What is Orthopaedic Manual Therapy anyway?

Patient: “That feels a lot better” he said. “What were you doing there?”
Me” “Some hands-on treatment for your neck – I suspected some of your shoulder pain might have been coming from your neck, and I think we just found the main source of your problem,” I said.
Patient: “I had lots of manual therapy for my shoulder, and it never helped the pain – why didn’t they work on my neck too?”
I have had a version of this conversation with many patients over the years. He has asked a good question; how should I respond?

Jason Silvernail DPT, DSc, FAAOMPT

Twitter @jasonsilvernail
Clinician, Researcher, Health Care Executive
Disclaimer: The opinions expressed are Dr Silvernail’s personal opinion and commentary and do not reflect the official policy or position of the US Army, the Defense Health Agency, the Department of Defense, or the United States Government.
Author bio(s): Jason Silvernail is a career military officer as well as clinician and researcher in the United States Army where he holds the rank of Colonel and is currently the Consultant to the Army Surgeon General for Physical Therapy.

Patient: “That feels a lot better” he said. “What were you doing there?”

Me” “Some hands-on treatment for your neck – I suspected some of your shoulder pain might have been coming from your neck, and I think we just found the main source of your problem,” I said.
Patient: “I had lots of manual therapy for my shoulder, and it never helped the pain – why didn’t they work on my neck too?”

I have had a version of this conversation with many patients over the years. He has asked a good question; how should I respond?

Moreover, it’s not just patients that ask, either. Often colleagues and students wonder the same thing, especially when clinical practice guidelines and systematic reviews categorize or discuss manual therapy as “passive” care or when professional discussions about manual therapy frame it in terms of an additional element or modality such as you might discuss therapeutic ultrasound or electrotherapy. It is often discussed as something you can choose to add or subtract from clinical care just as you might an exercise or a cold pack.

The response you suggest to my patient’s question depends on how you define orthopedic manual therapy (OMT), and it certainly depends on whether you see it as an additional modality to add or subtract to care as some do. I have written elsewhere¹ that OMT is “…a ‘process’ of care centered on a reasoning model, not a ‘product’ consisting of one or more manipulative techniques. That is definitely how many experts see things, but I think this perspective may not be informing our professional discussions of OMT and the way it is captured in systematic reviews and clinical guidelines, and that has implications for the care our patients receive.

The International Federation of Orthopedic Manual Physical Therapists (IFOMPT) says that Orthopaedic Manual Therapy is a specialized area of physical therapy for the management of neuromusculoskeletal conditions, based on clinical reasoning, using highly specific treatment approaches including manual techniques and therapeutic exercises. This definition is much closer to what I told my patient, and it’s different than the way many people see OMT – as merely a list of techniques to be applied to a patient lying passively on an exam table. But this is a curiously narrow view of OMT, isn’t it? Is physical therapy just a list of exercises? Is medicine only a bottle of pills? Is surgery only a scalpel? Why do we sometimes see OMT as different?

Now, some clinicians use OMT like that – try through trial and error a series of techniques without a coherent differential diagnosis, attention to dosage, or clinical reasoning process. “Is the patient not getting better? Let’s add some manual therapy!” However, that misconception of OMT is as common as it is of physical therapy, medicine, or surgery. Just because we *can* see something in the most narrow and limited possible way, doesn’t mean that we should, or that perspective is valuable for our patients.

Medication should be prescribed after a history, examination, and diagnostic process. The type and dosage of medication selected tailored to the patient’s diagnosis and needs, aligned with research evidence and the clinician’s expertise. It would not be possible to prescribe the right medication therapy without that diagnostic process and tailoring. We can standardize pharmacological therapy for clinical trials that inform practice guidelines – but we have to do it in a way that mirrors clinical practice.

Surgical care proceeds after a history, examination, and diagnostic process. The specific procedure performed should be tailored to the patient’s diagnosis and needs, aligned with research evidence and the clinician’s expertise. It would not be possible to determine the right surgical approach or procedure without that diagnostic process and tailoring. We can standardize surgical care for clinical trials that inform practice guidelines – but we have to do it in a way that mirrors clinical practice.

Why should OMT not be seen the same way? Orthopedic Manual Therapy is a process of care structured around a reasoning model, tailored to the patient’s presentation with precise manual intervention, carefully dosed reinforcing exercises, comprehensive activity advice, complex clinical judgment, and continuous interaction and reassessment – not just the performance of assorted manipulative techniques. Exercise therapy, activity advice, and other treatment is prescribed based on the diagnostic process and tailoring.

I know some might see this perspective as ‘special pleading’ – a desire to treat a particular treatment (in this case, OMT) as special or different and not held to the same standards of evidence as others. Nevertheless, it is the opposite; I’m advocating that we should be consistent in the way we discuss and study treatments – including OMT. We should have the same expectations of OMT that we have of any other process in medicine, the expectation that treatments be applied by trained personnel in a patient-centered model, not provided as a laundry list of interventions divorced from a reasoning model.

Patient: “Oh well that makes sense, you just do the hands-on therapy differently than the others did.”
Me: “Yep. I get that a lot. I’m glad we are on the right track to helping you feel better!”