10/14/13

Objec>ves  
Discuss  the  appropriate  use  of  thrust  manipula>on  to  augment  a  
comprehensive  and  evidence-­‐informed  manual  physical  therapy  
approach.  (Why)    
Thrust  Manipula.on:  Who,  What,    
Understand  the  defini>on,  principles  of  prac>ce  and  performance  of  
Where,  When  &  Why   thrust  technique  (What)  
Recognize  common  thrust  techniques  u>lized  in  physical  therapy  
  prac>ce.  (What)  
 
  Understand  Indica>ons  &  Contraindica>ons  (When)  
Elaine  Lonnemann  PT,  DPT,  OCS,  FAAOMPT    
Understand  who  should  perform  this  technique  within  the  PT  
Paul  Lonnemann  PT,  OCS,  FAAOMPT     profession.  (Who)  
Recognize  evalua>ve  components  involved  in  clinical  management  
using  thrust  as  an  interven>on  (Who)    
 
Recognize  the  need  to  understand  state  prac>ce  act  limita>ons  for  
use  of  thrust  (Where)    
 

Wha
Thrust  &  Non-­‐Thrust  Technique   t?  

Manipula>on  
Guide  to  PT  Prac.ce-­‐  
Mobiliza>on/Manipula>on  =  “A  manual  therapy  technique  
Why?  
comprised  of  a  con>nuum  of  skilled  passive  movements  to  joints  
and/or  related  soZ  >ssues  that  are  applied  at  varying  speeds  and  
amplitudes,  including  a  small  amplitude/high  velocity  therapeu>c  
movement”  
  Evidence  
APTA  Manipula>on  Educa>on  Commi\ee,  June  2003  
Thrust  Manipula>on-­‐  high  velocity,  low   Scope  of  Prac>ce  Protec>on  
amplitude  therapeu.c  movements  within  or  at  
end  range  of  mo.on.        

2007   Recommenda.on  7  

Clinical  Guidelines:    Diagnosis  and  Treatment  of   For  pa>ents  who  do  not  improve  with  self-­‐care  op>ons,  
Low  Back  Pain:  A  Joint  Clinical  Prac.ce  Guideline   clinicians  should  consider  the  addi>on  of  
from  the  American  College  of  Physicians  and  the   nonpharmacologic  therapy  with  proven  benefits  
American  Pain  Society   ü for  acute  low  back  pain-­‐-­‐spinal  manipula>on  
ü for  chronic  or  subacute  low  back  pain—  
Roger  Chou,  Amir  Qaseem,  Vincenza  Snow,  Donald  Casey,  J.  
Thomas  Cross,  Jr,  Paul  Shekelle,  Douglas  K.  Owens,  the   intensive  interdisciplinary  rehabilita>on,  exercise  
Clinical  Efficacy  Assessment  Subcommi\ee  of  the  American   therapy,  acupuncture,  massage  therapy,  spinal  
College  of  Physicians  and  the  American  College  of  
Physicians/American  Pain  Society  Low  Back  Pain  Guidelines  
manipula>on,  yoga,  cogni>ve-­‐behavioral  therapy,  or  
Panel   progressive  relaxa>on  (weak  recommenda>on,  
Ann  Intern  Med  2007  147:478-­‐491   moderate-­‐quality  evidence).  
 

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Summary  of  2007  Clinical  Guidelines:     Summary  of  Clinical  Prac>ce   Systematic

Guidelines    for  LBP  

Reviews & Meta-
Diagnosis  and  Treatment  of  Low  Back  Pain   analyses of RCTs

For  treatment  of  LBP,  the  following  

•  be  reassured  of  a  good  prognosis     recommenda.ons  were  common  to  the  
•  be  educated  in  self-­‐care         guidelines:  
•  remain  ac>ve         •  Recommenda>ons  in  favor  of  exercise  therapy  
in  subacute  and  chronic  LBP  
•  use  over-­‐the-­‐counter  medica>ons  or  
•  Recommenda>ons  for  spinal  manipula>on,  
spinal  manipula>on  or  both  as  a  first  line  
– the  >ming  of  applica>on  and  target  groups  
of  symptom  control    
tend  to  vary,  but  fairly  strong  evidence  
exists  for  Acute  LBP  

World  Tour  of  Manipula.on  Today  (Koes  2010)  +  

Recommend  
for  acute  LBP  
Short  Course  for  non  
responders  as  an  
 
  Thrust  is  part  of  the  con>nuum  
op>on  for  an    
 
ac>va>on  strategy    
 
At  the  comple>on  of  the  content  the  student  will  
Netherlands   UK,  US,  Denmark,  Germany,  Finland,  New   be  able  to  select  and  safely  perform  interven>ons  
Zealand,    Austria,  Europe  *  
  including  manual  therapy  techniques  that  may  
Recommend  for  acute  LBP   Italy                                                            Norway   include:    
aZer  2  weeks   2-­‐6weeks  
•  Manual  trac>on  
Use  for  addi>onal  or  short   France,  Sweden   Why
?  
•  Massage    
term  pain  relief     –  connec>ve  >ssue  
Don’t  recommend  at  all   Spain     –  therapeu>c  massage  
•  Passive  range  of  mo>on  
Inconclusive   Australia,  Mexico,  Israel,  Canada   •  Mobiliza>on/Manipula>on  
 
  –  soZ  >ssue    
  –  spinal  and  peripheral  joints  (thrust  and  non-­‐thrust)  

WCPT  guideline  for     WCPT  guideline  for    

PT  professional  (entry  level)  educa.on   PT  professional  (entry  level)  educa.on  
    be  equipped  for  
Ø Physical  therapists  should  
The  physical  therapist  professional   curriculum   evidence  based  prac.ce.  
includes  content,  learning  experiences  and  clinical  
educa>on  experiences  for  each  student  that   Ø Professional  educa>on  prepares  physical  
encompass:   therapists  to  be  autonomous  prac>>oners.  
–  management  of  pa>ents/clients  with  an  array  of   Ø The  goal  of  physical  therapy  educa>on  is  the  
condi>ons  across  the  lifespan  and  the  con.nuum  of   con>nuing  development  of  physical  therapists,  
care   who  are  en>tled,  consistent  with  their  educa>on,  
–   prac>ce  in  mul>ple  selngs   to  prac.ce  the  profession  without  limita.on  in  
–  opportuni>es  for  involvement  in  interdisciplinary   accordance  with  the  defini>on  of  physical  
prac>ce   therapist  prac>ce  in  individual  countries.  
 

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 10/14/13  

2012   Recent  Study  

November  2012  
It’s  Effec>ve!          
There  is  evidence  to  support  the  use  of  spinal  
manipula.on  by  physical  therapists  in  clinical  prac.ce.    
Early  use  of  thrust  manipula>on  versus  non-­‐
Physical  therapist  administered  spinal  manipula.on  
appears  to  be  a  safe  interven.on  that  improves  clinical   thrust  manipula>on:  A  randomized  clinical  
outcomes  for  pa.ents  with  low  back  pain.   trial.  

 Chad  Cook,  Kenneth  Learman,  Chris  Showalter,  Vincent  

Systema>c  Review:    Effec>veness  of  Physical  Therapist    Kabbazde,  Bryan  O'Halloran  
administered  spinal  manipula>on  for  the  treatment  of  low  back  
pain:    A  systema>c  review  of  the  literature.  

Kuczynski  J,  Schwieterman  B,  Columber  K,  Knupp  D,  Shaub  L,  Cook  C  

Which  Pa>ents  with  Low  Back  Pain  Benefit  

from  Spinal  Manipula>on?    
Valida>on  of  a  Clinical  Predic>on  Rule  

Capt.  John  D.  Childs,  PT,  PhD,  MBA  

Julie  M.  Fritz,  PT,  PhD  
Timothy  W.  Flynn,  PT,  PhD  
James  J.  Irrgang,  PT,  PhD  
Kevin  K.  Johnson,  PT  
Guy  R.  Majkowski,  PT  
Anthony  Deli\o,  PT,  PhD  

Childs,  J.;  Fritz,  J.  M.;  Flynn,  T.  W.;  Irrgang,  J.  J,  et  al.  A  clinical  predic.on  rule  to  iden.fy  pa.ents  with  low  back  
pain  most  likely  to  benefit  from  spinal  manipula.on:  a  valida.on  study.    Ann  Int.  Med  2004;  141(12):920-­‐8  

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 10/14/13  

Evidence  Suppor.ng  Thrust  and  Non-­‐Thrust  

Manipula.on   Evidence  Summary  
 “  The  current  body  of  evidence  does  not  enable    Clinical  reasoning  and  motor  skills  are  
confident  direct  clinical  applica>on  of  any  of  the   required  to  prac>ce  in  an  evidence  based  manner  
iden>fied  CPR’s.       to  provide  best  care  possible  for  pa>ents  
Further  valida>on  studies  u>lizing  appropriate  
research  designs  and  rigorous  methodology  are      
required  to  determine  the  performance  in   Evidence  is  strong  for  use  of  
generalizability  of  the  derived  CPR’s  to  other      Thrust  +  Exercise      
pa>ent  popula>ons,  clinicians  and  clinical  
selngs.”  

Haskins  R,  Rive\  D,  Osmotherly  P.    Clinical  predic>on  rules  in  the  physiotherapy  
management  of  low  back  pain:  a  systema>c  review.    Manual  therapy  2011  1-­‐13.  

States  in  USA  with  Chiroprac>c  

Legisla>ve  Challenges    
Average  #  of  States  per  year  
Na>onal  Chiroprac>c  Agenda  to  
25  
Own  Manipula>on   20  

15  
Average  #  of  States  per  
And  eliminate  the  compe>>on…   10  
year  

  5  

0  
1997-­‐1999   2002-­‐2004   2005-­‐2007   2008-­‐2012  

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 10/14/13  

Evidence  of  a  Coordinated  Na>onal  

Legisla>ve  Challenges  
Chiroprac>c  Agenda  
•  Opposi>on  to  PTs  performing  TJM  started  in   •  Mul>ple  states  encounter  the  same  
1960s   chiroprac>c  challenges  in  the  same  year  
•  Opposi>on  intensified  in  the  1990s  in  response  to   •  ShiZ  in  strategy  the  following  year  
PT  professions  movement  toward  direct  access  
•  2003  and  2004  prime  examples  
and  Doctoral  educa>on  
–  23  states  had  legisla>ve  challenges  in  1998  
•  Number  of  legisla>ve  challenges  is  less  per  year  
(typically  4-­‐8  states),  but  the  intensity  of  the  
legisla>ve  and  regulatory  challenges  con>nues  

Chiroprac>c  mo>va>on       Chiroprac>c  Arguments  

•  Economics  is  the  primary  reason  for  the   •  Thrust  manipula>on  is  outside  of  PT  scope  of  
legisla>ve  challenges   prac.ce  
•  “The  biggest  compe>>ve  threat  will  come   •  PTs  lack  training  in  thrust  manipula>on  
from  physical  therapists”   •  Pa>ent  safety  is  compromised  when  thrust  
–  The  Future  of  Chiroprac>c  Revisited:  2005-­‐2015   manipula>on  is  performed  by  physical  
  therapists  

CAPTE  Evalua.ve  Criteria  (effec.ve  

Norma.ve  Model  Of  PT  Professional  
2006)  
Educa.on,  APTA  (effec.ve  2004)  
 
–  “provide  physical  therapy  interven.ons  including:     for  entry-­‐level  
–  “interven.ons  appropriate  
mobiliza.on/manipula.on  thrust  and  non-­‐thrust   graduates  include:  manual  therapy-­‐spinal  and  
techniques.’   peripheral  joints  (thrust  and  non-­‐thrust  
–  Language  prior  to  2006:  stated  interven>ons   techniques)”  
included  manual  therapy  (per  the  Guide  to  PT   –  Language  prior  to  2004:  stated  interven>ons  
Prac>ce)     included  manual  therapy  (per  the  Guide  to  PT  
Prac>ce)    

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 10/14/13  

Student  Percep.ons   CI  U.lized   CI  DID  

HVTM   NOT  use  
Sharma,  Sabus-­‐  Descrip>on  of  PT  student  use  of   HVTM  
manipula>on  during  clinical  internships.  J  PT  
Educa>on.  2012   Students   74%   28%  
–  Surveyed  2  classes  of  DPT  students-­‐HVTM  experience  
in  OP  Ortho  clinical  selngs   Performed  
–  50%  (24/48)  of  students  did  not  incorporate  HVTM   HVTM  
into  plans  of  care.  
•  15/24  stated  pa>ent  popula>on  not  appropriate  
•  9/24  stated  CIs  did  not  have  qualifica>ons-­‐inadequate  
supervision  
•  1/24  unsure  state  prac>ce  act  allowed  HVTM  

Clinical  Educa.on   CI  U.lized   CI  DID  

HVTM   NOT  use  
•  Struessel  et  al,  Student  percep>on  of  applying   HVTM  
joint  manipula>on  skills.  J  PT  Educa>on.  2012  
–  Surveyed  all  PT  program  students  in  final  year  of   Students   92%   33%  
training  or  within  3  months  post-­‐gradua>on.   Performed  
–  54%  of  students  stated  CIs  limited  student  use  of   or  
HVTM   Prac.ced  
•  No  one  on  staff  adequately  qualified  to  supervise   HVTM  
•  Concerns  about  liability  
•  CI  belief  that  HVTM  not  an  entry-­‐level  skill  

Who?   Teaching  Manipula>on  

•  PT  Students    with  supervision   Who  can  perform  
•  Physical  Therapists   manipula>on?  
 
Link  to  Resource  Here  
 
Recent  Issue  with  Physical  Therapy  Assistants  

6  
 10/14/13  

Methods  of  Instruc>on   What  we  know  about  motor  learning  

in  medicine  
In  the  Surgical  Literature    
2012   –  Physical  prac>ce  is  the  single  most  important  
determinant  of  motor  skill  acquisi>on.    
n     From  the  Dental  Literature  
ruc>o
la > o n  Inst –  Feedback  is  key  to  learner  advancement  in  skill  
u  
Manip siotherapy and  is  acquired  both  directly  and  indirectly.  
 Phy e   (Resnick  &  McRae,  2006)  
icin
 Med rac>c   –  Timely,  precise  feedback  contributes  to  learning  
p
 Chiro athy   and  the  development  of    self  assessment  skills  
s t eop
 O (Hauser  and  Bowen,  2009).  

                     
     Recommended  Methodology   Teaching  &  Learning    
Spinal  manipula>on  in  physical  therapist  professional  
degree  educa>on:  a  model  for  teaching  and  integra>on   Thrust  Manipula.on  
into  clinical  prac>ce  
ü Analyze  ra>onale  and  applica>on  of  the   Experienced  instructors    
procedure,  then  provide  feedback.     The  learning  process  will  con>nue  over  a  few  years  
ü Role  play  as  a  clinical  instructor     of  clinical  prac>ce.    
ü Final  prac>cal  examina>on  includes  a   Early  training  for  complex  motor  skills  
pa>ent  scenario     Posi>ve  feedback  that  highlights  the  outcome  
ü Students  tested  on  a  minimum  of  3  thrust  
spinal  manipula>on  procedures.    
   
Flynn et. al 2006

Red  Flags   Red  Flags  

Past  Medical  History  (Personal  or  Family)   Pain  Pa\ern  
ü  Personal  or  family  history  of  cancer  
ü  Recent  (last  6  weeks)  infec>on  (e.g.,  mononucleosis,  upper   ü Pain  accompanied  by  full  and  pain-­‐free  range  
respiratory  infec>on  [URI],  urinary  tract  infec>on  [UTI],   of  mo>on  
bacterial  infec>on  such  as  streptococcal  or  staphylococcal;  viral  
infec>on  such  as  measles,  hepa>>s),  especially  when  followed  
by  neurologic  symptoms  1  to  3  weeks  later  (Guillain-­‐Barré   ü Night  pain  –  constant  and  intense  
syndrome),  joint  pain,  or  back  pain  
ü  Recurrent  colds/flu  with  a  cyclical  pa\ern  (i.e.,  the  client   ü Pain  described  as  throbbing,  knife  like  or  
reports  that  s/he  just  cannot  shake  this  cold  or  the  flu;  it  keeps   boring  
coming  back  over  and  over)Recent  history  of  trauma  such  as  
motor  vehicle  accident  or  fall  (fracture;  any  age)  or  minor  
trauma  in  older  adult  with  osteopenia/osteoporosis   ü Head  Ache  
ü  History  of  immunosuppression  (e.g.,  steroids,  organ  transplant,  
HIV)   ü Confusion  
ü  History  of  injec>on  drug  use  (infec>on)  
 

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 10/14/13  

Red  Flags   Red  Flags  

Cauda  Equina  Syndrome  
-­‐compression  of  the  lumbar  nerves  in  the  central  canal  causing  sensory  and  motor   Cervical  Myelopathy  
deficit,  saddle  anesthesia,  and  bowel  and  bladder  dysfunc>on.  
  ü Wide  based  spas>c  gait  
ü  Low  back  pain  
ü  Loss  of  sensa>on  in  the  lower  extremi>es  
ü Clumsy  hands  
ü  Muscle  weakness  and  atrophy   ü Visible  change  in  handwri>ng  
ü  Bowel  and/or  bladder  changes  
ü  Urinary  reten>on   ü Difficulty  manipula>ng  bu\ons  or  handling  coins  
ü  Difficulty  star>ng  a  flow  of  urine  
ü  Decreased  urethral  sensa>on   ü Hyperreflexia  
ü  Fecal  incon>nence  
ü  Cons>pa>on   ü Posi>ve  Babinski  test  
ü  Loss  of  anal  tone  and  sensa>on  
ü  Perineal  pain   ü Urinary  reten>on  followed  by  overflow  
ü  Saddle  and  perineal  hypoesthesia  or  anesthesia   incon>nence  
ü  Unilateral  or  bilateral  scia>ca  
ü  Change  in  deep  tendon  reflexes  (reduced  or  absent  in  lower  extremi>es)  

Contraindica>ons  to  OMT  

interven>ons:   Risk  factors  associated  with  an  increased  risk  of  either  internal  caro>d  
or  vertebrobasilar  arterial  pathology  
•  Mul>-­‐level  nerve  root  p  athology  
Past  history  of  trauma  to  cervical  spine  /  cervical  vessels    
•  Worsening  neurological  func>on   ü 
ü  History  of  migraine-­‐type  headache  
•  Unremilng,  severe,  non-­‐mechanical  pain   ü  Hypertension  
ü  Hypercholesterolemia  /  hyperlipidemia  
•  Unremilng  night  pain  (preven>ng  pa>ent  from   ü  Cardiac  disease,  vascular  disease,  previous  cerebrovascular  accident  or  transient  
falling  asleep)   ischemic  a\ack  
ü  Diabetes  mellitus    
•  Relevant  recent  trauma   ü  Blood  clolng  disorders  /  altera>ons  in  blood  proper>es    
ü  An>coagulant  therapy  
•  Upper  motor  neuron  lesions   ü  Long-­‐term  use  of  steroids  
•  Spinal  cord  damage   ü  History  of  smoking  
ü  Recent  infec>on  
•  CAD  (e.g.  vertebrobasilar  insufficiency  due  to   ü  Immediately  post  partum  
dissec>on)  (Kerry  et  al,  2008)   ü  Trivial  head  or  neck  trauma  (Haneline  and  Lewkovich,  2005;  Thomas  et  al,  2011)  
ü  Absence  of  a  plausible  mechanical  explana>on  for  the  pa>ent’s  symptoms.  
•   Upper  cervical  instability,  that  could  compromise   ü  Upper  cervical  instability  
the  vascular  and  neurological  structures.   (Arnold  and  Bousser,  2005;  Kerry  et  al,  2008)  

The  following  risk  factors  are  associated  with  the  poten>al  for  
bony  or  ligamentous  compromise  of  the  upper  cervical  spine   Indica>ons  
(Cook  et  al  2005)  
•  Segmental  Hypomobility  –2/3    
•  History  of  trauma  (e.g.  whiplash,  rugby  neck  injury)   –  Slight  hypomobility  
•  Throat  infec>on  
•  Congenital  collagenous  compromise  (e.g.  syndromes:  
Down’s,  Ehlers-­‐Danlos,  Grisel,  Morquio)  
–  Effects  of  Thrust  Manipula>on  
•  Inflammatory  arthri>des  (e.g.  rheumatoid  arthri>s,  
ankylosing  spondyli>s)   Neurophysiological    
–  Muscle  inhibi>on  
•  Recent  neck/head/dental  surgery  

8  
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Techniques   Lumbopelvic  Thrust  Manipula>ons  

No  technique  is  superior  
 Choose  techniques  to  enhance  learning  of  a    
variety  of  motor  skills  per>nent  to  HVT  
 
 Cleland  J,  Fritz  JM,  Whitman  JM,  Childs  JD,  Palmer  J  
 
The  use  of  a  lumbar  spine  manipula>on  technique  by  
physical  therapists  in  pa>ents  who  sa>sfy  a  clinical  predic>on  
rule:  a  case  series.    
         2006    
   

Cervical  Thrust/Non-­‐thrust  MNP    Thoracic  Spine  Thrust  Manipula>on  

Gross,  et  al,  Cochrane  review   •  Gross,  et  al,  Cochrane  review  
2010   2010  
Cervical  Manipula>on  for   •  Thoracic  Manipula>on  for  
subacute/chronic  neck  pain   acute/chronic  neck  pain  :  
Moderate  quality  evidence   Low  quality  evidence  
suggested  manipula>on  and   supported  thoracic  
mobilisa>on  produced  similar   manipula>on  as  an  
effects  on  pain,  func>on  and   addi>onal  therapy  for  pain  
pa>ent  sa>sfac>on  at   reduc>on  and  increased  
intermediate-­‐term  follow-­‐up.     func>on  in  acute  pain  and  
Low  quality  evidence  showed   favoured  a  single  session  of  
manipula>on  alone  compared   thoracic  manipula>on  for  
to  a  control  may  provide   immediate  pain  reduc>on  
short-­‐  term  relief  following   compared  to  placebo  for  
one  to  four  sessions   chronic  neck  pain  
h\p://summaries.cochrane.org/CD004249/ h\p://summaries.cochrane.org/CD004249/
manipula>on-­‐and-­‐mobilisa>on-­‐for-­‐ manipula>on-­‐and-­‐mobilisa>on-­‐for-­‐
mechanical-­‐neck-­‐disorders   mechanical-­‐neck-­‐disorders  

Extremity  techniques  
Extremity  Thrust  Manipula>ons  
Expert  opinion/Skill  acquisi>on  
•  Hoeksma  et  al.,  OA  Hip
—RCT.  Arthri>s  and  
Rheuma>sm.  51(5)  
2004.  

•  Young,  et.  al.,..Plantar  

Fasci>s..:  Case  Series.  
34(11):2004  

9  
 10/14/13  

Lab  Demonstra>on   References  

•  Bialosky  J,  Bishop  M,  Price  D,  Robinson  M,  George  S.    The  mechanisms  of  manual  therapy  in  the  
treatment  of  musculoskeletal  pain:    A  comprehensive  model.  Manual  Therapy.    2009  Vol  14,  531-­‐538  
Techniques   •  Fritz  J,  Koppenhavers  S,  Kawchuc  G,  Teyhen  D,  Hebert  J,  Childs  J.    Preliminary  Inves>ga>on  of  the  
Mechanisms  Underlying  the  Effects  of  Manipula>on:  Explora>on  of  a  Mul>variate  Model  Including  
Spinal  S>ffness,  Mul>fidus  Recruitment,  and  Clinical  Findings.  Spine.  Volume  36(21),  1  October  2011,  p  
 Wrist  Distrac>on—Lunate   • 
1772–1781  
Effects  of  dura>on  and  amplitude  of  spinal  manipula>ve  therapy  on  spinal  s>ffness.  Manual  Therapy  

 Lumbar  rota>on   • 
2012  Vaillant  M,  Edgecome  T,  Long  C,  Pickar  J,  Kawchuk  G  
Sharma  NK,  Sabus  CH.  Descrip>on  of  physical  therapist  student  use  of  manipula>on  during  clinical  
internships.  J  Phys  Ther  Educ.  
 Thoracic-­‐supine  technique   • 
• 
2012;26(2):9-­‐18.  
Struessel  TS,  Carpenter  KJ,  May  JR,  Weitzenkamp  DA,  Sampey  E,  Mintken  PE.  J  Phys  Ther  Educ.  
2012;26(2):19-­‐29.  
  •  Flynn  TW,    Wainner  RS,  Fritz  JM.  Spinal  manipula>on  in  physical  therapist  professional  degree  
educa>on:  a  model  for  teaching  and  integra>on  into  clinical  prac>ce.  J  Orthop  Sports  Phys  Ther.  
2006;36(8):577-­‐587.  
•  Trempe  M,  Sabourin  M,  Rohbanfard  H,  Proteau  L.  Observa>on  learning  versus  physical  prac>ce  leads  
to  different  consolida>on  outcomes  in  a  movement  >ming  task.  Exp  Brain  Res  2011;209(2):181–92.  
•  Krakauer  Jw.  Mazzoni  P.  Human  sensorimotor  learning:  adapta>on,  skill,  and  beyond.  Curr  Opin  
Neurobiol  2011;21(4):636–44.  
•  Wulf  G,  Shea  C,  Lewthwaite  R.  Motor  skill  learning  and  performance:  a  review  of  influen>al  
factors.  Med  Educ  2010;44(1):75–84.  

Thank  You!  

elonnemann@bellarmine.edu  
plonnemann@bellarmine.edu  
 
 
 

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