Case Study 1
In this under-treatment example, a player may hurt their ankle during a club county semi-final match. It is painful and swollen and the player is sent for an x-ray, which is reported as normal. The player is held out and rested by the club doctor and physiotherapist. The club final is two weeks later but in that second week, while the ankle is improving, it is still sore and more swollen than would be expected. The medical team is starting to get concerned about the possibility of a syndesmosis injury because of the clinical tests and areas of pain on palpation. The player and manager just want to play the match because the player can just about run on it and they are the goalie. There is a five-day wait for an MRI at the local private hospital and the orthopaedic ankle specialist does not have a free appointment slot for four weeks.
The player starts the match, misses the second attempt at goal and has to be taken off after 20 minutes. When the player finally gets an MRI two weeks later, it reveals a syndesmosis injury and a full anterior talofibular ligament (ATFL) tear. They have surgery eight weeks later, after the initial injury. Recovery is slow and painful and they are out of sport for six months. Even though it is the private sector, this is clearly a capacity issue. If the clinical concerns could have been acted on in that second week, the patient could have been triaged, sent for MRI and had a consultant opinion early. The player would not have played the match, had an earlier repair and made a quicker recovery.
Case Study 2
A 10-year-old girl, who had had a significant head impact playing basketball 10 weeks’ previously, presented to the Bon Secours paediatric concussion clinic in Cork, run by Dr Niamh Lynch, Consultant Paediatrician. She was not knocked unconscious but had amnesia and dizziness at the time of incident. She stayed in school that day but was confused. When she went home she was agitated, confused and had memory loss. She became more confused as the evening went on and was brought to the local emergency department, where she had an MRI. This was reported as normal and the patient was sent home. Over the next few days, her memory loss remained, dizziness increased and an altered gait and sleep issues developed also. She was seen by her GP three days later and referred to the emergency department, where she was again discharged after assessment and being cleared of any serious head injury. As things did not improve over the next few weeks, she was seen by an ENT consultant to investigate if there was a vestibular problem. This was ruled out and the patient was referred to a neurologist, where concussion was diagnosed. She was told to rest and it would settle. At this stage, her anxiety was becoming more problematic and both the patient and parents were very concerned. She was referred by the neurologist to a counsellor to treat her anxiety.
At the stage of referral, she had been out of school for nearly 10 weeks.
The patient was assessed by Dr Lynch and a senior chartered physiotherapist. The treatment prescribed was vestibular exercises for visual motion sensitivity and ocular exercises, as she had a convergence of 24cm (normal less than 5cm). Due to the length of time of the symptoms, the parents and patient required a lot of reassurance that treatment would not make them worse, but would be slow.
Significant progress was made, however. The parents and patient became much less anxious and were delighted that symptoms were resolving. On final assessment, her VOMS (vestibular/ocular-motor screening) was clear, and she had a normal gait with no car sickness, nausea or vertigo. She had returned to full social activity and school but was not involved in contact sport (basketball). The physiotherapist ran a final exertion test with the patient, which she passed with no issues. The patient was cleared to return to training and then to return to sport.
This is a clear example of how seeing the right person at the right time can make all the difference to patient outcome.
If you are involved in sports, be it at amateur or professional level, one of the most frustrating things that can happen is that you sustain an injury. This causes pain and suffering and removes you from your favourite recreation or your livelihood. What is even more frustrating is knowing that you need an expert opinion but not being able to source it. This can stem from not knowing where to go or not being able to get an appointment with the person (who you hope is the best one) to advise you and get you back to sport quickly. In the public sector, this is sadly an all-too-familiar a problem. Capacity issues have led to waiting lists in some services, such as orthopaedics and rheumatology, of several years.
With the establishment of the National Musculoskeletal (MSK) and Rheumatology triage service in 2012, the HSE has been having a positive impact on waiting lists in these clinical areas in the last few years. This is a model that is already in use internationally. This model uses clinical specialist chartered physiotherapists to triage patients and directs them to the appropriate investigations or treatment. This ensures that when patients see a consultant, they are much more likely to be the patients who need surgery or consultant-led interventions. In other words, consultants and surgeons see more of the patients that they need to see and patients get to see the clinician that they need to see at the right time. Waiting lists have improved significantly in MSK and rheumatology conditions as a result.
Sports injuries are also MSK injuries and treating them uses many of the same resources and treatment pathways as MSK problems presenting in the general population. Athletes with sports injuries will need access to physiotherapists, radiology and consultants in the same way as a patient with hip pain wondering about a hip replacement. Very different injuries or presentation, but very similar needs. In the private sector, treatment may involve either under-treatment or over-treatment.
The first case report documents a typical example of an MSK sports injury under-treatment scenario.
The second case study looks at a similarly unsatisfactory outcome with over-treatment of a concussion injury.
Development of a private sector MSK triage service
Mr Declan Bowler is a Consultant Orthopaedic and Sports Surgeon who moved to the Bon Secours Cork in 2016. With a special interest in lower-limb sports injuries, development of a new sports medicine model was a key goal.
In Galway, Ms Emilie McGrath had been newly-appointed as the Physiotherapy Manager. With 20 years’ experience running a sports physiotherapy clinic, she was all too aware of the issues of capacity that face clinicians and athletes in the community when seeking investigation and treatment of a sports injury.
A meeting before the second National Concussion Conference in September 2017 brought about the idea of developing a Bon Secours Health System Sports Injury treatment service. On 14 April 2018, the agreed sports injury treatment model was presented at the inaugural Bon Secours Sports Symposium in Thomond Park, Limerick.
This model dealt with the key issues of capacity and quality service provision in the private sector but modelled on the public sector musculoskeletal service. Sports injury patients will be able to access sports injury triage in three Bon Secours sites initially, with treatment usually at the same site or at another Bon Secours site, depending on availability and convenience for the patient.
A scenario would be as follows: An injured patient contacts the service either directly or through their GP or physiotherapist. Triage is arranged that day and the patient is advised whether they need to go directly to an emergency department at an acute hospital or is suitable for attendance for MSK triage. In the latter, they would go into the nearest Bon Secours hospital, where they are seen by a clinical specialist chartered physiotherapist and go through a triage process. If the patient does not need further tests or to see a consultant, they are treated by the clinical specialist physiotherapist at that site.
At this stage, they may go to their own GP/physio in the community or continue with treatment at the Bon Secours, whichever is most suitable and convenient for the patient. If the triage physiotherapist feels that further investigations or a consultant opinion are necessary, then the patient is referred to the consultant who is available on-site that day. Any investigations are ordered at this stage. When results come back, the physiotherapy and medical team confer and agree on the best pathway for the patient. If this is conservative management, the patient may again be referred back to their home GP/physio or have treatment at the Bon Secours, whichever they prefer. If surgery is deemed necessary, the patient then moves into the care of the most appropriate consultant surgeon for their condition and surgery is carried out. The surgery would usually be carried out at the triage site or another Bon Secours hospital, depending on availability of patient, surgeon and other resources. So the patient pathway, from injury to referral, to treatment to discharge, is much more streamlined and efficient.
There are clear advantages for patients in this type of model. Patients are seen early and sent in the right direction early on in their treatment pathway. Triage and treatment pathways are aligned at participating sites, so patients’ movement through the treatment pathway is smooth, as is transfer of information. Initial cost to the patient is also controlled. The patient pays an initial triage fee, which will cover their initial phone triage, their initial consultation and treatment with the MSK triage clinical specialist physiotherapist and any necessary initial consultant appointment that day, as appropriate. After this, costs are dependent on the needs of the patient. So if they are reviewed by the consultant and it is decided they do not need surgery or radiology at this point, the patient is either discharged fully or sent back to their referring physio or doctor with advice. Or the patient may clearly need an MRI as soon as possible to confirm a suspected anterior cruciate ligament (ACL) tear, for example, which will often need surgery.
Strong professional relationships are also a key component of this triage pathway. GPs and physiotherapists in the community have the reassurance that their patients will receive rapid and appropriate treatment for their injuries, as needed. As the patients’ primary healthcare providers, they will receive up-to-date and comprehensive information on their patients’ status as they are referred back to their care.
If patients require specialist rehabilitation services that are not generally available in the physiotherapy community, such as isokinetic evaluation and rehabilitation (Galway) and post-concussion assessment and rehabilitation (Cork and coming soon to Galway), then they can avail of these also, again with a clear pathway of communication and return to care between the service’s specialist chartered physiotherapists and the patient’s own referring physiotherapists.
Ms Emilie McGrath, Chartered Physiotherapist and Certified Strength and Conditioning Specialist, Physiotherapy Manager, Bon Secours Galway, and Mr Declan Bowler, Consultant Orthopaedic and Sports Surgeon, Bon Secours Cork