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A Description of Physical Therapists’ Knowledge in Managing Musculoskeletal Conditions

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Physical therapists increasingly provide direct access services to patients with musculoskeletal conditions, and growing evidence supports the cost-effectiveness of this mode of healthcare delivery. However, further evidence is needed to determine if physical therapists have the requisite knowledge necessary to manage musculoskeletal conditions. Therefore, the purpose of this study was to describe physical therapists' knowledge in managing musculoskeletal conditions. This study utilized a cross-sectional design in which 174 physical therapist students from randomly selected educational programs and 182 experienced physical therapists completed a standardized examination assessing knowledge in managing musculoskeletal conditions. This same examination has been previously been used to assess knowledge in musculoskeletal medicine among medical students, physician interns and residents, and across a variety of physician specialties. Experienced physical therapists had higher levels of knowledge in managing musculoskeletal conditions than medical students, physician interns and residents, and all physician specialists except for orthopaedists. Physical therapist students enrolled in doctoral degree educational programs achieved significantly higher scores than their peers enrolled in master's degree programs. Furthermore, experienced physical therapists who were board-certified in orthopaedic or sports physical therapy achieved significantly higher scores and passing rates than their non board-certified colleagues. The results of this study may have implications for health and public policy decisions regarding the suitability of utilizing physical therapists to provide direct access care for patients with musculoskeletal conditions.
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BioMed Central
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BMC Musculoskeletal Disorders
Open Access
Research article
A description of physical therapists' knowledge in managing
musculoskeletal conditions
John D Childs
†1
, Julie M Whitman
†2
, Phillip S Sizer*
†3
, Maria L Pugia
†4
,
Timothy W Flynn
†2
and Anthony Delitto
†5
Address:
1
US Army-Baylor University Doctoral Program in Physical Therapy, Fort Sam Houston, San Antonio, TX, USA,
2
Department of Physical
Therapy, Regis University, Denver, CO, USA,
3
Department of Physical Therapy, Texas Tech University, Lubbock, TX, USA,
4
Department of Physical
Therapy, Los Angeles Air Force Base, Los Angeles, CA, USA and
5
Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA
Email: John D Childs - childsjd@sbcglobal.net; Julie M Whitman - jwitman55@comcast.net; Phillip S Sizer* - phil.sizer@ttuhsc.edu;
Maria L Pugia - maria.pugia@losangeles.af.mil; Timothy W Flynn - tflynn@regis.edu; Anthony Delitto - delittoa@upmc.edu
* Corresponding author †Equal contributors
Abstract
Background: Physical therapists increasingly provide direct access services to patients with
musculoskeletal conditions, and growing evidence supports the cost-effectiveness of this mode of
healthcare delivery. However, further evidence is needed to determine if physical therapists have
the requisite knowledge necessary to manage musculoskeletal conditions. Therefore, the purpose
of this study was to describe physical therapists' knowledge in managing musculoskeletal conditions.
Methods: This study utilized a cross-sectional design in which 174 physical therapist students from
randomly selected educational programs and 182 experienced physical therapists completed a
standardized examination assessing knowledge in managing musculoskeletal conditions. This same
examination has been previously been used to assess knowledge in musculoskeletal medicine
among medical students, physician interns and residents, and across a variety of physician
specialties.
Results: Experienced physical therapists had higher levels of knowledge in managing
musculoskeletal conditions than medical students, physician interns and residents, and all physician
specialists except for orthopaedists. Physical therapist students enrolled in doctoral degree
educational programs achieved significantly higher scores than their peers enrolled in master's
degree programs. Furthermore, experienced physical therapists who were board-certified in
orthopaedic or sports physical therapy achieved significantly higher scores and passing rates than
their non board-certified colleagues.
Conclusion: The results of this study may have implications for health and public policy decisions
regarding the suitability of utilizing physical therapists to provide direct access care for patients with
musculoskeletal conditions.
Published: 17 June 2005
BMC Musculoskeletal Disorders 2005, 6:32 doi:10.1186/1471-2474-6-32
Received: 22 November 2004
Accepted: 17 June 2005
This article is available from: http://www.biomedcentral.com/1471-2474/6/32
© 2005 Childs et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0
),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
BMC Musculoskeletal Disorders 2005, 6:32 http://www.biomedcentral.com/1471-2474/6/32
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Background
Musculoskeletal conditions account for roughly 25% of
patient complaints in the primary care setting[1]. How-
ever, physicians have been shown to lack confidence in
their evaluation and treatment skills of these patients [2-
6]. Although its de-emphasis in medical school curricula
has been repeatedly implicated,[1,5,7-9] almost half of
American medical schools still do not require any formal
training in musculoskeletal medicine[10]. This lack of
confidence is reflected by poor performance on formal
assessments of knowledge in musculoskeletal medi-
cine[7] and less than optimal practice patterns for patients
with musculoskeletal conditions[11]. Freedman and
Bernstein[7] assessed knowledge in musculoskeletal med-
icine among 85 physicians during their first week of their
internship following graduation from medical school
using a standardized examination. The mean score was
just under 60%, with only 18% of physicians scoring
above a level determined orthopaedic program directors
as the minimum threshold necessary to establish compe-
tency in musculoskeletal medicine in the primary care set-
ting[7]. Matzkin et al[12] recently demonstrated similar
suboptimal levels of knowledge in musculoskeletal medi-
cine among medical students and residents. Except for
orthopaedists, they also found that experienced physi-
cians across a variety of specialties demonstrated less than
adequate knowledge related to musculoskeletal medicine.
The authors concluded that training in both medical
school and non-orthopaedic residency training programs
was inadequate, a sentiment that has been echoed
elsewhere[13].
Considerable evidence supports the benefits of early
access to physical therapy care [14-18]. In particular, phys-
ical therapists increasingly provide their services without
physician referral (ie, direct access). Seventy percent of the
public reports they would seek care from a physical thera-
pist without physician referral for musculoskeletal condi-
tions, [19] with 39 states having passed legislation
supporting this mode of healthcare delivery [20]. Multiple
studies have demonstrated that physical therapists can
provide safe and cost-effective care for patients with mus-
culoskeletal conditions in direct access practice settings,
supporting the expansion of direct access physical therapy
services [21-26]. For example, physician referral episodes
of care reportedly increased physical therapy claims by
67%, office visits by 60%, and costs by 123% than when
patients directly accessed physical therapy without physi-
cian referral[24].
Despite the curricular emphasis placed on the manage-
ment of musculoskeletal conditions in physical therapy
programs, to date few studies have described physical
therapists' knowledge of the skills necessary to manage
these patients in a direct access setting. A musculoskeletal
written examination has been developed and validated for
this purpose[7,27]. The examination has been adminis-
tered to physician interns,[7] medical students and resi-
dents,[12] and a variety of physician specialists,[12]
making it a pragmatic reference standard for the initial
assessment of knowledge in managing musculoskeletal
conditions among physical therapist students and
licensed physical therapists. Therefore, the purpose of this
study was to describe physical therapists' knowledge in
managing musculoskeletal conditions using this examina-
tion. These data combined with clinical studies demon-
strating the benefits of direct access physical therapy [21-
26] may further clarify the role of physical therapists in
direct access environments.
Methods
We used a cross-sectional design to describe knowledge in
managing musculoskeletal conditions among physical
therapist students and licensed physical therapists in the
uniformed services. The study was approved by the Insti-
tutional Review Boards at Wilford Hall Medical Center in
San Antonio, TX and at Texas Tech University in Lubbock,
TX before subject recruitment and data collection began.
All subjects provided informed consent prior to
participation.
Based on an a priori sample size estimation, a total of 26
first-professional physical therapy programs accredited by
the Commission for Accreditation of Physical Therapy
Education were randomly selected for participation. Edu-
cational programs are rapidly transitioning to doctoral
programs, with approximately 80% of programs having
completed the transition to the Doctor of Physical Ther-
apy degree or in the transitioning process at the time of
the study [28]. Therefore, randomization was blocked by
the degree to be conferred upon graduation: master's (n =
13) vs. doctoral (n = 13) to permit comparisons based on
degree status. Program directors were contacted initially
by email to inform them of their program's selection,
describe the study procedures, and invite the program's
participation. Students in these programs were in the ter-
minal phase of their program's curriculum, defined as
having completed substantial portions of the didactic cur-
riculum and clinical affiliations. All licensed physical ther-
apists in the four uniformed health services (U.S. Air
Force, U.S. Army, U.S. Navy, and U.S. Public Health Serv-
ice) with at least one year of clinical experience were also
invited to participate.
Participants completed the identical examination origi-
nally developed by Freedman and Bernstein to assess
knowledge in musculoskeletal medicine among physician
interns, [7] and more recently administered to medical
students, residents, and a variety of physician specialists
[12]. The examination consists of 25 open-ended
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questions that were selected based on commonly encoun-
tered musculoskeletal diagnoses encountered in the pri-
mary care setting (ie, fractures and dislocations, low back
pain, sciatica, and arthritis) and consideration of ortho-
paedic emergencies that warrant immediate referral to an
orthopaedic surgeon or the emergency department (ie,
compartment syndrome, hip dislocation, etc.) [7]. Addi-
tional details related to the development and validation of
the examination are reported elsewhere [7,27].
The examination was administered in a web-based format
using Web Surveyor, version 3.6 (Web Surveyor Corpora-
tion, Herndon, VA). No time limit was imposed to be con-
sistent with previous methodology [7,12]. Subject
confidentiality was strictly maintained through assign-
ment of a unique computer-generated code. Administra-
tion of the examination was preceded by a brief
demographic survey that queried patients as to their edu-
cational background, board-certification status (Ortho-
paedic and/or Sports Clinical Specialist designation via
the American Board of Physical Therapy Specialties),
experience in different practice settings, and familiarity
with the studies by Freedman and Bernstein [7,27]. Data
from any therapists familiar with the studies by Freedman
and Bernstein [7,27] were excluded from analysis because
the examination questions and answer key were pub-
lished verbatim in these manuscripts.
Educational programs were requested to have participants
complete the study in a group setting with a proctor
present (eg, a computer lab) when possible. This would
insure that participants did not use any outside resources
(ie, textbooks, information available on the internet, per-
sonal communication, etc.) to assist them in answering
the questions. To maximize participation, however, pro-
grams were alternatively given the option to have partici-
pants complete the study on their own if a computer lab
or similar arrangement was unavailable, or if a participant
was not available at the designated time. Licensed physi-
cal therapists were also asked to complete the study in a
proctored setting. All participants were queried at the end
of the study as to whether they used any outside resources
to assist them in the completion of the examination. The
results of the demographic survey and content of the
examination were stored in a secure, password-protected
centralized database for subsequent analysis.
Data analysis
A total of 6 judges, blinded to the demographic survey
results and whether the participant was a physical thera-
pist student or licensed physical therapist scored blocks of
4–6 questions, resulting in each question being scored by
two raters. Judges were physical therapist faculty with con-
siderable experience in providing direct access care for
patients with musculoskeletal conditions. Each rater was
also trained in the scoring procedures by one of the inves-
tigators. An overall score and passing rate were deter-
mined using identical procedures as those described by
Freedman and Bernstein,[7] however a brief review is pro-
vided here. Each question was assigned a maximum pos-
sible of 1 point. Partial credit was assigned based on the
criteria for partial credit outlined in the answer key [7].
Scores were not penalized for incorrect spelling. Sums of
individual scores represented the overall score, which was
multiplied by 4 to obtain a percentage score. Inter-rater
reliability of the overall score was examined using the
intraclass correlation coefficient (ICC), equation 3,1 [29].
The ICC and associated 95% confidence interval was 0.91
(0.89, 0.92). Given a sufficiently high reliability coeffi-
cient, only data from the first rater were used in the anal-
ysis. Using the results from a single rater is also consistent
with the procedures utilized by Freedman and Bernstein
[7]. Participants were judged to have passed the examina-
tion if their score exceeded the previously established
threshold of 73.1% [7].
Descriptive statistics, including frequency counts for cate-
gorical variables and measures of central tendency and
dispersion for continuous variables were calculated to
summarize the data using SPSS for Windows 11.0.1 (Chi-
cago, IL). Independent sample t-tests were used to directly
compare differences in knowledge between educational
programs conferring the doctoral versus master's degree
and between licensed physical therapists who were board-
certified and those who were not. Differences in the pass-
ing rates among the physical therapist subgroups were
examined using the Pearson chi-square statistic. The
alpha-level was established a priori to be 0.05 utilizing a
two-tailed test.
Results
174 physical therapist students across 12 out of the 26
(46%) randomly selected programs volunteered and com-
pleted the study, representing 52% of students within
these programs. The mean age of physical therapist stu-
dent participants was 26.7 (3.3) (range = 22–40). Ninety-
two percent of physical therapist student participants (n =
160) completed the study in a proctored setting. 63.8% of
physical therapist students (n = 111) were enrolled in doc-
toral degree programs. 182 licensed physical therapists in
the uniformed services completed the study, representing
44% of uniformed physical therapists. The mean age of
the licensed physical therapist participants was 37.7 (6.7)
(range = 25–55). The average years of experience was 8.7
(6.3) (range = 1–30) and 28.6% (n = 52) of licensed phys-
ical therapists were board-certified.
No participant reported having received assistance to
complete the examination. One licensed physical thera-
pist reported being familiar with the Freedman and
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Bernstein studies, [7,27] thus these data were removed
from the analysis. No differences in performance on the
examination were observed between participants who
completed the examination in a proctored versus an un-
proctored setting (p = 0.465). Therefore, all responses
were included in the analyses.
Overall scores among the physical therapist students and
licensed physical therapists are reported in Figure 1. We
did not directly compare the results between physical
therapists and physicians using inferential statistics
because the data from these groups were derived from
unrelated studies. However, the identical examination
and similar procedures were used in these studies, thus it
is reasonable to discuss our findings in relation to the pre-
vious data among physicians. To facilitate this discussion,
we superimpose the overall scores among the different
physician subgroups with those of the different physical
therapist subgroups. This provides a frame of reference for
visualizing possible differences in knowledge related to
managing musculoskeletal conditions between physical
therapists and physicians (Figure 1).
Licensed physical therapists (n = 182) achieved an average
score of 75.9%, with an overall passing rate of 67%.
Licensed physical therapists who were board-certified
achieved significantly higher scores and passing rates than
their non board-certified colleagues (Table 2). Physical
therapist students (n = 174) achieved an average score of
66.2%, with an overall passing rate of 24%, versus a 19%
Overall scores on the musculoskeletal knowledge examination among physical therapist students, licensed physical therapists, and previous data using the same examination among physiciansFigure 1
Overall scores on the musculoskeletal knowledge examination among physical therapist students, licensed physical therapists,
and previous data using the same examination among physicians. All physician-related data was derived from Matzkin et al,[12]
except data for the subgroup of physician interns, which was derived from Freedman and Bernstein[7]. PT = physical therapist,
Phys = physician, OCS = Orthopaedic Clinical Specialist, SCS = Sports Clinical Specialist, DPT = doctoral physical therapy pro-
gram, MPT = master's physical therapy program, Ortho = orthopaedics, Other = anesthesia, emergency medicine. ophthalmol-
ogy, radiology, and transitional, FP = family practice, GS = general surgery, Res = Resident, Peds = Pediatrics, Med = internal
medicine, Med stu = medical student, OB = obstetrics-gynecology, and Psy = psychiatry
94
81
74
68
64
61
60
59
58
58
54
49
48
35
0
10
20
30
40
50
60
70
80
90
100
P
h
ys (O
r
t
ho
)
PT (OCS/S
C
S)
P
T(
no OC
S
/
SC
S)
PT stu
d
e
n
ts (
DPT)
PT students (Masters)
P
h
ys (
F
P
)
Phys (Intern
s
)
P
hys (GS)
P
h
ys (Re
s)
Phys (Peds)
P
hys (
Me
d)
P
h
ys (Me
d
stu)
Phys (OB)
P
h
ys (
Psy)
Overall score
%
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passing rate among physician interns [7]. Physical
therapist students enrolled in programs conferring the
doctoral degree achieved significantly higher scores than
students enrolled in programs conferring the master's
degree, although passing rates were statistically similar
(Table 1).
Discussion
Physicians assessed in the study by Freedman and Bern-
stein had just begun their internship year, [7] and Matzkin
et al [12] reported data from medical students, residents,
and a variety of physician specialists. Given the spectrum
of physician experience levels and specialties represented
in previous studies, [7,12] these data offer a compelling
reference standard for at least a preliminary discussion
related to the preparation of physical therapists versus
physicians with respect to managing musculoskeletal con-
ditions. It also seems reasonable to make preliminary gen-
eral observations about possible differences between
physical therapists and physicians since we used the iden-
tical examination and administered the examination
using similar procedures as those used in the previous
studies [7,12].
Figure 1 reveals that both physical therapist students and
licensed physical therapists tended to have higher levels of
knowledge in managing musculoskeletal conditions than
medical students, physician interns and residents, and all
physician specialists except for orthopaedists. This trend
may seem somewhat intuitive since topics related to man-
aging musculoskeletal conditions are emphasized in
physical therapy curricula. However, data were previously
lacking to support this contention. It is important to con-
sider that the physician data were derived from unrelated
studies, [7,12] thus we discuss our results in general terms
in relation to the previous studies among physicians
[7,12]. The implication that physical therapists have
higher levels of knowledge in managing musculoskeletal
conditions than physicians provide impetus for further
prospective research in this area.
It could be argued that performance among physical ther-
apist students remains suboptimal, supported by the fact
that physical therapist students overall achieved an aver-
age score of 66.2%. However, the average score among
medical students and interns (the most comparable phy-
sician group) was 49% [12] and 60%, [7] respectively.
One of the primary curricular areas more heavily empha-
sized in doctoral physical therapy educational programs is
the differential diagnosis of these conditions, a profi-
ciency necessary for competence in more autonomous
practice settings such as primary care [30]. Although pass-
ing rates were statistically similar, overall scores among
physical therapists enrolled in doctoral programs was sig-
nificantly higher than for master's programs (Table 1).
These data provide preliminary evidence that an increased
focus on the diagnosis of commonly encountered muscu-
loskeletal conditions and orthopaedic emergencies is
occurring in the curricula of doctoral physical therapy
programs. However, a threshold of 73.1% was established
by orthopaedic program directors as a minimum level of
knowledge necessary for competency in musculoskeletal
medicine. Given similar passing rates, and in light of
increasing availability of direct access care for patients
with musculoskeletal conditions, orthopaedic curricula
among doctoral physical therapy programs should con-
tinue to be enhanced.
Both physicians and physical therapists are at a relative
early juncture in their clinical education upon graduation
Table 1: Performance on the musculoskeletal knowledge examination between physical therapists enrolled in a program that confers
a master's vs. a doctoral degree. (Participants were judged to have passed if their score exceeded 73.1%[7].)
Degree Status (n = 174) Master's (n = 63) (95% CI) Doctoral (n = 111) (95% CI) p-value
Overall score 63.6 (60.6, 66.6) 67.6 (65.6, 69.6) .022
Passing rate (Overall score >.731) .21 (.11, .31) .26 (.18, .34) .416
Table 2: Performance on the musculoskeletal knowledge examination based on board-certification status. (Participants were judged
to have passed if their score exceeded 73.1%[7].)
Board-certification (OCS and/or SCS) (n = 182) Yes (n = 52) (95% CI) No (n = 130) (95% CI) p-value
Overall score 81.3 (79.2, 83.4) 73.7 (71.9, 75.5) <.001
Passing rate .88 (.80, .97) .58 (.50, .67) <.001
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from medical school or physical therapy school, thus they
might be expected to have scores below the level estab-
lished by residency program directors. However, the
licensed physical therapists in this study demonstrated
higher levels of knowledge in managing musculoskeletal
conditions than physical therapist students and all physi-
cian subgroups, except for orthopaedists (Figure 1).
Licensed physical therapists achieved an average score of
75.9% and an overall passing rate of 67%. This seems to
be markedly improved compared to the passing rate
amongst all physician subgroups except orthopaedists
[12]. Furthermore, most physicians, and with increasing
frequency physical therapists, receive graduate medical
education in the form of clinical residencies which lead to
board certification. In fact, board certification in ortho-
paedic physical therapy represents the largest area of spe-
cialization by physical therapists [31]. One of the key
findings from this study was that performance among
licensed physical therapists who were board-certified was
significantly better when compared to their non board-
certified colleagues, lending further credibility to the
physical therapist board-certification process, which was
not initiated until the 1980s.
Several limitations should be considered. Similar to med-
ical education, physical therapy educational programs do
not utilize standardized curricula, thus exposure to didac-
tic and clinical education experiences related to the man-
agement of musculoskeletal conditions differs. Physical
therapists with a stronger background in this area may
have achieved higher scores than with less exposure to an
orthopaedic curricula. Content of the examination was
also primarily focused on the differential diagnosis of
commonly encountered musculoskeletal diagnoses in a
primary care setting (ie, fractures and dislocations, low
back pain, sciatica, and arthritis) and orthopaedic emer-
gencies that warrant immediate referral to an orthopaedic
surgeon or the emergency department (ie, compartment
syndrome, hip dislocation, etc.) [7]. Therefore, these data
may not be generalizable to other physical therapy prac-
tice settings. We invited volunteer physical therapist stu-
dents and licensed physical therapists to participate, thus
the potential for selection bias cannot be excluded. How-
ever, physician participants in the study by Matzkin et al
[12] were also volunteers, posing a similar limitation that
likely mitigates any potential bias in discussing our results
in relation to this study. Furthermore, although the exam-
ination in the Freedman and Bernstein study [7] was
apparently completed by all physicians in the intern class,
the examination was only administered to one class [7].
The fact that physical therapist students from a wide vari-
ety of programs and licensed physical therapists in geo-
graphical locations throughout the country participated
in this study increases the generalizability of the findings.
Future research could be performed to determine if the
results demonstrated among licensed physical therapists
in the uniformed services who participated in this study
would be similar to the results among a group of civilian
physical therapists.
Conclusion
The results of this study corroborate existing clinical stud-
ies demonstrating that physical therapists can provide safe
and effective care for patients with musculoskeletal condi-
tions in a direct access setting [21-26]. In comparison to
previous studies among physicians, [7,12] physical thera-
pists demonstrated higher levels of knowledge in manag-
ing musculoskeletal conditions than medical students,
physician interns and residents, and most physician spe-
cialists except for orthopaedists. Physical therapist stu-
dents enrolled in educational programs conferring the
doctoral degree achieved higher scores than their peers
enrolled in programs conferring the master's degree. Fur-
thermore, licensed physical therapists who were board-
certified achieved higher scores and passing rates than
their colleagues who were not board-certified. Neverthe-
less, despite the benefits of early access to physical therapy
[14-17] and favorable legislation in most states, [20] the
primary barrier to patients receiving physical therapy serv-
ices without physician referral is that claims are infre-
quently reimbursed by third party payers. Combined with
existing evidence demonstrating that physical therapists
are capable of providing safe and effective care for patients
with musculoskeletal conditions in a direct access setting
at a reduced cost to the healthcare system and employers,
the results of this study may have implications for health
and public policy decisions regarding the care of patients
with musculoskeletal conditions.
Competing interests
None of the authors of this manuscript have any relevant
conflict of interest, financial or otherwise. This study was
supported by a grant from the Sports Physical Therapy
Section of the American Physical Therapy Association,
Inc. The funding organization had no role in the design
and conduct of the study, to include data collection; man-
agement, analysis, or interpretation of the data. The fund-
ing organization was also not involved in the preparation
of this manuscript, nor has it been asked to review and/or
approve this submission.
Authors' contributions
JC designed and coordinated the study, performed the sta-
tistical analysis, and drafted the manuscript. JW assisted
with the study design and drafting of the manuscript. PS
developed the web survey instrument and provided over-
sight for the technical aspects of the survey administra-
tion. MP coordinated with the first-professional programs
and assisted in the data analysis. TF conceived the idea
and assisted with study design and analysis. AD assisted
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BMC Musculoskeletal Disorders 2005, 6:32 http://www.biomedcentral.com/1471-2474/6/32
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with the study design and acted as a liaison to the program
directors. All authors read and approved the final
manuscript.
Disclaimer
The opinions or assertions contained herein are the pri-
vate views of the authors and are not to be construed as
official or as reflecting the views of the U.S. Air Force or
Department of Defense.
Acknowledgements
None
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Pre-publication history
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... Following Freedman and Bernstein study, 11 several medical schools and residencies used the MSD test to evaluate students and physicians. [12][13][14][15] Except for orthopedists, most of these studies found that students or physicians from various specialties had less than adequate knowledge in MSDs. ...
... 18 However, assessment of physical therapists' knowledge in managing MSDs was done in very few studies. 13,14,19 Childs et al showed that physical therapists with orthopedic or sports board certification had higher scores on the MSD test than medical students, interns, residents and most medical specialties except orthopedists. 13,19 In Saudi Arabia, however, physical therapy has not fully evolved into an autonomous practice and is still a secondary care that requires physician referral to manage patients with MSDs. ...
... 13,14,19 Childs et al showed that physical therapists with orthopedic or sports board certification had higher scores on the MSD test than medical students, interns, residents and most medical specialties except orthopedists. 13,19 In Saudi Arabia, however, physical therapy has not fully evolved into an autonomous practice and is still a secondary care that requires physician referral to manage patients with MSDs. 20 Physical therapy programs in Saudi Arabia grant bachelor's degrees (except for two universities), and their curricula do not adequately emphasize the contents of medical screening or differential diagnosis. ...
Article
Full-text available
Background: Musculoskeletal disorders (MSDs) are rapidly rising in Saudi Arabia and considered the 3rd reason for hospital visits across the country. Despite their prevalence, the adequacy of knowledge in diagnosing and treating MSDs has not been assessed. The purpose of this study is to assess MSD knowledge amongst healthcare providers (orthopedists, physicians, and physical therapists) and medical and physical therapy students and interns. Methods: In this cross-sectional study, a web-based 25-question MSD test was given to licensed physical therapists, primary care physicians and orthopedists, as well as final-year physical therapy and medical students and interns in Saudi Arabia. Two multivariable linear regression analysis models were used to determine MSD test score differences amongst (1) orthopedists, primary care physicians, and physical therapists and (2) amongst medical and physical therapy students and interns. Results: A total of 680 participants were included (response rate is 22.7%). The overall MSD test score was 48.2%, and the passing rate was 14%. Model 1 showed that orthopedist's group had a significantly higher mean score on MSD test than physical therapists (t482= 8.12, p < 0.001) and primary care physician (t482= 6.00, p < 0.05). However, primary care physician scores did not significantly differ from physical therapy group (t482= 6.47, p = 0.07). Model 2 showed that medical interns had significantly higher mean score on MSD test than physical therapy students (t240=4.46, p < 0.001), physical therapy interns (t240= 4.7, p < 0.05), and medical students (t240= 2.79, p < 0.05). There was also a significant difference between medical students and physical therapy interns (t240= 2.5, p < 0.05). However, there was no significant difference between medical students and physical therapy students. Conclusion: Except for orthopedists, the MSD knowledge appears inadequate amongst healthcare providers, medical and physical therapy students and interns in Saudi Arabia. To improve knowledge in MSDs, increasing content of MSDs in undergraduate education and postgraduate training is necessary.
... Secondly, Moretti et al. perfectly hit the nail on the head: Child et al. observed higher levels of knowledge in managing MSD than several physicians, except for orthopedic physicians, the medical specialty for MSD [26]. Accordingly, the highly specialized physician plays a key role when patients are referred for advanced management in the secondary care line. ...
... Accordingly, the highly specialized physician plays a key role when patients are referred for advanced management in the secondary care line. Similarly, based on Child et al. the utilization of PTs in primary care and as first contact professionals for minor and mild MSD seem to be suitable, with direct implications for both health and public policy decisions [26]. Accordingly, PTs have also been shown to possess the ability for higher selection accuracy for appropriate orthopedic consultation referral for those patients in need of more specific interventions [6,27]. ...
... Accordingly, PTs have also been shown to possess the ability for higher selection accuracy for appropriate orthopedic consultation referral for those patients in need of more specific interventions [6,27]. Notably, PTs possessing a musculoskeletal specialization were observed to have higher knowledge for the management of MSD than licensed colleagues [26]. Moreover, according to "article 6 of Law 43 of the 1st of February 2006" [28], the musculoskeletal specialization in physical therapy is earned during a two years postgraduate program (namely, a Master degree), which follow international educational standards [29]. ...
... PCPs often lack specialized knowledge about musculoskeletal conditions required to direct their patients to the appropriate early interventions or treatments. 2 PCPs may prescribe addictive opioids, [3][4][5] recommend unnecessary imaging, [6][7][8] or refer patients to orthopedic specialists who may recommend operations that may or may not resolve their condition or, finally, refer them to physical therapy (PT). [9][10][11][12] Each touch point in this pathway is costly and may be unnecessary. ...
... Direct access to PT addresses musculoskeletal conditions by inverting this traditional care pathway so that physical therapists, who are the most cost-effective practitioners with the most specialized knowledge about musculoskeletal health, triage patients on demand. 2 This means that patients expeditiously receive care, which may reduce the immediate use of prescription pain medications and imaging 13 as well as downstream injections and operations for common injuries and chronic conditions. 10,14-17 Digital PT, delivered via mobile applications (apps), is well positioned to provide patients direct access to PT as a workplace health benefit through employers. ...
... Digital PT may also be just as effective at reducing pain and improving function as in-person PT. [18][19][20][21] However, evidence for the effectiveness of digitally delivered musculoskeletal care is limited by small sample sizes 2,22 or relegated to a few conditions where patients are not treated by physical therapists. 2,23 To our knowledge, we are unaware of any studies that evaluate the clinical effectiveness of digital PT controlling for comorbidities, chronicity, and severity of condition and symptoms, which can significantly affect clinical outcomes. ...
Article
Full-text available
Objective To examine the impact of digital physical therapy (PT) delivered by mobile application (app) on reducing pain and improving function for people with a variety of musculoskeletal conditions. Design An observational, longitudinal, retrospective study using survey data collected pre and post-digital PT to estimate multilevel models with random intercepts for patient episodes. Setting Privately-insured employees participating in app-based PT as an employer healthcare benefit. Participants The study sample included 814 participants ages 18 years and older, who completed their digital PT program with reported final clinical outcomes between February 2019 (program launch) through December 2020. Mean age of the sample at baseline was 40.9 years (SD=11.89), 47.5% were female, 21% sought care for lower back pain, 16% for shoulders, 15% for knees and 13% for neck. Interventions Digital PT consisted of a synchronous video evaluation with a physical therapist followed by a course of PT delivered through a mobile app. Main Outcome Measure(s) Pain was measured by the Visual Analogue Scale (VAS) from 0 “no pain” to 10 “worst pain imaginable” and physical function by the Patient Specific Functional Scale (PSFS) on a scale from 0 “completely unable to perform” to 10 “able to perform normally”. Results After controlling for significant demographics, comorbid conditions, adverse symptoms, chronicity and severity, the results from multi-level random intercept models showed decreased pain (-2.69 points, 95% CI -2.86 – -2.53, p<0.001) and increased physical function (+2.67 points, 95% CI 2.45 – 2.89, p<0.001) after treatment. Conclusion(s) Digital PT was associated with clinically meaningful improvements in pain and function among a diverse set of participants. This early data is an encouraging indicator of the clinical benefit of digital PT.
... Physical therapists have repeatedly demonstrated their competency in musculoskeletal management compared to primary care physicians [17][18][19][20]. Physical therapists who directly refer for imaging are more compliant with evidence-based imaging guidelines than their primary care counterparts, thereby reducing diagnostic imaging utilization [4,[21][22][23][24][25][26][27][28][29][30][31][32]. ...
... ABPTS board-certified physical therapists were similarly found to routinely perform more imaging skills than those who were not ABPTS board certified. This is consistent with studies which found ABPTS board-certified physical therapists to have superior clinical competence [18,19]. Similar to those with residency or fellowship training, ABPTS board-certified physical therapists are more likely to practice advanced or contemporary treatment techniques, and have demonstrated greater diagnostic accuracy and clinical efficiency [66,68,70]. ...
Article
Objectives: To explore if physical therapists are practicing skills necessary to refer patients for musculoskeletal imaging. Methods: An expert panel established a list of nine requisite skills to refer for musculoskeletal imaging. A blinded expert panel validated the list using a 5-point Likert scale. The skills list was examined via an electronic survey distributed to United States physical therapists. Results: 4,796 respondents were included. Each of the nine skills were routinely performed by a majority of the respondents (range: 54.52-94.72%). Respondents routinely performed 6.95 (± 0.06) skills, with 67.41% routinely performing seven or more skills. Doctors of physical therapy routinely performed more imaging skills (7.15 ± 0.06) compared to their masters- (6.44 ± 0.19) and bachelors-trained (5.95 ± 0.21) counterparts (p < 0.001). Residency/fellowship-trained physical therapists were more likely to routinely perform more imaging skills (7.60 ± 0.11 vs. 6.79 ± 0.07, p < 0.001). Imaging skill performance was greater among board-certified physical therapists (7.39 ± 0.09 vs. 6.71 ± 0.08, p < 0.001) and APTA members (7.06 ± 0.07 vs. 6.65 ± 0.12, p < 0.001). Conclusion: Physical therapists are routinely practicing the requisite imaging skills to directly refer to a radiologist for musculoskeletal imaging. Keywords: Medical imaging; certification; educational status; nonmedical residency; patient education; referral and consultation; triage.
... Physiotherapists are health professionals who play an important role in restoring the mobility and functionality in people with physical impairments, thereby contributing to their independence and improving their quality of life [1]. Currently, the paradigm toward evidence-based practice (EBP) has been accepted as the best model to provide successful outcomes in the rehabilitation of various injuries and diseases, highlighting its use in clinical decision-making processes to develop optimal solutions [2]. ...
... 5,6 CBD are often multifactorial, including functional disabilities and psychological issues. 7 Physical Therapists (PTs), whose specialized knowledge of musculoskeletal conditions may exceed that of most physicians (with the exception of orthopedic surgeons), 8 have much to offer for improving appropriateness and effectiveness of CBD care. One example is that PTs have been shown to improve musculoskeletal management via triage, and spinal triage can in turn improve orthopedic surgery wait lists. ...
Article
Introduction: Virtual care using videoconference links between urban-based physical therapists and nurse practitioners in rural primary care may overcome access challenges and enhance care for rural and remote residents with chronic low back disorders (CBD). The purpose of this study was to evaluate the concordance of this new model of care with two traditional models. Methods: In this cross-sectional study design, each of 27 participants with CBD were assessed by: 1) a team of a nurse practitioner (NP) located with a patient, joined by a physical therapist (PT) using videoconferencing (NP/PTteam); 2) in-person PT (PTalone); and 3) in-person NP (NPalone). Diagnostic and management concordance between the three groups were assessed with percent agreement and kappa. Results: Overall diagnostic categorization was compared for PTalone versus NPalone and NP/PTteam: percent agreement was 77.8% (k = 0.474, p = 0.001) and 74.1% (k = 0.359, p = 0.004), respectively. In terms of management recommendations, the PTalone and NPalone demonstrated strong agreement on "need for urgent surgical referral" (92.6%, k = 0.649 (p < 0.00) and slight agreement for "refer to primary physician for pharmacology, lab or imaging" (81.5%, k = 0.372 (p = 0.013). The PTalone and NP/PTteam demonstrated strong agreement on "need for urgent surgical referral" (96.3%, k = 0.649, p = 0.000) and "recommendation for PT follow up" (88.9%, k = 0.664, p = 0.000). Discussion: The diagnostic categorization and management recommendations of the team using videoconferencing for CBD were similar to decisions made by an in-person PT. This model of care may provide a method for enhancing access to PT for CBD assessment and initial management in underserved areas.
... For example, ophthalmologists, dieticians, and pharmacists authored pages on musculoskeletal conditions such as back pain. Previous research has identified physical therapists as having musculoskeletal knowledge on par with that of orthopedists and exceeding that of other physician specialties (Childs et al., 2005), yet no physical therapists were identified as either authors or editors in pages we reviewed. ...
Article
Background Highly trafficked health websites are major sources of information, but the quality of their musculoskeletal information has not been thoroughly evaluated or their authorship characterized. Objectives To review information about common musculoskeletal conditions on highly trafficked websites and characterize their credibility, authorship, accuracy of information (as compared to treatment guidelines), and consistency with best practice recommendations. Design Systematic review. Methods We reviewed the top 15 most highly trafficked health websites, identified by web traffic data. Information about 7 common musculoskeletal conditions was identified and data extracted. Credibility was assessed using the Trust It or Trash It? tool, author backgrounds were identified, accuracy was determined by comparing webpage treatment recommendations to guidelines or systematic reviews, and consistency with best practice recommendations was assessed. Results Of 1760 webpages screened, 87 were reviewed. Less than half (44.8%, 39/87) had appropriate sources listed, but 65.5% (57/87) were updated in the previous 5 years. Journalists authored most webpages (55.2%, 48/87). Physician involvement was mostly editorial, and they often lacked expertise in musculoskeletal conditions. Information accuracy was concordant with guidelines for 49.4% (43/87) of webpages, but varied by condition. About half of best practice recommendations were followed (49.1%, 427/870). Pages were unlikely to mention psychosocial factors (16.1%, 14/87), limitations of imaging (18.4%, 16/87), or staying at work (4.6%, 4/87). Conclusions Popular health websites scored poorly for credibility, accuracy, and consistency with best practice recommendations for musculoskeletal conditions. Authorship, bias, and unsupported information are potential sources of inaccuracies that should be addressed in future by these websites.
... Moreover, the authors committed a misinterpretation by claiming a "higher level of confidence and appropriateness of physical therapists in the management of MSKD than physicians". Indeed, Childs et al. [6] (cited by Maselli et al.) reported that the level of knowledge of physiotherapists was still lower than that of orthopedists, the only category of medical specialists with expertise in MSKD included in the study. ...
Article
Full-text available
Purpose To systematically review the literature on effectiveness of remote physiotherapeutic e-Health interventions on pain in patients with musculoskeletal disorders. Materials and methods Using online data sources PubMed, Embase, and Cochrane in adults with musculoskeletal disorders with a pain-related complaint. Remote physiotherapeutic e-Health interventions were analysed. Control interventions were not specified. Outcomes on effect of remote e-Health interventions in terms of pain intensity. Results From 11,811 studies identified, 27 studies were included. There is limited evidence for the effectiveness for remote e-Health for patients with back pain based on five articles. Twelve articles studied chronic pain and the effectiveness was dependent on the control group and involvement of healthcare providers. In patients with osteoarthritis (five articles), total knee surgery (two articles), and knee pain (three articles) no significant effects were found for remote e-Health compared to control groups. Conclusions There is limited evidence for the effectiveness of remote physiotherapeutic e-Health interventions to decrease pain intensity in patients with back pain. There is some evidence for effectiveness of remote e-Health in patients with chronic pain. For patients with osteoarthritis, after total knee surgery and knee pain, there appears to be no effect of e-Health when solely looking at reduction of pain. • Implications for rehabilitation • This review shows that e-Health can be an effective way of reducing pain in some populations. • Remote physiotherapeutic e-Health interventions may decrease pain intensity in patients with back pain. • Autonomous e-Health is more effective than no treatment in patients with chronic pain. • There is no effect of e-Health in reduction of pain for patients with osteoarthritis, after total knee surgery and knee pain.
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Objectives: In 2000, the American PT Association (APTA) published its Vision statement advocating for DA (DA) to PT. This narrative review of the literature aims to identify the current state of DA in the United States (US) and compare that status to the US Military. Methods: Initial PubMed search in the English language with keywords physical therapy (PT), physiotherapy, DA, self-referral, and primary contact from the year 2000 onwards with subsequent focused searches using keywords DA/self-referral/primary contact of physical therapists/physiotherapists on outcomes/autonomous practice/economic impact/patient satisfaction yielded 103 applicable studies on the topic. This paper excluded 40 international articles to focus on US military and civilian research. Results: Current literature supports Physical Therapists (PTs) in an initial contact role based on patient safety, satisfaction, access to care, efficiency, healthcare utilization, and potential cost savings. Conclusions: Despite its success in the US Military, DA to PT in the US civilians remains limited and incomplete. PTs still await unrestricted DA and privileges associated with autonomous practice including the ability to order imaging and prescribe some medications.
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To evaluate the effectiveness and cost effectiveness of specially trained physiotherapists in the assessment and management of defined referrals to hospital orthopaedic departments. Randomised controlled trial. Orthopaedic outpatient departments in two hospitals. 481 patients with musculoskeletal problems referred for specialist orthopaedic opinion. Initial assessment and management undertaken by post-Fellowship junior orthopaedic surgeons, or by specially trained physiotherapists working in an extended role (orthopaedic physiotherapy specialists). Patient centred measures of pain, functional disability and perceived handicap. A total of 654 patients were eligible to join the trial, 481 (73.6%) gave their consent to be randomised. The two arms (doctor n = 244, physiotherapist n = 237) were similar at baseline. Baseline and follow up questionnaires were completed by 383 patients (79.6%). The mean time to follow up was 5.6 months after randomisation, with similar distributions of intervals to follow up in both arms. The only outcome for which there was a statistically or clinically important difference between arms was in a measure of patient satisfaction, which favoured the physiotherapist arm. A cost minimisation analysis showed no significant differences in direct costs to the patient or NHS primary care costs. Direct hospital costs were lower (p < 0.00001) in the physiotherapist arm (mean cost per patient = 256 Pounds, n = 232), as they were less likely to order radiographs and to refer patients for orthopaedic surgery than were the junior doctors (mean cost per patient in arm = 498 Pounds, n = 238). On the basis of the patient centred outcomes measured in this randomised trial, orthopaedic physiotherapy specialists are as effective as post-Fellowship junior staff and clinical assistant orthopaedic surgeons in the initial assessment and management of new referrals to outpatient orthopaedic departments, and generate lower initial direct hospital costs.
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We studied the process and outcomes of physical therapist management of 107 patients with low back pain at a walk-in clinic. Sixty-seven patients with low back pain concurrently were assigned randomly to internists at the clinic. Physicians and physical therapists recorded baseline clinical data and management plans on standard check lists. Physical therapists used a validated algorithm that directed diagnostic evaluations and physician consultations, but all other physical therapist treatment decisions were unconstrained. Patients in the physical therapist and physician groups did not differ significantly. Physical therapists referred more patients to the physical therapy department than did physicians but recommended muscle relaxants, prescription analgesics, and bed rest less frequently. The occurrence of new symptoms, duration of symptoms, and duration of activity limitations were similar between the physician and physical therapy patient groups at a one-month follow-up examination. Physical therapist-managed patients expressed greater satisfaction than physician-managed patients with several aspects of their care. The percentage of functional improvement for highly dysfunctional patients was significantly greater for the physical therapist-managed patients than for the physician-managed patients. The implications of a physical therapist first-contact care program for health service organizations, health care policy, physical therapist training, and credentialing are discussed.
Objectives: To assess the effectiveness of pediatric residency training as preparation for primary care and make recommendations for improving residency training. Method: Two surveys were sent to graduates of the pediatric residency at the University of Colorado from 1984 to 1991. The first survey requested information about practice patterns and ratings of preparedness in 45 areas important for primary care. The second survey requested ratings of importance for increasing training time in 25 areas judged as inadequate in the first survey. Results: Of 147 surveys mailed, 103 graduates responded and rated themselves as less than adequately trained in 25 of 45 areas selected for relevance to primary care. Graduates of the primary care track rated themselves as significantly better trained than graduates of non-primary care tracks in 10 of 45 areas; nonprimary care graduates had higher ratings in 2 of 45 areas. The second survey (completed by 70 of the 103 initial responders) indicated that the top 5 areas needing increased time in residency training were, in descending order, orthopedics, developmental and behavioral problems, learning disability, attention-deficit hyperactivity disorder, and school difficulty. Graduates of the primary care track rated themselves as adequately trained in developmental and behavioral problems and attention-deficit hyperactivity disorder, but they and nonprimary care graduates felt inadequately prepared in the other 3 areas. Conclusion: Implications of these results change with different content areas, suggesting the need to improve training for all residents in some areas and extending to all residents some of the curriculum already implemented in the primary care track.Arch Pediatr Adolesc Med. 1997;151:78-83
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This study described the physical therapy referral of workers compensated for back injury; characterized physical therapy by duration and choice of therapeutic techniques; and compared workers who were and were not referred for physical therapy in terms of age, gender, diagnosis, and absence from work. A cohort of 2,147 subjects were randomly selected from 54,401 workers compensated for back injuries in 1988. Each subject was followed for 2 years from date of entry into the study. Data were obtained from the Quebec Worker's Compensation Board computerized files, medical files, and initial reports completed by physical therapists. Of the cohort, 389 subjects (18%) had received physical therapy after referral by their physician. Exercise, heat, ultrasound, back education, manipulation, and transcutaneous electrical nerve stimulation were the most frequently selected treatments. Implementation of physical therapy within 1 month of back injury had a strong protective effect on return to work within 60 days. Female gender and presence of a specific diagnosis were predictors for greater than 60 days' absence. This study demonstrated that physicians request physical therapy services based on certain patient characteristics. Patients who were referred earlier tended to return to work sooner than those who were referred later, which indicates that timing of physical therapy is an important factor in the rehabilitation of workers with low back pain.