Commentary on Editorial JMMT Vol 2, 2018
- April 27, 2018
- Posted by: Pieter Kroon
- Category: Professional Identity
I would like to comment on the Editorial in the JMMT Vol 2, 2018 by Joshua Cleland, Jason Rodeghero and Paul Mintken. It was titled: “Manual Therapists: Have you lost that loving feeling?!” If you have not read it yet, you can do it here:
Too many people in our profession equate manual therapy with just joint manipulation, soft tissue work and endless fiddling with intricate arthrokinematic motions that nobody else can feel anyway. This is where manual therapy has been getting a bad rep as of late, even from within our own profession. (Blog posts such as “why I am not a manual therapist” and “Manual Therapy Sucks” abound on the internet)
But look at the definition of Manual Therapy, as adopted by IFOMPT in 2004:
Manual therapy is a specialized area of physical therapy for the management of neuromusculo-skeletal conditions, based on clinical reasoning, using highly specific treatment approaches including manual techniques and therapeutic exercises.
Manual therapy also encompasses, and is driven by, the available scientific and clinical evidence and the biopsychosocial framework of each individual patient.
This is the definition of excellent orthopedic physical therapy. It says nothing about just popping a few joints
At MTI we believe that a Fellow Graduate from our program needs to show mastery of the following domains:
• Advanced problem solving
• Joint mobilization/manipulation
• Soft tissue mobilization
• Treatment of Adverse Neural Tension
• Evaluation/treatment of muscle imbalance
• Tissue specific exercise prescription
• Pain science
• Patient education
And yes, we value joint manipulations highly, but it is just one of 8 things we need to be excellent at.
How is it even possible that respected leaders and researchers in our profession start to argue from a point of weakness, trying to make a point that manual therapy is still valid, but maybe in the background of things. It truly drives me to distraction, because instead of being the leaders in the field of orthopedic physical therapy, we are slowly driven to the fringes of our profession, and articles like this do not help.
I have tried to highlight a few of their comments and then add my counter point.
“We need to embrace contemporary pain science as well as neurophysiological, psychological and non specific patient factors as potential manual therapy modifiers modifiers to maximize our patient’s outcomes. Current best evidence suggests that any benefits seen from manual therapy likely arises from a complex interplay between neurophysiological effects, placebo, patient expectation and therapeutic alliance”
When I read this, I am nearly convinced that all I need to do to become a successful manual therapist is to be a nice guy who gets along with his patients really well, can tell a convincing story, and then throw some guru voodoo in my treatment, and presto, I have a successful treatment with good outcomes. Makes me wonder why we all have spent lots of money and time to become fellowship trained? We all know that is just nonsense.
The majority of our patients that walks through the door in a standard outpatient orthopedic facility is not by definition a chronic pain patient. For those chronic pain patients the above statement is undeniably true. However, for the vast majority of the patients, their problem is a true movement impairment, resulting in acute tissue breakdown. And for those patients manual therapy is the appropriate choice of treatment. If somebody comes in with an acute torticollis, it doesn’t do me any good at all to just talk about pain science, and trying to focus on non-specific patient factors etc. No, they want to be able to turn their head again so they can back up their car, and work on their computers 8 hours a day. So after ruling out all the necessary red flag conditions, chances are pretty good I will manipulate that cervical spine to restore their motion to wnl. And of course the manipulation is a short-term benefit! But that is perfectly fine, because then you follow that up with the appropriate exercises to address posture, strength and muscle length deficits, and 3 visits later all is well again. That is good physical therapy. I don’t know how you could possibly argue otherwise. I am never going to be able to talk a patient better, who comes in with an acute torticollis, no matter how good a patient alliance I am building, or how well I identify their psychological contributing factors, or discuss the flooding of their system with inflammatory cytokines and how their pain neurotags are changing as a result of the acute postural deformity.
And people are not stupid, because they instinctively know where to go when they suffer from acute back and neck problems. They go see their chiropractor. Exactly. Because they know the chiropractor will get them the quick short-term relief necessary to get back to their regular lives. I have yet to hear anybody say that they need to see their manual therapist because they jacked up their back. And articles like this make our professional identity even worse.
Bt reading the article, what I am taking away from that is that solid manual therapy skills are overrated and we need to seriously change the way we practice. I am not so sure about that. The overall tone of this editorial is that we simple souls have been barking up the wrong tree for all these years and that we need to repent and show understanding to all those therapists out there that think manual therapy sucks. I don’t think so. It is all good and well to point out where our profession is lacking, but you better not end an editorial on that note.
The following statement in the last paragraph of the editorial is just appalling: “The optimal treatment strategy for each patient requires an up-to-date knowledge of the evidence, combined with a strong patient-centered alliance with the individuals we are fortunate enough to care for”. What does that even mean? If you write a withering editorial like this, you better come with some good solutions as well, instead of these half baked trueisms. Of course we all need to stay up to date on the latest evidence, and of course we need to put the patient first. But we all are doing that already as Fellowship trained therapists. Tell us in concrete, easy to understand sentences what that means for my patients Monday morning at 8AM. Show us for real what you think needs to come next, and then hopefully we can truly become the practitioners of choice for patients with movement dysfunctions.
Editorials in highly respected Journals like the JOSPT and the JMMT are the bellwethers for our profession. They set the tone of where our profession is headed. This editorial basically throws the manual therapy profession under the bus. The editorial is arguing for our own weaknesses, not our strengths, of which there are plenty. The discussion of where our profession is headed needs to be had at a higher level than this.
To be continued.