Expert practice in physical therapy

BACKGROUND AND PURPOSE

The purpose of this qualitative study was to identify the dimensions of clinical expertise in physical therapy practice across 4 clinical specialty areas: geriatrics, neurology, orthopedics, and pediatrics.

SUBJECTS

Subjects were 12 peer-designated expert physical therapists nominated by the leaders of the American Physical Therapy Association sections for geriatrics, neurology, orthopedics, and pediatrics.

METHODS

Guided by a grounded theory approach, a multiple case study research design was used with each of the 4 investigators studying 3 therapists working in one clinical area. Data were obtained through nonparticipant observation, interviews, review of documents, and analysis of structured tasks. Videotapes made during selected therapist-patient treatment sessions were used as a stimulus for the expert therapist interviews. Data were transcribed, coded, and analyzed through the development of 12 case reports and 4 composite case studies, one for each specialty area.

RESULTS

A theoretical model of expert practice in physical therapy was developed that included 4 dimensions: (1) a dynamic, multidimensional knowledge base that is patient-centered and evolves through therapist reflection, (2) a clinical reasoning process that is embedded in a collaborative, problem-solving venture with the patient, (3) a central focus on movement assessment linked to patient function, and (4) consistent virtues seen in caring and commitment to patients.

CONCLUSION AND DISCUSSION

These findings build on previous research in physical therapy on expertise. The dimensions of expert practice in physical therapy have implications for physical therapy practice, education, and continued research.

Describing expert practice in physical therapy

In this article, the authors demonstrate how grounded theory may be used to develop models for understanding clinical practice. Through a series of research studies involving novice, experienced, and expert physical therapy practitioners, conceptual frameworks were continually revised based on data obtained from returning to the field and relevant literature available at the time. As concepts and relationships moved to larger themes, a theoretical framework for expertise in clinical practice was proposed. Current work on verifying the theoretical framework continues. Grounded theory is an excellent research approach to bound and help guide a multistage research program involving multiple researchers working in multiple settings.

Cause, prevalence, and response to occupational musculoskeletal injuries reported by physical therapists and physical therapist assistants

BACKGROUND AND PURPOSE

Physical therapists (PTs) and physical therapist assistants (PTAs) are susceptible to occupational musculoskeletal injuries. The purpose of this study was to examine the reported causes and prevalence of occupational musculoskeletal injuries to PTs and PTAs during a 2-year period.

SUBJECTS

A questionnaire was mailed to 500 PTs and 500 PTAs randomly selected from the American Physical Therapy Association 1996 active membership list. Six hundred sixty-seven questionnaires were returned, giving a response rate of 67%.

METHOD

Based on a literature review and a pilot study, an occupational injury questionnaire was constructed and mailed. Self-reports of injuries were obtained.

RESULTS

Thirty-two percent of the PTs and 35% of the PTAs reported sustaining a musculoskeletal injury. The highest prevalence of injury was to the low back (62% of injured PTs and 56% of injured PTAs). The PTs reported the upper back and the wrist and hand as having the second highest prevalence (23%). The PTAs reported the upper back as having the second highest prevalence (28%). The PTs and PTAs reported making changes in their work habits of improved body mechanics, increased use of other personnel, and frequent change of work position. The majority of PTs and PTAs reported they did not limit patient contact time or area of practice after sustaining an injury.

CONCLUSION AND DISCUSSION

Although PTs and PTAs are recognized to be knowledgeable in prevention and treatment of musculoskeletal injuries, they are susceptible to sustaining occupational musculoskeletal injuries because of performing labor-intensive tasks.

Physical therapists' perception of patients' pain and its effect on management

BACKGROUND AND PURPOSE

The purpose of this qualitative study was twofold: (1) to determine the factors that affected physical therapists' (PTs) perception of patients' pain and (2) to determine how this perception affected the management of patients.

METHODS

Forty-six PTs with at least two years' experience practicing in pain management clinics, outpatient clinics or sports medicine clinics were interviewed. The data collected were transcribed, coded and analyzed for main themes.

RESULTS

The most predominant factors found to affect PTs' perception of patients' pain were the therapist's personal and professional experience, area of practice and evaluative findings.

CONCLUSIONS

In this sample there exists a common link between experience and evaluative findings: the longer PTs have been practicing the more proficient they become in performing and interpreting a thorough subjective and objective evaluation. PTs practicing in pain clinics were found to have a more holistic and multidisciplinary approach to patient care, whereas therapists practicing in outpatient and sports medicine facilities were more apt to focus on patients' physical symptoms and complaints. Four main themes of perceived patient pain and their corresponding management were developed: (1) patients presenting with legitimate/acute pain profiles render a slow, conservative approach by the PT; (2) patients presenting with debilitating/chronic pain were most often treated with an approach that stressed functional gains and patient independence; (3) the preferred treatment of patients characterized with a non-legitimate pain profile was an aggressive and multidisciplinary approach; (4) 'special cases' and their management were dependent upon the patient's functional level and pain tolerance.

Physical therapy clinical education in a 2:1 student-instructor education model

BACKGROUND AND PURPOSE

The purpose of this descriptive qualitative field study was to explore a 2:1 student-clinical instructor (CI) model of clinical education and identify factors that promote or interfere with a successful 2:1 clinical education experience.

SUBJECTS AND METHODS

An initial conceptual framework was developed from the professional literature and researcher experience to bound the study and guide the study design and data analysis. The purposive sample consisted of three CIs and six students participating in a 2:1 clinical education experience. Observational data were collected during the rotation, and all subjects recorded their experiences in journals and participated in postexperience interviews.

RESULTS

The data included descriptions of a typical day and themes about communication, advantages and disadvantages, and factors designed to make the 2:1 model feasible. Based on these results, a new conceptual model was developed to describe the key factors that positively influence the 2:1 clinical education model.

CONCLUSION AND DISCUSSION

This article presents descriptions of the 2:1 student-CI experience, identifies factors that may contribute to the success of the model, and offers implementation suggestions.

Perceptions of physical therapists toward patient education

BACKGROUND AND PURPOSE

The purpose of this study was to assess the perceptions of physical therapists regarding their involvement in patient education. We developed a questionnaire to assess procedures or activities taught, methods or tools used, important physical therapist behaviors, techniques used to assess the effectiveness of teaching, barriers to delivering effective education, relative value of patient care activities as compared with other activities, and factors contributing to the development of teaching skills.

SUBJECTS AND METHODS

The questionnaire was sent to 300 American Physical Therapy Association members nationwide chosen by a random sample. Two hundred questionnaires, or 69% of the eligible responses were used in the data analysis.

RESULTS

Most respondents indicated they teach 80% to 100% of their patients. Nearly all respondents teach range-of-motion techniques, home programs, and treatment rationale through the use of demonstration and verbal discussion. Most respondents recognize the importance of many therapist behaviors related to patient teaching and use observation and evaluation to assess the effectiveness of their teaching. Barriers to patient education most frequently cited were psychological factors of the patient. Interaction with patients was considered most important to the development of respondents' teaching skills.

CONCLUSION AND DISCUSSION

Implications and suggestions for further research are discussed.

Alternative approaches to research in physical therapy: positivism and phenomenology

This article presents philosophical approaches to research in physical therapy. A comparison is made to demonstrate how the research purpose, research design, research methods, and research data differ when one approaches research from the philosophical perspective of positivism (predominantly quantitative) as compared with the philosophical perspective of phenomenology (predominantly qualitative). Differences between the two approaches are highlighted by examples from research articles published in Physical Therapy. The authors urge physical therapy researchers to become familiar with the tenets, rigor, and knowledge gained from the use of both approaches in order to increase their options in conducting research relevant to the practice of physical therapy.

Attribute dimensions that distinguish master and novice physical therapy clinicians in orthopedic settings

The purpose of this qualitative case study was to further investigate the work of master and novice clinicians within the practice setting. The sample consisted of three master clinicians and three novice clinicians practicing in orthopedic outpatient physical therapy settings in three different regions of the United States. Data collection by three researchers included observation of each clinician treating at least three patients, audiotaping of all treatment sessions, interviews with clinicians and patients, and a review of patient records. Analysis of the data within and across cases revealed five attribute dimensions that distinguished the master clinician from the novice clinician. One attribute dimension (ie, confidence in predicting patient outcomes) related to knowledge, and four attribute dimensions (ie, ability to control the environment, evaluation and use of patient illness and disease data, focus of verbal and nonverbal communication with patients, and importance of teaching to hands-on care) related to improvisational performance. Further investigations are needed to confirm these findings and add to the body of knowledge concerning the parameters of physical therapy that may affect the efficacy and quality of patient care.

Theory: the guide to clinical practice and research

Physical therapists are becoming increasingly aware of the importance of theory in physical therapy research and practice. In this article, we define theory and discuss its uses in both clinical practice and clinical research. We argue that both the quality of current practice and growth of physical therapy as a profession will be enhanced as more physical therapists appreciate and use theory to guide their work.

Physical therapist curricula for the 1990s: educating the reflective practitioner

This article discusses why many current physical therapy entry-level programs may not be designed to educate the type of physical therapy practitioner needed for the 1990s. We suggest a framework for analyzing curriculum content to determine how the curriculum is influencing student outcomes. This framework includes three reference points of analysis, as suggested by Eisner's model of implicit, explicit, and null curricula. We also describe a new kind of physical therapy practitioner, the "reflective practitioner" (Schon's model), and suggest how various curricular components can support the development of this type of practitioner.

The novice versus the experienced clinician: insights into the work of the physical therapist

The purpose of this study was to develop a conceptual framework and a data-collection tool to begin a systematic analysis of the work of the physical therapist. The primary method of data collection was nonparticipant observation of physical therapist-patient treatment sessions. A team of two researchers performed each of the observations. Eight physical therapists, representing three levels of experience, were observed in four different adult outpatient orthopedic settings. Field notes constructed from the observations and transcribed data were used to develop coding categories. These categories were the basis for the development of five themes that describe some aspects of the therapeutic intervention: 1) how treatment time is allocated, 2) the types and uses of information gathered from the patient, 3) the impact of the therapeutic environment, 4) the degree of responsive therapeutic interaction, and 5) the therapist integration of nontherapeutic interaction with therapeutic interaction. These findings are a beginning for understanding the practice of physical therapy.

Qualitative and quantitative research in clinical practice

The purpose of this article is to describe types of research that are particularly suitable for use in clinical settings. Examples of the case study, descriptive research, and quasi-experimental research and examples of both qualitative and quantitative methods to record and transmit subjective data are described briefly.

Age bias: physical therapists and older patients

The purposes of this study were to determine if, given a hypothetical patient description, physical therapists would establish the aggressiveness of treatment goals on the basis of the patient's age and to examine the relationship of both attitudes toward and knowledge about elderly adults to goal-setting aggressiveness for an elderly patient. Three questionnaires were administered to 127 therapists in clinical settings. Unbeknown to the therapists, half received a description in which the patient's age was 28 and the other half received a description of the same patient but with the age as 78. Therapists were significantly less aggressive in their goal setting with the elderly patient. Among therapists who received the old patient description, those with a more positive attitude were significantly more aggressive in goal setting for the elderly patient. Knowledge scores did not correlate with either aggressiveness or attitude in this group.

Effects of mental practice on balance in elderly women

This experimental field study examined the potential usefulness of mental practice for improving physical performance in health care. Ideokinetic facilitation, which involves the use of idealized visual and kinesthetic mental images, was used as mental practice. Thirty-six women over the age of 70 were assigned to one of three intervention groups: Group A, nonsense; Group B, relaxation; or Group C, ideokinetic facilitation. Baseline and final measures of one-legged balance time were compared after a three-day intervention period. Results showed significant improvement between baseline and final measures within Group C only (t = 2.64, p less than or equal to .05). The improvement in Group C, however, was not significantly more than the improvement in Groups A and B. This study suggests that mental practice of a physical task can improve performance and may be of use to the physical therapy clinician.

Lacrimal gland-directed B cell responses

Although it is accepted that IgA plasma cells predominate in the lacrimal gland, the factors leading to this prevalence are not known. A series of 4-day LPS-driven co-culture experiments performed with dissociated lacrimal gland and lymphoid cell populations was employed to study the direct effect of lacrimal gland cells on B cell differentiation. Lacrimal gland cells, when co-cultured with spleen or mesenteric lymph node cells, were found to suppress differentiation of cells to IgA, IgG, and IgM production. Furthermore, suppression of IgG and IgM responses occurred after co-culture of lacrimal gland cells with Peyer's patch cells. However, these Peyer's patch co-cultures led to a stimulation of the IgA response, a condition that was abrogated by removal of Peyer's patch T cells before co-culturing. Pretreatment of lacrimal gland cells with mitomycin C eliminated the suppression and stimulation previously observed. These results demonstrate the effects of lacrimal gland, both directly and indirectly through T cells, on B cell differentiation. These findings explain in part the preferential accumulation of IgA-plasma cells within the gland.

Lacrimal gland-directed B cell responses

Although it is accepted that IgA plasma cells predominate in the lacrimal gland, the factors leading to this prevalence are not known. A series of 4-day LPS-driven co-culture experiments performed with dissociated lacrimal gland and lymphoid cell populations was employed to study the direct effect of lacrimal gland cells on B cell differentiation. Lacrimal gland cells, when co-cultured with spleen or mesenteric lymph node cells, were found to suppress differentiation of cells to IgA, IgG, and IgM production. Furthermore, suppression of IgG and IgM responses occurred after co-culture of lacrimal gland cells with Peyer's patch cells. However, these Peyer's patch co-cultures led to a stimulation of the IgA response, a condition that was abrogated by removal of Peyer's patch T cells before co-culturing. Pretreatment of lacrimal gland cells with mitomycin C eliminated the suppression and stimulation previously observed. These results demonstrate the effects of lacrimal gland, both directly and indirectly through T cells, on B cell differentiation. These findings explain in part the preferential accumulation of IgA-plasma cells within the gland.

Physician knowledge and utilization of physical therapy procedures

The purpose of this study was to assess physician knowledge and utilization of physical therapy procedures. We sent a questionnaire to 600 physicians in three medical specialties (neurology, orthopedic surgery, and physical medicine and rehabilitation), in four geographic regions of the United States. The usable return was 41 percent. Overall knowledge, technical knowledge, and professional knowledge scores were compared by medical specialty, region of the country, years in practice, and three measures of utilization using analysis of variance, student's t, and chi-square statistics. Physical medicine and rehabilitation specialists and physicians in practice 10 years or more had the most knowledge of physical therapy procedures. Respondents preferred a prescriptive relationship when referring patients to physical therapists, and they most often selected "technical" procedures traditionally associated with the profession rather than "professional" procedures when referring patients to physical therapy. Those practicing medicine in their specialty 10 years or more were more conservative in their referral preferences than those in practice less than 10 years. The implications for educational intervention concerning the professional role of the physical therapist are briefly discussed.

Comparison of methods of teaching children proper lifting techniques

This study was designed to determine the effects of two teaching methods on children's ability to demonstrate and recall their mastery of proper lifting techniques. Seventy-six third and fifth grade public school children were divided by grade into three groups. Two of the groups (experimental) were taught the correct method for lifting a heavy object, either by lecture demonstration or guided discovery teaching format; one group (control) was not taught. The students' knowledge was measured pretest, one-week posttest, and eight-week posttest with a written and practical test. The students in the experimental groups in both grades significantly (p less than or equal to .001) increased their scores on the written portion of the test over those of the control groups on the one-week posttest. No group, however, showed significant gains on the practical portion. No differences were found between teaching methods. Results of this study stress the importance of evaluating verbally learned motor skills in a practical application format in school settings and in clinical patient education.

Relationship between verbal command volume and magnitude of muscle contraction

The purpose of this study was to investigate the hypothesized correlation between volume of a verbal command and magnitude of a resulting voluntary isometric muscular contraction, using a withdrawal-reinstatement (ABAB) research design. Nineteen volunteer male subjects between the ages of 18 and 30 years performed isometric contractions of the triceps brachii muscles in response to prerecorded verbal commands. With a volume increase of 22 decibels A scale, subjects averaged an 8 percent increase in muscle contraction strength, a difference that was significant at the .05 level. Through an awareness and use of the effects of voice volume on muscular contraction, the therapist may be able to improve the accuracy and consistency of examination methods, and increase the efficacy and efficiency of therapeutic procedures.

Clinical teaching in physical therapy education. An ethnographic study

The purpose of this ethnographic study was to examine the process of clinical education from the viewpoint of clinical teachers. A three-month field study based on a grounded theory approach and involving simultaneous collection and codification of data led to the discovery and explication of two major components of the clinical education process. One component, the clinical teaching situation, identified the organizational and human factors that influence the type, quality, and quantity of the student learning. The second component, teaching tools used by the clinical teachers, identified the strategies used to pace the student to professional competence. The authors view the findings as a beginning understanding of how and why clinical education is fundamentally different from academic education.

Factors related to job turnover in physical therapy

The purpose of this study was to determine the relative importance of personal and work-related factors in relation to job turnover in the physical therapy profession. A survey questionnaire was mailed to a nationwide sample of 820 physical therapists, and 567 responses (69%) were used in the data analyses. The two most important reasons for leaving a job were "desire to pursue a different area of physical therapy" and "insufficient salary to meet financial needs." Significant differences were found in the relative importance of job-turnover factors when the sample was stratified according to physical therapy education level, percentage of time in direct patient care, years in the physical therapy profession, and sex. A careful look at the factors contributing to job turnover will help physical therapy administrators retain staff members.

Factors influencing high school students' knowledge of physical therapy

A questionnaire in a closed-question format was used to survey 403 California high school students' accuracy of knowledge and available sources of information about physical therapy. Most students had some knowledge of physical therapy. The most recognized physical role was "instructing a patient in exercises" (83%). Very few students, however, were familiar with the role "provides wound care" (16%). A relatively common misconception was the belief that a physical therapist "prescribes medication" (24%). Very few significant differences in the recognition of individual tasks were found between junior and senior, male and female, urban and rural, or health career and nonhealth career oriented students. Health career students were more knowledgeable about physical therapy than any other group. The category of personal contacts was cited by the most students as their source of information (61%), and television (in the media category) was the most frequently cited single source (35%). Other studies have established that many high school students are making career decisions. This study of high school students' knowledge of physical therapy may assist in identifying career information useful to students and in stimulating a viable pool of applicants for physical therapy programs.

Research in physical therapy: philosophy, barriers to involvement, and use among California physical therapists

This study was designed to 1) determine the importance of research in physical therapy to professional physical therapists; 2) assess the factors impeding their involvement in research; and 3) examine the extent to which therapists use published research. The study was conducted in two parts, a series of personal interviews and a questionnaire developed from the results of the interviews. The sample for the interviews was drawn from the population of Santa Clara County, California, and the questionnaires were mailed to a random distribution of 300 physical therapists throughout the State of California. Lack of time and funding as well as unfamiliarity with both the research process and the use of statistics were cited as the main barriers to research involvement. Collaboration with other health professionals involved in research and an apprenticeships were listed as desirable methods to gain additional research skills; however, these were believed to largely unavailable. A large percentage of therapists used research information published in professional journals other than PHYSICAL THERAPY.

Use of small group interviews for selection into allied health educational programs

This article assesses the utility of small group interviews comprised of two or more interviewers and two or more interviewees as a selection tool for entrance into allied health educational programs. The article also suggests reasons for lack of predictive utility of the traditional admissions interview, examines data on decision-making processes in small group selection interviews, and makes specific recommendations on the use of small group selection interviews in allied health education programs.

Salary and status differences between male and female physical therapists

The purpose of this study was to compare employment profiles of men and women employed as physical therapists. A survey on salary and on demographic and professional characteristics was mailed to 500 male and 500 female physical therapists throughout the United States, and 658 (65.8%) were used in the data analysis. Several striking differences between the employment profiles of male and female physical therapists were identified, including: 1) men were more likely to be self-employed, 2) men were more likely to hold supervisory positions, and 3) men tended to have significantly higher incomes even when compared to women with similar employment characteristics. The salary and status differences between men and women in physical therapy approximate those found in other occupations in which women are in the majority. The findings of this study constitute strong evidence that sex discrimination exists in the physical therapy profession.

Considerations for curriculum design

Educational values held by academic and clinical faculties subtly but strongly influence curriculum design in physical therapy education. Five major value orientations, Curriculum as the Development of Cognitive processes, Curriculum as Technology, Curriculum as Self-Actualization, Curriculum as Social Reconstruction-Relevance, and Curriculum as Academic Rationalism, are presented. The suggestion is made that these underlying value-orientations influence the choice of curriculum design more than do "available resources." A second component of curriculum design, i.e., evaluation of student performance, also influences and is influenced by the direction and development of physical therapy curricula. A plea is made for expressive objectives and outcome objectives to be considered along with instructional or behavioral objectives to yield more comprehensive and creative appraisals of student growth.

The family in physical therapy

Family Focus is a training program implemented by the Division of Physical Therapy at Stanford University in cooperation with the Mental Research Institute of Palo Alto, California. Through this program, inpatients at the Stanford University Hospital and their families have the opportunity to live in a modular home on the hospital grounds prior to discharge and receive training in the activities they will need to carry out at home. Psychologists consult with the physical therapists on ways to help the family cope with stressful situations. The advantages of including the entire family in health care planning and treatment are described and suggestions are made for applying the principles in any physical therapy setting.