Joint Manipulation Curricula: The Story Continues

Abstract

In this issue of the Journal of Physical Therapy Education, Neena K. Sharma, PT1 PhD1 CMPT, and Carla H. Sabus, PT, PhD, along with Tamara S. Struessel, PT, DPT, OCS, MTC, et al, have provided readers with interesting data that continues the story related to thrust joint manipulation curricula. Ioint manipulation provides a specific example for discussions related to a broader challenge facing physical therapist academicians: ensuring that classroom knowledge and skills are being transitioned to the clinical setting. It is doubtful that any single intervention has been studied more than joint manipulation related to physical therapist professional education. The original paper titled Manipulative therapy in physical therapy was published in 1973, l with follow-up curricula benchmark studies published in 1988,2 1997,3 and 2004.4 Besides describing to what degree and how this content area was being integrated into the curriculum, these benchmark studies identified potential barriers to students developing competence. There is no longer any question as to whether joint manipulation is an entry-level skill. The Commission on Accreditation in Physical Therapy Education's (CAPTE) Evaluative Criteria for Accreditation of Education Programs for the Preparation of Physical Therapists lists Manual Therapy (including Mobilization/Manipulation Thrust and Nonthrust Techniques under Curricular Content.5 Despite this, student competence and the transition from classroom to clinic is not guaranteed. In fact, faculty surveyed in 2004 stated that the most beneficial way for students to further develop joint manipulation skills was increased emphasis during clinical affiliations.4 This led to an investigation of joint manipulation clinical education opportunities for physical therapist students.6 Results published in 20066 revealed that approximately 70% of surveyed clinical instructors (CIs) did not teach students joint manipulation. The reasons provided included the following: (1) the belief that joint manipulation was not an entry-level skill, (2) CIs lack of expertise, (3) professional liability concerns, (4) the belief that students were not academically prepared, and (5) the belief that joint manipulation techniques were not appropriate for the clinic's patient population. A follow-up study revealed that for some CIs' previous negative personal experiences with joint manipulation as a patient or student led to their decision to not teach students this skill.7 The gap in the literature at this point was the student perspective related to use of joint manipulation as an intervention. Although student utilization of joint manipulation techniques was first described by Flynn, Wainner, and Fritz8 in 2006, the emphasis was on utilization rates, the timing of joint manipulation utilization (initial visit, interim, or discharge session), patient outcomes, and reported adverse events (none were reported). There was no mention of encountered barriers.8 The following articles by Sharma and Sabus,9 and Struessel et al10 provide us with the missing link: student insight on the topic of joint manipulation. Sharma and Sabus9 surveyed students completing clinical internships in outpatient orthopedic clinics, noting that almost 90% agreed or strongly agreed that they were academically prepared to use joint manipulation techniques. Despite this level of confidence, 50% performed joint manipulation during the internships. The most oft-cited reason for not using joint manipulation during the internship was the belief that the technique was not appropriate for the clinic's patient population, followed by a lack of CI joint manipulation training. Consistent with the previous survey of CIs,6 Sharmus and Sabus found a correlation between CI utilization (or lack of) of joint manipulation and student utilization.9 The primary limitation of this study was the sample of students being from one physical therapy program. …