John Triano, DC, PhD, a clinician and researcher at TBI, will play an integral part in analyzing data gleaned from the study. Other investigators on the project include Drs. Jacqueline Bougie, John Scaringe and Susan Holm from SCUHS, and Carolyn Rogers, a biomedical engineer from a medical technology provider in Plano, Texas.
"This project was the result of a collaboration between Dr. Bougie and myself in pursuing our mutual interests to understand the role of skill in spinal manipulation and its relation to outcome," Dr. Triano said. "Work in the early 1990s in my lab at National College began to quantitatively study skilled performance. I continued that thread with two studies reported in collaboration with the Texas College of Chiropractic, where I am an adjunct professor. Dr. Bougie approached me with some ideas, and we decided to pool our efforts to learn more."1
"There are a number of pieces of information that we have learned already and have presented at various meetings and in publication," Dr. Triano continued. "We know, for example, that primary care doctors attempting to learn manipulation skills in weekend warrior courses2 do not get improved outcomes when the treat back pain over just the use of medication. At the same time, we know3 that trained and practiced chiropractors are significantly different in their performance of procedures than are trained but unpracticed novice DCs. ... So, a number of questions arise. What is a skillful manipulation, and what does it look like? Are there different strategies to achieve skill? Does one approach over another make a difference? Finally, the coup-de-grace: Does it make a difference in patient outcomes?"
"... Some other things that we have learned and are currently preparing for the final report include: 1) the relationship between biomechanical quantitative performance, instructor ratings and grades; 2) the effect of visual feedback on rapid-change and short-change retention of improved performance; and 3) a consensus on the qualities of skilled performance as a definition."
Study Parameters
The current study will attempt to determine which factors are the most important in acquiring expertise in spinal manipulative therapy. To answer this question, the researchers will examine the impact of feedback on students learning lumbar-pelvic manipulation. Feedback will be assessed at four times: the beginning of the fourth trimester of study; the end of the fourth trimester; the seventh trimester; and nine months later (after completing two trimesters of clinical internship and near graduation). The effects of manipulation will be measured using a Leander 900-Z series manipulation table modified with a force plate to evaluate the biomechanical characteristics of loads through a patient's body.
While performing the manipulations, an unspecified number of subjects will be assigned randomly to separate groups providing feedback (or no feedback). Both verbal and tactile cues will be included as part of the feedback process. The researchers will monitor changes in four parameters (preload, load rise time, peak load and load duration). These outcomes will be compared at pretraining, baseline posttraining, and one- and two-year intervals.
Differences will be evaluated via repeated measures of analysis of variance (AoV). In addition, with regard to two types of maneuvers (mammilary push at L4 and spinous push at L2), visual cues will be evaluated using a computer graphic representation of the student's performance.
"The remaining work of the present continuation grant from FCER will allow us to follow a single class in its skill development from conception of training to completion and graduation," Dr. Triano said. "Of specific interest to us is to look at the relationship of when learning occurs, does quantitative feedback help and how much, the relative improvement from course work versus student clinic versus outpatient clinic, and the relationship of overall learning to grades."
The final data collection phase of the study will take place this June. In addition to the research on feedback and manipulative skills, the investigators are working in conjunction with Dr. Niels Nilsson at the University of Denmark to examine the stability of performance of a practitioner who treats the same patient for the same condition on different dates, and the way practitioners moderate their techniques according to patient need.
The total budget for the study, including salaries and equipment, is more than $144,000. In addition to the FCER, Spinal Health Group, PLLC; Leader International Corporation; Innovative Spinal Technologies; and SCUHS have provided funding for the project.
References
- E-mail from Dr. Triano to Dynamic Chiropractic, March 31, 2004.
- Curtis P, Carey T, Evans P, Rowane MP, Garrett JM, Jackman A. Training primary care physicians to give limited manual therapy for low back pain: patient outcomes. Spine 2000;22:2954-9.
- Cohen E, Triano JJ, McGregor M, Papakyriakou M. Biomechanical performance of spinal manipulation therapy by newly trained vs. practicing providers: Does experience transfer to unfamiliar procedures? JMPT 1995;18(6):347-52.
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