A modern way to teach and practice manual therapy.

BACKGROUND: Musculoskeletal conditions are the leading contributor to global disability and health burden. Manual therapy (MT) interventions are commonly recommended in clinical guidelines and used in the management of musculoskeletal conditions. Traditional systems of manual therapy (TMT), including physiotherapy, osteopathy, chiropractic, and soft tissue therapy have been built on principles such as clinician-centred assessment, patho-anatomical reasoning, and technique specificity. These historical principles are not supported by current evidence. However, data from clinical trials support the clinical and cost effectiveness of manual therapy as an intervention for musculoskeletal conditions, when used as part of a package of care. PURPOSE: The purpose of this paper is to propose a modern evidence-guided framework for the teaching and practice of MT which avoids reference to and reliance on the outdated principles of TMT. This framework is based on three fundamental humanistic dimensions common in all aspects of healthcare: safety, comfort, and efficiency. These practical elements are contextualised by positive communication, a collaborative context, and person-centred care. The framework facilitates best-practice, reasoning, and communication and is exemplified here with two case studies. METHODS: A literature review stimulated by a new method of teaching manual therapy, reflecting contemporary evidence, being trialled at a United Kingdom education institute. A group of experienced, internationally-based academics, clinicians, and researchers from across the spectrum of manual therapy was convened. Perspectives were elicited through reviews of contemporary literature and discussions in an iterative process. Public presentations were made to multidisciplinary groups and feedback was incorporated. Consensus was achieved through repeated discussion of relevant elements. CONCLUSIONS: Manual therapy interventions should include both passive and active, person-empowering interventions such as exercise, education, and lifestyle adaptations. These should be delivered in a contextualised healing environment with a well-developed person-practitioner therapeutic alliance. Teaching manual therapy should follow this model.

New clinical decision tool to assist physical therapists with joint mobilization application to the pediatric population.

Joint mobilizations are well-established and extensively researched treatment modality for adults. However, it remains largely unexplored in the pediatric population. Physical therapists hesitate to perform joint mobilization on children because of lack of knowledge, concern for the developing skeletal system, and the paucity of research on the topic. The aim of this article is to present a decision tool created for a continuing education course with the purpose to instruct pediatric therapists in the safe and effective use of joint mobilizations in children. It is based on the pediatric paradigm of developmental and functional assessment to best address the concerns and preferences of physical therapists (PTs). To advance research in pediatric joint mobilization, PTs should listen to the concerns of pediatric therapists and respond to those concerns with effective, evidence-supported training. This decision tree will serve as a resource for the education of pediatric therapists in the safe and effective use of joint mobilizations.

COVID-19: how has a global pandemic changed manual therapy technique education in chiropractic programs around the world?

BACKGROUND: Manual therapy is a cornerstone of chiropractic education, whereby students work towards a level of skill and expertise that is regarded as competent to work within the field of chiropractic. Due to the COVID-19 pandemic, chiropractic programs in every region around the world had to make rapid changes to the delivery of manual therapy technique education, however what those changes looked like was unknown. AIMS: The aims of this study were to describe the immediate actions made by chiropractic programs to deliver education for manual therapy techniques and to summarise the experience of academics who teach manual therapy techniques during the initial outbreak of COVID-19 pandemic. METHODS: A qualitative descriptive approach was used to describe the immediate actions made by chiropractic programs to deliver manual therapy technique education during the COVID-19 pandemic. Chiropractic programs were identified from the webpages of the Councils on Chiropractic Education International and the Council on Chiropractic Education - USA. Between May and June 2020, a convenience sample of academics who lead or teach in manual therapy technique in those programs were invited via email to participate in an online survey with open-ended questions. Responses were entered into the NVivo software program and analysed using a reflexive thematic analysis by a qualitative researcher independent to the data collection. RESULTS: Data from 16 academics in 13 separate chiropractic programs revealed five, interconnected themes: Immediate response; Move to online delivery; Impact on learning and teaching; Additional challenges faced by educators; and Ongoing challenges post lockdown. CONCLUSION: This study used a qualitative descriptive approach to describe how some chiropractic programs immediately responded to the initial outbreak of the COVID-19 pandemic in their teaching of manual therapy techniques. Chiropractic programs around the world provided their students with rapid, innovative learning strategies, in an attempt to maintain high standards of chiropractic education; however, challenges included maintaining student engagement in an online teaching environment, psychomotor skills acquisition and staff workload.

COVID 19 and manual therapy: international lessons and perspectives on current and future clinical practice and education.

BACKGROUND: The COVID-19 pandemic has altered clinical practice and education in manual therapy globally. Social distancing has limited in-person care and changed health-care provision. Education in manual therapy has moved to online platforms with in-person instruction restricted. The global impact on the clinical practice of manual therapy and education has to date not been explored. METHODS: a questionnaire survey methodology was used. A sample of convenience of global leaders in manual therapy practice and education received an electronic link to two surveys: one on clinical practice and one on education. Contributors could complete one or both surveys. RESULTS: Twenty-five surveys were received on clinical practice and 23 on education in manual therapy, representing the six major continents. Global themes in clinical practice demonstrated a sudden and dramatic shift away from patient contact, with limited modifications to manual therapy in patient care currently adopted. Themes in education were of a major shift to online learning, development of new modes of student instruction including video-based assessment and virtual case-based instruction. CONCLUSION: The international perspectives provided demonstrate a major change in manual therapy practice and education globally. Various approaches have been taken in practice and education without a uniform approach being demonstrated.

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

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

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

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

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

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

Utilization and perception of live-blogging coverage of an international manual physical therapy conference.

Objective: The purpose of this study was to investigate the utilization and perception of live blogged sessions of a physical therapy (PT) conference. Methods: Sessions at an international PT conference were covered in real time using a live-blogging platform. Session coverage could be viewed remotely using computers and mobile devices. Viewers could interact with the content by clicking on links and using the comment feature. Sessions could also be replayed following their conclusion. An online survey of user perceptions was made available the week following the conference. Results: Twenty-four sessions were live blogged with an average session length of 67 min (range: 27-120). On average, live sessions received 27 views (range: 2-65), 18 clicks (range: 2-36), and 2 comments (range: 0-10). The average time spent viewing a live session was 28 min (32% of viewers <1 min; 68% >1 min). Following the conference, session replays totaled 7206 views and 2910 clicks. The average survey respondent (n = 17) watched five live sessions (range: 1-17) and found the updates easy to read (4.5 on a scale of 5.0). When asked if they learned something from the coverage, 94% of respondents said yes and 94% said they would view if available for an upcoming conference. Discussion: Live blogging extended the viewing audience and facilitated viewer engagement. Survey respondents found the coverage educational, of high quality, and would participate again in the future.

Estrategia metodológica para enseñar innovación en estudiantes de cinesiología / A methodological strategy to teach innovation in Kinesiology students

Introducción: Se realiza una adaptación del design thinking para enseñar innovación a estudiantes de cinesiología. Sujetos y métodos: Se utiliza un diseño cuasiexperimental con pre y postest y dos grupos de tratamiento evaluados con un cuestionario que mide la percepción de capacidad en habilidades para innovar. Resultados: Se obtuvieron diferencias significativas en ambos grupos con aumento en el postest. Conclusiones: La estrategia muestra un efecto importante sobre la calidad de los proyectos, la percepción de dominio y de capacidad para innovar

Introduction: This paper do an adaptation of design thinking methodology to teach innovation to Kinesiology students. Subjects and methods: It use a quasi-experimental design with pre and post-test, and two treatment groups evaluated with a questionnaire that measures capacity in innovation skills perception. Results: Shows statistically significant differences between the groups with an increase in the post-test. Conclusions: The strategy shows an important effect in the project quality, the domain perception and the perceived capacity to innovate

Study on Force Mechanism for Therapeutic Effect of Pushing Manipulation with One-Finger Meditation Base on Similarity Analysis of Force and Waveform.

OBJECTIVE: To reveal the force mechanism for therapeutic effect of pushing manipulation with one-finger meditation. METHODS: A total of 15 participants were recruited in this study and assigned to an expert group, a skilled group and a novice group, with 5 participants in each group. Mechanical signals were collected from a biomechanical testing platform, and these data were further observed via similarity analysis and cluster analysis. RESULTS: Comparing the force waveforms of manipulation revealed that the manipulation forces were similar between the expert group and the skilled group (P>0.05). The mean value of vertical force was 9.8 N, and 95% CI rang from 6.37 to 14.70 N, but there were significant differences compared with the novice group (P<0.05). The result of overall similarity coefficient cluster analysis showed that two kinds of manipulation forces curves were existed between the expert group and the skilled group. CONCLUSION: Pushing manipulation with one-finger meditation is a kind of light stimulation manipulation on the acupoint, and force characteristics of double waveforms continuously alternated during manual operation.

[Orthopaedic manual therapy : definition, characteristics and update on the situation in Belgium]. / La thérapie manuelle orthopédique : définition, caractéristiques et mise au point sur la situation en Belgique.

Although orthopaedic manual therapy (OMT) has existed for decades, and although a recent Belgian Royal Decree, published in 2014, recognized it as a particular professional qualification in physiotherapy for the treatment of neuromusculoskeletal dysfunctions, OMT remains little known by patients, but also by healthcare professionals. Yet, this professional qualification, based on clinical reasoning, using highly specific treatments, guided by the best available scientific and clinical evidence and the specific biopsychosocial characteristics of each patient, is the subject of a growing number of scientific studies pointing out its effectiveness. This article summarizes the knowledge related to OMT (definition, history, characteristics, techniques, indications, access and reimbursement) and describes its situation in Belgium.

Bien que la thérapie manuelle orthopédique (TMO) existe depuis des décennies et qu'un récent arrêté royal belge reconnaissant cette discipline comme une qualification professionnelle particulière en kinésithérapie pour la prise en charge des troubles neuro-musculo-squelettiques ait été publié en 2014, la TMO demeure méconnue des patients, mais également du monde médical. Pourtant, cette discipline, basée sur un raisonnement clinique, utilisant des approches thérapeutiques hautement spécifiques guidées par les meilleures évidences scientifiques et cliniques disponibles ainsi que par la spécificité biopsychosociale propre à chaque patient, fait l'objet d'un nombre croissant d'études scientifiques mettant en évidence son intérêt. Cet article vise à synthétiser les connaissances relatives à la TMO (sa définition, son historique, ses caractéristiques, ses techniques, ses indications, son accès et son remboursement, ainsi que son enseignement) en décrivant la situation en Belgique.

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

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

Risks in teaching manipulation techniques in master programmes.

High Velocity Techniques (HVT) in the (high) cervical spine are part of the standard curricula of manual therapy educational programmes. Little is known about the risk or the presence of adverse events during skills training sessions. This article describes two cases of students with both being at risk for an adverse event; one with a congenital artery aberration and one with cancer in the high cervical region. Teachers and educational programme developers should take risk management into account when teaching HVT.

Shoulder dystocia: guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF).

Shoulder dystocia (SD) is defined as a vaginal delivery in cephalic presentation that requires additional obstetric maneuvers to deliver the fetus after the head has delivered and gentle traction has failed. It complicates 0.5-1% of vaginal deliveries. Risks of brachial plexus birth injury (level of evidence [LE]3), clavicle and humeral fracture (LE3), perinatal asphyxia (LE2), hypoxic-ischemic encephalopathy (LE3) and perinatal mortality (LE2) increase with SD. Its main risk factors are previous SD and macrosomia, but both are poorly predictive; 50-70% of SD cases occur in their absence, and most deliveries when they are present do not result in SD. No study has proven that the correction of these risk factors (except gestational diabetes) would reduce the risk of SD. Physical activity is recommended before and during pregnancy to reduce the occurrence of some risk factors for SD (Grade C). In obese women, physical activity should be coupled with dietary measures to reduce fetal macrosomia and weight gain during pregnancy (Grade A). Women with gestational diabetes require diabetes care (diabetic diet, glucose monitoring, insulin if needed) (Grade A) because it reduces the risk of macrosomia and SD (LE1). Only two measures are proposed for avoiding SD and its complications. First, induction of labor is recommended in cases of impending macrosomia if the cervix is favorable at a gestational age of 39 weeks or more (professional consensus). Second, cesarean delivery is recommended before labor in three situations and during labor in one: (i) estimated fetal weight (EFW) >4500g if associated with maternal diabetes (Grade C), (ii) EFW >5000g in women without diabetes (Grade C), (iii) history of SD associated with severe neonatal or maternal complications (professional consensus), and finally during labor, (iv) in case of fetal macrosomia and failure to progress in the second stage, when the fetal head station is above +2 (Grade C). In cases of SD, it is recommended to avoid the following actions: excessive traction on the fetal head (Grade C), fundal pressure (Grade C), and inverse rotation of the fetal head (professional consensus). The McRoberts maneuver, with or without suprapubic pressure, is recommended first (Grade C). If it fails and the posterior shoulder is engaged, Wood's maneuver should be performed preferentially; if the posterior shoulder is not engaged, it is preferable to attempt to deliver the posterior arm next (professional consensus). It appears necessary to know at least two maneuvers to perform should the McRoberts maneuver fail (professional consensus). A pediatrician should be immediately informed of SD. The initial clinical examination should check for complications, such as brachial plexus injury or clavicle fracture (professional consensus). If no complications are observed, neonatal monitoring need not be modified (professional consensus). The implementation of practical training with simulation for all care providers in the delivery room is associated with a significant reduction in neonatal (LE3) but not maternal (LE3) injury. SD remains an unpredictable obstetric emergency. All physicians and midwives should know and perform obstetric maneuvers if needed, quickly but calmly.

Cervicogenic somatosensory tinnitus: An indication for manual therapy plus education? Part 2: A pilot study.

OBJECTIVES: The aim of this study was to evaluate the efficacy of Manual Therapy Utrecht (MTU) plus education in patients with cervicogenic somatosensory tinnitus (CeT). STUDY DESIGN: Pretest-posttest design. METHOD: Five hundred and six patients were referred or referred themselves. A subgroup of patients was identified with CeT, and within this a subgroup with tinnitus sensitization (TS). Two CeT groups were created based on the presence or absence of TS. Both groups underwent manual therapy combined with tinnitus education. Tinnitus intensity (VAS-tin 0-100 mm) was the primary outcome measure. Number of treatments and adverse effects were the secondary outcome measures. RESULTS: A total of 122 patients with CeT (24.1%) were included (average age 53.3 years [±9.8], female 38.5% and duration of tinnitus 7.3 years [±8.9]). Patients were divided into two groups: 55 patients (45.1%) with TS (CeT + TS group) and 67 patients (54.9%) without TS (CeT - TS group). Pretest to posttest differences on the VAS-tin were statistically significant within both groups (CeT - TS group: difference VAS-tin 5.9 [p = 0.01]; CeT + TS group: difference VAS-tin 18.2 [p = 0.00]), and between the groups in favor of the CeT + TS group (difference VAS-tin 12.3 [p = 0.01]). Pretest to posttest differences were clinically significant for the CeT + TS group (difference VAS-tin 18.2 [MCIC = ≥10 mm VAS-tin]) and between the groups (difference VAS-tin 12.3 in favor of the CeT + TS group). The average number of treatment sessions was 9.6 (±2.6) for the CeT - TS group and 10.3 (±2.5) for the CeT + TS group, a non-significant difference. There were no adverse effects in either group. CONCLUSIONS: Despite its limitations, this study provides valuable information on both the characteristics of patients with CeT and TS in a Dutch primary care manual therapy practice and on the potential effectiveness of MTU combined with tinnitus education for the subgroup of CeT + TS patients.

Cervicogenic somatosensory tinnitus: An indication for manual therapy? Part 1: Theoretical concept.

Tinnitus can be evoked or modulated by input from the somatosensory and somatomotor systems. This means that the loudness or intensity of tinnitus can be changed by sensory or motor stimuli such as muscle contractions, mechanical pressure on myofascial trigger points, transcutaneous electrical stimulation or joint movements. The neural connections and integration of the auditory and somatosensory systems of the upper cervical region and head have been confirmed by many studies. These connections can give rise to a form of tinnitus known as somatosensory tinnitus. To date only a handful of publications have focussed on (cervicogenic) somatosensory tinnitus and manual therapy. Broadening the current understanding of somatosensory tinnitus would represent a first step towards providing therapeutic approaches relevant to manual therapists. Treatment modalities involving the somatosensory systems, and particularly manual therapy, should now be re-assessed in the subgroup of patients with cervicogenic somatosensory tinnitus. The conceptual phase of this study aims to uncover underlying mechanisms linking the auditory and somatosensory systems in relation to subjective tinnitus through (i) review of the literature (part 1) and (ii) through design of a pilot study that will explore characteristics of the study population and identify relevant components and outcomes of manual therapy in patients with cervicogenic somatosensory tinnitus (part 2). This manuscript focusses the theoretical concept of (cervicogenic) somatosensory tinnitus, either with or without secondary central tinnitus or tinnitus sensitization.

Quantification of Motion Palpation.

CONTEXT: The palpation of motions is at the heart of the practice of foreign-trained osteopaths. When practicing osteopathic manual therapy (care provided by foreign-trained osteopaths) in the cranial field or osteopathic cranial manipulative medicine, the palpation of small motions (several tens of micrometers) is a key process. However, to the authors' knowledge, the smallest detectable motion has not been identified. OBJECTIVE: To quantify motion detection capacity by passive palpation. METHODS: Participants were instructed to hold a mechanical device containing a micrometric actuator between their hands and report when they felt motion while 6 series of 27 random motions were generated by the actuator. After each series, if a participant succeeded or failed to detect motion with a confidence level of greater than 98%, the motions in the next series were set to a smaller or larger magnitude, respectively. After 6 series, the individual motion detection capacity was recorded. Statistical significance was set at P=.02. RESULTS: A total of 21 participants were selected, comprising 14 osteopaths and 7 nonosteopaths. The average performance of the sample was 148 µm. Thirteen participants (62%) perceived motions of 200 µm or less, and 7 participants (33%) detected motions of 50 µm or less with bare hands. Osteopathic training did not notably affect the performance. Osteopaths were twice as likely to claim detection of nonexisting motions than to miss existing ones, whereas nonosteopaths were equally subject to both types of errors. CONCLUSION: The data show human passive palpatory sensitivity to be in the range of several tens of micrometers. This range is comparable to that reported for calvarial motion (10-50 µm).

Thrust joint manipulation curricula in first-professional physical therapy education: 2012 update.

STUDY DESIGN: Descriptive online observational survey. OBJECTIVES: To identify the extent of thrust joint manipulation (TJM) integration into first-professional physical therapy program curricula. BACKGROUND: The most recent survey of TJM curricula was published in 2004, with a wide variation in faculty responses noted. Since that time, faculty resources have been developed and TJM language in "A Normative Model of Physical Therapist Professional Education" from the American Physical Therapy Association has been updated, leaving the current status of TJM education in curricula unknown. METHODS: Faculty from 205 accredited physical therapy programs were invited to participate in an anonymous 35-item electronic survey during the summer of 2012. RESULTS: Seventy-two percent of programs responded to the survey, with 99% of programs teaching TJM and 97% of faculty believing TJM to be an entry-level skill. Cervical spine TJM is still being taught at a lower rate than techniques for other body regions. Faculty deemed 91% and 77% of students, respectively, at or above entry-level competency for implementing TJM in their clinical practice upon graduation. Most respondents indicated that increased utilization of TJM during clinical affiliations (78%) and lab hours (78%) would be beneficial to the student's knowledge/application of TJM. CONCLUSION: The utilization of TJM and faculty perceptions in first-professional physical therapy programs in the United States have evolved over the past decade. With TJM content more fully integrated into educational curricula, programs can now look to refine teaching strategies that enhance learning outcomes.

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

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