A model for teaching and assessing competence in

High Velocity Low Amplitude Thrust Techniques

by Keri Wells D.O.

Grad. Cert. Ed. (University Teaching and Learning)

Lecturer in: Osteopathic Diagnosis, HVLA Thrust Techniques

and Osteopathic Clinical Sciences

Any clinical skill that involves the manipulation of the bony protector of the spinal cord is not a skill to be applied without the operator’s full understanding of biomechanics and the anatomical structures involved.

It is the responsibility of educators to develop a teaching and assessment program that aspires to the highest possible standards. ‘Superficial learning’ is not an acceptable practice in this most important discipline.

Teaching and examining the clinical skill, the HVLA thrust can be an exhaustive task. It is the responsibility of instructors to provide a structured framework for the student to work within. Students want and need to be taught how to apply HVLA techniques safely and successfully. They want and need to know what to do to improve their skills.

The structured framework offered in this paper is one that provides clear instructions for students on what they need to learn, and includes information about how they will be examined.

Lecture presentation

Experts are not always the best teachers of complex manual skills.

Dreyfus & Dreyfus (1986) describe experts as those who have incorporated each of the factors (steps) of the skill into their performance to the extent that they can no longer identify the factors or the steps (de Tornyay & Thompson 1987) (1)

I have been witness to many lectures where experienced practitioners demonstrate techniques. The questions that immediately follow the demonstration include: What did you do? How did you do that? Having performed the technique hundreds of times, very often the practitioner is at a loss to explain the sequence of events, the steps that occurred.

Whilst such an incidence demonstrates expertise it is of absolutely no value to the novice if he/she cannot be taught how to do the same. The novice practitioner wants to know how they can do the technique, how they can become an expert.

Educators of any clinical skill will be aware that in order to develop skills of this nature students require many different abilities. Before preparing lectures and practical sessions to teach such skills, lectures must ask themselves: How can I be sure the students are taking notice of all the key pieces of information? How can I be sure the students are safe while they practice these skills?

It is most important to be consistent when presenting techniques so that students develop their understanding of how each criteria, as described, is important to the success of the technique overall.

With regard to the last criteria Explanation of technique, the ability to explain how each technique works is fundamental to developing understanding. An explanation of how each techniques works, should be included in every demonstration.

Irrespective of which techniques are taught, all of them can be subdivided into the following criteria. For example: A Supine Thoracic HVLA Technique.

Supine Thoracic HVLA

Right facet closed (‘closed’ in the saggital plane)

Lesion	T4/5 extended rotated and sidebent right, ERS right. The inferior facet on the right side of T4 has moved inferiorly, posteriorly and medially relative to the inferior left facet on T4 and the superior right facet on T5.
Restriction	T4/5 Flexion, rotation and sidebending left.
Patient position	Supine, arms crossed, hands clasping shoulders. Right hand on left shoulder i.e. thoracic spine sidebent left.
Operator position	At the side of the table, in this case the right. Level with patient’s waist. Operator’s left foot forward, right foot back, easy stance, knees slightly bent.
Contacts	Place the knuckles and thenar eminence of your right hand on the Transverse process of T5. The spinous process (SP) lay in your palm. Operator’s abdomen presses against pillow at patient’s elbows. Support the patient’s head with left forearm, left hand on posterior and lateral aspect of the patient’s left shoulder.
Lock up description	Using patient’s upper torso as a long lever. Sidebend and rotate left, then flex the patient down to *address the restriction barrier in the T4/5 joint.* Make sure you are localized by getting patient to push the elbows up into you, while you palpate the localized forces with your right hand. (Rotation can be introduced by moving the patient’s elbows to the left of the midline). *Take the weight of the patient on your back foot as you lift/roll them. Your right hand acts as a fulcrum*
Thrust	Ask patient to breathe in and out. At the end of exhalation deliver a quick short sharp thrust in a posterior superior direction, at approximately 45 degrees i.e. into flexion, sidebending and rotating left. *Retest.*
Explanation of technique	By sidebending and rotating left, then flexing the patient and adding a superior and posterior directed thrust, the thrust will open the relatively closed facet on the right of the T4/5 joint. The right inferior facet on T4 will move superior, anteriorly and laterally, relative to the left inferior facet on T4, and the superior facet of T5 on the right.

Bibliography

Greenman PE. 1989, Principles of Manual Medicine, Baltimore, Williams and Wilkins.

Kimberley PE. 1980, Principles of Manipulative Treatment and Illustrative Procedures for Specific Joint Mobilization,

Third Edition, Department of Osteopathic Theory and Methods, Kirksville College of Osteopathic Medicine, Missouri.

Waltons W.J., 1972, Textbook of Osteopathic Diagnosis and Technique Procedures, Colorado Springs, American Academy of Osteopathy.

Examining Competence in HVLA Technique Skills

When setting either a practical or written exam to assess students’ competence, the instructor must ask him/herself the following questions: What is the best method of examining these students? What competencies are being tested by this method of assessment? Is it better to use a combination of examination methods?

I suggest the use of practical and written examinations and have successfully employed these methods of examination to assess the student’s understanding and competence of HVLA thrust techniques over a number of years. In my opinion, the ability of the student to pass both methods of assessment demonstrates that ‘deep learning’ has taken place.

Examination methods:

Written Examination

Assessment of the student’s ability to write techniques (refer to written paper Questions 1,2 and 3) and;
The assessment of the student’s ability to analyze, interpret and understand the written account of HVLA thrust techniques (refer to written paper Question 4).

Practical Examination

The assessment of the student’s ability to successfully perform HVLA techniques on a variety of patients.

Practical assessment also includes the assessment of the student’s ability to verbally describe his or her own ‘visual image’ of the HVLA technique. To paint with words a ‘clear picture’ of what is happening to a given joint. This skill is tested by the verbal explanations required in the practical examination and in Question 3 in the written paper.

How to prepare for written examinations

Establish the total marks allocated and the duration of the written exam. Then decide in advance the mark that will be allocated to each question. It is a good idea and it expedites marking if you have a model answer prepared.

Questions for a written paper may include:

Describe the lock up procedures used in N,SLt,RRt, and FRS Rt lumbar roll techniques. Explain the reasons why the lock up procedure is different in these two techniques.

Describe the direction of thrust used in N,SLt,RRt, and FRS Rt lumbar roll techniques. Explain the reasons why the direction of thrust is different in these two techniques.

These questions examine the student’s ability to differentiate between two different techniques. The questions assess the students understanding of the rationale behind the positioning of the patient and the direction of the thrust.

3. Describe the movement that occurs to the inferior facets (left and right) of L3 and the superior facets (left and right) of L4 during the HVLA thrust to correct the lesion: L3/4 Neutral, sidebending right and rotating left, N,SRt,RLt.

This question examines how well the students understand their anatomy and biomechanics. It helps the instructor to know whether the student is developing the three dimensional visual image that experienced practitioners have in their ‘minds eye’ during any manipulation.

Write a technique ‘incorrectly’ and then ask the students to correct it.

This method of written assessment examines the student’s ability to interpret the written form of any technique. To successfully correct the incorrect technique the student must first know and understand the ‘correct’ technique and how and why all of the individual criteria are important to the technique overall.

The student is asked to correct the incorrect technique in the spaces provided.

The correct answers are in Italics.

Supine Thoracic HVLA

Right facet closed (‘closed’ in the saggital plane)

Lesion	T4/5 extended rotated and sidebent right, ERS right. The inferior facet on the right side of T4 has moved inferiorly, posteriorly and medially relative to the inferior left facet on T4 and the superior right facet on T5.
Restriction	T4/5 Extension, rotation and sidebending left. Flexion
Patient position	Supine, arms crossed, hands clasping shoulders. Left hand on right shoulder i.e. thoracic spine sidebent left.
Operator position	At the side of the table, in this case the right. Level with patient’s waist. Operator’s right foot forward, right foot back, easy stance, knees slightly bent. Right hand on left shoulder Operator’s left foot forward
Contacts	Place the knuckles and thenar eminence of your right hand on the Transverse process of T6. The spinous process (SP) lay in your palm. Operator’s abdomen presses against pillow at patient’s elbows. Support the patient’s head with left forearm, left hand on posterior and lateral aspect of the patient’s left shoulder. T5
Lock up description	Using patient’s upper torso as a long lever. Sidebend and rotate right, then flex the patient down to *address the restriction barrier in the T4/5 joint.* Make sure you are localized by getting patient to push the elbows up into you, while you palpate the localized forces with your right hand. (Rotation can be introduced by moving the patient’s elbows to the left of the midline). *Take the weight of the patient on your back foot as you lift/roll them. Your right hand acts as a fulcrum* Sidebend and rotate left.
Thrust	Ask patient to breathe in and out. At the end of exhalation deliver a quick short sharp thrust in a posterior direction, at approximately 45 degrees i.e. into flexion, sidebending and rotating left. *Retest.* Posterior and superior direction.
Explanation of technique	By sidebending and rotating left, then flexing the patient and adding a superior and posterior directed thrust, the thrust will open the relatively closed facet on the right of the T4/5 joint. The right inferior facet on T4 will move inferiorly, posteriorly and medially, relative to the left inferior facet on T4, and the superior facet of T5 on the right. T4 inferior right facet will move superiorly, anteriorly and laterally.

Your patient has two lesions (a) L4/5 is ERS left and (b) L1/2 is FRS right.

a) What findings would indicate to you that a HVLA technique was an appropriate technique to correct such lesions?

b) What findings would indicate to you that a HVLA technique was an inappropriate technique to correct such lesions?

c) Write out in full the corrective techniques to correct both of these dysfunctions.

Explain the reasons why the direction of thrust is different in these two techniques.

e) Explain the reasons why the lock up procedures are different in these two techniques.

This question examines the students understanding of the appropriateness of performing a HVLA technique to any patient. This question also assess the students ability to write- up techniques as well as their ability to differentiate the rationale for two different techniques as in Question 1 and 2.

How to prepare for practical examinations

Step One

Establish a teaching and assessment criteria

If the exam is to be considered a valid assessment of the curriculum then the teaching and the assessment practices must match. I propose that the criteria for teaching the techniques as described earlier, be followed by an examination method using the same criteria.

By using a format for assessment that the students are familiar with allows the

assessor to give precise feedback to student, an essential ingredient for quality

teaching and learning.

More information about the criteria of the examinations is detailed under the heading ‘General Assessment Criteria’.

What grade is a pass?

It is important where practicable, to have more than one examiner and that the examiners have a preliminary meeting to discuss what they consider is a ‘satisfactory’ or ‘unsatisfactory’ performance relative to the examinees experience. Different criteria may be used when examining a novice than a senior, clinically experienced student.

In my experience a high standard of proficiency in HVLA technique skills has been demonstrated in examinations when students have been made aware of the examiners’ high expectations. The higher the expectation, the more effort will go into meeting that standard.

Students can either successfully perform a technique or they cannot. If they cannot, then they should receive precise feedback on how they can improve. Practitioners cannot ‘half’ manipulate the spine, as a Dentist cannot ‘half’ pull out a tooth. Therefore, it is recommended that the pass mark for any technique should be 90% i.e. students need to achieve a 11.7 out of a possible 13 marks per technique, in the practical-examination marking form proposed.

c) How often is it necessary to conduct exams?

If the examinations are to be considered valid and reliable then the educators must ensure that all techniques taught in the curriculum are examined.

It is a good idea to conduct practical exams regularly, say after six or eight techniques have been taught.

It is the lecturer’s responsibility to closely monitor student progress, ensuring

patient safety at all times.

When exams are conducted on a regular basis the educator is provided

with the perfect opportunity to give regular feedback, thus ensuring quality

teaching and learning.

Included at the end of this text is an example of how to record individual student progress which provides a ‘check list’ ensuring that every student successfully performs every technique taught in the curriculum at least once.

d) How many techniques should be examined each time?

As a general rule it is a good idea to examine students on only four techniques at each exam, this takes approximately fifteen minutes face to face.

At the beginning of an exam students will be given a ‘selection’ of four techniques written on paper and allowed five minutes reading time before being asked to demonstrate their proficiency. The lecturer can prepare six or eight ‘selections’ of different questions, refer to Table 1, so that the same questions are not repeated too often. A large selection is particularly important for larger classes and examinations where students are treating other students. It is also important that students be instructed to leave the building immediately after their exam so as not to invalidate the examination process.

Table 1 shows how two different students can be examined on five different

somatic dysfunctions without giving the same questions to both students.

Table 1.

	Selection One	Selection Two
	C3/4 ERS right	C6/7 ERS right
	AA Rotated right	OA Anterior on left
	OA Posterior left	OA Posterior right
	C5/6 FRS left	C2/3 FRS right

Step two - Inform students of exam procedures

Early in the semester advise the students on the examination criteria, the number of techniques and the other examination procedures. Students cannot be expected to perform well if they have not been properly informed what to expect. A great deal of anxiety between examiners and students can be eliminated if good communication channels are maintained. Stressed students make poor examinees. Poor communication often result in more students needing to re-sit exams, thereby increasing the examiner workload.

Step three - Scheduling the exam

Establish resources

Check availability of examiners and rooms in which to conduct the exams.

b) Organize an exam timetable

Decide how many techniques each student will be assessed. Calculate how long each exam will take and work out a class roster allowing some ‘fudge’ time. Decide if students will be performing the techniques on each other or if they need to bring a suitable patient.

Step four - Examiner preparation

a) Who will examine the students?

Examiners should be chosen who have previous experience examining HVLA thrust techniques or, who have attained a high degree of personal skill and a depth of knowledge of HVLA thrust techniques from their clinical experience.

All examiners need to be familiar with the examination criteria before

commencing to examine the students.

Outline examiner duties and responsibilities

It is necessary to discuss how much prompting of students is to be allowed. Many poor students pass because a kind examiner has prompted them along. Many a good student has had a blank moment where a little prompting would have revealed a performance worthy of praise. How much prompting is acceptable to each examiner?

In my experience if the students are properly prepared for the examination and adequately informed of the examination criteria, very little prompting is needed.

c) What is a ‘successful’ performance of a HVLA technique?

A good guide when examining students is to ask, ‘can the student apply this technique to this particular patient effectively?’ Consideration must be given to all the possible variables brought to the examination by both the student and the patient. Variables such as patient vs student practitioner body size, patient mobility, age, and the height of the treatment couch.

Examiners and students must remember that the technique is not being applied to ‘the textbook’ it is being applied to ‘the patient’.

Technique assessment should be based on the agreed criteria, yet must be flexible

enough to accommodate for all the variables.

The mere presence of an audible ‘pop’ is not sufficient evidence of a successfully executed manipulation.

d) Decide on feedback.

Fundamentally important to the educator’s role is to provide the student with accurate and constructive feedback. Clear, concise and positive feedback by examiners creates an atmosphere within which students feel safe to be ‘wrong,’ to ask when they are unsure, to expose their lack of knowledge and to open themselves to more deeper understanding. In essence, to learn. With unclear or negative feedback students learning may be inhibited or completely stifled.

Examiners must agree upon whether or not the student is to receive immediate feedback after the performance of each technique, at the end of exam, or at a later date after all the exams are over. More time will need to be allocated for examining each student if you intend to give immediate feedback.

Regardless of when it is given it is important that all feedback is in a written form. Students quite often wish to reflect on the comments at a later date and if they are not written down it will be difficult for the examiner to remember all of the details.

It is also important for evidence of quality teaching that feedback is written down to add to the never ending paper trail of necessary information regarding a students development throughout the course.

Step five - Evaluate the exams

Finally, after the exams are over and the results are posted, take time to evaluate if all students were consistently good at certain aspects of the techniques examined, or whether there are obvious areas that need to be taught differently. Are there other ways of relaying information? What do the other examiners think of the exam process? Can the examiners offer any suggestions for improvement? What do the students think of the exam process? What constructive comments can students provide? What in the student’s opinion, can be taught differently? How?

Only by employing the continuing reflection cycle, Figure 1, can teachers teach effectively.

Be open with yourself and your students about teaching and assessment practices, it is the only avenue towards quality teaching and learning.

General Assessment Criteria

Practical Examination of HVLA techniques.

Total marks per technique = 15

Diagnosis - Three marks

In order to gain full marks in this section the student should:

give a verbal description of the lesion position and movement restriction of the joint described in the question, or,
explain the somatic dysfunction found in the patient on the bench

Operator and Patient Positions - Two marks (one mark each)

The examiner must assess the student’s ability to position themselves and the patient correctly to successfully administer each technique. Consideration should be given to all possible variables for example, where the patient is much larger than the practitioner and vice versa, or the bench is height adjustable or not.

Student must demonstrate an awareness of maintaining their own good posture and personal safety as well as the ability to recognize if it is appropriate for the patient to be maneuvered into the required position.

Patient modesty and safety is paramount.

Contact - Two marks

Equal consideration must be given to the involvement of both of the operator’s hands in the performance of each technique.

Lock Up description and Lock Up performance - Two marks (one mark each)

In order to gain full marks in this section the student should be able to give a verbal description of how the patient is being positioned, and the effects of those movements on the patient’s somatic dysfunction. Making sure all components of the restrictive barriers are addressed. The patient should be positioned, as described, and as required for successful application of the technique.

The student needs to verbalize the correct lock up description as well as perform the correct lock up to get two full mark in this section.

Localization - One mark

At least one examiner will palpate as closely as possible to the joint to make sure that all forces are localized to the required area. A ‘pop’ is neither evidence of localization or successful delivery of a technique.

Thrust - Three marks

Thrust ‘performance’, is assessed specifically, as it is distinctly different from the student’s ability to ‘say’ in which direction the thrust should or will be delivered.

The student’s ability to perform the thrust in the direction as stated is graded because often, with novices, the description and the performance of the actual thrust are at odds with each other.

Thrust speed: The criterion of speed is that it is high velocity on delivery.

Thrust force: Specific notice should be taken if appropriate force has been used in the execution of the thrust.

The examiners must decide if excessive force has been used which could possibly cause trauma to the patient, or if insufficient force has been applied rendering the technique ineffective. Remembering that the requirement for success is a low in amplitude force.

Explanation of the Technique - Two marks

To gain marks in this section the student must demonstrate that they have a thorough understanding of the aims and objectives of the technique. Also, that they have a three dimensional appreciation of how the technique works, which incorporates a sound knowledge of the relevant anatomy, physiology and biomechanics.

Bibliography

Cox KR., How to assess performance, The Medical Teacher, Second Edition, Churchill Livingstone.

HVLA

Practical Examination Marking Form

Date

Student’s Name

Examiner’s Name

Selection No

Students must score 13.5/15 ie. 90% to pass a particular technique, as well as pass 3 out of 4 techniques to pass the exam overall.

	Marks	Tech.1	Tech.2	Tech.3	Tech.4
Diagnosis	3
Operator Position	1
Patient Position	1
Left Contact	1
Right Contact	1
Lock Up Description	1
Lock Up Performance	1
Localization	1
Thrust Speed	1
Thrust Force	1
Thrust Direction (performance)	1
Explanation of Technique	2
Total	15	/15	/15	/15	/15

Comments:

HVLA

CORE TECHNIQUE EXAMINATIONS SUMMARY

STUDENT NAME

D = Date

M = Mark

Technique

Supine Thoracic