Orthopaedic Manual Physical Therapy: From Art to Evidence

937 Pages·2015·86.51 MB·English

by  Christopher H. Wise

From Art to Evidence
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Orthopaedic Manual
Physical Therapy
F R O M A R T T O E V I D E N C E
Christopher H. Wise,
PT, DPT, OCS, FAAOMPT, MTC, ATC
Doctor of Physical Therapy Program Director
Associate Professor of Physical Therapy
Alvernia University
Reading, Pennsylvania
Owner and President
WISE Physical Therapy LLC
Kutztown, Pennsylvania
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Library of Congress Cataloging-in-Publication Data
Orthopaedic manual physical therapy : from art to evidence / [edited by]
Christopher H. Wise.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-8036-1497-0 — ISBN 0-8036-1497-7
I. Wise, Christopher H., editor.
[DNLM: 1. Manipulation, Orthopedic—methods—United States. 2.
Evidence-Based Practice—United States. WB 535]
RM725
615.8'2—dc23
2014034975
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THIS BOOK IS DEDICATED
To my Lord and Savior Jesus Christ,
“In Him we live and move and have our being” (Acts 17:28)
and
with Him “all things are possible” (Matthew 19:26);
To Mom and Dad,
for the sacrifices that you have made for my happiness
and
for instilling within me a passion to pursue God’s will in my life;
To my big sis, Vicki,
my hero,
for teaching me to “soar with the eagles.”
Through your example, I am what I am today;
To Hilary, Jordyn, Nick, Jordan, and Jessica,
for bringing immeasurable joy to my life,
making me laugh, and inspiring me;
To Jodi,
the love of my life, for your patience, for believing in me,
and
for the way that you love me “today and every day.”
You make me better. This one is for you!
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Foreword
Orthopaedic manual physical therapy (OMPT) has become write on that particular “discovery.” Some in the process have,
recognized by the profession of physical therapy as a premier unfortunately, dammed what has gone before, but most recog-
area of clinical specialization. Once part of the practice of our nize that they share common roots of practice and that their
founders, it was shelved during the rise of chiropractic in the contribution is just that—a contribution.
1930s. Chiropractic claims to prevent and cure all diseases With the current emphasis on evidence-based practice man-
through manipulation caused the fledgling physical therapy ual and manipulative practice has fared well. This author feels,
profession to nearly cease the practice of manual therapy. It however, that some of this research is leading us down the
survived in a much deemphasized form under such terms as wrong path and that too much influence is being paid to the
passive movement, articulating, and mobilization. However, in the published literature rather than to patient’s wishes and most
1960s, with the advent of physical therapists such as Maitland, importantly the expertise of the practitioner—one of the three
McKenzie, and this author, manual therapy once again became legs of the stool described by Sackett. Seeking to publish often
an important area of clinical practice. Today, instruction in resorts in asking the simple questions in order to have a pub-
manual therapy is required within all first professional educa- lished article. The skill of manipulation is in danger of being
tional programs in the United States. dumbed down by those who would seek clinical prediction
National and international organizations now affirm stan- rules regardless of underlying specific impairments. What is
dards of practice and offer forums for the exchange of clinical required in manual therapy research is to ask the right ques-
and scientific knowledge. The Orthopaedic Section of the tions, not the simple ones, and to seek to validate the skills that
American Physical Therapy Association was founded by those the masters in this field have developed rather than the gross
interested in manual and manipulative therapy as was the Inter- techniques capable of being taught to the novice. Perhaps for
national Federation of Orthopaedic and Manipulative Physical the present we should be talking of evidence-influenced prac-
Therapy (IFOMPT). The American Academy of Orthopaedic tice rather than evidence-based practice, for there is too little
Manual Physical Therapists (AAOMPT) became the first entity published evidence on which to base practice, and much of it
to exist outside of the American Physical Therapy Association does not stand up to critical scrutiny.
(APTA) in order to have an organization that could set skill and In keeping with its title, Dr. Wise has created a text that
educational standards for membership. No such opportunity provides the reader with a sense of both the art and the science
existed within the APTA, and to be a member of IFOMPT such of OMPT, for surely manipulation is an art in search of its
standards are required. The academy has worked closely with science. Well suited for both physical therapy students and
the Orthopaedic Section and the APTA to develop operational clinicians, this text adopts an eclectic approach to OMPT that
definitions, standards of practice, and to defend practice via the incorporates detailed descriptions of examination and inter-
Manipulation Task Force. vention principles for each anatomic region. This should not
The question could be asked, “What is orthopaedic manual confuse readers but rather empower them to see the diversity
and manipulative physical therapy?” Since its inception, the prac- of practice and the opportunity to discover for themselves
tice of OMPT has espoused more than simply the mobilizing or which approach best suits their personal style as well as the
manipulating of joints. As Meadows states, OMPT represents patients and clients that make up their practice.
“an entire approach to musculoskeletal dysfunction and not just The selection of guest authors is excellent and their con-
a series of techniques, whose purpose is to mobilize or stabilize a tributions add to the depth and veracity of the content that is
particular joint or spinal segment.” As Riddle describes, OMPT presented. Manual therapy is no longer in the hands of those
is more than just the application of manual techniques and notes who led the rebirth of its practice in physical therapy. It has
that, “manual procedures (may be used) to collect data on patients matured, diversified, and in the process it has gained strength.
with musculoskeletal problems.” Farrell et al add that OMPT is, This text captures that essence and will prove to be an invalu-
“not a specialty that utilizes only passive movement techniques, able resource for students, clinicians, and researchers who are
(but) whose indications are multifactorial evolving from clinical interested in developing and advancing this area of specializa-
criteria rather than from descriptions of pathology.” tion within the profession of physical therapy.
That there are so many approaches to OMPT should not
Stanley V. Paris, PT, PhD, FAPTA
be cause for confusion, for many of the differences represent
FNZSP (Hon), NZMTA (Hon), IFOMT (Hon),
but a minor emphasis on one aspect or another from what has
FAAOMPT (Founding Fellow), MCSP (Eng)
gone before. If a therapist develops a particular interest, skill,
Chancellor, University of St. Augustine for
or “discovery” they wish to speak up, demonstrate, teach, and
Health Sciences
v
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Preface
The Purpose of this Book what Stoddard described as that, “elusive tissue texture
sense.”3
Mennell exclaimed, “the human hand is the oldest remedy
It is my hope that through deliberate study of these con-
known to man, and historically, no date can be given for its
cepts, strict attention to detail, and most importantly, reflec-
inception.”1 It has only been in recent years, however, that
tive practice, practice, practice, the reader will attain a level of
the profession of physical therapy has formally embraced
proficiency that when applied judiciously will have a pro-
orthopaedic manual physical therapy (OMPT) as an entire
found impact on those whom we serve and subsequently on
approach to the management of musculoskeletal dysfunction.
the profession of physical therapy. It would do the reader well
In fact, prior to the early 1990s, formal training in the art and
to consider the three pillars of Sackett’s model of evidence-
science of OMPT was not routinely included within the edu-
based practice when reading this text and when applying its
cational curricula of physical therapists. Many well-intentioned
principles.4 Let the title of this text serve as a reminder of
physical therapists have disregarded the use of these strategies
OMPT’s perplexing and sometimes conflicting nature as a
within their clinical practice due to the paucity of literature
science that is applied through a variety of art forms and
supporting their veracity or based in an honest attempt to
individualized expression.
establish distance between the field of physical therapy and
other health-related professions. Consequently, a significant
number of clinicians have spent a portion of their careers The Scope of this Book
without consideration of these strategies within their diagnos-
The scope of this book reflects its objective by presenting a
tic and intervention armamentarium. It is, therefore, time for
comprehensive review of the principles and practices of the
a more in-depth exposition of both the art and the science of
most significant schools of thought that have influenced the
this unique and important area of specialty practice. The pri-
practice of OMPT in the United States today. The compre-
mary objective of this text is to serve as the definitive resource
hensive, eclectic, and evidence-based manner in which this
on the principles and practice of OMPT for physical therapist
book was written facilitates its use in guiding clinical practice.
students, instructors, clinicians, and researchers.
This book, and the accompanying web-based instructional
videos, will attempt to achieve the critical balance between the-
About the Title ory and clinical application. Throughout the text, a preoccu-
pation is placed on appreciating concepts in light of the best
Orthopaedic Manual Physical Therapy: From Art to Evi-
available evidence with an emphasis on assisting the reader in
dencewas decided upon following extensive deliberation and
making connections between theory and practice through a
debate. Originally targeted to be more inclusive, the text was
process of critical thinking. This text focuses on supporting the
titled, Orthopaedic Manual Therapy. Upon the advice of several
development of the physical therapist student and clinician as
of the book’s contributors, who espoused the importance of
a specialist in “applied kinesiology.” Despite the strict attention
focusing the text on those aspects of manual therapy that have
given to every detail of technique performance, the manual
become essential to the practice of physical therapy, the title
procedures presented within this book are deemed to be sec-
was changed. This is not to say that all of the content con-
ondary to the development of astute clinical decision-making
tained herein has been developed, or is exclusively utilized,
skills within the reader.
by physical therapists. After all, the tenets of manual therapy
are not specific to any one profession and most strategies have
evolved through a gradual process of formative independent Philosophic Approach and
and collaborative contribution from a myriad of individuals Pedagogical Features
over the course of many years. The second portion of the
To accomplish its objectives, this book explicitly and implicitly
title, From Art to Evidence, was later added for the specific
revolves around four foundational themes:
intent of recognizing, embracing, and communicating the
notion that OMPT, in its truest form, is the culmination 1. This text approaches OMPT from an eclecticperspective
and amalgamation of both art and science. As Salter stated, that endeavors to equip the reader with an arsenal of
“Patient care is an art, but the art must be based on science.”2 clinical tools from which to draw. Developing within the
The writing of this book provided the challenge of coupling reader an appreciation for the value of each school of
science with the artful skill of developing within the reader thought as it applies to current practice is a major theme
vii
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viii Preface
of this text and one that has not been as comprehensively OMPT. The book is organized in a manner that facilitates
presented elsewhere. This feature is most vividly pre- clinical application. Chapter 2 is dedicated to principles
sented in Part II of this book, where 18 different ap- in preparation for OMPT. This chapter includes key
proaches are expertly presented by the originators of concepts designed to facilitate the effective and safe im-
or contributors to each specific school of thought. plementation of OMPT procedures. Concepts are pre-
2. In recent years, the profession of physical therapy has ex- sented that attempt to prepare individuals for practice
perienced a healthy paradigm shift toward evidence-based through principles that target the cognitive, affective, and
practice (EBP). Orthopaedic manual physical therapy has psychomotor domains of learning. Part III of this text is
not enjoyed a long history of evidence to support its dedicated to the practice of OMPT and is designed to
efficacy. In developing this resource, it was my intent to draw from each philosophic approach and provide a
present a review of the literature designed to stimulate template for the clinical application of OMPT. Using a
further inquiry that directly impacts clinical practice. It regional approach, each chapter in this section begins
is my hope that the presentation of these foundational with a review of kinematics followed by principles of
approaches side by side in light of the evidence will examination and intervention and concludes with an
advance the cause and the case for the integration of eclectic and essential skill set of OMPT joint mobilization
OMPT within the profession of physical therapy. To techniques that provides detailed instruction for optimal
support this objective, evidence is generously provided performance. To further enhance the psychomotor per-
throughout the exposition of each approach. Chapter 3 is formance of these OMPT techniques, a web-based in-
dedicated to the role of EBP within OMPT, and tools for structional resource that provides video demonstration
evaluating and applying evidence to clinical practice are with clear verbal and visual cues is also provided. The
provided. The time-sensitive and ever-evolving nature of conclusion of each chapter in Part II and III of the book
the published literature presented within a text of this contains a Clinical Case, which is designed to bring to-
kind poses several challenges. The literature presented gether the principles of exam and intervention previously
throughout the text provides foundational support for presented. Following the case, specific questions are in-
the concepts and practices contained herein; however, the cluded that require critical thinking and serve to ensure
presented literature in many cases is not the most current. that key concepts have been attained. Each chapter within
The reader is advised to consult other sources for the these sections concludes with a Hands-Onsection that
most recent published evidence. provides specific activities that students and educators
3. Another foundational philosophical emphasis of this may use in lab to facilitate learning within each domain.
text has been placed on assisting the reader in the devel-
opment of sound critical thinkingstrategies as they relate
The Organization of this Book
to OMPT. With this objective in mind, the reader is
empowered with more than just a collection of effective This book is divided into three main sections:
techniques, but rather an entire framework from which ● PART I: Perspectives and Principles in Orthopaedic
to make clinical decisions regarding how best to incor- Manual Physical Therapy
porate OMPT into a comprehensive examination and The first section of this book articulates the foundational
intervention schema. To facilitate the connection be- concepts that form the underpinnings of OMPT and
tween philosophical constructs and critical thinking, serves to equip the reader with information paramount to
each chapter in Part II is equipped with Clinical Pillar the understanding of concepts presented later in the text.
boxes, which provide foundational concepts that are in- Chapter 1, Historical Perspectives in Orthopaedic Manual
tegral and germane to each approach. The Questions for Physical Therapyisdesigned to provide the reader with an
Reflectionboxes enable the reader to engage in a process understanding of the origins of OMPT. Chapter 2, Princi-
of critical thinking as information is being presented. ples of Preparation for Orthopaedic Manual Physical
The Notable Quotableboxes provide thought-reflecting Therapy, addresses fundamental principles related to the
quotes from the originators of each approach that serve safe and effective performance of OMPT. The concept
to summarize key concepts and inspire. Lastly, summary of evidence-based practice is most explicitly covered in
boxes that review key points presented within the text Chapter 3, Principles of Evidence-Based Practice Applied
are placed throughout each chapter to allow the reader to Orthopaedic Manual Physical Therapy, which provides
to reflect on new concepts. practical tools to enhance the reader’s ability to critically
4. The final philosophical pillar on which this book was de- analyze the OMPT literature and sets the tone for the em-
veloped is its preoccupation with practical application. In phasis on EBP throughout the remainder of the book.
an effort to avoid the “paralysis of analysis” in which dis- ● PART II: Philosophical Approaches to Orthopaedic
cussion of theory interferes with practical application, this Manual Physical Therapy
book was written with clinicians, educators, and students This section consists of 18 chapters, each devoted to a
in mind. A clear and consistent emphasis has been placed current OMPT approach. Each chapter begins with a
on making connections between theoretical frameworks, brief historical perspectivesection, then progresses to
proven clinical efficacy, and the clinical performance of principles of examinationand principles of intervention
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Preface ix
sections, which highlight the primary clinical methods deliberation. My attempt to provide a resource designed to
germane to each approach. Each chapter concludes with a advance the specialization of OMPT has emerged as a direct
section entitled differentiating characteristicsthat at- result of the valuable contributions from these pioneers and
tempts to identify the unique features of each approach. leaders of this evolving craft.
Each approach is presented in a manner that facilitates A wise man once said, “Education is not the means of show-
clinical application and integration culminating in the ing people how to get what they want. Education is an exercise
presentation of a case study with discussion questions and through which enough people will learn to want what is worth
hands on lab activities. having. No true education can leave out the moral and spiritual
● PART III: Practice of Orthopaedic Manual Physical dimensions of human life and striving.” The challenges of cre-
Therapy ating a resource that highlights both the theoretical constructs
The third section consists of nine chapters, each of which as well as the practical application of the primary schools of
includes an essential skill set of joint mobilization tech- thought related to the practice of OMPT have been substantial
niques that are eclectic in nature and chosen for their but worthwhile. This book’s success in accomplishing its ob-
clinical effectiveness and ease of performance. A primary jective of becoming an essential and invaluable collection of
feature of the text are color photographs of each tech- scientific discourse, artful expression, and practical application
nique, which include anatomic overlays designed to direct will only be realized in your hands and through the passage
the reader to the structural nuances of each articulation. of time.
Enhanced with force vector arrows and clearly identified I invite you to join me on this continuous journey of growth
stabilization points, these highly illustrative photos guide and development. With this book as your trail guide, I hope
technique performance and distinguish this book from this resource challenges you...but makes you better, provides
others. A detailed description is also provided that will answers . . . but raises more questions, dispels myths and incites
guide the reader and the instructor toward correct tech- passion, and at every turn empowers you toward the relentless
nique performance. The accompanying web-based in- pursuit of clinical excellence in the service of others. It’s in your
structional OMPT technique videos complement the text hands now!
by highlighting key techniques for each anatomic region.
Christopher H. Wise
The primary feature of these videos is the presentation of
Reading, Pennsylvania
each technique in a manner that facilitates the use of se-
June 2014
quential partial-task practice (SPTP). Within this teach-
ing strategy, each technique is presented in a step-by-step
fashion, concluding with complete performance in real- R E F E R E N C E S
time. The reader may utilize this skill set as a starting
1. Mennell J. Back Pain: Diagnosis and Treatment Using Manipulative Techniques.
point but is encouraged to routinely modify, enhance,
Boston, MA: Little, Brown; 1960.
progress, and develop new techniques that most effec- 2. Salter RB. Textbook of Disorders and Injuries of the Musculoskeletal
tively meet the unique needs of each patient. System. 2nd ed. Baltimore, MD: Williams & Wilkins; 1983.
3. Paris SV, Loubert PV. Foundations of Clinical Orthopaedics, Course Notes.
St. Augustine, FL: Institute Press; 1990.
It’s in Your Hands Now 4. Sackett DL. Evidence-based medicine. Spine. 1988; 23:1085-1086.
Along with each contributor, I am proud to present to you this
“treatise” on the art and science of OMPT, which is the cul-
mination of many long hours of research, critical thinking, and