Blind and partially sighted physiotherapy in the United Kingdom. A century of development, success and challenge. Will it still belong?

Background:In 2019 the Association of Visually Impaired Chartered Physiotherapists, originally the Association of Blind Certificated Masseurs, celebrated the centenary of its formation and becoming the first ever Specific Interest Group admitted to the Incorporated Society of Trained Masseuses which, later in the 20th century, became the Chartered Society of Physiotherapy. These landmarks motivated the author to research for this chronological, descriptive, narrative review of the history of blind physiotherapy and its contribution to physiotherapy in the United Kingdom. Purpose:The early training and practice of massage by blind practitioners, the organizational milestones in mainstream and blind physiotherapy and the inter-relationship between the two is considered. Key developments, challenges, innovations and opportunities throughout the history are reviewed including the impact of World War 1 and contribution of blind physiotherapy to the profession. Conclusion:Significant changes in physiotherapy educational and training arrangements for blind students and changes in physiotherapy practice generally over the last four decades engender serious questions about whether blind physiotherapy will still "belong", despite the increasing aspiration within society toward acceptance of diversity and inclusion. The author challenges the profession about whether it will facilitate blind physiotherapy to continue making its valuable contribution and be included. Will it still "belong?"

An orthopedic manual physical therapy fellowship training's impact on professional development, involvement, personal lives, and income - A survey study.

Introduction: Little research exists investigating the personal and professional outcomes of postprofessional physical therapy (PT) training. Therefore, the purpose of the current descriptive, web-based survey study was to determine self-reported outcomes from a postprofessional PT fellowship program, including graduate professional, educational, and research involvement; perceptions of the impact of training on clinical and professional attributes; changes in employment and income; and barriers to training. Methods: Graduates of a part-time, hybrid-model, multisite orthopedic manual PT fellowship program were invited to complete the web-based survey. Descriptive data analyses were performed for all quantitative data, and responses to questions were analyzed and categorized into themes. Results: Of the 77 fellowship graduates, 75 (97%) completed the survey. Graduates were involved in teaching; 43% (32/75) filled lead instructor roles in PT education programs. Further, 75% (57/75) were involved in research. The mean (SD) and median (range) increase in annual gross income was $9560 ($17,545) and $2,500 ($0-$125,000), respectively. Perceived areas with the largest impact of training included clinical reasoning, patient-centered and evidence-based practice, and professionalism. Life balance and family commitments were frequent barriers during training. Discussion: Graduates noted substantial perceived professional, clinical, and financial benefits to fellowship training. Limitations included lack of a control group and surveying participants from a single program. Future research should determine the influence that program and participant-related factors have on personal and professional lives of graduates and on clinical outcomes. Level of Evidence: Descriptive survey, level 3.

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.

Comparing the range of musculoskeletal therapies applied by physical therapists with postgraduate qualifications in manual therapy in patients with non-specific neck pain with international guidelines and recommendations: An observational study.

The aim of this study is to compare Dutch usual care musculoskeletal therapy in patients with non-specific neck pain with recommendations from international clinical practice guidelines. Physical therapy is diverse, as it may consist of exercise, massage, advice, and other modalities. Physical therapists with post graduate qualifications in manual therapy (MT) may additionally apply spinal thrust manipulation or non-thrust mobilization techniques to treat neck pain. It is important that, in the absence of a Dutch clinical guideline for the treatment of patients with neck pain, musculoskeletal therapists use the available recommendations from international clinical practice guidelines when treating patients with neck pain. One updated clinical practice guideline was identified (Blanpied, 2017), a report from the Task Force on Neck Pain (Guzman et al., 2008) and the IFOMPT International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention (Rushton et al., 2014). At baseline 1193 patients are included and data with regard to pain, disability, fear avoidance, expectations and applied treatment modalities are gathered. Outcome is measured using the Global Perceived Effect questionnaire. Results show that patients with acute neck pain are treated significantly more often with manipulation compared to patients with sub-acute or chronic neck pain (p < .000) and younger patients are treated with manipulation more often than older patients (p < .000). In the presence of comorbidity, the preference of spinal manipulation seems to diminish, in favour of mobilization and exercise. Almost every patient receives multimodal therapy (94.3%) and spinal manipulation and mobilization are rarely used as a stand-alone treatment (4.5% and 0.8%). Dutch musculoskeletal therapists choose treatment strategies that correspond with recommendations from international guidelines.

Evaluating the international standards gap for the use of acupuncture needles by physiotherapists and chiropractors: A policy analysis.

BACKGROUND: Acupuncture needles have become an increasingly-popular treatment tool used by multiple health professions. However, the World Health Organization (WHO)'s 1999 training guidelines for acupuncture address only medical doctors and licensed acupuncturists, leaving a gap as to appropriate training standards for other professions. AIMS AND METHODS: With reference to an extensive document analysis, and interviews with seventeen acupuncture educators from across several professions in Ontario, Canada, this work uses a critical qualitative policy analytic approach to: a) present a comprehensive account of statutory training requirements for acupuncture-needling physiotherapists and chiropractors in the United States, Canada, and Australia; and b) evaluate competing stakeholder discourses pertaining to recent related controversies. RESULTS: A wide range of educational requirements are evident across the jurisdictions under study (most below the 200-hour WHO guideline for physicians); and there is considerable disagreement among stakeholders as to what constitutes sufficient training in various forms of acupuncture, including 'dry needling'. Organizations defending brief post-graduate training for needling physiotherapists and chiropractors are generally associated with these two professions, and contend that their 'dry needling' practices differ substantially from traditional acupuncture. Characterizing such brief training as insufficient, opportunistic and unsafe, and 'dry needling' as a subset of acupuncture practice, are the voices of all acupuncture educators interviewed, as well as professional organizations representing physicians, licensed acupuncturists, and some physiotherapists and chiropractors. DISCUSSION AND CONCLUSION: Critiquing claims on both sides of the debate, this work calls for the development of independent, international safety-geared training guidelines that explicitly address the recent, evidence-informed trend towards biomedicalized acupuncture needling. Findings also suggest a need for additional research regarding the current shift towards overlapping-rather than exclusive-health professional practice scopes in industrialized countries.

Perceptions of the professional and personal impact of hybrid fellowship training: a qualitative study.

OBJECTIVES: This study aimed to elucidate graduate perceptions of how fellowship training impacted their post-training professional and personal lives. METHODS: Interviews were conducted with 13 graduates of a hybrid (e.g. blended-learning) fellowship program. All participants were at least 1 year post completion of fellowship to limit recall bias and allow for post-training personal and professional development. Qualitative analysis was performed on interview transcriptions using directed content analysis with two coders other than the interviewers, followed by discussion until agreement was reached if there were disputes related to coding analysis. If needed, arbitration was provided from one of two interviewers. RESULTS: Analysis revealed three primary constructs of post-fellowship impact: practical, social, and personal. Practical subthemes were centric to care delivery. Social subthemes extended to intra, inter, and non-professional connections. Personal subthemes noted professional and cognitive evolution. DISCUSSION: Participants clearly described impact extending well beyond day-to-day practice suggesting that fellowship impacted the whole person versus sole practitioner. This study may impact program structure and content inclusion for fellowship programs as well as providing support for fellows in training.

Influence of residency training on the clinical reasoning development of Kenyan physiotherapists.

Objective: The purpose of this study was to explore the clinical reasoning development of physical therapists participating in an 18-month orthopaedic residency program in Nairobi, Kenya. Methods: A mixed methods research design was utilized. The participants' clinical reasoning was assessed through a live patient examination prior to entering the residency program and upon graduation. One-on-one interviews were performed with the residents to explore their clinical reasoning during the final examination. Results: Residents (n = 14) demonstrated a statistically significant improvement in their ability to perform an examination of a patient and determine a hypothetical diagnosis. The clinical reasoning process described by the participants included the hypothetical deductive and narrative reasoning models. The residents did not appear to incorporate pattern recognition during the patient assessment. Discussion: Similar to studies on novice and expert practice in physical therapy, residents demonstrated an improvement in cue acquisition, the ability to verify and refute a hypothetical diagnosis, and the ability to match interventions to patients impairments. In addition, the residents utilized a combination of clinical reasoning models during the examination and evaluation of the patient including hypothetical deductive reasoning and narrative reasoning. Level of Evidence: 4.

Feasibility of Training Physical Therapists to Implement a Psychologically Informed Physical Therapy Program for Deployed U.S. Sailors and Marines with Musculoskeletal Injuries.

This study assesses the feasibility of training U.S. Navy Physical Therapy staff members (PT staff) aboard a U.S. Navy Aircraft Carrier in psychologically informed physical therapy (PiPT). Training was conducted prior to deployment over 3 d and included background information, skills development, and application in the form of role playing and case studies. During deployment, nine phone conferences were conducted to reinforce training, assess skills, and discuss implementation. PiPT knowledge was assessed by a written test and role-playing skills. The adoption of the training was determined by analysis of clinical notes and verbal responses of the PT staff during phone conferences. There were two PT staff members on the carrier. Both received passing knowledge test scores and demonstrated role-playing proficiency. Clinical note assessment and discussions during conference calls also indicated successful implementation. The feasibility of training Navy PT staff to implement PiPT was demonstrated. PT staff successfully translated training into practice. This is significant, since PiPT has the potential to limit attrition due to musculoskeletal injuries in Navy personnel. Factors believed to be associated with the success of the training include adoption of the PiPT model by PT staff and reinforcement of changes in clinical practice during deployment.

Integrating self-management support for knee injuries into routine clinical practice: TRAK intervention design and delivery.

BACKGROUND: TRAK is a web-based intervention that provides knee patients with health information, personalised exercise plans and remote clinical support. The aim of this study was to fully define TRAK intervention content, setting and context and develop the training through an implementation study in a physiotherapy out-patient service. METHODS: A mixed methods study. Phase 1 was a qualitative interview study, whereby fifteen physiotherapists used TRAK for 1 month with a patient of their choice. Interviews explored patient and physiotherapist views of TRAK intervention and training requirements. In Phase 2 seventy-four patients were recruited, all received conventional physiotherapy, a subset of 48 patients used TRAK in addition to conventional Physiotherapy. Aspects of feasibility measured included: uptake and usage of TRAK. RESULTS: Patients and physiotherapists reported that TRAK was easy to use and highlighted the therapeutic benefit of the exercise videos and personalised exercise plans to remind them of their exercises and the correct technique. Patients reported needing to use TRAK with the guidance of their treating physiotherapist initially. Physiotherapists highlighted appointment time constraints and lack of familiarity with TRAK as factors limiting engagement. In Phase 2, 67% patients accessed TRAK outside of the clinical environment. A total of 91% of patients were given a personalised exercise plan, but these were only updated in 34% of cases. CONCLUSION: A comprehensive training package for patients and clinicians has been defined. The refined TRAK intervention is reported using the 'Template for Intervention Description and Replication in preparation for a definitive randomised control trial.

Health care provider confidence and exercise prescription practices of Exercise is Medicine Canada workshop attendees.

The Exercise is Medicine Canada (EIMC) initiative promotes physical activity counselling and exercise prescription within health care. The purpose of this study was to evaluate perceptions and practices around physical activity counselling and exercise prescription in health care professionals before and after EIMC training. Prior to and directly following EIMC workshops, 209 participants (physicians (n = 113); allied health professionals (AHPs) (n = 54), including primarily nurses (n = 36) and others; and exercise professionals (EPs) (n = 23), including kinesiologists (n = 16), physiotherapists (n = 5), and personal trainers (n = 2)) from 7 provinces completed self-reflection questionnaires. Compared with AHPs, physicians saw more patients (78% > 15 patients/day vs 93% < 15 patients/day; p < 0.001) and reported lower frequencies of exercise counselling during routine client encounters (48% vs 72% in most sessions; p < 0.001). EPs had higher confidence providing physical activity information (92 ± 11%) compared with both physicians (52 ± 25%; p < 0.001) and AHPs (56 ± 24%; p < 0.001). Physicians indicated that they experienced greater difficulty including physical activity and exercise counselling into sessions (2.74 ± 0.71, out of 5) compared with AHPs (2.17 ± 0.94; p = 0.001) and EPs (1.43 ± 0.66; p < 0.001). Physicians rated the most impactful barriers to exercise prescription as lack of patient interest (2.77 ± 0.85 out of 4), resources (2.65 ± 0.82 out of 4), and time (2.62 ± 0.71 out of 4). The majority of physicians (85%) provided a written prescription for exercise in <10% of appointments. Following the workshop, 87% of physician attendees proposed at least one change to practice; 47% intended on changing their practice by prescribing exercise routinely, and 33% planned on increasing physical activity and exercise counselling, measured through open-ended responses.

Facilitating awareness of philosophy of science, ethics and communication through manual skills training in undergraduate education.

BACKGROUND: Professional health science education includes a common theoretical basis concerning the theory of science, ethics and communication. Former evaluations by first-year students of the bachelor physiotherapy program at Oslo and Akershus University College of Applied Sciences (HiOA) show that they find it hard to understand the relation between these particular topics and future professional practice. This challenge is the starting point for a pedagogical development project that aims to develop learning contexts that highlight the relevance of these theoretical concepts. AIM: The aim of the study is to explore and present findings on the value of using Sykegrep manual skills classes as an arena in which students can be encouraged to think about, reflect on and appreciate the role and value of the philosophical perspectives that inform their practice and contributes to practise knowledge. METHOD: A qualitative study with data collection through focus groups was performed and analyzed using thematic content analysis. Eighteen first-year undergraduate students, who had completed the manual skills course, participated in the study. FINDINGS: Analysis of the data yielded three categories of findings that can be associated with aspects of philosophy of science, ethics and communication. These are as follows: 1) preconceived understanding of physiotherapy; 2) body knowledge perspectives; and 3) relational aspects of interactions. Undergraduate students' understanding and experience of philosophy of science, ethics and communication may be facilitated by peer collaboration, reflection on intimacy and touch and the ethical aspects of interaction during manual skills training. CONCLUSION: Practical classes in Sykegrep provide a basis for students' discussions about the body as well as their experiences with the body in the collaborative learning context. The students' reflections on their expectations of manual skills in physiotherapy and experiences of touch and being touched can facilitate an awareness of philosophy of science, ethics and communication. IMPLICATIONS: Our study will be an incitement to further develop a manual skills teaching program that incorporates philosophy of science, ethics and communication in undergraduate education.

Evaluation of a risk-stratification strategy to improve primary care for low back pain: the MATCH cluster randomized trial protocol.

BACKGROUND: Despite numerous options for treating back pain and the increasing healthcare resources devoted to this problem, the prevalence and impact of back pain-related disability has not improved. It is now recognized that psychosocial factors, as well as physical factors, are important predictors of poor outcomes for back pain. A promising new approach that matches treatments to the physical and psychosocial obstacles to recovery, the STarT Back risk stratification approach, improved patients' physical function while reducing costs of care in the United Kingdom (UK). This trial evaluates implementation of this strategy in a United States (US) healthcare setting. METHODS: Six large primary care clinics in an integrated healthcare system in Washington State were block-randomized, three to receive an intensive quality improvement intervention for back pain and three to serve as controls for secular trends. The intervention included 6 one-hour training sessions for physicians, 5 days of training for physical therapists, individualized and group coaching of clinicians, and integration of the STarT Back tool into the electronic health record. This prognostic tool uses 9 questions to categorize patients at low, medium or high risk of persistent disabling pain with recommendations about evidence-based treatment options appropriate for each subgroup. Patients at least 18 years of age, receiving primary care for non-specific low back pain, were invited to provide data 1-3 weeks after their primary care visit and follow-up data 2 months and 6 months (primary endpoint) later. The primary outcomes are back-related physical function and pain severity. Using an intention to treat approach, intervention effects on patient outcomes will be estimated by comparing mean changes at the 2 and 6 month follow-up between the pre- and post-implementation periods. The inclusion of control clinics permits adjustment for secular trends. Differences in change scores by intervention group and time period will be estimated using linear mixed models with random effects. Secondary outcomes include healthcare utilization and adherence to clinical guidelines. DISCUSSION: This trial will provide the first randomized trial evidence of the clinical effectiveness of implementing risk stratification with matched treatment options for low back pain in a United States health care delivery system. TRIAL REGISTRATION: NCT02286141. Registered November 5, 2014.

Interprofessional education increases knowledge, promotes team building, and changes practice in the care of Parkinson's disease.

OBJECTIVE: Examine outcomes for the National Parkinson Foundation (NPF) Allied Team Training for Parkinson (ATTP), an interprofessional education (IPE) program in Parkinson's disease (PD) and team-based care for medicine, nursing, occupational, physical and music therapies, physician assistant, social work and speech-language pathology disciplines. BACKGROUND: Healthcare professionals need education in evidence-based PD practices and working effectively in teams. Few evidence-based models of IPE in PD exist. METHODS: Knowledge about PD, team-based care, the role of other disciplines and attitudes towards healthcare teams were measured before and after a protocol-driven training program. Knowledge, attitudes and practice changes were again measured at 6-month post-training. Trainee results were compared to results of controls. RESULTS: Twenty-six NPF-ATTP trainings were held across the U.S. (2003-2013). Compared to control participants (n = 100), trainees (n = 1468) showed statistically significant posttest improvement in all major outcomes, including self-perceived (p < 0.001) and objective knowledge (p < 0.001), Understanding Role of Other Disciplines (p < 0.001), Attitudes Toward Health Care Teams Scale (p < 0.001), and the Attitudes Toward Value of Teams (p < 0.001) subscale. Despite some decline, significant improvements were largely sustained at six-month post-training. Qualitative analyses confirmed post-training practice changes. CONCLUSIONS: The NPF-ATTP model IPE program showed sustained positive gains in knowledge of PD, team strategies and role of other disciplines, team attitudes, and important practice improvements. Further research should examine longer-term outcomes, objectively measure practice changes and mediators, and determine impact on patient outcomes.

Importance Attributed to Cardiovascular and Pulmonary Competencies by Public Sector Physical Therapists in Kuwait: A Population-based Exploratory Study.

BACKGROUND AND PURPOSE: Indications for cardiovascular and pulmonary (CVP) physical therapy competencies are changing with the epidemic of non-communicable diseases in Kuwait, particularly lifestyle-related conditions. The degree to which the country's physical therapists (PTs) perceive the importance of CVP competencies (assessment/evaluation and clinical and laboratory investigation interpretation) in professional practice is relevant. Our study objectives were to (1) explore the importance attributed to specific CVP competencies by PTs to professional practice in Kuwait and (2) establish whether these are related to practitioner traits, for example, age, sex, practice setting and specialty. METHOD: The study design was exploratory with a stratified random sample. Questionnaires (n = 221) were distributed to PTs practicing in the facilities of the Ministry of Health, the primary employer of PTs in Kuwait. Questions included participants' demographics and perceived importance of specific CVP competencies (Likert rating scale 1-not important to 5-highly important). RESULTS: Response rate was 87% (n = 193). Participant mean age was 36(±9) years, 63% were women and 48% were Kuwaiti. Ratings of moderately important or higher were 84% for cardiac assessment/intervention skills, 78.8% for cardiac clinical/laboratory investigations interpretation, 77.2% for pulmonary assessment/intervention skills and 73.6% for pulmonary clinical/laboratory investigations interpretation. PTs in the musculoskeletal area attributed less importance to the competencies than those in other specialties. CONCLUSIONS: Participants perceived CVP competencies as generally relevant to practice. However, greater importance was attributed to these competencies in relation to management of CVP conditions (e.g. those that address lifestyle-related conditions) rather than across practice areas. Research is needed to elucidate whether this finding reflects the profession's commitment to holistic care, the prevalence of lifestyle-related risk factors and conditions irrespective of a patient's primary complaint presenting to the PT, best evidence-based, non-pharmacologic practice to address these or some combination. Copyright © 2015 John Wiley & Sons, Ltd.

Physical Therapists' Views and Experiences of Pregnancy-Related Low Back Pain and the Role of Acupuncture: Qualitative Exploration.

BACKGROUND: Low back pain is often accepted as a "normal" part of pregnancy. Despite research suggesting that quality of life for women who are pregnant is adversely affected, most are advised to self-manage. Although the use of acupuncture for the management of persistent nonspecific low back pain has been recommended in recent UK national guidelines, its use in the management of pregnancy-related low back pain remains limited. OBJECTIVES: This study aimed to explore the perceptions and experiences of physical therapists involved in treating women who are pregnant and have low back pain with the objective of informing the pretrial training program for a pilot randomized trial (Evaluating Acupuncture and Standard care for pregnant womEn with Back pain [EASE Back]). DESIGN: A qualitative phenomenological method with purposive sampling was used in the study. METHODS: Three focus groups and 3 individual semistructured interviews were undertaken, and an iterative exploratory thematic analysis was performed. To ensure transparency of the research process and the decisions made, an audit trail was created. RESULTS: Twenty-one physical therapists participated, and emergent issues included: a lack of experience in treating pregnancy-related complaints, mixed messages from previous acupuncture education, a mistrust of the current evidence for acupuncture safety and effectiveness, and personal and professional fear of causing harm. CONCLUSIONS: The findings suggest that UK physical therapists are reluctant to use acupuncture in the management of pregnancy-related low back pain. The explanations for these findings include perceived lack of knowledge and confidence, as well as a pervasive professional culture of caution, particularly fears of inducing early labor and of litigation. These findings have been key to informing the content of the training program for physical therapists delivering acupuncture within the pilot EASE Back trial.

An online community of practice to support evidence-based physiotherapy practice in manual therapy.

INTRODUCTION: The purpose of this study was to explore how a community of practice promoted the creation and sharing of new knowledge in evidence-based manual therapy using Wenger's constructs of mutual engagement, joint enterprise, and shared repertoire as a theoretical framework. METHODS: We used a qualitative approach to analyze the discussion board contributions of the 19 physiotherapists who participated in the 10-week online continuing education course in evidence-based practice (EBP) in manual therapy. The course was founded on community of practice, constructivism, social, and situated learning principles. RESULTS: The 1436 postings on 9 active discussion boards revealed that the community of practice was a social learning environment that supported strong participation and mutual engagement. Design features such as consistent facilitation, weekly guiding questions, and collaborative assignments promoted the creation and sharing of knowledge. Participants applied research evidence to the contexts in which they worked through reflective comparison of what they were reading to its applicability in their everyday practice. Participants' shared goals contributed to the common ground established in developing collective knowledge about different study designs, how to answer research questions, and the difficulties of conducting sound research. DISCUSSION: An online longitudinal community of practice utilized as a continuing education approach to deliver an online course based on constructivist and social learning principles allowed geographically dispersed physiotherapists to be mutually engaged in a joint enterprise in evidence-based manual therapy. Advantages included opportunity for reflection, modeling, and collaboration. Future studies should examine the impact of participation on clinical practice.