Joint Mobilizations and Manipulations: Evidenced-based Teaching and Learning

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.

Pre-approved credits for:

• Integrated Manual Therapist (IMT) Certification

Pre-approved for Continuing Education Credits for:

• Athletic Trainers
• Chiropractors
• Group Exercise Instructors
• Massage Therapists
• Occupational Therapists - Advanced
• Personal Trainers
• Physical Therapists
• Physical Therapy Assistants

This Course Includes:

• AI Tutor
• Study Guide
• Text and Illustrations
• Audio Voice-over
• Research Review
• Practice Exam
• Pre-approved Final Exam

Brookbush Institute Position Statement:

• 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.

Research Summary:

• More Lab: Studies suggest that students are generally dissatisfied with the proportion of lecture time dedicated to lab and practicing techniques.
• Lesson Plan Construction: 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.
• Types of Feedback: Staff instructors are most beneficial during lab instruction and should provide both qualitative and quantitative feedback.
• Feedback Timing: 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.
• Validity of Feedback: 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.
• Additional Findings: 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.

More Lab

1. 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.
2. 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.
   • Lesson Plan Construction
3. 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.
4. 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.
5. 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.
   • Integrating Didactic and Lab Instruction:
6. 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.
7. 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.
8. 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.
   • Types of Feedback
9. 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.
10. 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.
11. 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.
    • Feedback Timing
12. 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.
13. 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.
14. 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
    • Validity of Feedback
15. 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.
16. 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.
    • Additional Studies
17. 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.
18. 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
19. 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.
20. 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.
21. 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.
    • Inertial Sensors
22. 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.
23. 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.
    • Dynajust
24. 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
25. 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.
26. 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.
    • Effect on Variability and Accuracy
27. Lee, M., Moseley, A., & Refshauge, K. (1990). Effect of feedback on learning a vertebral joint mobilization skill. Physical therapy, 70(2), 97-102.
28. 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.
    • Effects on Reliability
29. Petersen, E. J., Thurmond, S. M., Buchanan, S. I., Chun, D. H., Richey, A. M., & Nealon, L. P. (2019). The effect of real-time feedback on learning lumbar spine joint mobilization by entry-level doctor of physical therapy students: a randomized, controlled, crossover trial. Journal of Manual & Manipulative Therapy, 1-11.
30. Gautam, N., & Sharma, S. (2011). Effect of concurrent quantitative feedback training on intra-rater and inter-rater reliability of grade III mobilization over fourth lumbar spinous process. Physiotherapy and Occupational Therapy, 5(1).
    • Retention
31. Chang, J. Y., Chang, G. L., Chien, C. J. C., Chung, K. C., & Hsu, A. T. (2007). Effectiveness of two forms of feedback on training of a joint mobilization skill by using a joint translation simulator. Physical therapy, 87(4), 418-430.
32. Marchand, A. A., Mendoza, L., Dugas, C., Descarreaux, M., & Pagé, I. (2017). Effects of practice variability on spinal manipulation learning. Journal of Chiropractic Education, 31(2), 90-95.
33. Snodgrass, S. J., Rivett, D. A., Robertson, V. J., & Stojanovski, E. (2010). Real-time feedback improves accuracy of manually applied forces during cervical spine mobilisation. Manual therapy, 15(1), 19-25.
34. Snodgrass, S. J., & Odelli, R. A. (2012). Objective concurrent feedback on force parameters improves performance of lumbar mobilisation, but skill retention declines rapidly. Physiotherapy, 98(1), 47-56.
    • Additional Limitations
35. Latimer, J., Lee, M., & Adams, R. (1996). The effect of training with feedback on physiotherapy students' ability to judge lumbar stiffness. Manual Therapy, 1(5), 266-270.
36. Cuesta-Vargas, A. I., & Williams, J. (2014). Inertial sensor real-time feedback enhances the learning of cervical spine manipulation: a prospective study. BMC Medical Education, 14(1), 1-5.
37. Young, T. J., Hayek, R., & Philipson, S. A. (1998). A cervical manikin procedure for chiropractic skills development. Journal of manipulative and physiological therapeutics, 21(4), 241-245.
    • Ultrasound
38. Markowski, A., Watkins, M. K., Burnett, T., Ho, M., & Ling, M. (2018). Using real-time ultrasound imaging as adjunct teaching tools to enhance physical therapist students' ability and confidence to perform traction of the knee joint. Musculoskeletal Science and Practice, 34, 83-88.