In Japan, physiotherapists who have approximately 5 years or 10 years of work experience, qualify as ‘experienced’ as someone with sufficient time in the field, regardless of their level, efficacy or quality of training. However, this definition is insufficient in establishing quality and uniformity among physiotherapists in Japan. In order to begin quantifying skill, it is first necessary to establish the feasibility of distinguishing between what the Japanese Physical Therapy Association (JPTA) considers ‘experienced’ from ‘novice’ based on basic physical therapy treatment technique and approach. The purpose of this study is to establish groundwork for standardization in education and evaluation.
Physiotherapy education in Japan began in 1963, and the JPTA was established in 1966. Undergraduate education for physical therapists in Japan consists of graduation from a three-year technical college, a four-year technical college or university program, as well as passing a national examination to become a licensed physiotherapist. A total of at least 800 hours of practical training is required during the course of study, however, educational methods vary depending on the facility where the training takes place and instructor. In addition, students may enter graduate school after graduation from training school, however, this is left to the decision of the individual, and not all physiotherapists go on to graduate school. JPTA considers lifelong learning to be important. Therefore, it provides physiotherapists with opportunities to learn skills, knowledge, and various other subjects.
In the area of skills, the more experienced physiotherapists teach the less experienced in clinical practice, and they teach based on individual therapists’ experience. Similarly, common skills should be taught equally in schools, but they are also taught based on experience. Therefore, physiotherapy education depends on the way of thinking of staff at each institution. In physiotherapy education, it is important to differentiate between experienced and novice, but firstly, it is necessary to define ‘experienced’. As previously mentioned, these differences tended to be distinguished by years of therapists’ unstandardized experience (5 years of practical experience permits the teaching of other physiotherapy students, with the approval of a governing association board) (Ministry of health, Labour and Welfare, 2019).
Additionally, in Japan, both experienced and new physiotherapists charge for physiotherapy at the same fee/rate under the public insurance system, which does not foster the desire to improve one’s own skills. Due to the aforementioned points, it is challenging to secure a minimum quality of physiotherapy services. For that reason, it is important to objectively evaluate the teaching methods in undergraduate training, as well as physiotherapy skills pre- and post-education.
There are the basic physiotherapy skills: range of motion (ROM) exercise (Cleland et al., 2010), manual muscle testing (MMT) (Florence et al., 1992), muscle strengthening exercise (Fowler et al., 2001), weight-bearing (Suchak et al., 2008), weight-shifting (WS) (Pizzi et al., 2007) and others. It is considered that these basic physiotherapies are major components of the quality of physiotherapy. Consequently, these are skills that are frequently used by physiotherapists. Therefore, it is considered that helping to standardize knowledge in physiotherapy skills by quantifying the influence (positive and/or negative effect) on the patient during the treatment by a physiotherapist is necessary. While there are many opportunities to practice ROM exercises, MMT, and muscle strengthening exercises in training school education, WS is a skill that is often learned after going into clinical practice. The influence of undergraduate education can be disregarded because it is learned post-graduation. For this reason, WS was chosen as the participant in this study. In addition, it was assumed to be a component until loading to the lower leg of one foot in the WS technique. This technique is a therapeutic technique and force plates are not used in therapeutic situations. However, if it becomes clear that force plates can be used to confirm the technique, it will be possible to objectively evaluate and improve the technique in future undergraduate and clinical education.
It is meaningful to establish objective evaluation and instruction of physiotherapy skills in the training and post-institutional education of physiotherapists. As a preliminary step, the purpose of this study was to clarify the characteristics of physiotherapy skill from the center of pressure (COP) and ground reaction force (GRF) of the simulated patient during WS of one of the basic physiotherapy skills was analyzed, as well as differences according to years of therapists’ experience and to which institution they were affiliated with.
Participants were 10 physiotherapists (6 clinical physiotherapists and 4 physiotherapy educators) from two institutions: average years of therapists’ experience of 14.5 ± 6.9 years.
The WS while standing (with the therapist guiding from behind) was repeated three times on a simulated patient where the speed of movement was at the discretion of the therapist (see Figure 1). All participants tried the task with the same simulated patient. Then, participants guided the simulated patient using bilateral manipulation from the posterior side at the lateral part of the pelvis. Next, participants guided WS to the right without the contralateral lower extremity lifting off the floor. First, participants shifted the weight of the simulated patient to the right direction from the pelvis. Second, participants shifted them left again, back to the upright standing position, and performed this three times. This study focuses on only the frontal plane form of the walking motion.
The GRF of the simulated patient was recorded during the task using force plates (AMTI). The COP was calculated from the GRF. The ratio of COP displacement was calculated by dividing COP displacement by the distance between both foot pressure canters of the simulated patient at the time to normalize.
Starting position of a simulated patient was upright. Participants shifted the ‘patient’ from upright standing to the right (a) and back to upright (b). This was repeated three times.
The mean and standard deviation were calculated for the ratio of COP displacement and the maximum GRF. Normality was tested using a Shapiro-Wilk test (this method tests whether the data are normally distributed). Correlational statistical analysis was used to confirm whether years of experience changes the degree of WS. In addition, it was compared by a non-paired t-test for statistical examination between their institutions. For the data analysis, SPSS software version 27.0 was used. The significance level was determined at 0.05.
The correlation coefficient between years of experience and degree of WS was r = -0.24 for the ratio of COP displacement and r = -0.07 for the maximum GRF.
The therapists’ years of experience for institution A (n = 3) was 17.5 ± 5.0 years, and for institution B(n = 7) was 12.5 ± 7.8 years.
The ratio of COP displacement and the maximum GRF are shown in Table 1. Institution A (n = 3) was 0.49 ± 0.07 and institution B (n = 7) was 0.25 ± 0.10, and there were significant differences between each institution’s ratios (p < 0.05). Institution A (n = 3) was 508.71 ± 1.53 N and institution B (n = 7) was 440.25 ± 51.00 N, and there were significant differences in the maximum GRF between institutions (p < 0.05).
|The ratio of COP displacement *||The maximum GRF *|
|Institution A (n=3)||0.49 ± 0.07||508.71 ± 1.53|
|Institution B (n=7)||0.25 ± 0.10||440.25 ± 51.00|
Mean ± SD. * Difference between institution A and institution B is statistically significant, at p<0.05.
Discussion and Conclusion
In this study, the ratio of COP displacement and the maximum GRF of a simulated patient was examined by means of WS, which is one of the basic physiotherapy skills. Subsequently, correlation between the data and years of therapists’ experience was explored. In addition, the differences according to their institution to clarify the characteristics of physiotherapy skill. As a result, weak negative correlation was confirmed between years of therapists’ experience and the ratio of COP displacement, while no correlation was found between years of therapists’ experience and the maximum GRF. There were significant differences in the ratio of COP displacement and the maximum GRF during WS when compared between institutions.
The results of this study confirm that the correlation between the data obtained and years of therapists’ experience is weak or absent. Form the results, suggest that there may be no difference in therapist’s command of the basic physiotherapy skills past their 6th year. Therefore, it was considered that the duration of years of therapists’ experience was not necessarily related to physiotherapy skill, at least in the performance of the specific skill evaluated in this study. However, the participants of this study had from 6 to 27 years of experience as therapists. Therefore, they all met the minimum of 5 years of therapists’ experience as per the clinical practice supervisor requirement in Japan. In the future, it will be necessary to include physiotherapy students, clinical physiotherapists and physiotherapy educators in their first to fifth year, and increase the number of participants to examine the differences in skill regarding the basic physiotherapy principles between different years of therapists’ experience. In addition, it will need to get information from the participants on how much additional training they have had/which courses they have attended.
In addition, especially in WS which is not often seen in post-graduate skill training in the basic physiotherapy skills, it is possible that they may not recognize the difference in years of therapists’ experience. For that reason, it is necessary to verify physiotherapy skills of all other basic physiotherapy principles by means of a practical evaluation or examination.
On the other hand, it was hypothesised that the factor that showed significant differences in the ratio of COP displacement and the maximum GRF between institutions was postgraduate education. WS is rarely taught at training schools of physiotherapy unlike ROM exercises and MMT. Additionally WS is not often taught even in clinical skill training at institutions as mentioned above. In addition, some institutions are planning the education for new physiotherapists, due to the number of new physiotherapists increasing rapidly. But other institutions are unable to perform education, as a result of the number of physiotherapy educators being too low. Consequently physiotherapist skills of these institutions are low too, because experienced educators are not present. This has a knock-on effect year after year.
Based on the above, it was clear that there were differences based on each institution regarding the characteristics of physiotherapy skill from the COP and GRF of the simulated patient during WS (one of the basic physiotherapy skills). Consequently, it was considered that the duration of years of therapists’ experience does not necessarily correlate with their physiotherapy skills when they have greater than 6 or more years of therapists’ experience. In the future, it is necessary to verify that physiotherapy skills and teaching methods are dependent on individual therapists’ experience (within a specific institution) as this in turn affects physiotherapy education.
It is considered that helping to gain knowledge in physiotherapy skills by quantifying and standardizing the aspects of physical movement during treatment by a physiotherapist or physiotherapy student as well as teaching methods for educators. This in turn will influence patient care. Subsequently, this study will help to transform experiential knowledge into formal knowledge.
Ministry of health, Labour and Welfare. (2019). Guidelines for guidance of physiotherapist and occupational therapist training facilities. Retrieved on 10 April 2022 from https://www.japanpt.or.jp/assets/pdf/info/20181009_02/02_Guideline_hikakuhyo_181005.pdf
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