Physiotherapy skills in the difference of years of therapists’ experience and affiliations

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Authors: Okayama Y, RPT, PhD1, and Daikuya S, RPT, PhD2
Institutions: 11Department of Physical Therapy, Osaka University of Human Sciences; 22Faculty of Health and Medical Sciences, Hokuriku University
DOI: to be allocated
Date submitted: 05/04/2022

Abstract

In Japan, physiotherapist is quantified ‘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. The purpose of this study is to establish groundwork for standardization in education and evaluation. Therefore, it was to clarify physiotherapy skills by means of a Weight Shifting (WS) practical assessment. Participants of this study were 10 physiotherapists from 2 institutions. The WS was repeated 3 times on a simulated patient. The ground reaction force (GRF) of the simulated patient was recorded during the task. The ratio of the center of pressure (COP) displacement was calculated by dividing COP displacement by the distance between the center of pressure of both feet of the simulated patient to normalize. Correlational statistical analysis was used to confirm whether years of experience changes the degree of WS. The obtained data was compared between their institutions. The results of this study confirm that the correlation between the data obtained and years of therapists’ experience is weak or absent. There were significant differences between each institution’s ratios for COP displacement as well as the maximum GRF. It was considered that years of therapists’ experience does not necessarily correlate with physiotherapy skill, especially if they have 6 or more years of experience. Greater differences were observed between institutions with regards to the characteristics of physiotherapy skill.

Physiotherapy skills in the difference of years of therapists’ experience and affiliations

Background

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.

Methods

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.

Figure 1. Weight-shifting as a basic physiotherapy skill.
Starting position of simulated patient was upright. Participant shifted ‘patient’ from upright standing to the right (a) and back to upright (b). Repeated 3 times.

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.

Results

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 ± 0.07508.71 ± 1.53
Institution B (n=7)0.25 ± 0.10440.25 ± 51.00
Table 1. The ratio of COP displacement and the maximum GRF at institution.
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.

References

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​

Cleland, J. A., Mintken, P. E., Carpenter, K., Fritz, J. M., Glynn, P., Whitman, J., & Childs, J. D. (2010). Examination of a clinical prediction rule to identify patients with neck pain likely to benefit from thoracic spine thrust manipulation and a general cervical range of motion exercise: Multi-center randomized clinical trial. Physical Therapy and Rehabilitation Journal, 90, 1239-1250.

Florence, J. M., Pandya, S., King, W. M., Robison, J. D., Baty, J., Miller, J. P., & Schierbecker, J. (1992). Intrarater reliability of manual muscle test (medical research council scale) grades in duchenne’s muscular dystrophy. Physical Therapy and Rehabilitation Journal, 72, 115-122.

Fowler, E. G., Ho, T. W., Nwigwe, A. I., & Dorey, F. J. (2001). The effect of quadriceps femoris muscle strengthening exercises on spasticity in children with cerebral palsy. Physical Therapy and Rehabilitation Journal, 81, 1215-1223.

Pizzi, A., Carlucci, G., Falsini, C., Lunghi, F., Verdesca, S., & Grippo, A. (2007). Gait in hemiplegia: Evaluation of clinical features with the Wisconsin gait scale. Journal of Rehabilitation Medicine, 39, 170- 174.

Suchak, A. A., Bostick, G. P., Beaupré, L. A., Durand, D. C., & Jomha, N. M. (2008). The influence of early weight-bearing compared with non-weight-bearing after surgical repair of the achilles tendon. The Journal of Bone and Joint Surgery, 90, 1876-1883.

Reviews

Author: Kim Buchholtz
Review date: 9 November 2022
DOI: to be allocated
Permalink: Review - Physiotherapy skills in the difference of years of therapists’ experience and affiliations

Thank you for the opportunity to review this article. I appreciate the effort taken to perform these tests and to write this study, but have a few concerns that would need to be addressed before it is ready for publication.

  1. Complete, coherent, and well-organized presentation:

There are some small English grammar errors that need some attention, but they do not affect the understanding of the paper. A final English check would be good before publication. For example: In the 1st and 3rd paragraph there are 2 sentences starting with ‘And’… this should be corrected to be appropriate for scientific writing. This error also appears in the Discussion section. The paper is presented in a logical manner, but the content is missing some key information to understand the links between education and study selected.

  1. Sufficient explanation of the significance of the problem:

I think a little more context in the introduction would be helpful, for example, an explanation of what the undergraduate physio training in Japan consists of (how many years, clinical exposure, level of degree). Some information on how long physio has been accredited in Japan could also help to provide background on why there is a gap in this area. This will help the reader to understand why ‘education for novice physios is not enough in Japan’ as stated in the background. Can you provide some examples of possible post graduate studies? Which courses are available, are there masters degree to specialise? What do physios usually do to gain additional skills?

  1. Clear demonstration of the relevance to the field (beyond the case presented):
  2. Original contribution to the topic of physiotherapy education:

This has potential to be interesting if the link to physiotherapy education can be strengthened. It would be very interesting to understand more about the context of physiotherapy training, both undergraduate and postgraduate, in Japan.

  1. Compelling presentation of the problem within a theoretical framework (where appropriate):

 

6. Establishment of a relationship between the problem and other relevant literature:

It is difficult to understand why the WS has been selected as the technique measured. Based on the reference used, it doesn’t appear to be a validated assessment tool. It seems to have been used as a treatment technique in the article (Pizzi et al) which was on gait in hemiplegia rather than WS. To make it clear what specific items you are using to determine skill, it would be helpful to include in the methods exactly which components in the WS technique you are measuring and how they would indicate skill in the therapist. If you can clearly justify the link between the technique used and how experience could be detected using this technique then it will significantly increase the importance of this paper. It would also help to show whether the physios recruited were generally working on neuro patients, because this must also be considered in terms of experience. If they have been a physio for 10 years but only seen neuro patients for 2 years then maybe the experience is not accurate? I think it would also be helpful to discuss when this skill is usually taught at an undergrad or postgrad level as it is not something that I have seen taught in this manner on force plates at other English-speaking universities (in Europe and Africa) and it is possible that there are differences in the curricula across the continents. This would help greatly to understand the decision for using this assessment as a measure of skill.

  1. Appropriate research design and method:

The design of the study is appropriate, but a clear rationale for the use of the assessment is needed. It is not clear how the test is an indication of competence or skill. In the background you mention experienced defined as 5 years, but then in your analysis you have used 11 years, so this needs to be clearly explained in your methods section. Maybe remove the reference of 5 years from the background section to avoid confusion. Is it possible to get information from the participants on how much additional training they have had/which courses they have attended so that you can include information on both experience in terms of years, but also additional training which could influence skill?

  1. Accurate and useful interpretation:

As the initial justification of the study is not clear, it is difficult to fully review whether the interpretation is accurate. In your discussion you mention that ‘there may be no difference in therapists command of the basic physiotherapy skills past their 6th year’… I think this is a very large assumption. You do later explain that it may be specific to this skill, but it might not be an appropriate to state this assumption at all.

  1. Sound argument and analysis:
  2. Effective conclusion about the implications for physiotherapy education, research, and/or practice:

The link between education and the technique used to assess the practitioners is not clear. This needs to be explained in greater detail so that the reader can clearly understand the implications in education of physio and how this research can be used to develop further skill training for physios.

Author: Ben Ellis
Review date: 5 August 2022
DOI: to be allocated
Permalink: Review - Physiotherapy skills in the difference of years of therapists’ experience and affiliations

Thank you for submitting this article. Overall your article addresses a potentially interesting topic, however there are some areas in which I think the article would benefit from some significant revision, particularly in relation to establishing the relevance and rationale of the research question.

The article has a clear overall structure and is organised appropriately for this type of study. However the key issue that I struggled with was understanding the premise for your research project in relation to how clinical skill was being evaluated using the study methodology. In order to provide sufficient explanation of the problem and demonstrate the relevance of your research it would be helpful to clarify and provide evidence to support what skilled performance of the weight shift task looks like and how your chosen outcome measures can therefore demonstrate differences in skill between groups of participants. It is not inherently clear to me that greater or lesser displacement of COP or ground reaction force during this task would be associated with different levels of clinical skill. My presumption would be that when looking to support a patient to shift weight, that either too much movement of the COP or conversely not enough would both be less effective (and potentially less safe), and that skilled clinicians may be more likely to adapt the amount and direction of weight shift in response to an individual patient. Establishing the rationale for using these measures as a proxy for clinical skill in your introduction is necessary to link the background that you present to your study methodology in order to show that this was an appropriate research design to answer your question.

In addition I would question the definition of novice and experienced clinicians used in the study given that all clinicians had over 5 years practice experience. The definition of experience as over 11 years needed justification as this appeared arbitrary. This distinction needs to be more clearly based on a theoretical framework for expertise development linked to this skill.

The methods are clearly described and repeatable, including appropriate  justification and selection of statistical analysis. Results are clearly presented. However the interpretation and analysis of results is unclear when these are discussed in the context of skill development and expertise. This relates back to the need to establish the premise for using these measures as a proxy for skill performance. The difference between institutions is not clearly relevant. The sample size is too small to draw any firm conclusions from as to the relevance of this finding and more data relating to training or other variables would be needed to support the assertion that any difference may be associated with educational differences between institutions.

The study conclusions are not clearly related to the findings. I wasn’t clear whether the implication was that using this methodology to quantify weight shift had potential utility in physiotherapy education, but this is not supported by the study findings.

Bearing in mind these overall comments, please find below further comments relating to each section:

Abstract:

This provides a concise overview. It would benefit from more clearly stating the research aims and briefly establishing why the methodology is appropriate to answer the question as discussed above, which would also help focus the conclusions.

Introduction/background

The introduction provides some broad background, but as discussed above, does not currently provide sufficient clarity on the research objectives or rationale for the methodology as a means to achieve them. This section would benefit from greater use of literature in developing the rationale for the study including considering a theoretical framework of development of expertise to explain why greater expertise may result in different application of the practical skill, and to provide a link to physiotherapy education to justify why understanding differences in skill performance between different groups of clinicians may be relevant to physiotherapy educational practice.

Methods

The methods themselves are clearly described and repeatable. The participant demographic information should come at the start of the results section rather than in the methods. There could be an argument for using correlational statistical analysis to see whether years of experience changes the degree of weight shift rather than comparison of means given the arbitrary cut-off between novice and experienced clinician.

Results

The results are clearly presented. The tables would benefit from including which differences are significant and the level of significance. Some of the wording to describe groups could be reviewed for clarity – eg “at each year of experience” suggests that the groups are more stratified than they are.

Discussion

In line with the previous recommendations, clearer establishment of why your data is a useful proxy for clinical skill in the introduction would help to support your discussion. Currently the discussion is based on your perceptions of the findings and does not place your findings in the context of other literature. Relating your findings to theoretical frameworks of skill development and other empirical findings of skill development will strengthen the critical analysis of your results. In addition, considering the strengths and limitations of your own study methodology in this section would add critical appraisal and help to consider more specific implications for future research.

Conclusions:

The concluding paragraph does not currently clearly relate to the study aims and objectives. Having a clearer rationale for how your study is attempting to answer the it’s questions in the introduction will allow you to draw your discussion together towards addressing those aims. More specific implications for practice and future research, that consider the validity of your findings will strengthen this section.

Thank you again for submitting this article. I would be interested to see a future iteration of it and happy to continue the discourse.

Conflict of interest statement

There are no conflicts of interest to declare.

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