DQ: Orthopedic And Musculoskeletal Conditions in Primary Care

Musculoskeletal disorders are a wide range of conditions that affect an estimated 1.7 billion people and are considered the second leading cause of disability worldwide [1]. This type of disease causes pain and physical deficits that limit the functional capacity of patients, impacting their social context and affecting their personal life. Furthermore, musculoskeletal pathology is also one of the main causes of chronic pain and contributes to the perpetuation of this clinical entity [2,3].

The high prevalence of these disorders constitutes one of the main reasons for assistance in primary care health services, reporting 18% of all general consultations [4]. Mainly the physiotherapy service is in charge of managing these alterations through conservative treatment and health education. The physiotherapeutic approach to musculoskeletal problems not only focuses on the functional status of the patient, but also takes into account a variety of contributors such as biomedical, psychological, or social factors [5].

The International Classification of Functioning (ICF) was proposed by the World Health Organization (WHO) in 2001 as a reference system for functioning. ICF combines categories and qualifiers to describe functioning and disability and relates these concepts to the patient’s context. In this way, ICF categories are structured with the following components: body structures and functions, activities and participation, environmental factors, and personal factors. Qualifiers provide a measure of the severity [6].

Since its approval, the clinical use of the ICF has been expanding, especially in rehabilitation and outcome assessment. However, their level of implementation is very heterogeneous when comparing countries, with Sweden and Australia reporting the most widespread use in clinical settings [7]. The development of ICF core sets promoted by the WHO and the ICF Research Branch has enhanced the likelihood of ICF use in multiple clinical settings [8]. Two ICF core sets were already developed for musculoskeletal conditions, targeting acute and post-acute stages [9,10,11]. However, there is a lack of an ICF-based tool for these disorders directly applicable at the community level. It is also not known whether the assessment instruments frequently used in this clinical setting cover the essential aspects of functioning in patients with musculoskeletal problems. In a recent study involving primary care physiotherapists, it was shown that current ICF core sets for musculoskeletal conditions only partially represented the perspective of these professionals, so the need to develop a tailored ICF core set for this clinical context was raised [12].

According to the methodology proposed by Selb et al., [13] preliminary studies for the development of ICF core sets aim to capture the perspectives of researchers, professionals, patients, and clinical settings. To describe the researcher’s perspective, a scoping review of outcome measures in the scientific literature is needed. It is assumed that researchers consider the functioning-related measures they use to be relevant.

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The objective of this study was to describe the researcher’s perspective on the management of musculoskeletal conditions in a primary care physiotherapy clinical setting in terms of ICF. Specific objectives were:

1. To identify the most frequent functioning concepts embedded in outcomes measures used when studying the target clinical context;

2. To link functioning concepts to ICF and compare them with the ICF core set for post-acute musculoskeletal conditions;

3. To assess the ability of the identified outcome measures to cover functioning aspects included in the ICF core set taken as a reference; and

4. To contribute to the development of a tailored ICF core set for primary care physiotherapy units by identifying additional ICF categories from outcome measures.

2. Materials and Methods

2.1. Study Design

This review was conducted following the methodology described by the ICF Research Branch [13] and was composed of five parts: (1) literature search study selection, (2) extraction of relevant concepts, (3) linkage of the concepts to the ICF, and (4) frequency analysis. The selected search strategy and methods of analysis of this review were registered in the PROSPERO database (ref: CRD42020156209). This report was written following the guidelines of the Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist [14].

2.2. Literature Search

An extensive literature search was conducted using the following electronic databases: MEDLINE/PubMed, CINAHL, Web of Science, Scopus, and PEDro. The studies published between January 2012 and June 2022 in English or Spanish were considered for inclusion. Combinations and variations of keywords and medical subject headings were used in each database: musculoskeletal conditions, primary health care, physical therapy, body functions, body structures, activities and participation, environmental factors musculoskeletal disorders, physiotherapy, primary health care, and outcomes measures. The complete search strategy can be found in Appendix A.

2.3. Study Selection

Studies were included according to the PICOS framework (population, intervention, comparison, outcomes, study design). To focus on the goal of this review, we did not use “C” as it was not considered relevant.

Population: the participants included in the published study had to be from Western countries (United States of America, Canada, Australia, New Zealand, United Kingdom, European Union, and member countries of the European Free Trade Association, such as Norway or Switzerland), and the sample included people older than 18 years diagnosed with a musculoskeletal condition in a primary care health setting.

Intervention: a physiotherapy intervention in a primary care setting was applied.

Outcomes: the publications had to be related to functioning as defined by the ICF.

Study design: randomized controlled trials, clinical controlled trials, cross-sectional studies, observational studies, and qualitative studies published were included.

Studies were excluded if they were based solely on specific health problems, the sample was not representative of the general population (the study selected participants according to their age, sex, race, nationality, etc.), the study was conducted over hospitalized participants, or the research was a study protocol, a systematic review, a meta-analysis, a case report, a doctoral thesis, a letter, a comment, or an editorial.

Results from the searches were gathered in LibreOffice Calc, and duplicates were removed. In the first round, titles and abstracts were screened for eligibility. Subsequently, full-text articles of the included abstracts were retrieved and screened for eligibility.

Two authors (H.H.L. and S.J.D.B.) screened the titles and abstracts of the identified studies for eligibility. After independently reviewing the selected studies for inclusion, Cohen’s kappa statistic was calculated to measure inter- and intra-rater reliability. If it was not clear whether the study met the inclusion criteria, advice was sought from a third researcher (L.C.L.) and an opinion consensus was formed. Once the agreement was reached, a full-text copy of the selected studies was obtained.

2.4. Extraction of Relevant Concepts

Relevant information from the selected studies was gathered using a standardized data collection form designed for this purpose. The items included were (a) the country and region where it was carried out, (b) the research design, (c) the size sample, (d) the participant characteristics (age and condition), and (e) assessment instruments used as outcome measures.

Data were independently extracted by two authors (H.H.L. and S.J.DB.) using the form (above). All discrepancies were reviewed, and an agreement was reached through discussion. In the event of disagreement, a third reviewer (L.C.L.) was consulted.

All assessment instruments used in the included studies were recorded, and the number of studies in which the individual measures were used was documented. Outcome measures were classified following the next criteria: (a) they were single or multi-item (e.g., the visual analogic scale for pain is a single-item measure and the neck disability index is a multi-item measure), (b) they could be patient-oriented measures (e.g., self-report questionnaires), clinical assessment (including those requiring specialized equipment), or non-tool measures (often single-patient-oriented questions).

From the outcome measures, individual items were extracted to be linked to the ICF.

2.5. Linkage of the Concepts to the ICF

The linking process consists of translating relevant concepts found in measurement instruments into ICF second-level categories. To achieve this, Cieza’s work was taken as a reference [15], and the WHO eLearning tool (www.icf-elearning.com (accessed on 7 December 2022)) about ICF was also used.

Meaningful concepts were identified from each item extracted from the outcome measures. A concept was defined as one separate meaningful entity; one or more concepts could be identified from a single item. The meaningful concepts were then linked to the most precise ICF category in the components of “body functions”, “body structures”, “activities and participation”, and “environmental factors” (e). Concepts were also linked to “personal factors” (pf), although these are not yet classified in the ICF. In case a concept was too general or vague, the code “nd” was assigned (not definable). Similarly, if the information was beyond the scope of the ICF, code “nc” (not covered) was used.

The linking process was performed independently by the same two reviewers (H.H.L. and S.J.D.B.). Results were compared, and disagreements were resolved by discussion. Discrepancies were discussed with a third reviewer (L.C.L.) until a final agreement was reached. Inter-rater agreement of the independent linking conducted for second-level categories was calculated with Cohen’s kappa.

2.6. Frequency Analysis

Frequency analysis was carried out to examine the total number of outcome measures and identified ICF categories. If an ICF category was repeatedly assigned within one multiple-item measure, it was counted only once.

2.7. Comparison with the ICF Core Set for Post-Acute Musculoskeletal Conditions

A comparison was made between the ICF categories identified and the comprehensive ICF core set for post-acute musculoskeletal conditions [10]. This ICF core set is composed of 70 ICF categories (7 categories belonging to the component “body structures”, 23 from the ICF component “body functions”, 22 from “activities and participation”, and finally, 18 from “environmental factors”). This ICF core set was used as a reference standard to assess whether the identified outcome measures are adequate to cover the essential aspects of functioning in our target population. The decision to select this ICF core set was made based on their similarity to the target population.

Additional ICF categories were also recorded and were considered relevant if they were identified in 5% or more of the selected studies [13]. Additional ICF categories were defined as those identified in the outcome measures but not included in the ICF core set taken as a reference.