Physical therapy referrals for systemic sclerosis underused in primary care
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There is a “large variability” in the use of physical therapy for systemic sclerosis, and patients who do receive it are rarely treated for hand or oral dysfunction, according to data published in Arthritis Care & Research.
In addition, the researchers found that 39% of patients with SSc who did not receive physical therapy reported that they were not aware of it as a treatment option, or were not referred.
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“Just like in other chronic inflammatory rheumatic diseases, [physical therapy (PT)] is generally considered an integral part of the management of SSc,” Sophie I.E. Liem, MD, of Leiden University Medical Center, in the Netherlands, and colleagues wrote. “However, improving PT care for SSc patients remains challenging due to a lack of insight into current PT use, and a lack of studies on the effectiveness and safety of PT in SSc.”
“In situations where evidence is lacking, the occurrence of practice variation and suboptimal care is likely,” they added. “To optimize PT in SSc, an evaluation of the actual content of provided PT and the identification of perceived gaps, and preferences for future delivery is mandatory to formulate areas for future research.”
To examine the use of physical therapy among patients with SSc, as well as their needs, satisfaction and preferences related to its practice, Liem and colleagues conducted a cross-sectional survey study of 405 adults from the Combined Care In Systemic Sclerosis (CCISS) at Leiden University Medical Center in July 2019.
Participants, all of whom met the American College of Rheumatology/EULAR 2013 criteria for SSc, received a 37-item questionnaire on their use of, and satisfaction with, physical therapy over a 2-year period. Questions also assessed participants’ physical therapy needs and preferences. A total of 204 patients completed the questionnaire.
According to the researchers, 63% of those who completed the questionnaire had used or were using physical therapy in a primary care setting. Among those not using physical therapy, 39% reported a lack of referral or a lack of knowledge as the reason for not using it. The most frequently reported active treatments were muscle-strengthening, used by 72%; range of motion, used by 60%; and aerobic exercises, used by 56%.
However, specific SSc hand- and mouth-opening exercises were reported by just 15% and 6% of patients, respectively.
Meanwhile, manual treatment such as massage or passive mobilization was reported by 65% of patients.
Mean satisfaction score — assessed on a scale of 0 to 10 — was 8.2. Regarding patients’ needs, 47% of the total group reported that they wanted to receive more information about physical therapy. In addition, 63% said they wished to continue, start or restart physical therapy in the near future, with 44% favoring individual treatment on a continuous basis.
“We confirm a large variability in use and practice of physical therapy in patients with SSc,” Liem and colleagues wrote. “Patients who receive PT are rarely treated for hand and oral dysfunction. The majority of SSc patients expresses an unmet need regarding PT health care services. In order to optimize PT care in patients with SSc, studies to assess appropriateness of PT care, the effectiveness of specific exercises and the perspectives of physical therapists treating SSc patients are warranted. This study is a first step in understanding and optimizing PT use in patients with SSc.”
Perspective
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Systemic sclerosis is marked by decreased quality of life on many levels, not the least of which are the loss of flexibility, decreased range of motion and the risk of contractures. Liem and colleagues show that there is much research still to be done in understanding the role physical therapy plays in treating SSc, along with determining which content/modalities are most helpful.
The authors also point out that the majority of patients in their study identified an unmet need for more education around the role PT plays in sustaining and improving their quality of life. This brings to the forefront the necessity of educating our patients on their disease and treatments. Busy practitioners don’t always have the time to adequately address the educational needs for each of their patients, but their nurses are uniquely trained to meet this need.
This is an opportunity for clinics and providers to train – and therefore empower – their nurses and other staff to meet this need. Liem and colleagues point out that ‘buy-in’ and adherence are both increased when the patient is informed of the availability and viability of physical therapy. Let’s equip our nurses to educate and therefore exponentially increase the opportunity for better adherence and outcomes.
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