Alexander Gentile

PTH 661
Dr. Zipple
HVLA Techniques and Entry Level Programs
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For this literature review I chose to look into high velocity low amplitude (HVLA)

techniques in entry-level programs. The question I am trying to answer is whether or not HVLA
techniques should be included in entry-level physical therapy programs or should it be reserved
for post-professional development? The article I reviewed to answer this question is Thrust
Joint Manipulation Curricula in First-Professional Physical Therapy Education: 2012 Update.
After reading the article by Noteboom et al I believe that HVLA techniques should be included
in entry-level physical therapy programs.
Joint mobilization/manipulation techniques include HVLA therapeutic movements,
termed thrust joint manipulation (TJM). In the article by Noteboom et al cited several sources
that believed TJM should be included in entry-level physical therapy programs. This view point
was supported by their research as they found that most physical therapy programs in the US
have included TJM in their curricula.
Though this was not the case back in 2004 according to a survey that Noteboom et al
reviewed. This previous survey was performed to find out if TJM was being taught, what body
region techniques, the qualification of faculty teaching, resources utilized and how students were
being assessed. At the time this survey displayed a wide discrepancy of opinions on TJM
curricula and entry-level physical therapy programs. Though now it is assumed that most
programs include TJM in their curricula, there is no specific guidance on how students are

evaluated and how faculty should instruct students. This is what led Noteboom et al to
researching the current status of TJM in the curricula of entry-level physical therapy programs.
The purpose of their study was to survey physical therapist professional degree programs in the
US regarding the current status of TJM curricula.
Noteboom et al decide to create their own survey to send out to each entry-level physical
therapy program in the US. They sent invites out to program directors of each physical therapy
program with the request that the faculty member in charge of manual therapy instruction
complete the survey. Of the 205 programs only 72% (147) responded to the survey which placed
the results into the excellent category for survey research (60-80% response rate). Out of this
72%, 99% stated that TJM was included in their curricula. Of these 147 programs 97% of them
believe that TJM is an entry-level skill where as in the survey from 2004 where only 47%
believed this. Noteboom et al does not specifically identify how or why this change occurred but
states it could be the result of programs switching to DPT programs, the distribution of the
Manipulation Education Manual, or the increase in peer-reviewed journals with positive TJM
outcomes.
As it stands today there has been a heavy increases in the acceptance of TJM into entrylevel curricula. The number of programs today that have integrated TJM into clinical science
courses is 94%, where as it was only 64% in 2004. While most programs are in agreement that
TJM should be included in entry-level curricula, the amount of time and body regions taught
varies a great deal. The average time programs have devoted to teaching TJM is 50 hours.
Though there is great variability here as 24 of the 147 programs teach less than or equal to 10
hours. Then there are 17 programs that teach over 100 hours of TJM techniques. Noteboom et
al stated that this discrepancy could be related to confusion between TJM techniques and the

broader mobilization/manipulation techniques. The body regions being taught also varied across
the board with different programs focusing on different regions of the body. Though the number
of programs teaching multiple regions of the body has increased since the 2004 survey. With a
majority of body regions being left out of the curriculum decreasing except for the cervical spine.
Noteboom et al believe that the low rate of TJM cervical spine techniques being taught is related
to an increased risk of injury for this region of the body.
Noteboom et al notes that a reason for these TJM increases in the curricula could be
related to an increase in faculty that have experience with TJM techniques. From their survey
they found that core faculty teaching TJM curricula is up to 97%. Having core faculty teaching
these classes allows the courses to be designed around graduation competencies. Also core
faculty in charge of these courses have some sort of actual training with TJM techniques.
Whether they are board certified in manual therapy or have taken some post graduate classes in
manual therapy. The faculty in charge of the TJM curricula also value assessing competency
more than they did in 2004. In 2004 only 34% of faculty valued skill check assessments and 4%
reported that they did not assess the students. Whereas now faculty are valuing written
assessments and psychomotor skill assessments at more than 80% favorability.
After all of data from the survey was collected and analyzed Noteboom et al they found
that nearly all entry-level physical therapy programs have integrated TJM courses into their
curricula. With that said the answer to the question of whether TJM/HVLA techniques should be
incorporated into the standardized curriculum is a resounding yes. Though the article does not
really touch on why these TJM techniques should be integrated into the curriculum. They hint at
possibilities of why there has been such an increase such as all programs switching to doctorate
degrees, an abundance of peer review articles and the previous distribution of the Manipulation

Education Manual but no definite correlations are found. The quality of this data is sound in
that you get to see on a grand scale just how important every program views TJM/HVLA
techniques for the entry-level physical therapist.
This article is very interesting because of the scope of Noteboom et als data gathering. A
resounding 72% compliance in the survey made this study a great success. It is also fascinating
to know that the majority of other programs besides CMU are also getting the same type of
TJM/HVLA techniques. Though not knowing what specifically other programs focus on in
terms of body regions is a bit disappointing. The next step for TJM/HVLA curricula would have
to be standardization so that all programs are learning the same techniques. This would allow for
greater consistency and efficiency of patient care across the board for future generations.

References

1. Noteboom J, Little C, Boissonnault W. Thrust Joint Manipulation Curricula in First-

Professional Physical Therapy Education: 2012 Update. J Orthop Sports Phys Ther.
2015;45(6):471-476. doi:10.2519/jospt.2015.5273.