Nicola J. Petty

Ready for a paradigm shift? Part 2: Introducing qualitative research methodologies and methods

This paper explores a number of commonly used methodologies and methods in qualitative research, namely grounded theory, case study, phenomenology, ethnography and narrative research. For each methodology a brief history of its development and variants is given, followed by typical methods of data collection and analysis. Examples of manual therapy qualitative research studies are highlighted for each methodology. Data collection methods are then discussed and include individual interviews, focus groups, observation and documentary analysis. A frequently used method of data analysis, thematic analysis, is briefly explained. Finally, the strategies to enhance the quality of qualitative research is explored and compared to those of quantitative research.

Ready for a paradigm shift? Part 1: Introducing the philosophy of qualitative research

The manual therapy professions have almost exclusively focused on the use of quantitative research to help inform their practices. This paper argues that a greater use of qualitative research will help develop a more robust and comprehensive knowledge base in manual therapy. The types of knowledge used in practice and generated from the two research paradigms are explored. It is hoped that an understanding of the philosophical and theoretical underpinnings of qualitative research may encourage more manual therapists to value and use this approach to help further inform their practice; for some, this may involve a paradigm shift in thinking.

The impact of a musculoskeletal masters course: Developing clinical expertise

A common aim of Masters (MSc) courses in the UK, accredited by the Manipulation Association of Chartered Physiotherapists (MACP), is to promote the clinical expertise of practitioners. Few studies have explored the extent to which this is achieved and understanding is further hampered by the contested nature of expertise. This paper reports on the impact of an MACP approved MSc on practitioners and offers a conceptual model of their development towards clinical expertise. A qualitative theory-seeking case study was used, drawing on the procedures and processes of grounded theory. Twenty-six semi-structured interviews were conducted with eleven alumni from one MACP approved MSc programme. Dimensional analysis and the constant comparative method of data analysis, was used to build the conceptual model. Prior to enrolment, practitioners uncritically accepted knowledge from others and followed habitual routines with their patients. Their diet of informal CPD appeared ineffective in developing these attributes. The impact of the MACP approved MSc involved three developmental aspects of clinical expertise: critical understanding of practice knowledge, patient centred practice and capability to learn in, and from, clinical practice. These inter-related aspects of knowledge, practice and learning offer a conceptual model of the development towards clinical expertise. The most powerful experience to trigger change was direct observation and feedback of their clinical practice by an MACP educator; this highlights the value of clinical mentors facilitating less experienced colleagues. The implementation of such mentorship within departments may offer a cost effective and manageable way to support CPD within the workforce.

Changes in Bending Stiffness and Lumbar Spine Range of Movement Following Lumbar Mobilization and Manipulation

OBJECTIVE The purpose of this study was to investigate the effects of lumbar rotational manipulation and lumbar central posteroanterior mobilization on lumbar bending stiffness and flexion and extension range of motion (ROM). METHODS A same-subject, repeated-measures, crossover design was used using 32 asymptomatic subjects (16 female and 16 male; mean [SD] age, 25.5 [4.5] years; weight, 65.7 [11.8] kg; and height, 1.70 [0.08] m). Each subject received mobilization or manipulation on 2 different occasions. Bending stiffness was calculated using a 3-point bending model using an electromagnetic tracking device and a force platform; lumbar flexion and extension ROM was measured using an electromagnetic tracking device. All variables were measured pre- and postintervention. Their effect was compared using paired t tests. RESULTS Manipulation and mobilization did not significantly alter either bending stiffness or lumbar flexion and extension ROM (mobilization: P = .175, P = .613, and P = .535; manipulation: P = .973, P = .323, and P = .439). Bending stiffness changes were not correlated to changes in ROM (Pearson r for stiffness-flexion = -0.102, P = .586; Pearson r for stiffness-extension = 0.014, P = .941). CONCLUSIONS Manipulation and mobilization had no significant effect on bending stiffness or flexion and extension ROM for this group of subjects. Some individual variations in effect were observed.

Accuracy of Feedback During Training of Passive Accessory Intervertebral Movements

Abstract The purpose of this study was to determine the accuracy of verbal feedback given by manipulative physiotherapy students after a fellow student had applied Passive Accessory Intervertebral Movements (PAIVMs). Twelve students working in pairs acted in turn as model and therapist. Student therapist performance in producing a Grade-III movement was compared subjectively by student models to that of an experienced therapist. Their performance was also objectively compared using a force platform measurement system. Performances were assessed in terms of peak force and the frequency and amplitude of force oscillations. The feedback provided by student models was found to be inconsistent and unreliable. Alternate teaching methods seem necessary in order to provide student therapists with feedback appropriate for learning.

Clinical expertise: Learning together through observed practice

The popularity of inservice training programmes and short courses, as well as clinically related MSc courses in higher education, suggest that manual therapy practitioners are only too aware of a need to enhance clinical effectiveness and efficiency. While national professional bodies may consider continuous professional development (CPD) activity as obligatory, practitioners themselves have long been driven by a strong moral responsibility to improve what they do for their patients, investing both their time and finances in their learning. But what sort of learning do they do and is it effective to develop clinical expertise? Typically, CPD activities involve in-service training in the workplace and short courses away from the workplace that focus on relevant literature and research and hands-on skill. Practitioners perform techniques on each other with guidance from someone with expertise. Practitioners then go back into clinical practice and apply their new knowledge and skill to patients. Over time, practitioners see numbers of patients and gain experience and ‘patient mileage’ (Richardson, 1996, 1999). Will this CPD diet of patient experience, in-service training and short courses, result in enhanced clinical practice; will it lead to clinical expertise? To address this question, the literature related to professional learning is briefly reviewed. The notion that patient mileage automatically leads to clinical practice expertise is not supported by the literature (Boud et al., 1993; Stathopoulos and Harrison, 2003; Conneeley, 2005). There may be a number of reasons for this:

Contribution of lumbar spine and hip movement during the palms to floor test in individuals with diagnosed hypermobility syndrome

The ability to place the hands to the floor forms part of the assessment of joint hypermobility. The test may be symptom free, or in the case of joint hypermobility syndrome, may be associated with pain in the spine, hip, and knee. The aim of this study was to identify the relative amount of movement at the lumbar spine and hip during this test in people with asymptomatic and symptomatic hypermobility compared with a control group. Thirty-six female subjects (10 asymptomatic hypermobility, 13 symptomatic hypermobility, and 13 control) ranging between 18 and 60 years of age participated in the investigation. Measurements were made by using digital photography and inclinometers. Measurement reliability was established prior to the investigation. There was a significant difference (p<0.05) between hip flexion range in the two hypermobility groups compared to the control group; there was no significant difference in lumbar spine movement between the three groups. The findings suggest that people with asymptomatic or symptomatic hypermobility perform the hand to floor test with the same relative contribution from the lumbar spine and hip joints. Both groups perform the hands to floor test and with a greater relative hip flexion range than a control group.

Professional doctorate: combining professional practice with scholarly inquiry

Professional doctorates in occupational therapy and physiotherapy in the United Kingdom offer a practice-based qualification equivalent in status to a PhD. Their aim is to develop professional practice and contribute to professional knowledge. Two doctorate journeys illustrate how applied research added both to each professions knowledge base and to practice. Their learning was enhanced by interprofessional peer support. It is argued that the professional doctorate is an attractive option for a senior practitioner in clinical practice, management or higher education who wants to influence practice.

Developing an observed practice programme for occupational therapists and physiotherapists: reporting the first phase of an action research study

Occupational therapists working in higher education have acknowledged the benefits of peer observation to their professional development and there has been discussion of its potential benefits in clinical settings. However, there is limited literature and no practical guidance on the implementation of observed practice within clinical practice. This action research study sought to develop a work-based observed practice programme for occupational therapists and physiotherapists in a United Kingdom mental health trust. Action research was chosen to enable the positive engagement of practitioners in order to co-create knowledge and to improve practice. Occupational therapists and physiotherapists with expertise of local practice and personal experience of staff development and clinical supervision formed a working group to develop and implement the programme. The group considered examples of similar programmes from higher education and addressed issues relating to the purpose, status and process of the programme. It also explored its relationship to existing preceptorship programmes and clinical supervision. This paper summarises the key steps of the observed practice process and the development of supporting documentation created by the working group. The observed practice programme was implemented at workshops in the autumn of 2009 to be followed by a formal evaluation.

The intra-rater reliability of a revised 3-point grading system for accessory joint mobilizations

Abstract Objectives: Joint mobilizations are often quantified using a 4-point grading system based on the physiotherapist’s detection of resistance. It is suggested that the initial resistance to joint mobilizations is imperceptible to physiotherapists, but that at some point through range becomes perceptible, a point termed R1. Grades of mobilization traditionally hinge around this concept and are performed either before or after R1. Physiotherapists, however, show poor reliability in applying grades of mobilization. The definition of R1 is ambiguous and dependent on the skills of the individual physiotherapist. The aim of this study is to test a revised grading system where R1 is considered at the beginning of range, and the entire range, as perceived by the physiotherapists maximum force application, is divided into three, creating 3 grades of mobilization. Method: Thirty-two post-registration physiotherapists and nineteen pre-registration students assessed end of range (point R2) and then applied 3 grades of AP mobilizations, over the talus, in an asymptomatic models ankle. Vertical forces were recorded through a force platform. Intra-class Correlation Coefficients, Standard Error of Measurement, and Minimal Detectable Change were calculated to explore intra-rater reliability on intra-day and inter-day testing. T-tests determined group differences. Results: Intra-rater reliability was excellent for intra-day testing (ICC 0.96–0.97), and inter-day testing (ICC 0.85–0.93). No statistical difference was found between pre- and post-registration groups. Discussion: Standardizing the definition of grades of mobilization, by moving R1 to the beginning of range and separating grades into thirds, results in excellent intra-rater reliability on intra-day and inter-day tests. Level of Evidence: 3b.