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Joint Mobilizations and Manipulations: Evidenced-based Teaching and Learning Audio

Evidence-based teaching and learning of joint manips and mobs. A review of lesson plan development and use of labs (hands-on learning) and didactic (lecture) teaching methods. The effectiveness of force recording instruments, manikins, tables, and gauges, and accuracy, variability, and reliability of these teaching tools for physio/physical therapy, chiropractic, and manual therapy students learning joint manipulations and mobilizations.

Joint Mobilizations and Manipulations: Evidenced-based Teaching and Learning

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I have almost completed my CPT certification and am half-way through the Human Movement certification to inform my massage practice. The different modalities of reading, watching audiovisual materials, and attending live or recorded webinars have been important to my learning style and for review.

Brookbush Institute has the most detailed, specific and effective tools for online learning for movement and/or bodywork professionals. I love the combination of the videos as well as the text available online.

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I have my personal trainer certificate through here and am almost finished my human movement specialist certification. Overall, the education that Brookbush has packaged together for clinicians and trainers is invaluable. I am a physio assistant so coming from more of a rehab background I appreciate that this education has been beneficial both as a trainer and in a rehab setting. I love that I have been able to do all learning at my own pace and able to work around my schedule. Thank you for setting up this platform! Highly recommend :)

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I have been following Brent Brookbush for nearly a decade- back when I was a personal Trainer and now as a Physical Therapist. BBI is an incredible resource for any movement nerds and corrective exercise specialists! The information is thorough with multiple real world applications. I am looking forward to an in-person Manual Therapist course the second they do one a little bit closer to Virginia ;)

I have taken both the Human Movement Specialist and Certified Personal Trainer certificate programs and have found the value in understanding the how and ways the body moves and functions and from evidence, non-biased, outcome, conceptual, theoretical, and practical approach to helping my clients/patients look better, feel better, and move better.

Over the last years I've returned time and again to Brookbush Institute for stellar coursework as I've worked toward a Human Movement Specialist certification. (I'm currently ACE CPT, and in training with Anatomy Trains for Structural Integration Manual Therapy.) Every Brookbush Institute module is fantastic and each one includes detailed informational videos, written descriptions of how to-do, and, more importantly, why to-do!

I am a 70 yr old chiropractor and no other healthcare provider was able to come up with an exercise protocol particular to my structural and balances and muscle deficits and keep me in the game. And as for continuing education on human skeletal movement, the website is phenomenal full of great exercises for particular mechanical dysfunction.

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Having courses count towards different certifications makes it so users can transition seamlessly from one certification to another. In my case, going from earning the BI CPT to earning the BI HMS was an easy decision and I am proud to have earned both certifications. I have also had the pleasure of going to a Live HMS workshop that was well taught by Instructor Boettcher and that was excellent to see how the methods and techniques are implemented.



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We learn principles in academia, we learn cool new modalities via whatever specialty certification, but BBI really concentrates on the nuances of passive treatment and they do a fantastic job. The format in which BBI instructs soft tissue specialists (DPTs, Chiros, ATs) like myself feels like almost like an apprenticeship. You get a thoroughly detailed explanation of the “why’s”, and a visual comprehension of how to apply. Personally, I believe application is where the good and the great are distinguished.

Brookbush has been incredibly helpful since I was in massage school and now as I’m in my career! I run my own practice and it gives me the resources I need to not only improve what I already know, but also help me navigate better, more efficient ways of treatment.

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Challenging concepts are explained in very understandable terms without dumbing down the material, and I find this program to be superior in quality to other personal training programs.

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Courses

This course discusses the research investigating various strategies for delivering manual therapy education, with the intent of improving the reliability and efficacy of a clinician's manual therapy technique. These findings could be applied to college and university programs, continuing education courses, and manual therapy technique certifications, as well as used by clinical educators working to improve clinical practice at their clinics (e.g. with staff physical therapists, physical therapy students during clinical affiliations, etc.). This course does not cover the construction of a quality written exam or multiple-choice question test; however, the information in this course likely has significant implications for practical examination, and perhaps patient education.

Although this course does not cover material that would be considered part of a "conventional" manual therapy course or manual technique certification, it is recommended that all sports medicine professionals and health care providers (physical therapists, athletic trainers, massage therapists, chiropractors, occupational therapists, etc.) take this course with the intent of improving the profession, and our ability to teach manual techniques for the treatment of pain. It is time the industry went beyond teaching anatomy, body mechanics, musculoskeletal dysfunction, and manual therapy techniques, and started thinking about how better teaching could improve the delivery, retention, and application of all coursework.

Research implies that ideal lesson plan development would include video instruction and step-by-step demonstration prior to live instruction. Live instruction would prioritize lab and blocked-practice sessions taught by the most experienced instructors. Feedback should be concurrent, student-paced, qualitative, and quantitative, and students should have opportunities to teach the techniques back to instructors and/or peers. Random-variable practice with progressively less feedback may be used to optimize retention.

 Studies suggest that students are generally dissatisfied with the proportion of lecture time dedicated to lab and practicing techniques.

Step-by-step instruction may be beneficial during the initial demonstration; however, whole technique practice is as effective during labs. Further, it may be beneficial to have students attempt to instruct a teacher and/or peer as part of proficiency development.

Integrating Didactic and Lab Instruction: 

Research suggests that ideal lesson plans might begin with video instruction prior to live instruction and live instruction would focus on practical application with concurrent feedback.

 Staff instructors are most beneficial during lab instruction and should provide both qualitative and quantitative feedback.

 Feedback should be concurrent and student-paced, blocked practice should be used for skill acquisition, and random-variable practice with progressively less feedback may be ideal for optimizing retention.

: Few studies are available to refine the validity of feedback; however, these studies should inspire more research comparing various instruction sets, cues, and alignment between student, instructor, and patient perception.

 Lectures may have important effects on practice beyond the recall of testable information (e.g. prevalence of use, confidence, etc.), and an exercise program may be beneficial for new students learning joint manipulation techniques.

Course Description: Joint Mobilizations and Manipulations: Evidenced-based Teaching and Learning

Research suggests that ideal lesson plans might begin with video instruction prior to live instruction, and live instruction would focus on practical application with concurrent feedback.

 Feedback should be concurrent and student-paced, blocked-practice should be used for skill acquisition, and random-variable practice with progressively less feedback may be ideal for optimizing retention.

: Few studies are available to refine the validity of feedback; however, these studies should inspire more research comparing various instructions sets, cues, and alignment between student, instructor, and patient perception.

The Addition of Force Recording Instruments (Instrumented Manakins, Tables and Gauges)

The addition of real-time feedback from instrumented tables, manakins, inertial sensors, or the Dynadjust™ may be beneficial for improving specific force characteristics, as well as reducing variability, improving accuracy, improving reliability, and potentially improving clinical outcomes. However, without multiple and continued practice sessions, these improvements degrade quickly, potentially resulting in a return to baseline within a month. It is recommended these tools should only be adopted if an affordable, portable, and convenient technology is developed that can be reasonably expected to be acquired by every school, facility, and/or professional. For example, a wearable inertial sensor and mobile application that uses a smartphone for hardware.

 Instrumented tables and manakins may improve joint mobilization and manipulation accuracy, peak force variability, and preload force, but may not improve the rate of force or thrust duration (which improves with experience).

 The addition of inertial sensors to joint mobilization and manipulation instruction may improve the rate of force, the magnitude of peak force, and length of thrust duration; interestingly, the force characteristics that were not improved by instrumented tables and manakins. Further, a study by González-Sánchez et al. demonstrated that use of inertial sensors may improve clinical outcomes.

 Adding the Dynadjust™ to instruction on spine manipulation may improve certain force characteristics, but only when sufficient time is allocated to technique practice.

Joint mobilization and manipulation instruction with the addition of pre-set target forces, force recording instruments, and real-time feedback, may improve accuracy and decrease variability; however, follow-up sessions are needed to maintain improvements.

 Four weeks or more of joint mobilization instruction with the addition of force recording instruments may increase inter-therapist and intra-therapist reliability of force characteristics.

The addition of force recording instruments to joint mobilization and manipulation instruction may improve specific performance characteristics; however, without additional and continued practice sessions, improvements degrade quickly, potentially resulting in a return to baseline within a month.

Additional limitations worth further consideration include no effect on the perception of error, effect on a narrow range of kinematic measures, and no effect on parameters related to technique, including those that would be commonly assessed during the practical examination of manual therapy students.

Introduction: Research Review

Publication on research investigating the ideal construction of courses and lectures has been increasing over the past 2 decades. Yamamoto et al. used qualitative research methods to analyze the education process of four mentors (Orthopedic Manual Physical Therapists) and five mentees learning cervical spine manipulations. The results showed that education was primarily focused on the mitigation of risk, with the next largest emphasis on clinical decision making, and the development of practical skills was taught separately with less emphasis. Mentees wanted more emphasis on the development of practical skills (1). Noteboom et al. used survey research to demonstrate that 99% of physical therapy programs include manipulations in their curricula; however, students were dissatisfied with the amount of time spent practicing the techniques during labs and clinical affiliations (2). These studies suggest that students are generally dissatisfied with the proportion of lecture time dedicated to lab and practicing techniques.

Studies have investigated a variety of lesson plan designs. Wise et al. demonstrated that instructing chiropractic students on the performance of lumbar spine manipulations using a sequential partial-task practice model improved confidence in the safety, efficacy, and proficiency of technique performance (3). Washmuth et al. compared a lab designed to practice the full technique to a lab designed to practice sequential steps of high-velocity low-amplitude thrust manipulations (HVLAT), demonstrating that both designs resulted in similar student confidence and outcomes when students were asked to teach the techniques back to classmates (4). And, Gradl-Dietsch demonstrated that a "Peyton's four-step teaching approach" (demonstrate, talk the student through it, student talks instructor through it, and the student does it) was more effective than conventional instruction (5). These studies likely suggest that step-by-step instruction may be beneficial during the demonstration portion of lectures; however, whole technique practice is as effective during labs. Further, it may be beneficial to have students attempt to instruct a teacher and/or peer as part of proficiency development.

Integrating Didactic and Lab Instruction:

Additional studies have investigated the value of lectures and experience prior to lab practice. Triano et al. compared students with little or no prior knowledge of manipulations to students with prior knowledge of manipulations, demonstrating that individuals with prior knowledge developed superior skills following a single session of instruction on a new manipulative technique (6). Watson et al. compared skill development and retention of a spinal manipulation technique following video instruction, instructor training with delayed feedback, and instructor training with concurrent feedback. The findings demonstrated that the 3 groups exhibited similar skill acquisition; however, there were significant differences in retention (8-days later) favoring the students who received instructor training with concurrent feedback (7). Harvey et al. investigated the use of a conventional teaching methodology in which didactic information was taught first, followed by instruction on assessment and clinical decision making, followed by the dictation of technique instructions, and last performing the technique, compared to an integrated teaching methodology that introduced practice early and throughout all lessons. The results revealed that students exposed to an integrated methodology exhibited superior peak force, time to peak force, and rate of force development (8). These studies suggest prior learning may improve new skill acquisition, initial skill acquisition is similar when it follows videos or live didactic instruction; and further, live didactic instruction should attempt to integrate practice with concurrent feedback early and throughout all lessons. These findings suggest that ideal lesson plans might begin with video instruction prior to live instruction and live instruction would focus on practical application with concurrent feedback.

Several studies have compared various types of feedback during the instruction of joint mobilizations and manipulations. Scaringe et al. demonstrated that during instruction of chiropractic manipulations, both qualitative and quantitative feedback improved accuracy and reduced the variability of force characteristics (9). Petty et al. compared the accuracy and reliability of feedback from a force plate, a fellow student, and an experienced therapist on a student's performance of a grade III spine mobilization. The findings demonstrated that the feedback from the student lacked accuracy and reliability (10). An RCT by Knobe et al. compared the efficacy of staff teachers, student-teachers, and peer-assisted learning, demonstrating that staff teachers were superior for lab/technique instruction, but student- and staff-teachers were similarly effective for didactic instruction (11). It is common practice for staff instructors to prioritize quantitative feedback over qualitative feedback, and prioritize teaching didactic lessons while delegating lab/technique practice to adjunct professors or student teachers. These studies imply that staff instructors should provide both qualitative and quantitative feedback, and are most beneficial during lab instruction.

Additional studies have investigated the timing of feedback during lessons on joint mobilizations and manipulations. As mentioned above, Watson et al. demonstrated that retention was better for students receiving instructor training with concurrent feedback when compared to instructor training with delayed feedback (7). Sheaves et al. demonstrated that students learning the appropriate force for lumbar mobilizations benefited more from student-controlled feedback (feedback when the student asked for it) when compared to constant feedback (instructor-dictated feedback) (12). Lardon et al. compared force during manipulations following continuous feedback over 10-sessions or progressively less feedback over 10 sessions, demonstrating no difference between the groups (13). In another study mentioned above, Scaringe et al. demonstrated that increasing the time between practice sessions reduced accuracy more than reliability (9). Last, Enebo et al. compared manipulation technique accuracy and variability following blocked practice, random/variable practice, visual feedback of force (using force gauges), and/or post-performance feedback from an instructor. Findings demonstrated that blocked practice had the largest impact on accuracy; however, random variable practice with visual feedback had the largest impact on accuracy over multiple sessions (retention) (14). These studies may suggest that feedback should be concurrent and student-paced, blocked-practice should be used for skill acquisition, and random-variable practice with progressively less feedback may be ideal for optimizing retention.

Research has started investigating which aspects of manipulations and mobilizations should be prioritized during lessons. O'Donnell et al. used survey data to identify the most important aspects of a side-lying lumbar manipulation. A consensus was reached for patient comfort, table height, localizing the target segment, log-rolling the patient towards the operator, moving up and over the patient, close contact between the operator and patient, maintaining contact using forearms, maintenance of localization during the manipulation phase, high-velocity and low-amplitude thrust by generating force through the body and legs, and dropping the body downwards. Although this may appear to be a long list of details, this list may be used to construct a set of instructions based on input from experienced practitioners (15). Pasquier et al. compared objective and subjective measures during a thoracic manipulation performed on a student by another student. Findings demonstrated that subjective ratings of comfort were strongly correlated with objective measures of preload force and thrust duration, but were not correlated with peak force during thrust, and assessment of comfort by an experienced instructor was weakly correlated with a momentary decrease in preload force (16). Although few studies are available to refine the validity of feedback, these studies should inspire more research comparing various instructions sets, cues, and alignment between student, instructor, and patient perception.

Lesson Plan Development

Research has investigated the potential benefits of adding force recording instruments and real-time feedback to instruction on joint mobilizations and manipulations.

Several studies have investigated the efficacy of teaching with instrumented tables and manikins. A single-blind RCT by Triano et al. compared chiropractic students learning an L4 mammillary push technique following conventional instruction with and without the addition of real-time visual feedback from instrumented tables. Following 10-minutes of a distracting activity (practice exam questions), students who received feedback from manikins were significantly closer to target forces (more accurate) (19). An RCT by Descarreaux et al. compared conventional teaching methods to the addition of instrumented manikins during 5-weeks of spinal manipulation training for chiropractic students, demonstrating that the addition of manikins reduced peak force variability and increased preload force (20). Pasquier et al. compared the force parameters of a simulated thoracic manipulation by 103 chiropractic students of various levels of experience (1st year, 3rd year, or 5th year) following augmented learning including instruction from a video and practice on a force recording table. The findings demonstrated that the augmented training improved the magnitude of preload force and reduced drops in preload force for all experience levels; however, the rate of force application and thrust duration were not influenced by augmented learning and only improved with experience (21). These studies suggest that instrumented tables and manikins may improve joint mobilization and manipulation accuracy, peak force variability, and preload force, but may not improve the rate of force or thrust duration (which improved with experience).

Two studies have investigated the efficacy of adding inertial sensors and real-time feedback to joint mobilization and manipulation instruction. An RCT by Cuesta-Vargas et al. compared conventional learning of thoracic manipulations to learning manipulations with real-time feedback from inertial sensors, demonstrating that the sensor group exhibited significantly larger improvements in peak force, time to peak force, and thrust duration (22). A double-blind RCT by González-Sánchez et al. compared a 90-minute lesson on two directions of ankle mobilization with conventional teaching methods or conventional teaching with the addition of real-time kinematic data via inertial sensors and a laptop. The findings suggest the addition of real-time kinematic feedback via a laptop improved velocity, runtime, and post-intervention outcomes for dorsiflexion ROM and stability (23). These studies imply that the addition of inertial sensors to joint mobilization and manipulation instruction may improve the rate of force, the magnitude of peak force, and length of thrust duration; interestingly, the force characteristics that were not improved by instrumented tables and manikins. Further, a study by González-Sánchez et al. demonstrated that the use of inertial sensors may improve clinical outcomes.

Three studies performed by Triano et. al. investigated the efficacy of adding the Dynadjust™ electromechanical training aid to conventional instruction of joint manipulations. An RCT by Triano et al. (2002) compared a full semester chiropractic manipulation course with and without the addition of the Dynadjust™, demonstrating that the addition of the Dynadjust™ improved lumbar manipulation performance based on several kinematic measures (24). Another study by Triano et al., performed the following year (2003), compared conventional instruction of cervical spine and thoracic spine manipulations, with and without the Dynadjust™, demonstrating the Dynadjust™ resulted in similar improvements in kinematic measures for the cervical and thoracic spine (25). And, Triano et al. (2014) compared 6-weeks of conventional instruction of manual therapy, with and without the Dynadjust™, for 2nd and 4th-year chiropractic students. Findings suggest that the addition of the Dynadjust™ did not benefit 2nd-year students; however, 4th-year students exhibited superior improvements in the rate and rise of peak force. Some consideration should be given to a larger proportion of didactic learning, and a smaller proportion of lab/technique practice, in the courses for 2nd-year students (26). These studies likely suggest that the addition of the Dynadjust™ to instruction on spine manipulation may improve certain force characteristics, but only when sufficient time is allocated to technique practice.

Effect of Force Recording Instruments on Accuracy, Variability, and Reliability

Force Recording Instruments (Instrumented Manikins, Tables and Gauges)

Several studies have investigated whether improvements were retained following the addition of force recording devices. Chang et al. compared peak displacement following a 45-minute practice session on a shoulder joint simulator with no feedback, concurrent feedback, or post-practice feedback, demonstrating that both feedback groups exhibited similar improvements in variability and similar retention during assessment 10-minutes and 5-days later (31). Marchand et al. demonstrated that practicing 45 manipulations, with variable or constant force goals, on a thoracic joint simulator, significantly increased peak force and reduced variability; however, variability increased during follow-up 48 hours later, suggesting retention requires additional practice sessions (32). Snodgrass et al. compared the force imparted by physiotherapy students following a session of cervical mobilization practice, with and without the addition of a table fitted with force plates, and a goal to match the average force from an experienced clinician. The findings demonstrated that practice with the instrumented table resulted in a reduction in mean variation following practice and during follow-up 8-days later; however, the variation was larger during follow-up (33). As mentioned above, Shannon et al. demonstrated a significant reduction in chiropractic student force variability following six 30-minute practice sessions over 4 weeks on an instrumented manikin, and although variability increased with each weekly follow-up it was still less than controls at week 8 (28). Another study by Snodgrass et al. compared physiotherapy students to expert force characteristics for mean peak force, force amplitude, and oscillation frequency following 3 sessions of lumbar mobilization practice, with and without the addition of a table fitted with force plates. The findings demonstrated that accuracy and variability improved with each of the 3 practice sessions; however, force parameters returned to baseline during a follow-up 1 month later, implying retention was poor (34). These studies imply that the addition of force recording instruments to joint mobilization and manipulation instruction may improve specific performance characteristics; however, without additional and continued practice sessions, improvements degrade quickly, potentially resulting in a return to baseline within a month.

Although many studies have demonstrated that the addition of force recording instruments to conventional instruction may improve several kinematic measures associated with joint mobilization and manipulation performance, several studies demonstrate limitations worthy of considerations before adoption by instructors. Latimer et al. demonstrated that 75 practice trials assessing L3 stiffness using a force recording instrument did not improve the accuracy of a student's perception of force applied (35). In a study mentioned above by Pasquier et al., 1-week of augmented training including instrumented manikins improved preload force and drop in preload force; however, the augmented training did not improve the rate of force and thrust duration, which only improved with experience (1st year, 3rd year, or 5th year) (21). A study mentioned above by Triano et al. demonstrated that the addition of the Dynadjust™ to 6-weeks of manual therapy instruction was not effective for 2nd-year students who were taking courses with a high proportion of didactic content; and further, was only effective for increasing the rate and rise of peak force for 4th years students who were taking courses with a high proportion of lab and technique practice (26). A study by Cuesta-Vargas et al. demonstrated that learning cervical manipulations with feedback from inertial sensors had no effect on pre-manipulation position, thrust displacement, or side-bending velocity; however, significant improvements were noted in angular velocity for rotation (36). Last, Young et al. compared teaching the diversified cervical manipulation technique with conventional hands-on learning to the addition of instrumented manikins, demonstrating that both sets of chiropractic students attained similar test scores during practical examination (37). In summary, the addition of force recording instruments to joint mobilization and manipulation instruction has potential benefits, but there are several limitations worth considering. These limitations include the need for multiple practice sessions (3+), regular and continued follow-up to maintain improvements, no effect on the perception of error, effect on a narrow range of kinematic measures, and no effect on parameters related to technique, including those that would be commonly assessed during the practical examination of manual therapy students.

Retention and Limitations

Yamamoto, K., Condotta, L., Haldane, C., Jaffrani, S., Johnstone, V., Jachyra, P., ... & Yeung, E. (2018). Exploring the teaching and learning of clinical reasoning, risks, and benefits of cervical spine manipulation. Physiotherapy theory and practice, 34(2), 91-100.

Noteboom, J. T., Little, C., & Boissonnault, W. (2015). Thrust joint manipulation curricula in first-professional physical therapy education: 2012 update. journal of orthopaedic & sports physical therapy, 45(6), 471-476.

Wise, C. H., Schenk, R. J., & Lattanzi, J. B. (2016). A model for teaching and learning spinal thrust manipulation and its effect on participant confidence in technique performance. Journal of Manual & Manipulative Therapy, 24(3), 141-150.

Washmuth, N. B., Ross, S., & Bowens, A. N. (2019). Effect of motor learning theory-assisted instruction versus traditional demonstration on student learning of spinal joint manipulation. Health Professions Education.

Gradl-Dietsch, G., Lübke, C., Horst, K., Simon, M., Modabber, A., Sönmez, T. T., ... & Knobe, M. (2016). Peyton’s four-step approach for teaching complex spinal manipulation techniques–a prospective randomized trial. BMC medical education, 16(1), 284.

Triano, J. J., Bougie, J., Rogers, C., Scaringe, J., Sorrels, K., Skogsbergh, D., & Mior, S. (2004). Procedural skills in spinal manipulation: do prerequisites matter?. The Spine Journal, 4(5), 557-563.

Watson, T. A., & Radwan, H. (2001). Comparison of three teaching methods for learning spinal manipulation skill: A pilot study. Journal of Manual & Manipulative Therapy, 9(1), 48-52.

Harvey, M. P., Wynd, S., Richardson, L., Dugas, C., & Descarreaux, M. (2011). Learning spinal manipulation: a comparison of two teaching models. Journal of Chiropractic Education, 25(2), 125-131.

Scaringe, J. G., Chen, D., & Ross, D. (2002). The effects of augmented sensory feedback precision on the acquisition and retention of a simulated chiropractic task. Journal of manipulative and physiological therapeutics, 25(1), 34-41.

Petty, N. J., Bach, T. M., & Cheek, L. (2001). Accuracy of feedback during training of passive accessory intervertebral movements. Journal of Manual & Manipulative Therapy, 9(2), 99-108.

Knobe, M., Holschen, M., Mooij, S. C., Sellei, R. M., Münker, R., Antony, P., ... & Pape, H. C. (2012). Knowledge transfer of spinal manipulation skills by student-teachers: a randomised controlled trial. European Spine Journal, 21(5), 992-998.

Sheaves, E. G., Snodgrass, S. J., & Rivett, D. A. (2012). Learning lumbar spine mobilization: the effects of frequency and self-control of feedback. journal of orthopaedic & sports physical therapy, 42(2), 114-124.

Lardon, A., Cheron, C., Pagé, I., Dugas, C., & Descarreaux, M. (2016). Systematic augmented feedback and dependency in spinal manipulation learning: a randomized comparative study. Journal of manipulative and physiological therapeutics, 39(3), 185-191.

Enebo, B., & Sherwood, D. (2005). Experience and practice organization in learning a simulated high-velocity low-amplitude task. Journal of manipulative and physiological therapeutics, 28(1), 33-43

O'Donnell, M., Smith, J. A., Abzug, A., & Kulig, K. (2016). How should we teach lumbar manipulation? A consensus study. Manual therapy, 25, 1-10.

Pasquier, M., Chéron, C., Barbier, G., Dugas, C., Lardon, A., & Descarreaux, M. (2020). Learning Spinal Manipulation: Objective and Subjective Assessment of Performance. Journal of Manipulative and Physiological Therapeutics, 43(3), 189-196.

Karas, S., Westerheide, A., & Daniel, L. (2016). A knowledge translation programme to increase the utilization of thoracic spine mobilization and manipulation for patients with neck pain. Musculoskeletal care, 14(2), 98-109.

Lardon, A., Pasquier, M., Audo, Y., Barbier-Cazorla, F., & Descarreaux, M. (2019). Effects of an 8-week physical exercise program on spinal manipulation biomechanical parameters in a group of 1st-year chiropractic students. Journal of Chiropractic Education, 33(2), 118-124.

Addition of Instrumented Tables and Manakins

Triano, J. J., Scaringe, J., Bougie, J., & Rogers, C. (2006). Effects of visual feedback on manipulation performance and patient ratings. Journal of manipulative and physiological therapeutics, 29(5), 378-385.

Descarreaux, M., Dugas, C., Lalanne, K., Vincelette, M., & Normand, M. C. (2006). Learning spinal manipulation: the importance of augmented feedback relating to various kinetic parameters. The Spine Journal, 6(2), 138-145.

Pasquier, M., Cheron, C., Dugas, C., Lardon, A., & Descarreaux, M. (2017). The effect of augmented feedback and expertise on spinal manipulation skills: an experimental study. Journal of Manipulative and Physiological Therapeutics, 40(6), 404-410.

Cuesta-Vargas, A. I., González-Sánchez, M., & Lenfant, Y. (2015). Inertial sensors as real-time feedback improve learning posterior-anterior thoracic manipulation: a randomized controlled trial. Journal of manipulative and physiological therapeutics, 38(6), 425-433.

González-Sánchez, M., Ruiz-Muñoz, M., Ávila-Bolívar, A. B., & Cuesta-Vargas, A. I. (2016). Kinematic real-time feedback is more effective than traditional teaching method in learning ankle joint mobilisation: a randomised controlled trial. BMC medical education, 16(1), 261.

Triano, J. J., Rogers, C. M., Combs, S., Potts, D., & Sorrels, K. (2002). Developing skilled performance of lumbar spine manipulation. Journal of manipulative and physiological therapeutics, 25(6), 353-361

Triano, J. J., Rogers, C. M., Combs, S., Potts, D., & Sorrels, K. (2003). Quantitative feedback versus standard training for cervical and thoracic manipulation. Journal of manipulative and physiological therapeutics, 26(3), 131-138.

Triano, J. J., McGregor, M., Dinulos, M., & Tran, S. (2014). Staging the use of teaching aids in the development of manipulation skill. Manual Therapy, 19(3), 184-189.

Lee, M., Moseley, A., & Refshauge, K. (1990). Effect of feedback on learning a vertebral joint mobilization skill. Physical therapy, 70(2), 97-102.

Shannon, Z. K., Vining, R. D., Gudavalli, M. R., & Boesch, R. J. (2019). High-velocity, low-amplitude spinal manipulation training of prescribed forces and thrust duration: A pilot study. Journal of Chiropractic Education.

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Joint Mobilizations and Manipulations: Evidenced-based Teaching and Learning

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