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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.

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AIM: The study mapped the support provided for newly qualified practitioners across Kent, Surrey and Sussex. BACKGROUND: Newly qualified practitioners require support and guidance to facilitate their transition from student to their new role as qualified practitioner. Professional bodies advocate that programmes be provided but the type and intensity of that support is variable. METHODS: Telephone interviews were conducted with 24 people delivering support for newly qualified practitioners across professions in 13 different health care trusts. Documents (n = 41) related to support programmes were analysed. Two case study site visits and a knowledge exchange conference of 45 delegates completed the data collection. Data were analysed using the constant comparative method of analysis. RESULTS: Support for newly qualified practitioners was largely idiosyncratic to profession and Trust. Evidence emerged of a conceptual shift from basic competency acquisition toward a corporate induction programme. CONCLUSIONS: Interdisciplinary programmes can provide generic transitional support, but the newly qualified practitioners favoured skill acquisition to help them to be effective in their new role. Measuring the impact of newly qualified practitioner support on patient outcome and the practitioner is required. IMPLICATIONS FOR NURSING MANAGEMENT: A career pathway for those who support newly qualified practitioners and one that includes specific preparation for the role is proposed.

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How practitioners conceive clinical practice influences many aspects of their clinical work including how they view knowledge, clinical decision-making, and their actions. Osteopaths have relied upon the philosophical and theoretical foundations upon which the profession was built to guide clinical practice. However, it is currently unknown how osteopaths conceive clinical practice, and how these conceptions develop and influence their clinical work. This paper reports the conceptions of practice of experienced osteopaths in the UK. A constructivist grounded theory approach was taken in this study. The constant comparative method of analysis was used to code and analyse data. Purposive sampling was employed to initially select participants. Subsequent theoretical sampling, informed by data analysis, allowed specific participants to be sampled. Data collection methods involved semi-structured interviews and non-participant observation of practitioners during a patient appointment, which was video-recorded and followed by a video-prompted reflective interview. Participants' conception of practice lay on a continuum, from technical rationality to professional artistry and the development of which was influenced by their educational experience, view of health and disease, epistemology of practice knowledge, theory-practice relationship and their perceived therapeutic role. The findings from this study provide the first theoretical insight of osteopaths' conceptions of clinical practice and the factors which influence such conceptions.

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There is limited understanding of how osteopaths make decisions in relation to clinical practice. The aim of this research was to construct an explanatory theory of the clinical decision-making and therapeutic approaches of experienced osteopaths in the UK. Twelve UK registered osteopaths participated in this constructivist grounded theory qualitative study. Purposive and theoretical sampling was used to select participants. Data was collected using semi-structured interviews which were audio-recorded and transcribed. As the study approached theoretical sufficiency, participants were observed and video-recorded during a patient appointment, which was followed by a video-prompted interview. Constant comparative analysis was used to analyse and code data. Data analysis resulted in the construction of three qualitatively different therapeutic approaches which characterised participants and their clinical practice, termed; Treater, Communicator and Educator. Participants' therapeutic approach influenced their approach to clinical decision-making, the level of patient involvement, their interaction with patients, and therapeutic goals. Participants' overall conception of practice lay on a continuum ranging from technical rationality to professional artistry, and contributed to their therapeutic approach. A range of factors were identified which influenced participants' conception of practice. The findings indicate that there is variation in osteopaths' therapeutic approaches to practice and clinical decision-making, which are influenced by their overall conception of practice. This study provides the first explanatory theory of the clinical decision-making and therapeutic approaches of osteopaths.

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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.

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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.

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BACKGROUND: Evidence suggests that practitioners who successfully complete a UK Master's level course, accredited by the Manipulation Association of Chartered Physiotherapists (MACP), enhance their clinical practice and demonstrate attributes of clinical expertise. What remains unclear is the process by which practitioners change and enhance their practice. Greater understanding of the learning process would help to inform programme design and delivery, and enhance the quality of the educational experience and impact for practitioners. OBJECTIVE: To explain the learning process experienced by physiotherapists on completion of an MACP-approved Master of Science (MSc) course. DESIGN: A naturalistic inquiry was conducted using a single theory-seeking case study. Dimensional analysis was used to develop a substantive theory of the learning transition. PARTICIPANTS: Twenty-six semi-structured interviews were carried out with 11 alumni from one MACP-approved MSc programme. RESULTS: The learning transition was from uncritical practice knowledge with routine, therapist-centred clinical practice to critical understanding of practice knowledge that enabled patient-centred practice and the capability to learn in, and from, practice. This development towards clinical expertise was primarily facilitated by critical evaluation of practice knowledge, particularly through mentorship in clinical practice. This highly challenging experience was helped by high levels of support from the mentor. The learning transition varied between participants and depended on a host of moderating factors. CONCLUSION: This is the first documented theoretical explanation of how physiotherapists enhance their clinical practice and develop attributes of clinical expertise within an MACP-approved MSc course. This explanatory theory may be of value for educational programmes that seek to facilitate practitioners' development towards clinical expertise. This study also offers a novel model of learning transition that may be applicable to other educational settings.

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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.

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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.

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Lumbar spine accessory movements, used by therapists in the treatment of patients with low back pain, is thought to decrease paravertebral muscular activity; however there is little research to support this suggestion. This study investigated the effects of lumbar spine accessory movements on surface electromyography (sEMG) activity of erector spinae. A condition randomised, placebo controlled, repeated measures design was used. sEMG measurements were recorded from 36 asymptomatic subjects following a control, placebo and central posteroanterior (PA) mobilisation to L3 each for 2min. The therapist stood on a force platform while applying the PA mobilisation to quantify the force used. The PA mobilisation applied to each subject had a mean maximum force of 103.3N, mean amplitude of force oscillation of 41.1N, and a frequency of 1.2Hz. Surface electromyographic data were recorded from the musculature adjacent to L3, L5 and T10. There were statistically significant reductions of 15.5% (95% CI: 8.0-22.5%) and 17.8% (95% CI: 12.9-22.4%) in mean sEMG values following mobilisation compared with the control and placebo, respectively. This study demonstrates that a central PA mobilisation to L3 results in a statistically significant decrease in the sEMG activity of erector spinae of an asymptomatic population.

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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.

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Individuals who participate in repetitive functional activities may have alteration in large diameter neural activity. It has been proposed that neurodynamic examination and treatment may affect large diameter afferent activity, and that neurological integrity tests should be carried out prior to neurodynamic testing. Vibration threshold testing (VTT) has been shown to be a valid measure of large diameter afferent conduction. The aim of this study was to assess whether examination and treatment of straight leg raise with plantar flexion and inversion (SLR) has an effect on the conduction of large diameter afferents supplying the lower leg in normal subjects and in a group of runners. Twenty sedentary asymptomatic subjects and 10 asymptomatic runners underwent VTT at the second and fourth metatarsals (representing the distribution of the superficial peroneal nerve) before and after examination of the SLR and after a mimicked treatment with SLR (VTT carried out immediately and 10min after treatment). A repeated measures ANOVA revealed no significant baseline differences in VT between runners and non-runners (P=0.171), or between any of the four test conditions in either group (P=0.5). Although not significant there was a trend for runners to have raised mean VT compared to non-runners, and for SLR treatment to cause an elevation in VT in both groups. These results suggest that examination and treatment of SLR may not be detrimental to function of the large diameter afferents in asymptomatic subjects.

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