I received my orthopedic manual therapy certification in 1990 from Curtin University in Perth, Western Australia. This world-renowned university has a program, the graduate diploma in manipulative therapy (GDMT) that is second to none in physical therapy postgraduate education. I was accepted into the program in 1990 and had to spend an entire calendar year in Perth. Back then, 1990’s if a physical therapist wanted to learn the fine art of spinal manipulation, they had to travel overseas to obtain this type of training. Australia, Norway, and England were places that you could obtain certifications in orthopedic manipulative physical therapy (OMPT). This new term, OMPT was used to not confuse our style of manipulation of the spine from the way Chiropractors manipulated the spine. Therefore, to differentiate it with the words orthopedic manual physical therapy, made for clarification. In simplistic terms, PT’s use spinal and peripheral joint manipulation to improve mobility in a joint, whereas Chiropractors may use the spinal manipulative techniques to adjust a spinal segment that they found from the palpation exam to be stuck, not moving, or out of proper alignment. These explanations of what each profession does is a simplistic way of saying that we both move joints with slightly different reasons and philosophy. This article is not intended to say that any one type of manual manipulative treatment is better than the other. They are all very effective in creating movement of the spine or extremity joints. The main goal for all of us healthcare professionals is to help our patients get out of pain.
Since the mid 2000’s PTs were not allowed to do spinal manipulations as those techniques and terminology was not in our practice act in many states across the United States. Today, every PT program across the US teaches spinal and peripheral joint manipulation (high velocity thrust techniques) and PT’s all over the nation use these techniques to help people get out of pain by restoring joint mobility. I have been teaching spinal manipulative therapy techniques in two different programs across the country since the mid 2000’s. I have found great pleasure in providing patients with pain easing manual therapy techniques. PTs also use more gentle mobilization techniques to ease pain in spinal joints just like the other professional (Chiropractors and Osteopaths) that manipulate the spine. They use their hands, or the activator adjusting tool. In summary, PT’s, DC’s, DO’s all move joints with varying degrees of force. From the gentlest mobilization technique to an end-of-range quick thrust technique to create intentional bone movement. Quick thrust techniques can also be performed in mid-range when there is still significant pain. Us manual therapists (PT’s, DC’s, and DO’s) all have slightly different ways that we explain the ‘how and why’ we use these techniques as our philosophies are different.
Since about 2005 the PT profession embraced this ability to manipulate the spine as well as mobilize the spine, which we had been doing for decades, the amount of research supporting all types of OMPT as a beneficial treatment when treating people with spine pain. It wasn’t till about 2010 when some of the OMPT research was supporting general exercise along with the spinal manipulative techniques for optimal results in pain relief. That was a slight paradigm shift that caused a great deal of concern to some as they thought that OMPT could be headed for less effectiveness in the future. Now, in 2024 the research has almost flipped on its head with the strong evidence for lifestyle medicine, general exercise that encompasses strength training, flexibility, balance, and mindfulness techniques to manage stress as key components to treating people with spine pain. OMPT now is the least important part of a treatment plan to help one get out of pain and stay out of pain. The interesting thing is that this has been demonstrated for almost all (neck, low back, shoulder, knee, and hip) musculoskeletal problems.
At this years’ annual conference of the American Academy of Orthopedic Manual Physical Therapist (AAOMPT) we heard from experts from all over the world present study after study about this massive shift on how we should be treating our clients with musculoskeletal pain with more lifestyle changes. These weren’t just the one off randomized clinical trial (RCT), they were meta-analysis reviews of RCT’s. That means pay close attention to the conclusions and recommendations stated by the authors.
A PT researcher from England, Dr. Jeremy Lewis, demonstrated that the most effective way of treating patients with rotator cuff related shoulder pain (RCRSP) is to provide OMPT and specific pain easing exercises in the beginning of the rehab and then progress to less OMPT techniques as the exercise portion of the rehab is ramped up. From the onset, a focus on lifestyle changes is imperative because the evidence is clear that changing poor lifestyle choices demonstrates better outcomes than mobilizing or manipulating the joints of the body. Simply getting good sleep, eating well, and exercising daily can make a huge impact on decreasing pain. There is also very poor evidence that passive treatments like the many massage therapy techniques will decrease chronic musculoskeletal pain. Here is a great way to think about it: if I have a painful and swollen knee joint, I will make quicker and longer lasting changes by icing the joint, drinking plenty of water, getting a good night’s sleep, and eating an anti-inflammatory diet than getting a massage. Getting rid of the inflammatory cells in the joint as quickly as possible will provide you with much quicker pain relief and, most importantly, is changing the chemistry of the joint from an inflamed joint to one that is less inflamed.
So, what are these lifestyle changes that need to be addressed. I wrote about Lifestyle Medicine in this paper on April 23, 2024. Those 6 pillars of Lifestyle medicine are: 1) physical activity, 2) whole foods, plant-based diet, 3) restorative sleep, 4) stress management, 5) avoidance of risky substances, and 6) having positive social connections. The licensed healthcare providers that are well versed in helping you out with musculoskeletal pain problems and addressing these lifestyle medicine topics are your primary care provider (PCP) or manual therapist (PT, DC, DO).
The blessing in this mounting evidence of research telling us to pay more attention to the lifestyle medicine piece with patients with musculoskeletal pain is what we have been doing all along. It has always been in the DNA of PT to help people make good healthy decisions and talk about their problems to sort out the best plan to get symptom free. Now there is evidence backing up that statement, “You should get in a good walk daily and incorporate tai chi, yoga, pilates, jazzercise class to get rid of your back pain.”
The other key take-away from this year’s conference and what has been demonstrated in the literature over the past decade is for clinicians to truly listen to their patients. When clinicians follow a patient-centered model of healthcare, patients’ outcomes demonstrate marked improvements in health and well-being. Several of the presenters recommended learning how to use motivational interviewing (MI) in clinical care would be a great way to improve communication with our patients. I first learned about MI in 2012 and have been using these patient-centered communication style for several years. The entire staff at Body Logic Physical Therapy, which is where I work, is well versed in all these current peer-reviewed recommendations in managing people with musculoskeletal pain. I am also sure that every PT practice in town is on board as well because we all communicate regularly and share ideas.
In the 34 years since my initial training in OMPT, I have witnessed and incorporated massive changes in the way I provide my PT treatments. Change is consistent in healthcare. We must follow the peer-reviewed literature in the recommendations for how to deliver evidence-based care to people with musculoskeletal pain. As a person that loved to “move” joints and exercises a little, I am learning to listen more, move joints a bit less, and empower clients with motivational interviewing techniques more frequently.
“Mi is a method of communication designed to bring out the other persons motivations to change.” Bill Miller, Author of Motivational Interviewing, 4th edition. Patient’s that come up with their own reasons for change are more likely to stick with their home exercise program than patients that are given exercises to do without any input.
I look forward to reading and then implementing the next changes as the literature guides us to do. I just hope we don’t go back to bloodletting for pneumonia or prolonged bed rest for low back pain. Stay active, be well.