Spinal Evaluation Techniques

A Survey Of Entry-Level Physical Therapy

Curricula In The United States, Canada, Australia,

New Zealand, And The United Kingdom

Allan Besselink, P.T., Dip.MDT

Austin, TX

Jeffrey Witten, MSPTSan Antonio, TX

Educational Process

• Curriculum content (what)

– validity

– reliability

– relevance

• Perception of importance of content (why)

• Clinical reasoning (how)

Purpose

• Establish current trends in spinal evaluation

curriculum content in entry-level physical

therapy educational programs

• Provide a foundation for further comparison

with the literature on reliability and validity

of spinal evaluation techniques

Methods And Research Design

• Survey consisting of questions regarding -

– 1. Authors or references cited in the

development of the curriculum content

– 2. Evaluation techniques taught in the

curriculum

– 3. Relative importance of each technique to the

overall scope of the spinal evaluation

curriculum

Survey Results

• Survey sent to 195 entry-level physical

therapy educational programs

– 148 United States, 47 International

• Return rate of 62.6 % (n = 122)

– 93 United States, 29 International

– 53 Bachelors (43.4 %) - 28 International

– 69 Masters (56.6 %) - 68 United States

Curriculum - Content

• Maitland

• Butler

• Kaltenborn

• Saunders

• Janda

• Grieve

• Waddell

• Kendall

• Travell

• Paris

• Evjenth

• McKenzie

• Cyriax

• Stoddard

• Mulligan

• Greenman

Curriculum - Content

• “The Big 2”

– McKenzie 95.1%

– Maitland 93.4%

• United States

– The Big 2, Cyriax, Kaltenborn, Paris, Kendall

• International

– The Big 2, Butler, Grieve, Cyriax, Janda

Curriculum - Content

• References that critically examine the

current status of spinal evaluation and

treatment:

– Spitzer et al 1987 (QTF) 5.7 %

• United States 1.1%

• International 20.7%

Curriculum - Techniques

• Palpation

• Postural Asymmetry

• ROM/Mobility

• Flexibility

• Manual Muscle Tests

• Isokinetic Testing

• Repeated Movement

• Provocative Testing

Sacroiliac Joint/Spine

• Passive Intervertebral

Joint Motion

• Non-Organic Tests

• Neurological Testing

• Neural Tension

• Pain Patterns/Behavior

Curriculum - Techniques

>95% of programs Total US INT

Asymmetry 1 1 1

Neurological 1 1 1

Neural Tension 3 6 1

Flexibility 4 4 8--

PIVM 4 8- 1

Palpation 6 8- 5

ROM/Mobility 6 7 6-

Curriculum - Techniques

>90% of programs Total US INT

Rep. Movement 8 8 6

Prov. Sacroiliac 9 3+ 11-

Prov. Spine 9 4+ 10-

Pain Patterns 11 12 8-

Curriculum - Techniques

Other Total US INT

MMT 12 11+ 11

Non-Organic 13 13 13

Isokinetic 14 14 14

Relative Importance

• What is the relative importance of each

technique to the overall scope of the spinal

evaluation curriculum?

• Prioritized ranking of 0 - 10

– 0 = “no priority/not taught”

– 10 = “high priority/great deal of time spent on

that particular technique”

Relative Importance by Rank

• International

– Neurological

– ROM/Mobility

– Palpation

– PIVM

• United States

– Asymmetry

– Neurological

– Palpation

– Flexibility

– ROM/Mobility

Relative Importance by Mode

• International

– Palpation

– ROM/Mobility

– Provocative Spine

– PIVM

– Neurological

– Neural Tension

– Pain Patterns

• United States

– Palpation

– Asymmetry

– Repeated

Movements

– PIVM

– Neurological

Faculty Profile

International United States

Gender M/F 20.7/55.2 57.0/38.7

Certification 38.0 38.6

Active 79.3 79.6

Hours 0-25 (3) 0-35 (10)

Years 0-35 (10) 0-25 (10)

Spinal Evaluation Curriculum

• Degree Program

• Content

• Techniques

– “eclectic teaching” approach

• Relative Importance

– faculty certification

Treatment Preferences

• Battie et al - Physical Therapy 1994

– 48% rated the McKenzie method as the “most

useful” approach

– 56.4% “poorly prepared at entry” to clinical

practice

Treatment Preferences

• Foster et al - Spine 1999

– treatment preferences in Britain and Ireland

– “The Big 2”

• 58.9% utilize Maitland

• 46.6% utilize McKenzie

Conclusions

• Current trends in entry-level physical

therapy spinal evaluation curriculum

• Consensus-based versus Evidence-based

curricula

• Are we preparing physical therapists for

entry-level practice?

Acknowledgements

• Iain Muir (Canada)

• Richard Dale (Canada)

• Harry Papagoras (Australia)

• Mark Laslett (New Zealand)

• Malcolm Robinson (United Kingdom)

Implications To MII

• McKenzie is referenced but repeated

movements are not perceived as important

by instructors

• McKenzie method is becoming well-

supported as an assessment technique

• Clinicians are poorly prepared at entry level

• Clinicians eventually rate it as effective