If you haven’t had the chance to watch the recent PT TV over @ Therapydia (here) entitled Future and Direction of Manual Physical Therapy, it is worth your time. Even if you aren’t a ‘manual therapist’, you will see some of the current and upcoming leaders in this field discussing a hot topic. The panelists were Tim Flynn, Joe Brence and John Ware. Technology is amazing that it can be streamed directly to your home and you don’t have to commit a significant amount of money or time to a conference to see our future in progress.
These were several of the topics with quotes from the PTs and a quick overview from me:
How do we talk and communicate to the patient in regards to not only the cause of the pain, but what manual techniques we do to assist in abolishing it. We need to do a better job at implementing a more neurophysiological vs biomechanical approach to patient education.
We know the literature is out there that there are not changes biomechanically from manual therapy (or level B evidence that there is not), vs level B evidence that there are changes neurophysiologically and chemically. The ‘joint is out of place’ and ‘this is rotated this way or that’ is not an honest way to tell the patient this is why he or she is in pain. This is what chiropractors have been doing for years and since 1895, it hasn’t been proven. John stated (and I paraphrase), ‘we need to move away from chiropractors and other specialists and actually be real therapists’ and ‘old verbage needs to be cleaned up’. I agree and think we are on this horse and carriage…just not there yet.
I agree with Tim in that this biomechanical model or structure is appropriate ‘in our mind’ as this is a simple (we need to keep it simple!) way to approach from a manual therapy intervention to address a complex system. He mentioned too that patients do not think about neuroscience. I think this is very true and I see it day to day. I do not think there is a perfect model out there, but combination of neuroscience, body mechanics, ‘get moving’ and other educational strategies are appropriate. The process is a whole, just not one part.
I have been telling my interns for a few years now to “use biomechanical principles to get neurophysiological results”. I think this statement would be agreed up by each of these gentlemen.
2. Wiggling vs thrusting (joint mobilization vs joint manipulation).
I think this whole mobilization topic will be around for awhile! You can tell Tim and John are opposites on this topic. This in itself could be an entire hour worth of debating but in general, all the therapists agreed that it is important to get their hands on the patients. We all know that in general, the combination of manual therapy and exercise will yield better results.
I have had more formal training in manipulation but I know, as well as anyone who uses clinical reasoning processes, that manipulation is not always the best treatment! We need to find what works best for the patient, not what is best for us. As Joe said, clinician beliefs will affect outcomes. Tim made a similar comment in that ‘bias of clinician affects decision making’. Don’t minimize a patient’s chance for recovery so that you can give your favorite treatment.
The concepts of clinical equipoise and subgrouping is a way of the future. Keep an eye out for more literature on these two.
3. People come to us for pain relief.
I find it quite amusing when my interns ask the patients on the initial evaluation ‘what are your goals with physical therapy?’. They are expecting some grand response to pick up grandchildren or walk to the park, but I would say 95%+ just answer simply, “to get out of pain”. As much as we want them to be more functional, this is what the patient comes to us for. My #1 goal of ‘a successful treatment’ written on my blog here a week or so ago is pain relief. The way we do this depends on #1 and #2 above. We know that within session results lead to between session results. Focus your practice on pain relief.
4. We are not yet the first choice for LBP.
I know myself and every therapist out there agrees with this statement, as well as the panel. This may be the biggest topic that needs to be addressed in order for us to propel ourselves to the forefront of musculoskeletal care.
I applaud these guys for taking up a tough and broad topic in a short period of time. If there is a round 2, I would like to hear their thoughts on dry needling, topics including ‘what is a manual therapist’, and more specific designators for an individual with additional training as a manual therapist.
Have you seen the discussion? What are your thoughts?