Physiotherapists Are Not Corn

It turns out I’m a terrible physiotherapist. If you practise in a ‘Hands On’ manner and believe everything you read online, then you might come to the conclusion that you are too. Such is the vehemence of opinion in the “Hands On Hands Off” debate on platforms such as Twitter, it seems to echo the polarizing political discourse that is now so common.

Now, we know we’re not terrible therapists. We know we’re part of an organization that has a long, proud history of excellence in clinical knowledge, techniques and reasoning. But lately it seems that the Orthopaedic Division (OD) is facing some serious challenges. There has long been a perception that we’re all about mobs and manips but this has been amplified recently through social media. The potential impact of this negative rhetoric is worth considering, even if you are not active on social media yourself. Will recent graduates continue to study our curriculum when faced with the plethora of educational opportunities available in conjunction with obdurate voices on social media? Fewer physiotherapists might complete the syllabus. In the face of the naysaying, some therapists could lose faith in their training, maybe thinking twice about instructing within the OD system. Might therapists of all levels of experience suffer an ortho identity crisis?

A clear professional identity is important. It guides our path and it gives us strength when facing challenges. The identity of our profession has been and continues to be evaluated in different ways. Pat Miller, Vanina Dal Bello-Haas and Chantal Lauzon are finalizing the core professional values of the CPA through a Delphi process.¹Dave Walton and the Physio Moves Canada team connected with physiotherapists nation-wide about opportunities and threats they face. Publication of these results will help form a clearer idea of what is needed to ensure our profession continues to thrive.

Certainly for that future to be successful, we need patients and third parties to have faith in our profession thus they need to know who we are and what we do, at least in broad strokes. Public bickering in the Twitter-verse about out-of-context minutiae won’t help our case. It will more likely drive patients to seek help from professions that seem to have their professional act together, leaving us “eating ourselves until we are no more. ”CAMPT has already taken steps to promote a clear brand and the OD has also recently undergone rebranding, of which the new website where you find this blog is one part. This rebrand emphasizes excellence in advanced orthopaedics (not manual therapy specifically) within the context of a peer-supported network and a rigorous, globally-recognised evidence-informed education and examination curriculum. 

As the rebranding and new resources on our website continues to be rolled out, this is a good time to think about our ortho identity. How do we see ourselves? How do others see us? They’re complex questions and not ones to answer definitively here but they’re certainly worth considering because in the face of change, we really are Stronger Together. Let’s use The Window for a moment of reflection and consider some factors so we can continue to say it loud and proud: we are ortho.

I CAN TYPE IN ALL CAPS BETTER THAN YOU CAN 

Social media is great for knowledge translation, for sharing findings and facilitating discussion. Downsides include decontextualized information, user bias and negativity. Sometimes it seems a competition of who can SHOUT THE LOUDEST or cite the most articles to prove the ‘other side’ is woefully unsupported. Manual therapy (MT) and at times the OD come under fire for being ‘Hands On’ in a way that is a bit baffling. Does anyone practise entirely hands on or hands off? Presumably, most of us follow the middle course, varying treatments based on the patient in front of us, yet to voice this reasonable approach in a public forum can feel like a losing battle, assuming you’re brave enough to wade into the quagmire.

But what’s the alternative? By avoiding opposing voices, we risk barricading ourselves in an echo chamber, listening only to opinions matching our own. There remains the need for informed debate, so in that spirit, let’s talk plainly about the OD.

The Big Bad (and Old) Orthopaedic Division

One criticism is that the OD curriculum is based on an outdated biomechanical model. The OD has been around as a special interest group since the 70s and when the EV course syllabus was created around that time, the biomechanical model was the accepted framework.^2,3 Some early instructors (e.g. David Lamb, Cliff Fowler, John Oldham) were Cyriax-trained in the UK and the original courses were based on their own notes but as new evidence has been published, it has been incorporated into OD courses.³ Yes, we still learn about biomechanics (joints do move, after all) but also about the neurophysiology controlling joint and muscle function, movement screening, pattern recognition, pain science and exercise dosage. We are taught to clinically reason, to think in terms of the biopsychosocial model and to treat according to those influencers. It certainly isn’t all mobs and manips. The syllabus has come a long way.

When it comes to our course manuals, you’ll probably agree they’ve needed updating for a while. Compilation of those manuals started around 2001 while the most recent version was completed in 2009 and we all know how quickly printed information becomes outdated.^3,4 The update is now underway and the new manuals will be released in early 2019. Would it have been nice to have them sooner? Sure. But the OD is a large not-for-profit organization, founded and run by volunteers – it’s a big ship to mobilize and refurbish. This perhaps puts us at a disadvantage compared to smaller newer educational outfits but that shouldn’t discount the decades of experience, knowledge and expertise at the heart of the OD.

The reality is that the OD provides a layered educational system that works for many people in terms of time commitment, cost and structure. It provides a solid framework with which to approach clinical interactions, starting at the tissues and working through whole body regional interdependence. We have a great network of instructors and mentors to help develop sound clinical reasoning for choosing how and when to treat. And yes, the curriculum continues to teach and hone manual skills, with an emphasis on the mechanisms behind why manual therapy may work for specific populations and when it can be an effective tool with the right patient in the right context.

Physiotherapists Are Not Corn

Words are important, with the power to persuade, prejudice and pigeon-hole (among many other things). Perhaps part of the problem with our ortho identity is labelling; by identifying as a Manual Therapist or FCAMPT, maybe there’s an inaccurate expectation that you always practise with a focus on manual skills. But even those that identify as Manual Therapists will have taken courses that are not related to MT– we physiotherapists do love a varied toolbox! No two physiotherapists are alike in terms of their training, practice setting, funding model, clinical experiences, even life experiences, so we can’t expect everyone to treat in the same way. Nor should we –patients are not identical therefore they will not respond identically (or, as Dave Walton memorably put it during his Symposium keynote last year, we are not corn). An approach that works well for you maybe doesn’t work for me with my patient – and that’s OK! That’s why we have that diverse toolbox.

A possible downside of this variety is spreading ourselves too thin. With continuing education, it’s important to pick one thing and take the time to get really good at it. For people currently in the OD system or those that have completed it, advanced orthopaedics is what they chose to focus on for that period of time. Afterward they may develop an interest in additional skill sets but they will always have that solid ortho foundation to build from and complement the other skills in their toolbox.   

For physiotherapists that don’t necessarily identify as Manual Therapists, phrases like “manual therapy” and “hands on” can still be problematic due to certain assumptions but even Peter O’Sullivan (often held up as a proponent of the Hands Off approach) states that he places his hands on all his patients. However, he also states: “What I DON’T do is use ‘HANDS ON’ to tell the patient that I am ‘fixing’ their ‘dysfunctions’ and ‘instabilities’…or to reinforce dependence on passive therapies.⁵ Certainly we should be careful with the words we use with patients. If we’re aiming to empower them to maximize their health and function, then we should correspondingly minimize the creation of fear or dependency through our words.

Perhaps we should also think about the words we use in relation to the OD brand, not just to patients. Should we talk less about ‘manual therapy’ and more about ‘advanced orthopaedics’? After all, this is what the OD curriculum actually encompasses. MT is only one component of a broader orthopaedic framework and of course, orthopaedics is only one area under the physiotherapy umbrella. We can seldom if ever, think of orthopaedic issues in isolation so maybe our own word choices lead to some of the pigeon-holing we experience.  Recognizing this, this was recently brought to the table at the OD strategic planning meetings and rebranding may be explored further.

Ultimately, we should encourage and celebrate diversity of education and practice in the OD, recognising that at the core of that practice is a solid foundation of advanced orthopaedic knowledge, techniques and clinical reasoning. An optimal outcome for the patient in front of us is more important than the means to achieve that outcome. One size doesn’t fit all, whether therapist or patient.

Ending the Identity Crisis: Our Window of Opportunity

Given the diversity among physiotherapists, what then are our commonalities within the OD that show who we are? How about;

• Evidence-informed, patient-based practice?
• Strong therapeutic relationships, built on connection, trust and frank discussions about treatments?
• Positive word choices that empower our patients and instil resilience?
• Optimal outcomes that are truly meaningful to the patient?
• Pride in our established yet evolving approach to advanced orthopaedics that includes manual therapy when appropriate?

These may indeed be some qualities that underpin the OD but perhaps too much of a mouthful. The OD’s new tagline is a more succinct way to encompass these ideas: “The Community for Advancing Orthopaedic Physiotherapy.” However, we practise individually, we are part of this community so let’s take the opportunity to promote our community’s brand whenever possible by;

1) Walking the walk. Take a moment to use The Window to reflect on your treatments, clinical reasoning, potential biases, word choice and outcomes. Does your practice currently advance orthopaedic physiotherapy or is anything in need of a refresher or update to stay abreast of the OD community?

2) Talking the talk. Let’s positively engage in reasoned debate in person, on social media, everywhere! Talk with entry-level students, syllabus students and other health professionals to emphasize the value of the OD and its curriculum in contrast to negative rhetoric.

In this way, the OD will continue to thrive with engaged students, members, FCAMPTs and instructors, who are all proud to say, we are not corn, we are ortho.

References

1. Physiotherapy Practice. Canadian Physiotherapy Association. 2018. 8(2):7-9.
2. Cleather J. Head, heart and hands: The story of physiotherapy in Canada. Toronto: Canadian Physiotherapy Association; 1995.p19-20.
3. In an email from B Padfield in April 2018
4. In an email from J MacMillan in April 2018.
5. O’Sullivan P. “’HANDS ON’ OR ‘HANDS OFF’ FOR TREATING PAIN??” [Twitter]. 2016 Feb 13 [cited 2018 Jun 09]. Available from: https://twitter.com/PeteOSullivanPT/status/786659198121672704