Physical therapist clinical reasoning and classification inconsistencies in headache disorders: a United States survey

ABSTRACT

Objective: The purpose of this study was to investigate the decision-making processes of physical therapists relating to evaluation and categorization of patients with headaches, including consistency with criteria proposed by the International Headache Society (IHS).

Methods: A national online survey was distributed in cooperation with the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Three hypothetical patient case vignettes featuring headache disorders were used as assessment instruments. Additionally, data on physical therapist education, clinical experience, manual therapy training, self-efficacy, and familiarity & consistency with IHS criteria were collected. Physical therapist identification and valuation of clinical features of headache disorders were also examined in the decision-making processes.

Results: Among the 384 respondents, 32.3% classified the tension-type headache case consistent with IHS criteria. The cervicogenic and migraine headache cases were classified at 54.8% and 41.7% consistent with IHS categories, respectively. Experienced clinicians and those with formal manual training categorized patient presentations with greater consistency. Clinician familiarity with IHS classification criteria was low with 73.6% collectively somewhat and not familiar, while 26.4% of physical therapists were self-described as very or moderately familiar.

Discussion: Clinicians’ headache categorization was significantly affected by symptom misattribution and weighting of individual examination findings. Weighting by practitioners of clinical features varied markedly with greatest emphasis being placed on detailed manual examination procedures, including passive intervertebral movements. Inconsistencies in valuation of clinical features in headache categorization suggest a need for further formal education in physical therapy educational curricula and in post-graduate education, including of IHS criteria and classification.

Level of Evidence: 2a

KEYWORDS:

• Headache
• primary care
• clinical reasoning

Acknowledgments

The authors acknowledge Sydney Thompson at the UK Center of Excellence in Rural Health in Hazard, KY for assisting with the statistical analysis described. They also thank the Kentucky Physical Therapy Association and the Academy of Orthopaedic Physical Therapy for distributing the survey to their members.

Disclosure statement

No potential conflict of interest was reported by the authors.

Ethics Approval and Informed Consent

The study was approved by the Institutional Review Board (IRB) of the University of Kentucky (Protocol 17-0406-X6B).

Additional information

Funding

The authors have no sources for funding or support relative to this project.

Notes on contributors

Philip C. Dale

Philip C. Dale, PT, DPT, is a full-time clinician with Kentucky Orthopedic Rehab Team (KORT) in Lexington, KY. He earned his Doctor of Physical Therapy (DPT) degree from the University of Kentucky in 2018. He also received a Bachelor of Science in Exercise Science from UK in 2014. He is a member of the American Physical Therapy Association (APTA) and American Academy of Orthopaedic Manual Physical Therapists (AAOMPT), where he has had the opportunity to present his doctoral research at both state and national conferences. His clinical interests include general orthopedics, manual therapy, industrial rehabilitation, and management of patients with vestibular disorders.

Jacob C. Thomas, PT, DPT, is a full-time outpatient clinician with Orthopedics Plus Physical Therapy in Bowling Green, KY. He graduated from the University of Kentucky in 2014 with a Bachelor of Science in Exercise Science and earned his Doctor of Physical Therapy (DPT) degree from the University of Kentucky in 2018. He is a member of the American Physical Therapy Association (APTA) and the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT), in which he has presented research on clinical decision-making of headache disorders at the state and national levels. His areas of clinical interest include management of orthopedic pathologies, sports medicine, manual therapy, and vestibular rehabilitation.

Charles R. Hazle, PT, PhD, is an Associate Professor at the University of Kentucky, teaching in all aspects of the program relating to musculoskeletal disorders. He began teaching with UK while still a full-time clinician managing an out-patient clinic and doing on-site industrial intervention. He has authored multiple publications relating to manual therapy and co-authored two text books on musculoskeletal imaging. His particular areas of interest relate to examination efficiency, clinical reasoning, diagnostic imaging, and manual therapy. He has had multiple international involvements and taught in, presented, or treated patients in Kenya, Australia, Brazil, and Ecuador.