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A Description of Physical Therapists’ Knowledge in Managing Musculoskeletal Conditions

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BMC Musculoskeletal Disorders
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Abstract and Figures

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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... Our study reported that 94.8% of the clinicians referred patients to physiotherapy, which is little lesser than other studies, however our study could not cover the detail of the referral system, which is one of the limitations of the study. 9 Our study has found that among the clinical doctors surveyed, physiotherapy in orthopaedic conditions has the maximum awareness (94.8%).The result is similar with the study by Childs et al (2005) which reported that GP's (general practitioner) consider physiotherapy to have a major role in the management of musculoskeletal conditions, and have a high opinion of the profession. 10,11 The fact that general practitioners recognize physiotherapy as competent practitioners for the management of musculoskeletal problems is well documented. ...
... 9 Our study has found that among the clinical doctors surveyed, physiotherapy in orthopaedic conditions has the maximum awareness (94.8%).The result is similar with the study by Childs et al (2005) which reported that GP's (general practitioner) consider physiotherapy to have a major role in the management of musculoskeletal conditions, and have a high opinion of the profession. 10,11 The fact that general practitioners recognize physiotherapy as competent practitioners for the management of musculoskeletal problems is well documented. 11,12,13 A key challenge facing physiotherapists in Nepal is low general awareness of the profession. ...
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Introduction: Physiotherapy as a profession has come a long way over the years. As the treatment of injuries and illness has developed over the decades, the practice has evolved and grown from general forms of physical therapies to specialized physiotherapy services in healthcare settings. Despite the recognition and advances gained worldwide in physiotherapy, yet there is lack of research study in Nepal to evaluate the awareness of physiotherapy among clinical doctors of Nepal. Objective of this study is to investigate the awareness of physiotherapy among clinical doctors working in various hospitals of Nepal. Methods: A cross sectional survey was conducted among the clinical doctors working in various hospitals of Nepal. A questionnaire was randomly distributed among 200 doctors. It comprised of 13 questions related to physiotherapy awareness. Data were collected and statistically analyzed. Results: Among 115 respondents, 98.3% were aware of physiotherapy and 87.8 % of the doctors reported to have physiotherapy services in their hospital. Referral to physiotherapy was found to be 94.8 %. With respect to referrals to physiotherapy in preoperative cases, it was found that 63% of the clinical doctors agreed to refer their patients to physiotherapists. The study also found that 93% of the clinical doctors agreed to refer their patients to physiotherapy post-operatively. Referrals to ICU were agreed by 88% of the doctors involved in this study. Among the clinical doctors surveyed physiotherapy in orthopedic conditions has the maximum awareness (94.8%). The study found that a very small percent of the clinical doctors knew about physiotherapy education in Nepal (39.1%) and Nepal Physiotherapy Association (NEPTA) (33%). Conclusions: The study concluded that the clinical doctors had a good awareness about physiotherapy profession. But awareness needs to be accelerated in terms of referrals and specialized services provided by the physiotherapists for potential benefits of the patients. Physiotherapists as a part of the health care team plays an essential role in reducing the hospital stay, quick recovery and in rehabilitation for a better quality life.
... The results of the current study also highlight the need for additional, specialized training on how to make keep/refer decisions and in recognizing the presence of serious pathology for registered Austrian physiotherapists. Previous studies have already demonstrated that supplementary in-depth red flag training is effective in improving the ability of physiotherapists to make accurate keep/refer decisions and recognise the presence of serious pathology [42][43][44]. In addition, study participants from CR Budtz, H Rønn-Smidt, JNL Thomsen, RP Hansen and DH Christiansen [41] indicated that feedback from doctors, to whom they had referred patients back for further evaluation, could help them to further develop their differential diagnostic skills. ...
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Background Serious pathology masking as musculoskeletal conditions is rare, still it is pertinent that physiotherapists can recognise it. This ability has been investigated internationally, however the decision-making skills of registered Austrian physiotherapists has not been examined. The aim of this study was to assess the ability of registered Austrian physiotherapists to make accurate keep-refer decisions based on clinical vignettes. Methods In this national survey registered Austrian (self-)employed physiotherapists were recruited and completed 12 clinical vignettes. Correctly answered vignettes were listed as percentages. Results 479 physiotherapists participated in the study. The response rate of the self-employed physiotherapists was 8.0%. On average participants classified 70.5% of the musculoskeletal cases, 79.4% of the non-critical medical cases, and 53.3% of the critical medical cases correctly. Conclusion This study suggests that, despite the limitations of using written clinical vignettes, registered Austrian physiotherapists welcome additional training to improve their skills in identifying serious pathology. Targeted training and educational programs including new and more detailed educational clinical vignettes relevant for non-direct access countries are needed to enhance physiotherapists’ diagnostic skills and decision-making processes.
... While no previous studies investigated the con dence of PTs in primary care, numerous studies explored their ability to conduct orthopedic differential diagnoses and recognize red ags [40][41][42]. Some studies compared PTs with other healthcare professionals [43,44]. ...
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Background Low back pain (LBP) is a common musculoskeletal disorder with distinct clinical features. Direct access to physiotherapy (PT), with PTs acting as primary care providers, can improve the management of individuals with LBP. However, the success of these treatments is related to clinician confidence. The objectives of this study were to develop the Primary Care Confidence Scale (PCCS) and to describe the confidence of PTs in treating LBP in primary care. Methods The PCCS questionnaire was developed through a seven-stage Delphi process involving experts who modified an existing self-confidence scale. The questionnaire was completed by 314 PTs, 140 of whom completed it again after 2 weeks. Structural validity was evaluated using exploratory and confirmatory factor analysis. Reliability was assessed with Cronbach’s alpha for internal consistency and intraclass correlation coefficients (ICC) for test-retest reliability. Spearman tests assessed correlations between background characteristics and PCCS scores. Two independent t-tests estimated the effects of gender and post-graduate education. One-way ANOVA was used to evaluate the impact of the workplace. Results The PCCS had a multidimensional structure with three factors demonstrating an acceptable model fit and good reliability (α = 0.83, ICC = 0.78). The mean level of confidence was 75% (PCCS = 45 ± 6/60), with moderate positive correlations between age and years of experience (r = 0.33) and PCCS scores (r = 0.42, p < 0.001( for both. PTs working in public or private outpatient clinics had significantly higher scores (PCCS = 45.3 and 47.0, respectively) compared to PTs working in an inpatient hospital or in rehabilitation centers (PCCS = 40.6 and 40.3, respectively, p < 0.009). Conclusions The newly developed PCCS demonstrated adequate validity and high reliability, suggesting that it is suitable for measuring confidence in treating patients with LBP in primary care settings. PTs showed similar confidence levels to other healthcare professionals treating patients in primary care, which could support direct access to PT. Health policy makers and educators could incorporate the PCCS into training and evaluation programs to assess the readiness and competence of clinicians to treat LBP in primary care.
... Another study found that physical therapists with 20 years or more of clinical experience were 3.98 (95% CI 1.03, 15.4) times more likely to correctly refer a patient who had no improvement in symptoms after 30 days of conservative treatment compared to clinicians with less than 10 years of experience 16 . The multifactorial presentation and the complex integration of signs and symptoms presented in the scenarios could lead to experience years not always being a positive factor in the decision making process 25,26 . Possible strategies to improve the recognition of red flags include expanding the discussion on the topic throughout the undergraduate course by inserting it into specific disciplines, as well as creating continuing education programs so professionals who are outside of college can update their knowledge. ...
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JUSTIFICATIVA E OBJETIVOS: O objetivo da triagem de bandeiras vermelhas é garantir que sinais e sintomas que levantam suspeitas de doenças graves sejam considerados durante a avaliação, auxiliando os fisioterapeutas no seu processo de decisão clínica. Os fisioterapeutas brasileiros são autônomos e podem atuar como profissionais de primeiro contato no manejo de distúrbios musculoesqueléticos, portanto, precisam saber reconhecer, rastrear e encaminhar pacientes com bandeiras vermelhas para melhor manejo terapêutico. Os objetivos deste estudo foram verificar se os fisioterapeutas brasileiros conseguem reconhecer e tratar pacientes que apresentavam bandeiras vermelhas, comparar as habilidades dos profissionais com diferentes níveis de formação acadêmica e experiência clínica e identificar quais fatores podem influenciar os resultados. MÉTODOS: Uma pesquisa transversal e quantitativa foi realizada, coletada através de um questionário online. O público-alvo consistiu em fisioterapeutas brasileiros com experiência clínica no manejo de pacientes com disfunções musculoesqueléticas. Os participantes preencheram dados demográficos e tomaram decisões clínicas com base em seis casos clínicos criados pelos autores, com base na literatura, e revisados por três especialistas. Os dados foram analisados por estatísticas descritivas,pelo teste qui-quadrado de independência e por regressão logística. RESULTADOS: Foram analisadas 384 respostas de fisioterapeutas brasileiros com experiência clínica em disfunções musculoesqueléticas. Os fisioterapeutas brasileiros, em geral, não demonstraram ser capazes de reconhecer e manejar adequadamente os casos clínicos que envolvem bandeiras vermelhas, com 23,2% da amostra realizando manejo adequado para condições médicas, 53,9% para condições de emergência e 61,8% para condições médicas com disfunção musculoesquelética associada. Mais anos de experiência clínica e educação pós-profissional não influenciaram positivamente os resultados. Graus acadêmicos mais elevados (Doutorado) podem influenciar positivamente no manejo de condições médicas não emergenciais. CONCLUSÃO: Fisioterapeutas brasileiros que atuam com pacientes com disfunções musculoesqueléticas apresentam um mau desempenho na identificação de bandeiras vermelhas em casos clínicos hipotéticos.Descritores: Assistência ambulatorial, Atenção primária à Saúde, Diagnóstico diferencial. Encaminhamento e consulta, Tomada de decisões.
... Another study found that physical therapists with 20 years or more of clinical experience were 3.98 (95% CI 1.03, 15.4) times more likely to correctly refer a patient who had no improvement in symptoms after 30 days of conservative treatment compared to clinicians with less than 10 years of experience 16 . The multifactorial presentation and the complex integration of signs and symptoms presented in the scenarios could lead to experience years not always being a positive factor in the decision making process 25,26 . Possible strategies to improve the recognition of red flags include expanding the discussion on the topic throughout the undergraduate course by inserting it into specific disciplines, as well as creating continuing education programs so professionals who are outside of college can update their knowledge. ...
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BACKGROUND AND OBJECTIVES The red flags screening purpose is to ensure that signs and symptoms that raise suspicion of serious diseases are being considered during the assessment, assisting physical therapists in their clinical decision process. Brazilian physical therapists are autonomous and can act as first contact professionals in the management of musculoskeletal disorders, therefore, they need to know how to recognize, screen and refer patients with red flags for better therapeutic management. The objectives of this study were to verify whether Brazilian physical therapists can recognize and manage patients who presented red flags, compare professionals’ skills regarding different academic degree levels and clinical experience and identify which factors can influence the results. METHODS A cross-sectional and quantitative research was conducted, collected from an online questionnaire. The target audience consisted of Brazilian physical therapists who have clinical experience in the management of patients with musculoskeletal disorders. Participants filled demographic data and made clinical decisions based on six clinical cases created by the authors, based on the literature, and reviewed by three experts. Data were analyzed using descriptive statistics, the Chi-square test of independence and logistic regression. RESULTS The study analyzed 384 answers from Brazilian physical therapists with clinical experience in musculoskeletal conditions. Brazilian physical therapists, in general, have not shown to be able to properly recognize and manage the clinical cases involving red flags, with 23.2% of the sample performing appropriate management for medical conditions, 53.9% for emergency conditions and 61.8% for medical conditions with associated musculoskeletal dysfunction. More years of clinical experience and post-professional education did not positively influence the outcomes. Higher academic degrees (Doctorate) can influence positively on the management of non-emergency medical conditions. CONCLUSION Brazilian physical therapists who work with patients with musculoskeletal disorders perform poorly in identifying red flags in hypothetical clinical cases. Keywords: Ambulatory care; Decision making; Differential diagnosis; Primary Health Care; Referral and consultation
... However, it has been shown that doctors lack faith in their abilities to diagnose and treat these patients. Still, only around 50% of American medical schools require specific musculoskeletal therapy training, despite the recurrent accusations that it is underemphasized in medical school curricula 7 . ...
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Aim: To find out the work related musculoskeletal complications experienced by the physical therapists in Pakistan. Methods: This cross sectional study was conducted on 98 physiotherapists. To gather precise data and address challenges, a self-administered questionnaire was created for demographics. A modified version of the Nordic Questionnaire was used and to locate pain or unpleasant feelings in nine different areas of the body, including the neck, shoulders, elbows, wrists, upper back, lumbar, thighs, knees, and ankles. Utilising a non-probability convenient sampling strategy, the sample size was determined. The Lahore hospitals will be asked for written consent. Data will be gathered from various hospitals in Lahore, including Jinnah Hospital and the UOL teaching hospital. Results: 52% reported that they have feeling trouble in neck during last 7 days. 52% have been feeling any trouble in shoulders. 47.9% have been feeling any trouble in upper back. 41.8% have been feeling any trouble in elbows. 41.8% have been feeling any trouble in wrist/ hands. 60.2% have been feeling any trouble in lower back. 29.5% have been feeling any trouble in hips/thighs. 26.5% have been feeling any trouble in knees. 30.6% have been feeling any trouble in ankles/feet. Conclusion:Physical therapists from Pakistan frequently suffered from work-related musculoskeletal conditions, particularly in the neck, shoulders, wrist, and lower back. Keywords: Physiotherapist, Musculoskeletal, Complications
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OBJECTIVE: To determine the test-retest reliability and concurrent validity of the Health Leads Screening Tool. DESIGN: Primary survey data collected between September 2021 and May 2022 with participants who received outpatient orthopedic physical therapy in a public hospital system. Participants completed the Health Leads Screening Tool (HLST) and the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) at 1 physical therapy visit to examine the concurrent validity of the HLST. They completed the HLST again at a follow-up visit to examine its test-retest reliability. METHODS: Paper surveys were used to collect information from participants who were over 18 years of age, spoke and read English or Spanish, and were receiving outpatient orthopedic physical therapy. Fifty-two participants completed the surveys to examine concurrent validity and 50 participants completed the surveys for test-retest reliability. Cohen’s kappa statistics were used to examine agreement. RESULTS: The HLST had excellent test-retest reliability for all 9 domains, with kappa values ranging from 0.91 to 1.00. It had greater than moderate concurrent validity (k>0.6) with the PRAPARE for 6 of 9 domains, including food, utilities, health care, transportation, employment, and mental health. CONCLUSIONS: The Health Leads Screening Tool demonstrated excellent test-retest reliability and moderate concurrent validity for 6 out of 9 domains and, thus, could be a feasible social needs screening tool in outpatient orthopedic physical therapy settings. JOSPT Open 2024;2(4):1-8. Epub 24 May 2024. doi:10.2519/josptopen.2024.1241
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Background The COVID-19 pandemic has highlighted the need to explore alternative methods of health care delivery, including telehealth. Minimal evidence is available regarding telehealth as a diagnostic tool for suspected orthopaedic pathology. Case Presentation A self-referred 66-year-old man presented with left shoulder pain that had been present for 6 weeks. Mechanism of injury included 2 falls 2 weeks apart. His physician diagnosed him with adhesive capsulitis and referred him to a physical therapist near his home. No imaging studies were performed. Initial management did not improve his status, so the patient requested a second opinion. A telehealth evaluation was chosen, as he resides 220 miles away. Live 2-way video conferencing was utilized throughout the evaluation. Visual motion observation noted marked active, but not passive, limitations. Pain in active external rotation was 8/10. Special testing noted positive drop arm test and impairments in external rotation. Outcome and Follow-Up A rotator cuff tear was suspected and the patient was referred for a surgical consultation, with subsequent surgery completed for a full-thickness supraspinatus tear. During follow-up 3 months after surgery, the patient reported that the telehealth visits were very convenient and more effective than prior management. Discussion A telehealth evaluation performed by a physical therapist was able to identify and manage, via referral, an undetected full-thickness rotator cuff tear. JOSPT Cases 2021;1(1):29–33. doi:10.2519/josptcases.2021.9990
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Three cases are reported where patients experienced severe central nervous system adverse effects on high-dose hydromorphone. These effects were rapidly alleviated following a change in therapy to morphine at 20-25% of the usually accepted potency equivalent dose. We recommend caution in using equivalent dose tables when changing opioid therapy in patients receiving high-dose opioid treatment.
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Current conceptions of chronic pain clearly suggest that proper care at the acute stage should prevent the development of chronic problems. Patients (198) seeking help for acute musculoskeletal pain (MSP), e.g., back and neck pain participated in two studies of the effects of an Early Active intervention which underscored 'well' behavior and function compared to a Treatment as usual control group. The quantity of the Early Active treatment was a median of 1 doctor's appointment and 3 meetings with a physical therapist. Study I concerned patients with a prior history of sick-listing for MSP, while study II involved patients with no prior history of MSP. Treatment satisfaction, pain experience, activities and sickness absenteeism were assessed before, after and at a 12-month follow-up. In study I (patients with a history of MSP), the results showed significant improvements for both groups, but virtually no differences between the groups. Similarly, in study II (no history of MSP) both groups demonstrated significant improvements, e.g., for pain intensity and activity levels. However, the Early Active treatment resulted in significantly less sick-listing relative to the control group. Moreover, the risk of developing chronic (> 200 sick days) pain was 8 times lower for the Early Activation group. This investigation shows that relatively simple changes in treatment result in reduced sickness absenteeism for 'first-time' sufferers only. Consequently, the content and timing of treatment for pain appear to be crucial. Properly administered early intervention may therefore decrease sick leave and prevent chronic problems, thus saving considerable resources.
Article
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.