 Procedural skills in spinal manipulation: do prerequisites
matter?
Spinal manipulation is frequently considered as a
treatment for back pain. However, there are many different
training methods for those pursuing spinal manipulation
as part of their healthcare practice. It is
of course assumed that the more in-depth training an
individual receives, the better he or she will be at
performing the spinal manipulation procedures. This
article discusses a study that looked into the validity
of that assumption, and assessed the best approach
in the early stages of preparation for performing spinal
manipulation procedures.
Training for performing spinal manipulation ranges
from full professional degree programs to weekend seminars.
As a result, health professionals can end up with widely
varying levels of skill, ranging from incompetent,
to
safe, to masterful. This study was undertaken to try
to determine what kind of training best prepares someone
to perform spinal manipulation. Once this information
is known, patients will be able to ask potential care-providers
about what type of education they received and decide
if they want to be treated by that individual.
The authors of the study chose a certain high velocity,
low-amplitude (HVLA) spinal manipulation procedure,
the L4 mamillary push, to use as the basis
of their comparison. This form of spinal manipulation
is one of the most widely used methods of treatment
for the lower back pain and lumbar spine problems.
Three groups of people were studied. One was
a group of eight internationally known experts chosen
for their reputation, with a range of 8 to 30 years
of clinical experience. All of the experts use
the procedure in question, and are very familiar with
it. The other two groups were college students,
at two different colleges, who were completing prerequisite
courses that were required prior to beginning
their specific training for HVLA spinal manipulation
procedures.
The prerequisite requirements at the two colleges
were different: one college focused on hands-on practice
more than laboratory study, and the other college reversed
that, focusing more on the preparatory lab courses
than the hands-on, clinical application. All of the
students had completed pre-med and were enrolled in
2nd year professional training.
Several parameters were chosen for comparison of the
groups, and each person was then observed performing
the procedure from initial positioning of the patient
through completion of the spinal manipulation procedure. The
group of experts was used to set the standards of how
this type of spinal manipulation should be done, and
the performance of each student was compared to those
standards.
The results of the study were very clear. Students
who were given a great deal of informative instruction
in the laboratory setting, before actually performing
any hands-on training, were much better prepared to
complete this HVLA spinal manipulation procedure. Every
comparison parameter was shown to favor the students
who had the more extensive laboratory preparation.
The authors observed that the most distinct difference
in the groups was in the pre-positioning of the patients.
The results suggest that extensive training before
ever performing a first spinal manipulation procedure
is an important component in the teaching and learning
of this type of skill. Additionally, it appears that
condensed learning sessions, without adequate preparatory
training, are inappropriate and could be dangerous
to patients.
From this study, the authors concluded that prerequisite
courses for spinal manipulation should emphasize laboratory
training, and then build slowly into rehearsal experience,
including prepositioning of the patient. Spinal manipulation
procedures performed by healthcare professionals with
this type of early training are likely to be safest
and most effective.
By: John J. Triano, DC, PhD, FCCS (C)
March 4, 2004
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