The future of orthopedic manual therapy: what are we missing?

Over the last decade, there has been an increased focus on and expansion in orthopedic manual physical therapy (OMPT) clinical practice and research. Along with this focus have come numerous research studies assessing the effectiveness of OMPT, a dramatic increase in the number of orthopedic residency and manual therapy fellowship programs, and an increased emphasis on OMPT in entry-level Physical Therapy academic programs [1–13]. These changes would seem to indicate that OMPT is an effective approach to the management of musculoskeletal (MS) dysfunctions. However, it is surprising to know that the evidence on the overall effectiveness of OMPT interventions remains quite controversial. While some recent systematic reviews and clinical trials demonstrate the positive benefit of OMPT in the management of neck pain, low back pain, and cervicogenic headache [6–14], others indicate small, short-term benefits from OMPT in the management of MS dysfunction [5,15], leaving clinicians without strong scientific support for the use of OMPT in the management of their patients. The recent studies suggest that manual therapy is not effective in the long-term management of MS dysfunction and pose great challenges to the provision of evidence-based physical therapy. Instead of simply accepting these conclusions, physical therapists (PT) should ask why the research on the effectiveness of OMPT in the long-term management of MS dysfunction remains inconclusive.

Over the last decade, there has been a large increase in the development of Treatment-Based Classification (TBC) systems, Clinical Practice Guidelines, and Clinical Prediction Rules [6,16,17]. These algorithms have provided clinicians with enhanced approaches to examination and treatment and have been a positive step in the right direction. Studies demonstrate cost savings and effective outcomes with the use of TBC systems in patient care [18–21]. While we understand the value of these evidence-based guidelines in assisting clinicians in the determination of which OMPT interventions to use in particular diagnostic categories, we suggest that they are insufficient, partially explaining the lack of evidence for positive long-term outcomes following OMPT.

We further suggest that the purpose of manual therapy interventions is to provide a window of opportunity for achieving a change in the neuromuscular system. Studies have shown that manual therapy provides a mechanical stimulus to alter the neuromusculoskeletal system through various neurophysiological mechanisms and reflexes [22]. This change in the neuromusculoskeletal system allows the clinician to tap into the movement system and begin to alter maladaptive movement strategies and to improve function. In other words, we propose that while, the treatment of MS dysfunctions rightfully begins with OMPT, it must progress beyond the management of body structure impairments through a continuum addressing every aspect of the movement system [23] if functional changes and long-term improvements are to occur.

Previous research has documented the variety of clinical reasoning strategies used by PTs during the differential diagnostic process and has emphasized the importance of ‘reasoning about procedures’ in the development of a treatment plan [24]. Given the complexity of the movement system and our role in reestablishing pain-free and improved function, PTs must be able to consider each patient as an individual and changing entity. Treatment plans must then be adjusted as the patient changes and progresses through the classifications becoming, in essence, a new patient for each treatment session. We do not suggest that PTs lack adequate clinical reasoning for when to apply a particular OMPT techniques. Rather, we suggest that the absence of an explicit clinical reasoning paradigm for the sequencing and progression of individual interventions, addressing each aspect of the movement system (mobility, neuromuscular re-education, functional skills) within each treatment session and across the episode of care, may be the underlying cause for the lack of long-term benefits of OMPT interventions rather than the OMPT techniques themselves. Simply put, a clinical reasoning paradigm for the progression of treatment offers clinicians a means through which they can monitor and alter a plan of care from patient to patient and from visit to visit for each patient.

In a recent case report, Masaracchio et al. [25] discussed the management of what can be considered a straight forward case of thoracic pain in a dancer. In this case, the application of an impairment-based classification system was helpful in the short-term management of the patient’s pain and function. However, it was not until the treating PT went beyond the framework of the impairment-based model to systematically and sequentially address the patient’s movement dysfunction, based on an understanding of the complexity and individualized nature of her movement system and maladaptive patterns, that the patient was able to return to pain-free and pre-injury level of function [25].

Similarly, Collins and Gilden [26] reported on the case of an Olympic tri-athlete with bilateral chronic exertional compartment syndrome (CECS) who was recommended for bilateral fasciotomies after an unsuccessful round of PT management. While, individual OMPT and other approaches to the PT management of CECS may be helpful in the short-term management of pain [27], these approaches do not often lead to long-term improvement with a return to pre-morbid levels of physical activity. The application of a clinical reasoning process sequenced to systematically address every aspect of the neuromusculoskeletal movement system, taking into consideration the influence of regional interdependence, was again successful in returning this individual to pain-free function as an Olympic tri-athlete with results remaining three years post-intervention. In fact, we suggest, the systematic approach to the application of OMPT is the reason for the success in the clinical management of this patient.

OMPT is valuable in the initial management of individuals with MS dysfunction and is necessary for changes and improvements in impairments of mobility, pain, and motor recruitment [22]. However, an understanding of how to sequence and progress specific interventions to address all aspects of the movement system are as necessary to PT care as they are rarely explicit in our scholarship [25,26].

Additionally, we propose that the paucity of support for the long-term effects of OMPT is a result of research design. Two different approaches to clinical research have been widely discussed in the literature. The use of a prescriptive treatment paradigm aims to maximize internal validity and minimize the potential for cofounding variables [6–8,10,11,13]. More recently, a pragmatic approach to manual therapy, where the clinicians choose the dosage and type of OMPT based on the results of the individual patient’s clinical presentation, has also been used [12,28,29]. Although the latter potentially creates additional confounding factors and may challenge the internal validity of the study, it enhances the external validity and generalizability of the study findings. This newer approach allows the clinician to pragmatically choose the intervention and progression on each treatment session, which is more representative of daily clinical practice. Regardless of the approach selected, researchers cannot forget that OMPT is made up of passive interventions provided by the therapist and must be combined with the neuromuscular re-education of functional movement patterns in order to restore efficient, pain-free movement.

Those of us involved in OMPT know that these techniques and our skills are effective in producing positive results for our patients and lead to improved pain-free functional skills. A focus beyond differential diagnosis, with an explicit clinical reasoning process for the application and sequencing of OMPT techniques, allows PTs to address the complexities of the entire movement system and its interrelationships. When we consider the entirety of the movement system and allow an individualized approach to patient care to inform our practice, we not only treat the whole patient; we also incrementally improve clinical practice and research.

Cristiana K. Collins and Michael Masaracchio
Long Island University, Brooklyn, NY, USA
Jean-Michel Brismée
Editor-in-Chief, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
[email protected]