Orthopaedic Physiotherapy Training in Canada: Reflections on Manual Therapy and the Orthopaedic Division

I am a supporter of online discussions.  I am supporter of questioning everything we do.  This means questioning others who might practice in a manner differently from me, this means challenging colleagues who share my same bias (I tend to spend most of my time doing that) and it also means being very critical of dubious practices (i.e. calling out the bullshit).  I do much less of the last one and only sometimes delve into the first area.  But it’s the first area I’d like to talk about most through a specific example.

In Canada we have the Canadian Physiotherapy Association and within that there are Divisions which represent specific areas of practice.   One division is the Orthopaedic Division.  The Orthopaedic Division trains therapists to receive their FCAMPT designation from IFOMPT.    The Orthodiv is primarily seen as the Manual Therapy division (I know that this is not all that they teach but this seems to be a large part of their training).   I’ve been reminded numerous times through the years that they are trying to create Advanced MSK Physios where doing Manual Therapy is just one part of that and the Division has ADDED on content in other areas in addition to the manual therapy.  I think trying to create highly educated therapists is great.   But it misses the primary issue. 

So, what is my point?  What are the critical reflections?.

Its not about adding “Pain Science” or other material its about what you are doing.

People will often tell me that the training in the Orthodiv goes beyond manual therapy and they regularly learn about the neuroscience of pain and dip into biopyschosocial reasoning in the training. Or that other material is covered and students learn to be better at clinical reasoning. 

Super.

But that is not the issue. 

The fundamental issue is how manual therapy is performed and explained, and the implicit assumption that manual therapy is a necessary part of being a highly trained clinician or an Advanced MSK Physio.  Here is a true or potentially untrue anecdote.  I went to Roger Kerry’s (@RogerKerry1) house in Nottingham, he plied me with way too much beer in an attempt to convince me that I liked his music.   Subsequently, I urinated on his living room rug.  When everyone rightly complained about this inappropriate behavior I asked them to just ignore the pee on the rug and focus on the great spinach dip that I had brought and how much better it made their night.  No one focused on the spinach dip.  I'd ruined the rug.

 

Its wonderful that people are potentially being taught to be advanced musculoskeletal therapists but I don’t think this can co-exist if the manual therapy you are taught or other contentious biomechanical paradigms are still rooted in the program.  You might have a case here where best evidence is conflicting with historical teachings.

 

Critical Issue #1:  The performance and justification of manual therapy that is taught is outdated and false

I have read the manuals that teach manual therapy.  I have read the examiners corner instructions that justify teaching manual therapy in a certain way.  I’ve spoken with those who have been through the program.  Much of what is still taught is antiquated and based on fully unsupported models.  Let me give a few examples of areas that extremely questionable:

 

-       you teach motion palpation of the SI Joint or any joint in the spine using PIVMS or PAMs (this is an unreliable and not valid technique).

-       You then use that information to inform your clinical decision-making thus rendering your clinical decision making suspect

-       You teach manipulative techniques that are biologically implausible.  An example would be thrusting in any direction that is not perpendicular to a bone and arguing that the force vector in that direction will create movement in that direction.  This has been soundly disproven more than 15 years ago and probably reduces the number of techniques you have by 60%

-       You continue to argue that your manipulative or mobilization techniques can be specific to a single joint

 

I could go on but these old biomechanical models of manipulation are not supported.  Nor are they necessary to be able attain IFOMPT standards.

Let me give you a quote from Jesse Awenus.  A recent FCAMPT graduate of the Orthopaedic Division and now someone who mentors those going through the program:

“Despite a lot of talk about how it's changed, i currently mentor two physiotherapists who are still learning how to assess rib rolls, clavicle accessory motions and differentiating between uncovertebral vs facet restrictions in the c-spine... it's maddening how they make you feel inept for not "feeling" what i'm sure they are only making up they can feel”

 

These statements don’t fit with best practice.  You can’t continue to have an antiquated model and yet add on different and better approaches.  They can’t co-exist.  You can’t explain to someone how their pain is multidimensional, build a therapeutic relationship that facilitates their independence, self efficacy and self management and then tell them their sacrum is misaligned, T12 doesn’t move properly on L1 and this has caused their hamstrings to shorten (exacerbated by their sitting) and that is why they have low back pain because of the wonders of “regional interdependence”.

Point #2: Manual Therapy is the Royalty of all Therapy

I had a colleague who took the initial training with the Orthopaedic Division but she could not become a full FCAMPT because she refused to perform cervical manipulation of the spine.  This is taught in the later levels because for some reason people think its difficult to crack the neck and you need to develop your technique elsewhere first.  Whatever, it’s a joke.  I cracked thousands of necks in chiro college..,its one of the easiest things to do.  Regardless, this elevation of manual therapy, which is at best a consistent secondary adjunct for helping people with painful conditions is a big issue.  It says you learning manual therapy is NECESSARY to obtain the highest ORTHOPAEDIC training in Canada yet performing manual therapy is NEVER NECESSARY in our guidelines for best practice.

Do you see the disconnect here? 

An emphasis is placed on the approach that is not best practice.  I am not a manual therapy basher (see this paper here).   But, I don’t think we need to elevate manual therapy in the treatment of orthopaedic conditions.  Yet, when you make learning it a necessary part of the program you do just that.

This is why its not a debate about hands on versus hands off.   If you want to do some manual therapy, fine go ahead.  But, you never HAVE to do manual therapy.   Manual therapy is option but is never a requirement.

And that leads us to a conclusion or even a recommendation.

 

I fully recognize that the Orthopaedic Division has no obligation to listen or do anything.   I mean, who the hell am I to tell them how to run their ship.  At the same time,  if I advocate for change I always have the option to find like minded therapists and create an Advanced Musculoskeletal Program which is consistent with best practice and could even lead to the FCAMPT as recognized by IFOMPT.   But, ugh, I don’t want to do that. 

The recommendation (whoa, it’s a doozy)

If the Orthopaedic Division is truly interested in teaching best practice and being THE teaching resource for Advanced MSK and Orthopaedic practice then they might want to consider having Manual Therapy as an elective.  In other words, an adjunct (did you see what I did there?) to the fundamentals of evidenced based practice.  You’d almost have to start from scratch and consider what the fundamentals of good care are within a biopsychosocial model but it can certainly be done.  After comprehensive basics are taught (diagnosis, pathology, the BPS model, clinical reasoning, critical thinking, exercise prescription etc) you then “stream” therapists into the routes they wish to adorn their clinical basics.   A lot of these courses (both fundamentals and electives) already exist in North America and the world so much could even be farmed out.  Traditional courses from the Orthopaedic Division on Manual Therapy could be one OPTIONAL stream.  Taught in an historical, whimsical way, like Astrology something.  Just kidding.  Too far?

You could still teach the manual therapy that is currently taught but teach it as an elective and perhaps with an extremely critical bend.  We did a similar thing at Canadian Memorial Chiropractic College in 1999.  Motion palpation, specificity and incredibly questionable techniques were taught but all with an understanding that the research did not support the things that people had said.

I’d like to end with another very positive quote from Jesse.  I obviously focused on negative aspects and that doesn’t reflect my thoughts on the clinicians I’ve met who have undergone the training.  There are definitely excellent clinicians and there are definitely dedicated teachers in the program.  But Jesse says it better:

 

“It may seem like I’m saying that becoming an FCAMPT was a waste of time, but that couldn’t be further from the truth. The program I was taught gave me a much more solid foundation in differential diagnosis, screening for red flags and understanding anatomy at a much deeper level. I feel better off for having been through the system and I am glad I stuck through it. There are rumblings that when the new manuals come out next year there will be less emphasis on motion palpation and biomechanics and more emphasis on neuroscience education and a more current model explaining the possible reasons why our hands can help make people feel so much better. I welcome these changes and hope to see more made in the future to keep our program relevant in light of all the emerging evidence surrounding manual therapy. I am a proud FCAMPT and I encourage anyone with any questions about it to contact me. I would be happy to help in any way that I can.”