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

Guideline adherent screening and referral: do third year Doctor of Physical Therapy students identify red and yellow flags within descriptive patient cases? a United States based survey study

INTRODUCTION

The need for early detection and appropriate management of flags in physical therapy has been established. The lack of early detection has been shown to lead to poor outcomes such as serious pathology, increased disability, prolonged symptoms, and increased healthcare utilization.

OBJECTIVE

The main purpose of this survey study was to assess third-year Doctor of Physical Therapy (DPT) students' adherence to clinical practice guidelines specifically in the identification and management of red and yellow flags through a case-based approach.

METHODS

A survey including three different flag case scenarios was sent to DPT students in 15 geographically diverse physical therapy programs. Previously published case scenarios measuring adherence to practice guidelines were used. Correlational analyses were performed to link student demographic details and guideline adherent management.

RESULTS

The survey was completed by 64 students. Guideline adherent management was greater for red flags (85%) than yellow flag cases (25% and 42%). No significant relationship was noted between the student details and guideline adherent management.

CONCLUSION

DPT students may need additional educational content related to yellow flag screening. Educators may consider utilizing published red and yellow flag cases to guide decision-making and highlight best screening practices.

Knowledge, beliefs, and attitudes of spinal manipulation: a cross-sectional survey of Italian physiotherapists

Background and Objective

High-velocity low-amplitude thrust spinal manipulation (SM) is a recommended and commonly used manual therapy intervention in physiotherapy. Beliefs surrounding the safety and effectiveness of SM have challenged its use, and even advocated for its abandonment. Our study aimed to investigate the knowledge and beliefs surrounding SM by Italian physiotherapists compared with similar practitioners in other countries.

Methods

An online survey with 41 questions was adapted from previous surveys and was distributed via a mailing list of the Italian Physiotherapists Association (March 22–26, 2020). The questionnaire was divided into 4 sections to capture information on participant demographics, utilization, potential barriers, and knowledge about SM. Questions were differentiated between spinal regions. Attitudes towards different spinal regions, attributes associated with beliefs, and the influence of previous educational background were each evaluated.

Results

Of the 7398 registered physiotherapists, 575 (7.8%) completed the survey and were included for analysis. The majority of respondents perceived SM as safe and effective when applied to the thoracic (74.1%) and lumbar (72.2%) spines; whereas, a smaller proportion viewed SM to the upper cervical spine (56.8%) as safe and effective. Respondents reported they were less likely to provide and feel comfortable with upper cervical SM (respectively, 27.5% and 48.5%) compared to the thoracic (respectively, 52.2% and 74.8%) and lumbar spines (respectively, 46.3% and 74.3%). Most physiotherapists (70.4%) agreed they would perform additional screening prior to upper cervical SM compared to other spinal regions. Respondents who were aware of clinical prediction rules were more likely to report being comfortable with SM (OR 2.38–3.69) and to perceive it as safe (OR 1.75–3.12). Finally, physiotherapists without musculoskeletal specialization, especially those with a traditional manual therapy background, were more likely to perform additional screening prior to SM, use SM less frequently, report being less comfortable performing SM, and report upper cervical SM as less safe (p < 0.001).

Discussion

The beliefs and attitudes of physiotherapists surrounding the use of SM are significantly different when comparing the upper cervical spine to other spinal regions. An educational background in traditional manual therapy significantly influences beliefs and attitudes. We propose an updated framework on evidence-based SM.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-022-00449-x.

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.

Integration of wheelchair service provision education: current situation, facilitators and barriers for academic rehabilitation programs worldwide

Purpose: An estimated 75 million people with disabilities need wheelchairs globally, of whom 5-15% have one. Access to an appropriate wheelchair requires rehabilitation professionals trained to provide wheelchair service. One aim of the International Society of Wheelchair Professionals (ISWP) is to promote and facilitate the integration of wheelchair service provision education into academic rehabilitation programs worldwide. To inform the development of integration strategies, the purpose of this study was to develop an in-depth global portrait of the wheelchair service provision education offered in academic rehabilitation programs, the process of its integration and the associated facilitators and barriers.Method: Semi-structured qualitative interviews were conducted with a purposive sample of 14 representatives from academic rehabilitation programs (i.e., occupational therapy, physical therapy, and prosthetics and orthotics) in 11 countries, including low, middle and upper resourced settings.Findings: Thematic data analyses identified three overarching themes. The first theme, "impact of context", portrays factors related to local population needs, governance and supply chain of equipment and service delivery. The second theme, "current and planned wheelchair education", describes the content, pedagogic approach, student evaluation and feedback process. The third theme, "integration process", details five states of this process.Conclusions: This study describes in-depth the wheelchair service provision education across academic rehabilitation programs and resource settings, illustrating the context-dependent nature of its integration. This understanding may assist the global community of educators in preparing future rehabilitation professionals to better serve wheelchair users. This work has informed the development of ISWP's Seating and Mobility Academic Resource Toolkit (http://smart.wheelchairnetwork.org/).Implications for RehabilitationThe Dynamics of Context-Dependent Integration of Wheelchair Service Provision Education in Curricula model, depicting the findings of this study, may help to inform key stakeholders (i.e., academic institutions, health care providers and policy makers) about potential barriers and facilitators to the implementation of adequate wheelchair service provision education in the curricula of academic rehabilitation program.Study findings may lead to creative strategies, such as the expansion of ISWP's Seating and Mobility Academic Resource Toolkit (SMART; http://smart.wheelchairnetwork.org/), that may enable academic rehabilitation programs to be a part of the solution to strengthening rehabilitation systems worldwide, through appropriately trained rehabilitation professionals in wheelchair service provision.

The clinical implementation of pain neuroscience education: A survey study

Pain neuroscience education (PNE) has gained considerable attention in research. Three systematic reviews have shown increasing efficacy of PNE decreasing pain, disability, pain catastrophization, movement restrictions, and healthcare utilization. In the development of any new therapeutic approach, it is proposed that there are three stages: development, validation, and implementation. To date, the development and validation of PNE have been well-established. The third stage, implementation, however, lacks when it comes to PNE. The purpose of this study was to survey physical therapists (PT) on their experience and implementation of PNE, following a 15-hour PNE class. Upon development and validation of a PT-PNE survey, a random sample of PTs was invited to take the online survey. Two hundred and eighty-six PTs (female 56%) completed the PNE questionnaire. Ninety-one percent of PTs reported not being taught PNE in PT school. PT's are applying PNE into clinical practice to a variety of patients, experience outcomes in line with the current best-evidence, but struggle establishing which patients are ideal for PNE. The same five patient characteristics associated with success were also associated with failure, albeit in a different ranking order. This finding highlight the need to further investigate the factors associated with success and failure of PNE.

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.

Factors affecting confidence and knowledge in spinal palpation among International Manual Physical Therapists

OBJECTIVES

We sought to find if there was a relationship between the confidence in use of static palpation, passive physiological intervertebral motion (PPIVM) and passive accessory intervertebral motion (PAIVM) and the manual therapist's (MTs) knowledge of the literature on these topics.

METHODS

We designed an international survey to achieve our objectives. Each skill was surveyed for the cervical, thoracic and lumbar spines. We also included several other factors that we believed might influence the use of these skills.

RESULTS

We concluded that familiarity of the literature was significantly associated with a MTs' confidence in the use of static palpation, PPIVM and PAIVM techniques. We also found a relationship with the country of practice of the MT and their confidence using these techniques.

DISCUSSION

Spinal palpation is an integral part of the MT's evaluation and treatment abilities. The vast majority of MTs use spinal palpation and nearly all entry-level education programmes include it in their training. Knowing what factors influence MTs' confidence assessing and treating the spine may allow for more effective teaching and training, as well as improved patient outcomes.

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.

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.

Complexity in the physiotherapy management of low back disorders: clinical and research implications

Over the past decade a wide variety of approaches for the management of low back disorders (LBD) have been developed and evaluated in clinical trials. As a consequence physiotherapists and researchers interested in LBD are faced with a range of issues to do with complexity. These issues will be explored and suggestions made to improve the delivery of high quality research evidence and better patient outcomes.

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.