Moving Manual Therapy Forward – Building from Maitland’s Pioneering Work

After my Decline of Manual Therapy Skills blog I received some constructive criticism on the post.  My brief touching upon “traditional manual therapy” and incomplete explanation of OMPT seemed to ruffle a few feathers. It was brought to my attention that Maitland was speaking of biopsychosocial issues way back in the 70s as evidenced by his text.  As I have studied Geoff Maitland in Fellowship I recognized that he was, like a lot of pioneers in our profession, way ahead of his time.  In my opinion, he brought the patient to the forefront of manual therapy treatment and made it about them and their experience with pain.  His chapter on communication remains one that I think any physical therapist should read to develop their communication skills with patients.

I was also pointed to a passage in one of his past texts that described “Psychological Factors”

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This passage represents the entirety of what I have found discussing more of a biopsychosocial thought process in a 500 page book.  It likely has been my own experience with reasoning strictly based on Maitland’s books, and seeing those who masterfully apply it, that has made me realize that it was grossly inadequate for complex pain states.  Our profession is recognizing it and those who practiced directly with Geoff Maitland recognized it.  This is not meant to downplay the amazing contributions of Geoff Maitland but to simply say the knowledge at the time of him creating his reasoning method was limited in the biopsychosocial and neuroscience domains.  Louis Gifford has an amazing set of books, his Aches and Pains series, where he spoke to his experience with Maitland himself applying the reasoning model.  I saw myself and my own experience in manual therapy speaking to me from these pages (page 43 of his 1st book in the Aches and Pains series).

 

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Of course physiotherapy has progressed since this time and I think (and hope) exercise has become more of a hallmark in our care.  I am thankful to clinicians such as Tim Fearon who pushed me to recognize the power of exercise.  In Gifford’s book he discusses many of the positives of the Maitland reasoning style.  He highlights the communication and listening pieces that are a hallmark of his clinical reasoning and actually have a huge amount of neuroscience to support them.  It seems that despite the lack of knowledge and science at the time that Maitland saw the power of good communication and listening.  Adriaan Louw had a great editorial titled the neuroscience of the Maitland concept that really did a fantastic job giving examples of how Maitland was a pioneer and there is a lot of neuroscience that supports a lot of what he was doing in the clinic.  We need to be eternally grateful to Geoff Maitland for pushing us to listen and better communicate with our patients, but we also need to recognize that, despite his immense contributions to our field, he also had failures and his model has been shown to not adequately encapsulate the entirety of the experience a patient in pain has.  Authority bias and the Asch effect are cognitive biases we must guard against in our critical thinking and reasoning if we truly want to move forward and build upon the work of such pioneers as opposed to camping out in theory that science is passing by.

Will our profession continue to be satisfied with the continuous coming and going of patients’ pain that Gifford discusses above? Doing this surely will keep schedules full and bills paid, but I feel we can and must become something much greater.  Surely there are patients who will respond beautifully to mechanically delivered treatments.  No one is saying we lose the skilled application of technique, but we may need to broaden the definition of what skilled performance truly is.  The context we create around the masterful technique and the admiration from our patients for our virtuosic performance must be considered.   Do we truly think that a robot who is taught the ability to produce the “perfect” performance of technique will create the same outcomes as a living, breathing, empathetic, and interacting human being?  Are we willing to ask ourselves if we are simply just temporarily modulating pain versus truly creating change that results in behavior change outside the 4 walls of the clinic?  My training and experience in physical therapy has shown me that creating change in the clinic is easy.  It is the change that remains present in the context of a patient’s life that is the truly hard and difficult work we must focus our practices on.  This goes well beyond the expert performance of technique.

Our clinical reasoning needs to stay up to date with science.  We have an absolute duty as professionals to keep our practice up to date with science even if it conflicts or brings us discomfort as we challenge our current practice patterns.  This especially applies to those who teach manual therapy coursework.    A big reason I teach with EIM is the fact that clinical reasoning and pain science are huge components of their fellowship program and we have people like Jason Steere who are leading a charge to integrate the two. This integration is the result of the science pushing to realize that we can no longer just tell a narrow mechanically-dominated side of the story in theory and application of manual therapy.  We need to be better than continuous comings and goings of pain that Gifford saw in Maitland’s practice.  Let’s be honest and recognize that we ALL have patients who wallow in our clinics.  There are variables that a physical therapist, and sometimes anyone else for that matter, is unable to affect that are serving to reinforce the pain and behaviors we see in the clinic.  Often we are quick to cast stones at fellow physical therapists or other professions whose clinics we feel patients are wallowing in but are we living in glass houses?

 

 

 

10 responses to “Moving Manual Therapy Forward – Building from Maitland’s Pioneering Work

  1. Colleen Louw says:

    As soon as I saw your post I was going to refer you to Adriaan’s editorial in our newsletter a few years back but you referenced it already! :-) It all comes back to what I always say – it’s ALWAYS about the patient and what sets our profession apart is our clinical reasoning skills. “Growing up” as a PT I followed Maitland principles and I am really grateful for that – he truly was way ahead of of time (as was Louis Gifford) and even today we as therapists still have so much to learn from both of them. Great blog Mark.

    1. Mark Kargela says:

      Thanks for reading Colleen! Gifford and Maitland both would be disappointed if we didn’t continue to move forward. Thankfully people like Adriaan and others are doing just that!

  2. Jason Steere says:

    Nice post Mark. Thanks for the cameo, but it seems this may emphasize a call to arms of sorts and a need to step up the game. I have read the exchange of ideas starting with your initial blog post, but my reads were superficial at best and so I may have poor appreciation for the depth of your and Ryan’s points of discussion. Exchanges like these are what will move us forward collectively as a group. “Physical therapy” is being pushed to the forefront of the battle against pain and disability in the global society as surgery and pharmacology are taking major criticisms. We should all be stepping up our game with a main objective of helping people to have the fortitude to flourish in life with self-efficacy, arming them to be able to accommodate the never-ending life stresses that they will encounter. With respect towards the topic here of manual therapy, or really any passive treatment (ie. functional cupping), shouldn’t we be assessing the effectiveness of these interventions in a bigger picture vision? How are our interactions with patients affecting their long-term cognitions and behaviors, conscious and subconscious? We may create within session and even between session changes, but are we supporting those changes with self-efficacious, long-term, life behavior changes? Maybe we should be looking in the mirror to make sure our practices do not mimic the “placebo” effects of surgeries or worse yet, the addictive effects of opioids. Do we want people to need us to support our own egos and business or should we aspire to be truly altruistic and increase our sensitivity to whether we are really helping our patients to not need us?

    1. Mark Kargela says:

      Great points Jason! I agree that there can definitely be a conflict of interest when we look at the business side of physical therapy. When our goal is to truly have a patient who is self-efficacious and able to manage the physical, mental, and emotional stressors that come their way. The sociocultural relationship of patient-healer has been here from as far as history can recall. The “healers” or health professionals need to hold themselves to models of care that put the patient at the forefront and not business models or bottom lines. I think it is possible to do this. We need a cultural shift to truly move patients toward a non-invasive and lower cost alternative. I don’t think those in pain will seek our help as much as we would like when we have a media and medical culture that directly opposes it.

      The opioid crisis seems to be pushing us into the limelight. I just hope we can raise our game and not just become another practitioner who practices on out dated theory that, as I said in my blog post, science is passing by.

  3. Rico L. Paras says:

    It is important to realize that pain is first and foremost a neurological response. In fact, I will go further and say it is an autonomic nervous system response. Each part of the body does not function in isolation, but rather as part of an extensive feedback-loop mechanism. Muscle spasm for example, occurs as an automatic response to pain. How many of us have stretched patient’s upper traps to no end without realizing it is just doing what the nervous system is making it do. Poor thing. Reading up papers on pain science is not enough in changing how we practice. There has to be a concerted effort in the academia to design a curriculum that reflects current evidence.

    1. Mark Kargela says:

      Couldn’t agree more Rico! Academia cannot stay steeped in outdated and incomplete understandings of pain. Thankfully, I have seen programs moving in this direction despite CAPTE maybe not being as quick to respond and change curricular requirements. These must change if we are to step into the role everyone thinks we need to step into. I think our profession has the potential to be the force in the care of pain we all speak of, but it will take a top to bottom adoption of modern understandings of pain to make this happen. I am sure CAPTE is aware of this and I am not aware of the processes our profession must go through to change these curricular requirements, but if the processes starts becoming a barrier to our professions growth then we need to be demanding change.

  4. Brian D'Orazio DPT, MS, OCS says:

    I don’t often see reviews of Maitland approaches these days, but a good historical rendering on manual therapy and pain approaches is very valuable.

    In a time when pain was often not the focus of a physician’s examination and treatment, Maitland provides a compassionate approach to the examination and verbal history of a patient in pain. Our profession was, in part, built on that compassion. The unintended consequence of Maitland’s approach was a repeated emphasis on pain, ordinal pain scales and success for the patient being measured against that pain scale. Functionality was never a part of the approach, so those chronic pain patients experienced the theory that if we can get rid of your pain, your function will return; a truly fatal assumption.

    Maitland, along with Mennell, Kaltenborn and later Paris, introduce us to joint examination as measured with varying degrees of specificity in grading movement dysfunction. Kaltenborn is the most liberal of the group, dividing accessory motion into Normal, Hypomobile and Hypermobile. Maitland and certainly Paris take this examination to extremes that would frustrate students who were not able to feel fractions of a millimeter of movement. Of course, neither was anyone else with any degree of reliability. But, it did get us thinking about joint function from a different perspective. It didn’t necessarily provide us with the best approach to restoration of normal movement and in fact it caused many in the profession to become so biomechanical as to think about spinal dysfunction as a product of an X,Y,Z axis around which all pathology could be assessed.

    In 50 years, our biopsychosocial and neuroscience approaches to assessment will likely be criticized, as better science is discovered. But we have to start with building blocks that allow future clinicians to excel.

  5. Karen Drilling says:

    I submit that generative listening and communication with the patient only enhances the effect of any manual skill we apply to the patient. If as a therapist you can’t communicate what you want the patient to do and why they are doing it your result will be sub-optimal at best.

  6. Venus Algus says:

    Such a nice post Mark you emphasizes the psychological strings attached with the pain. Mostly in our society we never thought about psychologically attachment with each other. If we see any person in pain we started thinking about it and even start feeling that pain too.

  7. I totally agree with you Mark. I was suffering stomach problems i visit many doctors but non of them cure me well. Someone suggest me a Psychologist my first thought was are you mad you think i am lunatic but i agree and visited him now I am a good life .

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