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The HyDAT Project: UK Aquatic
Physiotherapy Data Collection
2009
HyDAT team: Liz Bryant1, Anna Carter2,3 , Sarah Cox2, Do Heath2, Anne Jackson2,4,1*, Ann Moore1, Raija Kuisma1,2, Jacqueline Pattman2,5, Sarah-Jane Ryan1,2*
1University of Brighton 2Aquatic Therapy Association of Chartered Physiotherapists
3East Sussex Hospitals NHS Trust
4Western Sussex Hospitals NHS Trust 5Brighton and Sussex University Hospitals NHS Trust
*Contact for correspondence
*Contact for correspondence: Sarah-Jane Ryan [email protected] Dr. Anne Jackson [email protected]
Please reference this document: HyDAT Team (2009) The HyDAT Project: UK Aquatic Physiotherapy Data Collection. London: Chartered Society of Physiotherapy
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Terminology Aquatic physiotherapy is:
A therapy programme utilising the properties of water, designed by a suitably qualified physiotherapist specifically for an individual to improve function, carried out by appropriately trained personnel, ideally in a purpose built, and suitably heated hydrotherapy pool. Aquatic Therapy Association of Chartered Physiotherapists (ATACP) (2006).
Although the term ‘aquatic physiotherapy’ is used throughout the main body of this report, prior to 2008 aquatic physiotherapy was called ‘hydrotherapy’ in the UK. This latter term is therefore used both in early material prepared for the HyDAT project and in the appendices. The reason for the change to aquatic physiotherapy was twofold 1) to be in line with the international term aquatic physical therapy and 2) to make use of the protected term physiotherapy. The word patient is used here to include any person (e.g. student, pupil, client) attending aquatic physiotherapy treatment sessions. Abbreviations
AHP Allied Health Professional ATACP Aquatic Therapy Association of Chartered Physiotherapists CSP Chartered Society of Physiotherapy DH Department of Health HEI Higher education institute HyDAT National Hydrotherapy Data Collection (team/tool/project) IQR Interquartile range NPRN National Physiotherapy Research Network MSK Musculoskeletal SDC Standardised data collection NASS National Ankylosing Spondylitis Society SPSS Statistical Package for the Social Sciences
Glossary
Audit trail - development
Steps/processes in developing a SDC tool e.g. HyDAT
Audit trail - methods Documentation capable of tracing each completed HyDAT tool back to the original patient notes - used in case of query, stored as patient notes
Convenience sample A sample this is convenient and practical, although not guaranteed to be representative of a population, it is accepted practice and pragmatic for a descriptive study
HyDAT team The authors of this report made up the HyDAT team HyDAT tool The form used to collect data from patients – given in appendix D HyDAT project The whole of the work described in this report and includes developing the
tool, the methods, guidance notes, coding, classification and records. Inter-quartile range The inter-quartile range (IQR) is the distance between the 75th percentile and
the 25th percentile. The IQR is essentially the range of the middle 50% of the data. Because it uses the middle 50%, the IQR is not affected by outliers or extreme values
Mean The average of a set of scores and is derived from adding all the scores together and dividing the total by the number of scores
Median The mid score in a set of results Mode The most frequently occurring score in a set of results Maintenance [aquatic exercise] group
Is for patients/clients who have completed their course of aquatic physiotherapy but continue with their aquatic exercises with or without the supervision / input of an aquatic physiotherapist.
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Contents 1 Introduction 7
1.1 The aim of the HyDAT project ............................................................................................. 7 1.2 The political context of data collection ............................................................................... 7 1.3 Background to the HyDAT project ....................................................................................... 8 1.4 The Southeast Aquatic Physiotherapy Research and Audit Group ..................................... 8
2 Methods 9 2.1 Inclusion criteria .................................................................................................................. 9 2.2 Exclusion criteria .................................................................................................................. 9 2.3 The HyDAT tool – the development audit trail.................................................................... 9
2.3.1 The origins of the HyDAT tool ......................................................................................... 9 2.3.2 The emerging HyDAT tool ............................................................................................... 9
2.4 Recruiting physiotherapists to the HyDAT project ............................................................ 10 2.5 The HyDAT tool .................................................................................................................. 10
2.5.1 Data collection forms .................................................................................................... 10 2.5.2 The methods audit trail ................................................................................................. 10
2.6 Data collection ................................................................................................................... 11 2.7 Data input .......................................................................................................................... 12 2.8 Data analysis ...................................................................................................................... 12
3 Describing the data 13 3.1 Data sets ............................................................................................................................ 13 3.2 Participating physiotherapists ........................................................................................... 13
3.2.1 Speciality area ............................................................................................................... 14 3.2.2 Number of patients treated per week .......................................................................... 15
3.3 Focus on the patients ........................................................................................................ 15 3.3.1 Referral source .............................................................................................................. 15 3.3.2 Age of patients treated ................................................................................................. 16 3.3.3 Patient’s gender ............................................................................................................ 16 3.3.4 Patient’s occupation / education .................................................................................. 17 3.3.5 Mode of employment ................................................................................................... 18 3.3.6 Nature of referral .......................................................................................................... 18 3.3.7 Specific reasons for referral .......................................................................................... 19 3.3.8 Other relevant diagnoses .............................................................................................. 20
3.4 Focus on treatment ........................................................................................................... 21 3.4.1 Number of weeks waiting for treatment ...................................................................... 21 3.4.2 Type of intervention ...................................................................................................... 21 3.4.3 Number of weeks on treatment.................................................................................... 22 3.4.4 Previous aquatic physiotherapy treatment episodes ................................................... 22 3.4.5 Physiotherapists weighting of psychosocial and physical factors ................................. 23 3.4.6 Treatment details .......................................................................................................... 23 3.4.7 Specific aquatic physiotherapy techniques ................................................................... 24 3.4.8 Exercise/Education booklet / information used ........................................................... 24 3.4.9 Number of treatments this episode .............................................................................. 24 3.4.10 Grade of physiotherapist(s) involved in treatment ....................................................... 24 3.4.11 Factors influencing the outcome of treatment ............................................................. 25
3.5 Focus on outcomes of the treatment ................................................................................ 26 3.5.1 Outcome of referral/treatment .................................................................................... 26 3.5.2 Goal achievement at discharge ..................................................................................... 27
3.6 Summary of findings .......................................................................................................... 27 4 Discussion and implications 28
4.1 Future standardised data collection and audit ................................................................. 28 4.2 Future research ................................................................................................................. 28
4.2.1 Areas of further enquiry ................................................................................................ 28 4.3 Reflection and limitations .................................................................................................. 29
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5 Conclusion 30 6 Appendix A (Letter to colleagues) 31 7 Appendix B (Summary of the HyDAT project) 32 8 Appendix C (the HyDAT team) 33 9 Appendix D (HyDAT tool) 35 10 Appendix E (HyDAT guidance notes/coding) 36 11 Appendix F (Classifications) 41 12 Appendix G (HyDAT methods) 44 13 Appendix H (HyDAT record) 46 14 References 47
List of figures and tables Figure 1: The South-East Aquatic Physiotherapy Research and Audit group 8 Figure 2: Selecting and completing the HyDAT tools- the processes 12 Figure 3: Grouping physiotherapists’ specialities 14 Figure 4: Number of patients treated per week 15 Figure 5: Age range of patients treated 16 Figure 6: Mode of employment 18 Figure 7: Nature of referral 19 Figure 8: Specific reasons for referral – classifications 19 Figure 9: Number of weeks waiting for treatment 21 Figure 10: Number of weeks participating in aquatic physiotherapy treatment 22 Figure 11: Number of aquatic physiotherapy treatments per episode of care 24 Figure 12: Goal achievement at discharge 27 Table 1: Participating trusts/units divided into Strategic Health Authorities (SHAs) 13 Table 2: Speciality areas in aquatic physiotherapy 14 Table 3: Patient referral source 15 Table 4: Patient’s gender 16 Table 5: Patient occupations 17 Table 6: Nature of referral 18 Table 7: Specific reason for referral – classifications 20 Table 8: Other relevant diagnosis – classifications 20 Table 9: Intervention type 21 Table 10: Previous episodes of aquatic physiotherapy 22 Table 11: Weighting of psychosocial and physical factors in percentages 23 Table 12: All treatment interventions recorded 23 Table 13: Grade of physiotherapist(s) involved in treatment 24 Table 14: Factors influencing the outcome of treatment 25 Table 15: Outcome of referral/treatment 26
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Acknowledgements ATACP members, and other physiotherapy colleagues, across the UK who made this project possible by their work and commitment in collecting anonymised data from their patients. The University of Brighton, Brighton and Sussex University Hospitals NHS Trust, East Sussex Hospitals NHS Trust and Western Sussex Hospitals NHS Trust for staff and other expert resources. The ATACP for financial support and academic expertise via study days and publications in its journal, Aqualines.
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Executive Summary Aim: To provide a snapshot of aquatic physiotherapy practice in the UK, across all settings, in 2007. This report focuses on the methods and description of the data collected; detailed discussion and implications will follow in future publications. Objectives:
To provide comprehensive information of current aquatic physiotherapy practice in the UK
To provide a baseline for future data collection and potential research projects
To demonstrate the impact of aquatic physiotherapy on health and social care. Background: The HyDAT team is based in the South-East of England. The team consists of members from the University of Brighton, 3 local NHS trusts and 2 private practitioners. It is also linked with the ATACP executive committee and the South- East hub of the National Physiotherapy Research Network (NPRN) of the Chartered Society of Physiotherapy (CSP). This project built on previous work of HyDAT team (Jackson 2001, Jackson et al 2003, Jackson et al 2004 and Carter et al 2005). Following outcome data collection and audit of outcome measures used in aquatic physiotherapy the HyDAT team turned to a broader standardised data collection (SDC) approach. The HyDAT SDC tool was developed from an existing tool developed by Moore et al (1996, 1998, 1999, and 2006). Design: The HyDAT tool was developed and used to collect anonymised data relating to aquatic physiotherapy practice in the UK. The HyDAT team collated, analysed and presented these data in this report. Data collection period: 1 June 2007 – 31 July 2007 with a follow up period (to enable patients to complete their intervention) until 30 September 2007. Data collected: The HyDAT tool was developed following a systematic process involving consultation with ATACP members through 2 study days in 2006 and short articles in the ATACP journal Aqualines. ATACP members and other physiotherapy colleagues practicing aquatic physiotherapy across the UK provide data from patient records by completing HyDAT tools and sending them to the HyDAT team. 117 physiotherapists took part in this study and the HyDAT team received 1,762 completed patient data sets from 74 locations from across the UK. Data included patient details, diagnose, referral information, treatment details, outcome of referral, goal achievement and service related details. Data analysis: The data collected using the HyDAT tool were entered into SPSS (version 15) and analysed. The descriptive data are shown in this report. Main findings: One hundred and seventeen physiotherapists across the UK took part in this study and collected data during a 2 month period in 2007. In total 1,762 completed data sets were received.
Patient details: - 70% of patients were aged 40 years and above - 62% were female - 34% were retired.
Nature of referral: - 73% of patients had a long-term condition - 62% had mobility problems coexisting with their reason for referral - 35% had difficult social circumstances - 25% had a condition described as severe by the treating physiotherapists - 20% had communication or sensory difficulties - 14% had back pain (the most frequently reported reason for referral) - A wide range of diagnoses was represented.
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Referral information: - 47% of patients were referred from NHS medical consultants - Average (median) number of weeks waiting was 2 weeks.
Treatment details: - 55% of patients were described as having at least one of range of movement exercises,
active strengthening exercises, self-management, functional exercises - the average (mode) number of treatments was 6 - 51% of patients were given written advice - 10% were given specialist aquatic therapy interventions e.g. Bad Ragaz, Halliwick,
Watsu or Ai-Chi.
Goal achievement: - 77% of all patients achieved all or some of their goals on discharge
Service related details: - Average (median) number of weeks waiting time was 2 weeks (Range 0-157, IQR 4).
The HyDAT tool was found to be user-friendly and provides valuable information for clinical and research debate (Cox et al, 2009). Implications for future practice: The HyDAT project has provided a comprehensive database of aquatic physiotherapy activity across the UK. This has led to a recommendation from the HyDAT team that the ATACP form a sub group to advise and co-ordinate research efforts in aquatic physiotherapy. It is hoped that this report will also facilitate clinicians to reflect on their aquatic physiotherapy practice. It also demonstrates that standardised data collection (supporting evidence based practice) can be undertaken in the clinical field. Ongoing work is likely to involve further collaboration in the UK and perhaps overseas.
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1 Introduction The National Hydrotherapy DAT a collection (HyDAT) project is the first UK standard data collection (SDC) project in aquatic physiotherapy. It is intended to provide a snapshot of practice to give, for example: an insight for clinicians to reflect on their practice a benchmark for managers to assist in making decisions about service delivery evidence of clinical effectiveness for commissioners a basis for formulating meaningful research questions that may form the basis of ATACP national
research priorities.
1.1 The aim of the HyDAT project
To provide a snapshot of aquatic physiotherapy practice in the UK, across all settings from June to September 2007. This project report focuses on the methods used and a description of the data collected. The intention is to publish baseline data to encourage others to embark on standardised data collection, which is fundamental to the evidence base of aquatic physiotherapy. Detailed discussion and implication of the findings will follow in future publications.
1.2 The political context of data collection
Recent changes in health policy across the UK bring opportunities for physiotherapists but they also bring challenges. SDC projects, such as this, are increasingly important in enabling physiotherapists, and other allied health professionals (AHPs) to demonstrate their impact in improving health so that they are in a strong position to bid to develop new and existing services. In a recent report, High Quality Health Care for All, the UK Department of Health (DH) promotes world class commissioning as a means to reduce health inequalities and promote health and well being for all (DH, 2008). Services will be evidence-based and of the best quality, and people will have choice and control over services so they become more personalised. Thus AHPs must demonstrate their contributions to health and well-being to ensure that they can show that their services are worthy of world class commissioning. The push is for an NHS
‘….that gives patients and the public more information and choice, works in partnership and has quality of care at its heart’ (DH, 2008 p 7).
In a similar way AHPs in Northern Ireland, Wales and Scotland need to demonstrate that their services should and can be commissioned. February 2009 saw the launch of ‘Be active Be Healthy a plan for getting the nation moving’ (DH, 2009). This guidance paper focussed on the delivery of physical activity to the nation incorporating the London 2012 Olympics as a driver. The centre of this paper is not just on health but across education, charities and sport and suggests
‘that health practitioners are well placed to encourage their patients to be more active. We therefore continue to develop our physical activity care pathway (PACP) model that targets a brief intervention at inactive adults to encourage sustained behaviour change.’ (DH, 2009 p 7).
In 2009, the economic recession, an aging population, increasingly expensive health care and a more demanding population, has led to a focus on delivering quality through a greater focus on innovation, productivity and prevention (QIPP) (DH, News, 2009). This builds on Lord Darzi’s work last year. Using SDC, as described here, enables physiotherapists to demonstrate quality (e.g. patient outcomes) and productivity (e.g. number of patients seen). Future SDC projects might be designed to indicate physiotherapy’s contribution in preventative health care. A baseline, such as the data presented here, is necessary to demonstrate the value of service innovation. Physiotherapy has never been in a stronger position to make an impact on health in the UK but we can only move forwards if evidence, starting with standardised data, is at the heart of what we do.
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1.3 Background to the HyDAT project
The HyDAT team was developed out of the South-East Aquatic Physiotherapy Research and Audit group. This group came together both to follow up earlier studies in the South-East of England e.g. investigating outcome of aquatic physiotherapy using the measure yourself medical outcome profile (MYMOP) (Jackson 2001, Jackson & Jackson 2003), students projects investigating older people’s involvement in aquatic exercise (Jackson et al 2004), and to bring together local experts keen to work collaboratively. An initial survey by the group (Carter et al, 2005) found that 27 of the 40 physiotherapists who responded were keen to be involved in a national audit. Twenty five different outcome measures were used and 30% of respondents reported using the MYMOP as recommended by the ATACP. The audit tool developed in this project was a modified version of data collection tools used in previous audits of outcomes following intervention for musculoskeletal (MSK) physiotherapy (Moore 1996; Moore 1998; Moore 1999 and Moore et al. 2006). These tools were used to inform the development of the HyDAT standardised data collection tool.
1.4 The Southeast Aquatic Physiotherapy Research and Audit Group
The HyDAT team was made up of committed physiotherapists (figure 1) working across different settings and in different roles.
Figure 1: The southeast Aquatic Physiotherapy Research and Audit group
Chartered Society of Physiotherapy
ATACP Aquatic Therapy Association of Chartered Physiotherapists
NPRN National Physiotherapy Research Network
3 NHS Hospital Trusts, 2 Private Practitioners
Brighton and Sussex University Hospitals East Sussex Hospitals Western Sussex Hospitals South West London South Lincolnshire
University of Brighton
School of Health Professions Physiotherapy division
Clinical Research Centre
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2 Methods
2.1 Inclusion criteria
The aim was to be inclusive of all aquatic physiotherapy i.e. a therapy programme using the properties of water, designed by a suitably qualified physiotherapist. The following inclusion criteria were applied i.e. people:
attending aquatic physiotherapy sessions in the UK where there has been input from a physiotherapist (note that a technician or assistant might run the programme designed by a physiotherapist)
of any age
in all settings (e.g. NHS, private, self-help groups, community groups, school groups, pre-school groups, National Ankylosing Spondylitis Society (NASS) groups)
with all diagnoses e.g. learning disabilities, cerebral palsy, back pain
attending group or individual treatment sessions.
2.2 Exclusion criteria
People attending pool sessions:
With no input from a physiotherapist at any stage e.g. school exercise in water sessions run by a teacher/carer with no physiotherapy input, aqua-aerobics at local leisure pool etc.
2.3 The HyDAT tool – the development audit trail
2.3.1 The origins of the HyDAT tool
Following research and discussion of currently available SDC tools, the HyDAT team decided to modify previously developed tools for physiotherapy outpatient services (Moore 1996; Moore, 1998; Moore, 1999; Moore et al, 2006). In this way the HyDAT tool was derived from a series of SDC and audit projects in physiotherapy in the Southeast of England. One of the previous SDC projects, in 1994-1996 (Moore 1996), focussed on outpatient physiotherapy in the then Mid Kent Healthcare Trust. Using a series of focussed discussion groups, a pilot SDC tool for MSK physiotherapy services was drafted. A series of steps refined this pilot tool so that it had content and face validity with physiotherapists. Further work refined the tool again so that it appealed to more specialised MSK physiotherapists before it was used in SDC involving 14 trusts in the South Thames region. This SDC tool was found to be user friendly, practical and quick to use. It was developed and used extensively in the NHS in outpatient physiotherapy i.e. a scope of practice similar to that under consideration here. For these reasons the HyDAT team worked to adapt this existing SDC tool so that it would suit the needs and requirements of aquatic physiotherapy e.g. including specific aquatic physiotherapy treatment modalities. Moore (1996) recommended an audit trail in developing a tool which included wide-ranging collaboration with the target audience through national survey, focus groups and piloting.
2.3.2 The emerging HyDAT tool
The HyDAT team met several times in 2005 to adapt and draft the HyDAT tool from the original MSK SDC tool
The first version of the HyDAT tool was presented at the Spring 2006 ATACP Study Day in London where members, organised into focus groups according to their speciality, were asked to comment on all aspects of the tool e.g. diagnoses, treatment details and outcome measures. Following extensive group discussion detailed feedback was given and the recommendations recorded.
The HyDAT tool was re-drafted following these recommendations.
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The second version of the HyDAT tool was presented at the Autumn 2006 ATACP Study Day in Birmingham. Following a second round of focus groups, minor changes were made to ensure content and face validity with aquatic physiotherapists.
The final version of the HyDAT tool was piloted at two aquatic physiotherapy sites to assess user friendliness. Physiotherapists working at these pilot sites had not been involved in developing the HyDAT tool therefore its clarity of use was easily assessed. The tool was found to be user friendly and, on average, took 5 minutes to complete. Minimal changes were made to the HyDAT tool at the pilot stage.
Thus the target population of aquatic physiotherapists were involved in all stages of the development process.
Following completion of the pilot study the HyDAT project was launched at the ATACP Study Day in April 2007 and Professor Ann Moore spoke at this launch.
2.4 Recruiting physiotherapists to the HyDAT project
The success of the HyDAT project depended recruiting physiotherapists, from across the UK, to participate in data collection. This was done in several ways:
Involving the ATACP membership in developing the tool (section 2.3)
Running ongoing articles in Aqualines, the journal of the ATACP
Calling for physiotherapists to participate via the CSP’s interactive electronic network, iCSP
Members of Association of Chartered Physiotherapists for People with Learning Disabilities (ACPPLD) were invited to participate in a presentation in March 2007
2.5 The HyDAT tool
2.5.1 Data collection forms
There were two 2 data collection forms for participating physiotherapists.
HyDAT tool (appendix D) - one was completed for each patient record included in the audit and returned to the audit team.
HyDAT record (appendix H) – was completed by each physiotherapist and retained by the participating physiotherapist. This provided an audit trail for each participant but ensured the anonymity of the data; no identifier was included with the data
2.5.2 The methods audit trail
To protect patients’ identity but to ensure a methodological audit trail i.e. a pathway to any patient’s full notes to follow up potential queries:
Each participating aquatic physiotherapy setting (unit or department) was asked to register by e-mail and each was sent a ‘trust / unit code’ e.g. WOR01.
Each setting allocated a personal ‘therapist i.d.’ code to each individual therapist e.g. T1, T2, and T3 etc.
To ensure patient confidentiality, hospital number could not be used therefore each therapist allocated a ‘patient i.d.’ code to each participating patient e.g. P1, P2, P3 etc
These codes were recorded on the HyDAT tools and HyDAT records accordingly. Participating physiotherapists were asked to complete all HyDAT forms as fully as possible and store them securely in accordance with local data protection policies. It was recognised that in a project of this nature missing data was inevitable, but to encourage maximum data collection participants were asked to submit all that was available.
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2.6 Data collection
Participating physiotherapists were asked to review their practice and decide how many HyDAT tools they could feasibly complete in the timescale i.e. a convenience sample. Flexibility was needed because while aquatic physiotherapists running a small group each week might complete a HyDAT tool for each patient, those running busy clinics each week were more likely to participate if they were asked to complete a manageable number of HyDAT tools. In the first week of the data collection physiotherapists were asked to mark the notes of a variety of patients on treatment until they reached the number that they could feasibly complete. This would make the notes of included patients easy to identify should the HyDAT team have a query about an individual patient at a later stage (figure 2). From 1 June to 31 July 2007 participating physiotherapists were asked to:
Begin completing HyDAT tools for the patients whose notes they had marked regardless of whether they were a new or ongoing patient
Use the HyDAT guidance notes to assist completion of the HyDAT tools (appendix E).
The decision to include continuing patients enabled the inclusion of maintenance groups that may not be led by physiotherapists.
If a patient had completed their course of aquatic physiotherapy (or stopped attending) by 30 September 2007, participating physiotherapists were asked to:
complete one HyDAT tool for each patient as their treatment finished or they had stopped attending
enter each patient’s details onto the HyDAT record. If a patient’s aquatic physiotherapy was ongoing after 30th September 2007, participating physiotherapists were asked to:
finish completing one HyDAT tool for each patient
give their outcome as of 30 September e.g. a goals of a self-help group may be to provide facilities for patients to continue with their aquatic physiotherapy programme and the form should be completed accordingly
enter each patient’s details onto the HyDAT record. At the end of the data collection participating physiotherapists were asked to:
send their completed HyDAT forms to the HyDAT team at a given central address
keep their HyDAT records, stored securely in accordance with data protection policies, until the project report was completed. This was to enable the HyDAT team to clarify any points or discrepancies that arose.
Two HyDAT team members acted as contact points for participating physiotherapists. These team members dealt with specific questions e.g. about i.d. codes and how to code individual patient’s diagnosis. Furthermore they gave assistance with interpreting and applying the HyDAT guidance notes.
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Figure 2: Selecting and completing the HyDAT tools – the processes
YES NO
YES NO
2.7 Data input
Data were transferred from the paper data collection forms to an Excel spreadsheet between December 2007 and April 2008. With a response to the HyDAT project that was greater than anticipated, the ATACP committee sponsored a member of their executive committee to complete this task and thus the HyDAT team gained a new member.
2.8 Data analysis
This was completed between June 2008 and August 2008 at the University of Brighton using the Statistical Package for the Social Sciences (SPSS version 15). The HyDAT team reviewed the data analysis and began to write up this report in autumn 2008.
Clinical team discussion on number of data sets that can be collected between 1st June and 31st of July
Patient fits inclusion criteria
Mark patient’s hydrotherapy notes clearly and start to input initial data on HyDAT tool
DO NOT COLLECT DATA
Hydrotherapy episode completed by 30
th September
Complete HyDAT tool and return to University of Brighton
Complete HyDAT tool and return to University of Brighton giving outcome achieved as of 31
st
of September
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3 Describing the data This section is dedicated to describing the HyDAT data but in order to assist the reader:
a few words of explanation or qualification are added on occasions
presentation of data is in the same order as the questions on the HyDAT tool.
3.1 Data sets
Completed HyDAT forms were received from 44 trusts/units across the UK during the data collection period, see table 1. The number of data sets collected per trust/unit ranged from 1 to 327. The average (mean) number of data sets collected per trust/unit was 39 (SD 53) Table 1: Participating trusts/units divided into Strategic Health Authorities (SHAs)
South East Coast Bexhill Chichester Crawley Dartford Eastbourne Hastings Haywards Heath Maidstone Oxted Sidcup Worthing London East London Charing Cross Brentwood Bromley Harrow Mile End Tooting West Midlands Derby
North East Durham Middlesbrough North West Manchester Southport Liverpool East of England Chelmsford Colchester Essex Ipswich Stevenage Southend East Midlands Boston Lincolnshire Northamptonshire
Scotland Aberdeen Edinburgh South Central Basingstoke Aldershot Isle of White Slough Oxford South West Bristol Dorchester Exeter Shrewsbury
3.2 Participating physiotherapists
One thousand seven hundred and sixty two data (1762) sets were collected from 117 participating physiotherapists.
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3.2.1 Speciality area
Practitioners were asked to select up to two major areas of speciality in aquatic physiotherapy. The table below (table 2) shows the number of times the speciality areas were selected by the practitioners while completing the HyDAT tool per patient. While the majority of physiotherapists work in just a few specialities, physiotherapists using aquatic therapy have a wide spread of specialist skills. Table 2: Speciality areas in aquatic physiotherapy
Speciality area 1st speciality area 2nd speciality area Frequency (n =) (n =) Neuromusculoskeletal (outpatients) 692 86 Orthopaedics 642 446 Rheumatology 119 246 Neurological 88 111 Paediatrics 71 2 Learning difficulties 53 24 Pain management 28 121 Cardio-respiratory 2 0 Women's Health 2 0 Mental health 2 9 Sport 2 28 Amputees/Vascular 1 0 Palliative care 1 17 Not reported 59 672 In figure 3 the speciality areas (1st and 2nd) as reported by the participants have been combined. The “Other” category in this graph includes:- cardio-respiratory, women’s health, amputees/vascular, mental health, sport and palliative care. Figure 3: Grouping physiotherapists’ specialities
Almost 75% of physiotherapists working in aquatic therapy specialise in neuromusculoskeletal areas including orthopaedics.
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3.2.2 Number of patients treated per week
Practitioners were asked to estimate the number of patients attending sessions supervised or run by them each week. The numbers ranged from 1 to 123 patients. Some practitioners recorded a range, such as 30-50 as opposed to an actual number. Figure 4 displays the frequency (percent) of practitioners reporting the number of patients treated. This information was not reported for 5% of patients. Figure 4: Number of patients treated per week
3.3 Focus on the patients
3.3.1 Referral source
The majority of patients were referred by NHS medical consultants as shown in the table below (Table 3) Table 3: Patient referral source
Referral source Number Percent
NHS medical consultant 835 47
Other AHP within your organisation 360 20
GP 293 17
Self referral can include carer referral 110 6
Other AHP outside your organisation 80 5
Private consultant 39 2
Other eg. teacher 13 1
Not reported 32 2
Total 1762 100
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3.3.2 Age of patients treated
The patients ages ranged from less than 1 year to 96 years. The mean age was 51 years (SD 19). This information was not available for 6% of patients. Figure 5: Age range of patients treated
70% (n=1234) of patients were aged 40 years and above 25% (n=437) of patients were younger than 40 years old 5% (n=91) of patients were not reported
3.3.3 Patient’s gender
The majority of patients treated were female as shown in the table below. Table 4: Patient’s gender
Gender Number Percent
Female 1089 62
Male 648 37
Not reported 25 1
Total 1762 100
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3.3.4 Patient’s occupation / education
Standard occupational classifications were used within this tool (Standard Occupational Classification 2000). One third of the patients were retired as shown in table 5. Table 5: Patient occupations
Occupation Number Percent
Retired (if more than 2 yrs) 590 33.5
Long term sickness 134 7.6
Housewife/husband (if more than 2 yrs) 124 7.0
Clerical & Secretarial 93 5.3
Other occupation 83 4.7
Unemployed (if more than 2 yrs) 81 4.6
School person, junior/secondary school 76 4.3
Associate Professional & Technical 65 3.7
Craft & Related Occupations 65 3.7
Managers & Administrators 60 3.4
Professional Occupations 50 2.8
Adult with learning difficulties unable to work 46 2.6
Personal & Protective Service 43 2.4
Student HE/FE, other 34 1.9
Sales Occupations 33 1.9
Plant & Machinery 27 1.5
Other 18 1.0
Child unable to attend education 17 1.0
Not reported 123 7.0
Total 1762 100
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3.3.5 Mode of employment
This question was reported ‘not applicable’ for almost half of all patients as shown in figure 6. This is probably due to one third of the patients being retired for more than 2 years. This information was not reported for 19% of patients. Figure 6: Mode of employment
3.3.6 Nature of referral
Details of the nature of referral are shown in table 6 and figure 7. The majority of patients (74%) had a long-term condition. Table 6: Nature of referral
Nature of referral Number Percent Chronic > 6 weeks 587 33 Long term/maintenance 451 26 Acute < 6 weeks 398 23 Acute on chronic 261 15 Unknown 65 4 Total 1762 100
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Figure 7 Nature of referral
3.3.7 Specific reasons for referral
Practitioners were asked to refer to a specific classification list (the World Health Organisation International Classification of Disease) selecting the patient’s primary diagnosis. Over 130 different classifications were reported. This information was provided for almost all patients (99%). Figure 8 Specific reasons for referral – classifications
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Table 7 Specific reason for referral – classifications
Classification Number Percent
Lumbar pain 250 14
Osteoarthritis 229 13
Arthroplasty - hip & thigh 97 6
Arthroplasty - knee & leg 80 5
Rhematoid arthritis 57 3
Impaired mobility 46 3
Discectomy - back & neck 39 2
Fracture - humerus 36 2
Ankylosing spondylitis 34 2
Arthroscopy - knee & leg 33 2
Spinal fusion / stabilisation 32 2
Cerebral palsy 30 2
Multiple joint pains 29 2
Total 992 62
3.3.8 Other relevant diagnoses
Practitioners could record co-morbidity or other relevant diagnosis that would be considered in their treatment of a specific condition. This information was provided for 39% of all patients. The most frequently reported classifications are shown in table 8. Table 8: Other relevant diagnosis – classifications
Classification Number Percent
Osteoarthritis 73 4
Lumbar pain - back & neck 53 3
Impaired mobility 46 3
Sciatica 30 2
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3.4 Focus on treatment
3.4.1 Number of weeks waiting for treatment
There was substantial variability in reported waiting times (from the date of referral to the commencement of treatment) as shown in the figure below, the data was skewed. The average number of weeks waiting time (median) was 2 weeks, whilst the most frequently reported (mode) was 1 week. This information was not reported for 0.7% of patients. Figure 9: Number of weeks waiting for treatment
3.4.2 Type of intervention
Practitioners recorded if the patients were treated individually or in groups. This information was provided for almost all patients (99%). Table 9: Intervention type
Intervention type Number Percent
Individual 954 54
Group 539 31
Both 248 14
Unknown 21 1
Total 1762 100
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3.4.3 Number of weeks on treatment
There was substantial variability in reported length of treatment times from 0 weeks to 81 weeks. This included maintenance groups for patients with long term conditions e.g. local groups of the NASS. Almost one third of all patients (31%) were still receiving treatment at the end of the data collection period. The median number of weeks on treatment was 6 weeks, whilst the most frequently reported (mode) was 5 weeks. Figure 10: Number of weeks participating in aquatic physiotherapy treatment
3.4.4 Previous aquatic physiotherapy treatment episodes
The majority of patients, 63%, had not previously participated in aquatic physiotherapy. Table 10: Previous episodes of aquatic physiotherapy
Previous episodes Number Percent
No previous episodes 1103 63
One previous episode 202 12
Two previous episodes 46 3
Three previous episodes 20 1
Many previous episodes 137 8
Unknown 254 14
Total 1762 100
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3.4.5 Physiotherapists weighting of psychosocial and physical factors
Participating physiotherapists were asked to rate (using a 4 point Likert scale) any factors which may have had an effect on physiotherapy management and or patient recovery. The scale was: none / mild / moderate or severe. Table 11: Weighting of psychosocial and physical factors in percentages
Weighting None Mild Moderate Severe Not
reported
The problem 8.6 16.8 46.7 25.6 2.4
Communication 79.5 9.7 5.6 3 2.2
Mobility 34.7 28 24.6 10.6 2.2
Social circumstances 61.1 21.9 10.8 4 2.2
Risks 71.5 17.8 6.6 1.8 2.4
25% of patients had a condition (pathology or dysfunction) described as severe.
20% of patients had some communication or sensory difficulties.
74% of patients had some mobility (or co-existing mobility difficulties).
35% of patients had difficult social circumstances (e.g. parent, carer, bereavement, financial problems, and unemployed).
27% of patients had associated risk factors (e.g. heart conditions, epilepsy).
3.4.6 Treatment details
Practitioners were asked to record up to six types of aquatic physiotherapy intervention from a list of 15 (see appendix E). The frequency of use for all interventions is shown in the table below. Table 12: All treatment interventions recorded
Treatment interventions Number Percent
Active range of movement exercises 1507 17.7
Active strengthening exercises 1429 16.7
Education / Advice re self management 896 10.5
Functional exercises 793 9.3
Gait re-education 632 7.4
Core stability 606 7.1
Relaxation / pain relief 562 6.6
Balance re-education 491 5.8
Passive stretching 474 5.6
Re-education of movement patterns 454 5.3
Aerobic exercises 295 3.5
Social / group interaction 159 1.9
Swimming 96 1.1
Accessory movement 70 0.8
Education / Advice to carer 68 0.8
Total 8532 100
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3.4.7 Specific aquatic physiotherapy techniques
Practitioners could record specific aquatic physiotherapy techniques that he used in conjunction to the treatment interventions in Table 10. This information was provided for less than 10% of all patients. The techniques reported included:
Bad Ragaz (n=391)
Halliwick (n=281)
Watsu (n=23)
Ai-Chi (n=16)
3.4.8 Exercise/Education booklet / information used
Practitioners were asked to report if they gave any written material to their patients, and also to record the type of information provided (whether it was aquatic physiotherapy specific).
Approximately 50% of all patients received some exercise/educational printed material
Specific ‘aquatic physiotherapy’ material was only provided for 22% patients
3.4.9 Number of treatments this episode
The average number of treatments (mean) was 6, and the most frequently reported (mode) was 6. The average number reported varied substantially from 0-100 which may indicate that all treatments to that date were included. This information was not reported for 9% of patients. Figure11. Number of aquatic physiotherapy treatments per episode of care
3.4.10 Grade of physiotherapist(s) involved in treatment
Practitioners were asked to record the grade of therapists involved in the treatment for each patient. This information was not reported for 3% of patients.
Table 13: Grade of physiotherapist(s) involved in treatment
Grade Number Percent
Specialist/consultant 211 12.0
Senior 855 48.5
Junior 302 17.1
Technical instructor/assistant 138 7.8
Student 3 0.2
More than 1 practitioner 194 11.0
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3.4.11 Factors influencing the outcome of treatment
Practitioners could record up to 4 factors which they felt may have influenced the outcome of treatment for each patient. Of all the factors, the most frequently reported was ‘No factors influencing outcome’ for 25% of all patients. Table 14: Factors influencing the outcome of treatment
Factors Number Percent
No factors influencing outcome 627 25.6
General state 372 15.2
Other interventions 233 9.5
Life style influences 223 9.1
Time since onset 176 7.2
Other medical conditions 160 6.5
Patient expectations 158 6.4
Irregular patient attendance 157 6.4
Other medical interventions 96 3.9
Exacerbation of condition 64 2.6
Financial situation 44 1.8
Re-referred to referring source 41 1.7
Transport difficulties 26 1.1
Access to pool difficult 25 1.0
Patient moved from area 12 0.5
Spontaneous recovery 12 0.5
Therapist absence 9 0.4
Inappropriate referral 8 0.3
Deceased during course of treatment 6 0.2
Parking difficulties 4 0.2
Total 2453 100
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3.5 Focus on outcomes of the treatment
3.5.1 Outcome of referral/treatment
The outcome of referral/treatment was reported for 82% of all patients. The most frequently reported outcome was “Aquatic physiotherapy completed, referred back to dry land therapy” for almost 40% of patients. It should be noted here that for many complex patients aquatic physiotherapy is part of a patients’ rehabilitation pathway or physiotherapy package. Table 15: Outcome of referral/treatment
Outcome Number Percent
Aquatic therapy completed, referred back to dry land therapy 667 37.9
Treatment completed. Regular discharge 271 15.4
Advice / referral to self help/maintenance group 130 7.4
Treatment interrupted (UTA) includes self discharge 106 6.0
Treatment interrupted (dept not informed) 57 3.2
Advice to / referral to local pool 54 3.1
Aquatic physiotherapy not effective 40 2.3
Referred back to GP/Consultant 35 2.0
Advice to / referral to maintenance group (physiotherapist led) 34 1.9
Treatment not commenced (DNA) 26 1.5
Transferred outside district 11 0.6
Patient non compliant 10 0.6
Transferred within district 7 0.4
Inappropriate referral 6 0.3
Treatment not commenced (dept informed) 2 0.1
Unknown 306 17.4
Total 1762 100.0
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3.5.2 Goal achievement at discharge
All or some of the goals were achieved by 77% of the patients. Half of all patients ‘mostly achieved’ (31%) or ‘fully achieved’ (19%) their goals at discharge as reported by the physiotherapists. It has to be remembered that a relatively high proportion of the population of aquatic physiotherapy patients are complex (section 3.4.5) and have more than one diagnosis (section 3.3.8). This information was not reported for 11% of patients. Figure: 12. Goal achievement at discharge
3.6 Summary of findings
One thousand seven hundred and sixty two data sets were collected from 117 participating physiotherapists in 44 trusts/units. Almost 75% of physiotherapists working in aquatic physiotherapy specialise in neuro-musculoskeletal areas including orthopaedics. The number of patients treated per week ranged from 1 to 123 patients. The majority of patients were referred from NHS medical consultants. The mean age of the patients was 51 years and the most common occupational group were retirees. Almost two thirds of patients were female and almost three quarters of patients had a long-term condition. Over 130 different reasons for referral were reported with low back pain being the highest reported. The average waiting time for commencement of aquatic physiotherapy from referral date was 2 weeks. Over half of the patients were treated individually, commonly over a 5 week period and 63% had not previously experienced aquatic physiotherapy. Physiotherapists weighting of psychosocial and physical factors indicated that 72% of the patients had a condition that was described as moderate to severe with 35% having difficult social circumstances. Range of movement and strengthening exercises were the main type of aquatic physiotherapy intervention reported with approximately half of all patients receiving some educational printed material, specific to aquatic physiotherapy. Most patients received 6 treatment sessions with almost half of the patients treated by senior physiotherapists. Aquatic physiotherapy programme was completed by 66% of the patients with 77% of the patients achieving all or some of their goals on discharge.
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4 Discussion and implications
The standardised data collection period has been a useful exercise for both the participating aquatic physiotherapists and the HyDAT team. It has meant that considerable collaboration has taken place between the clinicians, researchers and academics within the team. The information presented in this report will serve as useful baseline data in which to set standards of care in practice in aquatic physiotherapy. It facilitates an interest in audit activities in relation to clinical effectiveness in aquatic physiotherapy in the future. It is intended that the data will provide a stimulus for the production of a series of informed research questions and inform the development of the ATACP research strategy. The current focus on innovation, productivity and prevention (QIPP, DH 2009) is requiring all health professionals to account for their practice. Standardised data collection is a useful tool to enable physiotherapists to demonstrate quality (e.g. patient outcomes) and productivity (e.g. number of patients seen) Future standardised data collection projects might be designed to indicate physiotherapists’ contribution in preventative health and social care. A baseline, such as the data presented here, is necessary to demonstrate the value of service innovation. Physiotherapy has never been in a stronger position to make an impact on health in the UK but we can only move forwards if evidence, starting with standardised data is at the heart of what we do.
4.1 Future standardised data collection and audit
This work may be used as a reference for future data collection of aquatic and other physiotherapy practices. These may focused on one area of practice as described here or can review total service provision. Suggestions for improvements:
Time taken to input the collated data from all sites; The Interactive Chartered Society of Physiotherapy (icsp) could be sued as a platform to access online data collection tools.
The detail of information collected: by reviewing and adapting the standardised data collection form, data collection can be more user friendly and specific to trusts/units or specialties within aquatic physiotherapy
It is recommended that future data collection:
Record ethnicity of patients, in relation to uptake of aquatic physiotherapy services by some ethnic minorities
Consider the cost-effectiveness of aquatic physiotherapy services
4.2 Future research
4.2.1 Areas of further enquiry
This report provides a foundation in which to develop further areas of inquiry, as suggested below.
A further exploration of the demographics of aquatic physiotherapy patients, considering age, gender, ethnicity, referral source, access to out of hour services.
Consideration of the psychosocial and physical weighting results in realtion to previous work completed on MSK patients within this region (Moore et al, 1996, 1998, 1999, 2006)
A further exploration of the conditions seen in aquatic physiotherapy including the chronicity of conditions usually seen.
Consideration of referral sources and screening to aquatic physiotherapy
Consideration of the cost-effectiveness of aquatic physiotherapy in relation to specific conditions and individual versus group therapy
Collaboration on a series of single case study designs among ATACP members to build the evidence for aquatic physiotherapy
Further research questions to consider in light of the findings and the recent Department of Health recommendations:-
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What is the effect of the introduction of self-referral schemes to AHP services on the uptake of aquatic physiotherapy?
What is the effect of the development of patient pathways on aquatic physiotherapy?
Large trials e.g. RCTs in aquatic physiotherapy should focus on the bigger patient populations, eg.
Back pain. Waller et al (2009) in their systematic review concluded that there is sufficient evidence to suggest that therapeutic aquatic exercise is potentially beneficial to patients with chronic low back pain and pregnancy related low back pain. This supported the recommendations of the CSP Clinical guidelines for the physiotherapy management of persistent Low Back Pain (Mercer et al 2006) which stated that Aquatic physiotherapy should be considered when aiming to improve function. There is however a further need for high quality trials to substantiate the use of aquatic physiotherapy in this patient population. This is essential in light of the recently published NICE back pain guidelines (NICE, 2009) which failed to mention aquatic physiotherapy despite recommending exercises and self management.
National guidelines for Osteoarthritis (Royal College of Physicians, 2008) state that strengthening and aerobic exercises should be a core treatment for people with osteoarthritis irrespective of other factors such as age, co-morbidity, severity or disability. A number of relevant RCT studies were reviewed as part of these guidelines however the evidence for aquatic physiotherapy was not of sufficient quantity and high quality to be included as a specific recommendation. Consideration also needs to be made for potentially large number of people who may struggle to perform strengthening and aerobic exercise on land. There is a great need for high quality scientific evidence to support the use aquatic physiotherapy in this patient group.
In order to provide the best treatment for different patient groups, innovative research designs need to be considered. ATACP members collaboration on a series of single case study designs may be the way forward initially to build the evidence for aquatic physiotherapy.
4.3 Reflection and limitations
This report contains detailed descriptive statistics but little discussion and consideration of the implications. The reason for this was to publish details of the findings as they have become available with a view to exploring the enormous potential of these findings in future publications. Members of the HyDAT team may take forwards some aspects of the findings but readers are invited to base future work on the HyDAT project. Readers should take into account that the convenience sample of patients in the HyDAT project may not have been representative of the population participating in aquatic physiotherapy in the UK. However, in standardised data collection, random sampling is neither practical nor possible and convenience sampling is the accepted methodology. There was a time delay between collecting the HyDAT data and presenting these results. With improving technology this time delay could be reduced in the future by collecting and collating data electronically, perhaps using e-data collection tools. These data was collected between June and September. Future data collection project may shed light on whether data collected at other times of the year, e.g. the winter months, would bring the same results.
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5 Conclusion A standardised data collection tool has been developed which is specifically designed for use in aquatic physiotherapy. The pilot study found that this tool was easy to use. The tool provides a comprehensive record of patient’s details, treatment and outcomes. This collaborative effort has involved work between academics, clinicians and researchers, both within the NHS, HEIs and private sector. There needs to be a continued commitment to investigate aquatic physiotherapy and what it may or may not achieve. We should continue to promote standardised data collection tools to be used as outcome measures. Following this work the HyDAT team feel that the next step should be to write a research strategy based on this document in collaboration with the ATACP. The future of aquatic physiotherapy requires continued collaboration both in the UK and overseas. In addition to the success of this project the HyDAT team recommend future data collection / audits in the UK. The findings of this project will be submitted for publication/dissemination (see appendix C).
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6 Appendix A (Letter to colleagues) School of Health Professions
49 Darley Road Eastbourne
BN20 7UR June 2007
Dear Colleague, The national hydrotherapy data collection (HyDAT) project Enclosed are four documents:
HyDAT tool (separate document for ease of reproducibility)
HyDAT methods pg.2
HyDAT guidance notes pg. 6
HyDAT record pg. 14 Please contribute to the HyDAT project by completing the HyDAT tool for a sample of the people you treat with hydrotherapy. The HyDAT guidance notes will help you complete the tool, the HyDAT methods give you an outline of the project and the HyDAT record is for you to record the patients that you have included. Your trust / unit location i.d. is …………………………………………………………… Please contact the HyDAT team if you have any queries or want to discuss anything in more detail. If you have colleagues, in other settings, who wishes to participate in the project please ask them to contact the HyDAT team for a trust / unit location i.d. Anne Jackson: [email protected] 01903 286778 Sarah-Jane Ryan: [email protected] 01273 643515 Please send all completed tools to Sara-Jane Ryan, Senior Lecturer in Physiotherapy, at the above address as soon as possible after 30th September 2007. Thank you for your help. We will keep you in touch with progress through Aqualines and the hydrotherapy network of iCSP. Best wishes, Anne Jackson, Anna Carter, Sarah-Jane Ryan, Raija Kuisma, Jacqueline Pattman.
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7 Appendix B (Summary of the HyDAT project)
Decide on how patients you personally can collect data for between 1st June and 31st July
(see section 2.4)
Person fits
inclusion criteria
Mark hydrotherapy notes clearly
No
Do not collect data
Yes
Hydrotherapy episode
completed by 30th September
No
Hydrotherapy episode ongoing
on 30th September 2007
Finish
completing HyDAT tool
as hydrotherapy finishes
regardless of whether
hydrotherapy is continuing elsewhere.
Finish completing HyDAT tool
giving outcome achieved on 30th
September
ASAP after 30th September 2007:
update all IRs and store securely complete all HyDAT tools as fully as possible and forward to:
Sarah-Jane Ryan Senior Lecturer in Physiotherapy School of Health Professions 49 Darley Road Eastbourne BN20 7UR. please mark your envelope with HyDAT
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8 Appendix C (the HyDAT team) All team members made ongoing contributions to team meetings, designing the HyDAT tool, writing the report, driving the project e.g. by ongoing liaison with ATACP members at study days. The table below indicates where HyDAT team members took a lead.
Name Position Organisation Lead Contribution Liz Bryant PhD BSc (Hons)
Musculoskeletal Research Fellow
University of Brighton Data analysis Report write up
Anna Carter BSc (Hons) MCSP HT
Aquatic physiotherapist
East Sussex Hospitals NHS Trust
Developing the HyDAT tool Report write up Publications/presentations
Sarah Cox BSc (Hons) MCSP HT
Private practitioner Wimbledon/ Nottinghamshire
Data input Report write up Publications/presentations
Do Heath MCSP HT
Private Practitioner South West London The early stages of developing the HyDAT tool
Anne Jackson PhD MSc BA (Hons) MCSP HT
Superintendent Physiotherapist
Western Sussex Hospitals NHS Trust
HyDAT team lead Developing the HyDAT tool Report write up Publications/presentations
Raija Kuisma PhD MSc BSc(Hons) MCSP
Principal Lecturer University of Brighton Developing the HyDAT tool Report write up Publications/presentations
Prof Ann Moore PhD, Grad Dip Phys, FCSP, FMACP, Dip TP, Cert Ed
Director of Clinical Research,
University of Brighton Mentor to the HyDAT team Presenting at the HyDAT launch
Jackie Pattman Grad Dip Phys MCSP HT
Aquatic Physiotherapist
Brighton and Sussex University Hospitals NHS Trust
Developing the HyDAT tool Publications/presentations
Sarah-Jane Ryan MSc BSc (Hons) PGC MCSP HPC FHEA
Senior Lecturer
University of Brighton HyDAT team lead Report write up Developing the HyDAT tool Publications/presentations
Funding All team members gave much personal time to the project and in addition the following organisations part-funded the project.
Organisation Funding Aquatic Therapy Association of Chartered Physiotherapists
data input costs, travel costs to some meetings
Brighton and Sussex University Hospitals NHS Trust
Staff time for attending meetings
East Sussex Hospitals NHS Trust Staff time for attending meetings University of Brighton Staff time for attending meetings
Data analysis Western Sussex Hospitals NHS Trust Staff time for attending meetings
Conflicts of interest: None.
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Presentations by the HyDAT team on final report
Presenter Journal /Event / conference Place / date Outline Sarah Cox Aqualines 21 (1) 2009 Summary of results
Anne Jackson CSP Clinical Interest Group conference
Leeds, 05.02.09 Collaboration in the HyDAT project
Anne Jackson Association of Chartered Physiotherapists for people
with a learning disability Southeast England group
London, 01.04.09 Feed back of the HyDAT results
Sarah-Jane Ryan
CSP Congress 2009 Liverpool 09 HyDAT project launch
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9 Appendix D (HyDAT tool)
36
10 Appendix E (HyDAT guidance notes/coding)
Advice for completing the HyDAT tool. Pilot sites have reported that each tool takes about 5 minutes to complete.
1. Trust/unit location id. Please insert the trust or unit location i.d. number allocated to you by the audit team on your covering letter.
2. Therapist id. Choose a number for each therapist in your department e.g. T1, T2 etc.
3. Speciality area. Please insert your major area of speciality in hydrotherapy
1) Neuro-musculoskeletal
2) Orthopaedics
3) Cardio-respiratory
4) Paediatrics
5) Women’s Health
6) Learning difficulties
7) Pain management
8) Rheumatology
9) Amputees/Vascular
10) Neurological
11) Mental Health
12) Sport
13) Palliative care
14) 2 or more specialities
3a. Number of patients treated per week.
4. Patient’s id.
Please allocate an i.d. code for each patient e.g. P1, P2 etc. To maintain patient confidentiality
this should not be the trust patient’s i.d.
5. Referral Source
Please insert where the patient was referred from
1. NHS consultant and their team
2. Private consultant and their team
3. GP
4. Other Allied Health Professional within your organisation
5. Other Allied Health Professional outside your organisation
6. Self referral can include carer referral
7. Referral from insurance company
8. Other e.g. teacher
6. Patient’s date of Birth Please complete patient’s date of birth in the form: day, month and year e.g. 22 06 46
7. Patient’s occupation /Education
Please give patient’s occupation / education
1. Managers and Administrators (inc. officers in UK armed forces, senior police officers, senior prison officers, senior fire service officers)
2. Professional Occupations (inc. Judges, teachers, psychologists, librarians)
3. Associate Professional and Technical Occupations (inc. nurses, authors, physiotherapists, computer
programmers, professional athletes, actors)
4. Clerical and Secretarial Occupations
5. Craft and Related Occupations (inc. builders, butchers, mechanics)
6. Personal and Protective Service Occupations (inc. armed forces, police, fire and prison officers, waiters,
hairdressers, assistant nurses, dental nurses)
7. Sales Occupations (inc. floral arrangers, buyers)
8. Plant and Machinery Operatives (inc. bus conductors, taxi drivers)
9. Unemployed (more than 2 years)
10. Retired (more than 2 years)
11. Housewife/husband (if more than 2 years)
12. Other Occupation (inc. farm workers, postal workers, window cleaners)
13. Prisoner
14. Long-term sickness
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15. Other
N.B.: Use categories 1-8 or 14 if employment ceased for less than 2 years for reasons stated in categories
9-11
16. Child unable to attend education
17. Adult with learning difficulties unable to work
18. School person, Junior/Secondary school
19. Student HE/FE, other
8. Patient is employed full/part-time employment
Please give patient’s employment status
1. Full-time
2. Full-time – shift work
3. Part-time
4. Part-time – shift work
5. Not Applicable
9. Patient’s gender
Please give patient’s gender
1. Female
2. Male
10. Nature of referral
This refers to the nature of the referral that the patient has been referred to you with
1. Acute < 6 weeks eg. post-op, 1st episode of condition, new diagnosis
2. Acute on Chronic eg. a acute condition has developed on an ongoing condition
3. Chronic >/= 6/52 duration of condition
4. Long-term/maintenance
11. Specific reason for referral
This refers to the reason that they are attending for this session of hydrotherapy. Please refer to the
classifications list (appendix A) and as far as possible select the patient’s major diagnosis.
12. Other relevant diagnoses
This section is to allow you to include other relevant diagnosis that would be considered in your
treatment of the specific condition your patient has been referred for e.g. a patient referred post total
knee replacement but who also has rheumatoid arthritis.
13. Date of referral for physiotherapy/hydrotherapy treatment This refers to this episode. Please complete day, month and year e.g. 22 06 46
14. Type of Intervention
This section is for to identify whether you will be treating your patient individually, as part of a group
or both.
a. Individual
b. Group
c. Both
15. Date of start of hydrotherapy treatment Please complete day, month and year e.g. 22 06 46.
16. Date completion of hydrotherapy treatment Please complete day, month and year e.g. 22 06 46. If treatment is ongoing at the end of the data
collection period please complete as 99 99 99.
17. Number of previous hydrotherapy treatment episodes.
This section is for patients that have had past hydrotherapy treatments that you are aware of.
18. Physiotherapist weighting of psychosocial and physical factors. Please rate using the scale below as an ongoing assessment any factors (18a-e) which may have or had
an effect on physiotherapy management and/or patient recovery.
0. None,
1. Mild
2. Moderate
3. Severe
a. Problem
38
Please give an indication of the severity of the’ specific reason for referral’ (question 11) i.e. in terms
of pathology and/or dysfunction
b. Communication/sensory
Please give an indication of the severity of communication or sensory difficulties, e.g. secondary
diagnosis, inability to communicate, hearing impairment or language problems.
c. Mobility
Please give an indication of severity of any co-existing mobility problems. Consider pool entry e.g.
necessity for a walking aid, wheelchair, stair entry, hoist etc.
d. Social circumstances Please give an indication of severity of any social circumstances which may impact on treatment
strategy. These could include parent, carer, being cared for, bereavement, financial problems,
unemployment, etc.
e. Risks Please give an indication of risk factors that may influence a patient’s response to hydrotherapy
treatment e.g. Heart conditions, epilepsy etc.
f. Total of above scores (15 = maximum score)
19. a. Treatment details: This section allows the recording of up to six types of hydrotherapy intervention
1. Education/Advice to carer
2. Education/Advice re; self management
3. Active ROM exercises
4. Active strengthening exercises
5. Passive stretching
6. Accessory movements
7. Aerobic exercises
8. Re-education of movement patterns
9. Functional exercises
10. Balance re-education
11. Core Stability
12. Gait-re-education
13. Social/Group Interaction
14. Relaxation/pain relief
15. Swimming
19b. Supporting specific hydrotherapy techniques used in patient treatment
16. Watsu
17. Ai-Chi
18. Halliwick
19. Bad Ragaz
20a. Education/exercise sheet/booklet used:
1: Yes
2: No
20b. Type of information: was this…
1: Hydrotherapy specific
2: General
21. Number of treatments (in this treatment episode)
22. Factors influencing the outcome of treatment
Please give a maximum of four factors from the list below:
1. Inappropriate referral
39
2. Re-referred to referring source
3. Other medical intervention, e.g. drugs, injection, collar, corset, surgery, etc…
4. Other inventions e.g. land physiotherapy, osteopath, reflexology etc.
5. General state, e.g. stress levels, level of intelligence, attitude of patient, motivation, social
circumstances, understanding of condition, compensation case smoking, drinking, etc.
6. Life-style influences, e.g. job, home circumstances, age, sport, etc
7. Other medical conditions, e.g. cardiac.
8. Time since onset
9. Patient expectations (either high or low)
10. Patient moved from the area
11. Irregular patient attendance e.g. patient unwilling, difficulty with childcare, difficulty with
obtaining work absence
12. RIP
13. Exacerbation of condition
14. Transport difficulties
15. Parking difficulties
16. Access to hydrotherapy pool difficulties
17. Spontaneous recovery
18. Therapist absence e.g. sickness, maternity leave, meetings etc.
19. Financial situation e.g. unable to afford continued treatment
20. No factors influencing outcome.
23. Grade of the physiotherapist(s) involved in treatment. Please indicate the level they are working at
for up to 3 therapists involved in treating this patient
1. Specialist/consultant hydrotherapist/physiotherapist
2. Senior physiotherapist
3. Junior physiotherapist
4. Technical Instructor/Assistant
5. Student
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24.Outcome of referral/treatment
1. Inappropriate referral
2. Treatment not commenced (department informed)
3. Treatment not commenced (department not informed) (DNA)
4. Treatment interrupted (department not informed)
5. Treatment interrupted (UTA – department informed – includes self discharge)
6. Transferred within district
7. Transferred outside district
8. Hydrotherapy completed, referral back to dry land therapy
9. Treatment completed. Regular discharge
10. Deceased
11. Referred back to GP/Consultant
12. Patient non compliant
13. Hydrotherapy not effective
14. Advice to/referral to local pool
15. Advice to/Referral to self-help/maintenance group
16. Advice to/Referral to maintenance group (physio led)
25. Goal Achievement (at completion of treatment/end of data collection period)
This applies to goals as agreed with therapist and patient at outset of treatment episode. Goals may include
pain reduction, improved function, patient’s perceived improvements, return to work, improved exercise
endurance, increased socialising or maintenance of fitness etc.
1. Not at all achieved
2. Mostly not achieved
3. Partially achieved
4. Mostly achieved
5. Fully achieved
26. Outcome measure used
Please note the outcome measure that you have used, if different from MYMOP and specify
scores achieved if possible. Please write name of outcome measure in full on at least one tool.
27. MYMOP scores if used
If you have used the measure yourself medical outcome profile (MYMOP) then please put in patients pre-
intervention scores, post-intervention scores and MYMOP profile score.
If you are unable to calculate the profile score leave e. blank. If you are not using the MYMOP then please
leave this section blank. We are not suggesting that the MYMOP is the only scale or the best scale and we
want to avoid asking you to do extra work by collecting additional outcome data. However if you are using
this scale, that is suggested by the HACP, then this is a good opportunity to collate the results nationally.
http://www.hsrc.ac.uk/mymop/main.htm
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11 Appendix F (Classifications) Uses the WHO (World Health Organisation) International Classification of Disease (ICD) as used across
the NHS in the UK
(Reasons for referral to hydrotherapy)
Rheumatological conditions:
Rheumatoid arthritis (RA) 714
Juvenile rheumatoid arthritis 714.3
Osteoarthritis (OA) 715
Ankylosing spondylitis (AS) 720
Systemic lupus erythematosus (SLE) 710
Polymyositis 710.4
Polymyalgia rheumatica 725
Psoriatic arthritis 696
Osteoporosis 733
Chronic regional pain syndrome (CRPS) 337.9
Fibromyalgia 729.1
Myofascial pain syndromes H01
Osteogenesis imperfecta 756.5
Haemophilia 286.0
Hypermobility syndrome 728.5
Dermatomyositis 710.3
Other
Amputees:
Above knee X09.3
Below knee X09.5
Partial foot X10.4
Symes X10.1
Toes X11
Upper limb 887.4
Congenital limb deficiency H02
Other
Orthopaedic / Musculoskeletal conditions:
Multiple fractures 829
Foot - Sprains and strains 845
- Fracture metatarsals 825.2
- Fracture calcaneus 825.0
- Dislocation 838
- Arthrodesis V45.4
Other
Ankle - Sprains and strains 845
- Fracture 824
- Achilles tendon repair T67
- Tendon transfer T64
- Dislocation 837
- Arthrodesis V45.4
42
Other
Knee & Leg - Sprains and strains 844 - Fracture patella 822
- Fracture tibia and fibula 823
- Total/uni condylar knee
arthroplasty W42
- Revision arthroplasty W58
- MUA W91
- Dislocation 836
- Arthroscopy W87.9
- Tibial tubercle transfer T64
- Ligament repair W74
- Meniscal injury/repair 959.7
- Quads tendon repair T67
- Tendonitis/opathy 726.9
- Chondromalacia patella 717.7
- Bursitis 726.6
Other
Hip & Thigh - Sprains and strains 843
- Fracture neck femur 820
- Fracture shaft femur 821
- Total arthroplasty W39
- Hemi-arthroplasty W39
- Resurfacing H03
- Osteotomy H04
- Dislocation 835
- Dynamic hip screw W28
- Bursitis 726.5
- Perthes disease 732.1
Other
Pelvis - Sprains and strains 846
- Fracture 808
- Coccydinia 724.7
- Symphysis pubis dysfunction 665.6
Other
Back and Neck - Sprains and strains 847
- Lumbar pain 724.5
- Sciatica 724.3
- Thoracic pain 724.1
- Cervical pain 723.1
- Laminectomy V33.1
- Discectomy V33.7
- Disc replacement H05
- Spinal fusion/stabilisation V38
- Prolapsed intervertebral disc 722
- Spondylolisthesis 756.1
- Retrolysthesis H06
Other
Shoulder & Arm - Sprains and strains 840
- Total shoulder arthroplasty W51
43
- Hemi-arthroplasty H07
- Arthroscopy W87.9
- MUA W91
- Fracture clavicle 810
scapula 811
humerus 812
forearm 813
- Dislocation shoulder 831
elbow 832
- ASAD W08
- Rotator cuff syndrome 726.1
- Rotator cuff repair W77
- Stabilisation W77
- Tendon rupture 727.6
- Tendon repair T67
- Adhesive capsulitis 726
Other
Neurological conditions:
Guillain-Barre syndrome (GBS) 357.0
Multiple sclerosis (MS) 340
Muscular dystrophy (MD) 359.1
Motor neurone disease (MND) 335.2
Parkinsons disease (PD) 332
Hemiplegia (not CVA) 342
Paraplegia 344.1
Quadraplegia 344.0
Cerebrovascular accident (CVA) 436
Myasthenia gravis 358
Cerebral palsy (CP) 343
Post ITU syndrome H08
Post polio syndrome H09
Diabetic neuropathy 250.5
Transverse myelitis H10
Dystonia 333.7
Ataxia 781.3
Spina bifida 756.1
Traumatic brain injury (TBI) 854
Developmental co-ordination disorder H11
Nerve injuries - brachial plexus 953.4
- pelvic girdle & lower limb 956
- shoulder girdle & upper limb 955
- spinal cord 952
Miscellaneous:
Multiple joint pains 719.4
Falls E888
ME / chronic fatigue syndrome 780.7
Cardiac Rehabilitation H12
Pulmonary Rehabilitation H13
Oncology H14
Impaired Mobility H15
Impaired Social skills and personal development H16
Obesity H17
General lack of fitness H18
Lack of independent swimming skills H19
44
12 Appendix G (HyDAT methods)
1 Introduction
Aim: to provide a snapshot of hydrotherapy practice in the UK, across all settings, in 2007.
Objectives:
demonstrate the impact to health care made by physiotherapists working in
hydrotherapy
provide a baseline for future audits and research.
Design: an audit of participants of hydrotherapy programmes with input from a physiotherapist. Data will be
collected from a sample of patients with the HyDAT tool. Data analysis will describe the hydrotherapy treatment
and outcomes.
Data collection period: June 1st 2007 – July 31
st 2007 with a follow up period until September 30
th 2007. Note
that you do not have to be at work for the whole data collection period to participate.
Data collectors: HACP members from across the UK are encouraged to collect data, ask colleagues and contacts
working in hydrotherapy to contribute and to send completed HyDAT tools to the audit team. The success of the
project depends on everybody’s participation.
The audit team: is based in the Southeast and is linked with the HACP executive committee, the National
Physiotherapy Research Network (NPRN), the University of Brighton and local NHS trusts. The audit team
members are: Anna Carter, Anne Jackson, Raija Kuisma, Jacqueline Pattman and Sarah-Jane Ryan.
2 Details of the methods
Inclusion criteria:
The aim is to include patients: attending hydrotherapy sessions in the UK where there has been some input from
a physiotherapist (note that a technician or assistant might run the programme designed by a physiotherapist) of
any age in all settings (e.g. NHS, private, self-help groups, community groups, school groups, pre-school groups,
National Ankylosing Spondylitis Society (NASS) groups) with all diagnoses e.g. learning disabilities, cerebral
palsy, back pain seen as individuals or in groups.
Exclusion criteria:
People attending pool sessions with no input from a physiotherapist at any stage.
There are 2 data collection forms: (1) HyDAT tool - one completed for each patient included in the audit and
returned to the audit team. (2) HyDAT record – one completed by each physiotherapist and retained by the
participating physiotherapist.
Identification (i.d.)
Each participating hydrotherapy setting will be given a ‘trust / unit id’ code in their covering letter.
Each setting should allocate a personal ‘therapist id’ code to each participating therapist e.g. T1, T2.
Each therapist should allocate a ‘patient i.d.’ code to each participating patient e.g. P1, P2, P3 etc.
To ensure patient confidentiality do not use a hospital number. Record these numbers on the HyDAT tool
tools and HyDAT records as indicated on the forms.
HyDAT records will only ever be used to ask for clarification if any part of a HyDAT tool is unclear. Please
store HyDAT records securely as for patient notes in accordance with data protection policies.
Please complete all forms as fully as possible. However if there is missing data then please send what you have.
We recognise that for some groups it may not be possible to collect all the data.
Collecting the HyDAT data
Decide how many HyDAT tools you can feasibly complete. E.g. if you run a small NASS group each week
then you may be able to complete one HyDAT tool for each patient but if you run several busy hydrotherapy
45
clinics each week you may be able complete a HyDAT tool for a small proportion of your patients. Aim not to
be too ambitious but to complete (as fully as possible) and return all your HyDAT tools. The number of
patients for whom you can complete a HyDAT tool is called X in the discussion below.
In the first week of the data collection period, that you are able to collect data, mark the notes of a variety of
patients that you treat until you reach the number X. A coloured star or label would make the notes easily
identifiable.
From 1st June to 31
st July begin completing HyDAT tools for these X patients regardless of whether they are
new to hydrotherapy or are continuing with a course of hydrotherapy. Use the HyDAT guidance notes to
help you complete the HyDAT tools. Including continuing patients enables us to include school groups and
maintenance hydrotherapy groups etc. in the audit. Once you have identified your X patients do include any
further patients in the audit. After 31st July do not include any new patients in the audit.
If hydrotherapy finishes by 30th
September: finish completing one HyDAT tool for each patient when their
hydrotherapy finishes or they stop attending. Enter each patient’s details onto your HyDAT record.
If hydrotherapy is ongoing after 30th
September: finish completing one HyDAT tool for each patient
regardless of whether hydrotherapy has finished. Enter each patient’s details onto your HyDAT record. Give
their outcome as of 30th
September e.g. a goals of a self-help group may be to provide facilities for patients to
continue with their hydrotherapy programme, if this is achieved complete the form accordingly.
At the end of the audit please send completed HyDAT forms to:
Sarah-Jane Ryan
Senior Lecturer in Physiotherapy
School of Health Professions
49 Darley Road
Eastbourne
BN20 7UR
Please mark your envelope with ‘HyDAT’.
The HyDAT tools will be analysed to give a snapshot of hydrotherapy practice. Please keep your HyDAT
records to enable us to clarify any points in the future.
Data analysis
The audit team will start to analyse the data in autumn 2007 at the University of Brighton. We will keep you
informed of progress through Aqualines, HACP study days and iCSP.
Questions or difficulties
Please contact one of the following members of the audit team: Anne Jackson [email protected] or 01903 286778
Sarah-Jane Ryan [email protected] or 01273 643515
Or see the hydrotherapy iCSP site where the audit team will host a discussion about the
HyDAT project.
Terminology
The word patient is used here to include anybody (e.g. student, pupil, client, person) attending hydrotherapy
treatment sessions.
46
13 Appendix H (HyDAT record)
This information is confidential and should be kept secure as with all patient records. Use one form for each
physiotherapist. By keeping this record you can assist us in the event of us needing more information for a
particular patient.
Staff name:……………………………………………………………………………………………
Personal therapist identification number (question 2 on HyDAT tool):……...
Patient i. d.
(question 4 on
HyDAT tool)
Patient name Patient date
of birth
Hospital / unit
identification
number
Location of
records / notes
(if it helps
locate them
later)
Please do not send this identification record to the audit team!
47
14 References
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Carter A, Heath D, Jackson A, Kuisma R & Ryan S-J. 2005. Report from the Southeast hydrotherapy research group: Planning a national audit. Aqualines; 17(2): 20-22.
Cox S, Bryant L, Carter A, Jackson A, Kuisma R, Pattman J, Ryan S-J. 2009. HyDAT Floats! National Hydrotherapy Data Collection (HyDAT) Project - Summary and Findings. Aqualines; 21 (1) 4-7.
Department of Health, News, Recent stories. 2009. Jim Easton has been appointed NHS National Director for Improvement and Efficiency, the Department of Health announced today. Department of Health: London. http://www.dh.gov.uk/en/News/Recentstories/DH_101712. Department of Health. 2009. Be active, Be healthy. Surrey: The Stationary office: London. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_094358
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Jackson A, Kuisma R, Mason Z and Cox J. 2004. Older people's experience of water based exercise programmes. Aqualines 16 (2) 5-11.
Mercer C, Jackson A, Hettinga D, Barlos P, Ferguson S, Greenhalgh S, Harding V, Hurley Osing D, Klaber Moffett J, Martin D, May S, Monteath J, Roberts L, Taylor N & Woby S. 2006. Clinical guidelines for the physiotherapy management of persistent low back pain. Part 1: exercise and Part 2: manual therapy. Chartered Society of Physiotherapy: London.
Moore A P. 1996. The development of the mid Kent and Brighton outcome measurement tool for physiotherapy outpatient services. University of Brighton: Brighton.
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Moore A P. 1999. An audit of the outcome of physiotherapy intervention for outpatients with cervical spine pain and dysfunction. University of Brighton: Brighton.
Moore A, Bryant E, Barfield J et al. 2006. Whiplash associated disorder: a one year standardised data collection project. University of Brighton: Brighton.
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National Institute for health and Clinical Excellence. 2009. Low back pain:
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Early management of persistent non-specific low back pain. NICE clinical guideline 88. National Institute of Health and Clinical Excellence: London. http://guidance.nice.org.uk/CG88/NiceGuidance/pdf/English
Royal College of Physicians. 2008. Osteoarthritis: National clinical guideline for care and management in adults. NICE clinical guideline 59. National Institute of Health and Clinical Excellence: London. http://guidance.nice.org.uk/CG59/Guidance/pdf/English Standard Occupational Classification. 2000 National Office of Statistics.
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