Evaluation of extended scope practitioner physiotherapist management and clinical outcomes of patients with degenerative meniscal tears

Meta-analysis of clinical trials highlights that non-operative management of degenerative meniscal tears (DMTs) is as effective as Arthroscopic Partial Meniscectomy (APM) surgery. However, UK surgical guidelines continue to support a role for APM, and this surgery is commonplace. Extended Scope Practitioner (ESP) Physiotherapists working within orthopaedic settings play an independent, role in the assessment and management of patients presenting with a DMT. Their clinical management choices for treating patients presenting with a DMT have not been evaluated. The research aim was to report the clinical management approach adopted and to describe longitudinal change in symptoms in patients with a DMT, with a hypothesis that ESPs would favour non-operative management approaches and that this would not affect outcomes. A 1-year cohort of patients with confirmed DMTs in the absence of advanced osteoarthritis (Kellgren-Lawrence ≤ 3), presenting to ESP-led orthopaedic clinics in a regional referral centre was identified. Clinical management decision was recorded. Outcomes were collected at 1- and 2-years through the Forgotten Joint Score-12 (FJS-12) and Numerical Rating Scales (NRS) for both worst and average pain. Treatment allocation/decision and change in this over time is evaluated. The primary analysis was baseline to 2-year change in outcomes across the cohort, evaluated by one-way repeated measures ANOVA with Bonferroni corrected post-hoc tests to determine differences between timepoints. Significance was accepted at p<0.05 and effect size calculated by the eta squared (η²) statistic. Further exploratory analysis was performed by separate repeated measure ANOVAs with Bonferroni post-hoc comparisons, evaluating the outcomes reported by those receiving different treatment options. Eighty-one patients met the study criteria and were included, 50 (61.7%) male and 31 (38.3%) female and mean age 46.5 years (SD13.13). Forty-nine (60.5%) patients were initially listed for surgery and 32 (39.5%) were planned for non-operative management. Over the two years, nine patients crossed over to non-operative groups and six to the surgical group. Cohort scores improved over time in all three outcome measures (p<0.001) with large effect sizes. Patients were categorised into surgical, ESP-led active intervention groups and no active intervention groups. The surgical group was younger than the others (p=0.02). All three groups improved over time in all outcome measures (p<0.001) with large effect sizes. The surgical group improved more than the others in terms of FJS-12 score (p=0.01), but no other differences in outcome were seen between groups. Isolating patients that stuck to their initial management decision for the 2-year period (n=65), all outcomes were found to be superior in the surgical group compared to the other two management options. The ESPs listed a higher proportion of patients for surgery and less for physiotherapy than expected. The FJS-12 and NRS pain scores improved over the 2-year period irrespective of initial management decision. However, in those that continued with their initial management plan, patients undergoing APM surgery reported superior outcomes to the non-operative management groups. Whether this is attributable to the intervention or the selection for receiving that intervention is not assessable with this data. Reasons for clinical decision making and the clinical relevance of the outcomes are considered, and suggestions for future research made.