Physical therapists drive thrust-manipulation research

This editorial is my last as the editor-in-chief at JMMT. Consequently, I’ve considered a number of possible topics and have decided to reflect on an issue that was a passion of the late Dr. Peter Huijbregts, who was the editor-in-chief of this journal from 2004 to 2006. Peter was very concerned about the political pressures against physical therapists’ clinical use of thrust manipulation.1 If I can take the liberty to summarize his concerns, he felt that the stance that other professions had against the use of thrust-manipulation by physical therapists was hypocritical in context and was likely more politically motivated than patronal. I’m not a political creature by nature, thus it is my hope to address this differently. To me, if a profession is well within their practice, acting safely and effectively, performs a treatment for a troublesome disorder for the improvement of health outcomes in the lay population and contributes to the literature to enhance the application of the technique, then it’s irrefutable evidence in the good.

Recently, I encountered evidence to support this assumption. At my university, graduate students are responsible for systematically compiling the findings of a dedicated line of research and evaluating the quality and implications of the findings. When efforts are substantially good, we submit the work as a manuscript, specifically a systematic review. One of my doctoral of physical therapy student groups completed a systematic review that looked at randomized controlled trials, which involved physical therapists applying thrust manipulation to patients with low back pain. There were six studies2^–7 that were included in the review. The six studies reported results on 504 patients after a small amount of drop outs from the original enrollees. All studies measured pain and/or disability outcomes; one reported on whether adverse outcomes occurred as well.4 The majority of the studies scored well on the PEDRO risk of bias scale with five of the six scoring 7/10 or higher. In nearly all cases, thrust-manipulation performed better than the comparator with effect sizes reaching >1·0 in one case.3 These are useful findings and help support the use of thrust-manipulation in clinical practice but the unwritten, un-emphasized message of the paper is the one I want to speak of during this editorial.

There were no serious adverse outcomes reported in any of the studies. Yes, only one reported on the non-adverse outcome deliberately, and those that were recorded for patients who received thrust-manipulation were very minor (e.g., soreness), and were actually fewer than the comparator group. Others8 have stated that the use of thrust-manipulation to the low back is safe and is rarely associated with adverse outcomes in clinical practice. Although all studies should have reported adverse events as a dedicated measure, it is relatively safe to say that it is highly unlikely that the 504 patients enrolled in the 6 trials encountered significant problems.

Thrust manipulation is inexpensive. In some of the studies, patients were seen for thrust-manipulation only twice (sometimes once!) and still had good outcomes. The average healthcare costs for a patient encounter with spine problems in 2005 was $6096 (95%CI = 5670, 6522),9 whereas average costs from manual providers for LBP care ranged from $369 to $760 in a recently reported study from the Journal of the American Osteopathic Association,10 and yes, I do realize that different patient problems require different intensities of care, I wasn’t born yesterday. By the way, I state this in support of any health care profession who legally and effectively uses thrust-manipulation in clinical practice (Osteopathy, chiropractic, etc.). Thrust is worth trying before more expensive, more invasive measures, unless that invasive measure is absolutely necessary (e.g., cauda equina syndrome).

Some of the papers identified by the students are extremely well cited. A cited paper means that people are writing about the findings, using the findings to help drive guidelines, or using the information as a reference (source) document for their works. According to one citation source, and as of August 1, 2012, the Childs and colleagues paper3 has been cited 357 times. 357 times! These are impact papers and it is important to recognize that physical therapists were the drivers of the information.

Thrust was used internationally by physical therapists in the review5,6 and is currently used by physical therapists in multiple countries. I’ve had the luxury of visiting several international environments over the last several years and the message is very consistent. Physical therapists use thrust manipulation internationally, and they do so with very good success and with good safety records. Is there a better litmus test for success than the very long track record in other countries, as well as in selected environments in the United States, such as the military?

Thrust has been included in a number of LBP guidelines,11^–13 sometimes for acute LPB,11 sometimes for chronic LBP,12 and sometimes for both conditions.13 Guidelines are created to minimize variation of care and guidelines are typically affiliated with evidence based criteria. Physical therapists are passionate about thrust-manipulation and should be able to treat within the guidelines that are recommended by multiple healthcare groups. And, most notably, physical therapists are contributing to the evidence that has helped build the guidelines.

As I mentioned, this is my final editorial. For me, it’s a bit different than what I’ve written previously. In past editorials, I’ve been very critical about selected things, I’ve been pedantic in some cases, but for this editorial I want to be complimentary. For the physical therapists that have been responsible for contributing to the evidence for all forms of manual therapy, I tip my hat to you. You have made our profession better. You have increased awareness and have improved patient outcomes. You have performed a great service to this profession. And to those who may still oppose the use of thrust manipulation by a physical therapist (if there are any left), please, help me understand this. I can’t make that math work.