Diagnostic and procedural imaging curricula in physical therapist professional degree programs.

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research report

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Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at New York University on May 29, 2015. For personal use only. No other uses without permission. Copyright © 2014 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

WILLIAM G. BOISSONNAULT, PT, DHSc1 • DOUGLAS M. WHITE, DPT, OCS, RMSK2 • SARA CARNEY, DPT, ATC3,4 BRITTANY MALIN, DPT4 • WAYNE SMITH, DPT, MEd, SCS, ATC, RMSK5

Diagnostic and Procedural Imaging Curricula in Physical Therapist Professional Degree Programs

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hile the integration of diagnostic and procedural imaging (eg, plain-film radiography/radiographs, magnetic reso nance imaging [MRI], computed tomography [CT], scintigraphy [bone scan], and ultrasonography) in US military physical therapist practice has an extensive history,14,16 the TTSTUDY DESIGN: Descriptive survey.

TTOBJECTIVE: To describe the status of diagnos-

tic and procedural imaging curricula within United States physical therapist professional degree programs.

TTBACKGROUND: As patient direct access to

physical therapy services increases, the ability to refer patients directly for diagnostic imaging could promote more efficient delivery of care. Appropriate patient referral is contingent on physical therapists having the requisite knowledge base and skills. While evidence describing imaging competence of physical therapists with advanced training in military institutions exists, evidence is lacking for other physical therapists, including new graduates of physical therapist professional degree programs.

TTMETHODS: Faculty members teaching imaging

at 206 United States physical therapist professional degree programs recognized by the Commission on Accreditation in Physical Therapy Education were recruited via e-mail correspondence. An e-mail attachment included the survey on which faculty reported imaging curricula and faculty qualifications, attitudes, and experiences.

TTRESULTS: Faculty from 155 (75.2%) programs

responded to the survey, with imaging being included in the curriculum of 152 programs. Content

was integrated by required standalone courses or clinical science track courses, and/or through elective courses. The average reported estimate of imaging contact hours was 24.4 hours (range, 2-75 hours). Emphasis was on the musculoskeletal system, including 76.3% of the required standalone course content. Student competence was assessed in 147 (96.7%) programs, primarily by written (66.7%) and practical (19.7%) examinations. Faculty rated student competence on a scale of 1 (not competent) to 5 (competent), with ratings ranging from a high of 4.0 (identifying normal anatomy on plain-film radiography) to a low of 1.9 (identifying common tissue pathological processes/injuries on ultrasound).

TTCONCLUSION: While a majority of programs

reported including imaging curricula, variability was noted in all curricular aspects. These results may serve as a benchmark for faculty to assess existing curricula, allow for further development of imaging curricula, and provide a benchmark for the profession regarding current level of training for recent graduates of entry-level physical therapist professional degree programs. J Orthop Sports Phys Ther 2014;44(8):579-586. doi:10.2519/ jospt.2014.5379

TTKEY WORDS: diagnostic tests, education, MRI, radiology, ultrasonography, X-ray

role of imaging in care provided by physical therapists in civilian sectors is largely unknown. Few published examples describe civilian-sector practice models that include physical therapists referring patients directly for imaging tests,7 and a recent summary of physical therapy practice act language for the 50 states and the District of Columbia regarding the role of imaging revealed tremendous variability. The language ranged from “prohibiting the use of roentgen rays for any purpose” (physical therapists cannot turn the X-ray machine on) to prohibiting physical therapists from referring patients for diagnostic imaging to being “silent” on the issue.7 The continued effort to pass “patient direct access to physical therapy services” (referred to as first-contact practice) legislation has fueled discussions on physical therapists’ abilities (or lack of ) to refer patients directly to radiologists for diagnostic imaging. To enhance efficiency of health care delivery, and for health care consumers to maximally benefit from first contact with physical therapists, the ability to directly refer patients to other providers, including radiologists, would seem paramount.7,13 Inherent to this ability is the responsibility of appropriate patient referral for diagnostic imaging. Despite clinical guidelines directing appropriate ordering of imaging modalities

Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, WI. 2Milton Orthopaedic & Sports Physical Therapy PC, Milton, MA. 3MVP Physical Therapy, Fircrest, WA. 4(At time of study) Program in Physical Therapy, University of Wisconsin-Madison, Madison, WI. 5A.T. Still University, Phoenix, AZ. The University of Wisconsin-Madison Institutional Review Board approved the study protocol. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr William G. Boissonnault, University of WisconsinMadison, Physical Therapy Program, 5190 Medical Science Center, 1300 University Avenue, Madison, WI 53706-1532. E-mail: [email protected] t Copyright ©2014 Journal of Orthopaedic & Sports Physical Therapy® 1

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[ for patients with neck or low back pain, numerous examples exist within other professions of discordant rates of utilization of imaging.11,12,17,22,26,30 Since the mid 1990s, this overutilization has been associated with disproportionate increases in health care costs.17,20 Boyles et al7 raised the question of whether physical therapists are adequately educated regarding appropriate imaging referral. The authors are unaware of studies describing physical therapist education in the area of diagnostic and procedural imaging, and few publications exist that describe physical therapist competence related to appropriate patient referral for diagnostic imaging tests.23,25,28 Springer et al28 demonstrated that military physical therapists were as competent as orthopaedists in the utilization of the modified Ottawa ankle rules (determining whether ankle-foot radiographs were indicated for patients postinjury). The participating physical therapists had been credentialed as neuromusculoskeletal physician extenders, having completed an advanced training program. Moore et al23 retrospectively reviewed more than 50 000 new patient records seen via direct access in military physical therapy clinics and found no evidence of physical therapists having their credentials or licenses modified/revoked, nor any litigation cases filed against the US government. In that study,23 88% of participating physical therapists had completed postgraduate training in diagnostic imaging. As with the military model, the civilian institutions allowing physical therapists to refer patients directly to radiologists required the completion of imaging training programs.6 The required training raises the question (also raised by Boyles et al7 and Elliott13) as to whether physical therapists in general are adequately trained in imaging or such required training is simply meant to be a refresher course. Although the advent of Doctor of Physical Therapy (DPT) degree programs (professional and postprofessional/transitional) has resulted in increased emphasis on imaging as a content area,

research report no accepted standard for expected depth and breadth of imaging content in physical therapist professional degree programs exists.3,9 In addition, authors were unable to find publications that described current imaging curricula in these programs. Our study’s purpose was to describe the current status of diagnostic and procedural imaging curricula in US physical therapist professional degree education programs. The survey research investigated (1) whether imaging content was included, (2) how/where in the curriculum the content was integrated, (3) what content was included, (4) if/how student competence was assessed, (5) faculty perceptions of student competence, and (6) faculty qualifications and experiences. The survey results may (1) provide a benchmark for the profession regarding current level of training for recent graduates of professional degree programs, (2) provide a benchmark for faculty to assess existing curricula, (3) allow for further development of imaging curricula, and (4) identify potential obstacles to such development.

METHODS Survey Instrument Development

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he model for our survey was the instrument developed by Boissonnault et al5 to investigate joint manipulation curricula in physical therapist professional degree programs, adapted for assessing diagnostic and procedural imaging curricula. The datacollection categories included (1) physical therapist program demographics, (2) descriptive information regarding imaging curricula, and (3) faculty demographics and experiences. Three experts (physical therapists) responsible for teaching imaging in physical therapist professional degree programs and/or in postprofessional venues, with extensive clinical experience marked by integration of diagnostic and procedural imaging, provided the initial review of the original version of the survey. Feedback was provided via e-mail and phone correspondence. Subsequent-

] ly, the survey was revised and sent to a second panel of experts (7 physical therapists) for piloting. These experts also had experience teaching imaging content to students and practitioners. Based on their feedback, the survey was finalized (APPENDIX, available online).

Participants Faculty from US physical therapist professional degree programs (n = 206 at the time of data collection) recognized by the Commission on Accreditation in Physical Therapy Education as accredited or candidate were queried. The survey was sent directly to program faculty members responsible for teaching/coordinating imaging content, or, if the faculty were unknown, the survey was sent to program directors with instructions to “… please forward the survey to the primary faculty member teaching and/or coordinating the imaging component of the curriculum.”

Administration of the Survey The University of Wisconsin-Madison School of Education Human Subjects Committee reviewed and approved the study protocol. The survey was e-mailed as an attachment to programs in February 2013. The survey’s introduction described the study’s purpose, emphasized results being reported in the aggregate, promised anonymity of individual responses, and stated that participation was voluntary. The surveys were coded by number to track nonresponders and to facilitate follow-up communication. Three to 4 weeks after the initial survey distribution, a follow-up e-mail, with survey attached, was sent to the nonresponder programs. Approximately 4 weeks following the second distribution, a final e-mail was sent to the nonresponder programs.

Data Analysis The data were hand entered into a Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, WA) by 2 research assistants. To promote accuracy, the assistants routinely met with the lead author

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to clarify interpretation of survey responses. In addition, each assistant completed an independent comparison of the other’s previously entered data, and the lead author compared survey responses to previously entered data sets for 30% of the surveys and found no inconsistencies. Descriptive statistics were calculated to determine the demographics of the education programs and participating faculty and the current status of diagnostic and procedural imaging curricula.

RESULTS

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f the 206 US Commission on Accreditation in Physical Therapy Education–accredited physical therapist programs, 155 (75.2%) responded to our survey. Physical therapist program response rates by regional accreditation bodies of degree-granting higher-education institutions included the Southern Association of Colleges and Schools (78.8%, 41 of 52 programs), Northwest Commission on Colleges and Universities (80.0%, 8 of 10 programs), North Central Association of Colleges and Schools (79.1%, 53 of 67 programs), New England Association of Schools and Colleges (56.3%, 9 of 16 programs), Middle States Association of Colleges and Schools (68.1%, 32 of 47 programs), and Western Association of Schools and Colleges (85.7%, 12 of 14 programs). One hundred fifty-two programs were granting a DPT degree and reported that an average of 6.8 years had passed since their first DPT graduating class. The remaining 3 programs projected granting a DPT degree in 2014 or 2015. Twentyseven programs reported being located in states whose practice acts allow physical therapists to refer patients to radiologists for diagnostic imaging, 111 respondents stated physical therapists were unable to do so, and 17 responders were unsure. Sixty-nine programs were in states whose practice act allows physical therapists to utilize procedural imaging (eg, ultrasound imaging) as an intervention adjunct, 50 respondents reported that this was not allowed, and 34 were unsure.

Diagnostic and Procedural Imaging Faculty Demographics Faculty demographic information revealed that 141 (92.8%) of the respondents were full- or part-time core faculty. The remainder held either associated or adjunct faculty positions. One hundred forty-two (93.4%) faculty responsible for teaching imaging were physical therapists; the remaining 10 respondents included 8 physicians, 1 physician assistant, and 1 respondent who did not state a discipline. Faculty reported that the average number of years they had been teaching imaging was 7.7. While 90 (59.2%) respondents reported not receiving any entry-level education/training in imaging, 139 (91.4%) reported postprofessional training through many venues, including (1) continuing education without certification (n = 97, 63.8%), (2) clinical practice mentoring (n = 63, 41.4%), (3) postprofessional advanced degree program (MS, PhD, DSc, etc) (n = 45, 29.6%), (4) transitional DPT program (n = 32 of 142, 22.5%), (5) American Physical Therapy Association (APTA)-credentialed residency program (n = 24 of 142, 16.9%), and (6) APTA-credentialed fellowship program (n = 23 of 142, 16.2%). Ninety-eight (69.0%) of 142 physical therapist faculty respondents reported holding an American Board of Physical Therapy Specialties clinical specialist certification (93.9% holding certification in orthopaedics or sports). Twenty-seven (19.0%) of the respondents reported being a Fellow of the American Academy of Orthopaedic Manual Physical Therapists, and 48 (33.8%) reported being members of the APTA Orthopaedic Section’s Imaging Special Interest Group. Fifty-four (38.0%) faculty were unaware that the Orthopaedic Section Imaging Special Interest Group existed. One hundred fourteen (75.0%) respondents reported practicing in clinical settings, with averages of 13.8 years full time and 13.6 years part time, and working an average of 11.4 hours per week. The primary areas of practice were orthopaedics (n = 100, 65.8%), followed

by sports (n = 22, 14.5%). Eighty-nine (62.7%) physical therapist responders stated they were unable to refer patients to radiologists, 21 (14.8%) stated yes, 18 (12.7%) were unsure of the practice act language, and the remainder (n = 14, 9.8%) did not respond. Twenty of the 142 (14.1%) physical therapist faculty estimated having directly referred an average of 4.75% of their patients to a radiologist for diagnostic imaging. A wide range of opinions were expressed regarding qualifications faculty should possess to teach imaging: (1) ongoing clinical practice with mentoring (n = 77, 50.7%), (2) clinical practice without mentoring (n = 71, 46.7%), (3) continuing education without certification (n = 60, 39.5%), (4) continuing education with certification (n = 59, 38.8%), and (5) clinical experience directly referring patients for imaging (n = 48, 31.6%). Other recommendations were noted with less than a 20% response rate, including American Board of Physical Therapy Specialties certification, completion of APTA-credentialed residency/fellowship program, and completion of a Registered in Musculoskeletal Sonography certification by the American Registry for Diagnostic Medical Sonography.

Diagnostic and Procedural Imaging Curricula One hundred fifty-two (98.1%) programs reported including imaging in their curricula. The 3 programs that did not include imaging reported the following reasons: (1) lack of qualified faculty, (2) not considered to be an entry-level skill, (3) not a curricular priority, and (4) not enough time. One of the 3 programs reported having no immediate plans to include imaging in the current curriculum. In the following results, reported aggregate sample sizes less than 152 represent incomplete data sets. One hundred forty of 151 (92.7%) programs introduce imaging content in the first or second year of the program (year 1, 96 of 151 [63.6%]; year 2, 44 of 151 [29.1%]). The programs were asked how they in-



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research report

Contact Hours for Teaching Imaging Content*

TABLE 1 Educational Venues for Imaging Content

Hours


Classroom/lecture

14.4 (0-75)

Laboratory

3.6 (0-22.5)

Online coursework

4.1 (0-60)

Simulated patient experiences

1.1 (0-20)

Supervised actual patient care experience

0.3 (0-14)

Video/CD-ROM coursework

0.6 (0-16)

Other

0.3 (0-8)

Total number of contact hours for imaging curricula

24.4 (2-75)

*Values are mean (range).

TABLE 2

Number of Programs Assessing Student Competence in Imaging (n = 151)*

Utilization of clinical guidelines for referring patients for diagnostic imaging

Plain-Film Radiography

MRI

CT

US

Bone Scan

131 (86.8)

84 (55.6)

73 (48.3)

48 (31.8)

55 (36.4)

39 (25.8)

Adjunct to patient interventions

84 (55.6)

64 (42.4)

55 (36.4)

68 (45.0)

Identify normal anatomy

137 (90.7)

116 (76.8)

97 (64.2)

61 (40.4)

53 (35.1)

Identify skeletal pathological processes/injuries

132 (87.4)

110 (72.8)

103 (68.2)

47 (31.1)

82 (54.3)

82 (54.3)

119 (78.8)

67 (44.4)

61 (40.4)

22 (14.6)

Identify soft tissue pathological processes/injuries

Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging; US, ultrasonography. *Values are n (%).

tegrated the content into the curriculum and were allowed to select more than 1 response. Seventy-six of 152 (50.0%) programs included a required/standalone imaging course as part of the core curriculum. The course content emphasis was divided by percentage into the following areas: (1) musculoskeletal system, 76.3%; (2) adult neurology, 9.2%; (3) cardiovascular and pulmonary systems, 7.7%; and (4) pediatric neurology, 2.9%. Of these 76 programs, 44 (57.9%) reported imaging also being integrated elsewhere in the curriculum, whereas the remaining 32 (42.1%) offered no other didactic exposure. Eighty-six of 151 (57.0%) programs reported incorporating imaging into their clinical science tracks. Of these programs, 79 (91.9%)

incorporated imaging in the musculoskeletal system track, 46 (53.5%) in the neurologic (adult and pediatric) track, 34 (39.5%) in the cardiovascular track, and 30 (34.9%) in the pulmonary track. Thirty (19.9%) of 151 programs reported imaging being a component of multiple courses (eg, biomechanics, exercise science, differential diagnosis, and physical agents) other than a required standalone course or the core clinical science track courses, and 6 (4.0%) offered an elective course. Of the 6 programs with elective courses, only 1 reported offering no other didactic exposure. The imaging elective content was devoted by percentage: musculoskeletal system track, 75.0%; adult neurologic track, 10.0%; cardiovascular/pulmonary tracks, 9.7%; and

] pediatric track, 3.7%. The average total estimated contact hours for imaging theory, clinical application, and skills was 24.4 hours, ranging from 2 hours (4 programs) to 75 hours (1 program). Responder comments noted difficulty in reporting exact hours when imaging was intermixed with other curricular content. TABLE 1 provides a summary of hours and venue of content delivery (eg, classroom lecture, laboratory experience, video/CD-ROM). Approximately 50% of the average contact hours covered the use of clinical guidelines regarding the appropriateness of patient referral for imaging and the influence imaging results might have on patient plan of care. Sixty-eight (44.7%) of the programs required an imaging textbook, ranked in the order of use by author as follows: McKinnis,21 Malone et al,18 and Swain et al.29 An additional 71 (46.7%) programs recommend 1 of these textbooks, and 78 (51.3%) programs utilize websites, journal articles, manuals, videos, and CD-ROMs. Some resource examples noted included the Journal of Orthopaedic & Sports Physical Therapy Musculoskeletal Imaging feature,4,10 the American College of Radiology website (including Appropriateness Criteria),1 and websites of various medical schools (radiology departments). One hundred forty-seven (96.7%) programs reported testing students on imaging material. Of these, 98 programs (66.7%) include written and 29 (19.7%) utilize practical examinations, in which students are asked to identify normal and abnormal structures on images. The remaining programs utilize one or a combination of the following approaches: verbal examination, simulated patient examination/treatment, or “live” patient visit formats. Of the 87 programs requiring a final (end of the curriculum) preparatory/competency examination, 56 (64.4%) programs include imaging items. TABLE 2 provides a summary of specific imaging competencies (eg, identifying normal anatomy, identifying pathological processes/injuries, utilization of



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TABLE 3

Faculty Rating of Student Competence (n = 151)* Plain-Film Radiography

MRI

CT

US

Bone Scan

Utilization of clinical guidelines for referring patients for diagnostic imaging

3.7  1.3 (3.5, 3.9)

2.9  1.6 (2.6, 3.2)

2.7  1.6 (2.4, 3.0)

2.0  1.8 (1.7, 2.3)

2.5  1.7 (2.2, 2.8)

Identify normal anatomy

4.0  1.1 (3.8, 4.2)

3.1  1.4 (2.9, 3.3)

3.0  1.4 (2.8, 3.2)

2.0  1.4 (1.8, 2.2)

NA†

Identify common skeletal and/or soft tissue pathological processes/injuries

3.7  1.1 (3.5, 3.9)

2.8  1.3 (2.6, 3.0)

2.8  1.4 (2.6, 3.0)

1.9  1.4 (1.7, 2.1)

2.5  1.5 (2.3, 2.7)

Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging; NA, not applicable; US, ultrasonography. *From 1 (not competent) to 5 (competent). Values are mean  SD (95% confidence interval). † Not requested on survey; bone scan not typically used to identify normal anatomical structures.

clinical guidelines for referring patients for imaging tests) associated with various imaging modalities (radiographs, MRI, CT, scintigraphy, and ultrasonography). Students were most consistently assessed on radiographs, followed by MRI. Students were least frequently assessed on ultrasonography and bone scan; less than 50% of programs assessed student competence. TABLE 3 provides a summary of faculties’ perceptions of student competence in the following content areas: (1) identifying normal anatomy, (2) identifying common skeletal/soft tissue pathological processes/injuries, and (3) utilization of clinical guidelines for referring patients for diagnostic imaging. In addition, faculty rated student competence at 1.77 (1, not competent; 5, competent) for utilization of ultrasound. The 10 non– physical therapist faculty had higher competence scores than their physical therapist counterparts (0.5 point or greater) in the following categories: (1) radiographs, identifying normal anatomy and common skeletal pathological processes/injuries; (2) CT, identifying normal anatomy and common skeletal pathological processes/injuries and utilizing clinical guidelines for patient referral; (3) ultrasonography, utilizing clinical guidelines for patient referral and ultrasound as an intervention adjunct; and (4) scintigraphy, utilizing clinical guidelines for patient referral. Of the 3 items for which the non–physical therapist faculty gave lower com-

petency scores, none had a differential of 0.5 point or greater. Finally, faculty (n = 152) responses (on a scale of 1 to 5, with 1 as strongly disagree and 5 as strongly agree) to the question “Do you believe having the knowledge base and skills necessary for referring patients directly to radiologists for imaging tests is a minimum required skill of new physical therapist program graduates?” were 4.32 for radiographs, 3.90 for MRI, 3.74 for CT scan, 3.74 for ultrasonography, and 3.62 for bone scan. Comparing opinions of the 10 non–physical therapist faculty to the physical therapist faculty, the only area of discrepancy greater than 0.5 point was the bone scan, with the 10 non–physical therapist faculty giving a rating of 3.1. Last, respondents were asked, “What would be the most beneficial way to increase students’ knowledge/application of imaging content?” Faculty could check more than 1 item. The most-frequently noted responses were increase the laboratory hours (104 of 151, 68.9%) and the emphasis during clinical education (104 of 151, 68.9%), followed by an increase in lecture hours (64 of 151, 42.4%), including specialist guest lecturers (27 of 151, 17.9%) or having a specialist teach the course (17 of 151, 11.3%). If respondents answered an increase in lecture or laboratory hours as most beneficial, they were asked to provide barriers preventing the implementation of this strategy. One hundred four (68.8%) identified lack of time as the primary reason.

DISCUSSION

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hese results provide the first description of diagnostic and procedural imaging curricula in US physical therapist professional degree education programs. While a majority of responding programs (98.1%) stated that imaging was currently included in their curricula, the results illustrate variability in (1) when the content is introduced in the curriculum, (2) how and to what extent the content is integrated with other material, (3) what content is included, and (4) how students are assessed to determine competence. This inconsistency may be related to a current lack of educational guidelines and standards for imaging content, which may be a reflection of the current variable role of imaging in the delivery of physical therapist services and is in part predicated by inconsistent language found in physical therapist state practice acts. Overall, imaging content is typically introduced in curricula earlier as opposed to later in the program, at year 1 in a majority of programs (63.6%), with only 6.6% of programs waiting until the final didactic year. Some responders reported that imaging was initially introduced in human anatomy courses, to provide an example of how anatomy course material will be applied in clinical practice. How imaging content is integrated in curricula (required standalone course, elective course, etc) is difficult to ascertain, due to responders possibly checking multiple



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[ categories. All but 1 program included content in required standalone imaging or clinical science courses, and/or in other required courses, including differential diagnosis, biomechanics, exercise physiology, and physical agents. Regardless of content integration, the current emphasis appears to be on the musculoskeletal system. This emphasis could be a reflection of the majority of faculty (n = 122, 80.3%) identifying their primary area of practice as orthopaedics or sports, and for physical therapist faculty these 2 practice areas represent the majority (92.5%) of American Board of Physical Therapy Specialties clinical specialist certification specialties and reported APTA-credentialed residency/fellowship training specialties. The musculoskeletal system bias could also reflect the greater integration of imaging (starting in the military more than 40 years ago16) into outpatient physical therapy practices serving patients with musculoskeletal conditions. Exploration of the reported lesser neurology and cardiopulmonary imaging emphasis would be useful. Has the role of imaging in these physical therapist practice areas been defined and is the current emphasis appropriate, or is the role of imaging less defined than in the musculoskeletal practice arena? Of the 5 imaging modalities investigated, radiographs, followed by MRI, appear to be integrated in curricula to the greatest extent. For radiographs, 137 (90.1%) of the programs assess student abilities related to identifying normal anatomy, 132 (86.8%) on identifying skeletal pathology/injuries, and 131 (86.2%) on utilization of clinical guidelines for patient referral for radiographs. For MRI, 116 (76.3%) of the programs assess student abilities related to identifying normal anatomy, 119 (78.3%) on identifying soft tissue pathological processes/injuries, 110 (72.4%) on identifying skeletal pathology/injuries, and 84 programs (55.3%) on utilization of clinical guidelines for patient referral for MRI. Ultrasonography was among the least integrated of the imaging modali-

research report ties in curricula, and ranked the lowest regarding perceived student level of competence upon completion of the program. Although relatively new in rehabilitation, this modality may have the greatest potential regarding application to physical therapist practice.8,15 Faculty perception of student competence (TABLE 3) also seems to reflect curricular emphasis on radiographs compared to other modalities. Last, the emphasis on radiographs seems to reflect the relative agreement (4.3 on 1-to-5 scale, with 1 as strongly disagree and 5 as strongly agree) of respondents that having the knowledge base and skills for referring patients directly to radiologists is a new-graduate minimumrequired skill. This is compared to ratings of 3.9 for MRI, 3.7 for CT, 3.7 for ultrasonography, and 3.6 for scintigraphy. Questions are associated with faculty assessment of students’ abilities regarding identification of skeletal/soft tissue pathological processes and injuries (TABLE 2), and of perceived student competence (TABLE 3) at doing so. Are students being taught this material in the context of imaging interpretation and patient diagnosis, and/or for other reasons, such as promoting (1) a better understanding of pathoanatomical/pathophysiological processes, (2) a better understanding of pathological processes and potential impact on the physical therapist’s plan of care, and (3) enhanced professional communication between physical therapists and physicians? Clarification of the intent or purpose for inclusion of this content was not specifically asked on the survey, nor were the responders asked if interpretation of images was considered to be a new-graduate minimum-required skill. Though the APTA position “Diagnosis by Physical Therapists”2 states, “When indicated, physical therapists order appropriate tests, including but not limited to imaging and other studies, that are performed and interpreted by other health professionals. Physical therapists may also perform or interpret selected imaging or other studies,” there is little evidence of physical therapists

] interpreting imaging or other studies for the purpose of patient diagnosis. Even in the longstanding military direct-access model, physical therapists are ordering the imaging, but radiologists and/or other physicians are interpreting the tests.24 Similarly, in the direct-access model established at University of Wisconsin Hospital/Clinics, radiologists are interpreting the plain radiographs ordered by physical therapists.6 Physical therapists then integrate the information derived from the radiologist’s report with the data gathered from a patient’s history and physical examination to arrive at a diagnosis and commence treatment, or to initiate a referral to another physician. It is unknown in these settings whether drawing the line between physical therapists ordering the imaging but not interpreting the results for diagnostic purposes is driven by state practice act language, internal institutional policies, and/or lack of education. Considering that the APTA position includes the statement, “Physical therapists may also perform or interpret selected imaging or other studies,” the question exists as to whether the necessary training to competently interpret the imaging results falls within the scope of professional degree education or represents an advanced skill beyond the expectations of a new physical therapist graduate. To increase student imaging competence, faculty believed that increased emphasis during clinical internships and increased laboratory classroom hours would be most beneficial, followed by increased lecture hours. The primary obstacle reported to increasing the classroom hours was lack of time available in the curriculum. The wide range of hours (2-75 hours) devoted to imaging suggests programmatic variability in perceived priority. The goal of increased emphasis during clinical internships is associated with multiple challenges and questions, including (1) the existing state practice act imaging language limiting clinical practice, (2) questions regarding the knowledge and



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skill level of clinical instructors related to imaging, and (3) questions regarding clinical instructors’ attitudes associated with the role of imaging and physical therapy practice. Ultimately, it must be asked whether there are adequate imaging clinical education experiences for students. Though the answer is beyond the scope of this study, the findings do suggest that future research would be beneficial in describing clinical education imaging opportunities for students. The reported variability by faculty indicates the need for consensus within the profession as to how and to what extent imaging curricula should be included in physical therapist professional degree programs. The variability also suggests the need for development of curricular resources to assist faculty responsible for teaching imaging. A template for such resources exists for another curricular content area: thrust joint manipulation. The Manipulation Education Manual19 was created to promote evidence-based instruction in thrust joint manipulation. Physical therapy program faculty teaching thrust joint manipulation were provided with sample instructional and student evaluative materials, comprehensive instructional resource lists, and recommendations for academic and clinical faculty qualifications. The creation of such resources may foster consistency between programs and accelerate the development of imaging curricula. A number of responding faculty commented that their program was in the early stages of developing imaging curricula. Last, the reported extent of imaging curricula variability, combined with inconsistent state practice act language and the variation in imaging “privileges” in clinical practice, suggests that a tremendous collaborative opportunity exists within our profession for legislative and regulatory advocates, educators, and clinicians to better define the role of imaging and physical therapist practice. Consensus would provide guidance for the profession on multiple levels.

Limitations While a 75% response rate falls within the 60%-to-80% response range considered excellent for survey research,27 the survey did not address educational philosophy or curricular models that may explain the rationale for programs’ decisions related to imaging content. Respondents noting that imaging content was integrated throughout multiple courses reported difficulty in providing exact numbers of hours devoted to imaging. This would most likely result in underreporting of curricular hours. Some programs did not have a specified faculty member overseeing/coordinating the program’s imaging curricula, so multiple faculty completed portions of the survey. This again calls into question the reported hours of instruction as well as students’ imaging competence levels. Regarding student competence, the reasons for lower ratings were not ascertained; for example, ultrasonography competence was rated low (2.0 or lower; 1 [not competent] to 5 [competent]). It is unclear if low ratings were due to overall student performance or to students having limited exposure (eg, shoulder only). In this case, students may be competent at identifying normal shoulder anatomy but not other body regions. Despite the limitations, this study provides, to our knowledge, the first summary of imaging curricula in physical therapist professional degree programs.

CONCLUSION

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ne hundred fifty-two of the 155 respondents reported integrating imaging content into their program, with 2 of the remaining 3 reporting plans of adding the content area. Faculty assessment of student abilities related to imaging revealed perceived competence in some areas but not others. There was also a mismatch between faculty beliefs of new physical therapist graduates’ minimal knowledge base/skill sets for referring patients directly to radiologists and student competence for some of the

imaging modalities. This mismatch and the reported variability in imaging curricula suggest a need for the development of curricular guidelines and resources for physical therapist program instructors. t

KEY POINTS FINDINGS: Diagnostic and procedural

imaging variation exists regarding how content is integrated into the curriculum, what content is included, and how students are assessed to determine competence. Current curriculum emphasis appears to be on the musculoskeletal system. To increase student competence, respondents suggested increased emphasis during clinical internships and increased laboratory classroom hours. IMPLICATIONS: The reported variability suggests the need for consensus within the profession regarding diagnostic and procedural imaging curricula and physical therapist professional education, and also for the development of curricular resources to aid faculty responsible for this content area. CAUTION: The survey did not address educational philosophy or curricular models that may explain some of the variation between programs. ACKNOWLEDGEMENTS: The authors would like

to thank the following individuals who participated in the development and piloting of the survey instrument: Hilmir Agustsson, PT; David Ebaugh, PT; Charles Hazle, PT; Lynn McKinnis, PT; Eric Ordorica, PT; Rebecca Rodda, PT; Michael Ross, PT; and Michael Wong, PT.

REFERENCES 1. A merican College of Radiology. Practice Guidelines and Technical Standards. Available at: http://www.acr.org/quality-safety/standardsguidelines. Accessed December 14, 2013. 2. American Physical Therapy Association. Diagnosis by Physical Therapists. Available at: http://www.apta.org/uploadedFiles/APTAorg/ About_Us/Policies/Practice/Diagnosis.pdf. Accessed April 24, 2014. 3. American Physical Therapy Association. A Normative Model of Physical Therapist Profes-



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[ 4.


5.

6.

7.

8.

9.

10.

11.

12.

13.

sional Education: Version 2004. Alexandria, VA: American Physical Therapy Association; 2004. Blake CG, Ross MD. Femoral neck fracture in a military trainee. J Orthop Sports Phys Ther. 2008;38:578. http://dx.doi.org/10.2519/ jospt.2008.0409 Boissonnault W, Bryan JM, Fox KJ. Joint manipulation curricula in physical therapist professional degree programs. J Orthop Sports Phys Ther. 2004;34:171-178; discussion 179-181. http:// dx.doi.org/10.2519/jospt.2004.34.4.171 Boissonnault WG, Badke MB, Powers JM. Pursuit and implementation of hospital-based outpatient direct access to physical therapy services: an administrative case report. Phys Ther. 2010;90:100-109. http://dx.doi.org/10.2522/ ptj.20080244 Boyles RE, Gorman I, Pinto D, Ross MD. Physical therapist practice and the role of diagnostic imaging. J Orthop Sports Phys Ther. 2011;41:829837. http://dx.doi.org/10.2519/jospt.2011.3556 Callaghan MJ. A physiotherapy perspective of musculoskeletal imaging in sport. Br J Radiol. 2012;85:1194-1197. http://dx.doi.org/10.1259/ bjr/54277010 Commission on Accreditation in Physical Therapy Education. Evaluative Criteria for Accreditation of Education Programs for the Preparation of Physical Therapists. Alexandria, VA: American Physical Therapy Association; 2009. Dauber JA, Naspinsky SR. Radial head fracture following a fall. J Orthop Sports Phys Ther. 2010;40:30. http://dx.doi.org/10.2519/ jospt.2010.0401 Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating chronic back pain: time to back off? J Am Board Fam Med. 2009;22:62-68. http:// dx.doi.org/10.3122/jabfm.2009.01.080102 Di Iorio D, Henley E, Doughty A. A survey of primary care physician practice patterns and adherence to acute low back problem guidelines. Arch Fam Med. 2000;9:1015-1021. Elliott JM. Magnetic resonance imaging:

research report

14.

15.

16.

17.

18. 19.

20.

21.

22.

23.

]

generating a new pulse in the physical therapy profession. J Orthop Sports Phys Ther. 2011;41:803-805. http://dx.doi.org/10.2519/ jospt.2011.0109 Greathouse DG, Schreck RC, Benson CJ. The United States Army physical therapy experience: evaluation and treatment of patients with neuromusculoskeletal disorders. J Orthop Sports Phys Ther. 1994;19:261-266. http://dx.doi. org/10.2519/jospt.1994.19.5.261 Hodges PW. Ultrasound imaging in rehabilitation: just a fad? J Orthop Sports Phys Ther. 2005;35:333-337. http://dx.doi.org/10.2519/ jospt.2005.0106 James JJ, Stuart RB. Expanded role for the physical therapist. Screening musculoskeletal disorders. Phys Ther. 1975;55:121-131. Mafi JN, McCarthy EP, Davis RB, Landon BE. Worsening trends in the management and treatment of back pain. JAMA Intern Med. 2013;173:1573-1581. http://dx.doi.org/10.1001/ jamainternmed.2013.8992 Malone TR, Hazle C, Grey ML. Imaging in Rehabilitation. New York, NY: McGraw-Hill; 2008. Manipulation Education Committee of the APTA Manipulation Task Force. Manipulation Education Manual for Physical Therapist Professional Degree Programs. Alexandria, VA: American Physical Therapy Association; 2004. Martin BI, Deyo RA, Mirza SK, et al. Expenditures and health status among adults with back and neck problems. JAMA. 2008;299:656-664. http://dx.doi.org/10.1001/jama.299.6.656 McKinnis L. Fundamentals of Musculoskeletal Imaging. 3rd ed. Philadelphia, PA: F.A. Davis Company; 2010. Mitchell JM. Utilization trends for advanced imaging procedures: evidence from individuals with private insurance coverage in California. Med Care. 2008;46:460-466. http://dx.doi. org/10.1097/MLR.0b013e31815dc5ae Moore JH, McMillian DJ, Rosenthal MD, Weishaar MD. Risk determination for patients

24.

25.

26.

27.

28.

29.

30.

with direct access to physical therapy in military health care facilities. J Orthop Sports Phys Ther. 2005;35:674-678. http://dx.doi.org/10.2519/ jospt.2005.35.10.674 Murphy BP, Greathouse D, Matsui I. Primary care physical therapy practice models. J Orthop Sports Phys Ther. 2005;35:699-707. http:// dx.doi.org/10.2519/jospt.2005.35.11.699 Overman SS, Larson JW, Dickstein DA, Rockey PH. Physical therapy care for low back pain. Monitored program of first-contact nonphysician care. Phys Ther. 1988;68:199-207. Pham HH, Landon BE, Reschovsky JD, Wu B, Schrag D. Rapidity and modality of imaging for acute low back pain in elderly patients. Arch Intern Med. 2009;169:972-981. http://dx.doi. org/10.1001/archinternmed.2009.78 Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice. 3rd ed. Upper Saddle River, NJ: Pearson/Prentice Hall; 2008. Springer BA, Arciero RA, Tenuta JJ, Taylor DC. A prospective study of modified Ottawa ankle rules in a military population. Interobserver agreement between physical therapists and orthopaedic surgeons. Am J Sports Med. 2000;28:864-868. Swain J, Bush KW, Brosing J. Diagnostic Imaging for Physical Therapists. St Louis, MO: Elsevier/ Saunders; 2009. Weiner DK, Kim YS, Bonino P, Wang T. Low back pain in older adults: are we utilizing healthcare resources wisely? Pain Med. 2006;7:143-150. http://dx.doi. org/10.1111/j.1526-4637.2006.00112.x

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ONLINE APPENDIX

A SURVEY OF DIAGNOSTIC AND PROCEDURAL IMAGING CURRICULA IN FIRST PROFESSIONAL (ENTRY-LEVEL) PHYSICAL THERAPY EDUCATION PROGRAMS


Dear Faculty Member, This survey should be completed by the faculty member who teaches and/or coordinates the diagnostic and procedural imaging component of the physical therapy curriculum. The survey is being sent to all physical therapy professional degree programs accredited by CAPTE. The survey takes approximately 15 minutes to complete. Your participation is voluntary. Regardless of whether you choose to participate, no personal identity or program identifiers will be published. If any information is revealed that is sensitive, personal, or identifiable, it will be deleted and not included in any publications. In addition, the survey does contain open-ended questions and comment areas; the corresponding responses will be summarized in the aggregate, again with no personal identifiers included. Please contact me if you have any questions regarding the survey. Study purpose: descriptive data from this survey may be of value as an assessment tool for faculty and existing curricula within the framework of your program’s educational philosophy and curricular plan. The data may also be helpful for the development of diagnostic and procedural imaging curricula in new physical therapy education programs. This is a University of Wisconsin-Madison research study (IRB approval: January 14, 2013). As PI for the study, my contact information is: 608-263-5095 (phone) and [email protected] (e-mail). The approving IRB is housed under the School of Education, University of Wisconsin-Madison. There are no anticipated risks for study participants, and potential benefits to all entry-level physical therapy programs related to medical imaging curricula. By completing this survey, you are indicating consent to participate in this study. Thank you! William Boissonnault

journal of orthopaedic & sports physical therapy | volume 44 | number 8 | august 2014 | B1


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ONLINE APPENDIX

As the instructor responsible for teaching and/or coordinating the program’s imaging curricula, please fill in or check the appropriate responses. Your written comments are also appreciated.


Institution Demographics 1. What professional/entry-level degree does your program grant upon graduation? ____ MSPT ____ MPT/MSC ____ DPT If your program currently grants an entry-level masters degree, in what year will the transition to the DPT occur? ____ If your program currently grants a DPT degree, in what year did the first DPT class graduate? ____ 2. What is the current accreditation status of your PT program? ____ Accredited ____ Probationary accreditation ____ Developing program or initial accreditation 3. What is the length of your program in months? ____ 4. How many students are enrolled in the current first-year class? ____ 5. Is your institution located in a state that allows patients direct access to physical therapy services? ____ Yes If yes, in what year did your state attain direct access? ____ ____ Year ____ Don’t know ____ No 6. Is your institution located in a state whose practice act allows physical therapists to directly refer patients to radiologists/radiology departments for diagnostic imaging? ____ Yes (please respond to the appropriate item): ____ Physical therapists were never restricted to refer patients for imaging by law, or ____ Provide the year your state approved such language allowing physical therapists to refer patients directly to radiology ____ ____ Year ____ Don’t know ____ No ____ Don’t know 7. Is your institution located in a state whose practice act allows physical therapists to utilize procedural imaging (eg, ultrasonography as an adjunct to Rx)? ____ Yes (please respond to the appropriate item): ____ Physical therapists were never restricted in the use of procedural imaging, or ____ Provide the year in which your state approved such language allowing physical therapists to utilize procedural imaging____ ____ Year ____ Don’t know ____ No ____ Don’t know Please provide any additional comments/information regarding your institution applicable to this survey: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________

B2 | august 2014 | volume 44 | number 8 | journal of orthopaedic & sports physical therapy


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ONLINE APPENDIX

Diagnostic and Procedural Imaging Curricula 8. Is diagnostic and procedural imaging included in your program’s curriculum? ____ Yes (If the answer is yes, proceed directly to question 11) ____ No


If the answer is NO to question 8, please answer the next 2 questions (9 and 10) and then proceed to question 29. 9. Why is imaging not included in your PT program’s current curriculum? (please check all that apply) ____ Lack of qualified faculty available to instruct ____ Lack of money available to hire adjunct faculty ____ Not considered by faculty to be high-enough curricular priority for inclusion ____ Not considered by faculty to be an entry-level skill ____ Lack of published literature regarding imaging and physical therapist clinical practice ____ Not enough time available in curriculum to include ____ Lack of published criteria to guide what is to be taught ____ Other ___________________________________________________________ 10. What are the plans to initiate/integrate imaging content into your current curriculum? (please check all that apply) ____ Establish new required course ____ Establish new elective course ____ Modify existing course content ____ No plans to add to current curriculum ____ Other (please describe) ___________________________________________________________ Please Proceed to Question 29 11. When in the curriculum is imaging first introduced? ____ First year: ____ Semester 1 ____ Quarter 1 ____ Semester 2 ____ Quarter 2 ____ Semester 3 ____ Quarter 3 ____ Quarter 4 ____ Second year: ____ Semester 1 ____ Quarter 1 ____ Semester 2 ____ Quarter 2 ____ Semester 3 ____ Quarter 3 ____ Quarter 4 ____ Third year: ____ Semester 1 ____ Quarter 1 ____ Semester 2 ____ Quarter 2 ____ Semester 3 ____ Quarter 3 ____ Quarter 4 ____ Fourth year: ____ Semester 1 ____ Quarter 1 ____ Semester 2 ____ Quarter 2 ____ Semester 3 ____ Quarter 3 ____ Quarter 4



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ONLINE APPENDIX

12. Imaging is currently taught as a (check more than one if applicable): ____ Required, separate/standalone course as part of core curriculum If so, what percentage of the course content is devoted to (total should equal 100%): ____ Musculoskeletal system ____ Cardiovascular/pulmonary systems ____ Neuroimaging: adults ____ Neuroimaging: pediatrics ____ Part of a required clinical science course(s) (check all that apply): ____ Musculoskeletal track ____ Neurological track ____ Cardiovascular track ____ Pulmonary track ____ Separate elective course (title: ___________________________________________________________) If so, what percentage of the course content is devoted to (total should equal 100%): ____ Musculoskeletal system ____ Cardiovascular/pulmonary systems ____ Neuroimaging: adults ____ Neuroimaging: pediatrics ____ Component of multiple courses other than the core clinical science courses ____ Other (please describe) ___________________________________________________________ 13. How many total contact hours does your curriculum spend teaching imaging theory, clinical application, and skills within each of the following categories? ____ Classroom/lecture ____ Laboratory (practice identifying structures/conditions) ____ Online coursework ____ Simulated patient experiences ____ Supervised actual patient care experience ____ Video/CD-ROM coursework ____ Other (please specify) ___________________________________________________________ Total number of contact hours for imaging curricula: ____ 14. Please provide the estimated number of instructional hours for each of the following topics: Physical properties of imaging modalities ____ Strengths and limitations of imaging modalities ____ Integration of imaging results in patient medical screening, including use of clinical guidelines for when a patient referral for imaging is indicated ____ Integration of imaging results with other examination findings for patient plan of care development, other than for patient referral ____



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15. What are the primary student resources used for imaging coursework? ____ Greenspan A, Orthopedic Radiology ____ Required ____ Recommended ____ Malone et al, Imaging in Rehabilitation ____ Required ____ Recommended ____ McKinnis, Fundamentals of Musculoskeletal Imaging ____ Required ____ Recommended ____ Swain et al, Diagnostic Imaging for Physical Therapists ____ Required ____ Recommended ____ Other (including key websites, journal articles, manuals, videos and CD-ROM: please list and note if they are required or recommended sources): ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ 16. Who teaches the imaging content in your program? Please indicate below who teaches the imaging content in your program by percentage. Total should equal 100%. Note: do not include lab assistants unless they are actively involved in teaching. Full-time or part-time core faculty ____ Adjunct faculty (guest lecturers from other departments) ____ Clinical faculty ____ Other ____ 17. What are the primary faculty resources used to teach imaging? ____ Greenspan A, Orthopedic Radiology ____ Malone et al, Imaging in Rehabilitation ____ McKinnis, Fundamentals of Musculoskeletal Imaging ____ Swain et al, Diagnostic Imaging for Physical Therapists ____ Other (including key websites, journal articles, manuals, videos and CD-ROM: please list): ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ 18. How do you assess student competency related to imaging? Please answer by showing grading methods by percentage. ____ Students are not tested (if not tested, please go to question 21) ____ Written examination ____ Oral examination ____ Practical examination (identify normal/abnormal structures on images) ____ Simulated patient examination/treatment ____ Actual patient examination/treatment ____ Other (please describe) ___________________________________________________________ 19. Is student competency assessed at the end of the curriculum as part of final preparatory/competency examination? ____ Yes, is included as a content area ____ No, is not included as a content area ____ Program does not have a final preparatory/competency examination



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20. For which of the following do you assess student competency in imaging? Please place an X in all boxes that apply. Plain-Film Radiography

MRI

CT

US

Bone Scan

□ □ □ □

□ □ □ □

□ □ □ □

□ □ □ □

□ □ □ □

□

□

□

□

□

Identify normal anatomy Identify skeletal pathological processes/injuries


Identify soft tissue pathological processes/injuries Utilization of clinical guidelines for referring patients for diagnostic imaging Adjunct to patient intervention(s)

Comments: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ 21. Plain-film radiology: please note the level of student competence upon completion of your program. Please circle the appropriate number for each item.

Identifying normal anatomy Identifying common skeletal pathological processes/injuries (eg, degenerative joint disease, fractures) Utilization of existing clinical guidelines for referring patients for plain-film radiographs

Not Taught or Assessed 0

Not Competent 1

0 0

1

2 2

3 3

4 4

1

2

3

4

Competent 5 5 5

Comments, including providing examples for above: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ 22. Magnetic resonance imaging: please note the level of student competence upon completion of your program for. Please circle the appropriate number for each item.

Identifying normal anatomy Identifying common neuromusculoskeletal pathological processes/injuries (eg, ligamentous injuries, spinal nerve root compression, osseous stress reaction injuries) Utilization of existing clinical guidelines and other examination findings for referring patients for magnetic resonance imagings

Not Taught Not or Assessed Competent 0 1 0

1

2 2

0

1

2

3 3

4 4

3

4

Competent 5 5

5

Comments, including providing examples for above: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________



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23. Computed tomography scan: please note the level of student competence upon completion of your program. Please circle the appropriate number for each item. Not Taught Not or Assessed Competent 0 1


Identifying normal anatomy Identifying skeletal pathological processes/injuries (eg, fractures) Utilization of existing clinical guidelines and other examination findings for referring patients for computed tomography scan

0

1

2 2

3 3

4 4

0

1

2

3

4

Competent 5 5 5

Comments, including providing examples for above: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ 24. Ultrasonography: please note the level of student competence upon completion of your program. Please circle the appropriate number for each item. Not Taught Not or Assessed Competent 0 1

Identifying soft tissue or skeletal pathological processes/injuries

0

1

Utilization of existing clinical guidelines and other examination findings for referring patients for ultrasonography Apply/utilize ultrasonography as an adjunct to other interventions?

0

1

2 2 2

0

1

2

Identifying normal anatomy

3 3 3

4 4 4

3

4

Competent 5 5 5 5

Comments, including providing examples for above: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ 25. Bone scan: please note the level of student competence upon completion of your program. Please circle the appropriate number for each item.

Identifying soft tissue or skeletal pathological processes/injuries Utilization of existing clinical guidelines and other examination findings for referring patients for bone scan

Not Taught Not or Assessed Competent 0 1 0

1

2 2

3 3

4 4

Competent 5 5

Comments, including providing examples for above: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________



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ONLINE APPENDIX


26. Do you believe that having the knowledge base and skills necessary for referring patients directly to radiologists/radiology departments for imaging is a minimum required skill of new physical therapist graduates?

Plain-film radiography Magnetic resonance imaging Computed tomography Ultrasonography Bone scan

Strongly Disagree 1 1 1 1 1

Disagree 2 2 2 2 2

Neutral 3 3 3 3 3

Agree 4 4 4 4 4

Strongly Agree 5 5 5 5 5

Comments, including providing examples for above: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ 27. If necessary, what would be the most beneficial way to increase your students’ knowledge/application of imaging? (check all of the following that you feel would be beneficial) ____ Increase lecture hours ____ Increase laboratory hours ____ Increase emphasis during clinical affiliations ____ Have a specialist teach the course ____ Have a specialist guest lecture in the course ____ No change is necessary ____ Other ___________________________________________________________ 28. If you answered increase hours for question 27, what barriers are preventing this (check all that apply)? ____ Lack of qualified faculty to instruct ____ Lack of money available to hire adjunct faculty ____ Not enough time in curriculum to include ____ Other ___________________________________________________________ Please provide any additional comments/information regarding diagnostic and procedural imaging curricula applicable to this survey: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ Faculty Member Demographic Information 29. Gender ____ Female ____ Male 30. Age____ years 31. What is your professional (entry-level) physical therapy degree? ____ BSPT ____ MSPT ____ MPT ____ DPT If you are not a physical therapist, please check the appropriate item and then go to question 37: ____ MD ____ PA ____ NP ____ RN ____ Other ________ 32. In what year did you receive your entry-level physical therapy degree? ____



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ONLINE APPENDIX

33. Please check any postprofessional degrees you have earned or advanced training you have received: ____ MS ____ EdD ____ MA ____ t-DPT ____ PhD ____ DSc ____ DHSc ____ Other ____ ____ APTA-credentialed residency program in what practice/specialty area? ____ Orthopaedics ____ Sports ____ Geriatrics ____ Pediatrics ____ Neurology ____ Other (please specify) ___________________________________________________________ ____ APTA-credentialed fellowship: what practice specialty area? ___________________________________________________________ 34. Please indicate if you hold American Board of Physical Therapy Specialties clinical specialist certification in any of the following areas: ____ Orthopedics ____ Cardiopulmonary ____ Sports ____ Clinical electrophysiological ____ Geriatrics ____ Neurology ____ Pediatrics ____ Women’s health 35. Are you a Fellow of the American Academy of Orthopaedic Manual Physical Therapists? ____ Yes ____ No 36. Are you a member of the Orthopaedic Section, APTA Imaging Special Interest Group? ____ Yes ____ No If no, were you aware the Imaging Special Interest Group existed? ____ Yes ____ No 37. As the program’s primary instructor/coordinator of imaging curricula, please state which of the following reflects your academic position within the program. ____ Core faculty, full time ____ Core faculty, part time ____ Associated/adjunct faculty 38. State the number of years you have been working as a physical therapy program faculty member in an academic setting (enter a number or 0 for each choice): Number of years, full time ____ Number of years, part time ____



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ONLINE APPENDIX


Primary Faculty Member: Education/Training Related to Imaging 39. Did you receive any education/training in imaging during your entry-level professional education program? ____ Yes (please describe in what capacity: check all relevant boxes below) ____ As a method to learn human anatomy, neuroanatomy ____ To better understand pathological processes/conditions ____ How imaging findings may impact a patient’s plan of care (evaluation, diagnosis, prognosis, and intervention) ____ Imaging used as an intervention adjunct (eg, using ultrasound to assist in rehabilitative outcome or biofeedback ____ Imaging guidelines when patient referral is indicated for imaging ____ Other (please describe) ___________________________________________________________ ____ No Comments: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ 40. Have you received any education/training/self-study in imaging since graduation from your entry-level professional program? ____ Yes (please check all that apply) ____ Completion of an APTA-credentialed residency program ____ Completion of an APTA-credentialed fellowship program ____ Transitional DPT degree program ____ Postprofessional/advanced degree program (MS/PhD, etc) ____ Continuing education certification program ____ Continuing education without certification ____ Ongoing clinical practice mentoring If yes, mentored by whom (PT, radiologist, other physician) _______________ ____ Other ___________________________________________________________ ____ No Comments: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ 41. How many years have you been teaching imaging in an academic setting?____ 42. How would you rate yourself regarding your qualifications to teach imaging? Minimally Qualified 1

Well Qualified

2

3

4

5

43. What do you feel is the best way to increase your personal expertise related to teaching imaging? Please rank each item 0 to 5, with 0 being no help at all and 5 being very helpful. Please label ALL categories. Not Helpful Continuing education Residency/fellowship training programs Textbooks/videotapes/CD-ROM Clinical experience with mentoring Other _______________________________ Other _______________________________

0 0 0 0 0 0

Very Helpful 1 1 1 1 1 1

2 2 2 2 2 2

3 3 3 3 3 3

4 4 4 4 4 4

5 5 5 5 5 5



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ONLINE APPENDIX

44. What qualifications should a faculty member have in order to teach imaging? (check all that apply) ____ Completion of an APTA-credentialed residency program In what practice area(s)? ___________________________________________________________ ____ Completion of APTA-credentialed fellowship program In what practice area(s)? ___________________________________________________________ ____ Hold ABPTS specialist clinical certification In what area(s) of specialist certification? ___________________________________________________________ ____ Transitional DPT degree program ____ Postprofessional/advanced degree program ____ Continuing education certification program ____ Continuing education without certification ____ Registered diagnostic musculoskeletal certification in ultrasound ____ Ongoing clinical practice with mentoring If yes, mentored by whom (PT, radiologist, other physician)? ________________ ____ Ongoing clinical practice ____ Has clinical experience directly referring patients to radiology for diagnostic imaging ____ Other ___________________________________________________________ Comments: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ Primary Faculty Member: Clinical Practice Background 45. State the number of years you have been practicing in a clinical setting (enter a number or 0 for each choice): Number of years: full time ____ Number of years: part time ____ 46. Are you currently practicing in a clinical setting? ____ No (go to question 52) ____ Yes (go to question 47) 47. If yes, how many hours per week? ____ 48. What is your primary area of clinical practice? ____ Orthopaedics ____ Sports ____ Geriatrics ____ Pediatrics ____ Outpatient neurorehabilitation ____ Outpatient cardiovascular and/or pulmonary ____ Inpatient acute care ____ Other ___________________________________________________________ 49. Do you practice in a state whose practice act allows for physical therapists directly referring patients to radiologists/radiology departments? ____ Yes (go to question 50) ____ No (go to question 52) ____ Unsure



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ONLINE APPENDIX

50. Have you directly referred patients to a radiologist/radiology department for diagnostic imaging? ____ Yes (please check for which of the following imaging modalities): ____ Plain-film radiography ____ Computed tomography ____ Magnetic resonance imaging ____ Ultrasonography ____ Bone scan ____ Other ___________________________________________________________ If yes, state for how many years you have been referring patients directly to radiology for diagnostic imaging____ ____ No Comments: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ 51. What estimated percentage of your patients do you refer directly to a radiologist/radiology department for diagnostic imaging?____ Comments: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ 52. Please share any additional comments or suggestions you may have on teaching diagnostic and procedural imaging to professional physical therapy students. __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ THANK YOU FOR RESPONDING TO THIS SURVEY!



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