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

Philip C. Dale, Jacob C. Thomas, Charles R. Hazle

Research output: Contribution to journalArticlepeer-review

6 Scopus citations


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.

Original languageEnglish
Pages (from-to)28-40
Number of pages13
JournalJournal of Manual and Manipulative Therapy
Issue number1
StatePublished - Jan 1 2020

Bibliographical note

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

Publisher Copyright:
© 2019, © 2019 Informa UK Limited, trading as Taylor & Francis Group.


  • Headache
  • clinical reasoning
  • primary care

ASJC Scopus subject areas

  • Physical Therapy, Sports Therapy and Rehabilitation


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