Characteristics of high-performing physical therapists managing cervical and lumbar conditions: a mixed methods review

ABSTRACT

Objective

To identify self-reported characteristics of physical therapists who consistently achieve superior outcomes in the management of cervical and lumbar conditions.

Methods

Mixed-methods study combining quantitative analysis of risk-adjusted patient-reported outcome data with qualitative surveys and structured interviews. Clinicians from Jefferson Moss-Magee Rehab were included if their Focus on Therapeutic Outcomes (FOTO) scores for cervical or lumbar patients met or exceeded risk-adjusted national benchmarks from 2021–2023. High-performing therapists were surveyed regarding demographics, clinical experience, post-professional education, and treatment approaches. A subset participated in structured interviews, and thematic analysis was used to identify common characteristics contributing to success.

Results

For the lumbar cohort, 32 therapists met criteria; for the cervical cohort, 11 met criteria. Surveys were completed by 20 lumbar and 6 cervical cohort members; 18 participated in interviews. Thematic analysis revealed four key characteristics among high performers: (1) use of evidence-informed practice, (2) commitment to lifelong learning via post-professional training, (3) strong therapeutic alliance, and (4) clinical experience with spinal conditions.

Discussion/Conclusion

Effective management of cervical and lumbar conditions is linked not only to clinical expertise but also to key clinician attributes, such as ongoing professional growth and strong interpersonal skills. These findings may guide professional development and quality improvement efforts in musculoskeletal physical therapy practice.

Introduction

Physical therapy is commonly recommended as a first-line treatment for neck and back pain and has been shown to reduce pain and disability in these populations [1–3]. Cervical and lumbar conditions account for approximately 40–50% of the orthopedic diagnoses in outpatient physical therapy [1,3]. Treatment approaches for spinal pain vary widely. Broad clinical practice guidelines aim to reduce heterogeneity while allowing for clinical decision making through a pragmatic approach. Consequently, many clinicians pursue post-professional training, including continuing education, residency training, and fellowship training to improve outcomes. Evidence remains limited on which type of training, if any, leads to the most effective management of spinal conditions.

Tracking patient outcomes in physical therapy is essential for evaluating treatment effectiveness, identifying areas for improvement, and ensuring optimal patient recovery and long-term health benefits. One approach is to collect patient-reported outcome measures (PROMs) using Focus on Therapeutic Outcomes (FOTO), a computer adaptive tool widely used in outpatient rehabilitation facilities throughout the United States [4]. Using risk-adjusted benchmarking, FOTO allows providers to compare their results with national data while accounting for patient complexity. FOTO data provide a crosswalk of the Neck Disability Index for patients with cervical diagnoses and the Oswestry Disability Index for those with lumbar diagnoses. The crosswalks use item-response theory, meaning subsequent questions are tailored based on previous responses. This increases the reliability and statistical power of the outcomes compared to static PROMs [5].

When patients complete an assessment, FOTO generates a report that includes an expected functional score change and the expected number of visits. Follow-up assessments allow clinicians to track self-reported progress and limitations throughout care. At discharge, FOTO data include functional score changes, number of visits, and patient satisfaction. Results are benchmarked against aggregated data within the FOTO system, providing insight into overall care effectiveness and potential best practices. FOTO also provides nationally benchmarked data for an individual provider, identifying high and low performers among physical therapy clinicians based on patient outcomes. While FOTO effectively highlights variations in performance, there is limited understanding of the specific predictors or associations that distinguish high-performing clinicians. Identifying these determinants could offer insights for improving clinical practices, patient care, and outcomes.

This study aimed to identify self-reported characteristics of physical therapists in a single institution’s outpatient network who consistently achieved superior patient outcomes in the cervical or lumbar musculoskeletal populations, as measured by FOTO. The findings may inform quality improvement initiatives within the institution’s outpatient physical therapy program to improve network clinicians’ effectiveness in managing patients with cervical and lumbar conditions. Additionally, these insights may help therapists across settings enhance their overall effectiveness in managing patients with cervical and lumbar conditions.

Methods

This mixed-methods study examined physical therapists practicing across 14 hospital-based outpatient facilities within the Jefferson Moss-Magee Rehab Therapy System between January 2021 to December 2023. Inclusion criteria required physical therapists to have completed greater than 15 cases and achieved mean patient outcomes that met or exceeded the expected effectiveness outcomes for cervical or lumbar conditions, as measured by FOTO. Clinicians were excluded if they did not manage 15 cases, failed to meet the expected outcomes threshold, or were no longer employed within the health system. The study received exempt status from the Thomas Jefferson University Office of Human Research Institutional Review Board and was reported using the Good Reporting of a Mixed Methods Study Checklist (GRAMMS) (Appendix A).

Data collection and analysis

Clinicians within the healthcare system are enrolled in FOTO and use FOTO as a primary outcome tool. Data are collected and stored electronically within the FOTO database. The FOTO Dashboard provides several years of data to help categorize patients and evaluate clinical performance centered around treatment effectiveness, efficiency, and patient satisfaction. No identifiable patient information is available through the dashboard.

Two cohorts were derived for this study by analyzing therapy outcomes for clinicians and their management of cervical and lumbar spine conditions respectively from 2021 through 2023. The cervical spine cohort included clinicians whose mean functional scores met or exceeded the expected score for managing patients with cervical spine conditions; the lumbar spine cohort included clinicians who met or exceeded expected outcomes for those with lumbar spine conditions. Once the cohorts were identified, surveys were created and distributed to collect additional clinician characteristics. The creation of the survey was a collaborative effort of three co-investigators who possessed subject matter expertise and had experience in research methodology, questionnaire design, and data analysis. Surveys consisted of closed and open-ended questions and were built using Qualtrics (Qualtrics, Provo UT). Surveys were available from 9 September 2024 through 30 September 2024. The surveys used in this study were developed and reviewed by a panel of experienced clinicians and researchers to ensure content relevance and clarity. However, the surveys were not subjected to formal psychometric validation. The surveys were distributed through Jefferson Health’s secure Microsoft Outlook by a research assistant. Follow-up reminder e-mails were sent weekly until 30 September 2024.

The surveys collected clinician demographic information such as gender, years of experience, experience treating patients with orthopedic conditions, percentages of caseload consisting of patients with orthopedic conditions, weekly hours of direct patient care, post-professional education/training, treatment preferences, and attributes clinicians self-identified as contributing to their success with treating these patient populations (Appendices B and C).

At the end of each survey, participants were invited to participate in a 1:1 structured interview. Survey respondents who elected to take part were provided a calendar of time slots to schedule an interview. Participants received a consent form one week prior to the interview, outlining the study’s purpose, the interview procedures, and potential risks associated with participation. Participation in the interviews served as an indication of implied consent. Three of the study’s investigators conducted interviews, which took place on Jefferson Health’s secure Zoom application (Version 6.3.11); transcripts were recorded within Zoom (Version 6.3.11) and de-identified for analysis. Each interview was scheduled for 30 minutes. Participation was voluntary and could be stopped at any time at the request of the participant. During the interviews, participants were asked closed and open-ended questions pertaining to their success in managing these patient populations. All interviews lasted 15–30 minutes. None of the participants were given the transcripts and no repeat interviews were conducted. To minimize bias and enhance the credibility of our findings, several methodological safeguards were implemented. Interviews were conducted by multiple investigators to reduce the risk of interviewer bias, with all investigators using a standardized script to ensure consistency across sessions. Importantly, the interviewers were distinct from the thematic coders – those who conducted the qualitative analysis were not involved in the interviews – thereby reducing the risk of confirmation bias and limiting the influence of prior expectations on theme development. Throughout the study, the team remained mindful of how their professional backgrounds and personal experiences might influence interpretation, and discussions around potential biases were a routine part of the analysis meetings.

This study used inductive thematic analysis guided by a phenomenological approach to explore lived experiences of participants. Phenomenology seeks to understand how individuals perceive and make sense of their experiences, while thematic analysis provides a structured approach to identifying patterns and themes emerging from qualitative data without imposing preconceived categories [6]. This approach enabled us to explore the perspectives of high-performing clinicians on the key factors contributing to their success in treating cervical and lumbar spine populations, with the goal of identifying common patterns across the interviews. The two study investigators who did not participate in the structured interviews independently used thematic coding to analyze the interview transcripts. The investigators familiarized themselves with the data and then coded for keywords independently of each other. Coding was performed manually using interview transcripts. While formal qualitative data analysis software was not utilized, rigor was maintained through systematic coding procedures, consistent review of emerging themes, and regular cross-checking among the research team to ensure accuracy and credibility of the findings. All coauthors discussed the keywords. Two of the study authors (BT and EB) then independently generated themes prior to discussing them as a group to review identified themes. An external reviewer (MF) was then consulted to complete the same process to form a consensus on the themes present, increasing rigor and producing trustworthy and insightful findings.

Results

FOTO outcomes data were reviewed for 135 clinicians managing lumbar conditions and 129 managing cervical conditions. Of those, 32 clinicians (23.7%) met the inclusion criteria for the lumbar spine cohort and 11clinicians (8.5%) met the criteria for the cervical spine cohort. Five clinicians met the criteria for both cohorts. Clinicians who completed the study survey included 20 of the 32 (62.5%) in the lumbar spine cohort and 6 of the 11 (54.5%) in the cervical spine cohort. Information about the participants is presented in Table 1. The lumbar spine cohort comprised 12 female and eight male therapists. Five of the clinicians had less than 5 years of experience, five had 6–10 years of experience, and 10 had greater than 10 years of experience. Eight of the lumbar cohort clinicians were APTA certified specialists, two were fellows of the American Academy of Orthopaedic Manual Physical Therapists, and two were certified McKenzie therapists. The cervical spine cohort comprised five females and one male participant. Two of the therapists had 3–5 years of experience and four had > 10 years of experience. Two of the six were APTA certified specialists and one was a certified McKenzie therapist. All survey respondents (100%) reported using multimodal treatment interventions, which commonly included combinations of manual therapy, therapeutic exercise, patient education., and biophysical agents. The average treatment effectiveness, treatment efficiency (visits), and patient satisfaction (%) scores for each cohort and the national averages for each of these measures during the same time frame (2021 through 2023) provided by FOTO are presented in Table 2. Of those who completed the surveys, 12 (60%) clinicians in the lumbar cohort and all 6 (100%) in the cervical cohort agreed to participate in the 1:1 structured interviews.

Table 1.

Clinician demographics and experiences.

	Cervical Spine	Lumbar Spine
	Cohort n = 6	Cohort n = 20
Gender (female)	5 (83.3%)	12 (60%)
PT Experience
0–2 years	0	1 (5%)
3-5 Years	2 (33.3%)	4 (20%)
6–10 years	0	5(25%)
> 10 years	4 (66.7%)	10 (50%)
Experience treating ortho
0–2 years	0	1 (5%)
3–5 years	2 (33.3%)	5 (25%)
6–10 years	0	6 (30%)
> 10 years	4 (66.7%)	8 (40%)
% of caseload treating ortho
0–25%	1 (16.7%)	1 (5%)
26–50%	0	2 (10%)
51–75%	3 (50%)	9 (45%)
> 76%	2 (33.3%)	8 (40%)
Clinicians providing multimodal care	6 (100%)	20 (100%)
APTA certified specialist	2 (33.3%)	8 (40%)
AAOMPT Fellow	0	2 (10%)
Certified MDT	1 (16.7%)	2 (10%)
APTA certified specialist & AAOMPT Fellow	0	2 (10%)
APTA certified specialist & Certified MDT	0	1 (5%)
AAOMPT Fellow & Certified MDT	0	1 (5%)
Continuing education for specific region	6 (100%)	19 (95%)

Data collected from survey responses.

Multimodal PT = physical therapy approach integrating multiple interventions (e.g. exercise, manual therapy, education, modalities) to optimize patient outcomes.

Table 2.

Clinician treatment outcomes.

	Average	Expected	Average	Expected	Average
	FS change	FS change	visits	visits	satisfaction
					(%)
National Averages – Cervical Spine (n = 354,263)	12.59	11.91	12.00	11.09	97.3
Study Cohort – Cervical Spine (n = 11)(mean episodes = 20.82)	14.83	11.93	11.10	11.23	98.2
National Averages – Lumbar Spine (n = 885,500)	14.47	13.82	12.00	11.20	97.2
Study Cohort – Lumbar Spine (n = 32) (mean episodes = 43.34)	15.51	12.84	11.81	11.18	97.5

Data collected from Focus on Therapeutic Outcomes (FOTO).

FS = Functional score.

Through an iterative process of thematic coding of interview transcripts, four key themes of clinician characteristics emerged as essential for successfully managing patients with cervical and lumbar spine conditions: 1) employing evidence-informed practice, 2) engaging in lifelong learning through post-professional training, 3) establishing a strong therapeutic alliance, and 4) possessing experience in treating these conditions. These themes are summarized within a visual matrix (Table 3) aligning qualitative themes from structured interviews with corresponding quantitative survey data and participant quotes.

Table 3.

Joint display of integrated qualitative themes and quantitative findings related to high-performing physical therapists.

Qualitative Theme	Quantitative Support	Illustrative Quotes	Interpretation/Implications
Evidence-Informed Practice	100% report using multimodal interventions	‘Using my education and being able to apply my knowledge to their current status, understanding how I need to tailor individualized programs and address their deficits or their psychosocial beliefs’ ‘Keep up with the literature in a way that works for you.’	Clinical reasoning is driven by research and personalized care.
Lifelong Learning	40% lumbar/33% cervical were APTA certified specialists; 2 in lumbar cohort were AAOMPT fellows; 2 in lumbar and 1 in cervical cohort were McKenzie certified	‘Finding a mentor. I feel whether it’s with a residency or a fellowship finding somebody that you trust, and somebody that you respect to help you navigate difficult situations … I think it is a huge help.’ ‘The training you get in school is just not anywhere good enough, because patients come in so many shapes, sizes, flavors … patient presentation is complex. The intervention strategies are much different for the spine. So, I think that … continuing education plays a huge role in that.’	Post-professional training fosters more consistent outcomes.
Therapeutic Alliance	Interview-only theme	‘I think about interactions with patients as a partnership and as much as it’s important for … me to educate a patient about … tissue healing, the nature of the injury … I think it’s equally important for me to learn from them what they need for healing … And so, 1st and foremost, I think about these interactions as I have as much to learn about them as they have to learn about … the body and how it heals.’ ‘I would say, in a world full of mouths, learn how to be ears, … Don’t underestimate the power of really listening to your patient.’	Not directly measured but widely emphasized as key to satisfaction and outcomes.
Years of Clinical Experience	50% had > 10 years experience; but mixed evidence from literature	‘I think working for 10 years has really helped me pick up on cues in the history … I’ve just gotten so much quicker at identifying the problem and then figuring out what … I need to do to get them better. I think that’s kind of why I’ve improved so much.’ ‘I’ve been a therapist for a long time and you kind of have over the years … gotten down to what works and what doesn’t work. So, I think I’m just more efficient.’	Perception of value, but evidence suggests experience alone isn’t predictive.

Use of evidence-informed practice

The first emerging theme was the use of evidence-informed practice. Clinicians highlighted the importance of staying current with research and integrating the best available evidence. They also emphasized pattern recognition and individualized care tailored to patient expectations as key factors in achieving positive therapy outcomes.

Life-long learning through post professional training

The second emerging theme was continuous professional development. Clinicians reported that mentorship, residency or fellowship training, and continuing education courses focused on neck and LBP contributed to improved outcomes. This cohort consistently mentioned residency training and McKenzie courses as critical to success.

Building a therapeutic alliance

The third theme that emerged was the value of building a therapeutic alliance. Clinicians reported that strong interpersonal skills and patient-clinician relationships were associated with better treatment outcomes. Developing a therapeutic alliance, characterized by collaboration, communication, and trust, was seen as an essential component of patient-centered care.

Years of experience

The final theme to emerge was years of experience. Numerous participants associated a greater number of years of experience treating individuals with cervical and lumbar spine conditions with successful patient outcomes.

Discussion

Despite the widespread use of patient-reported outcomes measures such as FOTO in outpatient physical therapy, there remains a gap in the literature regarding the specific clinician-related factors that distinguish high performing therapists in the management of cervical and lumbar spine conditions. While existing tools such as FOTO effectively identify variations in treatment effectiveness, they do not explain the underlying factors driving superior outcomes. Addressing this gap, the present study was undertaken with two primary aims: (1) to explore the self-reported characteristics of physical therapists who consistently exceed national benchmarks in treating spinal conditions, and (2) to examine how these characteristics, including education, experience, and interpersonal strategies, may contribute to clinical effectiveness. This is the first study to seek out and examine the self-reported characteristics of physical therapists who consistently achieve superior outcomes in managing patients with cervical and lumbar spine conditions, as measured by FOTO, within a large outpatient rehabilitation network. By integrating outcome data with clinician surveys and interviews, this mixed-methods study offers novel insights into the clinician-related factors associated with success in managing these musculoskeletal populations. This study revealed four clearly defined themes that characterize physical therapists who consistently outperform national benchmarks when treating patients with cervical and lumbar conditions. These themes include: (1) practicing evidence-informed care, (2) engaging in continuous professional development, (3) building strong therapeutic alliances with patients, and (4) accumulating clinical experience specific to spinal care. These clinician-driven attributes offer a practical framework for improving care delivery and enhancing physical therapy outcomes for spinal conditions.

The identification of evidence-informed practice as a critical determinant of clinical success aligns with existing clinical practice guidelines that recommend integration of research, clinical success, and patient values [1,3]. Numerous clinical practice guidelines have been published for the management of neck and LBP, providing the most current evidence to enhance the translation of research findings into practice. A systematic review of LBP clinical practice guidelines identified recommendations for providing improved care, including providing a comprehensive, patient-centered approach using the most current evidence [7]. Further, our finding that evidence-informed practice is a factor in successful management aligns with another review highlighting that physical therapy, when informed by the latest evidence, led to more efficient and effective treatments for musculoskeletal pain conditions [8]. Within this framework, shared decision-making further enhances patient-centered care by promoting collaboration between clinicians and patients in the development of treatment plans that align with both clinical evidence and patient preferences. Shared decision making involves clinicians sharing the best available evidence with patients and supporting them in considering their options when making decisions [9]. While the direct impact of shared decision-making on clinical outcomes remains under investigation, its absence has been associated with poorer PROMs [10,11].

Despite evidence supporting patient-centered care, significant barriers hinder its consistent implementation in clinical practice, with current evidence indicating that only 54% of clinicians follow clinical guidelines [12]. While clinical practice guidelines advocate for patient-centered approaches as a key component to clinical success, clinicians often lack the time to thoroughly review and apply these guidelines consistently. Furthermore, few studies incorporate patient perspectives on what constitutes meaningful care, which is essential for developing truly responsive practices. These limitations highlight the urgent need for research that not only defines patient-centered care in physical therapy but also examines its practical application, sustainability, and impact on health equity and outcomes.

Lifelong learning, especially through residency, fellowship training, and focused continuing education, also emerged as a distinguishing feature of high performers. Within this cohort, attending residency courses and McKenzie courses were mentioned more consistently than others as being critical to their successes. Some evidence suggests that post-professional training can affect outcomes. Fellowship training, a post-professional advancement beyond clinical specialty, demonstrated increased effectiveness compared to non-fellowship-trained clinicians in managing orthopedic conditions [13]. Still, it is uncertain if fellowship-trained clinicians are more successful at managing spinal conditions alone. Another study found that orthopedic certified therapists provided more efficient care than non-specialized therapists [14]. Regarding McKenzie coursework, physical therapists who underwent McKenzie training had slightly greater improvements in functional status in LBP patients compared to those clinicians who had not received any McKenzie training [15]. However, some studies suggest that the use of the McKenzie method is not more effective than other treatment approaches [16,17]. Advanced training through continuing education should keep clinicians up to date on the evidence and help advance clinical reasoning and decision making, potentially leading to improved patient outcomes, but current evidence does not strongly support this and there is limited evidence to suggest one type of training is more successful than another [18,19]. This may be related to the quality or content of physical therapy continuing education courses. Although these courses are intended to support clinicians in lifelong learning and enhance patient outcomes, recent evidence suggests that much of the content is not aligned with clinical practice guidelines or supported by systematic reviews [20]. This disconnect highlights a critical gap between educational offerings and the evolving demands of clinicians seeking lifelong learning. While post-professional education remains an integral part of clinical growth, further research is needed to improve continuing education content and clarify its direct impact on patient outcomes.

Therapeutic alliance refers to the mutual engagement between a therapist and a patient in therapy, established through collaboration, communication, goal agreement, mutual trust, and respect [21]. In this study, participants reported that developing a strong relationship and connection with patients was associated with greater satisfaction and improved outcomes. A biopsychosocial framework in physical therapy is essential for providing patient-centered care, as it accounts for the multifactorial nature of pain and dysfunction. Developing a therapeutic alliance is a vital component of biopsychosocial patient management, as the trust and collaboration fostered in this relationship help address the biological, psychological, and social factors influencing a patient’s experiences [22]. Among individuals with chronic LBP, trust in the therapist has been positively correlated with improved outcomes [23]. Additionally, a systematic review examining this association found that a strong alliance was linked to better pain outcomes in patients with chronic pain [24]. While further research is needed, current evidence supports the importance of developing a therapeutic alliance as part of delivering patient-centered care.

The final theme to emerge was the perception of a correlation between increased years of experience treating individuals with cervical and lumbar spine conditions and positive patient outcomes. While the concept of ‘more experience leads to better outcomes’ may seem intuitive, this may not be accurate. A retrospective study of physical therapists’ expertise using risk adjusted outcomes found no difference in years of clinical experience between groups classified as expert or average clinician, further challenging the assumption that experience is necessary to achieve superior patient outcomes [25]. A systematic review of the characteristics of good physical therapists found responsive, ethical, communicative, caring, competent, collaborative physiotherapists to be higher performers [26]. These qualities of a ‘good physical therapist’ emphasize human interaction between clinician and patients alongside technical competence. However, years of experience was not mentioned as a quality of a good physical therapist. In a systematic review exploring the relationship of clinical experience and quality of care in physician practice, findings showed physicians who have been in practice for more years possess less factual knowledge, are less likely to adhere to standards of care and may have poorer patient outcomes [27]. A 2022 study explored characteristics of excellence in physicians with findings that include motivation, personality, and competence in communication, professionalism, and knowledge to be associated with excellent physicians [28]. While an increase in knowledge may occur with increased experience, years of experience alone does not lead to excellence in patient outcomes.

Strengths

Several strengths enhance the credibility and relevance of our findings. The use of a mixed-methods approach allowed for a comprehensive understanding of both outcome data and clinician perspectives, enabling deeper insights into factors associated with superior performance in managing cervical and lumbar spine conditions. The use of FOTO, a validated and widely used PROM with risk-adjusted benchmarking, strengthens the credibility and generalizability of the quantitative findings. Employing a structured phenomenological thematic analysis, the qualitative approach incorporated triangulation through independent coding and external reviewer validation, methodological safeguards that strengthen the reliability and trustworthiness of the results. The study also distilled clinician excellence into four clear, actionable themes that hold significant implications for both individual professional development and system-level quality improvement initiatives. Finally, the study followed the GRAMMs checklist, ensured IRB exempt status, and clearly reported limitations and methodology, contributing to its overall transparency and rigor.

Limitations

There are several limitations. The survey distributed lacked survey validation and reliability testing. Without proper validation, the survey may not accurately measure the intended constructs, leading to potential biases or misinterpretations of the data. As a result, the findings may be less generalizable and could be influenced by measurement errors, undermining the study’s overall credibility and validity. The structured interview portion involved only 18 clinicians (12 lumbar, 6 cervical), which, while valuable for thematic analysis, was relatively small for drawing broader conclusions. The study also relied on voluntary participation for both the surveys and the structured interviews. This could have introduced bias, as clinicians with stronger opinions may have been more likely to respond. Additionally, response bias may have occurred if clinicians tailored their answers to align with what they perceived as the interviewer’s expectations, potentially skewing the accuracy of the data. Recall bias also may have influenced the findings, as participants were required to reflect on and report their past education, clinical approaches, and experiences, which may have been subject to inaccuracies or incomplete recollection. The study also took place within one healthcare organization, which limits the generalizability of the findings with other organizations. Organizational culture, policies, patient populations, and available resources may differ across institutions, potentially influencing the applicability of results in other institutions. Additionally, the sample of therapists may not represent all orthopedic physical therapists, and the result should be interpreted with caution. The findings also focused entirely on clinician reported data, and did not incorporate patients’ perspectives on what they perceive as effective care. Successful care was defined by exceeding FOTO outcomes, but this may not capture all dimensions of patient improvement.

Future research

Findings from this study can be used within the field of physical therapy to address professional development and craft strategies for better addressing patients with cervical and lumbar musculoskeletal conditions. Further research may investigate how to best measure patient-centered care and its association with improved outcomes in all musculoskeletal conditions. Fostering lifelong learning is essential in a dynamically changing healthcare world, but steps should also address the quality of continuing education courses to ensure they provide learning experiences aligned with current research. Another avenue for research is how we measure trust and therapeutic alliance. Current evidence demonstrates the need to develop an alliance between clinicians and patients, but research is warranted on how to best develop these trusting relationships. One of the themes that emerged in this study was years of clinical experience. However, current evidence does not consistently link years of experience to clinical excellence. This disconnect highlights the need for future studies to examine whether, how, and under what conditions clinical experience contributes to superior patient outcomes. Future studies should expand on our findings by incorporating patient perspectives, exploring the impact of specific educational interventions, and validating these clinician attributes across diverse clinical settings.

As a direct extension of this study, Jefferson Moss-Magee Rehab will consider launching a quality improvement initiative designed to translate these findings into sustainable practice enhancements. The aim would be to elevate clinical performance through a structured approach centered on the themes identified within this study. This initiative may include establishing formal mentorship to connect high-performing therapists with early-career clinicians, consistently integrating evidence-based clinical practice guidelines into routine practice, and providing targeted training to improve patient communication and support shared decision-making. Additionally, organizational continuing education offerings will be reassessed to ensure alignment with current clinical practice guidelines and emerging evidence.

To support these efforts, FOTO dashboards will be used more intentionally as feedback tools, allowing clinicians to track their effectiveness, efficiency, and patient satisfaction compared to national benchmarks. Future research will evaluate the impact of this initiative across multiple sites within the outpatient network, with plans to analyze shifts in clinician performance, patient outcomes, and engagement with professional development activities over a 12-month period.

Future research should evaluate the effectiveness of this implementation strategy and explore how targeted interventions around mentorship, evidence uptake, and communication training contribute to both clinician development and improved patient outcomes.

Conclusions

This mixed-methods study provides new insight into the self-reported characteristics of physical therapists who consistently achieve superior outcomes when managing patients with cervical and lumbar spine conditions. By analyzing both outcome metrics and qualitative data, four key attributes were identified among high-performing clinicians: use of evidence-informed practice, commitment to lifelong learning through post-professional education, development of strong therapeutic alliances, and clinical experience.

While years of experience were perceived by some as beneficial, the findings suggest that success in treating spinal conditions may be more closely linked to qualities such as adaptability, interpersonal skill, and ongoing professional development rather than experience alone. The results emphasize the importance of fostering a culture of continuous learning and patient-centered care within physical therapy practice. They also underscore the potential for enhancing patient outcomes by supporting clinician growth not only through advanced training but also by nurturing communication skills and therapeutic rapport. These findings may inform professional development strategies, continuing education design, and mentorship models within outpatient rehabilitation networks.

Biographies

John Morris, PT, MSPT, DSc, is a physical therapist, clinical manager, and orthopedic residency director at Jefferson Moss-Magee Rehab in Lansdale, PA, and a healthcare leader with over two decades of experience in both clinical practice and organizational leadership. He earned his degree in physical therapy from Ithaca College in 2002 and achieved board certification as an Orthopedic Clinical Specialist (OCS) in 2009. In 2019, he completed a Fellowship in Orthopedic Manual Therapy through Regis University, earning recognition as a Fellow of the American Academy of Orthopaedic Manual Physical Therapists (FAAOMPT). John has held numerous leadership positions throughout his career, including serving as Clinical Manager for MossRehab outpatient clinics and as Director of the MossRehab (now Jefferson Moss-Magee Rehabilitation) Orthopedic Physical Therapy Residency Program. To complement his leadership responsibilities and enhance his impact on program development and healthcare delivery, John pursued and completed both a Master of Business Administration and a Doctor of Science in Physical Therapy. In addition to his professional roles, John serves as Board Chair of the International WAGR Syndrome Association, where he advocates for rare disease awareness, research, and family support.

Patricia Crane, PT, DPT, MBA, DSc, is a 2003 graduate from Long Island University, where she earned a BS/MS in physical therapy. She furthered her education, receiving her transitional DPT from Widener University in 2006, completed a Fellowship in manual therapy at Regis University in 2019, obtained a Master’s in Business Administration (MBA) in 2019 from West Chester University, and a Doctor of Science in 2019 from Bellin College. Currently, Trish is an assistant professor at Thomas Jefferson University in Philadelphia, PA. She maintains clinical practice at Jefferson-Moss-Magee Rehab in the suburbs of Philadelphia, PA, where she treats a mixed caseload of orthopedic and pelvic floor patients. She is a board-certified Orthopedic Clinical Specialist through the American Physical Therapy Association and serves as an associate editor for the Journal of Women’s & Pelvic Health Physical Therapy. Outside of physical therapy, Trish enjoys spending time with her husband and two young sons, particularly cheering on her kids’ sports teams.

Evan Bohan, PT, DPT, received his Doctor of Physical Therapy degree (DPT) from Jefferson University in 2023. He then completed Jefferson Moss Magee Rehab’s Orthopedic Residency in 2025 to further increase his clinical reasoning, efficacy in treating musculoskeletal disorders. After completing residency, he now primarily treats at JMMR-Tabor Road. He has experience working with a variety of patient populations, including orthopedic conditions, chronic pain conditions, spinal conditions, and high-level athletes.

Brooke Tripp, PT, DPT, received her Doctor of Physical Therapy degree (DPT) from Drexel University in 2024. She then completed Jefferson Moss Magee Rehab’s Orthopedic Residency in 2025. She has experience working with a variety of patient populations, including pediatrics and high-level performing arts athletes.

Michael Parlatore, PT, DPT, earned a Doctorate in Physical Therapy from Arcadia University in 2004 and spent 17 years in hospital-based outpatient care, specializing in orthopedic and neurological disorders. For 15 years, he also served as an adjunct faculty member within Arcadia’s Physical Therapy program, teaching doctoral candidates in both residential and hybrid formats. Over the past decade, he has advanced to a leadership role in clinic operations, continuing to shape patient care and professional development.

Maria Flach, PT, DPT, is the Program Director for Spinal Cord Injury, Amputation, and General Rehabilitation at Jefferson Moss Magee at Center City and Elkins Park. Her clinical area of expertise is prosthetics and gait. Maria also worked for many years in education and professional development for rehabilitation health professionals.

Funding Statement

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethical consent

This study was reviewed and approved by the Thomas Jefferson University Office of Human Research Institutional Review Board and received exempt status. All procedures were conducted in accordance with institutional guidelines and the principles of the Declaration of Helsinki.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/10669817.2025.2554213