Preface

Mennell exclaimed, “the human hand is the oldest remedy known to man, and historically, no date can be given for its inception.”¹ It has only been in recent years, however, that the profession of physical therapy has formally embraced orthopaedic manual physical therapy (OMPT) as an entire approach to the management of musculoskeletal dysfunction. In fact, prior to the early 1990s, formal training in the art and science of OMPT was not routinely included within the educational curricula of physical therapists. Many well-intentioned physical therapists have disregarded the use of these strategies within their clinical practice due to the paucity of literature supporting their veracity or based in an honest attempt to 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 without consideration of these strategies within their diagnostic and intervention armamentarium. It is, therefore, time for a more in-depth exposition of both the art and the science of this unique and important area of specialty practice. The primary objective of this text is to serve as the definitive resource on the principles and practice of OMPT for physical therapist students, instructors, clinicians, and researchers.

Orthopaedic Manual Physical Therapy: From Art to Evidence was decided upon following extensive deliberation and debate. Originally targeted to be more inclusive, the text was titled, Orthopaedic Manual Therapy. Upon the advice of several of the book's contributors, who espoused the importance of focusing the text on those aspects of manual therapy that have become essential to the practice of physical therapy, the title was changed. This is not to say that all of the content contained herein has been developed, or is exclusively utilized, 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 and collaborative contribution from a myriad of individuals over the course of many years. The second portion of the title, From Art to Evidence, was later added for the specific intent of recognizing, embracing, and communicating the notion that OMPT, in its truest form, is the culmination and amalgamation of both art and science. As Salter stated, “Patient care is an art, but the art must be based on science.”² The writing of this book provided the challenge of coupling science with the artful skill of developing within the reader what Stoddard described as that, “elusive tissue texture sense.”³

It is my hope that through deliberate study of these concepts, strict attention to detail, and most importantly, reflective practice, practice, practice, the reader will attain a level of proficiency that when applied judiciously will have a profound impact on those whom we serve and subsequently on the profession of physical therapy. It would do the reader well to consider the three pillars of Sackett's model of evidence- based practice when reading this text and when applying its principles.⁴ Let the title of this text serve as a reminder of OMPT's perplexing and sometimes conflicting nature as a science that is applied through a variety of art forms and individualized expression.

The scope of this book reflects its objective by presenting a comprehensive review of the principles and practices of the most significant schools of thought that have influenced the practice of OMPT in the United States today. The comprehensive, eclectic, and evidence-based manner in which this book was written facilitates its use in guiding clinical practice.

This book, and the accompanying web-based instructional videos, will attempt to achieve the critical balance between theory and clinical application. Throughout the text, a preoccupation is placed on appreciating concepts in light of the best available evidence with an emphasis on assisting the reader in making connections between theory and practice through a process of critical thinking. This text focuses on supporting the development of the physical therapist student and clinician as a specialist in “applied kinesiology.” Despite the strict attention given to every detail of technique performance, the manual procedures presented within this book are deemed to be secondary to the development of astute clinical decision-making skills within the reader.

To accomplish its objectives, this book explicitly and implicitly revolves around four foundational themes:

1. This text approaches OMPT from an eclectic perspective that endeavors to equip the reader with an arsenal of clinical tools from which to draw. Developing within the reader an appreciation for the value of each school of thought as it applies to current practice is a major theme of this text and one that has not been as comprehensively presented elsewhere. This feature is most vividly presented in Part II of this book, where 18 different approaches are expertly presented by the originators of or contributors to each specific school of thought.

2. In recent years, the profession of physical therapy has experienced a healthy paradigm shift toward evidence-based practice (EBP). Orthopaedic manual physical therapy has not enjoyed a long history of evidence to support its efficacy. In developing this resource, it was my intent to present a review of the literature designed to stimulate further inquiry that directly impacts clinical practice. It is my hope that the presentation of these foundational approaches side by side in light of the evidence will advance the cause and the case for the integration of OMPT within the profession of physical therapy. To support this objective, evidence is generously provided throughout the exposition of each approach. Chapter 3 is dedicated to the role of EBP within OMPT, and tools for evaluating and applying evidence to clinical practice are provided. The time-sensitive and ever-evolving nature of the published literature presented within a text of this kind poses several challenges. The literature presented throughout the text provides foundational support for the concepts and practices contained herein; however, the presented literature in many cases is not the most current. The reader is advised to consult other sources for the most recent published evidence.

3. Another foundational philosophical emphasis of this text has been placed on assisting the reader in the development of sound critical thinking strategies as they relate to OMPT. With this objective in mind, the reader is empowered with more than just a collection of effective techniques, but rather an entire framework from which to make clinical decisions regarding how best to incorporate OMPT into a comprehensive examination and intervention schema. To facilitate the connection between philosophical constructs and critical thinking, each chapter in Part II is equipped with Clinical Pillar boxes, which provide foundational concepts that are integral and germane to each approach. The Questions for Reflection boxes enable the reader to engage in a process of critical thinking as information is being presented. The Notable Quotable boxes provide thought-reflecting quotes from the originators of each approach that serve to summarize key concepts and inspire. Lastly, summary boxes that review key points presented within the text are placed throughout each chapter to allow the reader to reflect on new concepts.

4. The final philosophical pillar on which this book was developed is its preoccupation with practical application. In an effort to avoid the “paralysis of analysis” in which discussion of theory interferes with practical application, this book was written with clinicians, educators, and students in mind. A clear and consistent emphasis has been placed on making connections between theoretical frameworks, proven clinical efficacy, and the clinical performance of OMPT. The book is organized in a manner that facilitates clinical application. Chapter 2 is dedicated to principles in preparation for OMPT. This chapter includes key concepts designed to facilitate the effective and safe implementation of OMPT procedures. Concepts are presented that attempt to prepare individuals for practice through principles that target the cognitive, affective, and psychomotor domains of learning. Part III of this text is dedicated to the practice of OMPT and is designed to draw from each philosophic approach and provide a template for the clinical application of OMPT. Using a regional approach, each chapter in this section begins with a review of kinematics followed by principles of examination and intervention and concludes with an eclectic and essential skill set of OMPT joint mobilization techniques that provides detailed instruction for optimal performance. To further enhance the psychomotor performance of these OMPT techniques, a web-based instructional resource that provides video demonstration with clear verbal and visual cues is also provided. The conclusion of each chapter in Part II and III of the book contains a Clinical Case, which is designed to bring together the principles of exam and intervention previously presented. Following the case, specific questions are included that require critical thinking and serve to ensure that key concepts have been attained. Each chapter within these sections concludes with a Hands-On section that provides specific activities that students and educators may use in lab to facilitate learning within each domain.

This book is divided into three main sections:

• PART I: Perspectives and Principles in Orthopaedic Manual Physical Therapy

  The first section of this book articulates the foundational concepts that form the underpinnings of OMPT and serves to equip the reader with information paramount to the understanding of concepts presented later in the text. Chapter 1, Historical Perspectives in Orthopaedic Manual Physical Therapy is designed to provide the reader with an understanding of the origins of OMPT. Chapter 2, Principles of Preparation for Orthopaedic Manual Physical Therapy, addresses fundamental principles related to the safe and effective performance of OMPT. The concept of evidence-based practice is most explicitly covered in Chapter 3, Principles of Evidence-Based Practice Applied to Orthopaedic Manual Physical Therapy, which provides practical tools to enhance the reader's ability to critically analyze the OMPT literature and sets the tone for the emphasis on EBP throughout the remainder of the book.

• PART II: Philosophical Approaches to Orthopaedic Manual Physical Therapy

  This section consists of 18 chapters, each devoted to a current OMPT approach. Each chapter begins with a brief historical perspective section, then progresses to principles of examination and principles of intervention sections, which highlight the primary clinical methods germane to each approach. Each chapter concludes with a section entitled differentiating characteristics that attempts to identify the unique features of each approach. Each approach is presented in a manner that facilitates clinical application and integration culminating in the presentation of a case study with discussion questions and hands on lab activities.

• PART III: Practice of Orthopaedic Manual Physical Therapy

  The third section consists of nine chapters, each of which includes an essential skill set of joint mobilization techniques that are eclectic in nature and chosen for their clinical effectiveness and ease of performance. A primary feature of the text are color photographs of each technique, which include anatomic overlays designed to direct the reader to the structural nuances of each articulation. Enhanced with force vector arrows and clearly identified stabilization points, these highly illustrative photos guide technique performance and distinguish this book from others. A detailed description is also provided that will guide the reader and the instructor toward correct technique performance. The accompanying web-based instructional OMPT technique videos complement the text by highlighting key techniques for each anatomic region. The primary feature of these videos is the presentation of each technique in a manner that facilitates the use of sequential partial-task practice (SPTP). Within this teaching strategy, each technique is presented in a step-by-step fashion, concluding with complete performance in realtime. The reader may utilize this skill set as a starting point but is encouraged to routinely modify, enhance, progress, and develop new techniques that most effectively meet the unique needs of each patient.

Along with each contributor, I am proud to present to you this “treatise” on the art and science of OMPT, which is the culmination of many long hours of research, critical thinking, and deliberation. My attempt to provide a resource designed to advance the specialization of OMPT has emerged as a direct result of the valuable contributions from these pioneers and leaders of this evolving craft.

A wise man once said, “Education is not the means of showing people how to get what they want. Education is an exercise through which enough people will learn to want what is worth having. No true education can leave out the moral and spiritual dimensions of human life and striving.” The challenges of creating a resource that highlights both the theoretical constructs as well as the practical application of the primary schools of thought related to the practice of OMPT have been substantial but worthwhile. This book's success in accomplishing its objective of becoming an essential and invaluable collection of scientific discourse, artful expression, and practical application will only be realized in your hands and through the passage of time.

I invite you to join me on this continuous journey of growth and development. With this book as your trail guide, I hope this resource challenges you ... but makes you better, provides answers ... but raises more questions, dispels myths and incites passion, and at every turn empowers you toward the relentless pursuit of clinical excellence in the service of others. It's in your hands now!

1. Mennell J. Back Pain: Diagnosis and Treatment Using Manipulative Techniques. Boston, MA: Little, Brown; 1960.

2. Salter RB. Textbook of Disorders and Injuries of the Musculoskeletal 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.

4. Sackett DL. Evidence-based medicine. Spine. 1988; 23:1085-1086.