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176 APPENDICES Physiotherapy KCE reports vol. 40
The evidence for and against physiotherapeutic modalities applied to treat bronchiolitis in infants and children are very
weak. As other European countries, chest physiotherapy (e.g., vibration, percussion, postural drainage, assisted
coughing, forced exhalation techniques) is widely used by Belgian ambulatory physiotherapists. They are generally
recommended by experts consensuses from French-speaking European countries although they have not been found
to be helpful to treat bronchiolitis. Moreover, the safety of chest physiotherapy (as well as of specific devices as CPAP
and CNEP) should in further studies to be addressed as it has never been really studied. However, in the absence of
other effective treatment modalities and evidence against, it is hazardous to give up chest physiotherapy. Weak
evidence has only been demonstrated in education of the parents/family, a treatment modality frequently applied by
Belgian ambulatory physiotherapists (74%).
Conclusion about the effectiveness of treatment modalities applied by Belgian ambulatory
physiotherapists
Among the five selected conditions, enough evidence relative to physiotherapeutic modalities was only available in low
back pain and hemiplegia/hemiparesis conditions. Overall, evidence has been found in the literature for the most
common treatment modalities applied by Belgian ambulatory physiotherapists to treat these two conditions. More
studies investigating the evidence level of physiotherapeutic modalities applied in total knee replacement, gait
disorders in the elderly, and bronchiolitis in infants and children are required before drawing any conclusion about the
effectiveness of treatment modalities applied by Belgian ambulatory physiotherapists to treat these conditions.
1.3.3. Functional tests used in Belgium ambulatory physiotherapy and key element in the
establishment of physiotherapeutic treatment planning
Although most of the Belgian ambulatory physiotherapists (89%) consider the patient s functional status as the key
element to establish their treatment planning, they do not use in their practice standardised functional assessment
tools (i.e., functional tests whose metric properties and quality appraisal have been pretty documented in the
literature) to determine the evolution of their patients. One exception however occurs in the assessment of gait
disorders in elderly people. Indeed, two standardised functional assessment tools (i.e., Tinetti Balance and Gait
Evaluation, 6-Minutes Walk Test) are regularly used by Belgian ambulatory physiotherapists as they are requisite by
the INAMI/RIZIV but other standardised tools are rarely carried out. The non-use of standardised functional
assessment tools in physiotherapeutic practice has been demonstrated for only the five conditions selected in the
survey but it can be assumed that the same trend would be found in other conditions requiring a physiotherapeutic
treatment.
Unlike standardised functional assessment tools, clinical tests are regularly carried out by Belgian ambulatory
physiotherapists as part of the patients clinical examination. Ambulatory physiotherapists seem to appraise the
evolution of the patients on an everyday basis using observation, anamnesis, palpation, muscular testing, and
goniometry. Although these clinical tests can be useful in the physiotherapeutic management, they can hardly be used
as a rationale for financing physiotherapy since their metric properties and quality appraisal have not (or almost not)
been documented in the literature.
Discussions with the physiotherapists associations that have collaborated to the development of the survey have
highlighted some interesting points about the implementation of standardised assessment tools as a rationale for
financing physiotherapy:
The implementation of standardised assessment tools as a rationale for financing physiotherapy should not
increase the physiotherapists administrative workload.
Some time allocated to perform the functional assessment should be planned to avoid harming the patients,
especially for those requiring more refundable sessions than the predetermined quota.
A functional assessment carried out during one single session is not always representative of the actual
treatment needs of the patients.
In addition to the functional assessment of motor and physical problems, psychological, mental, behavioural,
and social aspects should be taken into account.
The implementation of a functional cut-off within the framework of the refunding of physiotherapeutic
sessions (e.g., patients with a score > x would be eligible for only Y refundable sessions) is dangerous as it is
difficult to entirely cover all dimensions representative of the actual treatment needs of the patients.
These points highlighted by some ambulatory physiotherapists could be used as thinking basis in the possible
implementation of standardised assessment tools as rationale for financing physiotherapy.