Comparison of Student Manipulation Performance Following Simulation and
Standard Training
Alyssa Diaz SPT, Luciana Hud SPT, Jenny Mathew SPT, Andrea Allsop SPT, John Millison
SPT, Garrett Rumsby SPT, Eric Folkins DPT, Michael Knapp DPT, Jeffrey Rogers DPT
Background
A high velocity low amplitude (HVLA) thrust manipulation is the application of a
physical force performed over a brief period of time. The successful performance of a
HVLA manipulation must include appropriate peak force, pre-load force, and rate of force.
HVLA manipulations are a skill utilized in physical therapy (PT), and are a required
component of the doctoral of PT curriculum. HVLA manipulations are primarily taught to
PT students through standard lab training. Although they are taught in the classroom
students are not always confident in their ability to perform them in the clinic. Research
with chiropractic students demonstrated that simulated training and motor learning
Figure 1. Atlanto-occipital manipulation
principles improved spinal joint manipulation performance and confidence. Simulated
manipulation training has not been researched with physical therapy students or for
extremity and spinal distraction HVLA manipulations.
Purpose
Compare performance of atlanto-occipital (AO), coxofemoral (CF), and talocrural (TC)
joint manipulation in doctoral physical therapy students who receive simulation training
with biofeedback and motor learning principles to students who receive standard lab
training.
Methods
Subjects
▪ Twenty-eight 2nd year PT students were randomly selected to standard training (13, 8
female) or simulated training (15, 9 female).
▪ Inclusion criteria:No previous manipulation education or clinical experience.
▪ Exclusion criteria: No injuries that would limit their ability to perform manipulation within
the past two weeks and refusal to have three manipulations performed on them.
Intervention
▪ All participants received 4-hours of didactic education on indications, contraindications
and technique of AO, CF and TC (Figure 1-3) manipulations.
▪ Standard training: Subjects practiced the three manipulation on other subjects and
received feedback from qualified instructors as is customary in PT education.
▪ Simulation training: Subjects practiced three manipulations (figure 4) on Baltimore
Therapeutic EquipmentTM Primus (BTE) with six trials at 100%, 75%, and 50% auditory
and visual feedback on pre-load, peak and rate of force for a total of 18 trials for each
manipulation.
Testing
▪ Subjects returned 2-14 days following training.
▪ The average of 5 trials on the BTE for pre-load, peak and rate of force was recorded for
the three manipulations.
▪ Independent t-tests conducted to compare groups using SPSS 24 for Windows.
Results
● AO pre-load was significantly more (t(19)) = -3.67, p < 0.01) for simulation group
(M=126.98, SD=30.20) than standard group (M=69.35, SD=49.18) (Figure 5.
● TC pre-load was significantly more (t(26) = -3.78, p < 0.01) for simulation group
(M=188.46, SD=46.82) than standard group (M=112.98, SD=58.89) (Figure 5).
● CF pre-load was significantly more (t(26)) = -2.21, p = 0.036) for simulation group
(M=217.28, SD=57.99) than standard group (M=161.68, SD=74.78) (Figure 5).
● AO peak force was significantly more (t(26)) = -2.60, p = 0.015) for simulation group
(M=329.57, SD=71.02) than standard (M=244.87, SD=100.68) (Figure 6).
● TC peak force was significantly more (t(26)) = -3.49, p < 0.01) for simulation group
(M=446.22, SD=68.2) than standard group (M=340.86, SD=91.42) (Figure 6).
▪ Rate of force parameters and CF peak forces were non-significant (p>0.05) between groups
Figure 2. Talocrural manipulation
Figure 4. Talocrural manipulation on BTETM
*
* *
*
Figure 5. Box plots for pre-load force comparison between
standard and simulated training for AO, CF and TC Manipulations
*Statistically (p<.05) greater force than standard group
Discussion
▪ Extremity and spinal distraction manipulation training using simulation for PT students is
in agreement with simulation training for chiropractic students for improved spinal
manipulation performance.
▪ The simulation group’s manipulation pre-load and peak forces for the AO, CF and TC are
similar to forces produced by Fellows of the American Academy of Orthopedic Manual
Physical Therapy with years of experience and specialized training. 1 Whereas the
standard group only demonstrated similarity during CF peak force and produced
Figure 3. Coxofemoral manipulation
significantly less force than the simulation group in all but the CF HVLA manipulation.
▪ The simulation group’s spinal and extremity joint force parameters of pre-load and peak
force are similar to previously reported chiropractic spinal force parameters. 2
▪ The use of simulation training and motor learning principles leads to improved
performance of HVLA manipulations which has been shown to improve student
self-efficacy and increase utilization of manipulation in the clinic. 2,3
Limitations
▪ The lack of differences in rate of force may be due to the BTE TM measurement not being
sensitive enough to measure to 1000th of a second.
▪ A device that is sensitive to measure the rate of spinal manipulation forces is indicated
to improve this aspect of the technique.
▪ Our study is only representative of one Physical Therapy Program.
*
Clinical Relevance
▪ Students can use the BTETM for visual and verbal feedback to practice manipulations in
order to see how much force they are exerting.
▪ Utilizing the BTETM when training students in performing manipulations provides them with
greater and more accurate feedback, allowing them to make necessary adjustments to
improve their technique.
▪ Utilizing the BTETM instead of other students when performing manipulations may
improve safety.
▪ BTETM can be used to test and practice long axis distraction manipulations.
▪ This study opens the door for more research regarding forces used for long axis
distraction manipulations and effectiveness.
▪ Simulation training utilizing motor learning principles training produces more pre and peak
forces and more closely resembles manipulation forces of Fellows of the American
Academy of Orthopedic Manual Physical Therapy
Conclusion
To our knowledge, this was the first study to compare simulation training vs. standard
training for long axis distraction manipulations in physical therapy students. The
simulation group demonstrated force parameters similar to clinicians with advanced
training and years of experience. Physical therapy graduates that are more proficient in
manipulations may utilize manipulations at a higher rate according to evidence based
practice. Simulation training should be utilized in physical therapy education to optimize
student performance of HVLA thrust manipulations.
Figure 6. Box plots for peak force comparison between standard
and simulated training for AO, CF and TC Manipulations
*Statistically (p<.05) greater force than standard group