I would like to take a minute to express my agreement with recent letter to editor in JMMT entitled “Manual Therapy: process or product” by Jason Silvernail, DPT, DSC, FAAOMPT (subscription required).  I typically like to read these individual memos from top professionals in our field not only because they are short :), but honestly provide a straightforward commentary but respectable disagreement of several topics of interest.  As a young clinician myself, it tends to fill the gaps that I may not have “thought” of yet so far in my career; at least not to the extent to put into well constructed paragraphs.  

First and foremost, I am a huge advocate of teaching clinical reasoning to my interns rather than just simple, quotable knowledge of memorized facts.  This recent written account by Dr. Silvernail comparing the systemic clinical reasoning model likes of Mechanical Diagnosis and Therapy (MDT) system and manual therapy is definitely up my alley.  In my amateur perspective, it seems MDT therapist(s) overwhelm manual therapy therapists in simple numbers in physical therapy for the treatment of spinal disorders.  As a manual therapist and not MDT therapist (is this proper terminology?); Why is this?.  I know MDT has been shown in research to provide positive outcomes but I get positive outcomes everyday through other approaches.  It is my opinion that most therapists attend MDT as it provides them not only a positive outcome-based approach to treating spinal disorders, but more importantly, provides a systemic process of examination and treatment.  Now remember, I have not had any formal training in MDT so my comments to this approach is layman at best.  

What I do know is that my short experience in teaching doctoral interns (students), is that they want a way to examine but most importantly; to treat.  Such as “how did you come up with that conclusion to treat the patient this way”.  I teach an comprehensive approach of neurodynamics, directional preference movements, manipulation, soft tissue releases, etc. but I find students have a hard time fitting the correct treatment approach to the situation.  Maybe they just need more experience?

I find that MDT does a better job at this compared to manual therapy, at least to the extent of an algorithmic, precise process.  Clinical prediction rules are a start for us manual therapists, but we need to get better at getting young therapists on board.  I agree with Dr. Silvernail that it is a ‘process’, not a ‘product’ that gets us there; but how?  I want to be able to better explain my reasoning model to someone who has minimal experience to get them jump-started early.  

I will post later this week a sample examination method that I use for spinal patients but would love to have your feedback, even now.  This could be a great way to share ideas to help create a structured intervention approach. 

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5 comments

  1. You know I agree! I’m both MDT and a OMPT fellow, so the process is absolutely paramount. I teach the MDT system for clinical decision making, but introduce OMPT to treat the dysfunctions or to speed along the derangements. In terms of what to do now, my system of treatment is soft tissue, then joint mob/manip, neurodynamics, corrective exercise in that order (if needed) then reassess function. Both systems work well for every intern that walks in. It’s the topic of my next post, It Doesn’t Have to be Complex.

    1. Thanks Dr. E for the comment. I still haven’t gotten around to posting about examination process but could definitely be a collaborative approach once we get our data together.

  2. I have first hand witnessed a pair of MDT therapists lose a referral base from a neurosurgery group in the same building, essentially because they refused to be creative in their treatment approaches, and the MD’s were not happy with their patients outcomes. While I’m positive this is the norm, any time that a PT limits the tools they use, they limit the potential benefit of their patients.

    In my experience, utilizing a combination of manual techniques to address symptom producing structures / areas, and motor control / strengthening exercises to restore normal functionality of the causative segment usually produces positive results.

    In my opinion, having an open mind as far as treatment options, good clinical reasoning skills, some sort of manual therapy skill, and basic understanding of anatomy, physiology, and neuroscience are a nice foundation to fostering a quality physical therapist.

    1. Joseph,
      I totally agree with you.. You make great points, especially the point of clinical reasoning and what is best for the patient. I think we tend to get stuck in our own “favorite treatment” and ‘set ways’ that we forget we are here for the patient.

      Thanks for following!
      Harrison

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