Orthopaedic Manual Physical Therapy- History, Development and Future Opportunities

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Orthopaedic Manual Physical Therapy-History, Development and Future Opportunities

Peter A. Huijbregts, PT, MSc, MHSc, DPT, OCS, FAAOMPT, FCAMT

Abstract

Manual therapy is among the oldest interventions inmedicine with records of its use dating back over 4,000 years.Although currently manual therapy is a well-established part ofphysiotherapy practice around the world, few therapists areaware that it has been a continuous and inextricable part of thephysiotherapy scope of practice dating back at least as far as1813 AD, with noted contributions to the field by ourprofessional colleagues for now almost two centuries. Thispaper intends to acquaint the reader with the definition, historyand development of orthopaedic manual physical therapy(OMPT) with specific attention to the paradigm shift withinOMPT from an authority-based to an evidence-based and nowan evidence-informed paradigm. This historical paper concludeswith suggestions for the role the Journal of Physical Therapymight play in the ongoing development of OMPT.

Key words: Orthopaedic Manual Physical Therapy, History,Evidence-Informed Practice

Corresponding author:Dr. Peter Huijbregts, Shelbourne Physiotherapy Clinic,100B-3200 Shelbourne Street, Victoria, BC V8R 6A4 Canada.Email: [email protected]

I would like to startthis historical paper byexpressing my gratitude to theEditor-in-Chief for providingme with the opportunity tocontribute to my chosenprofession as an AssociateEditor for the Journal ofPhysical Therapy (JPT). Thestart of a new professional

journal such as the Journal ofPhysical Therapy allows us toreflect on the role we wouldlike to see such a journal playin the ongoing development ofour profession. In my 20 yearsas a physiotherapy clinician,educator and researcher Icertainly have seen significantand ongoing changes withregard to increasedprofessional autonomy,responsibility, scope of

practice, educational level andopportunities, and researchefforts. All of thesedevelopments have led to anongoing paradigm shift thathas had and continues to havea major impact on how ourprofession is developing. As aPhysiotherapist with a specialinterest in orthopaedic manualphysical therapy (OMPT), mygoal for this paper is acquaintthe reader with the definition,

history and development ofOMPT, which will lead us to adiscussion of futureopportunities and challengesand the role I envision for theJPT in addressing such futuredevelopments.

Definition of OrthopaedicManual Physical Therapy

Both as an entry-levelskill set and as a postgraduatespecialization, OMPT is a well-established part ofphysiotherapy practice aroundthe world, although perhapsmore so in Europe, Australiaand New Zealand, and NorthAmerica. Whereas many ofour patients and health carecolleagues from otherprofessions may equateOMPT exclusively with thehigh-velocity, low-amplitudethrust maneuver, it, of course,also encompasses a great

variety of other techniques.The American PhysicalTherapy Association hasdefined manual therapytechniques as skilled handmovements intended toimprove tissue extensibility,increase range of motion,induce relaxation, mobilize ormanipulate soft tissue and

joints, modulate pain, andreduce soft tissue swelling,inflammation or restrictionTechniques include massage,manual lymphatic drainage,manual traction, mobilization/manipulation, neural mobil-zation, joint stabilization, self-mobilization exercises, and

Key points and pre-publication history of this article are available at the end of the paper .
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passive range of motion. 1,2 Within physiotherapy in theUnited States definedsynonymously as a manualtherapy technique comprised

of a continuum of skilledpassive movements to jointsand/or related soft tissues thatare applied at varying speedsand amplitudes, including asmall amplitude/high velocitytherapeutic movement, inmost other parts of the worldthe term manipulation is usedto describe a thrust techniqueperformed at a pathologicalendrange of a joint, whereasmobilization describes a non-thrust, sustained or oscillatory,low-velocity movement withinor at t he end of range of jointmotion. 1

Adding an emphasisbeyond the purely technicaland thereby also reflecting therecent paradigm shift we willdiscuss later from an authority-based to an evidence-basedand now evidence-informedparadigm, in 2004 theInternational Federation ofOrthopaedic ManipulativePhysical Therapy (IFOMPT)defined OMPT as aspecialized area ofphysiotherapy/physicaltherapy for the management ofneuromusculoskeletalconditions, based on clinicalreasoning, using highlyspecific treatment approachesincluding manual techniquesand therapeutic exercises.OMPT also encompasses, and

is driven by, the availablescientific and clinical evidenceand the biopsychosocialframewor k of each individualpatient... 3

Early Manual Therapy

Manual therapy isamong the oldest recordedinfluential interventions in

medicine. Documentation of itspractice dates back over 4,000years to Egyptian scrolls(Edwin Smith papyrus) and itsuse is also depic te d in ancientThai sculptures. 4 The firstmention of massage appearsin 2598 BCE in the oldestexisting medical work, the NeiChing dedicated to theChinese Emperor Huang Ti.Ancient Indian and Greektexts, including the work ofHippocrates, describemassage as an effective

Figure 1 Figure 2

therapy for treating injuriesresulting due to war or sports. 5

Hippocrates (460-385 BCE)(Figure-1) described acombination of traction andmanipulation on the back of apatient lying prone on awooden bed in his treatise, OnSetting Joints by Leverage. 6 Whether Hippocrates solelyattempted by this method toreposition traumaticallydisplaced vertebrae or if heintended to manipulate slightlyluxated vertebrae for a variety

of indications to this dayremains a matter of debate. 7 The Roman physician Galen(131- 202 CE) (Figure-2)commented on Hippocratestechniques in 18 of his 97surviving treatises, as did the

Figure-3 Figure-4

Arabic physician Abu Ali ibnSina, also known as Avicenna(980-1037 CE) (Figure 3). Hippocrates manipulativeprocedures were againincluded in the 16th centurywriting of Guido Guidi andAmbrose Pare (Figure 4). Pare

(1506-1590), a militarysurgeon who served fourFrench kings, in 1580 advisedthe use of manipulation in thetreatment of spinal curvature.In 1656, Friar Thomasdescribed manipulativetechniques for the extremitiesin his book, The CompleteBone Setter , and in as late as1674 Johannes Scultetus stillincluded descriptions ofHippocrates manipulativemethods in his te xt, TheSurgeons Storehouse. 8

Manipulation fell outof favor in medicine when SirPercival Pott (1714-1788)described tuberculosis of thespine and condemned tractionand manipulation as not onlyuseless but dangerous. 6-8 However, manipulation in theform of bone-setting continuedto be practised with some ofits lay practitioners attaininggreat notoriety including SarahMapp in 18th century and SirAlbert Baker in 20th centuryEngland, who both countedroyalty among their patients. Inthe United States, the male
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members of the Rhode IslandSweet family were reputed topossess hereditary skills inbone setting. One of them,Waterman Sweet, in 1829

even published a text called,An Essay on the Science ofBone Setting. Bone-settingcontinues to be practicedtoday in large parts of theworld by lay practitio ne rs as aform of folk medicine. 9

During this time,manual therapy in medicinewas relegated to a number offringe clinicians, foremostamong them the 1784Edinburgh University graduateEdward Harrison. Harrisonpublished in the LondonMedical and Physical Journal on a proposedpathophysiological connectionbetween spinal subluxationsand visceral disease andadjusted vertebrae by pressingon the spinous or transverseprocesses with his thumbs orwith a device. 6,7,10 In 1828,Glasgow physician ThomasBrown popularized in themedical community theconcept of spinal irritation.Brown proposed that a sharednerve supply could implicatethe spine in visceral diseaseand nervous conditions, whichled him to target the spine withnon-manipulative heroicmedicine interventionsincluding local blistering,application of leeches, andcautery. Dr. Isaac Parrish ofPhiladelphia introduced the

concept of spinal irritation inNorth America with an articleon the topic in The AmericanJournal of MedicalSciences. 10,11 Riadore, aprominent London physicianpractising manipulation, statedin 1842, if an organ is

insufficiently supplied withnervous energy or blood, itsfunction is decreased andsooner or later its st ructurebecomes endangered. 6 With

at least their theoriesacceptable even to manyeminent 19 th century medicalphysicians, it is easy tounderstand how firstosteopathy after 1874 andthen chiropractic after 1895and its offshoots, naturopathyafter 1902 and naprapathyafter 1905, rapidly gainedwidespread acceptanceamong at least the Americangeneral population.

Early Physiotherapy

Examples of renewedmedical interest included an1867 paper in the BritishMedical Journal that reportedon a lecture by Dr. JamesPaget, On the Cases thatBonesetters Cure . In 1871, Dr.Wharton Hood wrote a seriesof papers for the Lancet complementary to bonesettingbased on his experiences witha bonesetter by the name ofHutton and in 1882 there wasa discussion of bonesetting atthe 50 th annual meeting of t heBritish Medical Association. 6,8 The successful establishmentof thriving practices by theearliest Swedish-educatedphysiotherapists in variouscountries, including the UnitedKingdom, may have broughtabout this renewed interest.

Physiotherapy as agovernment-sanctioned,university-educated professionbegan when in 1813 inStockholm Pehr Hendrik Ling(1776 -1839) (Figure 5)founded the KungligaGymnastiska Centralinstitutet

Figure-5

or Royal Central Institute forGymnastic s (RCIG) inStockholm. 12 Students at theRCIG were either noblemen orbelonged to the upperechelons of society; most werealso army officers. They wereinstructed in physicaleducation, military gymnastics(mainly fencing, which was notsurprising considering Lingsbackground as a fencingmaster and his personalexperience with its effects onphysical wellbeing), andphysiotherapy (medicalgymnastics). The RCIGeducation included a strong

Figure-6.Thoracic traction ad modemLing (Reproduced with kindpermission from Dr. Ottoson,http://www.chronomedica.se/ )


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manual therapy component,leading medica l historian Dr.Anders Ottoson 13 to describephysiotherapy as the worldsoldest manual therapy

profession easily predatingosteopathy and chiropractic(Figures 6 and 7). Although bytodays standards the OMPTtechniques instructed canhardly be called sophisticated,RCIG-educated cliniciansfurther developed andpublished on more sp ecif icmanipulative interventions. 14

Figure 7. Temporomandibular joint mobilization ad modemLing (Reproduced with kindpermission from Dr. Ottoson,http://www.chronomedica.se/ )

Empowered by theirscientific training andpropelled by an unwaveringconviction that physiotherapycould positively affect manyconditions including amultitude of non-musculoskeletal pathologies(and thereby not unlikeosteopathic and chiropracticpractitioners), RCIG graduatestraveled around the globe todisseminate their current best

evidence approach to patientmanagement. As early as the1830s they established clinicsin many European cities.Foreign doctors and laymen

traveled to Stockholm to studywith Ling's successorprofessor Lars GabrielBranding (1799-1881).Meanwhile in Sweden, an 80-year turf war erupted betweenthese early physiotherapistsand the fledgling orthopaedicmedicine specialization, fromwhich the orthopaedicphysicians at the KarolinskaInstitute even tually emergedvictorious. 12,15

Physiotherapyeducation in Sweden andeventually world-wide wasrestructured to a technicaleducation producing alliedhealth technicians. In English-language countriesphysiotherapy was oftenpractised by nurses withadditional course work inmassage and exercisetherapy. In other WesternEuropean countries, physicaleducation teachers withadditional course work inrehabilitative exercise, oftenbegrudgingly gave up theirprevious professionalindependence for support fromthe medical profession in theirsearch for societalrecognition. 16

In rapid successionthese physiotherapytechnicians established

national associations. In 1889in the Netherlands,physiotherapists founded theworlds first professionalassociation, the Society forPractising Heilgymnastics inthe Netherlands. In 1894 inGreat Britain, the Society of

Trained Masseuses wasfounded and in 1906 inAustralia the Australa sianMassage Association. 16,17 Physiotherapy in the United

States had a relatively latestart with the founding of theAmerican Womens PhysicalTherapeutic Association in1921. When the US enteredWorld War I, it did not, incontrast to its European allies,have a military with anestablished division ofphysiotherapy. By commandof the Surgeon General, anumber of university physicaleducation programs, institutedphysiotherapy WarEmergency Courses to trainwomen who could physicallyrehabilitate returning soldiers.

As a result, 90% ofWorld War I physicaltherapists came from schoolsof physical education; in fact,the physician then in charge ofthe Army PhysiotherapyDivision stipulated that alltherapists have 4-yearuniversity degrees in physicaleducation in addition to theirphysiotherapy training. Whenin 1922 the military reducedtherapy services as a result ofgovernment cutbacks manytherapists previouslyemployed by the military wereforced into the private sector.This led to conflicts with othermanual medicine practitionersincluding nurses, osteopaths,and chiropractors all claimingto practice physiotherapy. It

was this early conflict withespecially the chiropracticprofession that causedtherapists to align themselvesmore closely with medicalphysicians. To garnerphysician support, USphysiotherapists in 1930


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voluntarily relinquished theirright to see pat ients withoutphysician referral. 18

In the US, this close

alliance with the medicalprofession and the adversarialrelationship betweenphysicians and especiallychiropractors also hadphysiotherapists in theircommunication withphysicians de-emphasize theuse of manual therapy in theirclinical practice, althoughthese interventions continuedto be used and furtherdeveloped within theprofession with variouspublications during this periodon this topic in the USphysiotherapy literature. 19 InWestern Europe andScandinavia, this adversarialstance never developed.Instead, medical physiciansembraced osteopathy,chiropractic, and the variousmanual medicine approachesindigenous to Europe.Through-out Europe,postgraduate manual medicinetraining institutes were wellattended by physicians andeven academic chairs inmanual medicine wereestablished. 20

These Europeanphysicians also educated theirphysiotherapy technicians inmanual therapy. Dr. JamesMennell (1880-1957), themedical officer at St.ThomasHospital in London, taught

manipulation to therapists asof 1916. His son, Dr. JohnMcMillan Mennell (1916-1992)(Figure 8), educated bothphysicians and therapistsworldwide in manipulation andwith Dr. Janet Travell co-founded the North American

Academy of ManipulativeMedicine.

Figure-8 Figure-9

Dr. James HenryCyriax (1904-1985) (Figure 9),Mennells successor at St.Thomas, stated thatphysiotherapists were themost apt professionals to learnmanipulative techniques. He ismost known for developingand instructing to therapistsand physicians worldwide hissystem of orthopaedicmedicine emphasizing clinicaldiagnosis and conservativemanagement by way of frictionmassage, exercise,manipulation, and infiltration.Less well-known is his link toearly Swedish physiotherapythough his father Dr. EdgarCyriax (1874-1955) and hismaternal grandfather Jonas

Henrik Kellgren (1837-1916),both RCIG graduates. Anotherinfluential person teachingmanipulation to therapists atthis time at the London Schoolof Osteopathy was Dr. AllanStoddard, qualified both inmedicine and osteopathy.Therapists and physicianswere also educated in manualtherapy at the British S ch ool ofOsteopathy as of 1920. 8

Orthopaedic ManualPhysical TherapyApproaches

Without a doubt themost influential person toagain increase the emphasison manual therapy within theprofession of physiotherapy

and arguably the father ofmanual therapy wasNorwegian-born FreddyKaltenborn (1928-). Alreadytrained as a physical

education teacher in 1948 hewas admitted as the first malestudent to the Norwegianprogram in physiotherapy.Educated in London inorthopaedic medicine by Dr.James Cyriax from 1952-1954and qualifying in chiropractic inGermany in 1958 and inosteopathy at the LondonSchool of Osteopathy with Dr.Stoddard in 1962, Kaltenborn

from 1968 on associated withphysical therapist Olav Evjenth(Figure 10)- developed aneclectic manual therapysystem known as theKaltenbor n-Evjenthapproach. 15

Figure-10(From left- Evjenth, Kalternborn)

With Kaltenborn the firstto apply the new science ofarthroki ne matics to manualtherapy, 8 central to theKaltenborn-Evjenth approachis the emphasis on restorationof the gliding component of anormal joint roll-glidingmovement. Also central is theconcept of a treatment planedefined as the plane acrossthe concave joint surface. Withmanual translatoric techniques


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defined in this system asencompassing traction,compression, and glidingtechniques, traction andcompression are performed

perpendicular to this treatmentplane, whereas glidingtechniques induce movementparallel to this plane.Mobilization and manipulationtechniques are used to reducepain and increase range ofmotion. Joint restrictions areclassified as peri-articular,articular, intra-articular, orcombined in etiology. Peri-articular restrictions due toadaptive shortening ofneuromuscular and inertstructures (including skin,retinacula, and scar tissue)and articular structures(capsule and ligaments) aretreated with sustainedmobilization techniques,whereas peri-articularrestriction due to arthrogenicmuscle hypertonicity ismanaged withneurophysiological inhibitorytechniques including thrusttechniques. 21 Intra-articularrestrictions are treated with(traction) manipulation initiatedfrom the actual restingposition. 22

In Australia,physiotherapist Geoff Maitland(1924-2010) (Figure 11), afterstudying abroad with Cyriaxand Stoddard andphysiotherapists GregoryGrieve and Jennifer Hicklingdeveloped his own approach

and started teaching thisOMPT system at theUniversity of Adelaide in theentry-level physical therapyprogram. The worlds first 3-month postgraduate certificatewas offered in 1965. In 1974,12-month postgraduate

diploma courses inmanipulative therapy wereoffered at physiotherapyprograms in Australia. Thisapproach to manual therapy is

now referred to as theMaitland or Australianapproach. 23

Figure-11

(Geoffrey Douglas Maitland)Although often

associated with variations ofthe non-thrust postero-anteriorpressure technique, theMaitland system uses a wholespectrum of thrust and non-thrust techniques. Perhaps itsgreatest contribution is itsemphasis on structured clinicalreasoning. History taking isused to gather information thatis used in the subsequentphysical examination toestablish the patientsconcordant or comparablesigns. A concordant signconsists of pain or othersymptoms reproduced uponphysical examinations that areindicated by the patient as hisor her chief complaint orreason to seek out therapy. 24

A thorough history-taking allows the clinician todistinguish betweenconcordant and discordantsigns. Discordant signs arefindings on physicalexamination seeminglyimplicating a source ofsymptoms that are, however,in no way related to the chief

Complaint. 25 Unique to theMaitland approach are alsothe frequent immediate post-intervention re-evaluations ofthe deemed most relevant

concordant or so-calledasterisk signs to guide furthermanagement.

Figure-12(Stanley V Paris)

In 1960, New Zealandphysiotherapist Stanley Paris(Figure 12) received ascholarship from the NewZealand WorkersCompensation Board to studywith Freddy Kaltenborn andAllan Stoddard. Upon hisreturn to New Zealand heorganized courses andintroduced among others-physiotherapists RobinMcKenzie and Brian Mulliganto manual therapy beforeleaving to teach and practicein the US. Once there, Parisbecame the voice of manualtherapy as a specializationwithin orthopaedicphysiotherapy both within theUS and worldwide. Deniedaccess as a non-physician tothe North American Academy

of Manipulative Medicine byDr. Janet Travell, he foundedthe North American Academyof Manipulative Therapy in1968, which was disbanded in1974 to become the ManualTherapy Special InterestGroup in Canada and the


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David Butler (Figure 15), andMichael Shacklock (Figure 16)have contributed greatly to ourunderstanding of the possiblerole of impaired neural mobility

in the etiology ofneuromusc ulosk eletaldysfunction. 32,33

Figure-15(David S Butler)

Also used in diagnosis,interventional neuralmobilization techniquesattempt to restore normalneural mobility orneurodynamic function inrelation to the structuressurrounding the nerve byinducing stretch or tension inthe effected nerves or bymobilizing the surroundingtissues. 2

Figure-16(Michael Shacklock)

Butler has more recently

expanded on this approach byintegrating new insights withregard to pain physiology andthis emerging knowledge onpain physiology has thepotential to complement and attimes replace the previouslydominant mechanical

hypotheses in determining theindications and content ofmanual therapymanagement. 34

Other manual therapysystems include eclecticsystems such as the Grimsby,Canadian, and Dutch manualtherapy approaches. TheGrimsby approach developedby Norwegian physiotherapistOla Grimsby and theCanadian approach initiallydeveloped by Canadian andEnglish physiotherapists DavidLamb, Erl Pettman, CliffFowler, Jim Meadows, AnnHoke, and Diane Lee arederived mainly from theKaltenborn-Evjenth approachbut continue to be developedinto progressively moredistinct systems o f diagnosisand management. 35-40 Mostcharacteristic of the Grimsbyapproach is its emphasis onvery specific exerciseprogressions. The Canadianapproach emphasizes the useof screening examinations toguide further examination anddiagnosis. The Dutch manualtherapy system 41 combinesvarious manual therapyapproaches developed withinmedicine, physiotherapy,chiropractic, and osteopathyand bases diagnosis andmanagement on assumptionswith regard to three-dimensional joint motionbehavior and on extrapolationsrelated to somato-somatic andsomato-autonomic neuro-

anatomical connections.

Although oftenerroneously associated withPehr Hendrik Ling, Swedishmassage was popularized inthe late 19th century as aviable medical treatment by

Dr. Johan Georg Mezger(1838-1909), a Dutch physicaleducation teacher turnedphysician. 16 Traditional or -when applied to athletes-

sports massage42

incorporateseffleurage or rhythmic strokinghand movements, petrissageor kneading, tapotement ormanual percussive massage,friction or deep penetratingpressure delivered through thefinger t ips, and vibration orshaking. 5 James Cyriaxpromoted deep frictionmassage transverse to thefiber direction for the treatmentof ligament and tendoninjuries 4 and from this variousinstrumented-assistedversions have developedincluding most prominentlyGraston technique and ASTM(assisted soft tissuemobilization).

Physiotherapists alsouse soft-tissue mobilization,which includes techniquesintended to affect muscles andconnective tissues such asstretching, myofascial release,trigger point techniques, an ddeep tissue techniques. 2 Active release technique(ART) is a form of deep tissuetechnique developed by thechiropractor P. Michael Leahy.

In ART, protocols basedon symptom patterns arelinked to manual treatment ofspecific anatomic sites.Specific techniques are thenused for release of proposed

soft tissue adhesions thatconsist of applying deep digitaltension usually with the thumbor two fingers combined withboth active and passivepassage of the tissue throughthis area of deep tension. Anactive home stretching


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program follows this manualtreatment. 43

Manual therapyinterventions include bothstatic and facilitated stretching.In the 1950s, physiotherapistsMargaret Knott & DorothyVoss 44 developedproprioceptive neuromuscularfacilitation (PNF) that by wayof a combination of isometriccontractions and mid throughendrange movements in three-dimensional naturallyoccurring spiral and diagonalpatterns used reflexogenicactivation and relaxation forspecific stretching,strengthening, andstabilization. Post-isometricrelaxation is a Europeanmanual medicine techniquesimilar to a PNF hold-relax-stretch technique in that thepatient is asked to gentlycontract a muscle from aslightly lengthened positionfollowed by a further gentlestretch upon relaxation. 45

In the late 1930s, Dr.Janet Travell (Figure 17), at

that time a cardiologist andmedical researcher, becameinterested in muscle pain.

Figure-17 Figure-18(Janet Travell) (David Simons)

In the early 1960s,physiatrist Dr. David Simons(Figure 18) and his wife,physiotherapist Lois Simons,started collaborating withTravell, which eventuallyresulted in the Trigger Point

Manuals , consisting of twovolumes on the upper and thelower half of the body. 46,47 Although initially in addition tospray-and-stretch techniquesheavy ischaemic pressure wasadvocated as a manualtechnique for treatment ofmyofascial trigger points, theupdated second edition of thefirst volume instead suggestedthe use of gentle digitalpressure or manual triggerpoint pressure release. 48

Paradigm Shift

The above approachesto OMPT were all developed ina time when the traditionalmedical paradigm was still thepredominant paradigm guidingclinical practice. Kuhn 49 firstadopted the term paradigm torefer to a set of practices thattogether defined a scientificdiscipline in a given historicalperiod. The defining set ofpractices of the traditionalmedical paradigm was thatpatient management wasguided mainly by apathophysiologic rationale orextrapolation from basicscience and by knowledgeprovided by respectedauthorities in the field. With itsemphasis on expert opinionthis traditional medicalparadigm has also been calledthe authority-basedparadigm. 50 Associated withthis paradigm, diagnosticclassification models usedwithin OMPT at that time (andstill to this day) were an

amalgam of patho-anatomicaland mechanism-basedclassification models. Thepatho-anatomical classificationassumes a direct correlationbetween underlying pathologyand signs and symptoms, 51 whereas the mechanism-

based classification system isbased on the premise thatdysfunctions identified duringexamination are the cause ofpain and decreased function. 52 The intent of this amalgam ofpatho-anatomical andmechanism-based OMPTdiagnosis is to identify the

joint(s) and/or soft tissuesimplicated, the extent ofdamage to the tissue, thepossible neuro-reflexive exten-sion of the local impairment,and the levels of reactivity andability for a targeted orselective response tointervention within the nervoussystem .41

Kuhn 49 describedhow scientific revolutionscome about by way ofparadigm shifts, whereby achange occurs in the basicassumptions within thepredominant or central theoryof a specific scientificdiscipline. Although Kuhnreserved his observations forthe hard sciences, the termparadigm shift has since alsobeen applied to other fields ofstudy and practice includingmedicine and the other healthsciences, specifically todescribe the shift from thetraditional medical paradigm tothe evidence-based practice(EBP) paradigm.

The EBP paradigm canbe traced back to the late1970s, when a group ofclinical epidemiologists atMcMaster University in

Hamilton, Ontario in Canadaled by David Sackett publisheda series of articles in theCanadian Medical AssociationJournal for practicingphysicians on critical appraisalof research information foundin professional journals.


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In 1990, Dr. Gordon Guyatt,an internal medicine specialistand residency director ofinternal medicine at McMasterUniversity, then proposed

plans for restructuring theresidency program to onebased less on authority-basedknowledge and more onknowledge and understandingof the relevant medicalresearch literature. His firstchoice for the name of thisnew paradigm, scientificmedicine , understandably metwith more than a littleresentment and resistancefrom his colleagues and theuniversity administrators but asecond try by Guyatt atrenaming this new paradigm toevidence-based medicine ,proved more fortuitous andthis new method of teachingmedicine gained acceptanceat initially McMaster Universityand in rapid succession atincreasing numbers of medicalprograms worldwide.Acknowledging the broadapplication of this newparadigm also in areas ofhealth care clinical practiceother than solely medicine, theterms evidence-based healthcare or EBP have since beenwidely adopted. 53

Evidence-basedpractice has since also rapidlybeen embraced by otherhealth care professio nsincluding physiotherapy. 54 Within current-day OMPT theEBP paradigm is most closelyassociated with the treatment-based diagnostic classificationsystem in which a cluster ofsigns and symptoms from thepatient history and physicalexamination ideally derivedfrom clinical prediction rule(CPR) or other relevant

research is used to classifypatients into subgroups withspecific implications formanagement. Clinicalprediction rules (CPR) are

decision-making tools thatcontain predictor variablesobtained from patient history,examination, and simplediagnostic tests; they canassist in making a diagnosis,establishing prognosis, ordetermining appropriatemanagement. 55

Within the OMPTcommunity, this paradigm shiftfrom the authority-based to theEBP paradigm has met andcontinues to meet with notedresistance. For many, theirperception of an overreliancein this paradigm on strictlydefined types of researchevidence in the decision-making process seemedmirrored in the early definitionof EBP as the conscientious,explicit, and judicious use ofcurrent best evidence inmaking decisions about t hecare of individual patients. 56 Of course, the oftenunwarranted and extravagantclaims made in the early daysby EBP proponents, theperceived disregard forestablished clinical practice,and a social context thatinvolved clinicians trying tomaintain their autonomy in theface of increased managerialinfluence within the healthcare system, increasingfinancial constraints on clinical

practice, and the need forincreased risk managementstrategies have not helped todiminish the resi stanc e to theparadigm shift. 57,58 Other

justified criticisms have beenrelated to the fact that theemphasis of EBP was (at least

initially) placed on solelymedical practice, that itsevidence concerned singleclinical interventions ratherthan the more pragmatic multi-

intervention approachescommon in areas of healthcare other than medicine, andthat there was anoveremphasis within theparadigm on evidenceproduced by randomizedcontrolled trials (and meta-analyses of such trials), astudy design modeled afterpharmacological research andconsidered less appropriatefor producing evidencerelevant to these ot her healthcare professions. 59 An evenmore powerful philosophicalcriticism against the adoptionof EBP as the predominantparadigm in OMPT but also inphysiotherapy in general isthat the evidence-basedrational model of decision-making does not reflect thereality of the individualized andcontextualized clinicalpractice. This holds trueespecially in non-medicalpractice such as OMPT clinicalpractice in which the healthproblems with which patientspresent are often multi-factorial and less well def inedthan in medical practice. 60

However, in the face ofall this resistance and criticismit should be recognized thatEBP is not a static concept. 58 Although at first the paradigmundeniably placed the

randomized controlled trial onan undeserved pedestal as theonly truly relevant form ofevidence to guide clinicalpractice, EBP has evolved towhere it now adopts a moreinclusive view of evidence thatrecognizes not only the value


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Figure-19(ICF Conceptual framework relevant to diagnosis in rehabilitation)

of different research designsbut also of clinical expertise,patient values, andpreferences, and evencontextual factors in the

clinical decision-makingprocess. 57, 59 As such it moreclosely mirrors the extendeddiagnostic process relevantto rehabilitationprofessionals proposed bythe World Healthorganization in theInternational Classification ofFunctio n ing, Disability andHealth 61 (Figure 19). Sackettet al 62 also de-emphasizedthe perceived pre-eminenceof research evidence in favorof an EBP paradigmsupported equally by threepillars when they defined theparadigm as the process ofintegrating the best researchevidence available with bothclinical expertise andpatients values.

Over time, EBP haschanged its focus from aconsistent use of bestavailable research evidenceto an approach thatacknowledges that clinicaldecision-making requires a

judicious mixture of manyforms of knowledge otherthan research evidenceincluding once againclinician experience andexpertise .58 In effect, theparadigm has changed frombeing evidence-driven to onethat is evidence-informed. 63 Practicing under theevidence-informedparadigm, the clinician takesthe evidence from researchinto account when makinghis or her clinical decisionwith regard to patientmanagement but evidencedoes not dictate this

Decision. 57,58 However, adoptingthe evidence-informed paradigmdoes not represent a solelysemantic difference in that theterm is more palatable to manyclinicians. The evidence-informed paradigm has notredefined EBP to simply includeclinician experience but ratheracknowledges that as clinicianswe recognize the importance ofand are learning to combine thevarious types of knowledge inaddition to research evidence that form the basis of real-lifeclinical decision-making. 58

Future Developments and aRole for the Journal ofPhysical Therapy

In discussing the history

and development of manualtherapy, this paper should serveto highlight to the reader notonly the contribution made byphysiotherapists to techniqueand concept development andresearch within manual therapy

but also that manual therapyhas been a continuous andinextricable part of thephysiotherapy scope ofpractice dating back at leastas far as 1813. With theincreasing integration ofresearch evidence into clinicalpractice and the associatedparadigm shift from anauthority-based to anevidence-based and now anevidence-informed paradigm,as also stressed by IFOMP Tin their definition of OMPT, 3 we find ourselves as aprofession learning tointegrate various diagnosticclassification models relevantto OMPT and variousrationales for determiningindications, contra-indications,

and precautions for use ofdiverse manual therapyinterventions. Perhaps mostimportant in this regard is theemerging knowledge withregard to pain physiology andimplications on the integrationof OMPT interventions within a


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comprehensive andmultidisciplinary approach tomanagement of especiallypatients with chronic painsyndromes.

It is my hope that theJournal of Physical Therapywill serve as a medium forexchange of informationbetween clinicians, educatorsand researchers. Specific tomy interest area of OMPT, Iwould hope to see a respectfuland constructive discussionthat values and acknowledgesthe importance of clinicalexperience and expertise,basic and applied researchevidence, but also contextualfactors relevant to patientmanagement, integrating artand science of OMPT in theform of case reports and caseseries, narrative andsystematic literature reviewsand meta-analyses, researchstudies, commentaries,historical papers and any otherform of communicationrelevant and committed tooptimal, patient-centered andevidence-informed clinicalcare for our patients.

Ethical approvalExempted.

AcknowledgmentsNone.

Conflicts of interestNone declared.

Article pre-publicationhistory:

Date of invitation- 1 st April 2010.Date of submission- 7 th April 2010.Reviewer- P. Senthil KumarDate of acceptance- 10 th April 2010.Date of publication- 24 th April 2010.WFIN: JPT-2010-ERN-102-1(1)-11-24

References:

1. American Physical TherapyAssociation. Guide to PhysicalTherapist Practice. 2 nd ed. Phys Ther. 2001;81:9-744.

2. Sluka KA, Milosavljevic S. Manualtherapy. In: Sluka KA, Ed.Mechanisms and Management of Painfor the Physical Therapist . Seattle,WA: IASP Press, 2009:205-214.

3. Orthopaedic Manual Therapy(OMT) Definition [website]. Availableat: http://www.ifomt.org/ifomt/about/omtdefinition . Accessed April 9, 2010.

4. Cyriax JH. Textbook of OrthopaedicMedicine . Vol 1 . 8th ed. London, UK:Bailliere Tindall, 1982.

5. Goats GC. Massage: The scientific

basis of an ancient art. Part 1. Thetechniques. Br J Sports Med.1994;28:149-152.

6. Paris SV. A history of manipulativetherapy through the ages and up tothe current controversy in the UnitedStates. J Man Manip Ther. 2000;8:66-77.

7. Lomax E. Manipulative therapy: Ahistorical perspective from ancienttimes to the modern era. In: GoldsteinM, Ed. The Research Status of SpinalManipulative Therapy . Bethesda, MD:US Dept. of Health Education andWelfare, 1975:11-17.

8. Pettman E. A history ofmanipulative therapy. J Man ManipTher. 2007;15:165-174.

9. Oths KS, Hinojosa SZ, Eds. Healingby Hand: Manual Medicine andBonesetting in a Global Perspective .Walnut Creek, CA: Altamira Press,2004.

10. Terrett A. The search for thesubluxation: An investigation ofmedical literature to 1985. ChiroprHist. 1987;7:29-33.

11. Gevitz N. The D.O.s: OsteopathicMedicine in America . Baltimore, MD:The Johns Hopkins University Press,1982.

12. Ottoson A. Sjukgymnasten-VartTog Han Vgen? Ph.D. diss.Gteborg, Sweden: HistoriskaInstitutionen Gteborgs Universitet,2005.

13. Ottoson A. When thephysiotherapist was a doctor ofphysiotherapy or why physiotherapistsdont know about their history:Swedish Physiotherapy 1813-1934 .Poster presentation: Conference ofthe International Society of MedicalHistory. Kos, Greece, 2008.

14. Kellgren A. Technics of LingsSystem of Manual Treatment .Edinburgh, UK: Young J. Pentland,1890.

15. Kaltenborn F. Early history ofphsyiotherapy in Sweden and Norway:Implications for professional autonomyand direct-access clinical practice.Tijdschr Man The.r 2008;5(2):6-9.

16. Terlouw TJA. Roots of physicalmedicine, physical therapy, andmechanotherapy in the Netherlands in

the 19th

century: A disputed areawithin the health care domain. J ManManip Ther. 2007;15:E23-E41.

17. Huijbregts PA. Chiropractic legalchallenges to the physical therapyscope of practice: Anybody else takingthe ethical high ground? J Man ManipTher. 2007;15:69-80.

18. Linker B. Strength and science:Gender, physiotherapy, and medicinein early twentieth-century America. JWomens Hist. 2005;17:105-132.

19. Paris SV. Thirty-Seventh McMillanLecture: In the best interests of the

patient. Phys Ther. 2006;86:1541-1533.

20. Sollmann AH, Blaurock-Busch E.Manipulative therapy of the spine: Thedevelopment of manual medicine inGermany and Europe. Chiropr Hist .1981;1:37-41.

21. Kaltenborn F M, Evjenth O,Baldauf Kaltenborn T, Morgan D,Vollowitz E. Manual Mobilization of theExtremity Joints: Joint Examinationand Basic Treatment. Vol. I: TheExtremities , 6th revised ed. Oslo,Norway: Norli, 2007.

22. Kaltenborn F M, BaldaufKaltenborn T, Vollowitz E. ManualMobilization of the Joints: JointExamination and Basic Treatment.Vol. III: Traction-Manipulation of theExtremities and Spine, Basic ThrustTechniques . Oslo, Norway: Norli,2008.


13/14

J Phys Ther. 2010;1:11-24.

23


Historical paper

Huijbregts P A

J Phys Ther. 2010;1:11-24.

23. Bentley P, Dunstan D.Physiotherapy in Australia to the1980s: The Path to Professionalism .Victoria, Australia: AustralianPhysiotherapy Association, 2006.

24. Laslett M, Young SB, Aprill CN,McDonald B. Diagnosing painfulsacroiliac joints: A validity study of aMcKenzie evaluation and sacroiliacprovocation tests. Aust J Physiother. 2003;49:89-97.

25. Cook CE. Orthopaedic ManualTherapy: An Evidence-BasedApproach . Upper Saddle, NJ: River,Pearson Prentice Hall, 2007.

26. Paris SV. Mobilization of thespine. Phys Ther. 1979;59:988-995.

27. McKenzie RA. The Lumbar Spine:Mechanical Diagnosis and Therapy.

Waikanae, New Zealand:SpinalPublications, 1981.

28. Mulligan BR. Manual Therapy:NAGS, SNAGS, MWMS etc . 5thed. Wellington, New Zealand: PlaneView Services Ltd, 2004.

29. Exelby L. Peripheral mobilisationswith movement. Man Ther. 1996;1:118-126.

30. Hsieh C Y, Vicenzino B, Yang CH, Hu M H, Yang C. Mulligansmobilization with movement for thethumb: A single case report usingmagnetic resonance imaging toevaluate the positional faulthypothesis. Man Ther. 2002;7:44-49.

31. Shacklock M, Ed. Biomechanics ofthe Nervous System: Breig Revisited .Adelaide, Australia: NeurodynamicSolutions, 2007.

32. Butler DS. Mobilisation of theNervous System . Melbourne,Australia: Churchill Livingstone, 1991.

33. Shacklock M. ClinicalNeurodynamics: A New System ofMusculoskeletal Treatment .Edinburgh, UK: Elsevier, 2005.

34. Butler DS. The Sensitive NervousSystem . Adelaide, Australia: NOIGroup, 2000.

35. Pettman E. Manipulative ThrustTechniques . Abbotsford, Canada:Aphema Publishing, 2006.

36. Sanzo P, MacHutchon M. LengthTension Testing of the Lower

Quadrant . Thunder Bay, Canada:Active Potential, 2007.

37. Sanzo P, MacHutchon M. LengthTension Testing of the UpperQuadrant . Thunder Bay, Canada:

Active Potential, 2007.38. Whitmore S, Gladney K, Driver A.The Upper Quadrant: A Workbook ofManual Therapy Techniques . Guelph,Canada: Whitmore Physiotherapy,2004.

39. Whitmore S, Gladney K, Driver A.The Lower Quadrant: A Workbook ofManual Therapy Techniques . Guelph,Canada: Whitmore Physiotherapy,2005

40. Grimsby O, Rivard J, Eds.Science, Theory and ClinicalApplication in Orthopaedic Manual

Physical Therapy. Vol 1: AppliedScience and Theory . Taylorsville, UT:The Academy of Graduate PhysicalTherapy, 2008.

41. Van der El A. Orthopaedic ManualTherapy Diagnosis: Spine andTemporomandibular Joints . Sudbury,MA: Jones & Bartlett Publishers,2010.

42. Moraska A. Sports massage: Acomprehensive review. J Sports MedPhys Fitness. 2005;45:370-380.

43. Schiottz-Christensen B, MooneyV, Azad S, Selstad D, Gulick J,Bracker M. The role of active releasemanual therapy for upper extremityoveruse syndromes: A preliminaryreport. J Occup Rehab. 1999;9:201-211.

44. Voss DE, Knott M. ProprioceptiveNeuromuscular Facilitation . SanFrancisco, CA: Harper & RowPublishers, 1956.

45. Lewit K, Simons D. Myofascialpain: Relief by post-isometricrelaxation. Arch Phys Med Rehabil .1984;65:452-456.

46. Travell JG, Simons DG.Myofascial Pain and Dysfunction: TheTrigger Point Manual. Vol. 2 .Baltimore, MD: Williams & Wilkins,1992.

47. Travell JG, Simons DG.Myofascial Pain and Dysfunction: TheTrigger Point Manual. Vol. 1. Baltimore, MD: Williams & Wilkins,1983.

48. Simons DG, Travell JG, SimonsLS. Travell and Simons' MyofascialPain and Dysfunction: The TriggerPoint Manual. Vol. 1 . 2 nd ed.Baltimore, MD: Williams & Wilkins,1999.

49. Kuhn T. The Structure of ScientificRevolutions . 2 nd ed. Chicago, IL:University of Chicago Press, 1970.

50. Poolman RW, Petrisor BA, MartiRK, Kerkhoffs GM, Zlowodzki M,Bhandari M. Misconceptions aboutpracticing evidence-basedorthopaedic surgery. Acta OrthopScand. 2007;78:2-11.

51. Fritz JM. A research-basedapproach to low back pain . Presentedat the Distinguished Lectures inSports Medicine Series; Holland, MI,October 12, 1999.

52. Van Dillen LR, Sahrmann SA,Norton BJ, et al. Reliability of physicalexamination items used forclassification of patients with low backpain. Phys Ther. 1998;78:979-988.

53. Guyatt G. Preface. In: Guyatt G,Rennie D, Eds. Users Guide to theMedical Literature: A Manual forEvidence-Based Clinical Practice .Chicago, IL: AMA Press, 2002:xiii-xvi.

54. Beattie P. Evidence-basedpractice in outpatient physical therapy:Using research findings to assistclinical decision-making. Ortho PhysTher Pract. 2004;16(3):23-25.

55. Laupacis A, Sekar N, Stiell I.Clinical prediction rules: A review andsuggested modification ofmethodological standards. J Am MedAssoc. 1997;277:488-494.

56. Sackett DL, Rosenberg WM, GrayJA, Haynes RB, Richardson WS.Evidence based medicine: What it isand what it isnt. BMJ. 1996;312:71-72.

57. Rycroft-Malone J, Seers K,Titchen A, Harvey G, Kitson A,McCormack B. What counts asevidence in evidence-based practice?J Adv Nurs. 2004;47:81-90.

58. Pencheon D. Whats next forevidence-based medicine? Evidence- Based Health Care & Public Health.2005;9:319-321.


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