I’m just returning from a visit to the annual conference of the American Academy of Orthopedic Manual Physical Therapists (AAOMPT) in Reno, Nevada. The wonderful thing about the AAOMPT conference is that you’re constantly surrounded by physical therapists that have contributed so much to our profession and are on a continual journey of lifelong learning. I’ve been to the conference a couple of times now, but this time was particularly special, as I got to participate in the new fellow recognition ceremony and present a topic during the conference.
Upon leaving the conference, it occurs to me that “manual therapy” is not exactly the household name we in the field sometimes wish it would be. I’d like to take the time here to give answers to some of the common questions I hear.
What it is:
The best definition of orthopedic manual therapy may come from AAOMPT itself, which states: Orthopaedic Manual Physical Therapy (OMPT) is a specialized area of physical therapy practice utilized in the management of musculoskeletal conditions and based on clinical reasoning and the use of highly specific manual techniques and therapeutic exercises.
Who Does it:
Many other healthcare professionals perform hands-on techniques. Massage techniques are usually associated with massage therapists, for example. However, the definition above defines orthopedic manual therapy as something different than just administering a hands-on technique. What differentiates orthopedic manual therapists from other providers, and even other therapists, is often the clinical reasoning underpinning those techniques.
Physical therapy is (relatively) new to formal postgraduate training programs. The first residency program (which happened to be in orthopedic manual therapy) began about 30 years ago in California’s Kaiser Permanente health system. There has been a tremendous growth in the number of residency programs, but only a very small percentage of physical therapists complete this training. Current residency programs are about a year long and focus on an area of specialty of practice, like orthopedic physical therapy, in order to improve the knowledge and understanding of physical therapists that enter the programs.
Fellowship training, on the other hand, is training in a subspecialty area (ie, not just orthopedics, but orthopedic manual physical therapy) and includes mentorship. The best comparison is in medicine, where you see doctors go through a residency in “general surgery” and a fellowship in “joint replacement surgery.” In physical therapy, however, our fellowships tend to be longer and more intense than our residencies, which is opposite of the medical model. There aren’t a lot of fellowship-trained physical therapists in the U.S. The number of fellows in the United States is growing, but they still represent only around 0.5% of physical therapists.
What it helps:
Overall, we have a good idea that going through training like residencies and fellowships improves outcomes. Probably the best study on this comes from Rodeghero and colleagues in 2015, which found fellowship-trained physical therapists got people better and did it more quickly. In the graph below, the green bar represents PTs that have been through fellowship training, showing they produced better outcomes for their patients (source: https://www.jospt.org/doi/full/10.2519/jospt.2015.5255)
In terms of specific conditions, we have good evidence that manual therapy helps for patients with acute low back pain, neck pain, hip osteoarthritis, and knee osteoarthritis. For other conditions (particularly those that have been around for a very long time), it’s less clear, but the approach of a manual therapist (i.e., thinking, reasoning, and doing a good examination) should be beneficial in almost every case.
Why it helps:
We have to file the answer to this question in the “unknown” area right now. We do know that it’s more than just tissue that is changing. There is a very complex and still unclear answer to this, but studies show changes at the tissue as well as in the spinal cord and brain when manual therapy is applied. Whether it’s simply getting your body used to touch or if it’s moving something that you have difficulty moving on your own, manual therapy can often be a successful addition to treatment. That said, I will contend that a good manual therapist also will realize when manual therapy is not going to be helpful and instead focus on another form of treatment (exercise, education, etc).