Manipulative Physiotherapists Research Articles

Use of the International IFOMPT Cervical Framework to inform clinical reasoning in postgraduate level physiotherapy students: a qualitative study using think aloud methodology

BackgroundVascular pathologies of the head and neck are rare but can present as musculoskeletal problems. The International Federation of Orthopedic Manipulative Physical Therapists (IFOMPT) Cervical Framework (Framework) aims to assist evidence-based clinical reasoning for safe assessment and management of the cervical spine considering potential for vascular pathology. Clinical reasoning is critical to physiotherapy, and developing high-level clinical reasoning is a priority for postgraduate (post-licensure) educational programs.ObjectiveTo explore the influence of the Framework on clinical reasoning processes in postgraduate physiotherapy students.MethodsQualitative case study design using think aloud methodology and interpretive description, informed by COnsolidated criteria for REporting Qualitative research. Participants were postgraduate musculoskeletal physiotherapy students who learned about the Framework through standardized delivery. Two cervical spine cases explored clinical reasoning processes. Coding and analysis of transcripts were guided by Elstein’s diagnostic reasoning components and the Postgraduate Musculoskeletal Physiotherapy Practice model. Data were analyzed using thematic analysis (inductive and deductive) for individuals and then across participants, enabling analysis of key steps in clinical reasoning processes and use of the Framework. Trustworthiness was enhanced with multiple strategies (e.g., second researcher challenged codes).ResultsFor all participants (n = 8), the Framework supported clinical reasoning using primarily hypothetico-deductive processes. It informed vascular hypothesis generation in the patient history and testing the vascular hypothesis through patient history questions and selection of physical examination tests, to inform clarity and support for diagnosis and management. Most participant’s clinical reasoning processes were characterized by high-level features (e.g., prioritization), however there was a continuum of proficiency. Clinical reasoning processes were informed by deep knowledge of the Framework integrated with a breadth of wider knowledge and supported by a range of personal characteristics (e.g., reflection).ConclusionsFindings support use of the Framework as an educational resource in postgraduate physiotherapy programs to inform clinical reasoning processes for safe and effective assessment and management of cervical spine presentations considering potential for vascular pathology. Individualized approaches may be required to support students, owing to a continuum of clinical reasoning proficiency. Future research is required to explore use of the Framework to inform clinical reasoning processes in learners at different levels.

The Musculoskeletal 30-question multiple choice questionnaire (MSK-30): a new assessing tool of musculoskeletal competence in a sample of Italian physiotherapists

BackgroundThe prevalence and cost of musculoskeletal diseases increased dramatically over the past few decades. Therefore, several institutions have begun to re-evaluate the quality of their musculoskeletal educational paths. However, current standardized questionnaires inadequately assess musculoskeletal knowledge, and other musculoskeletal-specific exams have limitations in implementation. The musculoskeletal 30-question multiple choice questionnaire (MSK-30) was proposed as a new tool for assessing basic musculoskeletal knowledge.AimTo analyse basic musculoskeletal knowledge in a sample of Italian physiotherapists by administering the MSK-30 questionnaire.MethodsAfter a transcultural adaptation process, the MSK-30 was developed and administered to Italian physiotherapists to assess their musculoskeletal knowledge. Participants were invited to participate in the survey via the SurveyMonkey link. Mann-Whitney test and the Kruskal-Wallis test with Bonferroni correction were used to observe the differences between groups in the MSK-30 scores.ResultsFour hundred-fourteen (n=414) physiotherapists participated in the survey. The median MSK-30 value was higher in physiotherapists who attended the International Federation of Orthopaedic Manipulative Physical Therapists postgraduate certification than in those who attended unstructured postgraduate training in musculoskeletal condition or in those who had not completed any postgraduate training in this field (p<0.001).ConclusionsThis work demonstrates significant differences in the management of musculoskeletal disorders between those with specific postgraduate university education and those without. The findings can contribute to the advancement of the physiotherapy profession in Italy. Authors recommend further research with more robust methodologies to deeper understand this topic. Musculoskeletal conditions will continue to represent a significant portion of primary care visits, and future generations of physiotherapists must be prepared to address this challenge.

Abstracts from the New Zealand Manipulative Physiotherapists Association Conference

Abstracts from the New Zealand Manipulative Physiotherapists Association Conference

Risk assessment of vascular complications following manual therapy and exercise for the cervical region: diagnostic accuracy of the International Federation of Orthopaedic Manipulative Physical Therapists framework (The Go4Safe project).

What is the diagnostic accuracy of the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) framework to assess the risk of vascular complications in patients seeking physiotherapy care for neck pain and/or headache? Cross-sectional diagnostic accuracy study. One hundred and fifty patients seeking physiotherapy for neck pain and/or headache in primary care. Nineteen physiotherapists performed the index test according to the IFOMPT framework. Patients were classified as having a high, intermediate or low risk of vascular complications, following manual therapy and/or exercise, derived from the estimated risk of the presence of vascular pathology. The reference test was a consensus medical decision reached by a vascular neurologist and an interventional neurologist, with input from a neuroradiologist. The neurologists had access to clinical data and magnetic resonance imaging of the cervical spine, including an angiogram of the cervical arteries. Diagnostic accuracy measures were calculated for 'no contraindication' (ie, the low-risk category) and 'contraindication' (ie, the high-risk and intermediate-risk categories) for manual therapy and/or exercise. Sensitivity, specificity, predictive values, likelihood ratios and the area under the curve were calculated. Manual therapy and/or exercise were contraindicated in 54.7% of the patients. The sensitivity of the IFOMPT framework was low (0.50, 95% CI 0.39 to 0.61) and its specificity was moderate (0.63, 95% CI 0.51 to 0.75). The positive and negative likelihood ratios were weak at 1.36 (95% CI 0.93 to 1.99) and 0.79 (95% CI 0.60 to 1.05), respectively. The area under the curve was poor (0.57, 95% CI 0.49 to 0.65). The IFOMPT framework has poor diagnostic accuracy when compared with a reference standard consisting of a consensus medical decision.

Manual therapy improves symptom severity and disability in patients with carpal tunnel syndrome

Aim: The aim of the study was to assess early outcomes of manual therapy in patients with carpal tunnel syndrome. Materials and methods: In this study, patients diagnosed with electrophysiologically confirmed carpal tunnel syndrome received manual therapy. The therapy was used in 41 individuals who received one session in line with IFOMPT (International Federation of Orthopaedic Manipulative Physical Therapists) standards per week for 5 weeks. Grip strength was assessed using a dynamometer, disability was assessed using the DASH (Disability of Arm, Shoulder and Hand) questionnaire, and the quality of life was assessed using VASEQ5D5L (Visual Analog Scale of the 5-level EQ-5D). Data was collected before the first treatment and one week after the last treatment. Results: We observed significant change in DASH score and quality of life. Grip strength tended to improve, but the effect was statistically significant only in patients over 50 years of age. Symptom severity (Carpal Tunnel 6 score, Douleur Neuropathique 4 score and peripheral cutaneous threshold assessed with Semmes–Weinstein monofilament) improved significantly. There was no significant correlation between changes in DASH score and grip strength. Conclusion: Manual therapy significantly improves quality of life and reduces upper limb disability in patients with carpal tunnel syndrome.

International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention: International IFOMPT Cervical Framework.

SYNOPSIS: This position statement, stemming from the International IFOMPT (International Federation of Orthopaedic Manipulative Physical Therapists) Cervical Framework, was developed based upon the best contemporary evidence and expert opinion to assist clinicians during their clinical reasoning process when considering presentations involving the head and neck. Developed through rigorous consensus methods, the International IFOMPT Cervical Framework guides assessment of the cervical spine region for potential vascular pathologies of the neck in advance of planned interventions. Within the cervical spine, events and presentations of vascular pathologies of the neck are rare but are an important consideration as part of patient examination. Vascular pathologies may be recognizable if the appropriate questions are asked during the patient history-taking process, if interpretation of elicited data enables recognition of this potential, and if the physical examination can be adapted to explore any potential vasculogenic hypothesis. J Orthop Sports Phys Ther 2023;53(1):7-22. Epub: 14 September 2022. doi:10.2519/jospt.2022.11147.

Accreditation of advanced clinical practice in musculoskeletal physiotherapy: Multi-methods analysis to inform implementation of advanced practice in the United Kingdom

Purpose: Physiotherapists are experts in managing patients with musculoskeletal (MSK) conditions. The international Educational Standards from the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) ensures the appropriate postgraduate level of clinical practice, governance and quality of care in MSK physiotherapy internationally. The fast-evolving physiotherapy scope of practice in the UK has led to the development and implementation of Advanced Clinical Practice (ACP). This study aimed to map the IFOMPT Educational Standards to the Multi-professional Framework for ACP in England and the Musculoskeletal Core Capabilities Framework for First Contact Practitioners. Further, the study evaluated physiotherapy stakeholders’ thoughts, views and perceptions about the potential accreditation of advanced practice for MSK physiotherapy in the UK and the governance procedures that are required to assure the quality of practice.

Interexaminer Agreement and Reliability of an Internationally Endorsed Screening Framework for Cervical Vascular Risks Following Manual Therapy and Exercise: The Go4Safe Project.

ObjectiveClinicians are recommended to use the clinical reasoning framework developed by the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) to provide guidance regarding assessment of the cervical spine and potential for cervical artery dysfunction prior to manual therapy and exercise. However, the interexaminer agreement and reliability of this framework is unknown. This study aimed to estimate the interexaminer agreement and reliability of the IFOMPT framework among physical therapists in primary care.MethodsNinety-six patients who consulted a physical therapist for neck pain or headache were included in the study. Each patient was tested independently by 2 physical therapists, from a group of 17 physical therapists (10 pairs) across The Netherlands. Patients and examiners were blinded to the test results. The overall interexaminer agreement, specific agreement per risk category (high-, intermediate-, and low-risk), and interexaminer reliability (weighted κ) were calculated.ResultsOverall agreement was 71% (specific agreement in high-risk category = 63%; specific agreement in intermediate-risk category = 38%; specific agreement in low-risk category = 84%). Overall reliability was moderate (weighted κ = 0.39; 95% CI = 0.21–0.57) and varied considerably between pairs of physical therapists (κ = 0.14–1.00).ConclusionThe IFOMPT framework showed an insufficient interexaminer agreement and fair interexaminer reliability among physical therapists when screening the increased risks for vascular complications following manual therapy and exercise prior to treatment.ImpactThe IFOMPT framework contributes to the safety of manual therapy and exercise. It is widely adopted in clinical practice and educational programs, but the measurement properties are unknown. This project describes the agreement and reliability of the IFOMPT framework.

Short-term effects of the traction-manipulation protocol in dizziness intensity and disability in cervicogenic dizziness: a randomized controlled trial

Purpose Analyse the short-term effects of traction-manipulation protocol in dizziness and pain intensity and disability, cervical mobility and postural instability. Materials and methods Randomized controlled assessor-blind clinical trial. The traction-manipulation protocol was carried out in the intervention group and compared with a control group where the subjects were kept supine. The intervention protocol follows the IFOMPT safety recommendations. Dizziness and pain intensity, Dizziness Handicap Inventory (DHI), cervical mobility and balance were measured after 48 h and a one-month follow-up. Results Forty subjects with cervicogenic dizziness were randomly assigned to an intervention or control group. Significant differences were found in favour of the intervention protocol group in: dizziness intensity (p < 0.001; d = 1.31), DHI (p < 0.001; d = 0.76) pain intensity (p < 0.007; d = 0.92), upper cervical flexion (p < 0.032; d = 0.30) and extension (p < 0.012; d = 0.80) at 48 h follow up. At one-month follow up there were significant differences in favour of the intervention group in: dizziness intensity (p < 0.001; d = 0.95), DHI (p < 0.001; d = 0.0.92) pain intensity (p < 0.001; d = 1.38) and upper cervical extension (p < 0.005; d = 0.92). Postural instability improved in mediolateral displacement static with eyes closed (p < 0.032; d = 0.79) and in dynamic with eyes open (p = 0.003; d = 0.55) at one-month follow-up in the intervention group. Conclusion The traction-manipulation protocol reduces the dizziness and pain intensity, ameliorates disability and improves upper cervical mobility and postural instability. IMPLICATIONS FOR REHABILITATION The intervention protocol reduces the dizziness and pain intensity, and improves self-perceived disability in patients with cervicogenic dizziness. Manual therapy improves the cervical range of motion and the postural instability in the cervicogenic dizziness. The intervention protocol follows the safety recommendations of the International Federation of Orthopaedic Manipulative Physical Therapists.

Thoracic thrust joint manipulation: An international survey of current practice and knowledge in IFOMPT member countries

BackgroundThe perceived relative safety of thoracic thrust joint manipulation (TTJM) has contributed to a growth in evidence supporting use in practice. Yet adverse events (AE) have been documented following TTJM. Knowledge of current practice is therefore required to support further research. PurposeTo investigate TTJM knowledge and pre-TTJM examination across IFOMPT Member Organisations (MO) and Registered Interest Groups (RIG). MethodsAn e-survey was designed based on existing evidence and piloted. Eligibility criteria: physiotherapists from member countries of the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) who use TTJM. Recruitment was through IFOMPT networks (May 2018–March 2019). Data analyses included descriptive analyses and content analysis for free text data. ResultsRespondents (n = 363) from 20 countries. Pre-TTJM examination included patient history (22%, n = 81) and physical examination (69%, n = 248). Across presentations (>80% threshold of agreement) contraindications included osteomyelitis, fracture and metastatic disease. Spinal deformity, respiratory disease, serious joint disease and hypermobility achieved >60% agreement as precautions. Consent was obtained by 93% respondents (n = 250). Preferred technique was PA/AP thrust (61%, n = 144). Perception of primary effect was neurophysiological (52%, n = 134), biomechanical (42%, n = 109) and placebo (3%, n = 8). From those who reported AE (n = 100), these included fractures (36%, n = 42) and cord signs/symptoms (6%, n = 7). ConclusionPre-TTJM examination is common, although bias towards physical examination. Differential testing for upper versus lower thoracic spine is limited. Inconsistencies across knowledge of contraindications and precautions, and beliefs for biomechanical effect were found. Findings highlight the importance of high levels of clinical reasoning during patient history for TTJM.

Management of whiplash-associated disorder in the Italian emergency department: the feasibility of an evidence-based continuous professional development course provided by physiotherapists

Purpose The management of whiplash and associated disorders (WAD) in the Italian Health System is still empirical and influenced by a single professional’s expertise. Therefore, the purpose of our study is to describe a structured management changes in an Italian emergency department (ED) after an evidence based continuous professional development (CPD) course. Methods A CPD course was organized by Orthopedic Manipulative Physical Therapists (OMPT) for personnel of ED in the hospital Girolamo Fracastoro (San Bonifacio, Verona, Italy), based on latest scientific evidence. Data regarding the number of X-Rays, computed tomography (CT) scan, orthopaedic referrals, neck collars and WAD IV (i.e., severe diagnosis) before and after the course were compared. Results 3066 cases of WAD have been analyzed in 2016 and 2185 in 2017/2018. The number of X-Rays dropped down from 15.1% to 13.5%; the CT scans increased from 1.3% to 1.9%; the WAD IV diagnosis increased from 0.7% to 1.6%; the orthopaedic referrals dropped from 1.5% to 1.1%; the collars prescription dropped from 8.8% to 2.5%. Conclusion An updated framework increased the efficiency of ED’s maintaining the same level of safety (i.e., WAD IV diagnosis). Given that, it can also be argued that, in line with other countries, the implementation of an OMPT role within the ED multidisciplinary team is advised also in Italy. Implications for rehabilitation Physiotherapists were commissioned to organize a management change of patients in an Italian Emergency Department clinical setting for the management of whiplash; Guidelines and other appropriate clinical rules facilitate the delivery of an evidence-based and more appropriate management and care plan; An inter-disciplinary continuous professional development course has the potential to positively influence patients’ journey and to optimize the use of departmental resources; The involvement of other health professionals (e.g., Physiotherapists) within the Italian Emergency Department organizational chart might lead to further improvement of service provided.

Predictors of instantaneous relief from spinal manipulation for non-specific low back pain: a delphi study

BackgroundThere is some evidence and anecdotal reports that high-velocity low-amplitude (HVLA) spinal manipulation therapy (SMT) for non-specific low back pain (NSLBP) may immediately reduce pain in some patients. The mechanism for such a change remains unclear and the evidence is conflicting. The aim of this study was to seek consensus among a sample of expert manual therapists as to the possible clinical predictors that could help identify patients who are most likely to receive instant relief from NSLBP with SMT intervention.MethodsThirty-seven expert chiropractors and manipulative physiotherapists from around the world were invited to participate in a three round online Delphi questionnaire during the second half of 2018. Participants were provided with a list of 55 potential signs and symptoms as well as offering them the option of suggesting other factors in the first round. The variables were rated using a 4-point Likert likelihood scale and a threshold of 75% agreement was required for any item to progress to the next round.ResultsOf these 37 experts, 19 agreed to participate. Agreement as to the proportion of patients who receive instantaneous relief was minimal (range 10–80%). A total of 62 items were ranked over the 3 rounds, with 18 of these retained following the third round. The highest rated of the 18 was ‘A history including a good response to previous spinal manipulation’.Discussion/conclusionFive categories; patient factors, practitioner factors, signs and symptoms of NSLBP presentation, an instrument of measurement (FABQ), and the presence of cavitation following SMT best describe the overall characteristics of the factors. The 18 factors identified in this study can potentially be used to create an instrument of measurement for further study to predict those patients with NSLBP who will receive instantaneous relief post-SMT.

International Framework for Red Flags for Potential Serious Spinal Pathologies.

The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) led the development of a framework to help clinicians assess and manage people who may have serious spinal pathology. While rare, serious spinal pathology can have devastating and life-changing or life-limiting consequences, and must be identified early and managed appropriately. Red flags (signs and symptoms that might raise suspicion of serious spinal pathology) have historically been used by clinicians to identify serious spinal pathology. Currently, there is an absence of high-quality evidence for the diagnostic accuracy of most red flags. This framework is intended to provide a clinical-reasoning pathway to clarify the role of red flags. J Orthop Sports Phys Ther 2020;50(7):350-372. Epub 21 May 2020. doi:10.2519/jospt.2020.9971.

The use of smartphone apps in clinical practice: A survey of South African physiotherapists.

BackgroundThere is anecdotal evidence that physiotherapy clinicians increasingly are using medical apps and health-related apps as part of their clinical practice, and in some cases, even ‘prescribing apps’ to patients. However, there is limited information on how South African physiotherapists use, and what they think about, the integration of mobile apps in their practice.ObjectivesThis study aimed to describe the use of smartphone apps as part of clinical practice in a small group of South African physiotherapists.MethodThis study made use of a cross-sectional, descriptive design and a self-administered questionnaire to survey practitioners. The population included all 1300 physiotherapists who were registered with the Orthopaedic Manipulative Physiotherapists Group (OMPTG) of the special interest group of the South African Society of Physiotherapists (SASP), with a sample of 270 out of 1300 who responded (response rate = 21%). Descriptive data are presented using graphs, figures and percentages, and responses to open-ended questions are included in support of the themes.ResultsThe majority of the participants used apps as part of their practice (60%) but did not prescribe apps to patients. Most apps are used for administrative and communication purposes. Even clinicians who used apps themselves expressed concerns about prescribing them to patients, and there were clear misconceptions about the use of apps.ConclusionMany clinicians in this study reported that there were real benefits to the use of smartphone apps as part of their practice. However, they raised concerns about the more general prescription of apps for clients.Clinical implicationsFurther research, education and collaboration amongst all stakeholders is necessary to produce guidelines for the use of apps in clinical practice

Short-term effects of an upper cervical spine traction-manipulation program in patients with cervicogenic dizziness: A case series study.

Damage on the somatosensory system could cause sensation of dizziness, a condition known as cervicogenic dizziness (CD). Manual physical therapy has shown beneficial effects, relieving the symptoms of cervicogenic dizziness. However, the effect of upper cervical spine manipulation is unknown, as this is a technique that respects the International Federation of Orthopedic Manipulative Physical Therapists (IFOMPT) safety criteria. To assess the effects of upper cervical spine traction-manipulation in subjects with cervicogenic dizziness. This was a descriptive case series study. Treatment focused on the upper cervical spine manipulation procedure. Evaluation was performed before and after the treatment. Variables recorded include upper and lower cervical range of motion, Cervical Flexion-Rotation Test (CFRT), dizziness intensity and cervical pain (VAS), self-perceived dizziness measured with Dizziness Handicap Inventory (DHI) and subjective perception of outcome (GROC-scale). Ten subjects were recruited. After the treatment protocol, there was an increased range of movement towards the most restricted side, as measured by the CFRT (p< 0.001), decreased intensity of dizziness (p< 0.001) and intensity of pain (p< 0.001). Functional capacity also improved after the intervention (p< 0.011). Upper cervical spine manipulation may decrease dizziness intensity and cervical pain and improve functional ability and upper cervical spine mobility in patients with cervicogenic dizziness.

Large variability found in musculoskeletal physiotherapy scope of practice throughout WCPT and IFOMPT affiliated countries: An international survey

BackgroundAdvanced practice physiotherapy (APP) rights are part of the evolution of the Physical Therapy profession. To date, no study has investigated musculoskeletal APP rights within the World Confederation for Physical Therapy (WCPT). ObjectiveTo investigate musculoskeletal APP rights for physical therapists worldwide and examine the relationship between level of education (entry and post-professional) and direct access for countries that are vs. are not members of the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT). DesignCross-sectional study with descriptive and exploratory online surveys. MethodsAn electronic survey-based descriptive and exploratory investigation was conducted. We assessed variability between WCPT member organizations descriptively and the strength of the relationships among the number and types of APP rights with: (1) country affiliation to IFOMPT; (2) entry-level professional degree; (3) post-professional training; and (4) direct access. ResultsSome countries reported having the right to practice all 20 APP rights while others reported no APP rights. Countries with IFOMPT member organization countries displayed fair correlation (rs = .48, p < .03) between entry-level physical therapy degrees and number of APP rights. IFOMPT member organization countries were less likely to require post-professional training for direct access and manipulation. ConclusionAPP rights for countries with direct access were significantly higher than for countries without direct access. IFOMPT member organizations demonstrated higher APP rights prevalence and were less likely to require post-professional training to obtain the right to direct access and perform manipulation.

Physical Function ICU test – scored (PFIT-s)

Advanced practice physiotherapy (APP) rights are part of the evolution of the Physical Therapy profession. To date, no study has investigated musculoskeletal APP rights within the World Confederation for Physical Therapy (WCPT).To investigate musculoskeletal APP rights for physical therapists worldwide and examine the relationship between level of education (entry and post-professional) and direct access for countries that are vs. are not members of the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT).Cross-sectional study with descriptive and exploratory online surveys.An electronic survey-based descriptive and exploratory investigation was conducted. We assessed variability between WCPT member organizations descriptively and the strength of the relationships among the number and types of APP rights with: (1) country affiliation to IFOMPT; (2) entry-level professional degree; (3) post-professional training; and (4) direct access.Some countries reported having the right to practice all 20 APP rights while others reported no APP rights. Countries with IFOMPT member organization countries displayed fair correlation (rs = .48, p < .03) between entry-level physical therapy degrees and number of APP rights. IFOMPT member organization countries were less likely to require post-professional training for direct access and manipulation.APP rights for countries with direct access were significantly higher than for countries without direct access. IFOMPT member organizations demonstrated higher APP rights prevalence and were less likely to require post-professional training to obtain the right to direct access and perform manipulation.

Cervical artery dysfunction: updating the international federation of orthopaedic manipulative physical therapists (IFOMPT) consensus clinical reasoning framework for best practice

Cervical artery dysfunction: updating the international federation of orthopaedic manipulative physical therapists (IFOMPT) consensus clinical reasoning framework for best practice

Investigation of four self-report instruments (FABT, TSK-HC, Back-PAQ, HC-PAIRS) to measure healthcare practitioners' attitudes and beliefs toward low back pain: Reliability, convergent validity and survey of New Zealand osteopaths and manipulative physiotherapists

BackgroundHealthcare practitioner beliefs influence advice and management provided to patients with back pain. Several instruments measuring practitioner beliefs have been developed but psychometric properties for some have not been investigated. AimsTo investigate internal consistency, test-retest reliability and convergent validity of the Fear Avoidance Beliefs Tool (FABT), the Tampa Scale of Kinesiophobia for Health Care Providers (TSK-HC), the Back Pain Attitudes Questionnaire (Back-PAQ), and the Health Care Pain and Impairment Relationship Scale (HC-PAIRS). A secondary aim was to explore beliefs of New Zealand osteopaths and physiotherapists regarding low back pain. MethodFABT, TSK-HC, Back-PAQ, and HC-PAIRS were administered twice, 14 days apart. ResultsData from 91 osteopaths and 35 physiotherapists were analysed. The FABT, TSK-HC and Back-PAQ each demonstrated excellent internal consistency, (Cronbach's α = 0.92, 0.91, and 0.91 respectively), and excellent test-retest reliability (lower limit of 95% CI for intraclass correlation coefficient >0.75). Correlations between instruments (Pearson's r = 0.51 to 0.77, p < 0.001) demonstrated good convergent validity. There was a medium to large effect (Cohen's d > 0.47) for mean differences in scores, for all instruments, between professions. ConclusionsThis study found excellent internal consistency, test-retest reliability and good convergent validity for the FABT, TSK-HC, and Back-PAQ. Previously reported internal consistency, test-retest and convergent validity of the HC-PAIRS were confirmed, and test-retest reliability was excellent. There were significant scoring differences on each instrument between professions, and while both groups demonstrated fear avoidant beliefs, physiotherapist respondent scores indicated that as a group, they held fewer fear-avoidant beliefs than osteopath respondents.

August 2017 Letters to the Editor-in-Chief.

Letter to the Editor-in-Chief of JOSPT as follows: "Manual Therapy: More Than Elaborate Swordplay" with Authors' Response "Comparing Dry Needling to Corticosteroid Injection for Greater Trochanteric Pain Syndrome" with Authors' Response J Orthop Sports Phys Ther 2017;47(8):580-585. doi:10.2519/jospt.2017.0204.