskeletal disorders. Participants filled demographic data and made clinical decisions based on six clinical cases created by the authors, based on the literature, and reviewed by three experts. Data were analyzed using descriptive statistics, the Chi-square test of independence and logistic regression.
RESULTS: The study analyzed 384 answers from Brazilian physical therapists with clinical experience in musculoskeletal conditions. Brazilian physical therapists, in general, have not shown to be able to properly recognize and manage the clinical cases involving red flags, with 23.2% of the sample performing appropriate management for medical conditions, 53.9% for emergency conditions and 61.8% for medical conditions with associated musculoskeletal dysfunction. More years of clinical experience and post-professional education did not positively influence the outcomes. Higher academic degrees (Doctorate) can influence positively on the management of non-emergency medical conditions.
CONCLUSION: Brazilian physical therapists who work with patients with musculoskeletal disorders perform poorly in identifying red flags in hypothetical clinical cases.

Keywords

Ambulatory care, Decision making, Differential diagnosis, Primary Health Care, Referral and consultation

Resumo

JUSTIFICATIVA E OBJETIVOS: O objetivo da triagem de bandeiras vermelhas é garantir que sinais e sintomas que levantam suspeitas de doenças graves sejam considerados durante a avaliação, auxiliando os fisioterapeutas no seu processo de decisão clínica. Os fisioterapeutas brasileiros são autônomos e podem atuar como profissionais de primeiro contato no manejo de distúrbios musculoesqueléticos, portanto, precisam saber reconhecer, rastrear e encaminhar pacientes com bandeiras vermelhas para melhor manejo terapêutico. Os objetivos deste estudo foram verificar se os fisioterapeutas brasileiros conseguem reconhecer e tratar pacientes que apresentavam bandeiras vermelhas, comparar as habilidades dos profissionais com diferentes níveis de formação acadêmica e experiência clínica e identificar quais fatores podem influenciar os resultados. 
MÉTODOS: Uma pesquisa transversal e quantitativa foi realizada, coletada através de um questionário online. O público-alvo consistiu em fisioterapeutas brasileiros com experiência clínica no manejo de pacientes com disfunções musculoesqueléticas. Os participantes preencheram dados demográficos e tomaram decisões clínicas com base em seis casos clínicos criados pelos autores, com base na literatura, e revisados por três especialistas. Os dados foram analisados por estatísticas descritivas, pelo teste qui-quadrado de independência e por regressão logística. 
RESULTADOS: Foram analisadas 384 respostas de fisioterapeutas brasileiros com experiência clínica em disfunções musculoesqueléticas. Os fisioterapeutas brasileiros, em geral, não demonstraram ser capazes de reconhecer e manejar adequadamente os casos clínicos envolvendo bandeiras vermelhas, com 23,2% da amostra realizando manejo adequado para condições médicas, 53,9% para condições de emergência e 61,8% para condições médicas com disfunção musculoesquelética associada. Mais anos de experiência clínica e educação pós-profissional não influenciaram positivamente os resultados. Graus acadêmicos mais elevados (Doutorado) podem influenciar positivamente no manejo de condições médicas não emergenciais. 
CONCLUSÃO: Fisioterapeutas brasileiros que atuam com pacientes com disfunções musculoesqueléticas apresentam um mau desempenho na identificação de bandeiras vermelhas em casos clínicos hipotéticos. 

Palavras-chave

Assistência ambulatorial, Atenção primária à Saúde, Diagnóstico diferencial. Encaminhamento e consulta, Tomada de decisões

References

1 Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL, Beneciuk JM, Leech RL, Selfe J. International Framework for Red Flags for potential serious spinal pathologies. J Orthop Sports Phys Ther. 2020;50(7):350-72.

2 George SZ, Beneciuk JM, Bialosky JE, Lentz TA, Zeppieri G Jr, Pei Q, Wu SS. development of a review-of-systems screening tool for orthopaedic physical therapists: results from the Optimal Screening for Prediction of Referral and Outcome (OSPRO) Cohort. J Orthop Sports Phys Ther. 2015l;45(7):512-26.

3 Ferguson F, Holdsworth L, Rafferty D. Low back pain and physiotherapy use of red flags: the evidence from Scotland. Physiotherapy. 2010;96(4):282-8.

4 Conselho Regional de Fisioterapia e Terapia Ocupacional da 5ª Região (CREFITO-5). Manual de Especialidades da Fisioterapia. http://www.crefito5.org.br/wp-content/uploads/2017/08/Manual-Especialidades-Online.pdf/; 2020 Accessed 1 June 2020.

5 Ladeira CE. Physical therapy clinical specialization and management of red and yellow flags in patients with low back pain in the United States. J Man Manip Ther. 2018;26(2):66-77.

6 American Physical Therapy Association (APTA). Guide to Physical Therapy Practice 3.0. http://guidetoptpractice.apta.org/content/1/SEC1.body/; 2014 Accessed 29 September 2019.

7 Boissonnault WG, Ross MD. Physical therapists referring patients to physicians: a review of case reports and series. J Orthop Sports Phys Ther. 2012;42(5):446-54.

8 Leerar PJ, Boissonnault W, Domholdt E, Roddey T. Documentation of red flags by physical therapists for patients with low back pain. J Man Manip Ther. 2007;15(1):42-9.

9 Jette DU, Ardleigh K, Chandler K, McShea L. Decision-making ability of physical therapists: physical therapy intervention or medical referral. Phys Ther. 2006;86(12):1619-29.

10 de Souza FS, Ladeira CE, Costa LOP. Adherence to back pain clinical practice guidelines by brazilian physical therapists: a cross-sectional study. Spine (Phila Pa 1976). 2017;42(21):E1251-E1258.

11 Li LC, Bombardier C. Physical therapy management of low back pain: an exploratory survey of therapist approaches. Phys Ther. 2001;81(4):1018-28.

12 Ladeira CE, Cheng MS, Hill CJ. Ladeira CE, Samuel Cheng M, Hill CJ. Physical therapists’ treatment choices for non-specific low back pain in Florida: an electronic survey. J Man Manip Ther. 2015;23(2):109-18.

13 Ladeira CE, Cheng MS, da Silva RA. Clinical specialization and adherence to evidence-based practice guidelines for low back pain management: a survey of US physical therapists. J Orthop Sports Phys Ther. 2017;47(5):347-58.

14 Goodman CC, Snyder TEK. Diagnóstico Diferencial em Fisioterapia. 4ª ed. Rio de Janeiro: Elsevier, 2010.

15 Conselho Regional de Fisioterapia e Terapia Ocupacional da 10ª Região (CREFITO-10). Número de fisioterapeutas inscritos no Brasil em 2019. https://crefito10.org.br/portal/; 2019 Accessed 05 September 2019.

16 Learman KE, Ellis AR, Goode AP, Showalter C, Cook CE. Physical therapists’ clinical knowledge of multidisciplinary low back pain treatment guidelines. Phys Ther. 2014;94(7):934-46.

17 Hendrick P, Mani R, Bishop A, Milosavljevic S, Schneiders AG. Therapist knowledge, adherence and use of low back pain guidelines to inform clinical decisions--a national survey of manipulative and sports physiotherapists in New Zealand. Man Ther. 2013;18(2):136-42.

18 Scheermesser M, Allet L, Bürge E, Stegen C, Nast I, Schämann A. Direktzugang zur Physiotherapie in der Schweiz. Physioscience. 2011;7:143-49.

19 Vaughn DW, Shoemaker MJ, Da Prato D, Murray KS, Huisen JV. The ability of final-year doctor of physical therapy students to make keep/refer decisions. J Phys Ther Educ. 2011;25:60-7.

20 Mount HE. Screening for medical referral: determining variables that influence accuracy [dissertation]. University of Alabama. 2012.

21 Beyerlein C. Direktzugang in der Physiotherapie–Wie entscheiden sich Physiotherapeuten im Management ihrer Patienten [dissertation]. Universitätsklinikum Ulm. 2010.

22 Eubank BHF, Lackey SW, Slomp M, Werle JR, Kuntze C, Sheps DM. Consensus for a primary care clinical decision-making tool for assessing, diagnosing, and managing shoulder pain in Alberta, Canada. BMC Fam Pract. 2021;22(1):201.

23 Bourassa M, Kolb WH, Barrett D, Wassinger C. Guideline adherent screening and referral: do third year Doctor of Physical Therapy students identify red and yellow flags within descriptive patient cases? a United States based survey study. J Man Manip Ther. 2023;31(4):253-260.

24 Bourassa M, Kolb WH, Barrett D, Wassinger C. Guideline adherent screening and referral: do third year Doctor of Physical Therapy students identify red and yellow flags within descriptive patient cases? a United States based survey study. J Man Manip Ther. 2023;31(4):253-260.

25 Childs JD, Whitman JM, Sizer PS, Pugia ML, Flynn TW, Delitto A. A description of physical therapists’ knowledge in managing musculoskeletal conditions. BMC Musculoskelet Disord. 2005;6:32.

26 Riddle DL, Hillner BE, Wells PS, Johnson RE, Hoffman HJ, Zuelzer WA. Diagnosis of lower-extremity deep vein thrombosis in outpatients with musculoskeletal disorders: a national survey study of physical therapists. Phys Ther. 2004;84(8):717-28.

27 Aron A, Cunningham S, Yoder I, Gravley E, Brown O, Dickson C. Diagnostic momentum in physical therapy clinical reasoning. J Eval Clin Pract. 2023;1-9.

28 Ladeira CE. Evidence based practice guidelines for management of low back pain: physical therapy implications. Rev Bras Fisioter. 2011;15(3):190-9.

29 Ross MD, Boissonnault WG. Red flags: to screen or not to screen? J Orthop Sports Phys Ther. 2010;40(11):682-4.
 


Submitted date:
05/19/2023

Accepted date:
01/17/2024

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