Joint manipulation curricula in physical therapist professional degree programs

Dry needling curricula in entry-level education programs in the United States for physical therapists

Objectives: The objective of this paper was to determine the extent to which dry needling is instructed in entry-level education programs for physical therapists. Methods: Program directors from 226 entry-level education programs recognized by the Commission on Accreditation in Physical Therapy Education were recruited via e-mail to participate in an anonymous 35-item electronic survey during the 2017-2018 academic year.  The survey evaluated dry needling curricula, faculty qualifications, attitudes and experience, and programs' future plans for teaching dry needling. Results: A total of 75 programs responded to the survey (response rate = 33.1%).  Forty (53.3%) had integrated dry needling theory and psychomotor training into their programs and 8 (10.6%) planned to include such content in their curriculum in the future.  Of the 40 respondents, 28 indicated that dry needling education was integrated into a required course, 4 indicated that dry needling was an elective course, and 8 did not specify how dry needling education was integrated. Faculty teaching dry needling appear to be well qualified, with the majority having 5-10 years of experience using dry needling in clinical practice. The primary reason for programs not teaching dry needling is that it was not considered an entry-level skill. Discussion: There appeared to be variability in how dry needling was integrated into the curricula, as well as in the depth and breadth of instruction.  Our research may serve as a baseline for faculty to assess existing dry needling curricula and as a guide for developing curricula in new or existing physical therapy programs.

Reliability and accuracy of an expert physical therapist as a reference standard for a manual therapy joint mobilization trial

Objective: Previous studies on learning joint mobilization techniques have used expert practitioners as the reference standard as there is no current evidence on what ideal forces would be for effective mobilizations. However, none of these trials have documented the reliability or accuracy of the reference standard. Therefore, the purpose of this study was to report both the reliability and accuracy of an expert physical therapist (PT) acting as a reference standard for a manual therapy joint mobilization trial.Methods: A secondary analysis was performed using data from a published randomized, controlled, crossover study. The mobilization technique studied was the central posterior to anterior (PA) joint mobilization of the L3 vertebra. Reliability and accuracy data for the reference standard were collected over four time periods spanning 16 weeks.Results: Intrarater reliability of the expert PT for R1 and R2 joint forces was excellent (R1 Force ICC_3,3 0.95, 95%CI 0.76-0.99 and R2 Force ICC_3,3 0.90, 95%CI 0.49-0.99). Additionally, the expert PT was 92.3% accurate (mean % error±SD, 7.7 ± 5.5) when finding Grade III mean peak mobilization force and 85.1% accurate (mean % error±SD, 14.9 ± 8.3) when finding Grade IV mean peak mobilization force. Finally, correlations between actual applied forces and computed ideal forces were excellent (Pearson r 0.79-0.92, n = 24, P < 0.01 for all correlations).Discussion: The expert PT in this manual therapy joint mobilization trial showed excellent reliability and accuracy as the reference standard. The study supports the use of implementing quantitative feedback devices into the teaching of joint mobilization when a reliable and accurate reference standard has been identified.Level of Evidence: 2b.

Use of thrust joint manipulation by student physical therapists in the United States during clinical education experiences

Introduction: Thrust joint manipulation (TJM) is used in physical therapy practice and taught in entry-level curricula in the United States (US); however, research regarding implementation by student physical therapists (SPT)s is scarce. Objectives: To explore the use of TJM in SPT clinical education and factors influencing implementation. Methods: In a cross-sectional exploratory study, accredited physical therapy (PT) programs in the US (n = 227) were invited to participate in an electronic survey. SPTs were queried about TJM use and their clinical instructor's (CI) credentials during their final musculoskeletal clinical experience. Results: Forty-five programs participated in the study, consisting of 2,147 SPTs. Of those, 414 (19.3%) responses were used for analysis and 69% reported using TJM. SPTs who utilized TJM were more likely to have a CI who used TJM (p < 0.001) and/or had advanced certification/training in manual therapy (p < .001). A majority of students agreed or strongly agreed that their academic preparation provided them with clinical reasoning tools (84%) and psychomotor skills (69%) necessary to perform TJM. SPT use of TJM was facilitated by CI clinical practice, SPT competence in psychomotor skill, confidence in clinical reasoning, and practice setting. A main barrier to student use of TJM was CI lack of TJM use. Conclusions: Clinical practice of the CI appears to be a key factor in determining student use of TJM. Level of evidence: 2b.

The effect of real-time feedback on learning lumbar spine joint mobilization by entry-level doctor of physical therapy students: a randomized, controlled, crossover trial

OBJECTIVE

To examine the effects of real-time, objective feedback on learning lumbar spine joint mobilization techniques by entry-level Doctor of Physical Therapy (DPT) students.

METHODS

A randomized, controlled, crossover design was used. Twenty-four 1st Year DPT students were randomized into two groups. Group 1 (n = 12) practiced with the real-time feedback device first and then without it, while Group 2 (n = 12) practiced without the device first and then with it. Both practice periods with and without the device were 4 weeks long. Data were collected at Baseline, 5 weeks, 11 weeks, and 16 weeks. The crossover period was 5 weeks long, during which neither group practiced with or without the device. Eight force parameters were measured: R1 force; R2 force; Grade III and Grade IV mean peak force, frequency, and amplitude.

RESULTS

When students practiced with the real-time feedback device, they more closely matched the reference standard for two outcomes: 1) the mean difference in R2 force between student and reference standard was better with device (38.0 ± 26.7 N) than without it (51.0 ± 38.5 N); P = .013; and 2) the mean difference in Grade III peak to peak amplitude force was also better with device (8.9 ± 9.3 N) than without it (11.8 ± 11.0); P = .026. All other force parameters improved when students practiced with the real-time feedback device, however, the differences between when they practiced without the device were not statistically significant.

DISCUSSION

Real-time, objective feedback using a direct force measurement device improved learning for some aspects of lumbar spine joint mobilization by entry-level physical therapy students.

LEVEL OF EVIDENCE

2b.

Large variability found in musculoskeletal physiotherapy scope of practice throughout WCPT and IFOMPT affiliated countries: An international survey

BACKGROUND

Advanced practice physiotherapy (APP) rights are part of the evolution of the Physical Therapy profession. To date, no study has investigated musculoskeletal APP rights within the World Confederation for Physical Therapy (WCPT).

OBJECTIVE

To investigate musculoskeletal APP rights for physical therapists worldwide and examine the relationship between level of education (entry and post-professional) and direct access for countries that are vs. are not members of the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT).

DESIGN

Cross-sectional study with descriptive and exploratory online surveys.

METHODS

An electronic survey-based descriptive and exploratory investigation was conducted. We assessed variability between WCPT member organizations descriptively and the strength of the relationships among the number and types of APP rights with: (1) country affiliation to IFOMPT; (2) entry-level professional degree; (3) post-professional training; and (4) direct access.

RESULTS

Some countries reported having the right to practice all 20 APP rights while others reported no APP rights. Countries with IFOMPT member organization countries displayed fair correlation (r_s = .48, p < .03) between entry-level physical therapy degrees and number of APP rights. IFOMPT member organization countries were less likely to require post-professional training for direct access and manipulation.

CONCLUSION

APP rights for countries with direct access were significantly higher than for countries without direct access. IFOMPT member organizations demonstrated higher APP rights prevalence and were less likely to require post-professional training to obtain the right to direct access and perform manipulation.

Effective teaching of manual skills to physiotherapy students: a randomised clinical trial

CONTEXT

To date, despite the relevance of manual skills laboratories in physiotherapy education, evidence on the effectiveness of different teaching methods is limited.

OBJECTIVES

Peyton's four-step and the 'See one, do one' approaches were compared for their effectiveness in teaching manual skills.

METHODS

A cluster randomised controlled trial was performed among final-year, right-handed physiotherapy students, without prior experience in manual therapy or skills laboratories. The manual technique of C1-C2 passive right rotation was taught by different experienced physiotherapist using Peyton's four-step approach (intervention group) and the 'See one, do one' approach (control group). Participants, teachers and assessors were blinded to the aims of the study. Primary outcomes were quality of performance at the end of the skills laboratories, and after 1 week and 1 month. Secondary outcomes were time required to teach, time required to perform the procedure and student satisfaction.

RESULTS

A total of 39 students were included in the study (21 in the intervention group and 18 in the control group). Their main characteristics were homogeneous at baseline. The intervention group showed better quality of performance in the short, medium and long terms (F_1,111  = 35.91, p < 0.001). Both groups demonstrated decreased quality of performance over time (F_2,111  = 12.91, p < 0.001). The intervention group reported significantly greater mean ± standard deviation satisfaction (4.31 ± 1.23) than the control group (4.03 ± 1.31) (p < 0.001). Although there was no significant difference between the two methods in the time required for teaching, the time required by the intervention group to perform the procedure was significantly lower immediately after the skills laboratories and over time (p < 0.001).

CONCLUSIONS

Peyton's four-step approach is more effective than the 'See one, do one' approach in skills laboratories aimed at developing physiotherapy student competence in C1-C2 passive mobilisation.

Clinical Specialization and Adherence to Evidence-Based Practice Guidelines for Low Back Pain Management: A Survey of US Physical Therapists

Study Design Electronic cross-sectional survey. Background The American Physical Therapy Association (APTA) evidence-based practice guideline for low back pain (LBP) elaborated on strategies to manage nonspecific LBP in routine physical therapy practice. This guideline described LBP associated with mobility deficit, leg pain and a directional preference, coordination impairment (lumbar instability), and fear-avoidance behavior. Objectives To assess American physical therapists' adherence to the clinical practice guidelines (CPGs) for LBP of the Orthopaedic Section of the APTA, and to compare adherence among physical therapists with different qualifications. Methods The investigators contacted 1861 members of the Orthopaedic Section of the APTA and 1000 members of the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT). Participants made treatment choices for 4 clinical vignettes: LBP with mobility deficit, coordination impairment, leg pain (directional preference), or fear-avoidance behavior. The investigator used logistic regression analyses to compare guideline adherence among physical therapists with the following qualifications: orthopaedic clinical specialists (PTOs), Fellows of the AAOMPT (PTFs), PTOs and PTFs (PTFOs), and physical therapists without clinical specialization but with a musculoskeletal interest (PTMSs). Results A total of 410 physical therapists completed all sections of the survey (142 PTOs, 110 PTFOs, 74 PTFs, and 84 PTMSs). Adherence to the APTA's CPG was highest for LBP associated with leg pain and a directional preference (72.2%), followed by LBP with mobility deficit (57.1%), LBP with coordination impairment (46.1%), and fear-avoidance behavior (29.5%). Physical therapists who were PTFOs adhered better to the CPG for LBP than did PTMSs for all 4 patient vignettes. Orthopaedic clinical specialists adhered better to the CPG for LBP for the vignettes of mobility deficit and of LBP with fear-avoidance behavior than did PTMSs. Conclusion Physical therapists who were PTFOs and PTOs adhered better to the CPG than did PTMSs. Based on our preliminary results, further education on the CPG for LBP management is needed, particularly for managing LBP with coordination impairment and with fear-avoidance behavior. J Orthop Sports Phys Ther 2017;47(5):347-358. Epub 3 Mar 2017. doi:10.2519/jospt.2017.6561.

Strategies to overcome size and mechanical disadvantages in manual therapy

The practice of manual therapy (MT) is often difficult when providing care for large patients and for practitioners small in stature or with other physical limitations. Many MT techniques can be modified using simple principles to require less exertion, permitting consistency with standards of practice even in the presence of physical challenges. Commonly used MT techniques are herein described and demonstrated with alternative preparatory and movement methods, which can also be adopted for use in other techniques. These alternative techniques and the procedures used to adapt them warrant discussion among practitioners and educators in order to implement care, consistent with the best treatment evidence for many common musculoskeletal (MSK) conditions. The inclusion in educational curricula and MT training programs is recommended to enrich skill development in physical therapists (PTs), spanning entry-level practitioners to those pursuing advanced manual skills.

A model for teaching and learning spinal thrust manipulation and its effect on participant confidence in technique performance

BACKGROUND

Despite emerging evidence to support the use of high velocity thrust manipulation in the management of lumbar spinal conditions, utilization of thrust manipulation among clinicians remains relatively low. One reason for the underutilization of these procedures may be related to disparity in training in the performance of these techniques at the professional and post professional levels.

PURPOSE

To assess the effect of using a new model of active learning on participant confidence in the performance of spinal thrust manipulation and the implications for its use in the professional and post-professional training of physical therapists.

METHODS

A cohort of 15 DPT students in their final semester of entry-level professional training participated in an active training session emphasizing a sequential partial task practice (SPTP) strategy in which participants engaged in partial task practice over several repetitions with different partners. Participants' level of confidence in the performance of these techniques was determined through comparison of pre- and post-training session surveys and a post-session open-ended interview.

RESULTS

The increase in scores across all items of the individual pre- and post-session surveys suggests that this model was effective in changing overall participant perception regarding the effectiveness and safety of these techniques and in increasing student confidence in their performance. Interviews revealed that participants greatly preferred the SPTP strategy, which enhanced their confidence in technique performance.

CONCLUSION

Results indicate that this new model of psychomotor training may be effective at improving confidence in the performance of spinal thrust manipulation and, subsequently, may be useful for encouraging the future use of these techniques in the care of individuals with impairments of the spine. Inasmuch, this method of instruction may be useful for training of physical therapists at both the professional and post-professional levels.

Thrust joint manipulation utilization by U.S. physical therapists

STUDY DESIGN

Online survey study.

OBJECTIVE

To determine physical therapists' utilization of thrust joint manipulation (TJM) and their comfort level in using TJM between the cervical, thoracic, and lumbar regions of the spine. We hypothesized that physical therapists who use TJM would report regular use and comfort providing it to the thoracic and lumbar spines, but not so much for the cervical spine.

BACKGROUND

Recent surveys of first professional physical therapy degree programs have found that TJM to the cervical spine is not taught to the same degree as to the thoracic and lumbar spines.

METHODS

We developed a survey to capture the required information and had a Delphi panel of 15 expert orthopedic physical therapists review it and provide constructive feedback. A revised version of the survey was sent to the same Delphi panel and consensus was obtained on the final survey instrument. The revised survey was made available to any licensed physical therapists in the U.S.A. using an online survey system, from October 2014 through June 2015.

RESULTS

Of 1014 responses collected, 1000 completed surveys were included for analysis. There were 478 (48%) males; the mean age of respondents was 39.7 ± 10.81 years (range 24-92); and mean years of clinical experience was 13.6 ± 10.62. A majority of respondents felt that TJM was safe and effective when applied to lumbar (90.5%) and thoracic (91.1%) spines; however, a smaller percentage (68.9%) felt that about the cervical spine. More therapists reported they would perform additional screening prior to providing TJM to the cervical spine than they would for the lumbar and thoracic spines. Therapists agreed they were less likely to provide and feel comfortable with TJM in the cervical spine compared to the thoracic and lumbar spines. Finally, therapists who are male; practice in orthopedic spine setting; are aware of manipulation clinical prediction rules; and have manual therapy certification, are more likely to use TJM and be comfortable with it in all three regions.

CONCLUSION

Results indicate that respondents do not believe TJM for the cervical spine to be as safe and efficacious as that for the lumbar and thoracic spines. Further, they are more likely to perform additional screening, abstain from and do not feel comfortable performing TJM for the cervical spine.

CLINICAL RELEVANCE

Our research reveals there is a discrepancy between utilization of TJM at different spinal levels. This research provides an opportunity to address variability in clinical practice among physical therapists utilizing TJM.

Standing on the Precipice: Evaluating Final-Year Physiotherapy Students' Perspectives of Their Curriculum as Preparation for Primary Health Care Practice

Purpose: To explore final-year physiotherapy students' perceptions of primary health care practice to determine (1) aspects of their curriculum that support their learning, (2) deficiencies in their curriculum, and (3) areas that they believe should be changed to adequately equip them to make the transition from student to primary health care professional. Methods: Framework analysis methodology was used to analyze group opinion obtained using structured group feedback sessions. Sixty-eight final-year physiotherapy students from the four higher education institutions in Ireland participated. Results: The students identified several key areas that (1) supported their learning (exposure to evidence-based practice, opportunities to practise with problem-based learning, and interdisciplinary learning experiences); (2) were deficient (primary health care placements, additional active learning sessions, and further education and practice opportunities for communication and health promotion), and (3) required change (practice placements in primary health care, better curriculum organization to accommodate primary health care throughout the programme with the suggestion of a specific primary health care module). Conclusion: This study provides important insights into physiotherapy students' perceptions of primary health care. It also provides important indicators of the curriculum changes needed to increase graduates' confidence in their ability to take up employment in primary health care.

Thrust joint manipulation curricula in first-professional physical therapy education: 2012 update

STUDY DESIGN

Descriptive online observational survey.

OBJECTIVES

To identify the extent of thrust joint manipulation (TJM) integration into first-professional physical therapy program curricula.

BACKGROUND

The most recent survey of TJM curricula was published in 2004, with a wide variation in faculty responses noted. Since that time, faculty resources have been developed and TJM language in "A Normative Model of Physical Therapist Professional Education" from the American Physical Therapy Association has been updated, leaving the current status of TJM education in curricula unknown.

METHODS

Faculty from 205 accredited physical therapy programs were invited to participate in an anonymous 35-item electronic survey during the summer of 2012.

RESULTS

Seventy-two percent of programs responded to the survey, with 99% of programs teaching TJM and 97% of faculty believing TJM to be an entry-level skill. Cervical spine TJM is still being taught at a lower rate than techniques for other body regions. Faculty deemed 91% and 77% of students, respectively, at or above entry-level competency for implementing TJM in their clinical practice upon graduation. Most respondents indicated that increased utilization of TJM during clinical affiliations (78%) and lab hours (78%) would be beneficial to the student's knowledge/application of TJM.

CONCLUSION

The utilization of TJM and faculty perceptions in first-professional physical therapy programs in the United States have evolved over the past decade. With TJM content more fully integrated into educational curricula, programs can now look to refine teaching strategies that enhance learning outcomes.

Diagnostic and procedural imaging curricula in physical therapist professional degree programs

STUDY DESIGN

Descriptive survey.

OBJECTIVE

To describe the status of diagnostic and procedural imaging curricula within United States physical therapist professional degree programs.

BACKGROUND

As patient direct access to physical therapy services increases, the ability to refer patients directly for diagnostic imaging could promote more efficient delivery of care. Appropriate patient referral is contingent on physical therapists having the requisite knowledge base and skills. While evidence describing imaging competence of physical therapists with advanced training in military institutions exists, evidence is lacking for other physical therapists, including new graduates of physical therapist professional degree programs.

METHODS

Faculty members teaching imaging at 206 United States physical therapist professional degree programs recognized by the Commission on Accreditation in Physical Therapy Education were recruited via e-mail correspondence. An e-mail attachment included the survey on which faculty reported imaging curricula and faculty qualifications, attitudes, and experiences.

RESULTS

Faculty from 155 (75.2%) programs responded to the survey, with imaging being included in the curriculum of 152 programs. Content was integrated by required standalone courses or clinical science track courses, and/or through elective courses. The average reported estimate of imaging contact hours was 24.4 hours (range, 2-75 hours). Emphasis was on the musculoskeletal system, including 76.3% of the required standalone course content. Student competence was assessed in 147 (96.7%) programs, primarily by written (66.7%) and practical (19.7%) examinations. Faculty rated student competence on a scale of 1 (not competent) to 5 (competent), with ratings ranging from a high of 4.0 (identifying normal anatomy on plain-film radiography) to a low of 1.9 (identifying common tissue pathological processes/injuries on ultrasound).

CONCLUSION

While a majority of programs reported including imaging curricula, variability was noted in all curricular aspects. These results may serve as a benchmark for faculty to assess existing curricula, allow for further development of imaging curricula, and provide a benchmark for the profession regarding current level of training for recent graduates of entry-level physical therapist professional degree programs.

Inertial sensor real-time feedback enhances the learning of cervical spine manipulation: a prospective study

BACKGROUND

Cervical Spinal Manipulation (CSM) is considered a high-level skill of the central nervous system because it requires bimanual coordinated rhythmical movements therefore necessitating training to achieve proficiency. The objective of the present study was to investigate the effect of real-time feedback on the performance of CSM.

METHODS

Six postgraduate physiotherapy students attending a training workshop on Cervical Spine Manipulation Technique (CSMT) using inertial sensor derived real-time feedback participated in this study. The key variables were pre-manipulative position, angular displacement of the thrust and angular velocity of the thrust. Differences between variables before and after training were investigated using t-tests.

RESULTS

There were no significant differences after training for the pre-manipulative position (rotation p = 0.549; side bending p = 0.312) or for thrust displacement (rotation p = 0.247; side bending p = 0.314). Thrust angular velocity demonstrated a significant difference following training for rotation (pre-training mean (sd) 48.9°/s (35.1); post-training mean (sd) 96.9°/s (53.9); p = 0.027) but not for side bending (p = 0.521).

CONCLUSION

Real-time feedback using an inertial sensor may be valuable in the development of specific manipulative skill. Future studies investigating manipulation could consider a randomized controlled trial using inertial sensor real time feedback compared to traditional training.

Learning lumbar spine mobilization: the effects of frequency and self-control of feedback

STUDY DESIGN

Controlled laboratory study, longitudinal.

OBJECTIVES

To investigate the effects of frequency and self-control of feedback on physiotherapy students learning lumbar spinal mobilization.

BACKGROUND

Posterior-to-anterior mobilization is included in most physiotherapy curricula. However, force application varies between therapists and the optimal feedback for learning is unknown.

METHODS

Sixty-two physiotherapy students were randomized to 3 feedback groups: constant (100% of practice trials), intermittent (33%), and self-controlled (varied according to student choice) feedback. Students performed 12 practice trials of grade II posterior-to-anterior mobilization to the third lumbar vertebra while receiving real-time feedback. The differences between students' force parameters (mean peak force [N], force amplitude [N], and oscillation frequency [Hz]) and those of a physiotherapist expert were compared between groups posttest and at a follow-up of 5 to 7 days using analysis of covariance. Students completed a survey regarding their perceptions of feedback.

RESULTS

Students in the self-controlled group applied mean peak force (mean difference between student and expert, 6.7 N; 95% confidence interval [CI]: 4.4, 9.0) and force amplitude (6.3 N; 95% CI: 4.2, 8.4) that more closely matched the expert's than those applied by the constant group (13.7 N; 95% CI: 8.7, 18.6; P = .021, and 13.1 N; 95% CI: 8.9, 17.4; P = .028) at posttest, with similar results at follow-up for force amplitude only (self-controlled, 9.5 N; 95% CI: 5.8, 18.1; constant, 21.0 N; 95% CI: 13.3, 28.7; P = .018). There were no other significant differences. All students reported a better understanding of manual force application, but feedback preferences varied.

CONCLUSION

Self-controlled feedback appears to be more beneficial than constant feedback for students learning to apply forces during lumbar mobilization.

A comparison of cervical spine mobilization forces applied by experienced and novice physiotherapists

STUDY DESIGN

Clinical measurement, cross-sectional.

OBJECTIVES

To compare cervical mobilization forces applied by physiotherapists and students, and the factors associated with forces for each group.

BACKGROUND

Cervical spine joint mobilization is a common manual technique for treating patients with mechanical neck pain. But little is known about the forces applied during this technique. Potential variability between therapists may result from clinical experience or may be due to factors present in individuals prior to clinical practice exposure.

METHODS

One hundred sixteen practicing physiotherapists and 120 physiotherapy students without clinical experience applied grades I through IV posteroanterior mobilization to the premarked C2 and C7 spinous and articular processes of 1 of 67 asymptomatic subjects. An instrumented table recorded applied forces (N), force amplitudes (N), and oscillation frequencies (Hz), and a custom device measured subjects' spinal stiffness (N/mm). Independent t tests were used to compare the forces applied by therapists and students, intraclass correlation coefficients were used to determine variability, and linear regression was used to establish factors associated with applied forces.

RESULTS

Students' forces were generally lower (mean difference, 15.7 N for grades III and IV; P<.001) and applied with slower oscillation frequencies (0.12 Hz; P<.001) than therapists' forces. Similar factors were associated with applied forces for both groups: male gender and greater subject body weight were associated with higher applied forces, and greater C2 stiffness with lower forces. Having thumb pain was associated with lower applied forces for therapists but higher ones for students.

CONCLUSIONS

Students apply lower forces than therapists. Similar factors appear to affect applied forces regardless of clinical experience.

Cervical spine mobilisation forces applied by physiotherapy students

OBJECTIVES

Postero-anterior (PA) mobilisation is commonly used in cervical spine treatment and included in physiotherapy curricula. The manual forces that students apply while learning cervical mobilisation are not known. Quantifying these forces informs the development of strategies for learning to apply cervical mobilisation effectively and safely. This study describes the mechanical properties of cervical PA mobilisation techniques applied by students, and investigates factors associated with force application.

PARTICIPANTS

Physiotherapy students (n=120) mobilised one of 32 asymptomatic subjects.

METHODS

Students applied Grades I to IV central and unilateral PA mobilisation to C2 and C7 of one asymptomatic subject. Manual forces were measured in three directions using an instrumented treatment table. Spinal stiffness of mobilised subjects was measured at C2 and C7 using a device that applied a standard oscillating force while measuring this force and its concurrent displacement. Analysis of variance was used to determine differences between techniques and grades, intraclass correlation coefficients (ICC) were used to calculate the inter- and intrastudent repeatability of forces, and linear regression was used to determine the associations between applied forces and characteristics of students and mobilised subjects.

RESULTS

Mobilisation forces increased from Grades I to IV (highest mean peak force, Grade IV C7 central PA technique: 63.7N). Interstudent reliability was poor [ICC(2,1)=0.23, 95% confidence interval (CI) 0.14 to 0.43], but intrastudent repeatability of forces was somewhat better (0.83, 95% CI 0.81 to 0.86). Higher applied force was associated with greater C7 stiffness, increased frequency of thumb pain, male gender of the student or mobilised subject, and a student being earlier in their learning process. Lower forces were associated with greater C2 stiffness.

CONCLUSION

This study describes the cervical mobilisation forces applied by students, and the characteristics of the student and mobilised subject associated with these forces. These results form a basis for the development of strategies to provide objective feedback to students learning to apply cervical mobilisation.

Real-time feedback improves accuracy of manually applied forces during cervical spine mobilisation

PURPOSE

To determine if real-time feedback enables students to apply mobilisation forces to the cervical spine that are similar to an expert physiotherapist.

METHODS

An instrumented treatment table collected mobilisation force data with feedback about forces displayed on a computer screen. An expert physiotherapist performed posteroanterior mobilisation of C7 on 21 asymptomatic subjects while forces were recorded. These data were used as force targets for 51 students who mobilised one of the asymptomatic subjects on two occasions. Students' forces were recorded before and after practice either with (experimental group) or without real-time feedback (control group). Improved performance was defined as a smaller difference between expert and student forces, comparing groups with non-parametric statistics.

RESULTS

Students receiving feedback applied more accurate forces than controls (median difference between student and expert forces in the experimental group, 4.0N, inter-quartile range (IQR) 1.9-7.7; in controls, 14.3N, IQR 6.2-26.2, difference between groups p<0.001). One week later, these students still applied forces that more closely matched the expert's compared to controls (p<0.01), but the differences between the students' and expert's forces were greater (6.4N, IQR 3.1-14.7).

CONCLUSION

Practice with real-time objective feedback enables students to apply forces similar to an expert, supporting its use in manual therapy training.

Assessment of the importance of glenohumeral peripheral mechanics by practicing physiotherapists

BACKGROUND AND PURPOSE

Physiotherapists develop clinical reasoning theories and applied manual therapy skills through a variety of educational exposures. No studies have assessed the importance of selected theories such as the convex-concave rule, capsular pattern and scapulohumeral rhythm during clinical decision-making by physiotherapists. The present study investigated which variables physiotherapists considered were associated with the importance of these theories during practice and investigated physiotherapists' perception of translational motion biomechanics of the glenohumeral (GH) joint.

METHOD

Six hundred and sixty physiotherapists in the USA volunteered to participate in this study. Using ologit regression analyses, the identifier themes and clinical background characteristics were associated with importance of peripheral biomechanics in manual therapy application and reliability/validity of the scapulohumeral rhythm theory in predicting pathological sequences of the shoulder complex. An intraclass correlation coefficient (ICC) was used to determine agreement regarding necessary translation of the GH joint for normal movement.

RESULTS

The majority of physiotherapists indicated that all theories were important or very important during treatment decision-making and reported frequent utilization. Regression models identified that the importance placed on peripheral biomechanics was negatively influenced by academic qualification (bachelors and masters degrees) and gender (men were less likely to report that scapulohumeral rhythm was a reliable/valid predictor of shoulder pathology). ICC values identified excellent agreement among clinicians regarding translational motion.

CONCLUSIONS

The importance of biomechanics of the periphery for use, validation and frequency was based heavily on adoption of selected theories of glenohumeral movements despite evidence that suggests the theories lack validity.

Spinal manipulation in physical therapist professional degree education: A model for teaching and integration into clinical practice

Spinal manipulation for low back complaints is an intervention supported by randomized clinical trials and its use recommended by clinical practice guidelines. Physical therapists in this country and internationally have used thrust spinal manipulation at much lower-than-expected rates, despite evidence supporting its efficacy for the treatment of acute low back pain (LBP). The purpose of this clinical commentary is to describe a physical therapist professional degree curriculum in thrust spinal manipulation and outline a method of monitoring ongoing student performance during the clinical education experience. Increased emphasis on evidence-based decision making and on the psychomotor skills of thrust spinal manipulation was introduced into a physical therapist professional degree curriculum. As part of ongoing student performance monitoring, physical therapy students on their first full-time (8-week) clinical education experience, collected practice pattern and outcome data on individuals with low back complaints. Eight of 18 first-year students were in outpatient musculoskeletal clinical settings and managed 61 individuals with low back complaints. Patients were seen for an average (+/-SD) of 6.2 +/- 4.0 visits. Upon initial visit the student therapists employed spinal manipulation at a rate of 36.2% and spinal mobilization at 58.6%. At the final visit, utilization of manipulation and mobilization decreased (13% and 37.8%, respectively), while the utilization of exercise interventions increased, with 75% of patients receiving some form of lumbar stabilization training. Physical therapist students used thrust spinal manipulation at rates that are more consistent with clinical practice guidelines and substantially higher then previously reported by practicing physical therapists. Education within an evidence-based framework is thought to contribute to practice behaviors and outcomes that are more consistent with best practice guidelines.

Thrust joint manipulation clinical education opportunities for professional degree physical therapy students

STUDY DESIGN

Descriptive survey.

OBJECTIVE

Describe the availability of thrust joint manipulation clinical educational opportunities for physical therapy professional degree students.

BACKGROUND

In the United States, most of the faculty teaching manual therapy content in physical therapy programs believe that the best way for their students to develop thrust joint manipulation skills is to receive additional training during clinical education experiences. There are no data that describe the availability of such training opportunities.

METHODS AND MEASURES

Seventy-three physical therapy programs that include thrust joint manipulation in their curricula were divided into 5 geographic regions. Of these programs, 27% (total, n = 20) were randomly selected per region to participate. Program academic coordinators of clinical education (ACCEs) identified their clinical instructors working in outpatient orthopaedic settings. ACCEs and clinical instructors were surveyed regarding thrust joint manipulation clinical education opportunities for students.

RESULTS

Survey return rates were 100% for ACCEs and 67.4% for clinical instructors. Of ACCEs, 70% were unsure which sites employed clinical instructors trained in thrust joint manipulation and 85% did not consider whether thrust joint manipulation training was provided when scheduling the experience. The ACCEs who did consider availability cited lack of qualified instructors as the number-one barrier to finding sites that offered thrust joint manipulation. Of clinical instructors, 30% provide thrust joint manipulation training including lecture/theory, technique demonstration, practice on "normals," and direct patient care supervision. Clinical instructors who did not teach thrust joint manipulation cited reasons that included the belief that it is not an entry-level skill (57%), lack of qualified staff (53%), liability concerns (46%), and students not being academically prepared (41%).

CONCLUSIONS

Results suggest that the availability and scope of thrust joint manipulation clinical educational opportunities are limited, vary considerably, and are not considered when selecting clinical education sites for students. Potential obstacles to offering thrust joint manipulation training were identified, which suggested the need for resources, including clinical education curricula and philosophical guidelines for clinical instructors.

The influence of experience and specialty certifications on clinical outcomes for patients with low back pain treated within a standardized physical therapy management program

STUDY DESIGN

Secondary analysis of a randomized trial.

OBJECTIVES

To examine the influence of experience and specialty certification on outcomes for patients with low back pain receiving a standardized manipulation or stabilization exercise intervention program.

BACKGROUND

Little research has examined the impact of therapist-related factors on the outcomes of clinical care for patients with low back pain. It is assumed that therapists with more clinical experience or specialty certification will achieve better clinical outcomes; however, few studies have examined this hypothesis.

METHODS AND MEASURES

One hundred thirty-one participants in a randomized trial were included (70 randomized to receive manipulation, 61 stabilization). All subjects completed an Oswestry Disability Questionnaire at baseline, and after 1 and 4 weeks of treatment. Therapists were categorized based on total years of experience, years of experience with manual therapy, and specialty certification status. Two-way repeated-measures analyses of covariance were performed within each intervention group to examine the effects of the therapist characteristics on outcomes. Hierarchical linear regression models were used to examine the relative effects of therapist characteristics and intervention on clinical outcomes.

RESULTS

Thirteen therapists participated (average 6.0 years of experience [standard deviation, 4.01, 4 (30.8%) with specialty certification). A significant interaction between time and specialty certification status (P = .04) was detected for subjects receiving the manipulation intervention. No significant interactions were detected in the stabilization group. The regression models found that the intervention group significantly contributed to explaining clinical outcomes, but that therapist characteristics did not.

CONCLUSIONS

With the standardized protocol utilized in this study, it appears that the therapist-related factors of increased experience and specialty certification status do not result in an improvement in patients' disability associated with low back pain.

Joint manipulation curricula in physical therapist professional degree programs

STUDY DESIGN

Descriptive observational survey.

OBJECTIVE

To describe the status of joint manipulation curricula within physical therapist professional degree programs in the United States.

BACKGROUND

Studies have described the evolution of manual therapy curricula, including spinal and extremity joint mobilization, in physical therapist professional programs, but minimal information exists related to joint manipulation curricula.

METHODS AND MEASURES

Primary faculty members responsible for teaching manual therapy curricular content at the 199 physical therapist professional degree programs located in the United States recognized by the Commission on Accreditation in Physical Therapy Education were asked to participate in this project. The survey documented joint manipulation curricula, faculty qualifications, attitudes and experience, and programs' future plans for teaching manipulation.

RESULTS

Of the 116 programs responding to our survey, 87 (75%) currently include joint manipulation in their curriculum or plan to soon include such content in their curriculum. Of the programs currently teaching joint manipulation, 75% taught it as part of a required integrated clinical science course. Faculty teaching manipulation content appear to be well qualified and are in clinical practice an average of 12 hours per week. The programs currently not teaching joint manipulation reported reasons, including belief that it was not an entry-level skill (45%), lack of time (26%), lack of qualified faculty (71%), and perceived lack of scientific evidence regarding efficacy (7%).

CONCLUSIONS

Of the responding professional degree programs, 75% are either currently teaching joint manipulation or soon plan to do so. Our research may serve as a benchmark for faculty to assess existing manual therapy curricula and as a guide for developing curricula in new or existing physical therapy programs.