Specialty Practice Within Physical Therapy: My Journey
As a nationally ranked collegiate athlete who had experienced multiple injuries from gymnastics and diving, I had had my fair share of physical therapy. Even then, prior to physical therapy school, there was a clear distinction to me between conventional rehabilitation and evidence-based, progressive physical therapy. The latter treatment that I consistently received from the LSU team Physical Therapist inspired me to pursue a career in physical therapy.
Once in PT school, I soaked up every ounce of knowledge I could from my coursework and my clinical rotations; however after graduation, I still felt unprepared to treat patients with chronic neuromusculoskeletal disorders as a Doctor of Physical Therapy. I knew how to examine, diagnose, administer modalities, and follow post-operative protocols, but I did not feel adequately prepared to do what the team PT at LSU had consistently done for me—treat the underlying cause of the problem. I felt that my treatment skills were contingent upon the experience and individual skill level of my outpatient clinical instructors. Further, I didn’t realize that I would need to spend even more money once I graduated, on continuing education courses to learn how to effectively treat patients, especially those with chronic neuromusculoskeletal conditions.
Like most new graduates, I aggressively pursued continuing education courses, quickly exhausting my $2,000 continuing education allowance on four mediocre courses. I specifically remember my very first one, a headache course. After three days and $600, I was able to differentiate between migraine and cervicogenic headaches and administer screening tests (most of which I learned in PT school), but disappointingly, I wasn’t taught how to actually treat these conditions!
I did learn some useful treatment strategies by taking an instrument-assisted soft-tissue mobilization course and a taping course, but the techniques only seemed applicable to specific patient populations. In the fourth course, I was taught how to use muscle energy techniques to correct back pain. Back in clinic, I diligently referenced my new course manual and treated patients according to the positional faults I was taught, but nothing happened! My spine patients were still not consistently improving. After a year of utilizing the techniques, my pre-post improvement on the Oswestry Disability Index averaged a mere 30%, and even then I wasn’t sure if the improvement was due to my treatment or natural history and maturation. Sure, I could rehabilitate a total knee replacement or follow a post surgical SLAP repair protocol, but I still felt lost treating patients with whiplash, chronic back pain, knee osteoarthritis, sciatica, and, God forbid, a headache!
After several years of clinical practice, I felt I had become a glorified massage therapist with an expertise in teaching core stabilization.1-4 I felt inadequate, as my vision of being a DPT looked very different than what I was actually doing each day in clinical practice. The company I worked for encouraged me to pursue a manual therapy specialty, but after taking 5 of the 7 required courses for the certification, my outcomes (especially for spine) were still not improving.
Fortunately, I had a PT colleague that suggested we take a course through the Spinal Manipulation Institute (www.spinalmanipulation.org) that appeared to have a focused approach on the use of high-velocity, low-amplitude thrust manipulation of the spine. I consented with skepticism, as I did not know of any physical therapist doing any sort of spinal cracking, popping, manipulating, adjusting, etc. After reading the website, I was quickly impressed with the clarity of the approach and the evidence provided to support the use of spinal manipulation in a variety of neuromusculoskeletal disorders.
In the first five minutes of the course, I was hooked. The feisty British man standing in front of me was passionate, and it was contagious. He spoke of exactly what I was so fed up with in our profession: stagnancy, cliques, too much reliance on tradition, jumping through insurance hoops, a lack of branding, a lack of autonomy, and a lack of specialization. “What are your outcomes like,” he asked? “Are you proud of what you do? Or are you sick of doing what you’ve always done?”
This instructor had my attention. His lectures consisted of research study after research study, including those that supported spinal manipulation and those that did not. He used the research to justify hand placement, speed, amplitude, and force of the techniques, right down to the number of required Newtons. He used the research to support an evidence-based approach to pre-manipulative screening, examination, diagnosis, and most importantly, how to treat pain and disability in patients with chronic neck pain, back pain or headaches. Then he showed us how to manipulate, pop, or adjust the spine (with plenty of sounds per thrust!5-10) and how to do it well.
I learned that weekend how to manipulate (i.e. with 3-4 or more pops per thrust, not pseudo manipulations without any audible sounds!5-10) an atlas, the occipito-atlantal joint, the cervico-thoracic junction, the thoracic spine, the lumbar spine and even the SI joint. For the first time, everything in the class was backed with evidence from the literature instead of opinion. When I returned to the clinic on Monday morning, I tried to downplay my expectations, as I was prepared for disappointment. However, my patients with neck pain (who I previously dreaded treating) were coming back visit after visit with markedly less symptoms and improved function. I also began combining thrust techniques with dry needling, which I first learned from a colleague, and discovered even better patient outcomes.
Later that year, I completed the Spinal Manipulation Institute’s advanced cervicothoracic and cervicogenic headache HVLA thrust manipulation course (SMT-2) and the advanced lumbopelvic HVLA thrust manipulation course (SMT-3). I also took DN-1 and DN-2 through the Dry Needling Institute. In December, I sat for the SMT certification exam, the most difficult oral, written and practical exam I have ever taken, earning the Certification in Spinal Manipulative Therapy credential or Cert. SMT designation. Importantly, it wasn’t just a series of letters to come after my name. Rather, the certification demonstrated my ability to achieve dramatically better patient outcomes and, at times, even cure my patients’ pain and disability. Within one year, my neck outcomes, as measured by the Neck Disability Index, improved from an average of 30% (i.e. the mean change score in percent from baseline to discharge) to a consistent 67% reduction in pain and disability. The year I earned my Cert. SMT, my clinic had the best spine outcomes (as measured by the NDI and ODI) and the second best overall patient outcomes of 182 clinics in my company.
I’m also proud to report that I recently earned the Diploma in Osteopractic through the American Academy of Manipulative Therapy. I am honored to be part of a specialty that has changed, and certainly for the better, how physical therapists approach chronic spinal and extremity pain syndromes. I am no longer a simple ‘movement specialist,’ which has no immediate brand recognition to the consumer; but rather an osteopractic physical therapist who has manual skills to help eliminate neuromusculoskeletal pain. If one can be a Pediatric Physical Therapist, Manual Therapist, Orthopaedic Manual Physical Therapist, Certified Lymphedema Therapist, Mechanical Diagnosis Therapist, Mulligan Practitioner, Certified Hand Therapist, or Certified Kinesio Taping Practitioner, then why not an Osteopractic Physical Therapist?
I feel that the Diploma in Osteopractic can certainly tell both patients and my colleagues what it is that I do most of the time in my clinic. Isn’t that why medical physicians advertise themselves as dermatologist, pediatrician and neurosurgeon rather than just medical doctor? For the same reason, dentists refer to themselves as orthodontist, endodontist, or periodontist instead of simply dentist. We claim to follow the medical model in regards to our training; however, it seems that physical therapy may be the only health care profession that does not award titles (i.e. a word, a noun, not just Board Certified in….), and/or title protection, after completion of residencies and fellowships. For example, even a new physical therapist graduate can use the title ‘orthopaedic physical therapist’ or ‘manual therapist’; however, a recent medical physician graduate can’t use pediatrician without first completing a residency in pediatrics. As for fellowship training in and of itself within the physical therapy profession, I believe it is a necessary step and that is why I am one of 30 Fellows-in-training presently enrolled in the American Academy of Manipulative Therapy (AAMT) 12-month Fellowship program.
The critics in the profession will say that there are no randomized controlled trials to support my claims of dramatic outcomes and that there are no studies with long term outcomes to support the use of dry needing for any spinal musculoskeletal condition.9 My response to that is simple. There are 3 pillars to evidence-based practice, not one, and each pillar has equal importance. Put more eloquently by Sacket et al11—the originator of the term and era of “evidence-based medicine”, “External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how should it be integrated into a clinical decision.” Moreover, evidence-based medicine is not restricted to randomized controlled trials, systematic reviews and meta-analyses.11 In the seminal article “Evidence-based medicine: what it is and what it isn’t”, Sackett et al11 stated, “Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient.”
Michelle Tanner, DPT, FAAOMPT, Dip. Osteopractic
Graduate, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Clinic Director, Benchmark Physical Therapy, Atlanta, GA
- Lederman E. The myth of core stability. Journal of Bodywork and Movement Therapies. 2010;14:84-98.
- MacDonald DA, Moseley GL, Hodges PW. The lumbar multifidus: does the evidence support clinical beliefs? Man Ther. 2006;11(4):254-263.
- Mens JM, Snijders CJ, Stam HJ. Diagonal trunk muscle exercises in peripartum pelvic pain: a randomized clinical trial. Phys Ther. Dec 2000;80(12):1164-1173.
- Holm S, Indahl A, Solomonow M. Sensorimotor control of the spine. J Electromyogr Kinesiol. Jun 2002;12(3):219-234.
- Dunning J, Mourad F, Barbero M, Leoni D, Cescon C, Butts R. Bilateral and multiple cavitation sounds during upper cervical thrust manipulation. BMC Musculoskelet Disord. 2013;14:24.
- Ross JK, Bereznick DE, McGill SM. Determining cavitation location during lumbar and thoracic spinal manipulation: is spinal manipulation accurate and specific? Spine (Phila Pa 1976). Jul 1 2004;29(13):1452-1457.
- Beffa R, Mathews R. Does the adjustment cavitate the targeted joint? An investigation into the location of cavitation sounds. J Manipulative Physiol Ther. Feb 2004;27(2):e2.
- Flynn TW, Fritz JM, Wainner RS, Whitman JM. The audible pop is not necessary for successful spinal high-velocity thrust manipulation in individuals with low back pain. Arch Phys Med Rehabil. Jul 2003;84(7):1057-1060.
- Dunning J, Butts R, Mourad F, Young I, Flannagan S, Perreault T. Dry needling: a literature review with implications for clinical practice guidelines. Phys Ther Rev. Aug 2014;19(4):252-265.
- Evans DW, Lucas N. What is ‘manipulation’? A reappraisal. Man Ther. Jun 2010;15(3):286-291.
- Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. Bmj. Jan 13 1996;312(7023):71-72.