Competency revalidation study of specialty practice in sports physical therapy.

IJSPT

ORIGINAL RESEARCH

COMPETENCY REVALIDATION STUDY OF SPECIALTY PRACTICE IN SPORTS PHYSICAL THERAPY Edward P. Mulligan, PT, DPT, SCS, OCS, ATC1 Mark D. Weber, PT, PhD, SCS, ATC2 Mark F. Reinking, PT, PhD, SCS, ATC3

ABSTRACT Background and Purpose: Every ten years the American Board of Physical Therapy Specialties conducts a practice analysis to revalidate and revise the description of specialty practice for sports physical therapy (SPT). The primary purpose of this paper is to describe the process and results of the most recent analysis, which defines the competencies that distinguish the subspecialty practice of (SPT). Additionally, the study allowed for the comparison of responses of board certified specialists in SPT to respondents who were not specialists while reflecting on demographic changes and evolving trends since the previous analysis of this physical therapy specialty practice was conducted 10 years ago. Methods: A survey instrument based on guidelines from the American Board of Physical Therapy Specialties was developed by the Sports Specialty Council (SSC) and a panel of subject matter experts (SME) in SPT to re-evaluate contemporary practice. The instrument was pilot tested and following revisions, was sent to 1780 physical therapists, 930 of whom were board certified specialists in SPT and 850 of whom were randomly selected members of the Sports Physical Therapy Section (SPTS) who were not board certified specialists in SPT. 414 subjects returned completed surveys for a 23% response rate. 235 of the respondents were known to be board certified sports specialists, 120 did not indicate their specialty status, and 35 were non-specialists in SPT. All were members of the SPTS of the American Physical Therapy Association. The survey responses were analyzed using descriptive statistics. Univariate comparisons were performed using parametric and nonparametric statistical tests in order to evaluate differences between specialist and non-specialist item responses. Results: The survey results were reviewed by the SSC and a panel of SME. Using a defined decision making process, the results were used to determine the competencies that define the specialty practice of SPT. Survey results were also used to develop the SPT specialty board examination blueprint and define the didactic curriculum required of accredited SPT residency programs. A number of significant comparisons between the specialists and non-specialists were identified. Conclusion: The competency revalidation process culminated in the publication of the 4th edition of the Sports Physical Therapy Description of Specialty Practice in November of 2013. This document serves to guide the process related to the attainment and maintenance of the board certified clinical specialization in SPT. In anticipation of the continued evolution of this specialty practice, this process will be repeated every 10 years to reassess the characteristics of these providers and the factors they consider critically important and unique to the practice of SPT. Keywords: Continued Competence, Practice Validation, Sports Certified Specialist, Sports Physical Therapy Clinical Specialization

1

UT Southwestern School of Health Professions, Dallas, TX, USA 2 University of Mississippi Medical Center, Jackson, MS, USA 3 Saint Louis University, Saint Louis, MO, USA Acknowledgments: The authors would like to acknowledge the efforts of the members of the subject matter expert panel (Mike Rosenthal, Barbara Springer, Teresa Schuemann, Mike Fink, Matt Briggs, and Patrick Pabian), the consultants, members of the American Board of Physical Therapy Specialists, and the Department of Specialist Certiﬁcation, American Physical Therapy Association. This study would not have been possible without the support, direction, and guidance these individuals provided.

CORRESPONDING AUTHOR Edward P. Mulligan 1901 Pintail Parkway Euless, TX 76039 E-mail: [email protected]

The International Journal of Sports Physical Therapy | Volume 9, Number 7 | December 2014 | Page 959

INTRODUCTION Sports physical therapy is a specialized subset of physical therapy practice that focuses on the health care management of the physically-active individual that has been injured in or aspires to return to athletic endeavors. The sports physical therapist establishes a customized plan of injury prevention, injury management, or performance enhancement in order to enable and maximize the athlete’s participation in sporting activities. Additionally, they have important administrative, educational, and ethical responsibilities to ensure the safety and well-being of the athlete. Performance of these responsibilities requires the sports physical therapist to be able to effectively communicate with athletes, coaches, parents, administrators, and other healthcare professionals. 1,2,9 Specialist certification exists to provide formal recognition for sports physical therapists that possess a unique body of knowledge with specific clinical expertise, experience, and skills in sports physical therapy. In 1978, the American Physical Therapy Association’s (APTA) House of Delegates identified a process by which physical therapists with advanced knowledge could be formally recognized as certified clinical specialists in their respective areas of specialization.2 The first four areas of specialization in physical therapy, cardiopulmonary, neurology, orthopedics, and pediatrics, were recognized that same year and were managed by the Commission for Certification of Advanced Clinical Competencies. In 1980 this commission became the Board for Certification of Advanced Clinical Competency (BRACC) and was the governing body that oversaw the administration and development of the specialization process. In 1985, the BRACC was replaced by the American Board of Physical Therapy Specialties (ABPTS), which has continued to regulate the clinical specialization process to present date.3 The Sports Physical Therapy Section (SPTS) initially began work on the clinical specialization process in the mid-1970s with the identification of advanced clinical competencies and completion of a task analysis. Through this process, 18 advanced competency statements (15 areas of clinical skills along with administration, education, and research) were developed and published by Skovly, et al, in

1980.4 In 1981, the SPTS petitioned the BRACC for recognition as a specialty area. The House of Delegates approved sports physical therapy as an area of specialization the same year.5 Subsequently; those therapists meeting the required criteria for this distinction were recognized as certified sports clinical specialists. After approval from the House of Delegates as an area of specialization, a second major study was conducted in order to validate the original competency statements. This validation study was completed in 1984 and guided the development and implementation of the examination used to identify clinical specialists in sports physical therapy from 1986-1994.6, 7 The ABPTS requires that each specialty area revalidate its competencies every 10 years to determine if any changes in the description of practice have occurred. The Sports Specialty Council (SSC) completed a revalidation study in 1992 and this study identified 30 different competency statements in nine different areas. The results of the 1992 revalidation study were used to create the Description of Advanced Clinical Practice (DACP) and to identify the competencies that would be assessed by the certification process.2 By defining the competencies related to the practice of sports physical therapy, the DACP provided interested individuals with a template for self-assessment in order to determine their readiness to engage in the certification process. In 2001, a second revalidation study of specialty practice was initiated. The purposes of this revalidation study were to assess the currency of competency statements regarding the practice of sports physical therapy and to develop a new Description of Specialty Practice (DSP) to replace the DACP. In addition to updating the description of the practice of sports physical therapy, per the ABPTS defined template, the DSP was to be consistent with the Guide to Physical Therapist Practice, 2nd edition.8 The survey was created in 2001, piloted and revised, and the final survey was distributed in 2002. Subsequently the members of a subject matter expert (SME) group and members of the SSC met to discuss the results of the survey and to write the DSP. The primary purpose of the 2001 study was to revalidate the competencies related to the specialty practice


of sports physical therapy. From this practice analysis, 53 competency statements were written in six competency areas. Additionally, the study allowed for the comparison of responses of board certified specialists in sports physical therapy to those of respondents who were not specialists. The results of this study were published in the North American Journal of Sports Physical Therapy in 2009 by Weber et al9 and a full description of each competency can be found in the document entitled “Sports Physical Therapy Description of Specialty Practice (DSP)”.7 In 2010, a third revalidation study of specialty practice was initiated to abide by the 10-year authentication mandate. The primary purpose of this paper is to describe the process and results of the most recent analysis which defines the competencies that distinguish the subspecialty practice of (SPT). The latest version of the sport physical therapy (SPT) DSP is available from the Department of Specialist Certification, American Physical Therapy Association.10 METHODS Practice Analysis Overview The SSC was responsible for carrying out the practice analysis within the framework developed by the ABPTS. The analysis was designed to define the professional practice behaviors and knowledge areas in the practice domain of sports physical therapy specialists. The initial step in the practice analysis was development of a survey questionnaire, which was undertaken by the SSC in collaboration with an ABPTS appointed consultant and an SME group in sports physical therapy. The supporting documents used to develop the questionnaire included the 2002 DSP, 7 the Guide to Physical Therapist Practice, 8 and the ABPTS approved survey instrument template. The initial form of the practice analysis questionnaire was piloted by a group of 30 active SPT members or current board certified sports specialists identified by the SME panel at the 2011 Combined Sections Meeting in New Orleans, LA. Input from the pilot study respondents were used to clarify current competencies, recommend potential new competencies, and identify any grammatical errors. Based on the consistent feedback from the pilot volunteers regarding survey burden based on the length, the SSC and ABPTS appointed revalidation consultant proposed that the

formal survey would allow respondents the option of completing only one of the three randomly assigned Sections of knowledge, professional roles, and patient/ client management. All respondents were requested to provide information on the percentage of body regions treated and the demographics section. This new survey format was approved by the ABPTS and resulted in four unique subgroups of respondents. One group only answered survey questions regarding sports physical therapy knowledge and professional roles, one group on patient/client examination, evaluation, diagnosis, and prognosis, one group on items regarding patient/client interventions and outcomes, and one group that chose to respond to all sections of the survey. Within these respective groups, not all respondents answered all items within their section. The final version of the survey questionnaire consisted of 188 items, 157 of which asked the participant to respond to that item on three different scales related to the frequency, importance, and level or judgment or mastery. The ordinal characteristics of these three scales are further explained in the section describing the survey instrument. The ABPTS approved form of the survey questionnaire was sent to all 930 current board-certified sports clinical specialists and 850 randomly selected nonspecialists who were members of the SPTS. A cover letter that accompanied the questionnaire explained the purpose of the study and encouraged respondents to return the survey within 10 days. Follow-up reminders were sent two, four, and eight weeks later to non-respondents. The survey was closed to additional data collection when the 8-week reminder notice was relatively unproductive in recruiting new respondents. Survey recipients were encouraged to contact the SSC Chair and project coordinator if they had questions about the survey. Following tabulation of the questionnaire responses, the revalidation panel including the SSC, SME panel, and the revalidation consultant reviewed the results. This panel met and, based on the survey results, developed the new DSP for sports physical therapy over a day-long caucus. Survey Instrument The survey instrument was based on the ABPTS mandated model and consisted of five sections: 1)


knowledge areas, 2) professional roles, responsibilities, and values, 3) patient/client management model, 4) ranking of body regions treated, and 5) demographic information. Each item in Section 1 was assessed on three scales: frequency (never, less than once a month, monthly, weekly, or daily), importance (not important, minimally important, moderately important, or very important) and level of judgment (do not use, recall, application, or analysis). Items in Sections 2 and 3 were assessed on the same frequency and importance scale but the level of judgment was replaced by a level of mastery scale (advanced beginner, competent, proficient, or expert skill level). Section 4 asked respondents to estimate the percentage of their patient populations based on body regions treated. Finally, Section 5 requested respondent demographic information. A copy of the survey instrument can be requested from the APTA Department of Specialist Certification. Sample The survey questionnaire was sent to 1780 physical therapists of which 930 were certified sports clinical specialists, hereafter referred to as specialists. This represented 100% of the total number of sports certified specialists at the time of the survey. Another 850 survey questionnaires were sent to randomly selected current members of the SPTS who were not certified sports clinical specialists, hereafter referred to as non-specialists. Data Analysis and Decision Model Survey responses and patient demographics were analyzed using standard descriptive statistical techniques (frequency charts, means, medians, and quartiles). Section 1 of the survey had 42 items measured on three different scales (frequency, importance, and judgment) giving a total of 126 data points. Section 2 of the survey had 18 items measured on three different scales (frequency, importance, and mastery) for a total of 54 data points. Finally, Section 3 of the survey had 97 items measured on three different scales (frequency, importance, and mastery) for a total of 291 data points. Because the entire survey had 471 data points, it was decided that for the SME panel to effectively interpret the results, the data should be collapsed into a more manageable set of data points.

The selected method was to add the results from the importance and level of judgment scales for Section 1 and add the results from the importance and level of mastery scales for Sections 2 and 3. The panel did so based on the collective experience from earlier revalidation studies in which it was found that these constructs (importance and judgment, importance and mastery) are strongly correlated. The results of Spearman’s correlation analyses on this data set supported this supposition. Never was an item was rated high on the importance scale and low on the judgment/mastery scales or vice versa. Utilization of this methodological approach reduced the number of data points in Section 1 to 42, in Section 2 to 18, and in Section 3 to 97. Frequency data was not included in the data collapse because it was recognized that there could be critical components of the sports physical therapy practice that only rarely occur (e.g. emergency management of significant cervical spine injuries). As such, the frequency results were available to the SME panel to inform discussion of items, but the combined importance and judgment/mastery scores were the primary results used to determine inclusion of an item in the DSP. Following this data collapse, descriptive statistics were obtained for each of the combined importance and judgment/mastery items. The combined items within each section were then ranked in descending order based on the median score using the mean score to break ties. To facilitate review and discussion, the ranked item list for each section was subdivided into quartiles. In April 2013, these data were distributed to the Specialty Council, the SME group, and the consultant for careful review. A meeting was then scheduled to discuss the survey findings, develop consensus on the decision model to determine the items that would be included in the new DSP, and formulate the new revised DSP. Consensus building determined the final competencies that currently describe sports physical therapy specialty practice. The process by which decisions were made regarding inclusion or exclusion of a competency item was discussed at length. The decision rule that was agreed upon was that all items ranked in the top three quartiles were included but those items ranked in the bottom quartile or below


the collective value of moderately important, proficient mastery, and application-level judgment were each separately discussed by the revalidation panel to determine their inclusion or exclusion in the final draft of the DSP. The panel reached 100% consensus on all items brought up for discussion. Additionally, responses from sports clinical specialists and nonclinical specialists were reviewed and compared. The rationale for not including a competency item in the new DSP included: (1) the competency median for Section 1 was below the moderately important level and application level of judgment, or for Sections 2 and 3 it was below the moderately important level and proficient mastery level; (2) the competency was considered to be an entry-level expectation; or (3) the competency did not differentiate between specialists and non-specialists. Following the development of the new sports physical therapy competencies, the panel developed the new board examination blueprint including the weighting and distribution of exam items. In addition to the new competencies, the decisions and development of the new blueprint was informed by the following sources: analyses of the current survey responses and existing examination blueprints from the 1994 Description of Advanced Clinical Practice and the 2002 DSP.7, 11 After reviewing all survey results and going through the decision model, the revalidation panel reorganized the competency categories using the model of physical therapy practice as described in the Guide to Physical Therapist Practice.8 Once the competency categories were determined, the panel incorporated the results from Section 4 (problems by body region) of the survey with the results from survey Sections 1 through 3 to determine the relative weighting of the examination content based on the competency categories. Examination content was not influenced by the type or nature of sports coverage reported by the respondents. The consensus decision regarding the breakdown of material for the examination is presented in Table 1. RESULTS Survey results from all mailings were combined for statistical analysis. A total of 414 respondents completed at least some portion of the survey (23% response rate). 259 of the respondents indicated they were board-certified clinical specialists in sports physical therapy, 120

Table 1. 2013 Description of Specialty Practice Competency Categories New DSP Categories

Target Percentage on Exam

Rehabilitation/Return to Sports: Examination/Evaluation/Diagnosis Prognosis, Interventions, and Outcomes Acute Injury/Illness Management Medical/Surgical Conditions Injury Prevention Sports Performance Enhancement Professional Roles and Responsibilities

20% 20% 15% 15% 15% 1 0% 5%

failed to indicate their board certification status, and 35 reported they were not board certified in sports physical therapy. Table 2 provides a demographic overview of the survey respondents. In the first three sections of the survey there were significant strong positive correlations between the importance and judgment/mastery scales for each item. Because of this consistent relationship, to reduce the number of analyses, the importance scales and judgment/mastery scales were summed. Based on the sum of these two scales, the items were rank-ordered by their mean summed scores. The maximum possible score was 6 and 0 was the minimum. Items with means closer to 6 were interpreted as having a greater perceived relevance to the practice of sports physical therapy. Tables 3 through 12 contain the knowledge, professional role, and patient/client management items that were a standard deviation above and below the mean as rated by all survey respondents. While all items from Section 1 of the survey were retained, the lowest ranked of the patient/client management model items tended to be associated with the physiology, evaluation, or management of medical diseases or conditions traditionally associated with primary care medicine. Based on the described decision process, all but one of the survey items was used to develop the DSP competencies. All items in Section 1 of the survey (knowledge areas) and Section 3 (patient/client management areas) met the pre-defined inclusion criteria. One item from Section 2 of the survey (professional roles) was not included in new DSP competencies. This item dealt with the development and implementation of policies and procedures related to drug testing and counseling. The consensus of the revalidation panel was that this item did not meet the judgment or importance threshold for the profession or sports


Table 2. Respondent Demographic Data Respondents Sex Male Female Ethnicity White (not of Hispanic origin) Asian or Pacific Islander Hispanic/Latino African American or Black (not of Hispanic origin) Other Age 25 – 34 yrs 35 – 44 yrs 45 – 54 yrs 55 – 64 yrs > 65 yrs Years in PT Practice 1-2 yrs 3-5 yrs 6-10 yrs 11-15 yrs 16-20 yrs 21-30 yrs 31 or more years Entry Level Professional Education Certificate Bachelor’s Master’s Doctorate Highest Earned Academic Degree No degree beyond entry level Advanced Master’s in Physical Therapy Advanced Master’s in Other Field Post-professional DPT Doctoral Degree Type of Practice Facility Private Outpatient Office or Group Practice Health System/Hospital Based Outpatient Clinic Athletic Organization Academic Institution Health & Wellness Facility Other Median Percentage of Time Spent in Professional Activities Direct Sports Patient/Client Care Direct Patient/Client Care, not Sports Teaching/Mentoring Administration/Management Consultation Athletic Field/Venue Coverage Research Provide Services in Athletic Venues Yes No Sport Category in Which Respondents Provide Athletic Venue Services Contact/Collision Sports Limited Contact Sports Non-contact Sports Respondents Who Completed a Credentialed Sports Physical Therapy Residency Yes No Respondents Who Have Additional Certifications Yes No Most Common Additional Certifications of Respondents Certified Strength and Conditioning Specialist Athletic Trainer, Certified Orthopedic Clinical Specialist

67% 33% 88% 7% 3% 1% 1% 34% 41% 17% 7% 1% 2% 15% 24% 28% 10% 17% 5% 4% 22% 44% 30% 48% 7% 9% 24% 13% 40% 33% 10% 9% 2% 3% 40% 30% 10% 10% 5% 5% 3% 69% 31%

65% 20% 10% 21% 79%

69% 31% 54% 47% 40%


Table 2. Respondent Demographic Data Referral Sources Orthopedic Surgeons Primary Care Physicians Primary Care Sports Medicine Physicians Autonomous Practice Physician Specialists Physician Assistants Podiatrists Nurse Practitioners Chiropractors Geographic Representation of Respondents AK, CA, HI, OR, WA CO, ID, MT, NV, NM UT, WY AR, LA, OK, TX DE, DC, FL, GA, MD, NC, SC, VA, WV AL, KY, MS, TN CT, ME, MA, NH, RI, VT NJ, NY, PA IA, KS, MN, MO, NE, ND, SD IL, IN, MI, OH, WI Patients/Clients Treated Per Day > 25 21-25 16-20 11-15 6-10 4.79 (mean) + 0.77 (SD)] Section 1 Knowledge Areas M ean Normal Movement Science: Kinesiology/Clinical Biomechanics 5.85 Human Anatomy/Physiology: Musculoskeletal System 5.85 Normal Movement Science: Principles of Coordination (e.g. balance, 5.79 agility, proprioception, kinesthesia) Pathology/Pathophysiology: Tissue Inflammation, Healing, and Repair 5.73 Medical/Surgical Considerations: Recognize the indications and contraindications associated with techniques related to the development of 5.72 an appropriate physical therapy program Human Anatomy/Physiology: Exercise Physiology and Sports Specific 5.72 Physiological Demands Normal Movement Science: Principles of Locomotion (e.g. running, 5.67 cycling, swimming) Human Anatomy/Physiology: Neuromuscular System 5.63 Medical/Surgical Considerations: Understand and recognize the goals, 5.62 principles, and surgical interventions used for common athletic injuries Pathology/Pathophysiology: Differential diagnosis including the sign and 5.57 symptoms of disease/injury. mean rank based on the sum of the importance and judgment scales for the item

physical therapy specialist. Two items from Section 1 and five from Section 3 did not meet the inclusion criteria but were retained in the practice description at the discretion of the SME panel. The two items from Section 1 that did not meet the inclusion criteria were 1) concepts regarding the anatomical and physiological knowledge of histology, and 2) the assessment, monitoring, and activity modifications related to endocrine dysfunctions and issues. The five items from Section 3 that did not meet the inclusion criteria but were retained in the description of practice were 1) evaluation of ventilation and respiration, 2)

SD 0.55 0.55 0.57 0.56 0.71 0.73 0.74 0.75 0.78 0.86

aerobic capacity testing, 3) assessment of human performance enhancement, 4) application of physical agents and electrotherapeutic modalities, and 5) education of those involved with sports in regard to issues related to the reproductive system. The decision to include these criteria was based on the panel discussion and consensus that these items are a part of the specialty practice of a sports physical therapist. In regards to professional roles (Tables 5 and 6) the survey respondents rated consultation and education to all members of the athletic rehabilitation team


Table 4. Items from Section 1 (Knowledge) that were 1 Standard Deviation Below the Mean for all Knowledge Areas {< 4.79 (mean) – 0.77 (SD)] Section 1 Knowledge Areas Medical/Surgical Considerations: Recognize the indications and contraindications associated with infectious diseases as the relate to development of an appropriate physical therapy program Medical/Surgical Considerations: Understand the use and purpose of ancillary tests to sports medicine (e.g. lab studies, EKG, electrophysiological exams) Human Anatomy/Physiology: Other Body Systems (e.g. endocrine, reproductive, digestive) Medical/Surgical Considerations: Recognize the indications and contraindications associated with genitourinary conditions as the relate to development of an appropriate physical therapy program Medical/Surgical Considerations: Recognize the indications and contraindications associated with gastrointestinal disorders as the relate to development of an appropriate physical therapy program Human Anatomy/Physiology: Histology

M ean SD 3.97

1.34

3.79

1.29

3.45

1.23

3.43

1.48

3.29

1.51

2 .9 2

1.52

mean rank based on the sum of the importance and judgment scales for the item

Table 5. Items from Section 2 (Professional Roles) that were 1 Standard Deviation Above the Mean for all Professional Roles [> 4.24 (mean) + 0.55 (SD)] Section 2 Professional Roles Consultation and Education: Educate and provide recommendations to athletes, parents, coaches, and athletic administrators regarding appropriate training principles, participation risk, physical demands and limitations, equipment or other areas which impact the health and well-being of athletes Critical Inquiry for Evidence Based Practice: Identify and interpret available evidence to answer clinical question Critical Inquiry for Evidence Based Practice: Maintain continued competence in sports physical therapy by participating in professional development (e.g. residency education , seminars, journal clubs) Critical Inquiry for Evidence Based Practice: Appropriately apply research findings to clinical practice

Mean SD 5.09

1.00

4.87

1.09

4.81

1.09

4.80

1.13

mean rank based on the sum of the importance and mastery scales for the item

Table 6. Items from Section 2 (Professional Roles) that were 1 Standard Deviation Below the Mean for all Professional Roles [< 4.24 (mean) – 0.55 (SD)] Section 2 Professional Roles Administration: Develop departmental policies and procedures (e.g. productivity measurement, financial management, marketing and public relations, staff orientation, employee supervision Administration: Develop and implement policies and procedures related to drug testing and counseling

M ean SD 3.59

1.52

2.92

1.71


(including coaches, parents, and athletic administrators) as the most important and critical role. Additionally, both identification and appropriate utilization of current best evidence from the literature were rated as important roles of the sports physical therapist yet the essential elements of analyzing, interpreting, or contributing to the body of literature were rated much lower.

Tables 7 through 12 contain information regarding survey respondent rating of skills related to patient/ client examination, evaluation, diagnosis, prognosis, intervention, and outcomes. Most of the lower ranking items from the patient management component of the survey were items more traditionally considered to be of greater importance in the domains of cardiopulmonary and integumentary physical therapy


Table 7. Items from Section 3 (Patient/Client Management: Examination, Evaluation, Diagnosis, and Prognosis) that were 1 Standard Deviation Above the Mean for all Management Areas [ > 4.56 (mean) + 0.62 (SD)]

Table 8. Items from Section 3 (Patient/Client Management: Examination, Evaluation, Diagnosis, and Prognosis) that were 1 Standard Deviation Below the Mean for all Management Areas [ < 4.56 (mean) – 0.62 (SD)] Section 3 Patient/Client Examination, Evaluation, Diagnosis, and Prognosis Mean SD Prognosis: Determine the extent of a genitourinary injury and possible sequelae to appropriately determine whether the athlete has the ability to 3.85 1.44 continue participation without incurring further injury 1.28 Examination: Select and perform tests and measurements to assess 3.85 environmental considerations (e.g. weather, altitude, venue conditions) Examination: Select and perform tests and measurement to assess skin 3.85 1.20 characteristics (e.g. color, texture, moisture, body temperature) Prognosis: Determine the extent of an integument injury (e,g, lacerations, abrasions, nail bed injuries) and possible sequelae to appropriately determine 3.74 1.24 whether the athlete has the ability to continue participation without incurring further injury Examination: Select and perform tests and measurements relevant to prosthetic devices (e.g. assessment of appropriateness, compliance, remediation of 3.67 1.55 impairment, alignment and fit, safety) Examination: Select and perform tests and measurements to assess anthropometric characteristics (e.g. body composition, body dimensions3.61 1.27 height, weight, girth, and edema Examination: Select and perform tests and measurements to assess ventilation and respiration /gas exchange (e.g. breathing patterns, chest wall mobility, 3.49 1.28 perceived exertion, pulmonary function testing) Examination: Select and perform tests and measurements to assess aerobic capacity/endurance (e.g. treadmill/ergometer submaximal and maximal stress 3.27 1.30 testing)


practice. In regards to intervention strategies, lower value was assigned to the procedures related to electrotherapeutics or physical agent modalities as compared to exercise, functional activities, education, and emergency care. Tables 13 and 14 contain the items from Sections 1, 2, and 3 of the survey in which specialist respon-

dents differed in their response from those respondents who were not specialists. These comparisons were made using a Mann-Whitney test. Due to the large number of items in the survey, the use of the Bonferroni correction technique for multiple univariate comparisons was not appropriate. As such, the results presented in the tables must be interpreted with caution; however, they perhaps provide some


Table 9. Items from Section 3 (Patient/Client Management: Patient/ Client Intervention that were 1 Standard Deviation Above the Mean for all Management Areas [> 4.56 (mean) + 0.62 (SD)] Section 3 Patient/Client Intervention Intervention: Implement performance-based functional progression programs to determine an athlete’s ability and readiness to return to desired activity Intervention: Provide patient/client education on diagnosis, prognosis, intervention, responsibility, and self-management based on evaluation of an athlete’s physiological condition, type and stage of injury, repair/recovery process and specific sport requirements Intervention: Provide therapeutic exercise instruction to improve muscle performance, joint mobility, muscle length, and aerobic capacity/endurance based on evaluation of an athlete’s physiological condition, type and stage of injury, repair/recovery process and specific sport requirements) Intervention: Emergency care and safety precautions for cervical, thoracic, and lumbar injuries

Mean SD 5.57

0.65

5.42

0.73

5.39

0.78

5.37

0.78


Table 10. Items from Section 3 (Patient/Client Management: Patient/ Client Intervention) that were 1 Standard Deviation Below the Mean for all Management Areas [< 4.56 (mean) – 0.62 (SD)] Section 3 Patient/Client Intervention M ean Intervention: Select, prescribe, apply, and as appropriate, fabricate orthotic devices and equipment to minimize acuity of injury and facilitate recovery 3.93 and return to competition Intervention: Educate athletes, coaches, family members, and administration on issues related to transmission and prevention of infectious 3.93 agents Intervention: Provide counseling and education on the risks and dangers related to performance enhancement substances (e.g. hormones, 3.88 prohormones, blood doping) Intervention: Select, prescribe, apply, and as appropriate, fabricate assistive and adaptive devices and equipment to minimize acuity of injury and 3.88 facilitate recovery and return to competition Intervention: Provide management and return to play recommendations for athletes presenting with integumentary disorders (e.g. dermatitis, fungal, 3.82 viral, or bacterial infections) Intervention: Inspect practice and competition venues for potential safety 3.82 risks Intervention: Educate and counsel athletes and coaches on banned 3.81 substances common to Olympic, collegiate, and professional sports Intervention: Educate athletes, coaches, and administrators on sports 3.25 participation and issues related to the reproductive system Intervention: Utilize electrotherapeutic modalities,(e.g. biofeedback, high volt stimulation, interferential current, TENS, iontophoresis, functional and neuromuscular electrical stimulation) based on evaluation of an athlete’s 3.24 physiological condition, type and stage of injury, repair/recovery process and specific sport requirements Intervention: Utilize physical agents (e.g. ultrasound, cryotherapy, deep thermal, hydrotherapy, superficial thermal) based on evaluation of an 3.24 athlete’s physiological condition, type and stage of injury, repair/recovery process and specific sport requirements mean rank based on the sum of the importance and mastery scales for the item

SD 1.24

1.43

1.42

1.24

1.50 1.60 1.51 1.45

1.42

1.55

Table 11. Items from Section 3 (Patient/Client Management: Patient/ Client Outcomes) that were 1 Standard Deviation Above the Mean for all Management Areas [ > 4.56 (mean) _ 0.62 (SD)] Section 3 Patient/Client Outcomes Mean SD Outcomes: Implement sport-specific testing criteria to determine athlete’s 5.39 0.88 readiness to return to participation Outcomes: Recommend level of athlete sports participation based on results 5.37 0,80 of sport specific testing mean rank based on the sum of the importance and mastery scales for the item *response differed between specialists and non-specialist


Table 12. Item from Section 3 (Patient/Client Management: Patient/ Client Outcomes) that was 1 Standard Deviation Below the Mean for all Management Areas [ < 4.56 (mean) – 0.62 (SD)] Section 3 Patient/Client Outcomes Outcome: Assessment of human performance enhancement (e.g. testing and measuring speed acceleration, VO2 Max, power, and other performance indicators)

Mean SD 3.84

1.42


explanatory analysis and insight into the differences in perception between specialists and non-specialists. The results presented in Tables 13 and 14 are ordered by their survey item number, not in a rank order.

4 of the survey, while head/maxillofacial/craniomandibular and forearm/wrist/hand ranked as the lowest weighted body regions. Table 15 provides the body region weighting by the survey respondents.

Shoulder and knee were ranked as the top two weighted body regions by the respondents in Section

Based on the survey data summarized in Tables 3 through 12 and the consensus opinion of the subject matter experts, the sports specialist examination blueprint was updated from the 2002 DSP. For the next 10-year cycle, beginning with the 2014 examination, 40% of the examination will be based on the patient management model as applicable to the examination, rehabilitation, and return to activity of athletes (20% on examination, evaluation, and diagnosis and 20% on prognosis, intervention, and outcomes). Acute injury and illness management, medical/surgical conditions, and injury prevention will each constitute 15% of the examination. Sports performance enhancement will constitute 10% of the examination, and the final 5% of the examination concerns professional roles and responsibilities.

Table 13. Section 1 (Knowledge) comparisons between specialists and non-specialists Item

t-Test p-value

Disease injury/epidemiology

p = 0.022

Infectious disease

p = 0.016

Mann Direction of Difference Whitney p-value p = 0.039 Specialists rated item as more important/critical p = 0.016 Specialists rated item as more important/critical

Table 14. Section 3 (Patient management) comparisons between specialists and non-specialists Item

t-Test p-value

Identify history of athlete’s major complaint(s) with regard to severity, chronicity, impairment, activity limitations, participation restrictions, level of irritability, previous therapeutic interventions, and emotional response to current situation

p = 0.016

Identify environmental considerations (weather, altitude, venue conditions)

p = 0.001

Assessment of sports specific biomechanics (e.g. kinetic, kinematic, and task analysis)

p = 0.036

Assessment of wounds (e.g. abrasions, lacerations, incisions)

p = 0.009

Educate, counsel, and recommend appropriate p = 0.028 electrolyte replenishment strategies during or following training or competition

Mann Direction of Difference Whitney p-value p = 0.011 Specialists rated item as more important/critical

p = 0.003 Specialists rated item as more important/critical



p = 0.041

Specialists rated item as more important/critical

DISCUSSION The primary purpose of this study was to revalidate the competencies that define the specialty practice of sports physical therapy. The results of the study led to the development of the current DSP published in November of 2013. The DSP defines the practice of sports physical therapy and is used as the guiding Table 15. 2013 Patient/Client Problems by Body Region as reported by survey respondents Body Region Thigh/Knee Shoulder Lumbar Spine Leg/Ankle/Foot Hip Cervica l Spin e Arm/Elbow Pelvic Girdle/Sacroiliac/Coccyx/Abdomen Thoracic Spine/Ribs Forearm/Wrist/Hand Head/Maxillofacial/Craniomandibular

% of Patients/Clients Treated 22% 20% 13% 11% 9% 7% 5% 5% 4% 3% 1%


document for the development of the sports physical therapy board certification examination as well as for the other requirements to attain and maintain the designation of a board certified sports physical therapist. Additionally, the DSP is used to define the curricular requirements of sports physical residency programs accredited by the American Board of Physical Therapy Residency and Fellowship Education. The DSP is available from the American Physical Therapy Association’s Department of Specialist Certification. Comparison to Previous Practice Analyses While comparisons to the 1994 description of advanced clinical practice are difficult because of changes in the survey methodology and historical evolvement of the profession it is possible to make comparisons between this new practice analysis and the DSP that was disseminated in 2002 and published in 2009.7, 9 Most survey items from the 2002 practice analysis were retained and only subject to clarification or reorganization by the SME panel. In regards to the two knowledge competency items retained in spite of failing the importance/judgment decision rule the SME panel believed that a foundational understanding of tissue healing and the monitoring of endocrine related diseases such as diabetes, abnormal thyroid function, and hypermegaly were important features of a specialist’s knowledge base. In addition there were two examination items and three intervention-related items from Section 3 of the survey (patient/client management) that did not meet the decision rule and required discussion and consensus by the SME panel. The panel agreed that based on the acute care nature of sports specialty practice, an understanding of the indications, contraindications, and precautions for the utilization of electrotherapeutic modalities and physical agents is a critical element in the management of many sports-related injuries. Additionally, although not responsible for the implementation or policies governing illegal drug screening processes, the panel felt it was important for the specialist to be able to make appropriate referral and educational recommendations to the athlete who has been identified as using illegal or dangerous performance enhancement substances. Specific to the lower-rated examination skills from Section 3, the panel agreed that the specialist must be able to recognize distressed

breathing patterns or ventilation issues as the specialist may periodically encounter athletes with asthma, rib fractures, pneumothorax, or vocal cord dysfunctions. Finally, the panel concurred that the ability to conduct aerobic capacity assessments such as submaximal stress tests were skills inherent to the expertise of a specialist. According to the respondents’ feedback the lowest rated item in Section 1 was the pathophysiological expertise related to histology. Ironically, the physiologic process of tissue inflammation, healing, and repair was one of the highest rated items. It would seem that the foundational knowledge of tissue histology would be necessary to maximize the therapeutic response in patient care. Not surprising was the premium value placed on knowledge concerning sports specific movement principles and biomechanical, musculoskeletal, and neuromuscular considerations as they relate to athletic activities and injuries. The lowest rated professional role by the respondents was developing and implementing policies and procedures related to drug testing and counseling. It may be that the relatively low percentage of respondents, who work for an athletic organization, where this responsibility would be more common, is the reason for the low value placed on this role. The SME panel agreed with this finding and decided to not include this skill set as a part of the DSP. However, it is important to reiterate that the patient management skill of providing counseling and education on the risks and dangers related to performance enhance substances remains an important area of competency for the sports clinical specialist. In addition to evaluation strategies that emphasize the manual assessment of articular integrity, joint mobility, muscle performance, and balance; a premium value was assigned to performance-based rehabilitation, customized therapeutic exercise, and appropriate emergency care of acute spinal injuries. Near universal agreement on the importance of sport-specific testing as a prognostic basis for return to activity was also apparent. Though not appearing in the items that were a full standard deviation under the mean score for importance and mastery, survey inquiries regarding the sports physical therapist’s knowledge or role in nutritional counseling were rated on the cusp of significance. To emphasize


the expectation of this knowledge, case study questions related to nutritional concepts were added to the revised DSP. The same rationale and action was used to highlight the expectation of the specialist in managing sports participation for the disabled athlete including considerations regarding prosthetic and adaptive equipment use. Ultimately only a minor alteration was made in the examination blueprint for the current version of the board certification examination. The percentage of the examination content from the acute injury/illness management category was increased by 5% at the expense of the sports science section, which was honed to only include content related to sports performance enhancement. The sports performance enhancement category now represents 10% of the examination content. The reason for increasing the management of acute sports-related injuries and illnesses was multifactorial, including the requirement for field/venue coverage to obtain initial and maintain certification, the high importance and mastery scores provided by the survey respondents related to this professional role, and the unique knowledge and skills that are entrenched within the specialty of sports physical therapy practice. Further evidence to this content’s importance is that certification as an athletic trainer, emergency medical technician, paramedic, or emergency responder is a unique prerequisite to sit for the sports specialty examination. Finally, examination questions regarding acute injury management have also been incorporated into the examination/evaluation/diagnosis category. Specialist and Non-specialist Comparisons While the intent of the survey was not to differentiate specialist and non-specialist perspective, the practice analysis also allowed for the comparison of the responding specialists to those respondents who were SPTS members but not specialists. Breakdown by respondent age, sex, ethnicity, education, experience, and practice setting were essentially identical. However, this process revealed some interesting contrasts between specialists and non-specialists. Caution should be used in the interpretation of these findings as only 35 respondents identified themselves as non-sports clinical specialists responded to the survey.

Regarding demographic characteristics, the specialists were much more likely to have completed an accredited residency program (21% vs. 6%) but somewhat surprisingly, less likely to provide venue or field coverage services (31% vs. 46%) or have additional board certifications (31% to 49%). This finding from non-specialists regarding field coverage may simply be based on the asymmetry of the sample size or the possibility of regression to the mean if a subsequent measurement of its frequency was conducted. It is also possible that these non-specialists have invested significant time and interest to the specialty of sports physical therapy as evidenced by their proclivity to have additional non-specialist credentials and a willingness to provide field coverage services. Finally, this phenomenon could be that the relatively small sample of non-specialists respondents were represented by physical therapists whose athletic training credential increased the likelihood of providing event coverage services. Specialists were more likely to have a caseload that emphasized the care of injuries in the peripheral extremities. The two most prevalent body regions treated by the specialist were the shoulder and knee while the most common body region treated by the non-specialist was the lumbar spine. After collapsing the categories into axial skeleton (spine/pelvis/ head), upper extremity (shoulder, elbow, wrist/ hand), and lower extremity (hip, knee, ankle, foot) groups; the self-reported time spent by specialists with patients with spine-related and upper extremity related injuries was 30% each. The greatest percentage of time for specialists providing care was for managing injuries in the lower extremity at 40%. In contrast non-specialists spent 40, 25, and 35% of their time managing spine, upper extremity, and lower extremity injuries respectively. The seven responses that were significantly different between specialists and non-specialists in Sections 1 - 3 of the survey are reported in Tables 13 and 14. Two of these seven items were from the knowledge (disease status and medical/surgical considerations) and professional roles (evidence-based practice) sections. Each of these items could be considered generic or universal physical therapy practice concepts. Differences in the perceived importance and mastery of specific skills and knowledge between


specialists and non-specialists were more apparent in the items surveyed from the patient management section. These items tended to specifically mention a psychomotor skill or knowledge content with an athletic qualifier or had a sport environmental context. Particularly notable were the specialist’s perception regarding the unique role of the sports physical therapist in educating the athlete regarding performance enhancement, environmental influences, and electrolyte replacement. Additionally, the specialists placed greater importance and mastery on athletic injury management and sport-specific biomechanics, kinematics, and task analysis. Of these five items, none were rated in the top 10 based on importance/mastery. While these items reflect a difference in perception of the importance for higher levels of cognitive and professional functioning as well as clinical decision making, it is unclear from this study if these results represent true differences between the specialist and non-specialist or if these results are related to unidentified confounding variables. Because the study’s primary purpose was revalidation of competencies that define specialty practice, it was not designed to distinguish if the differences in perception, especially those common to all practice patterns, were a result of the respondent’s clinical experience, decision-making skills, cognitive level, or professional function. Changes/Trends in Respondent Perspectives in Past Decade The demographics of the respondents have shown some interesting trends in the past ten years. There is a mild trend towards a younger demographic with a larger percentage of female input. While the range of median practice experience for survey respondents remains 11-15 years the distribution of age ranges skews towards the younger clinician as opposed to the older clinician in the 2002 survey. There is also a notable shift in the entry-level education preparation of the survey respondents with 30% having a DPT as compared to 2% in the previous survey. In contrast to the last survey, where 56% of the respondents were trained at the bachelor’s level, only 22% of the respondents were trained at that level on this survey. There also seems to be a shift in the job responsibilities of the survey respondents as well as the educational method that was

most influential in the development of their current clinical skills. Clinical residency training is now an important mechanism towards achieving sports certification, particularly in light of the trend towards seeing non-sports patients in the clinic. In 2002, respondents spent 60% of their time in direct care of sports injuries with an additional 20% of their time managing non-sports-related injuries. In the most recent survey the percent of time spent with sports injured patients was down to 40% with a concurrent increase in non-sports patient management (30%) and an increase in teaching and mentoring responsibilities from 5 to 10% of their time. Contrary to the last two practice analysis surveys it appears that in the past decade there is a mild trend towards an increased percent of time devoted to patient care. In both the 1994 and 2002 surveys, respondents reported that approximately 60% of their time was devoted to patient care. In the current survey, the professional responsibility of patient care, be it for sports or non-sports related cases, increased to 70%. CONCLUSION The primary purpose of this study was to revalidate the competencies that define the practice of sports physical therapy. In doing so, the cognitive as well as psychomotor skill domains, which were perceived to be of greater importance to the practice of sports physical therapy, were identified. The results of the study were used by a panel of experts in sports physical therapy to develop the guidelines, which will be used through 2023 to define and guide the requirements to attain and maintain the designation of a board certified clinical specialist in sports physical therapy in the United States. This information will also be used as a foundational template for developing an accredited post-professional residency didactic educational curriculum. REFERENCES 1. Sports Physical Therapy Section of the American Physical Therapy Association. What is Sports Physical Therapy? 2012. Available at http://www. spts.org/about-spts/what-is-sports-physical-therapy. Accessed March 12, 2014. 2. Zachazewski JE, Felder CR, Knortz K, et al. Competence revalidation study: A description of


advanced clinical-practice in sports physical therapy. J Orthop Sports Phys Ther. 1994; 20(2):11024. 3. American Physical Therapy Association (APTA): Essentials for Certiﬁcation of Physical Therapy Specialists, House of Delegates Policy 06-78-20-51. Alexandria, VA: APTA 1978. 4. Skovly RC, Davies GJ, Mangine RE, Mansell RE, Wallace LA. Results of the task analysis study sports physical therapy section American physical therapy association. J Orthop Sports Phys Ther. 1980;1(4):22938. 5. American Physical Therapy Association (APTA): Sports Physical Therapy Specialization, House of Delegates Policy 06-81-15-54. Alexandria, VA: APTA. 1981. 6. Krugh I. Advanced Clinical Competencies for the Sports Physical Therapist. Unpublished master’s thesis. University of North Carolina, Chapel Hill, NC 1984.

7. Sports Physical Therapy Description of Specialty Practice. 2002. Alexandria, VA, American Physical Therapy Association. 8. Guide to Physical Therapist Practice, 2nd ed. Phys Ther. 2001;81:9-744. 9. Weber MD, Thein-Nissenbaum J, Bartlett L, Woodall WR, Reinking MF, Wallmann HW, Mulligan EP. Competency revalidation study of specialty practice in sports physical therapy. N Am J Sports Phys Ther. 2009;4(3):110-22. 10. Sports Physical Therapy Description of Specialty Practice. 2013. Alexandria, VA, American Physical Therapy Association. 11. Sports Physical Therapy Description of Advanced Clinical Practice. 1994. Alexandria, VA, American Physical Therapy Association.


DIAGNOSTIC IMAGING IN A DIRECT-ACCESS SPORTS PHYSICAL THERAPY CLINIC: A 2-YEAR RETROSPECTIVE PRACTICE ANALYSIS.

Opinions of sports clinical practice chiropractors, with sports specialty training and those without, about chiropractic research priorities in sports health care: a centering resonance analysis.

knee osteoarthritis in Dutch general practice and physical therapy practice: an observational study.

Reflection, return to practice and revalidation.

Methods of genomic competency integration in practice.

Revalidation for trainees and the annual review of competency progression (ARCP).

Developing Competency to Sustain Evidence-Based Practice.

Introducing a New Competency Into Nursing Practice.

Cardiopulmonary physical therapy practice in the paediatric intensive care unit.

Public health practice competency improvement among nurses.

Examining the construct validity of the Cognitive Competency Test for occupational therapy practice.

Compatibility of scientific research and specialty training in general practice. A cross-sectional study.

Improving the practice of sports science research.

Commentary on "Nationwide survey of school-based physical therapy practice".

Nationwide survey of school-based physical therapy practice.

Sports therapy in mental illness.

The Value of Urodynamics in an Academic Specialty Referral Practice.

Evaluation of an advanced-practice physical therapist in a specialty shoulder clinic: diagnostic agreement and effect on wait times.

Growing a Specialty-Specific Community of Practice in Education Scholarship.

Task Force on Standards for Measurement in Physical Therapy. Standards for tests and measurements in physical therapy practice.

Standardized Patients versus Volunteer Patients for Physical Therapy Students' Interviewing Practice: A Pilot Study.

Advancing Physical Therapy Practice through Curriculum Revision: The Malawi Experience.

[Sports cardiology - a general practice oriented update].

Restoring prognosis as a core competency in medical practice.