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Interesting opinion piece on manual therapy assessment here. Curious what people of think of it. Be sure to skim through the responses at the end of the article as well.
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I remember reading this article this summer and being both encouraged and discouraged.
The author makes a lot of good points. And I feel most of the manual therapy community has shifted in the direction he mentions. Most therapist now understand that manual therapy is creating a neurophysiologic cascade of events rather than strictly increasing mobility at a segment.
I think the research has demonstrated well that we can identify hypomobilities but might not be as good at identifying hypermobilities. Like the article mentioned, we definitely can’t divide 1mm of movement into a 5-7 degree scale.
The article questions the necessity of specificity. In the third true/false question in the article the author makes the point that one can pick any level randomly and have the same benefit as a specifically picked segment. As this is somewhat true and he backs up his argument with studies, most studies show some superiority of specific technique over general technique. The differences are generally not found to be significant and are rather small, but are slightly better none the less. So, perhaps, it is in our best interest for the patient to be the best we can be and continue to attempt to be as specific as we can with out techniques.
I really liked this statement by Jim Meadows in the commentary section as well. Helping show that clinicians play a role in research and shaping the direction of PT practice.
“That you are predicting that your article will not make it into a
peer reviewed journal is, I think, an appalling statement about the
state of the clinician’s place in a world where researchers (who
are not always the innovators and bright sparks that you would
like leading) rule.” -
Great post August. I love all the points it brings up.
I feel like as I treat more and more patients that I use less and less specific spinal joint assessment (PIVMs especially) to evaluate; maybe with the exception of cervical spine. However, like everything we do in PT – understanding the limitations of the evidence is an important part of good clinical decision making.
I believe that improving your touch, and psycho motor skills of assessing specific joint mobility is an important part of learning to be a manual therapist. It is only one piece of a comprehensive evaluation, that may lead to specific directed treatment to improve mobility (by whatever means – mechanical, neurophysiological, or placebo); and teach people how to move more efficiently.
Those are my first thoughts – again great post
Hopefully ALL our residents read, think and contribute to this discussion
Happy Holidays
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Great post
I liked how the article told the story and transformation of his practice. I also like how he started with the challenging deep thinking and then simplified to the less biomechanical treatment.
I would argue that if he had not done the higher level thinking about the biomechanics he would not have had such a deep appreciation and understanding of the anatomy and body. I feel that if you start with the more simplified methods you have capped your thinking at a ceiling. The best PTs I have worked with all started with knowing a ton of different ways of thinking and higher level training before simplifying and taking what they needed to treat a patient. If you only know one simplified method I feel it may limit you as a clinician.I also am a fan of Jim Meadows thinking and liked his editorial the most. He is right about the practice based evidence over evidence based practice. I think he really is showing how clinicians should be the ones deciding research, not just the researchers. It becomes a political world and who you are connected with to determine whos papers get published and I don’t feel that is going to keep our profession at the front.
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That was an interesting statement he made, August. I almost feel like that is just a way of him validating non-specific techniques for himself; It is easier to do, therefore, I feel more comfortable as a clinician. Is it truly better to assess in a no-specific way because you feel more comfortable?
For an analogy: I like chicken alfredo. The kind out of a jar is much easier and I am more comfortable making it (obviously). It taste fine but no where near homemade alfredo that takes much longer and is much easier to make a mistake while preparing.
So in regards to the assessment. I may feel more comfortable because I have to “feel” for less things when assessing in a non-specific manor. But to state that I am providing better care because I am more comfortable is possibly a bold statement.
Thoughts?
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Really great thread – one of my favorites so far. I think it is important to recognize another factor that may have propelled this type of thinking. There was a time where manual therapy did not have the strongest outcomes in our literature and as a result, insurance companies were questioning payment for certain procedures. We now know that much of this was due to poorly designed studies assuming that all back or neck pain was created equally. Enter the classification system, which was an initial attempt to show that when applied appropriately, to the appropriate subgroup, our techniques actually do work. The problem, as I am sure you are all aware, are the extremist views that our CPRs are gospel and replace our clinical reasoning, and even more dangerous, perhaps, are studies indicating prescriptive types of treatments (mobilizing L4 for all back pain can have the same results as specific assessment and techniques, for example). I think it is imperative that we know where we came from historically as a profession, what lead to some of the initial designs of these studies (to get us paid, to get us DPT and MSK expert status, etc) and not swing towards the extremists views that may water down what it is that we do that is so special – care for individual patients in a specific and not prescriptive manner.
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I think you all make great points. This makes me think about some of the MET techniques that I see with some of the clinicians I work with. I get frustrated because they will see an “Flexed Rotated Sidebent (FRS) Left L5” or a “Left on Right sacral torsion” or “the FRS left corrects when moving from anterior pelvic tilt to posterior pelvic tilt, see?”
Many times, I don’t see. And it is frustrating. These patients feel better when treated with MET techniques, but I wonder if a regular UPA would have had the same effect.
I loved reading the responses, they were very informative. I really wonder about the whole “specific technique vs general technique” debate. I went to AAOMPT 2015 in Louisville, KY. There was a round table discussion with many big names in our field, and they all agreed we should stop doing studies about whether technique A or technique B is better for treating X. I found this really crazy as a student, but knowing more about the neurophysiological effects of manual therapy, it makes more sense now and fits with the theme of the article.
I think specificity of technique leads to improved outcomes. I don’t know if this is what is backed up by research anymore. I also don’t know what evidence I would need to be able to change my mind.
If you agree, what evidence/study would you need to see in order to change your mind that specific techniques are no better than general techniques?
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