Journal of Orthopaedic & Sports Physical Therapy

Official Publication of the Orthopeadic and Sports Physical Therapy Sections of the American Physical Therapy Association

Manual Physical Therapy: Moving Beyond the Theoretical

Timothy W. Flynn, PT, PhD, OCS, FAAOMPT 1
his special issue of the Journal is dedicated to the topic of manual physical therapy. The growing body of evidence supporting the effectiveness of manual physical therapy1,2,4,6,7,10,12,16 for a wide variety of patient populations makes this a timely and important topic. The variety of patient populations addressed in this special issue highlights the diversity of conditions for which manual physical therapy should play a role in evidence-based patient management. Like many aspects of practice, however, there appear to be barriers hindering the integration of the evidence supporting manual therapy into the decision-making processes of practicing clinicians and the curricula of programs educating physical therapists.5,17 These barriers need to be identified and dismantled. Perhaps the greatest barrier blocking a wider and more consistent integration of manual therapy into physical therapy practice and education is the language we choose to use. All too often our terminology is specific to a particular paradigm of manual therapy, creating a professional tower of Babel, leading to confusion and an inability for intraprofession and interprofession communication. The terminology employed by particular schools of thought often has the effect of intimidating the uninitiated and creating an illusion of specificity that cannot be supported by the evidence. For example, an impairment in extension range of motion might be labeled an FRS dysfunction, PA hypomobility, down-slope restriction, closing dysfunction, TP right, etc, depending on the particular paradigm used. Each term generally describes the same impairment, but the terminology employed creates a perception of differences that are actually without distinctions. Well-intentioned clinicians all too often allow their particular model to become reality and expend great effort in learning and subsequently defending the theory underlying the system, instead of focusing on the evidence supporting manual physical therapy interventions. Recent research has questioned the validity of many theories underlying manual therapy. Yet evidence for the effectiveness of manual therapy is also prevalent. For example, an assessment of segmental mobility restrictions, or end play, is advocated by many manual therapy paradigms, based on a theoretical model proposing the effectiveness of manual therapy as determined by a reduction of movement restrictions identified by manual assessment at specific joints. Haas et al11 recently reported on the reductions in neck pain experienced by patients when cervical manipulation was performed at the cervical segment identified by the clinician, based on an assessment of joint mobility, versus cervical manipulation performed at a randomly selected cervical segment. No differences in pain reduction were noted between the 2 approaches. This finding certainly questions the veracity of the theory that clinicians can identify specific joint mobility restrictions, and the theory that the benefit of manipulation is related primarily to reducing joint restrictions. However, it does not change the fact that randomized trials have provided evidence supporting the superior effectiveness of manual physical therapy for patients with neck pain.12 Recent studies examining manual therapy techniques in the thoracic and lumbar spine have raised similar questions regarding the ability to direct a

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Associate Professor, Department of Physical Therapy, Regis University, Denver, CO.

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Journal of Orthopaedic & Sports Physical Therapy

manual therapy technique to a specific segment.3,13,15 Yet the evidence supports effectiveness of these techniques for appropriate patients. The paper in this issue by Whitman and colleagues indicates that our time might be better spent on developing standardized intervention protocols than debating theoretical constructs. Another important aspect of integrating manual therapy into practice and education is the importance of identifying the subgroups of patients who are likely to benefit from the interventions. Evidence supports the importance of subgrouping (or classifying) patients based on clusters of examination findings and tailoring interventions to fit the specific subgroups.9 Studies have been performed examining the characteristics of patients with low back pain most likely to respond to interventions incorporating manual therapy.6,8 However, little information is available for patients with other conditions. The paper by Childs and colleagues in this special issue proposes subgrouping criteria for identifying patients with neck pain who may respond to interventions incorporating manual physical therapy. The case studies and review papers highlight the clinical decision making that leads to decisions to incorporate manual therapy into the care of patients with a variety of conditions, including cervical myelopathy, lateral epicondylalgia, and plantar fasciitis. These reports begin a process of identifying the examination findings that should guide a physical therapist to apply manual therapy procedures. Further research in diagnostic decision making and particular intervention strategies will certainly clarify, adjust, and improve upon these initial observations. Many of the barriers to a wider integration of manual physical therapy are self-imposed. At a recent faculty workshop,14 an appeal was made for increased standardization of the terminology used in manual physical therapy, particularly the language describing manipulative interventions. We would urge the readership to assist the American Physical Therapy Association and the American Academy of Orthopaedic Manual Physical Therapists in accomplishing these types of efforts. Our continued allegiance to paradigms and personalities often leads us to focus more on defending theories than promoting evidence. As physical therapists advocating evidence-based practice, we will accrue the greatest benefit to our profession and patients by focusing our attentions on disseminating and contributing to the evidence related to manual physical therapy, and away from theories, paradigms, and schools of thought.

REFERENCES
1. Aure OF, Nilsen JH, Vasseljen O. Manual therapy and exercise therapy in patients with chronic low back pain: a randomized, controlled trial with 1-year follow-up. Spine. 2003;28:525-531; discussion 531-522. 2. Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther. 2000;30:126-137. 3. Beffa R, Mathews R. Does the adjustment cavitate the targeted joint? An investigation into the location of cavitation sounds. J Manipulative Physiol Ther. 2004;27:E2. 4. Bergman GJ, Winters JC, Groenier KH, et al. Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and pain: a randomized, controlled trial. Ann Intern Med. 2004;141:432-439. 5. Boissonnault W, Bryan JM, Fox KJ. Joint manipulation curricula in physical therapist professional degree programs. J Orthop Sports Phys Ther. 2004;34:171-178; discussion 179-181. 6. Childs JD, Fritz JM, Flynn TW, et al. Validation of a clinical prediction rule to identify patients with low back pain likely to benefit from spinal manipulation. Ann Intern Med. In press. 7. Deyle GD, Henderson NE, Matekel RL, Ryder MG, Garber MB, Allison SC. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med. 2000;132:173-181. 8. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. 2002;27:2835-2843. 9. Fritz JM, Delitto A, Erhard RE. Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain: a randomized clinical trial. Spine. 2003;28:1363-1371; discussion 1372. 10. Giles LG, Muller R. Chronic spinal pain: a randomized clinical trial comparing medication, acupuncture, and spinal manipulation. Spine. 2003;28:1490-1502; discussion 1502-1493. 11. Haas M, Groupp E, Panzer D, Partna L, Lumsden S, Aickin M. Efficacy of cervical endplay assessment as an indicator for spinal manipulation. Spine. 2003;28:1091-1096; discussion 1096.
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12. Hoving JL, Koes BW, de Vet HC, et al. Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain. A randomized, controlled trial. Ann Intern Med. 2002;136:713-722. 13. Kulig K, Landel R, Powers CM. Assessment of lumbar spine kinematics using dynamic MRI: a proposed mechanism of sagittal plane motion induced by manual posterior-to-anterior mobilization. J Orthop Sports Phys Ther. 2004;34:57-64. 14. Manipulation in First Professional Physical Therapist Programs: An Academic Faculty Workshop. Denver, CO: Regis University; 2004. 15. Ross JK, Bereznick DE, McGill SM. Determining cavitation location during lumbar and thoracic spinal manipulation: is spinal manipulation accurate and specific? Spine. 2004;29:1452-1457. 16. Struijs PA, Damen PJ, Bakker EW, Blankevoort L, Assendelft WJ, van Dijk CN. Manipulation of the wrist for management of lateral epicondylitis: a randomized pilot study. Phys Ther. 2003;83:608-616. 17. Turner PA, Whitfield TWA. Physiotherapists reasons for selection of treatment techniques: a cross-national survey. Physiother Theory Pract. 1999;15:235-246.

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J Orthop Sports Phys Ther Volume 34 Number 11 November 2004

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