Dry needling curricula in entry-level education programs in the United States for physical therapists.

Objectives: The objective of this paper was to determine the extent to which dry needling is instructed in entry-level education programs for physical therapists. Methods: Program directors from 226 entry-level education programs recognized by the Commission on Accreditation in Physical Therapy Education were recruited via e-mail to participate in an anonymous 35-item electronic survey during the 2017-2018 academic year.  The survey evaluated dry needling curricula, faculty qualifications, attitudes and experience, and programs' future plans for teaching dry needling. Results: A total of 75 programs responded to the survey (response rate = 33.1%).  Forty (53.3%) had integrated dry needling theory and psychomotor training into their programs and 8 (10.6%) planned to include such content in their curriculum in the future.  Of the 40 respondents, 28 indicated that dry needling education was integrated into a required course, 4 indicated that dry needling was an elective course, and 8 did not specify how dry needling education was integrated. Faculty teaching dry needling appear to be well qualified, with the majority having 5-10 years of experience using dry needling in clinical practice. The primary reason for programs not teaching dry needling is that it was not considered an entry-level skill. Discussion: There appeared to be variability in how dry needling was integrated into the curricula, as well as in the depth and breadth of instruction.  Our research may serve as a baseline for faculty to assess existing dry needling curricula and as a guide for developing curricula in new or existing physical therapy programs.

The knowledge of low back pain management between physical therapists and family practice physicians.

Objectives: The purpose of this study was to compare knowledge in managing patients with low back pain (LBP) between physical therapists and family practice physicians. Methods: Seventy-three physical therapists and 30 family practice physicians completed standardized examinations assessing knowledge, attitudes, the usefulness of clinical practice guidelines, and management strategies for patients with LBP. Beliefs of physical therapists and family practice physicians about LBP were compared using relative risks and independent t-tests. Results: Scores related to knowledge, attitudes, and the usefulness of clinical practice guidelines were generally similar between the groups. In addition, there was no difference between the groups for knowledge regarding optimal management strategies for patients with LBP. However, physical therapists were less likely to have difficulty assessing motivation levels of patients with LBP compared to family practice physicians (64.6% vs 26.7%; relative risk: 2.41 [95% confidence interval: 1.30-4.48] and physical therapists were less likely to agree that interventions by health care providers have little positive effect on the natural history of acute LBP (17.8% vs. 50.0%; relative risk: 0.36 [95% confidence interval: 0.19-0.66]). Discussion: The results of this study may have implications for third-party payers and health care administrators regarding the utilization of physical therapists in the management of patients with LBP in expanded scopes of practice, including direct access and potential placement in primary care clinics.

Measurement of outcomes for patients with centralising versus non-centralising neck pain.

OBJECTIVE: The purpose of this study is to determine whether individuals with neck pain who demonstrate centralisation of symptoms have more favourable outcome than individuals who do not demonstrate centralisation. METHODS: Eleven subjects with neck pain were evaluated and treated by two physical therapists certified in Mechanical Diagnosis and Therapy (MDT). Eleven physical therapy patients underwent a routine initial evaluation and were treated 2-3 times per week using MDT principles and other physical therapy interventions. The Neck Disability Index (NDI) tool was administered at the initial examination, approximately 2 weeks following the initial examination, each subsequent re-evaluation, and at discharge from the study to measure changes in functional outcomes for each subject. Patients continued with treatments until they were discharged or removed from the study. Four subjects were referred back to their physician by treating physical therapist secondary to non-centralisation (NC) and worsening of symptoms. RESULTS: Of the 11 subjects, six demonstrated centralisation (CEN) and five demonstrated NC. At initial evaluation, the average NDI score for the CEN group was 51.0 (SD ± 19.4) and 56.4 (SD ± 17.6) for the NC group. For the CEN group, the average change in NDI score between initial evaluation and discharge was 41.2 (SD ± 13.2 and 12.2 (SD ± 13.0) for the NC group. The correlation coefficient of CEN and change in NDI score was 0.772 and was statistically significant (P = 0.005). CONCLUSIONS: In this limited sample, people with neck pain demonstrated more favourable outcomes when the CEN phenomenon was observed. Future research on CEN should be investigated with a larger sample size and with a greater number of clinicians trained in the MDT approach.

The reliability of the cervical relocation test on people with and without a history of neck pain.

BACKGROUND: Physical therapy intervention is often sought to treat cervical spine conditions and a comprehensive physical therapy examination has been associated with more favourable outcomes. The cervical relocation test (CRT) is one method used to assess joint position sense (PS) integrity of the cervical spine. Previous research has found significant differences in the CRT between symptomatic and asymptomatic subjects. Impaired kinaesthetic awareness in the cervical spine may be associated with degenerative joint disease, chronicity of the complaint and increased susceptibility to re-injury. PURPOSE: The purpose of this study was to determine the intertester and intratester reliability of cervical relocation using the cervical range of motion instrument (CROM) and an affixed laser (AL) device among subjects with and without a history of neck pain. In addition, it was hypothesised that those individuals with a history of neck pain would have greater difficulty on the CRT. METHODS: A total of 50 asymptomatic subjects (n = 50) were assigned to two researchers. The CRT was performed for each tester by the subject rotating the cervical spine for three trials to the right and left for the CROM and AL. RESULTS: The results indicate a significant intertester reliability of the CROM (interclass correlation coefficient (ICC) = 0.717[0.502-0.839]; 0.773[0.595-0.873]) for the subjects in this sample. CONCLUSION: This study demonstrated that the CROM is a reliable device for measuring cervical relocation between different testers. Future research should investigate if the CRT is predictive of prognosis in patients with cervical pathology.

The relationship between Quebec Task Force Classification and outcome in patients with low back pain treated through mechanical diagnosis and therapy.

OBJECTIVE: To determine the correlation between the Quebec Task Force Classification (QTFC) system and outcome in patients with non-specific low back pain (LBP). METHODS: Forty-nine patients who were treated in outpatient physical therapy clinics of Catholic Health System (CHS) of Western New York (WNY) were classified according to the QTFC at the initial examination by physical therapists (PTs) with training in Mechanical Diagnosis and Therapy (MDT). The patient's perceived level of function was assessed with the Focus On Therapeutic Outcomes (FOTO) tool at the initial examination, 2 weeks following the initiation of physical therapy and again at discharge. RESULTS: A linear regression model between acuity and change in FOTO score was performed and demonstrated statistical significance (P<0·05) as the more favorable outcome was found with the more acute patients. Spearman correlations between change in FOTO score and QTFC, duration of treatment and acuity of condition, and number of visits and change in FOTO score were not found to be statistically significant. CONCLUSIONS: The patients treated in this study demonstrated functional improvement in an average of eight visits, indicating efficacious care. Future research is needed to determine prioritized intervention strategies for designated LBP classifications.

Clinical decision-making in the management of cervical spine derangement: a case study survey using a patient vignette.

BACKGROUND: Neck pain is one of the most common, potentially disabling, and costly musculoskeletal conditions seen in outpatient physical therapy (PT). Clinical decision-making involves referral or the selection of intervention based on the results of the PT examination. Despite evidence that suggests that treatment based classification is most efficacious, it is hypothesized that examination and intervention may be heavily influenced by post-graduate training experiences. PURPOSE: The purpose of this study was to analyze which tests, measures, and interventions are most commonly selected by physical therapists (PTs) holding a credential from the McKenzie Institute and those holding the McKenzie credential plus the credentialc of Fellow of the American Academy of Orthopaedic Manual Physical Therapy (FAAOMPT). Their responses were based on a simulated case vignette involving a patient with a presentation of cervical spine disk derangement. METHODS: A survey administered through Survey Monkey was sent to 714 members of the McKenzie Institute who are certified or hold a diploma in mechanical diagnosis and therapy (MDT) or these credentials with the addition of Fellowship credentialing (MDT+FAAOMPT). Of the 714 surveyed PTs, 83 completed the survey for a response rate of 11.6%. As the PTs were given further information regarding the patient, they were asked to progress through a clinical decision-making process by indicating their sequence of examination techniques, and then indicating which interventions would be performed based on the results of the examination. RESULTS: A descriptive analysis was conducted to determine the most common sequences chosen by the PTs based on their training. To perform the analysis, only respondents who completed the survey were included: clinicians with MDT credentials, (n = 77), and clinicians with both the MDT and FAAOMPT credentials (MDT+FAAOMPT), (n = 6). Initially, the most common examination chosen regardless of credential was postural analysis. After receiving additional information regarding the patient's posture, the majority of clinicians in each of the three groups then chose active range of motion (AROM). However, after additional information was given, the majority of the MDT group chose repeated end range cervical movements as their next examination measure, and the FAAOMPT group varied. The majority of the FAAOMPT group continued to assess the patient through an entire examination sequence, while the majority of the MDT group discontinued testing. A descriptive analysis of the intervention sequences depicted a trend toward direction of preference (DP) exercises for the MDT group (80.3%), and passive movements or mobilization exercises for the FAAOMPT group. CONCLUSION: The results of this study suggest that PTs with post-graduate training through the McKenzie Institute or through Orthopaedic Manual Physical Therapy (OMPT) Fellowship training may demonstrate an inherent bias toward their advanced training in the assessment and treatment of acute cervical derangement. Although no significant findings can be reported secondary to sample size limitations, future studies may be performed to further explore this topic.

Effectiveness of mechanical diagnosis and therapy in patients with back pain who meet a clinical prediction rule for spinal manipulation.

Recently a clinical prediction rule (CPR) for lumbar regional spinal thrust manipulation (STM) has shown predictive success in patients with back pain who met specific selection criteria. The purpose of this study was to compare the effectiveness of STM and mechanical diagnosis and therapy (MDT) in patients who are positive for the STM CPR. Following initial examination, 31 participants were randomized to the STM group (n = 16) and to the MDT group (n = 15). Two weeks following initial examination, four participants chose to cross over from the STM group to the MDT group. The Oswestry Disability Index (ODI), Fear-Avoidance Beliefs Questionnaire work subscale (FABQw), and the Numerical Pain Rating Scale (NPRS) were administered initially, and at 2-weeks and 4 week follow-up (discharge). Data were analyzed to determine changes in ODI and NPRS scores from initial examination through one month. Of the 31 participants, one patient who met only three of five selection criteria and four others who chose to switch groups were removed from the analysis. Both groups exhibited statistically significant improvements in ODI and NPRS scores from baseline to final visit but there was no significant difference in scores between groups at 4 weeks. In this sample of patients, the selection criteria for this CPR were not exclusive for lumbopelvic STM. Mechanical diagnosis and therapy was an equally viable choice for these patients.

A Case Study Examining the Effectiveness of Mechanical Diagnosis and Therapy in a Patient who Met the Clinical Prediction Rule for Spinal Manipulation.

This single-subject case study was conducted as a part of a randomized trial investigating the efficacy of mechanical diagnosis and therapy (MDT) and spinal thrust manipulation (STM) in patients who meet a clinical prediction rule (CPR) for spinal manipulation. Following initial examination, a patient who met the CPR was treated initially with STM and then eventually with MDT. The Oswestry Disability Questionnaire (ODI), Fear-Avoidance Beliefs Questionnaire, and the Numerical Pain Rating Scale (NPRS) were administered at the initial examination and at a two-week follow-up. Data were analyzed based on changes in the pain rating scale, ODI, and straight leg raise scores from initial examination to discharge. In accordance with a study protocol in which the patient was part of, this patient was changed from STM to MDT after the second physical therapy visit due to failure of overall improvement. The patient received MDT during the third session and continued with this approach until discharge. This patient responded favorably to MDT presenting with a 20 degrees improvement in SLR on the left and 10 degrees on the right, 6 points lower on the NPRS, and a 4% decrease on the OSW after a total of 6 visits.