By: Brett Windsor PT, PhDc, MPA, OCS, FAAOMPT
For the last twelve years, manipulation has enjoyed the best of seats in the physical therapy house. Careers have been made, Medici-like empires constructed, all on the back of a technique once considered little more than a party trick for a handful of grizzled old romantics apparently intent on destroying the scientific method. Once regularly dismissed in higher circles, reduced to a bargaining chip for direct access in the state-house, manipulation has since driven its own agenda. It’s now taught in all pre-professional physical therapy schools in the US. No serious manual therapy program would consider anything other than the earliest of introductions as they groom their new progenies.
Still, many would have us regard manual therapy (manipulation particularly) as a rambunctious toddler at high tea; tolerated best when seen little seen and heard even less. From their lofty perches atop the mountain of wisdom, they proclaim that there is simply no evidence to support manual therapy. Any published statistics, of course, cannot be trusted; only their sophisticated post-hoc analyses can be trusted to affirm that manual therapy is, well – utterly useless. One should not allow facts to impede any biased pre-suppositions. To a hammer, all appears as nails….right?
Context anyone? None but the slickest of operators would consider wise the unyielding application of any treatment method to every patient that crosses their path a wise course. Such attitudes toward manipulation do nothing to raise OMPT above the bone-setters and lay-manipulators that, even today peddle their wares to anyone with a credit card. However, it would now seem fair to say that physical therapy as a whole has reached a reasonable balance between manual therapy and other interventions to arrive at a generally well-rounded management approach.
Manipulation is a tool. And as such, it is best suited to a specific purpose. More now than ever before, its effect appears to be largely neurophysiological, causative of changes in local muscle control initiated by the central nervous system. This explains the patient who falls on ice, manipulation at once producing the profound changes in function and pain. What was that almighty ‘clunk’? How did the patient go from the appearance of an acute disc to almost completely normal…in one technique? Skeptical? Don’t tell me it didn’t happen, help me explain why.
Physical therapy is an educational profession. Our highest charter is to know, and to explain, why. Then, physical therapists can facilitate optimal movement patterns in patients. This means postural education, movement retraining, individually dosed exercise and yes, manual therapy. Manual technique plays a key role, but the return to a pain free movement state will only be sustained through education and a long-term commitment to developing optimal postural and movement patterns. And we all know, there are a myriad of methods suited to each purpose. Use all the tools in the box. They all have a role to play.
Focus should move away from the latest treatment fads. The darling of the moment is dry-needling, now the magic remedy for seemingly any problem. What about evaluation? Where has that gone? Does anybody value a thorough, thoughtful evaluation anymore? Evaluation is now an endless procession of ‘special tests’, each statistically more useless than the one before. The dirty little secret is that superior understanding of anatomy, pathology and biomechanics, combined with a critical mind, good questions and a good memory renders special tests quite unnecessary. Diagnosis is made before the touch.
Would you like to have these skills? Would you like to be able to think though problems? Make decisions and understand the true nature of that which impedes movement? Would you like to be able to select any tool from a virtually unlimited box, applying each to the job for which it is designed?
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