Arizona Approved Physical Therapy Continuing Education Courses 2018
Abstract
Objective
The purpose of this study was to characterize the extent to which orthopedic and sports-related continuing education course descriptions approved for physical therapists in the United States taught interventions supported by evidence.
Methods
A review was conducted of courses available on CEU Locker from January through December 2020, estimated to represent most courses nationally available to physical therapists. This review focused specifically on courses teaching interventions for musculoskeletal conditions in adults. Specifically, courses for orthopedic and sports populations were identified. All course information was extracted, including the intervention name, course description, and target audience. Finally, clinical practice guidelines (CPGs) and systematic reviews with at least moderate-level evidence published through May 1, 2021, were searched to determine if treatments were recommended or not recommended, or if no evidence existed.
Results
The review identified 2406 available courses extracted from the database. After excluding courses that did not meet inclusion criteria, duplicates, and those with incomplete or inadequate information, the final number was 319. Most courses (52.7%, n = 168) taught interventions not supported by a CPG or systematic review. Approximately one-third of courses (34.2%, n = 109) taught interventions that were recommended by a CPG. Many courses were targeted to multiple disciplines (38.9%, n = 124), whereas 89 (27.9%) were specifically for physical therapists, physical therapist assistants, or both. The specific target was unclear for 106 (33.2%) courses. Courses usually focused on multiple body regions, and exercise was the most included intervention. Soft-skill courses were the most supported by evidence (82.9%, n = 29), whereas those teaching modalities were the least supported (30.5%, n = 29).
Conclusion
Fewer than one-half of courses that focused on management of musculoskeletal disorders taught interventions supported by a CPG or systematic review, and course descriptions often misrepresented the current state of evidence. Courses required for licensure renewal might not be meeting the intended goal of keeping clinicians current with new and emerging research.
Impact
Relatively few continuing education courses on orthopedic and sports-related physical therapist interventions are based on evidence provided by CPGs or systematic reviews, and some continuing education options required for physical therapists to meet annual licensure renewal requirements might not be keeping therapists current with the latest evidence. This study provides data that can facilitate candid dialog within the profession about potential solutions.
Introduction
Physical therapist practice in the United States is governed at the state level by state practice and licensure laws. One uniform requirement across almost all states is that physical therapists are periodically engaged in continuing education (Maine and Massachusetts are the exceptions). Each state has their own respective requirements regarding the amount and composition of education necessary for a physical therapist to renew their license. The requirement of continuing education aligns with that of most licensed clinicians in the United States. The intent of continuing education is to promote life-long learning, allowing clinicians to keep up with the continuously changing and evolving evidence to improve clinical practice. In theory, continued education keeps clinicians relevant, maximizes patient safety, and leads to improved outcomes. 1 Although limited evidence suggests it may not actually lead to improved outcomes in physical therapy, 2 , 3 it is hard to argue that continued education and knowledge do not bring any inherent value to a practicing clinician. Regardless of outcomes, practicing physical therapists credit continuing education courses with being the primary drivers of change in clinical practice—even more than scientific journals. 4 If continuing education is to be the key catalyst for improving clinical practice, the process that regulates continuing education requires more scrutiny. 5 The type and content of the education are likely very relevant factors to consider because its potential to align clinical practice with best-evidence recommendations and improve outcomes depends greatly on the nature of that education.
The purpose of this study was to assess the quality of orthopedic and sports-related continuing education courses registered and approved in the United States for physical therapy licensure renewal requirements. Our primary aim was to identify courses that taught interventions applicable to physical therapists and determine whether the intervention was supported in a clinical practice guideline (CPG) or systematic review.
Methods
We conducted a systematic assessment of the content of continuing education courses available for physical therapists in the United States. To count toward state licensure renewal requirements, most courses must apply to the state physical therapy association's continuing education committee or state board for approval. Most states require a minimum number of continuing education credits be completed for every license renewal. All publicly available data for orthopedic and sports physical therapy courses on a continuing education management service were abstracted for review and appraisal between January 1 and December 31, 2020.
Inclusion and Exclusion Criteria
CEU Locker (ceulocker.com) is a private company that provides a cloud-based service to independent associations to help their members manage their continuing education. The service is voluntarily subscribed to by state physical therapy associations. It hosts information provided directly from educational content providers with no external process for validating the reliability of the information. All courses approved by the participating state, along with descriptions and objectives for each approved course, are present and available for viewing, categorized at the state level. For inclusion in this review, courses needed to provide education specifically about an intervention for a musculoskeletal disorder present in adult populations. Courses not focused on interventions (ie, ethics, professional conduct, purely diagnostic) were excluded, as were courses for pediatric populations or other medical conditions (ie, rehabilitation in intensive care, respiratory therapy). For consistency, courses on concussion and vestibular conditions were not considered to be musculoskeletal. CEU Locker is estimated to represent most courses that require prior approval for physical therapists practicing across the United States due to current reciprocity policies (Fig. 1). This review included only courses posted on CEU Locker from January 1 through December 31, 2020.
Figure 1
Continuing education unit (CEU) requirements by state. This diagram illustrates state continuing education approval requirements that existed during the study period and how approval in a single state (West Virginia) could potentially allow for reciprocal approval in 34 of the 44 states that require prior course approval. "States with reciprocity" were those that appeared to provide automatic approval if another state body had approved the course. Massachusetts and Maine had no requirements for continuing education as a condition of license renewal. "States with separate submission process" required some separate action on the part of either the licensee or course representative. "States in CEU locker" were those that used CEU Locker for online administration of continuing education applications. Disclaimer: Final interpretation is left to the state based on state practice acts, which was updated July 5, 2021.
Search Strategy and Screening
To conduct a thorough screening of all courses, 3 reviewers (S.P., B.H., and K.W.) entered available data from every course into an online spreadsheet. No search was necessary for this step because this was an exhaustive list of all approved courses. However, the courses are removed from CEU Locker as the course date passes, and therefore the reviewers checked CEU Locker for new courses at least once every 6 weeks during the year of 2020. The 3 reviewers then collectively screened every course description to determine if the course met inclusion/exclusion criteria. Courses were initially screened by only 1 individual, but any courses that were unclear or questionable about meeting the criteria were flagged and any courses that did not have unanimous consensus were reviewed for arbitration by a fourth individual (D.R.). The same process was followed if there was a question about the strength of the evidence from practice guidelines and systematic reviews. Courses were limited to those focusing on orthopedic or sports-related conditions (common injuries to joints, muscles/tendons, and bones and associated structures).
Data Extraction
Data extracted for every course included course title, course description, the type of clinician the course is marketed toward, and website links for further information about the course. The reviewers categorized all courses according to a body region (upper extremity, lower extremity, spine, and not specific to a single body region) and noted the label and description for each intervention being discussed in the course. Those not specific to a body region included interventions for multiple body regions or more general conditions (ie, chronic pain). Courses for the pelvic floor, temporomandibular joint, and headaches were included in the "spine" category. Courses were also grouped into 4 broad categories of interventions (manual therapies, exercise therapies, modalities, and soft skills, the latter including topics associated with improving the quality of communication and interactions with patients, 6 such as motivational interviewing, pain neuroscience education, therapeutic alliance, etc). Courses were also categorized based on their intended clinician target (physical therapist, physical therapist assistant, and multiple disciplines). Claims in any of the course descriptions that appeared to contradict evidence were also extracted and then the claim confirmed by at least 2 individuals. These claims came directly from the content entered for the course description in CEU Locker or from websites provided in CEU Locker offering more information about the course. After data were fully extracted, the reviewers assessed all courses for duplicate entries (ie, different dates for the same course, same courses taught in multiple states), and all subsequent iterations of the same course were excluded. Data for each course were extracted by only 1 individual, but any content that was unclear or questionable for meeting a category of treatment, body region, or clinician target was flagged for review by all the other reviewers. Any content that did not have unanimous consensus was reviewed for arbitration by a fourth individual (D.R.).
Criteria to Determine Quality of Evidence Supporting Each Intervention
Course descriptions and supplementary course information provided in the associated web links were used to determine the specific interventions being recommended in the course. A hierarchy of evidence was established a priori with which to grade the strength of evidence for the interventions being taught, similar to what has been done in a prior assessment of CPG adherent musculoskeletal care by physical therapists. 5 First, any relevant CPG available for that condition was reviewed to determine if the intervention was mentioned in the guideline and then whether the guideline recommended for or against. If the intervention was not addressed in a CPG, then the reviewers attempted to identify any systematic review that supported the use of the intervention with at least moderate level evidence. We selected CPGs and systematic reviews because they synthesize the quantity and quality of collective research on a specific topic, facilitating assessment of the current state of evidence recommendations for a particular condition. 7 When there were multiple interventions taught in a course (eg, exercise and taping), the intervention with the lowest recommendation in the evidence guided the overall ranking for the course. 5 If 2 or more guidelines or systematic reviews existed and were conflicting, the most recent guideline or systematic review was used. If the intervention was either not recommended or recommended against in CPGs, the reviewers determined if any newer systematic reviews existed with moderate-quality evidence to support the intervention.
The review team followed a search algorithm to identify relevant practice guidelines and systematic reviews based on the list of interventions and body regions that had been extracted from the courses First, the reviewers used as a reference a list of CPGs and systematic reviews published in a recent systematic review that had curated all physical therapist interventions for musculoskeletal conditions based on CPGs and systematic reviews. 5 Second, for interventions not addressed in that systematic review, the team collected a list of known CPGs for musculoskeletal conditions from various sources (American Physical Therapy Association [APTA]; Academy of Orthopaedic Physical Therapy; American College of Physicians; Departments of Defense and Veterans Affairs; National Institute for Health and Care Excellence; American College of Rheumatology; Osteoarthritis Research Society International; etc [list of guidelines in the Supplementary Appendixes]). For any interventions not identified in the first 2 steps, we searched for the intervention and associated diagnosis in the Physiotherapy Evidence Database. 8 Finally, we searched the Cochrane Library of Reviews and Medline/PubMed for any remaining interventions that had not been identified in guidelines or systematic reviews using the corresponding intervention and diagnosis/body region search terms first with the addition of "practice guidelines" or "clinical guidelines" and then also limiting diagnosis/body region to systematic reviews. When identifying systematic reviews, we looked to see how the authors had graded the strength of the evidence to support that intervention (strong, moderate, weak). The list of all guidelines and systematic reviews used to make this assessment are listed in the Supplementary Appendixes. If the data extracted from the course were insufficient to determine which interventions were being recommended (eg, a statement along the lines of "treatment will be discussed"), then it was marked as "unclear" and excluded. Raw data are available on reasonable request.
Results
There were 2406 total courses initially extracted from CEU Locker during 2020, representing courses approved in 12 different states in the United States. After excluding duplicates, courses with incomplete or inadequate information to determine the nature of the course, and courses that met the exclusion criteria, 319 courses remained in the final review (Fig. 2; Tab. 1). Of these final courses, 251 (78.7%) of them taught only 1 category of intervention, 54 (16.9%) taught 2 categories of interventions, and 14 (4.4%) taught 3 categories of interventions.
Figure 2
Flow diagram outlining the flow of courses included in this review.
Table 1
Summary of Continuing Education Courses Screened That Teach Interventions for Physical Therapist Practice by State a
| State | Total Courses | Online Courses | MSK | MSK+ Treatment b | Unknown |
|---|---|---|---|---|---|
| Arizona | 212 | 180 | 52 | 48 | 0 |
| Colorado | 52 | 26 | 25 | 25 | 0 |
| Kansas | 378 | 340 | 115 | 109 | 1 |
| Michigan | 227 | 100 | 95 | 93 | 1 |
| Montana | 1 | 1 | 0 | 0 | 0 |
| Nebraska | 42 | 23 | 20 | 17 | 0 |
| South Carolina | 93 | 65 | 38 | 25 | 0 |
| Utah | 24 | 21 | 8 | 6 | 0 |
| Vermont | 28 | 12 | 24 | 24 | 0 |
| Virginia | 25 | 0 | 22 | 22 | 0 |
| West Virginia | 1054 | 1024 | 462 | 427 | 4 |
| Wisconsin | 270 | 232 | 88 | 76 | 0 |
| Total | 2406 | 2024 | 949 | 871 | 6 |
| State | Total Courses | Online Courses | MSK | MSK+ Treatment b | Unknown |
|---|---|---|---|---|---|
| Arizona | 212 | 180 | 52 | 48 | 0 |
| Colorado | 52 | 26 | 25 | 25 | 0 |
| Kansas | 378 | 340 | 115 | 109 | 1 |
| Michigan | 227 | 100 | 95 | 93 | 1 |
| Montana | 1 | 1 | 0 | 0 | 0 |
| Nebraska | 42 | 23 | 20 | 17 | 0 |
| South Carolina | 93 | 65 | 38 | 25 | 0 |
| Utah | 24 | 21 | 8 | 6 | 0 |
| Vermont | 28 | 12 | 24 | 24 | 0 |
| Virginia | 25 | 0 | 22 | 22 | 0 |
| West Virginia | 1054 | 1024 | 462 | 427 | 4 |
| Wisconsin | 270 | 232 | 88 | 76 | 0 |
| Total | 2406 | 2024 | 949 | 871 | 6 |
a Only 12 states had continuing education courses that met our inclusion/exclusion criteria. MSK = musculoskeletal.
b MSK+ treatment indicates the course specifically addressed treatment or an intervention for a musculoskeletal condition.
Table 1
Summary of Continuing Education Courses Screened That Teach Interventions for Physical Therapist Practice by State a
| State | Total Courses | Online Courses | MSK | MSK+ Treatment b | Unknown |
|---|---|---|---|---|---|
| Arizona | 212 | 180 | 52 | 48 | 0 |
| Colorado | 52 | 26 | 25 | 25 | 0 |
| Kansas | 378 | 340 | 115 | 109 | 1 |
| Michigan | 227 | 100 | 95 | 93 | 1 |
| Montana | 1 | 1 | 0 | 0 | 0 |
| Nebraska | 42 | 23 | 20 | 17 | 0 |
| South Carolina | 93 | 65 | 38 | 25 | 0 |
| Utah | 24 | 21 | 8 | 6 | 0 |
| Vermont | 28 | 12 | 24 | 24 | 0 |
| Virginia | 25 | 0 | 22 | 22 | 0 |
| West Virginia | 1054 | 1024 | 462 | 427 | 4 |
| Wisconsin | 270 | 232 | 88 | 76 | 0 |
| Total | 2406 | 2024 | 949 | 871 | 6 |
| State | Total Courses | Online Courses | MSK | MSK+ Treatment b | Unknown |
|---|---|---|---|---|---|
| Arizona | 212 | 180 | 52 | 48 | 0 |
| Colorado | 52 | 26 | 25 | 25 | 0 |
| Kansas | 378 | 340 | 115 | 109 | 1 |
| Michigan | 227 | 100 | 95 | 93 | 1 |
| Montana | 1 | 1 | 0 | 0 | 0 |
| Nebraska | 42 | 23 | 20 | 17 | 0 |
| South Carolina | 93 | 65 | 38 | 25 | 0 |
| Utah | 24 | 21 | 8 | 6 | 0 |
| Vermont | 28 | 12 | 24 | 24 | 0 |
| Virginia | 25 | 0 | 22 | 22 | 0 |
| West Virginia | 1054 | 1024 | 462 | 427 | 4 |
| Wisconsin | 270 | 232 | 88 | 76 | 0 |
| Total | 2406 | 2024 | 949 | 871 | 6 |
a Only 12 states had continuing education courses that met our inclusion/exclusion criteria. MSK = musculoskeletal.
b MSK+ treatment indicates the course specifically addressed treatment or an intervention for a musculoskeletal condition.
Most courses taught interventions not supported by a CPG or systematic review (52.7%, n = 168). Interventions not recommended by a CPG (65.8%, n = 210) were rarely supported by a systematic review (20.0%, n = 42). The courses were split evenly between those not focused on 1 specific body region (n = 169) and those focused on 1 specific region (n = 150). The largest proportion of courses was targeted to multiple disciplines and clinician types (38.9%, n = 124), whereas 69 (21.6%) were specifically for physical therapists only, 20 (6.3%) were for physical therapists and physical therapist assistants, and 106 (33.2%) were unclear regarding to whom the course was targeted (although approval for physical therapy continuing education meant this group was necessarily included). Of all the intervention categories, the soft-skill courses were the most supported by evidence (82.9%, n = 29), but this category comprised only 11.0% of courses reviewed. Proportions of courses within each category are outlined in Table 2. Table 3 highlights quotes taken directly from the marketing websites or course descriptions that the reviewers felt clearly overreached on their claims based on current evidence. The list of CPGs and systematic reviews linked to each course can be found in the Supplementary Appendixes.
Table 2
Characteristics of Continuing Education Intervention Courses for Orthopedic and Sports Patient Populations That Had Supporting Evidence From a CPG or Systematic Review With at Least Moderate-Level Evidence (N = 319) a
| Total Courses (N = 319) | Recommendation From CPG for Use of Intervention, No. (%) | At Least Moderate-Level Evidence From Systematic Review to Support Intervention, b No. (%) | Total Supported by Either CPG or Moderate-Level Evidence in a Systematic Review, No. (%) | ||
|---|---|---|---|---|---|
| Yes | No | Yes | No | ||
| Total | 109 (34.2) | 210 (65.8) | 42 (20.0) | 168 (80.0) | 151 (47.3) |
| Body region | |||||
| Upper extremity | 10 (30.3) | 23 (69.7) | 6 (26.1) | 17 (73.9) | 16 (44.4) |
| Lower extremity | 19 (38.0) | 31 (62.0) | 10 (32.3) | 21 (67.7) | 28 (53.8) |
| Spine c | 30 (44.8) | 37 (55.2) | 8 (21.6) | 29 (78.4) | 38 (55.9) |
| No specific body region | 50 (29.6) | 119 (70.4) | 18 (15.1 | 101 (84.9) | 68 (38.8) |
| Marketed towards | |||||
| PT | 29 (42.0) | 40 (58.0) | 11 (27.5) | 29 (72.5) | 40 (55.6) |
| PT and PTAs | 7 (35.0) | 13 (65.0) | 5 (38.5) | 8 (61.5) | 12 (50.0) |
| PT and other disciplines | 40 (33.3) | 84 (67.7) | 12 (14.3) | 72 (85.7) | 52 (41.9) |
| Unclear | 34 (32.1) | 72 (67.9) | 13 (18.1) | 59 (81.9) | 46 (43.0) |
| Intervention category | |||||
| Manual therapy | 39 (34.5) | 74 (65.5) | 14 (17.7) | 60 (74.7) | 53 (46.9) |
| Exercise | 72 (44.3) | 88 (55.7) | 22 (25.0) | 66 (75.0) | 93 (57.6) |
| Modalities | 14 (14.7) | 81 (85.3) | 15 (18.5) | 66 (81.5) | 29 (30.5) |
| Soft skills | 25 (71.4) | 10 (28.6) | 4 (40.0) | 6 (60.0) | 29 (82.9) |
| Total Courses (N = 319) | Recommendation From CPG for Use of Intervention, No. (%) | At Least Moderate-Level Evidence From Systematic Review to Support Intervention, b No. (%) | Total Supported by Either CPG or Moderate-Level Evidence in a Systematic Review, No. (%) | ||
|---|---|---|---|---|---|
| Yes | No | Yes | No | ||
| Total | 109 (34.2) | 210 (65.8) | 42 (20.0) | 168 (80.0) | 151 (47.3) |
| Body region | |||||
| Upper extremity | 10 (30.3) | 23 (69.7) | 6 (26.1) | 17 (73.9) | 16 (44.4) |
| Lower extremity | 19 (38.0) | 31 (62.0) | 10 (32.3) | 21 (67.7) | 28 (53.8) |
| Spine c | 30 (44.8) | 37 (55.2) | 8 (21.6) | 29 (78.4) | 38 (55.9) |
| No specific body region | 50 (29.6) | 119 (70.4) | 18 (15.1 | 101 (84.9) | 68 (38.8) |
| Marketed towards | |||||
| PT | 29 (42.0) | 40 (58.0) | 11 (27.5) | 29 (72.5) | 40 (55.6) |
| PT and PTAs | 7 (35.0) | 13 (65.0) | 5 (38.5) | 8 (61.5) | 12 (50.0) |
| PT and other disciplines | 40 (33.3) | 84 (67.7) | 12 (14.3) | 72 (85.7) | 52 (41.9) |
| Unclear | 34 (32.1) | 72 (67.9) | 13 (18.1) | 59 (81.9) | 46 (43.0) |
| Intervention category | |||||
| Manual therapy | 39 (34.5) | 74 (65.5) | 14 (17.7) | 60 (74.7) | 53 (46.9) |
| Exercise | 72 (44.3) | 88 (55.7) | 22 (25.0) | 66 (75.0) | 93 (57.6) |
| Modalities | 14 (14.7) | 81 (85.3) | 15 (18.5) | 66 (81.5) | 29 (30.5) |
| Soft skills | 25 (71.4) | 10 (28.6) | 4 (40.0) | 6 (60.0) | 29 (82.9) |
a CPG = clinical practice guideline; PT = physical therapist; PTA = physical therapist assistant.
b Systematic reviews were consulted if interventions were not already recommended by a clinical practice guideline.
c The temporomandibular joint, pelvic floor, and headaches were considered part of the spine body region.
Table 2
Characteristics of Continuing Education Intervention Courses for Orthopedic and Sports Patient Populations That Had Supporting Evidence From a CPG or Systematic Review With at Least Moderate-Level Evidence (N = 319) a
| Total Courses (N = 319) | Recommendation From CPG for Use of Intervention, No. (%) | At Least Moderate-Level Evidence From Systematic Review to Support Intervention, b No. (%) | Total Supported by Either CPG or Moderate-Level Evidence in a Systematic Review, No. (%) | ||
|---|---|---|---|---|---|
| Yes | No | Yes | No | ||
| Total | 109 (34.2) | 210 (65.8) | 42 (20.0) | 168 (80.0) | 151 (47.3) |
| Body region | |||||
| Upper extremity | 10 (30.3) | 23 (69.7) | 6 (26.1) | 17 (73.9) | 16 (44.4) |
| Lower extremity | 19 (38.0) | 31 (62.0) | 10 (32.3) | 21 (67.7) | 28 (53.8) |
| Spine c | 30 (44.8) | 37 (55.2) | 8 (21.6) | 29 (78.4) | 38 (55.9) |
| No specific body region | 50 (29.6) | 119 (70.4) | 18 (15.1 | 101 (84.9) | 68 (38.8) |
| Marketed towards | |||||
| PT | 29 (42.0) | 40 (58.0) | 11 (27.5) | 29 (72.5) | 40 (55.6) |
| PT and PTAs | 7 (35.0) | 13 (65.0) | 5 (38.5) | 8 (61.5) | 12 (50.0) |
| PT and other disciplines | 40 (33.3) | 84 (67.7) | 12 (14.3) | 72 (85.7) | 52 (41.9) |
| Unclear | 34 (32.1) | 72 (67.9) | 13 (18.1) | 59 (81.9) | 46 (43.0) |
| Intervention category | |||||
| Manual therapy | 39 (34.5) | 74 (65.5) | 14 (17.7) | 60 (74.7) | 53 (46.9) |
| Exercise | 72 (44.3) | 88 (55.7) | 22 (25.0) | 66 (75.0) | 93 (57.6) |
| Modalities | 14 (14.7) | 81 (85.3) | 15 (18.5) | 66 (81.5) | 29 (30.5) |
| Soft skills | 25 (71.4) | 10 (28.6) | 4 (40.0) | 6 (60.0) | 29 (82.9) |
| Total Courses (N = 319) | Recommendation From CPG for Use of Intervention, No. (%) | At Least Moderate-Level Evidence From Systematic Review to Support Intervention, b No. (%) | Total Supported by Either CPG or Moderate-Level Evidence in a Systematic Review, No. (%) | ||
|---|---|---|---|---|---|
| Yes | No | Yes | No | ||
| Total | 109 (34.2) | 210 (65.8) | 42 (20.0) | 168 (80.0) | 151 (47.3) |
| Body region | |||||
| Upper extremity | 10 (30.3) | 23 (69.7) | 6 (26.1) | 17 (73.9) | 16 (44.4) |
| Lower extremity | 19 (38.0) | 31 (62.0) | 10 (32.3) | 21 (67.7) | 28 (53.8) |
| Spine c | 30 (44.8) | 37 (55.2) | 8 (21.6) | 29 (78.4) | 38 (55.9) |
| No specific body region | 50 (29.6) | 119 (70.4) | 18 (15.1 | 101 (84.9) | 68 (38.8) |
| Marketed towards | |||||
| PT | 29 (42.0) | 40 (58.0) | 11 (27.5) | 29 (72.5) | 40 (55.6) |
| PT and PTAs | 7 (35.0) | 13 (65.0) | 5 (38.5) | 8 (61.5) | 12 (50.0) |
| PT and other disciplines | 40 (33.3) | 84 (67.7) | 12 (14.3) | 72 (85.7) | 52 (41.9) |
| Unclear | 34 (32.1) | 72 (67.9) | 13 (18.1) | 59 (81.9) | 46 (43.0) |
| Intervention category | |||||
| Manual therapy | 39 (34.5) | 74 (65.5) | 14 (17.7) | 60 (74.7) | 53 (46.9) |
| Exercise | 72 (44.3) | 88 (55.7) | 22 (25.0) | 66 (75.0) | 93 (57.6) |
| Modalities | 14 (14.7) | 81 (85.3) | 15 (18.5) | 66 (81.5) | 29 (30.5) |
| Soft skills | 25 (71.4) | 10 (28.6) | 4 (40.0) | 6 (60.0) | 29 (82.9) |
a CPG = clinical practice guideline; PT = physical therapist; PTA = physical therapist assistant.
b Systematic reviews were consulted if interventions were not already recommended by a clinical practice guideline.
c The temporomandibular joint, pelvic floor, and headaches were considered part of the spine body region.
Table 3
Direct Quotes of Unsupported Claims About the Effect of Interventions Taught in Continuing Education Courses Available to US Physical Therapists for Orthopedic and Sports Patient Populations a
| Intervention Label | Claim |
|---|---|
| Nonsurgical treatment of rotator cuff disorders | "Lastly, participants will learn to evaluate the presence of pelvic imbalances and how to bring them back into balanced alignment through advanced fascial release techniques, muscle energy, and core strengthening exercises." |
| Dry needling | "The fascial lines are used in conjunction with kinesiology taping techniques to support efficient human movement," and "emphasis on taping fascial chains to improve movement and enhance function." |
| Treatment for overhead athlete | "All treatments protocols are designed to correct tissue alterations, assist the provider with articular adjustments, and ultimately shorten treatment regimens required to resolve a case. In this way, it follows traditional chiropractic paradigms and methods." |
| Comprehensive shoulder treatment | "In this seminar you will receive extensive treatment for your own pelvic problems. Many times chronic, persistent headaches, neck, and back pain can be resolved with myofascial release to the pelvic area." |
| Treatment classification approach for shoulder disorders | "Delayed vastus medialis obliquus" [as a subgroup classification for causing shoulder disorders]. |
| Sacroiliac mobilization | "For many therapists, treating low back pain is the number 1 issue for their patients. While there are likely to be a myriad of causes for this pain, the biggest factor may be the quadratus lumborum muscle." |
| Spinal manual therapy for pelvic floor dysfunction | "The practitioner will identify the 3 energy systems"... "understand how addressing dysfunctions of the transitional regions of the spine – from the lumbosacral region to the upper cervical spine can positively affect lumbo/pelvic dysfunction." |
| Manual therapy for low back pain | "This technique incorporates direct muscle releases while lengthening and shortening the muscle both passively and actively. This allows the dysfunctional motor units to normalize and immediately start to work in a normal way again in functional movement patterns." |
| Core stability | "Core stability is the new trend in the Rehab and Sports Industry," "need to address a weak, dysfunctional, collapsing," and "[L]earn to lengthen these excessively overused muscles. Be trained to facilitate the deep core and blend it with the global system for a strong dual system to allow our patients to stand correctly against gravity, our biggest adversary." |
| Mobilization of cervical and thoracic spine and ribs | "Perform advanced cranial techniques to assess and treat neuromotor disorders of speech, dysphagia/feeding and dysarthria and hearing loss." "Differentiate and analyze stretch and release techniques for the dural tube for greater spinal mobility and comfort." |
| Evidence-based rehab for lumbar spinal stenosis | "This advanced lecture and lab course is structured so that clinicians will gain an appreciation for the patterned respiration influences on: rib torsion, asymmetrical oblique strength, costal and crural function, habitual use of accessory respiratory musculature, and a positionally restricted diaphragm. The focus of this course will be to assess and restore polyarticular muscular chain function of both hemi-lateral thoraxes and their respective pleura." "Participants will be able to immediately apply clinical assessment and intervention strategies when treating diagnoses that are related to undesirable airflow patterns, such as shortness of breath, thoracic outlet syndrome, and shoulder dysfunction." |
| 3D scoliosis treatment | "Meniscal mobilizations." |
| Manual therapy for temporomandibular joint | "The primary goal is to introduce the entire cranial scan and impart clinical mastery of this phenomenal diagnostic tool." "This course will cover the common pitfalls associated with applying the cranial scan in each system and how to best avoid getting sucked in to treating false positives." "In addition, the concept of 'preparing the cranium' to yield accurate results will be explored in depth." "Detailed treatment sequences to clear false positives from the scan will be demonstrated, followed with plenty of time for lab practice." |
| Use of clinical practice guidelines for low back pain | "Attendees will learn how to palpate all muscles that are responsible for dysfunction along with learning the difference between muscle function and action, so they will be able to immediately recognize muscle dysfunction and identify the specific muscle at fault." |
| Kinesiotaping | "Proper training and education is needed to ensure positive therapeutic outcomes. Additionally, physical therapists need to be able to support the use of this intervention in order to receive reimbursement." |
| Kinesiotaping | "The clinician will gain an appreciation for the influences of an asymmetrical pelvis and how this imbalance contributes to pelvis dysfunction. We will explore in detail the function of the pelvic inlet and outlet as it relates to anatomy, respiration, and asymmetry in a multiple polyarticular chain system. Participants will be able to restore pelvic and respiratory neutrality through a treatment approach while keeping individual activities of daily living in mind." |
| Core stability for extremity disorders | "Treatment emphasizes the restoration of pelvic-femoral alignment and recruitment of specific rotational muscles to reduce synergistic predictable patterns of pathomechanic asymmetry." |
| Therapeutic overview of fractures | "Why are our patients tight, stiff or collapsing? Why are so many of our athletes in significant dysfunction? This seminar is heavily evidence based on multiple theories on the core and the overriding effects of the global muscle groups, the latest studies on respiration and the diaphragm and its far-ranging effects on the trunk." |
| Counter strain and cranial scan | "By going slower and more gently I believe we are returning the innate mobility of the joints in a way the brain and nervous system agree with." |
| Manual therapy | "We're talking about fixing 95% of problems in 4 visits, vs 50% of them in 30 visits." |
| Therapeutic exercise interventions | "Ultrasound is widely used in rehabilitation to improve connective tissue extensibility and pain relief in musculoskeletal injuries and to promote tissue healing and remodeling." |
| Comprehensive treatment of the knee | "Treating the subtalar joint can have reflexogenic effects on the C1–2 spinal segment, a common site of rotational compensation." |
| Intervention Label | Claim |
|---|---|
| Nonsurgical treatment of rotator cuff disorders | "Lastly, participants will learn to evaluate the presence of pelvic imbalances and how to bring them back into balanced alignment through advanced fascial release techniques, muscle energy, and core strengthening exercises." |
| Dry needling | "The fascial lines are used in conjunction with kinesiology taping techniques to support efficient human movement," and "emphasis on taping fascial chains to improve movement and enhance function." |
| Treatment for overhead athlete | "All treatments protocols are designed to correct tissue alterations, assist the provider with articular adjustments, and ultimately shorten treatment regimens required to resolve a case. In this way, it follows traditional chiropractic paradigms and methods." |
| Comprehensive shoulder treatment | "In this seminar you will receive extensive treatment for your own pelvic problems. Many times chronic, persistent headaches, neck, and back pain can be resolved with myofascial release to the pelvic area." |
| Treatment classification approach for shoulder disorders | "Delayed vastus medialis obliquus" [as a subgroup classification for causing shoulder disorders]. |
| Sacroiliac mobilization | "For many therapists, treating low back pain is the number 1 issue for their patients. While there are likely to be a myriad of causes for this pain, the biggest factor may be the quadratus lumborum muscle." |
| Spinal manual therapy for pelvic floor dysfunction | "The practitioner will identify the 3 energy systems"... "understand how addressing dysfunctions of the transitional regions of the spine – from the lumbosacral region to the upper cervical spine can positively affect lumbo/pelvic dysfunction." |
| Manual therapy for low back pain | "This technique incorporates direct muscle releases while lengthening and shortening the muscle both passively and actively. This allows the dysfunctional motor units to normalize and immediately start to work in a normal way again in functional movement patterns." |
| Core stability | "Core stability is the new trend in the Rehab and Sports Industry," "need to address a weak, dysfunctional, collapsing," and "[L]earn to lengthen these excessively overused muscles. Be trained to facilitate the deep core and blend it with the global system for a strong dual system to allow our patients to stand correctly against gravity, our biggest adversary." |
| Mobilization of cervical and thoracic spine and ribs | "Perform advanced cranial techniques to assess and treat neuromotor disorders of speech, dysphagia/feeding and dysarthria and hearing loss." "Differentiate and analyze stretch and release techniques for the dural tube for greater spinal mobility and comfort." |
| Evidence-based rehab for lumbar spinal stenosis | "This advanced lecture and lab course is structured so that clinicians will gain an appreciation for the patterned respiration influences on: rib torsion, asymmetrical oblique strength, costal and crural function, habitual use of accessory respiratory musculature, and a positionally restricted diaphragm. The focus of this course will be to assess and restore polyarticular muscular chain function of both hemi-lateral thoraxes and their respective pleura." "Participants will be able to immediately apply clinical assessment and intervention strategies when treating diagnoses that are related to undesirable airflow patterns, such as shortness of breath, thoracic outlet syndrome, and shoulder dysfunction." |
| 3D scoliosis treatment | "Meniscal mobilizations." |
| Manual therapy for temporomandibular joint | "The primary goal is to introduce the entire cranial scan and impart clinical mastery of this phenomenal diagnostic tool." "This course will cover the common pitfalls associated with applying the cranial scan in each system and how to best avoid getting sucked in to treating false positives." "In addition, the concept of 'preparing the cranium' to yield accurate results will be explored in depth." "Detailed treatment sequences to clear false positives from the scan will be demonstrated, followed with plenty of time for lab practice." |
| Use of clinical practice guidelines for low back pain | "Attendees will learn how to palpate all muscles that are responsible for dysfunction along with learning the difference between muscle function and action, so they will be able to immediately recognize muscle dysfunction and identify the specific muscle at fault." |
| Kinesiotaping | "Proper training and education is needed to ensure positive therapeutic outcomes. Additionally, physical therapists need to be able to support the use of this intervention in order to receive reimbursement." |
| Kinesiotaping | "The clinician will gain an appreciation for the influences of an asymmetrical pelvis and how this imbalance contributes to pelvis dysfunction. We will explore in detail the function of the pelvic inlet and outlet as it relates to anatomy, respiration, and asymmetry in a multiple polyarticular chain system. Participants will be able to restore pelvic and respiratory neutrality through a treatment approach while keeping individual activities of daily living in mind." |
| Core stability for extremity disorders | "Treatment emphasizes the restoration of pelvic-femoral alignment and recruitment of specific rotational muscles to reduce synergistic predictable patterns of pathomechanic asymmetry." |
| Therapeutic overview of fractures | "Why are our patients tight, stiff or collapsing? Why are so many of our athletes in significant dysfunction? This seminar is heavily evidence based on multiple theories on the core and the overriding effects of the global muscle groups, the latest studies on respiration and the diaphragm and its far-ranging effects on the trunk." |
| Counter strain and cranial scan | "By going slower and more gently I believe we are returning the innate mobility of the joints in a way the brain and nervous system agree with." |
| Manual therapy | "We're talking about fixing 95% of problems in 4 visits, vs 50% of them in 30 visits." |
| Therapeutic exercise interventions | "Ultrasound is widely used in rehabilitation to improve connective tissue extensibility and pain relief in musculoskeletal injuries and to promote tissue healing and remodeling." |
| Comprehensive treatment of the knee | "Treating the subtalar joint can have reflexogenic effects on the C1–2 spinal segment, a common site of rotational compensation." |
a Quotes highlight course content that study reviewers felt overreached claims based on current evidence.
Table 3
Direct Quotes of Unsupported Claims About the Effect of Interventions Taught in Continuing Education Courses Available to US Physical Therapists for Orthopedic and Sports Patient Populations a
| Intervention Label | Claim |
|---|---|
| Nonsurgical treatment of rotator cuff disorders | "Lastly, participants will learn to evaluate the presence of pelvic imbalances and how to bring them back into balanced alignment through advanced fascial release techniques, muscle energy, and core strengthening exercises." |
| Dry needling | "The fascial lines are used in conjunction with kinesiology taping techniques to support efficient human movement," and "emphasis on taping fascial chains to improve movement and enhance function." |
| Treatment for overhead athlete | "All treatments protocols are designed to correct tissue alterations, assist the provider with articular adjustments, and ultimately shorten treatment regimens required to resolve a case. In this way, it follows traditional chiropractic paradigms and methods." |
| Comprehensive shoulder treatment | "In this seminar you will receive extensive treatment for your own pelvic problems. Many times chronic, persistent headaches, neck, and back pain can be resolved with myofascial release to the pelvic area." |
| Treatment classification approach for shoulder disorders | "Delayed vastus medialis obliquus" [as a subgroup classification for causing shoulder disorders]. |
| Sacroiliac mobilization | "For many therapists, treating low back pain is the number 1 issue for their patients. While there are likely to be a myriad of causes for this pain, the biggest factor may be the quadratus lumborum muscle." |
| Spinal manual therapy for pelvic floor dysfunction | "The practitioner will identify the 3 energy systems"... "understand how addressing dysfunctions of the transitional regions of the spine – from the lumbosacral region to the upper cervical spine can positively affect lumbo/pelvic dysfunction." |
| Manual therapy for low back pain | "This technique incorporates direct muscle releases while lengthening and shortening the muscle both passively and actively. This allows the dysfunctional motor units to normalize and immediately start to work in a normal way again in functional movement patterns." |
| Core stability | "Core stability is the new trend in the Rehab and Sports Industry," "need to address a weak, dysfunctional, collapsing," and "[L]earn to lengthen these excessively overused muscles. Be trained to facilitate the deep core and blend it with the global system for a strong dual system to allow our patients to stand correctly against gravity, our biggest adversary." |
| Mobilization of cervical and thoracic spine and ribs | "Perform advanced cranial techniques to assess and treat neuromotor disorders of speech, dysphagia/feeding and dysarthria and hearing loss." "Differentiate and analyze stretch and release techniques for the dural tube for greater spinal mobility and comfort." |
| Evidence-based rehab for lumbar spinal stenosis | "This advanced lecture and lab course is structured so that clinicians will gain an appreciation for the patterned respiration influences on: rib torsion, asymmetrical oblique strength, costal and crural function, habitual use of accessory respiratory musculature, and a positionally restricted diaphragm. The focus of this course will be to assess and restore polyarticular muscular chain function of both hemi-lateral thoraxes and their respective pleura." "Participants will be able to immediately apply clinical assessment and intervention strategies when treating diagnoses that are related to undesirable airflow patterns, such as shortness of breath, thoracic outlet syndrome, and shoulder dysfunction." |
| 3D scoliosis treatment | "Meniscal mobilizations." |
| Manual therapy for temporomandibular joint | "The primary goal is to introduce the entire cranial scan and impart clinical mastery of this phenomenal diagnostic tool." "This course will cover the common pitfalls associated with applying the cranial scan in each system and how to best avoid getting sucked in to treating false positives." "In addition, the concept of 'preparing the cranium' to yield accurate results will be explored in depth." "Detailed treatment sequences to clear false positives from the scan will be demonstrated, followed with plenty of time for lab practice." |
| Use of clinical practice guidelines for low back pain | "Attendees will learn how to palpate all muscles that are responsible for dysfunction along with learning the difference between muscle function and action, so they will be able to immediately recognize muscle dysfunction and identify the specific muscle at fault." |
| Kinesiotaping | "Proper training and education is needed to ensure positive therapeutic outcomes. Additionally, physical therapists need to be able to support the use of this intervention in order to receive reimbursement." |
| Kinesiotaping | "The clinician will gain an appreciation for the influences of an asymmetrical pelvis and how this imbalance contributes to pelvis dysfunction. We will explore in detail the function of the pelvic inlet and outlet as it relates to anatomy, respiration, and asymmetry in a multiple polyarticular chain system. Participants will be able to restore pelvic and respiratory neutrality through a treatment approach while keeping individual activities of daily living in mind." |
| Core stability for extremity disorders | "Treatment emphasizes the restoration of pelvic-femoral alignment and recruitment of specific rotational muscles to reduce synergistic predictable patterns of pathomechanic asymmetry." |
| Therapeutic overview of fractures | "Why are our patients tight, stiff or collapsing? Why are so many of our athletes in significant dysfunction? This seminar is heavily evidence based on multiple theories on the core and the overriding effects of the global muscle groups, the latest studies on respiration and the diaphragm and its far-ranging effects on the trunk." |
| Counter strain and cranial scan | "By going slower and more gently I believe we are returning the innate mobility of the joints in a way the brain and nervous system agree with." |
| Manual therapy | "We're talking about fixing 95% of problems in 4 visits, vs 50% of them in 30 visits." |
| Therapeutic exercise interventions | "Ultrasound is widely used in rehabilitation to improve connective tissue extensibility and pain relief in musculoskeletal injuries and to promote tissue healing and remodeling." |
| Comprehensive treatment of the knee | "Treating the subtalar joint can have reflexogenic effects on the C1–2 spinal segment, a common site of rotational compensation." |
| Intervention Label | Claim |
|---|---|
| Nonsurgical treatment of rotator cuff disorders | "Lastly, participants will learn to evaluate the presence of pelvic imbalances and how to bring them back into balanced alignment through advanced fascial release techniques, muscle energy, and core strengthening exercises." |
| Dry needling | "The fascial lines are used in conjunction with kinesiology taping techniques to support efficient human movement," and "emphasis on taping fascial chains to improve movement and enhance function." |
| Treatment for overhead athlete | "All treatments protocols are designed to correct tissue alterations, assist the provider with articular adjustments, and ultimately shorten treatment regimens required to resolve a case. In this way, it follows traditional chiropractic paradigms and methods." |
| Comprehensive shoulder treatment | "In this seminar you will receive extensive treatment for your own pelvic problems. Many times chronic, persistent headaches, neck, and back pain can be resolved with myofascial release to the pelvic area." |
| Treatment classification approach for shoulder disorders | "Delayed vastus medialis obliquus" [as a subgroup classification for causing shoulder disorders]. |
| Sacroiliac mobilization | "For many therapists, treating low back pain is the number 1 issue for their patients. While there are likely to be a myriad of causes for this pain, the biggest factor may be the quadratus lumborum muscle." |
| Spinal manual therapy for pelvic floor dysfunction | "The practitioner will identify the 3 energy systems"... "understand how addressing dysfunctions of the transitional regions of the spine – from the lumbosacral region to the upper cervical spine can positively affect lumbo/pelvic dysfunction." |
| Manual therapy for low back pain | "This technique incorporates direct muscle releases while lengthening and shortening the muscle both passively and actively. This allows the dysfunctional motor units to normalize and immediately start to work in a normal way again in functional movement patterns." |
| Core stability | "Core stability is the new trend in the Rehab and Sports Industry," "need to address a weak, dysfunctional, collapsing," and "[L]earn to lengthen these excessively overused muscles. Be trained to facilitate the deep core and blend it with the global system for a strong dual system to allow our patients to stand correctly against gravity, our biggest adversary." |
| Mobilization of cervical and thoracic spine and ribs | "Perform advanced cranial techniques to assess and treat neuromotor disorders of speech, dysphagia/feeding and dysarthria and hearing loss." "Differentiate and analyze stretch and release techniques for the dural tube for greater spinal mobility and comfort." |
| Evidence-based rehab for lumbar spinal stenosis | "This advanced lecture and lab course is structured so that clinicians will gain an appreciation for the patterned respiration influences on: rib torsion, asymmetrical oblique strength, costal and crural function, habitual use of accessory respiratory musculature, and a positionally restricted diaphragm. The focus of this course will be to assess and restore polyarticular muscular chain function of both hemi-lateral thoraxes and their respective pleura." "Participants will be able to immediately apply clinical assessment and intervention strategies when treating diagnoses that are related to undesirable airflow patterns, such as shortness of breath, thoracic outlet syndrome, and shoulder dysfunction." |
| 3D scoliosis treatment | "Meniscal mobilizations." |
| Manual therapy for temporomandibular joint | "The primary goal is to introduce the entire cranial scan and impart clinical mastery of this phenomenal diagnostic tool." "This course will cover the common pitfalls associated with applying the cranial scan in each system and how to best avoid getting sucked in to treating false positives." "In addition, the concept of 'preparing the cranium' to yield accurate results will be explored in depth." "Detailed treatment sequences to clear false positives from the scan will be demonstrated, followed with plenty of time for lab practice." |
| Use of clinical practice guidelines for low back pain | "Attendees will learn how to palpate all muscles that are responsible for dysfunction along with learning the difference between muscle function and action, so they will be able to immediately recognize muscle dysfunction and identify the specific muscle at fault." |
| Kinesiotaping | "Proper training and education is needed to ensure positive therapeutic outcomes. Additionally, physical therapists need to be able to support the use of this intervention in order to receive reimbursement." |
| Kinesiotaping | "The clinician will gain an appreciation for the influences of an asymmetrical pelvis and how this imbalance contributes to pelvis dysfunction. We will explore in detail the function of the pelvic inlet and outlet as it relates to anatomy, respiration, and asymmetry in a multiple polyarticular chain system. Participants will be able to restore pelvic and respiratory neutrality through a treatment approach while keeping individual activities of daily living in mind." |
| Core stability for extremity disorders | "Treatment emphasizes the restoration of pelvic-femoral alignment and recruitment of specific rotational muscles to reduce synergistic predictable patterns of pathomechanic asymmetry." |
| Therapeutic overview of fractures | "Why are our patients tight, stiff or collapsing? Why are so many of our athletes in significant dysfunction? This seminar is heavily evidence based on multiple theories on the core and the overriding effects of the global muscle groups, the latest studies on respiration and the diaphragm and its far-ranging effects on the trunk." |
| Counter strain and cranial scan | "By going slower and more gently I believe we are returning the innate mobility of the joints in a way the brain and nervous system agree with." |
| Manual therapy | "We're talking about fixing 95% of problems in 4 visits, vs 50% of them in 30 visits." |
| Therapeutic exercise interventions | "Ultrasound is widely used in rehabilitation to improve connective tissue extensibility and pain relief in musculoskeletal injuries and to promote tissue healing and remodeling." |
| Comprehensive treatment of the knee | "Treating the subtalar joint can have reflexogenic effects on the C1–2 spinal segment, a common site of rotational compensation." |
a Quotes highlight course content that study reviewers felt overreached claims based on current evidence.
Discussion
This review of available courses covering interventions delivered by physical therapists found that less than one-half (47.3%) consisted of interventions supported in a CPG or systematic review. Courses teaching interventions categorized as modalities were the least likely to be supported by evidence (30.5%), whereas those teaching soft skills were the most likely to be supported (82.9%). Emerging evidence over the last 3 decades about the strong psychological influence on pain and functional outcomes has led to a call for greater focus on biopsychosocial approaches to pain management and the potential harms of a purely biomedical approach. This evidence may help explain our finding that soft skills were more likely to be supported than were modalities. The largest proportion of courses was targeted to multiple clinician types, and some courses made claims that clearly misrepresented or contradicted current evidence.
This study's findings highlight the current quality of education available for physical therapists that is approved by state associations and required annually to meet licensure renewal requirements. Although the courses were approved in only 12 states, they likely represent courses across the entire country because 35 states (plus the District of Columbia) have reciprocity for continuing education approval (so they need to be approved in only 1 state) and 2 states have no continuing education requirements. Figure 1 highlights the current reciprocity rules and, in theory, how a single submission to West Virginia would cover approval for 34 of the 48 states with continuing education requirements. This could also be the reason why West Virginia had over 1000 courses registered compared with only 10% to 20% of that number for most other states.
One reason these findings are concerning is that physical therapists claim that continuing education courses are much more likely to influence clinical practice than articles published in scientific medical journals. 4 This appears to be the majority sentiment even though reading medical journals is recommended as the best way to stay aware of important advances in medical knowledge. 9 However, keeping up with the ever-growing body of literature is one of the biggest challenges for busy clinicians, 10 and a reason why attending a course that promises to summarize the current body of evidence is enticing. One key purpose of continuing education requirements for maintaining licensure is to improve quality of care delivery. The goal is that care will improve when clinicians continuously learn, refine their skills, and ideally keep up with emerging research. APTA supports continuing competence, lifelong learning, and ongoing professional development for all physical therapists. In alignment with APTA's core values and according to their policy, physical therapists are "obligated to engage in lifelong learning and are ultimately responsible for meeting or exceeding contemporary performance standards within their area (s) of practice." 11 The findings of this review call into question the physical therapy profession's approach to continuing education and whether it is meeting the intent of helping clinicians stay abreast of emerging research to ultimately meet or exceed contemporary performance standards within the areas of orthopedic and musculoskeletal practice. There could be potential for collective harm when clinicians take courses approved by state associations that are unsupported by evidence and therefore of questionable benefit to patients. Education courses of unknown value have been highlighted as potential drivers of inappropriate musculoskeletal care. 12 The claims made by many courses (Tab. 3) in their marketing materials and descriptions raise concern about how these courses are being regulated.
If a large portion of continuing education courses in physical therapy lack supporting evidence, then course review processes may require further scrutiny. Standards for course approval and quality control are not very high, 4 at least compared with those required to have a manuscript accepted in a peer-reviewed journal. Many states have a requirement that courses be "evidence-based," although it is unclear how this is being judged or enforced. Evidence-contrary claims were made by many of the courses we found (Tab. 3). Journal reviewers and editors invest substantial time and effort into the curation of evidence. Because course approval for continuing education credits is done at the state level, this also means the process is likely to be highly variable, with little standardization across 50 different states. In a 2006 McMillan lecture, Dr Stanley Paris voiced concern that states would become too liberal with their approval process due to the revenue that course approvals generate. 13 Although revenue may create an apparent conflict of interest, proper review is time-consuming and requires adequate resources if it is to be done properly. The fees seem necessary to sustain this type of effort. A centralized process could have the potential to standardize and improve the type of education available to physical therapists. Journals and researchers could play a greater role in the educational process to ensure continuing education requirements are valid and align with current best evidence. There are no simple answers to these problems, but they are important ones for the physical therapy profession to address if it is truly interested in having continuing education be a key driver for ensuring clinicians deliver better care and outcomes to patients. Finally, there is the potential that some of these courses do in fact cover evidence-based interventions, but the course descriptions are poor and need improvement to better reflect course content.
Physical therapy is not alone in the effort to link continuing education requirements with improved outcomes and a proficient clinical workforce. 14–17 This is standard practice for the medical community in general and any clinical specialty that requires a renewable license. They face similar challenges and questions related to proper regulation and appropriate measurement of the impact of education on practice. 18 Self-promotion, misinterpretation of research findings, insufficient or improper citation of the current body of literature, and poor disclosure of conflicts of interest are also problems with continuing education in the medical community. 19 The problem is exacerbated by poor reliability and rater agreement as to whether these important issues are addressed properly. 19 Those in the physical therapy profession have a responsibility to have candid conversations around potential solutions to these issues.
Limitations
This study has several limitations to consider. Even though only 12 states are tracked in this resource, the courses likely represent a large proportion of course offerings across all 50 states that require approval due to reciprocity policies currently in place (Fig. 1). These are more likely to be courses taught by high-volume content providers and education companies and less likely to be single one-time courses or those offered in small regional settings (eg, district meetings). All except for 2 states require that course material is approved, and therefore content providers must submit their courses with appropriate applications to the respective state bodies. Physical therapists could also take non-approved courses for reasons other than licensure renewal requirements. Course approvals only cover a 1-year period, and it is not clear how stable the course offerings are over a longer period or whether the results would be different in prior years. This limitation should be considered within the perspective of changes in clinical practice over the year 2020, which was uniquely impacted by the COVID-19 pandemic. It is unknown if course offerings were different than usual during this timeframe and if these differences would result in higher or lower levels of alignment with current evidence. CPGs and systematic reviews were used as the benchmark for determining appropriateness. As a result, it is possible that newer high-quality clinical trials were not yet represented in guidelines or systematic reviews. In addition, the quality of the systematic reviews and CPGs was not formally assessed. For some interventions, multiple systematic reviews have been completed. Attempts were made to use the most current review, but it is possible that a CPG or review exists but was not found. Also, a newer review does not necessarily mean a better review. However, this approach to assess the quality of physical therapist interventions has been previously used.5 These results could change if different thresholds for quality of evidence were established, such as only including interventions with strong evidence or all interventions even with weak supporting evidence. The current review is based on information that course applicants used to request approval for the course and their available marketing material, but this information may not represent everything that is actually taught in the course. There may be other, more valid ways to assess the quality of educational courses. However, no standard for this exists across state continuing education approval agencies. Finally, evidence-based practice consists of 3 equally important pillars, of which only 1 is best evidence; the others are clinical expertise and patient values. 20 This definition should be considered when assessing the current study's results.
The current review found that 47.3% of approved continuing education courses in the United States that focused on treatment for orthopedic and musculoskeletal disorders were clearly supported by evidence from CPGs or at least moderate-level evidence in systematic reviews. A clear determination was not possible for many courses based on the nature of the course description provided. Misrepresentation of current research findings occurred in course descriptions for many of the courses that physical therapists must take to meet licensure renewal requirements.
Author Contributions
Concept/idea/research design: S. Peterson, B. Halpert, D.I. Rhon
Writing: S. Peterson, D.I. Rhon
Data collection: S. Peterson, K. Weible, B. Halpert
Data analysis: S. Peterson, B. Halpert, D.I. Rhon
Project management: S. Peterson
Consultation (including review of manuscript before submitting): S. Peterson, K. Weible, B. Halpert, D.I. Rhon
Disclosures
S.P. and K.W. are partners in a continuing education company, The Movement Brainery, which began operations in 2021. S.P. was the chair of a continuing education committee of a state reviewed in this paper. He did not take part in grading of courses in that state. D.R. taught one course reviewed in this paper and did not take part in grading of that course.
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Published by Oxford University Press on behalf of the American Physical Therapy Association 2022.
This work is written by US Government employees and is in the public domain in the US.
Published by Oxford University Press on behalf of the American Physical Therapy Association 2022.
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