IJSPT
ORIGINAL RESEARCH
A COMPARISON BETWEEN CIVILIAN AND MILITARY PHYSICAL THERAPISTS’ KNOWLEDGE IN MANAGING MUSCULOSKELETAL CONDITIONS: A DESCRIPTIVE STUDY Ryan Rundle, PT, DPT1 Jared Roberts, PT, DPT1 Gabe Whitney, PT, DPT1 Steve Mankins, PT, DPT1 Caleb Dille, PT, DPT1 Megan Donaldson, PT, PhD, FAAOMPT1 Amy Hassen, PT, DPT, OCS, MTC1
ABSTRACT Background: Military physical therapists have been shown to have the necessary knowledge in musculoskeletal medicine in order to practice as a direct access provider. However, research about musculoskeletal knowledge in the civilian physical therapist (non-military) population is lacking. Purpose: The purpose of the current study was to compare the knowledge in managing musculoskeletal conditions between civilian and military physical therapists using a validated and standardized musculoskeletal competency examination. Furthermore, this study aims to investigate the potential factors that may lead to increased musculoskeletal competency. Study Design: Cross-sectional, electronic survey Methods: This study involved a cross-sectional, electronic survey completed in August and September of 2014 in order to assess licensed physical therapists’ knowledge in identifying and managing musculoskeletal conditions. Only physical therapists practicing in orthopedics were permitted to be involved in the study. Descriptive statistics of the participants, and logistic regressions analyzing variables correlated with passing the musculoskeletal exam were calculated using SPSS 22.0. Frequencies were produced for multiple variables. Binary logistic regressions were used to correlate the frequency variables with performing at competency level on the musculoskeletal exam. Results: A total of 22,750 surveys were sent to physical therapists in Arizona, Ohio, Texas, Maine and Wyoming. Two thousand sixty-five surveys were returned for a response rate of 10.6%. Of the 2,065 surveys completed, 408 responses were included for analysis. The average score for the respondents on the exam was 65.08% and only 28.2% of all respondents met the competency cutoff score (previously established to be 73.1%). Respondents who were orthopedic certified specialists (OCS) or sports certified specialists (SCS) were 3.091 times more likely to perform at the competency level on the examination with a p-value of 95%. Conclusion: The current study utilized the results from a previous study for a comparison between the civilian and military physical therapist populations. The results indicate that civilian physical therapists in the current study (65.08%) scored lower than their military counterparts in the previous study (75.9%) on the musculoskeletal exam. Potential reasons for this include less autonomous practice responsibilities and a disparity in educational experiences. Board certifications may enhance civilian physical therapists ability to practice with greater autonomy as primary care clinicians when managing musculoskeletal conditions. Level of Evidence: Level 4 Keywords: Board certifications, direct access, musculoskeletal competency
1
Walsh University, North Canton, OH, USA
CORRESPONDING AUTHOR Dr. Amy Hassen Department of Physical Therapy Walsh University 2020 East Maple Street North Canton, Ohio 44720 E-mail: [email protected]
The International Journal of Sports Physical Therapy | Volume 11, Number 1 | February 2016 | Page 115
INTRODUCTION Musculoskeletal conditions are common, accounting for nearly 15-30% of encounters in a primary care practice setting.1 It has been estimated that 53.9 million people in the United States report having one or more musculoskeletal conditions and medical costs associated with these conditions average more than $3,578 per capita.2 Episodes of care that involved a physician referral increased costs by 123%, duration of care by 65%, office visits by 60%, and overall physical therapy claims by 67% compared to direct access services provided by physical therapists without a physician referral.3 At present, direct access services can be provided by physical therapists without a physician referral in all 50 states including the District of Columbia.4 Although direct access is legislated in all 50 states, there are varying levels: unrestricted, limited, or with provisions.4 Researchers have shown that not only does direct access physical therapy services reduce healthcare costs and duration of care, but also has shown to have similar or better discharge outcomes without increased risk.2 Nonetheless, the standard of care remains that physicians are the most common point of entry into the healthcare system for patients with musculoskeletal conditions. However, primary care physicians have continually shown to be lacking in their management, confidence, evaluation, and treatment of these patients.2,5-8 In 1998, Freedman and Bernstein5 developed a musculoskeletal assessment which tested basic knowledge of musculoskeletal conditions. The assessment was administered to 85 physicians in the first week of their internship following graduation from medical school; the mean score was 59.6%, well under the accepted competency level of 73.1% set forth by medical orthopedic residency program directors.5,8 Additionally, 82% of physicians failed to meet basic competency for managing musculoskeletal conditions in the primary care setting.5,8 The lack of confidence and inadequacy in the treatment of patients with musculoskeletal conditions is reflected by the lack of musculoskeletal exposure in medical school curricula.5-8 Currently, only 51 of the 122 American Medical schools have preclinical coursework devoted to musculoskeletal medicine.9 Childs et al8 utilized the same assessment tool developed in the Freedman and Bernstein2 study to explore
the level of knowledge of musculoskeletal conditions in military physical therapists. The results indicated that military physical therapists displayed higher levels of knowledge in the management of musculoskeletal conditions (mean score 75.9%) when compared to physicians in a multitude of specialties (mean score range 35%-61%), except orthopedists (mean score 94%). Additionally, physical therapists who are board-certified in orthopedics (OCS) or sports (SCS) from the American Board of Physical Therapy Specialists (ABPTS) demonstrated higher levels of knowledge than their counterparts who did not hold any advanced certifications.8 Jette et al10 further supported this sentiment and reported that physical therapists holding an OCS were almost two times more likely to make correct decisions for medical conditions and musculoskeletal conditions when presented with simulated paper cases. Ross et al11 concluded that military physical therapists demonstrated knowledge levels equal to or higher than physicians when evaluating patients with low back pain (LBP) and were able to recommend the correct drug treatments for patients with acute LBP. The results of these studies support the ability of military physical therapists to practice in direct access environments when encountering patients with LBP. Since 1973, the military health care system has supported the use of physical therapists in the direct access environment.11 Furthermore, physical therapists in the uniformed services have shown to have the necessary knowledge in musculoskeletal medicine in order to practice as a direct access provider.8,11 Although this has been shown for physical therapists in the uniformed services, research about musculoskeletal knowledge in the civilian physical therapist (non-military) population is lacking. Even though direct access is legislated all fifty states, it is not utilized frequently secondary to reimbursement issues from third party payers. This limits civilian physical therapists’ exposure to direct access care.2 The purpose of the current study was to compare the knowledge in managing musculoskeletal conditions between civilian and military physical therapists using a validated and standardized musculoskeletal competency examination. Furthermore, this study aims to investigate the potential factors that may lead to increased musculoskeletal competency. The
The International Journal of Sports Physical Therapy | Volume 11, Number 1 | February 2016 | Page 116
authors hypothesize that civilian physical therapists will perform at similar levels as military physical therapists on a standardized examination that has been previously used to assess knowledge in managing musculoskeletal conditions. Furthermore, the authors hypothesize that civilian physical therapists who are board-certified in orthopedics (OCS) or sports (SCS) will perform at a higher competency level than those who are not. Finally, the authors hypothesize that civilian physical therapists who currently practice in direct access environments 50% of the time or greater will perform better than those who practice in direct access environments less than 50% of the time. This study has the potential to influence the utilization of physical therapists in managing musculoskeletal conditions without referral from a physician. METHODS Design This study involved a cross-sectional, electronic survey completed in August and September of 2014 in order to assess licensed physical therapists’ knowledge in identifying and managing musculoskeletal conditions. This study was approved by the Walsh University Human Subject Review Committee (1424) prior to the recruitment of subjects and distribution of surveys. Informed consent was obtained from all subjects prior to completion of the survey. Survey The survey completed by subjects has been published elsewhere.5 This basic-competency examination in musculoskeletal medicine has been previously used in research by Freedman and Bernstein5 and then again by Childs et al8 and Matzkin et al.6 The scenarios addressed in this survey are frequently encountered in orthopedic practice and include arthritis, fractures, dislocations, and low back pain. This survey also includes situations in which the physical therapists would need to identify an immediate referral during medical emergencies for necessary medical care. There are 25 questions on the survey, which were designed to be open-ended in order to eliminate the possibility of subjects earning points for guesses and accurately assess the subject’s knowledge of musculoskeletal conditions.
Respondents Respondents were recruited via their valid email addresses on file with their respective state boards. The following five states were targeted to represent the five geographic regions as defined by the United States Census Bureau Regions:12 Arizona (West), Maine (Northeast), Ohio (Midwest), Texas (South), and Wyoming (West). Therefore, an accurate representation of the population by region was sampled. Although only five states were targeted, there were respondents from all fifty states. The authors speculate this to be due to participants moving out of the region in which the email address was obtained. However, the respondents from other states that were not targeted by the survey were not included within the final data set used for comparison based on pre-determined exclusion criteria. The following are the exclusion criteria: the respondent must be practicing in orthopedics, must be a non-military physical therapist, in clinical practice greater than one year, and must not have knowledge of the Freedman and Bernstein study.5 Civilian physical therapists (military physical therapists were previously studied regarding their knowledge of musculoskeletal conditions8) who were licensed in their respective states as well as practicing in orthopedics for greater than one year were included in the study. While each physical therapist was currently licensed in his or her state, the subjects varied in professional degrees held and additional professional board certifications obtained. The professional degrees include Bachelor’s of Science in Physical Therapy, Masters of Physical Therapy, and Doctorate of Physical Therapy. The additional professional board certifications were grouped as either being an OCS and/or SCS, or not holding either of those board certifications. Procedure The survey was distributed through SurveyMonkey, Inc. (US). Consistent with previous studies,5,6,8 a time limit was not enforced. The survey was open for five weeks with four follow up reminder emails sent during that period. The emails included a hyperlink to the survey. The responses were confidential and could not be traced back to the participant. Further risk of bias was reduced by coding each variable in an isolated fashion.
The International Journal of Sports Physical Therapy | Volume 11, Number 1 | February 2016 | Page 117
Data Analysis Two civilian orthopedic physical therapists (MD and AH) graded the responses of participants. One is a fellowship trained manual therapist with eight years of experience teaching orthopedic content in an entry-level physical therapist program. The other therapist is board-certified in orthopedics and has earned a certification in manual therapy and has been teaching orthopedic content in entry-level physical therapist programs for six years. The senior author provided a training session on the scoring procedures. The two authors independently graded the responses using the answer key published in the Freedman and Bernstein study.5 Each question could receive a maximum score of one point; however, partial credit was given for some questions based on the criteria for partial credit provided in the Freedman and Bernstein study.5 Inter-rater reliability was performed on the first 100 responses. Substantial agreement or higher was reached for 21 out of 25 questions based on a kappa value of higher than 0.7. The two graders reached consensus through discussion for the four questions with kappa values 20 years Sex Male Female Missing value Highest Degree Earned Non-doctoral Doctoral Missing value Entry Level Degree Non-doctoral Doctoral Missing value Board Certifications OCS/SCS Non-OCS/SCS Missing value State Practicing Arizona Maine Ohio Texas Wyoming Other Missing value Do you feel qualified to practice direct access? Yes No Missing value Frequency of direct access practice? 0-49% 50-100% Missing value APTA Membership Yes No Missing value
0.148 48 (41.75) 19 (16.5%) 8 (7%) 8 (7%) 32 (27.8%)
106 (36.2%) 51 (17.4%) 43 (14.7%) 30 (10.2%) 63 (21.5%)
50 (43.5%) 63 (54.8%) 2 (1.7%)
113 (38.6%) 178 (60.8%) 2 (0.7%)
46 (40%) 68 (59.1%) 1 (0.9%)
138 (47.1%) 153 (52.1%) 2 (0.7%)
70 (60.9%) 44 (38.3%) 1 (0.9%)
182 (62.1%) 111 (37.9%) 0
39 (33.9%) 64 (55.7%) 12 (10.4%)
41 (14.0%) 208 (71.0%) 44 (15%)
29 (25.2%) 10 (8.7%) 24 (20.9%) 32 (27.8%) 3 (2.6%) 15 (13%) 2 (1.7%)
46 (15.7%) 24 (8.2%) 97 (33.1%) 77 (26.3%) 9 (3.1%) 39 (13.3%) 1 (0.3%)
0.320
0.199
0.894
ORIGINAL RESEARCH
A COMPARISON BETWEEN CIVILIAN AND MILITARY PHYSICAL THERAPISTS’ KNOWLEDGE IN MANAGING MUSCULOSKELETAL CONDITIONS: A DESCRIPTIVE STUDY Ryan Rundle, PT, DPT1 Jared Roberts, PT, DPT1 Gabe Whitney, PT, DPT1 Steve Mankins, PT, DPT1 Caleb Dille, PT, DPT1 Megan Donaldson, PT, PhD, FAAOMPT1 Amy Hassen, PT, DPT, OCS, MTC1
ABSTRACT Background: Military physical therapists have been shown to have the necessary knowledge in musculoskeletal medicine in order to practice as a direct access provider. However, research about musculoskeletal knowledge in the civilian physical therapist (non-military) population is lacking. Purpose: The purpose of the current study was to compare the knowledge in managing musculoskeletal conditions between civilian and military physical therapists using a validated and standardized musculoskeletal competency examination. Furthermore, this study aims to investigate the potential factors that may lead to increased musculoskeletal competency. Study Design: Cross-sectional, electronic survey Methods: This study involved a cross-sectional, electronic survey completed in August and September of 2014 in order to assess licensed physical therapists’ knowledge in identifying and managing musculoskeletal conditions. Only physical therapists practicing in orthopedics were permitted to be involved in the study. Descriptive statistics of the participants, and logistic regressions analyzing variables correlated with passing the musculoskeletal exam were calculated using SPSS 22.0. Frequencies were produced for multiple variables. Binary logistic regressions were used to correlate the frequency variables with performing at competency level on the musculoskeletal exam. Results: A total of 22,750 surveys were sent to physical therapists in Arizona, Ohio, Texas, Maine and Wyoming. Two thousand sixty-five surveys were returned for a response rate of 10.6%. Of the 2,065 surveys completed, 408 responses were included for analysis. The average score for the respondents on the exam was 65.08% and only 28.2% of all respondents met the competency cutoff score (previously established to be 73.1%). Respondents who were orthopedic certified specialists (OCS) or sports certified specialists (SCS) were 3.091 times more likely to perform at the competency level on the examination with a p-value of 95%. Conclusion: The current study utilized the results from a previous study for a comparison between the civilian and military physical therapist populations. The results indicate that civilian physical therapists in the current study (65.08%) scored lower than their military counterparts in the previous study (75.9%) on the musculoskeletal exam. Potential reasons for this include less autonomous practice responsibilities and a disparity in educational experiences. Board certifications may enhance civilian physical therapists ability to practice with greater autonomy as primary care clinicians when managing musculoskeletal conditions. Level of Evidence: Level 4 Keywords: Board certifications, direct access, musculoskeletal competency
1
Walsh University, North Canton, OH, USA
CORRESPONDING AUTHOR Dr. Amy Hassen Department of Physical Therapy Walsh University 2020 East Maple Street North Canton, Ohio 44720 E-mail: [email protected]
The International Journal of Sports Physical Therapy | Volume 11, Number 1 | February 2016 | Page 115
INTRODUCTION Musculoskeletal conditions are common, accounting for nearly 15-30% of encounters in a primary care practice setting.1 It has been estimated that 53.9 million people in the United States report having one or more musculoskeletal conditions and medical costs associated with these conditions average more than $3,578 per capita.2 Episodes of care that involved a physician referral increased costs by 123%, duration of care by 65%, office visits by 60%, and overall physical therapy claims by 67% compared to direct access services provided by physical therapists without a physician referral.3 At present, direct access services can be provided by physical therapists without a physician referral in all 50 states including the District of Columbia.4 Although direct access is legislated in all 50 states, there are varying levels: unrestricted, limited, or with provisions.4 Researchers have shown that not only does direct access physical therapy services reduce healthcare costs and duration of care, but also has shown to have similar or better discharge outcomes without increased risk.2 Nonetheless, the standard of care remains that physicians are the most common point of entry into the healthcare system for patients with musculoskeletal conditions. However, primary care physicians have continually shown to be lacking in their management, confidence, evaluation, and treatment of these patients.2,5-8 In 1998, Freedman and Bernstein5 developed a musculoskeletal assessment which tested basic knowledge of musculoskeletal conditions. The assessment was administered to 85 physicians in the first week of their internship following graduation from medical school; the mean score was 59.6%, well under the accepted competency level of 73.1% set forth by medical orthopedic residency program directors.5,8 Additionally, 82% of physicians failed to meet basic competency for managing musculoskeletal conditions in the primary care setting.5,8 The lack of confidence and inadequacy in the treatment of patients with musculoskeletal conditions is reflected by the lack of musculoskeletal exposure in medical school curricula.5-8 Currently, only 51 of the 122 American Medical schools have preclinical coursework devoted to musculoskeletal medicine.9 Childs et al8 utilized the same assessment tool developed in the Freedman and Bernstein2 study to explore
the level of knowledge of musculoskeletal conditions in military physical therapists. The results indicated that military physical therapists displayed higher levels of knowledge in the management of musculoskeletal conditions (mean score 75.9%) when compared to physicians in a multitude of specialties (mean score range 35%-61%), except orthopedists (mean score 94%). Additionally, physical therapists who are board-certified in orthopedics (OCS) or sports (SCS) from the American Board of Physical Therapy Specialists (ABPTS) demonstrated higher levels of knowledge than their counterparts who did not hold any advanced certifications.8 Jette et al10 further supported this sentiment and reported that physical therapists holding an OCS were almost two times more likely to make correct decisions for medical conditions and musculoskeletal conditions when presented with simulated paper cases. Ross et al11 concluded that military physical therapists demonstrated knowledge levels equal to or higher than physicians when evaluating patients with low back pain (LBP) and were able to recommend the correct drug treatments for patients with acute LBP. The results of these studies support the ability of military physical therapists to practice in direct access environments when encountering patients with LBP. Since 1973, the military health care system has supported the use of physical therapists in the direct access environment.11 Furthermore, physical therapists in the uniformed services have shown to have the necessary knowledge in musculoskeletal medicine in order to practice as a direct access provider.8,11 Although this has been shown for physical therapists in the uniformed services, research about musculoskeletal knowledge in the civilian physical therapist (non-military) population is lacking. Even though direct access is legislated all fifty states, it is not utilized frequently secondary to reimbursement issues from third party payers. This limits civilian physical therapists’ exposure to direct access care.2 The purpose of the current study was to compare the knowledge in managing musculoskeletal conditions between civilian and military physical therapists using a validated and standardized musculoskeletal competency examination. Furthermore, this study aims to investigate the potential factors that may lead to increased musculoskeletal competency. The
The International Journal of Sports Physical Therapy | Volume 11, Number 1 | February 2016 | Page 116
authors hypothesize that civilian physical therapists will perform at similar levels as military physical therapists on a standardized examination that has been previously used to assess knowledge in managing musculoskeletal conditions. Furthermore, the authors hypothesize that civilian physical therapists who are board-certified in orthopedics (OCS) or sports (SCS) will perform at a higher competency level than those who are not. Finally, the authors hypothesize that civilian physical therapists who currently practice in direct access environments 50% of the time or greater will perform better than those who practice in direct access environments less than 50% of the time. This study has the potential to influence the utilization of physical therapists in managing musculoskeletal conditions without referral from a physician. METHODS Design This study involved a cross-sectional, electronic survey completed in August and September of 2014 in order to assess licensed physical therapists’ knowledge in identifying and managing musculoskeletal conditions. This study was approved by the Walsh University Human Subject Review Committee (1424) prior to the recruitment of subjects and distribution of surveys. Informed consent was obtained from all subjects prior to completion of the survey. Survey The survey completed by subjects has been published elsewhere.5 This basic-competency examination in musculoskeletal medicine has been previously used in research by Freedman and Bernstein5 and then again by Childs et al8 and Matzkin et al.6 The scenarios addressed in this survey are frequently encountered in orthopedic practice and include arthritis, fractures, dislocations, and low back pain. This survey also includes situations in which the physical therapists would need to identify an immediate referral during medical emergencies for necessary medical care. There are 25 questions on the survey, which were designed to be open-ended in order to eliminate the possibility of subjects earning points for guesses and accurately assess the subject’s knowledge of musculoskeletal conditions.
Respondents Respondents were recruited via their valid email addresses on file with their respective state boards. The following five states were targeted to represent the five geographic regions as defined by the United States Census Bureau Regions:12 Arizona (West), Maine (Northeast), Ohio (Midwest), Texas (South), and Wyoming (West). Therefore, an accurate representation of the population by region was sampled. Although only five states were targeted, there were respondents from all fifty states. The authors speculate this to be due to participants moving out of the region in which the email address was obtained. However, the respondents from other states that were not targeted by the survey were not included within the final data set used for comparison based on pre-determined exclusion criteria. The following are the exclusion criteria: the respondent must be practicing in orthopedics, must be a non-military physical therapist, in clinical practice greater than one year, and must not have knowledge of the Freedman and Bernstein study.5 Civilian physical therapists (military physical therapists were previously studied regarding their knowledge of musculoskeletal conditions8) who were licensed in their respective states as well as practicing in orthopedics for greater than one year were included in the study. While each physical therapist was currently licensed in his or her state, the subjects varied in professional degrees held and additional professional board certifications obtained. The professional degrees include Bachelor’s of Science in Physical Therapy, Masters of Physical Therapy, and Doctorate of Physical Therapy. The additional professional board certifications were grouped as either being an OCS and/or SCS, or not holding either of those board certifications. Procedure The survey was distributed through SurveyMonkey, Inc. (US). Consistent with previous studies,5,6,8 a time limit was not enforced. The survey was open for five weeks with four follow up reminder emails sent during that period. The emails included a hyperlink to the survey. The responses were confidential and could not be traced back to the participant. Further risk of bias was reduced by coding each variable in an isolated fashion.
The International Journal of Sports Physical Therapy | Volume 11, Number 1 | February 2016 | Page 117
Data Analysis Two civilian orthopedic physical therapists (MD and AH) graded the responses of participants. One is a fellowship trained manual therapist with eight years of experience teaching orthopedic content in an entry-level physical therapist program. The other therapist is board-certified in orthopedics and has earned a certification in manual therapy and has been teaching orthopedic content in entry-level physical therapist programs for six years. The senior author provided a training session on the scoring procedures. The two authors independently graded the responses using the answer key published in the Freedman and Bernstein study.5 Each question could receive a maximum score of one point; however, partial credit was given for some questions based on the criteria for partial credit provided in the Freedman and Bernstein study.5 Inter-rater reliability was performed on the first 100 responses. Substantial agreement or higher was reached for 21 out of 25 questions based on a kappa value of higher than 0.7. The two graders reached consensus through discussion for the four questions with kappa values 20 years Sex Male Female Missing value Highest Degree Earned Non-doctoral Doctoral Missing value Entry Level Degree Non-doctoral Doctoral Missing value Board Certifications OCS/SCS Non-OCS/SCS Missing value State Practicing Arizona Maine Ohio Texas Wyoming Other Missing value Do you feel qualified to practice direct access? Yes No Missing value Frequency of direct access practice? 0-49% 50-100% Missing value APTA Membership Yes No Missing value
0.148 48 (41.75) 19 (16.5%) 8 (7%) 8 (7%) 32 (27.8%)
106 (36.2%) 51 (17.4%) 43 (14.7%) 30 (10.2%) 63 (21.5%)
50 (43.5%) 63 (54.8%) 2 (1.7%)
113 (38.6%) 178 (60.8%) 2 (0.7%)
46 (40%) 68 (59.1%) 1 (0.9%)
138 (47.1%) 153 (52.1%) 2 (0.7%)
70 (60.9%) 44 (38.3%) 1 (0.9%)
182 (62.1%) 111 (37.9%) 0
39 (33.9%) 64 (55.7%) 12 (10.4%)
41 (14.0%) 208 (71.0%) 44 (15%)
29 (25.2%) 10 (8.7%) 24 (20.9%) 32 (27.8%) 3 (2.6%) 15 (13%) 2 (1.7%)
46 (15.7%) 24 (8.2%) 97 (33.1%) 77 (26.3%) 9 (3.1%) 39 (13.3%) 1 (0.3%)
0.320
0.199
0.894
