Spinal Evaluation Techniques In Entry-Level Physical Therapy Curricula: Learning From The Past

I will be the first to admit that this research isn’t new; as a matter of fact, it has been 14 years since I initially presented the results at the 1997 McKenzie Institute International Conference in Philadelphia. This was followed-up in 1998 with a presentation at the APTA National Conference, and again at the 2000 McKenzie Institute North American Conference.

The presentations examined the entry-level curricula for spinal evaluation techniques in five countries: United States, Canada, Australia, New Zealand, and the United Kingdom. The goal of the surveys was to establish what was currently being being taught at the entry level, and what the faculty perceptions were with regards to the relative importance of the content.

The question you may be asking right now is “what makes these presentations relevant now?”. Perhaps a more important question would be “has anything changed since that time?”

At the time, the most interesting aspect of the research was the predominance of spinal evaluation techniques that are palpation-based. This would include passive intervertebral joint motion testing. These were given high priority in the vast majority of most educational programs in the United States and in other countries. I have included the 1997 and 2000 presentations for review.

Sadly, palpation-based techniques have been shown repeatedly to have poor inter-rater reliability. What that means is that two examiners generally won’t agree on what they feel. This certainly limits the validity of the testing procedure, and subsequently the clinical benefit to the patient in making a relevant, appropriate, and consistent diagnosis.

This is not exclusive to the physical therapy profession. Many (if not all) of the same spinal evaluation techniques are used by chiropractors, physicians, orthopedists, and massage therapists. In fact, most health care providers use some subset of these assessment techniques.

Another important focal point is that clinical guidelines that would effectively guide the assessment and treatment of spinal pain – studies such as the groundbreaking Quebec Task Force study of 1987 – were essentially non-existent in the curricula in the United States. Only 1.1% of US programs were using it, and 20.7% of international programs. The Quebec Task Force study had been around for a decade and had yet to really make its way into educational curricula.

With that said, the “state of the union” in 1997 was simple: a high priority was given in entry-level education to spinal evaluation techniques that have poor reliability and validity.

Fast forward to 2011 and examine the curricula in physical therapy programs today. Only a cursory review of current curricula is necessary. Go ahead and check chiropractic or physician curricula as well. Although we have 14 years of further research to confirm what we knew then regarding spinal evaluation techniques and the clinical guidelines that promote evidence-based practice, educational programs continue to focus on the same old content from 1997 and before. Not much has changed in terms of the relative importance placed on spinal evaluation techniques that have poor reliability and validity.

Of course, we could choose to learn from this experience, or we can simply continue to do what we have done. The latter is the path of least academic and professional resistance. The former would require changing our perceptions regarding what we teach, what we utilize clinically, and what we believe our role to be with patients. That will require a vigilant effort from educators, professionals, and professional associations like the APTA.

Based on the trends of the last 14 years, it is an effort that I truly don’t envision being a part of our health care reality. The worst part is that the loser in all of this is, once again, the patient.

Photo credits: angelocesare