by Ryan Hamic PT DPT
This blog is written in response to a previous blog by Mark Kargela PT DPT FAAOMPT that I urge you to read prior to reading this response. The blog post entitled “The Decline of Manual Therapy Skills?” can be found here:
Response 1: The article does not address the intended topic
To my dismay the question asked in the title was never, in my opinion, addressed in the underlying article. The author posits the question in the title and again in the final sentence and what lies in between is more or less unrelated in my opinion. In order to evaluate if manual therapy skills are declining it would seem reasonable to create an inventory of what manual therapy skills are, then provide opinion and evidence of their decline or lack thereof. The closest I could find to such an inventory is contained in the following passage:
“This is not to say there are not plenty of things we do in OMPT that remain vital to our practice. A solid subjective and physical examination remains a hallmark of what we do. Truly listening to the patient and learning their unique story from a biopsychosocial point of view is something the pain literature has pointed out as not being optional. Being able to perform: a screen for red flags in a patient presentation, vascular screening, a thorough neurologic examination including cranial nerves, and a solid orthopedic examination are all things that remain important pieces of our practice.”
Although I do not wish to imply it was his intention to provide a thorough taxonomy of the things that surround “manual therapy skills” in this passage, I must admit I am disheartened that this list didn’t include Clinical Reasoning Skills (such asAssessment, test/retest, hypothetico-deductive reasoning) or patient handling skills, specificity and intention of technique. While the skills of identifying red flags, neurological examination and vascular screening are no doubt important, they are in no way unique to OMPT, but rather a part of any responsible healthcare professional’s arsenal.
Since the blog itself does not address the central proposed topic until the final sentences and only in the form of a question we must be charitable to the author assuming that his intention was to set the table in order for the invited guests to furnish the meal. I will attempt to bring something to the potluck later in this post. For now though let’s move on from this response.
Response 2: The article deeply strawman’s “Traditional OMPT”
“Traditional OMPT Pain Reasoning was all About the Periphery” states the author. While this may be his perception based on his prior and current interactions it is demonstrably false. Viewing pain as a separate causal output of the brain/mind which may or may not be causally linked to peripheral input is not a new or even close to new line of thought. Although it may be making its appearance considerably more frequently these days due to the contributions of the current en vogue wave of pain science literature and its producers (who are doing great and important work), we should not make the mistake of thinking this is a new line of inquiry and was unappreciated by “Traditional OMPT”.
Perhaps it is my training in philosophy prior to coming to PT, but the current generation of pain science literature seems to me to be merely unpacking the mechanisms by which previously explored concepts of pain might be functioning. While this is no doubt important, it is wrong to view it as some type of paradigmatic watershed. 2500 years ago Plato and Aristotle proposed and held that pain was not a sensation or part of the realm of the senses, but rather an Emotion. I will not even attempt to describe what they mean by this and current understanding of anatomy and physiology would certainly discredit their belief that pain was an emotion seated within the heart. Suffice it to say, 2500 years ago leading minds were already writing down and discussing pain as being separate from periphery stimuli and a separate experience from injury.
When I was a philosophy student it came to my attention that philosophers are in love with phantom limb pain. It has formed a staple of mind body problem philosophy arguments and counterarguments. If anything demonstrates the highly non-directed perception of pain better than feeling pain in a limb which is no longer present I don’t know what will. In 1639 Rene Descartes wrote his meditations:
So we see 400 years ago thinkers discounting the periphery as being the driving cause in the perception of pain. I could literally cite hundreds of passages on this from the last 2500 years. Despite the disagreements and flaws in mechanistic explanation the idea of pain being a product of something besides the simple anatomy or pathoanatomy of a system is a very old and very well argued tradition.
So what does this have to with Traditional OMPT and its focus on the periphery? Perhaps the tradition is ignorant of this long history of mental inquest. Anybody discussing “traditional OMPT” would be hard pressed to not include Geoff Maitland as one of the most obvious progenitors in this vein. Well since my personal exposure to OMPT came through reading his texts prior to finding anybody to instruct me on what they thought it said let me quote from Vertebral Manipulation here:
This passage is to my knowledge included as far back as at least 1976, possibly before, but I simply don’t have an older copy to consult. To say that traditional OMPT did not account for a biopsychosocial model and a complex personal view of pain as an output of the individual is wholly disingenuous and dismissive in my opinion. Certainly it can be argued that individual clinicians and self-proclaimed masters and acolytes may have not integrated this view into their actions and kept searching down the rabbit hole of mysterious pelvic faults and mastery of physical technique to its detriment, but if we are honestly looking it is both apparent and obvious.
Response 3: Throwing the Baby out with the Bathwater
The author makes the claim “What if there was no baby at all?” Well sure, granted, but what do you take the baby to mean. It is unclear from this article what you think is worth rejection and that which is not and further what any parts of the metaphor exactly are. From textual clues in your responses I am given to believe you mean the unfounded models of evaluation and treatment and more importantly the story delivered to the patient and believed by the therapist. I certainly agree that being willing and interested to update our story to match the best available evidence is both important and honest. Being tied to dogma insulates any mind from expanding and examining new input. Further there can clearly be damage done to the patient when they believe they have a “fragile back” or a “rotated pelvis” or the incredibly insidious “ 1/4” leg length discrepancy!”, so I am totally on board with throwing out these unfounded biomechanical diagnoses to our patients.
Scientific models exist to explain real phenomenon and certainly when they sufficiently fail to describe the observed world they ought be updated, amended or outright dumpster binned. No advance in science however can change the truth of what is happening in the system it is attempting to explain. A patient arriving who cannot extend their lumbar spine who leaves with the ability to do so and a plan for how to maintain this range or address the symptoms on their own has been improved, even if the story about why or how turns out to be false. We must always remember that our updated current story of today is the outdated flat earth policy of tomorrow.
About one thing we can be certain if there is a baby in the bathwater it is the patient’s experience. They are the arbiters of their own health and wellness. They are the ones who decide if a treatment is effective or ineffective and they are the only one in the room whose opinion matters. Master clinicians have through countless hours of trial and error developed skills (techniques, reasoning and a method of patient interaction) that have an effect on the patient experience. If these skills turn out to be founded in poor dogma then by all means update the story, but don’t forget that they still worked. We don’t get to rewrite history nor the patient experience and good technique doesn’t become bad technique because of a research paper. If we define good technique as that which brings about the correct patient experience, then we all ought realize how much we have to learn from those who have been clinically successful.
Response 4: The Threat of Oversimplification
Let me state unequivocally for the record that I am excited to see the current crop of pain literature represented in our conferences. I appreciate the update to our story and have been able to use many of the concepts discussed to educate my patients and help them invest in their own health in a way that some of them would have been unable to prior. I do believe that as with everything introduced into the world it comes with a Pandora’s box of unintended consequences though. As the information becomes distilled from the level of science to clinical application I have seen many clinicians and would be clinicians using “nonspecific effects” and “pain education” as a crutch to be lazy in their development of patient handling skills, good technique and clinical reasoning. Further I have seen an overreaching of what the literature actually says, evidenced by hearing clinicians treating acute injury as if it was chronic pain and attempting to ignore real tissue based issues in favor of talking patients out of their pain. Make no mistake about it “Pain Science” is the current flavor of the month (in quotations to represent the marketable consumable image not the actual science performed), no doubt soon to be eclipsed by magnetic cupping with electrically stimulated needles with crystal infused tips. The good and useful clinical parts will hopefully exert influence into practice patterns and be integrated into the whole, but this is not nor will it ever be the alpha and omega of clinical practice.
I have had several interactions with clinicians in the past months that I believe illuminate the threat of oversimplification that I am referencing. During one conversation I was attempting to explain why a clinician might choose to use a Grade 1 or 2 mobilization with a patient with a highly severe and irritable condition, with onset of pain prior to resistance. I even referenced the argument currently being made by the modern pain science movement of skilled passive movement being a threat reducing stimulus in order to calm the CNS and the patient’s pain perception. The clinician stated “I just educate them on pain science and do grade 4’s and they get better”. When I pressed further to ask if the clinician had ever made a patient worse using this “method” they stated “No”. Well either I have found the grand champion clinician of the world or I have just unveiled a deeply seated clinical laziness. Without excusing the obvious lack here, I believe that when we continue to push “non-specific effects”, it emboldens the untrained to believe there is no value in training.
Another conversation I have had with multiple people is regarding the specificity of technique. Let’s take cervical PA’s for example. I had a clinician state to me quite confidently that you couldn’t target a specific segment. Now I will certainly agree that being able to move one spinal segment exclusive of those things attached to it, I wholly disagree that you can’t “target” a segment. Let’s just explore that thought for a minute. If I were intending to target the C5 segment and make it the primary segment experiencing an intended passive mobilization I would probably not begin by approximating my thumbs onto the patients left great toe. I would also likely not choose to mobilize the C5 of the spine model hanging in the corner of my room. Rather I would attempt as much as possible to target the vertebrae of interest in that particular patient’s cervical spine. Archers tend to aim at the bullseye even if they don’t always hit it….well unless you are this guy.
I also find it of interest that many of the people who are very interested in and driving the push to incorporate the latest pain science are those who have significant training in OMT skills. It reminds me of hearing a PGA golf pro tell people that golf is all about the mental game. Well sure if you can already pipe a ball 300+ yards down the fairway, chip to 2” and roll in birdie putts from all over the green I will agree the game is nearly 100% about the mental game. To those without this background though I would argue the game of golf is at least in large part a physical challenge. Likewise I believe this is the case with producing skillful manual therapy that is capable of interfacing with the nervous system and tissue based problems of the patient in front of you. We need to be careful that while addressing the biopsychosocial needs of the patient that we don’t forget that we still need to develop skillful ways of interfacing with all three of those areas. Many of these already exist and in my opinion are being lost or at least watered down to the point of rubbish in the rush to embrace non-specific effects.
Response #5 Addressing the Toolbox Therapist
The author of the blog makes the comment “I used to be a toolbox-obsessed therapist for a good portion of my career”. I have heard a great array of thoughts about this approach to physical therapy skill development, people proudly proclaiming that they are in a CEU course to “get another tool in their box” and the contrary admonishment to “not be a toolbox therapist”. Well I guess I will just state my opinion the toolbox therapist is a poor representation of what physical therapy should be. I believe this attitude towards skill acquisition is precisely what is driving down the skill level of our profession and keeping clinicians from approaching a higher mean level in our delivery of care to our patients.
I believe the CEU marketplace and its consumers are largely to blame for this as the weekend course without accountability has become the de facto method of skills transmission in our profession. We have an unending array of courses telling us how to stick something in, how to rotate something quickly, and how to shock, magnetize and manipulate things properly. These are generally taught with a cursory and biased glance at research evidence and largely without appeal to any real acquisition of reasoning processes that would inform the clinician whom should and should not have something stuck into them. Further and more importantly there is a failure to educate what to do when the procedural intervention you just “learned” in less than 8 hours fails.
The current education of many physical therapists is the equivalent of having the clinician standing at a locked door trying every key on the keyring until the door finally clicks open. There is little thought in this, just apply the next key in the loop until one of them works. If none of them work it must be time for the next CEU course to put another key on your ring! This method of education is reducing us to technicians, computer algorithms designed to work through permutations until we stumble on the code. Without transmission and education of solid clinical reasoning skills that underlie the manual (or any other intervention) techniques, we should not be surprised when we are all soon replaced by the new Physiotherapy app on our patients phones.
Well enough of that. I am off to sign up for the newest course I just heard about “The Kargela Crotch Punch Back Pain Eliminator Technique”
Full Disclosure: Mark and I are friends and have discussed this topic extensively while playing golf, so it’s all good.
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