Abstract
Objectives
This study aimed to evaluate the implementation of an advanced practice physiotherapist (APP) clinic in our paediatric institution and assess APP and orthopaedic surgeon satisfaction.
Methods
In this retrospective cohort study, all patient records from the APP clinic’s second year (March 2017 to March 2018) at CHU Sainte-Justine were reviewed. These were compared with the records of patients seen by orthopaedic surgeons within the gait clinic the year before implementing the clinic. The following data were collected: demographic, professional issuing referral, reason for referral, consultation delay, clinical impression, investigation, and treatment plan. We also documented every subsequent follow-up to rule out any diagnostic change and identify surgical patients. Clinician satisfaction was assessed by the Minnesota Satisfaction and PROBES Questionnaires along with a short electronic survey.
Results
Four hundred and eighteen patients were assessed by APPs and 202 by orthopaedic surgeons. APPs managed patients independently in 92.6% of cases. Nearly 86% of patients were discharged following the initial visit, and 7.4% were referred to a physiotherapist. Only 1% of APP patients eventually required surgery compared with nearly 6% in the orthopaedic group. The mean waiting time for consultation was greater in the APP group (513.7 versus 264 days). However, there was a significant reduction in mean waiting time over the last 3 months surveyed (106.5 days).
Conclusions
The feedback from all clinicians involved was positive, with a greater mean score on the Minnesota Satisfaction and PROBES Questionnaire for APPs. The APP gait clinic appears to be an effective triage clinic.
Level of evidence
III
Keywords: Advanced practice physical therapist, In-toeing, Metatarsus adductus, Paediatric gait disorders, Triage clinic
Graphical Abstract
Graphical Abstract.
It is estimated that one in eight children consult for a musculoskeletal disorder annually (1), generally seeing a primary care physician or a paediatrician. Unfortunately, in the undergraduate medical program little time is devoted to the musculoskeletal system, let alone to paediatric issues. This lack of knowledge and the fear of overlooking a serious pathology may lead to more referrals to orthopaedic surgeons (2). A study assessing the competency of UK foundation doctors determined that only 9% successfully completed a basic musculoskeletal cognitive examination. Primary care physicians had the lowest confidence level when it came to paediatric musculoskeletal assessment (3). Considering 1/8 of primary care visits in children are for a musculoskeletal disorder and up to 50% of referrals to orthopaedic surgeons are for normal variants, the issue is significant and must be addressed.
In March 2016, the waiting list for our gait clinic reached 1500 patients, some of whom had been waiting for more than 4 years. In the current economic situation of limited resources, establishing a collaboration with advanced practice physiotherapists (APPs) has become more relevant than ever. Many studies have shown that this care model is safe, efficient, and appreciated by the patients in the adult population (4,5). Since nearly 50% of paediatric orthopaedic consultations are for normal variants, this model seems even more pertinent (6,7). Interestingly, few studies have focused on this. Potential benefits include significantly shorter wait times, both for surgical and non-surgical patients (7), and fewer patients requiring an orthopaedic consultation. A study on a paediatric population by Belthur et al. showed that 93% of patients could be managed independently by APPs (8).
The objective of this study was to evaluate the implementation of an APP clinic at the CHU Sainte-Justine. Success indicators were a reduction in the number of patients ultimately being referred to the paediatric orthopaedic surgeon and a shorter waiting time. We also evaluated APP and orthopaedic surgeon satisfaction levels toward this new model of care.
METHODS
This level 3 retrospective study was conducted following the implementation of a gait clinic led by APP at CHU Sainte-Justine, a tertiary paediatric hospital caring for children from birth to 18 years. Consecutive records of all new patients seen during the clinic’s second year (March 2017 to March 2018) were reviewed and analyzed. As a comparison, the same analysis was undertaken on a cohort of patients from the gait clinic led by orthopaedic surgeons the year before implementing the APP clinic (March 2015 to March 2016). All referrals to the APP clinic and orthopaedic gait clinic were reviewed by the same orthopaedic surgeon for suitability. The following conditions were eligible: genu varum/valgum, planovalgus feet, tibial torsion, calcaneus valgus, hallux valgus, atypical gait, etc. Referrals requiring surgery, or a radiological follow-up were not included. Other exclusion criteria included follow-up visits of known patients, acute traumas, and incomplete charts. Approval for this study was granted by the institution’s ethics committee and parental consent was waived.
Four physiotherapists specialized in paediatric physical therapy underwent a training curriculum that included lectures (4,6,9) and numerous observation periods. Specifically, the first APP accompanied two orthopaedic surgeons over the course of four gait clinics. She subsequently did seven clinics under the direct supervision of an orthopaedic surgeon. Three other physiotherapists each completed one observation clinic followed by seven clinics under the supervision of the first physiotherapist. The physiotherapists’ primary role was to recognize normal variants and identify pathologies requiring the orthopaedist’s assessment. The following findings required a referral to the orthopaedic surgeon: abnormal neurological examination, angular deformity/misalignment of more than two standard deviations from the normal distribution (valgus/varus knee and foot-thigh angle), asymmetrical findings, and cavus foot. Gait clinics were always planned while an orthopaedic surgeon was available on-site if needed. Following the physiotherapist’s evaluation, the patient could be either discharged, transferred to physical therapy, followed by the APP or referred to the orthopaedic surgeon.
The following information was collected from every referral: demographic data (age, sex, place of residence), medical professional issuing the referral, reason for referral, consultation delay, diagnostic impression, prescribed tests, and treatment plan. Additionally, requests for input from an orthopaedist for patients seen by APPs were noted. We determined the percentage of patients managed independently by APPs and those requiring an additional orthopaedic consultation. Finally, we documented every subsequent follow-up with the reason for referral, to identify any changes in diagnosis and identify patients who required surgery.
The two patient cohorts (APP-led versus orthopaedic surgeon-led gait clinics) were compared using Student t tests for independent samples and Chi-square tests for categorical variables. Statistical analyses were done using IBM SPSS Statistics 25.0 (IBM Corp., Armonk, NY, USA). All significance tests were two-tailed with a significance level of 0.05.
Professional satisfaction for both models was evaluated using two standardized and validated questionnaires: Minnesota Satisfaction Questionnaire and Professional Role Behaviors Survey (PROBES) questionnaire. The Minnesota Satisfaction Questionnaire includes 20 items, each rated on a Likert scale from 1 (very satisfied) to 5 (very unsatisfied). The total score represents the general satisfaction and can be divided into intrinsic elements (10 items) and extrinsic elements (10 items). We were also interested in specific scores, such as autonomy and collegiality. We compared our results to a Canadian study involving specialized nurse practitioners because of the similarities in their practices (10). The PROBES questionnaire is also rated on a Likert-type scale with a neutral midpoint (−3=greatly decreased to 3=greatly increased).
To assess specific questions regarding professionals’ perception of this new model of care, we designed a short survey (4 questions presented in Supplementary Table 1).
RESULTS
A total of 735 patient files were reviewed with 436 patients in the APP group and 299 patients in the orthopaedic surgeon group. Of those, 418 (96%) and 202 (68%), respectively, met the inclusion criteria. Most excluded patients (104/116) were follow-up visits: 95/101 in the orthopaedic group versus 9/15 in the APP group. Other exclusion criteria included missing data (4/116), abnormal trajectory (1/116), specialized care (6/116), and acute trauma (1/116). Demographic data are presented in Table 1. Patients in the APP group were slightly older, and the difference was statistically significant although not clinically relevant as the spectrum of pathologies encountered were similar. In both groups, approximately 50% of referrals were from primary care physicians (57.2% in the APP group versus 49.5% in the ortho group) and around 30% from paediatricians (33.5% in the APP group versus 29.2% in the ortho group). The most common reasons for referral were in-toeing (33%), planovalgus feet (17%), and lower limb pain (12%) (Figure 1). The differences noted between the two groups essentially revolved around the following pathologies: pain, valgus knee, in-toeing, metatarsus adductus, and planovalgus feet (Table 2).
Table 1.
Demographic data
| APP group (%) | Orthopaedic surgeon group (%) | Total (%) | P-value | |
|---|---|---|---|---|
| Sex | 0.838 | |||
| Male | 223 (53.3) | 106 (52.5) | 329 (53.1) | |
| Female | 195 (46.7) | 96 (47.5) | 291 (46.9) | |
| Age (years) | 0.007 | |||
| Mean±SD | 7.1 ± 3.9 | 6.1 ± 4.6 | 6.8 ± 4.2 | |
| Agglomeration | 0.273 | |||
| Montreal | 183 (43.8) | 75 (37.1) | 258 (13.9) | |
| Periphery | 235 (56.2) | 127 (62.9) | 362 (19.5) | |
| Type of referent | 0.000 | |||
| Primary care physician | 239 (57.2) | 100 (49.5) | 339 (18.2) | |
| Paediatrician | 140 (33.5) | 59 (29.2) | 199 (10.7) | |
| Other specialist doctor/consultant | 33 (7.8) | 17 (8.4) | 50 (2.7) | |
| Unknown | 4 (1) | 23(11.4) | 27 (1.5) | |
| Other | 2 (0.5) | 3 (1.5) | 5 (0.3) |
APP advanced practice physiotherapy.
Figure 1.
Reason for referral.
Table 2.
Reason for referral
| APP group (%) | Orthopaedic surgeon group (%) | |
|---|---|---|
| In-toeing | 152 (36.4) | 53 (26.2) |
| Planovalgus foot | 79 (18.9) | 25 (12.4) |
| Lower limb pain | 33 (7.9) | 40 (19.8) |
| Genu valgum | 57 (13.6) | 12 (5.9) |
| Genu varum | 11 (2.6) | 7 (3.5) |
| Hallux valgus | 15 (3.6) | 1 (0.5) |
| Limb length discrepancy | 5 (1.2) | 5 (2.5) |
| Out-toeing | 23 (5.5) | 7 (3.5) |
| Metatarsus adductus | 4 (1) | 15 (7.4) |
| Minor toe issues | 10 (2.4) | 7 (3.5) |
| Osgood-Schlatter disease | 1 (0.2) | 0 |
| Cavus foot | 2 (0.5) | 0 |
| Toe walker | 15 (3.6) | 10 (5) |
| Other | 11 (2.6) | 20 (9.9) |
APP advanced practice physiotherapy.
The distribution regarding diagnostic impression also varied between groups (Table 3). Overall, the most frequent diagnoses were: normal (23%), increased femoral anteversion (20%), and physiological valgum/varum knee (11%). In the APP group, we noted a higher proportion of patients diagnosed with increased femoral anteversion, planovalgus feet, physiological varus knee, and increased internal tibial torsion (Table 3)
Table 3.
Diagnostic impression
| APP group (%) | Orthopaedic surgeon group (%) | Total (%) | |
|---|---|---|---|
| Normal | 95 (22.7) | 45 (22.3) | 140 (22.6) |
| Increased femoral anteversion | 93 (22.2) | 31 (15.3) | 124 (20) |
| Other | 33 (7.9) | 44 (21.8) | 77 (12.4) |
| Physiological genu valgum/varum | 53 (12.7) | 17 (8.4) | 70 (11.3) |
| Planovalgus feet | 35 (8.4) | 10 (5) | 45 (7.3) |
| Internal tibial torsion | 32 (7.7) | 7 (3.5) | 39 (6.3) |
| Toe walker | 22 (5.3) | 6 (3) | 28 (4.5) |
| Minor toe issues | 11 (2.6) | 6 (3) | 17 (2.7) |
| Metatarsus adductus | 6 (1.4) | 10 (5) | 16 (2.6) |
| Hallux valgus | 8 (1.9) | 3 (1.5) | 11 (1.8) |
| Achilles tendon or sural triceps retraction | 4 (1) | 6 (3) | 10 (1.6) |
| External tibial torsion | 9 (2.2) | 1 (0.5) | 10 (1.6) |
| Skew foot | 1 (0.2) | 6 (3) | 7 (1.1) |
| Calcaneum varus | 3 (0.7) | 2 (1) | 5 (0.8) |
| Hyperlaxity | 5 (1.2) | 0 | 5 (0.8) |
| Limb length discrepancy | 2 (0.5) | 3 (1.5) | 5 (0.8) |
| Increased genu valgum | 4 (1) | 0 | 4 (0.6) |
| Increased genu varum or Blount disease | 2 (0.5) | 2 (1) | 4 (0.6) |
| Osteochondroma | 0 | 3 (1.5) | 3 (0.5) |
APP advanced practice physiotherapy.
After the initial visit, 58% of patients were discharged. Interestingly, this proportion was much higher in the APP group (86%) compared with the orthopaedic group (49%). The APPs managed 96% of patients independently, requesting orthopaedic surgeon input during the initial assessment in a small number of cases. Following the APP’s evaluation, 6.5% of patients were transferred to physiotherapy, and 7.4% were referred to an orthopaedic surgeon (Table 4).
Table 4.
Patient orientation following the initial visit
| APP group (%) | Orthopaedic surgeon group (%) | Total (%) | |
|---|---|---|---|
| Discharge | 359 (85.9) | 99 (49) | 458 (73.9) |
| Physiotherapy | 27 (6.5) | 9 (4.5) | 36 (5.8) |
| Clinical follow-up | 0 | 93 (46) | 93 (15) |
| Clinical follow-up alone | 0 | 36 (17.8) | 36 (5.8) |
| Including radiological investigation or any intervention (cast or surgery) | N/A | 51 (25.2) | 51 (8.2) |
| Combined with physiotherapy | 0 | 6 (3) | 6 (1) |
| Orthopaedic consultation | 31 (7.4) | N/A | 31 (5) |
| Other medical consultation | 1 (0.2) | 1 (0.5) | 2 (0.3) |
APP advanced practice physiotherapy.
APPs were also more likely to counsel the patients regarding posture or bodyweight and demonstrate exercises: 55% in the APP group versus 15% in the orthopaedic group. Overall, surgery was necessary in 3% of cases. However, this represented 1% of patients in the APP group as opposed to 6% in the orthopaedic group.
The mean consultation delay was significantly longer in the APP group compared with the orthopaedic group: 513 ± 258 (median 457, 95%CI 489 to 539) days versus 263 ± 266 (median 162, 95%CI 226 to 301) days. However, a regression analysis revealed a decrease in consultation delays over the course of the observation period (Supplementary Figure 1).
We subsequently analyzed the most recent data over a 4-month period from the APP gait clinic (February 2019 to May 2019) and noted a substantial reduction in the mean waiting time: 107 ± 102 (range 9 to 332) days.
Regarding clinician satisfaction, three APPs and four orthopaedic surgeons completed all three surveys. The Minnesota Satisfaction Questionnaire total mean score was 4.3 in the APP group versus 3.7 in the orthopaedic group. The specific items of the Minnesota Satisfaction Questionnaire can be found in Supplementary Table 2. To compare the new APP gait clinic model of care with the traditional clinic led by orthopaedic surgeons, we administered the PROBES questionnaire. The mean scores were 1.3 in the APP group and 1.1 in the orthopaedic group, indicating a slight evolution in the clinical roles of both groups. Our short survey showed similar results between the two groups with high to very high satisfaction regarding the APP gait clinic.
DISCUSSION
APP role in orthopaedics and paediatric orthopaedics
In recent years, there has been a growing interest in multidisciplinary collaboration within the healthcare system. In orthopaedic clinics, APPs can have a significant impact. A study by Desmeules et al. (5) found that APPs were equal or superior to physicians in terms of diagnostic accuracy, treatment effectiveness, use of healthcare resources, economic costs, and patient satisfaction.
Our results showed a high level of independent management (93%) and an even superior discharge rate following the initial visit (86%). The first analysis was not able to demonstrate a reduction in the mean waiting time over the relatively short observation period. A regression analysis found shorter consultation delays over time in the APP group, whereas it remained stable in the orthopaedic group. Furthermore, a subsequent analysis of the most recent data from the clinic over a 4-month period (February 2019 to May 2019) revealed a mean waiting time of 107 days. In light of these results, we believe that the 1-year adjustment period was not sufficient to erase the patient backlog created over the years preceding the implementation of the APP gait clinic. During the study period, an average of 27 patients per month were assessed by orthopaedic surgeons while it averaged 36 patients per month in the APP group. The difference can be explained by the participation of 2 APPs per clinic compared with 1 orthopaedic surgeon per clinic. This new model of care allowed us to clear the backlog.
Other authors report similar findings with a waiting time for non-urgent conditions that were significantly reduced over a 3-year period (8,11). A financial analysis also confirmed that the clinic was cost-effective (8).
Paediatric orthopaedic consultation relevance
In our study, the APPs managed 96% of patients independently, only requesting orthopaedic surgeon input in a small number of cases. Following the APP’s evaluation, 6.5% of patients were transferred to physiotherapy, and 7.4% were referred to an orthopaedic surgeon (Table 4). Hence, most of the patients referred to the gait clinic did not require an orthopaedic surgeon’s expertise. Collaborative work with APP can ensure a thorough evaluation and recommendations for these children.
Studies have shown that in most cases medical visits for problems, such as bowlegs, knock knee, flat feet, in-toeing and out-toeing are simply a variation of normal development and correct themselves with time (12–16).
Clinician satisfaction
We did not find any studies on APP job satisfaction. However, a descriptive correlation study was done among Canadian Nurse Practitioners using the Misener Nurse Practitioner Job Satisfaction Survey and Minnesota Satisfaction Questionnaire. Overall, job satisfaction ranged from high to very high. Intrapractice partnership and collegiality, as well as challenge and autonomy, were found to have the most influence on job satisfaction (10). Similarly, our results outlined high satisfaction levels in the items related to autonomy, ability utilization, collegiality, recognition, and personal satisfaction. No statistically significant differences were found between APP and clinician, probably because of the small sample size.
Patient and parental satisfaction
While our study did not evaluate patient or parental satisfaction regarding this new model of care in our institution, current literature suggests a high satisfaction rate. Desmeules et al. (5) performed a systematic review of APP in patients with musculoskeletal disorders and found 7 studies comparing patient satisfaction for APP care to usual medical care. All studies demonstrated high patient satisfaction for the APP care. Moreover, 3 studies showed superior results with the APP care and 3 other studies (including one in a paediatric rheumatology clinic) did not find a significant difference between the 2 models of care (5).
To our knowledge, only one study, published in 2019, evaluated parental satisfaction in the setting of an APP paediatric orthopaedic clinic (17). This study demonstrated that parents were very satisfied with the APP clinic as the initial contact with the paediatric orthopaedic department. The themes with the highest satisfaction score were professionalism and communication. The model of care in this study was very similar to the one implemented in our institution therefore, we could suppose similar findings. Additionally, our survey within APPs and orthopaedic surgeons did not report negative feedback from the patients or families. In the future, it would be interesting to look at patient satisfaction in our institution and compare it to the published Irish study.
Interesting results and limitations of our study
Our results show that APPs were able to identify patients requiring surgery. Furthermore, there were no missed diagnoses when subsequent follow-up visits were reviewed. The time lapse between the initial encounter and chart review was more than 1 year. We felt this period was sufficient to assess a clinically relevant change in diagnosis, but it is not an absolute certainty since we don’t have an organized and systematic follow-up. This is a limitation of the retrospective nature of this study. It is also important to keep in mind that all patients attending the APP gait clinic were pre-screened by an orthopaedic surgeon to determine their eligibility. The difference in type of referral lies in the category with missing data (11.4% for the orthopaedic surgeon group versus 1% for the APP group). These proportions are still considered low as data were missing at random according to the waiting time outcome, and there is no clinical reason to believe that these patients with missing referral data (from the patient records reviewed) were managed differently. Patients previously assessed by orthopaedic surgeons in the gait clinic were comparable to those evaluated by APP. Although the reason for referral differed slightly between both groups, the pathologies were similar. More complex pathologies were assessed by orthopaedic surgeons in designated clinics rather than in the gait clinic. Our study also highlights differences in patient orientation following the initial evaluation. Eighty-six per cent of patients in the APP group were discharged without additional follow-up whereas this represented only 58% of patients in the orthopaedic group. A selection bias could contribute to this difference. Following the implementation of the APP gait clinic, potential surgical consults would have been sent to orthopaedic surgeons. This might explain why the surgical conversion rate was 1% in the APP group compared with 6% in the orthopaedic group. However, we believe other factors could have contributed to some of the differences in management. As evidenced by our study, APPs counsel patients and prescribe more exercises than orthopaedic surgeons. One hypothesis could be that orthopaedic surgeons are more likely to reassure patients and families by offering a follow-up appointment. The participation of fellows and residents in the orthopaedic clinic could also contribute to the higher proportion of follow-ups requested. Finally, the high rate of independent management by APPs (96%) supports the APP gait clinic as an effective management resource to help avoid unnecessary orthopaedic consultations.
Our study supports the role of APPs in paediatric orthopaedics. The implementation of an APP gait clinic at our institution was shown to be an effective triage and management method. Paediatric APPs have extensive knowledge of the musculoskeletal system and of the normal physiological development of a child and can help bridge the knowledge gap with primary care physicians. As our study and others have shown, a significant proportion of referrals are for physiological variants. Indeed, 93% of APP patients were managed independently and 86% were discharged in our study. In the current context of limited healthcare resources, a better use of all clinicians’ expertise, including orthopaedic surgeons and APP, would be beneficial. Although our original results did not show a decrease in the mean wait time, a subsequent analysis and data from the literature suggest that with enough time for the system to eliminate patient backlog, an APP-lead clinic can also help reduce consultation delays.
SUPPLEMENTARY DATA
Supplementary data are available at Paediatrics & Child Health Online by searching for pxac013.
ACKNOWLEDGEMENTS
The authors wish to thank Nathalie Jourdain for research assistance and Kathleen Beaumont for manuscript review and preparation.
Funding: There are no funders to report for this submission.
Potential Conflicts of Interest: Dr M.-L.N.’s secondary institution (HSCM) has received departmental funding for research and educational purposes from: Arthrex, Conmed, Depuy, Linvatec, Smith & Nephew, Stryker, Synthes, Tornier, Wright, Zimmer Biomet. This project did not receive any funding from these entities and they were not involved in any aspect of the submitted work. There are no other disclosures. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
IRB Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards and granted by the CHU Sainte-Justine # 2019-2243.
Contributor Information
Véronique Drapeau-Zgoralski, Surgery Department, Université de Montréal, Montreal, Quebec, Canada; Research Center, CHU Sainte-Justine, Research Center—Sainte-Justine University Health Center, Montreal, Quebec, Canada.
Marie Beauséjour, Research Center, CHU Sainte-Justine, Research Center—Sainte-Justine University Health Center, Montreal, Quebec, Canada; Orthopedic Surgery Department, Université de Sherbrooke, Longueuil, Quebec, Canada.
Ariane-Sophie Painchaud, Surgery Department, Université de Montréal, Montreal, Quebec, Canada.
Mélanie Sarda, Research Center, CHU Sainte-Justine, Research Center—Sainte-Justine University Health Center, Montreal, Quebec, Canada.
Marie-Lyne Nault, Surgery Department, Université de Montréal, Montreal, Quebec, Canada; Research Center, CHU Sainte-Justine, Research Center—Sainte-Justine University Health Center, Montreal, Quebec, Canada; Orthopedic Surgery Department, CIUSSS-NIM— Hopital du Sacré-Cœur de Montreal, Montreal, Quebec, Canada.
REFERENCES
- 1. Schwend RM, Geiger J. Outpatient pediatric orthopedics. Common and important conditions. Pediatr Clin North Am 1998;45:943–71. [DOI] [PubMed] [Google Scholar]
- 2. Gunz AC, Canizares M, Mackay C, Badley EM. Magnitude of impact and healthcare use for musculoskeletal disorders in the paediatric: A population-based study. BMC Musculoskelet Disord 2012;13:98. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Al-Nammari SS, James BK, Ramachandran M. The inadequacy of musculoskeletal knowledge after foundation training in the United Kingdom. J Bone Joint Surg Br 2009;91:1413–8. [DOI] [PubMed] [Google Scholar]
- 4. Desmeules F, Toliopoulos P, Roy JS, et al. Validation of an advanced practice physiotherapy model of care in an orthopaedic outpatient clinic. BMC Musculoskelet Disord 2013;14:162. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Desmeules F, Roy J-S, MacDermid JC, et al. Advanced practice physiotherapy in patients with musculoskeletal disorders: A systematic review. BMC Musculoskelet Disord 2012;13:107. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Carli A, Saran N, Kruijt J, et al. Physiological referrals for paediatric musculoskeletal complaints: A costly problem that needs to be addressed. Paediatr Child Health 2012;17:e93–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Ó Mir M, O’Sullivan C. Advanced practice physiotherapy in paediatric orthopaedics: Innovation and collaboration to improve service delivery. Ir J Med Sci 2018;187:131–40. [DOI] [PubMed] [Google Scholar]
- 8. Belthur MV, Clegg J, Strange A. A physiotherapy specialist clinic in paediatric orthopaedics: Is it effective? Postgrad Med J 2003;79:699–702. [PMC free article] [PubMed] [Google Scholar]
- 9. Miller S, Harris SR, Mulpuri K. Agreement between a physical therapist and an orthopedic surgeon in children referred for gait abnormalities. Pediatr Phys Ther 2016;28:85–92. [DOI] [PubMed] [Google Scholar]
- 10. LaMarche K, Tullai-McGuinness S. Canadian nurse practitioner job satisfaction. Nurs Leadersh (Tor Ont) 2009;22:41–57. [DOI] [PubMed] [Google Scholar]
- 11. O Mir M, Cooney C, O’Sullivan C, et al. The efficacy of an extended scope physiotherapy clinic in paediatric orthopaedics. J Child Orthop 2016;10:169–75. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Blackmur JP, Murray AW. Do children who in-toe need to be referred to an orthopaedic clinic? J Pediatr Orthop Part B 2010;19:415–7. [DOI] [PubMed] [Google Scholar]
- 13. Yeo A, James K, Ramachandran M. Normal lower limb variants in children. BMJ 2015;350:h3394. [DOI] [PubMed] [Google Scholar]
- 14. Nemeth B. The diagnosis and management of common childhood orthopedic disorders. Curr Probl Pediatr Adolesc Health Care 2011;41:2–28. [DOI] [PubMed] [Google Scholar]
- 15. Uden H, Scharfbillig R, Causby R. The typically developing paediatric foot: How flat should it be? A systematic review. J Foot Ankle Res 2017;10:37. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16. Sadeghi-Demneh E, Azadinia F, Jafarian F, et al. Flatfoot and obesity in school-age children: A cross-sectional study. Clin Obes 2016;6:42–50. [DOI] [PubMed] [Google Scholar]
- 17. O Mir M, OʼSullivan C, Blake C, Lennon O. An exploration of parental satisfaction with an advanced practice physical therapy clinic in pediatric orthopedics. Pediatr Phys Ther 2019;31:192–9. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.