The Problem with OMPT

[Jason Silvernail]

*This was originally posted on the EIM MyPTSpace discussion group. It has been slightly modified to stand on it's own here.
*OMPT = Orthopedic Manual Physical Therapy

I'd like to speak briefly (OK, not so briefly) about the "OMPT constructs" that seem to be so carefully defended here, and held up as obviously superior to the pain science and nerve physiology that underlies other work.

It seems to me from listening to many people in the PT world, that this OMPT paradigm has several advantages over all other constructs. I'd like to go ahead and list some of these foundational OMPT concepts and examination methods, and comment briefly on their reliability and validity. If I'm off base, I feel certain people will correct me.

Perhaps to start off I should explain my OMPT chops right off the bat. I treat many people with NMS problems and consider myself an Orthopedic Manual Physical Therapist. I am certified OCS, have my DPT, and am a member of both APTA and AAOMPT. However, the traditional OMPT view of our patients is coming under more and more uncertainty as our interventions (such as spinal manipulation) are tested more rigorously under controlled conditions. There is the beginning of a paradigm shift in our profession, and I believe that this thread and our discussions here on Soma Simple are the beginning of some of the growing pains of that shift.

Clearly, many of our patients have connective tissue injuries and problems that respond predictably to stress, movement, strengthening, and rehabilitation. Our profession is rather expert at helping these people and improving their function. Also, just as clearly, there are segments of our patient population whose symptoms cannot adequately be explained by a physical injury, loss of ROM or strength, problems with muscle length, or many of the other biomechanical measures that we have been taught are so important. Clearly, these patients seem to require a different approach, and we ignore that fact and the foundational science that supports it at our peril. We need both a connective tissue and a neural tissue (or mesodermal vs ectodermal) approach if we are to be successful for a wide variety of patients.

Let’s list some of these foundational concepts of the OMPT model, and examine them to see if they meet the high standards of reliability and validity so cherished by many in the orthopedic physical therapy world. For, if we were to find that the science underlying their approach was not so reliable and valid, then many (if not all) their criticisms aimed at others would apply equally to them.

I have listed some foundational tenets of OMPT along with a brief discussion:

-Manual Examination > the manual examination in OMPT is considered a very important aspect of the treatment, such that many OMPT teaching and certification organizations claim that the ability to be specific in their diagnosis of problems is the key to successful treatment. These examinations can include those of muscle strength and length, joint mobility, and joint movement. If the manual examination process was found to lack reliability or validity, that would be a very serious blow to the foundation of orthopedic manual therapy. In other words, if it was difficult for therapists to agree about the “findings” of the examination both between and within therapists (inter and intra-rater reliability) or the manual exam findings were not capable of discriminating between those with and without pain (a measure of validity) then a most serious problem will have been revealed. Would it surprise anyone to learn that the reliability (both inter- and intra-) of most manual examination procedures is quite poor? Would it surprise anyone to learn there have precious few studies looking at the presence or absence of these findings in an asymptomatic population? Even our most cherished procedure, measuring a joint’s range of motion, has what might be considered a shockingly low level of reliability. Clearly, placing too much emphasis on the importance of the manual examination is not warranted, given the current state of evidence. [see Dr Josh Cleland’s outstanding book Orthopedic Clinical Examination for specific measures – it’s an eye-opener] Also see a recent post on the EIM blog: http://blog.myphysicaltherapyspace.c...rd_to_giv.html

-Impairments in Function > The purpose of the manual examination process to discover “impairments” in one or more of these areas (strength, ROM, joint mobility, etc), which the therapist then uses OMPT methods to treat. It is presumed that the resolution of these impairments through manual therapy and exercise will lead to the resolution of the patient’s complaint. This complaint is almost always pain, though it may also be loss of mobility, strength, or movement ability. If the resolution of these impairments did not result in the resolution of the patient’s complaints, then a causal relation between these impairments and the patient’s complaints becomes difficult to support. If these impairments can be demonstrated in asymptomatic populations, or if resolution of impairment(s) does not resolve the complaint, then there is a serious problem with the validity of the impairment OMPT model. Again, we see major flaws. There have been very few studies attempting to assess the presence of these impairments in asymptomatic vs symptomatic patients. Studies demonstrating resolution of these impairments are unable to draw a conclusive causal relation between impairment and complaint, and there are many studies showing resolution of complaint after treatment even when one or more impairment(s) remain. Clearly, we cannot think too highly of these impairments as indicative of a superior treatment model, the evidence just isn’t there yet.

-Focus on Health of Connective Tissues > OMPT has long been focused, since Florence Kendall’s time, primarily on the connective tissues of muscle, joint, tendon, cartilage, spinal disc, and bone. In addition to being (by all accounts) a very nice lady, Florence Kendall codified many muscular examination techniques and connected pain complaints and degeneration to poor posture. The use of exercise and manual treatment to improve posture and address the health of these tissues is widespread in the physical therapy world. However, there has been no causal link between static posture and pain, and many complaints for which our patients seek assistance cannot be demonstrated on imaging studies designed to assess the health of these tissues. Multiple studies have demonstrated no causal link whatsoever between degeneration of connective tissue and the presence of pain and function complaints. Clearly, focusing on connective tissue alone is a flawed paradigm.

Often the recent LBP CPR for manipulation is mentioned in an apparent attempt to bolster points about the value of the OMPT paradigm. Unfortunately, the findings of the manipulation CPR for LBP do much more to refute the OMPT paradigm then they support it. After years of learning to examine and treat and supposedly diagnose the various articulations of the spine, we learn that findings relevant to success for manipulation appear to be: 1. number of days duration of the complaint 2. very generalized pain location (not beyond the knee) 3. hip rotation ROM 4. generalized spinal mobility – a finding of stiffness at at least one level (never mind whether others are also stiff) and 5. level of fear avoidance beliefs.
These studies conclusively proved that many of the detailed examination procedures we were using to determine likely success with manipulation were completely incorrect and actually useless! The two measures of impairment (generalized PA mobility and hip rotation ROM) were not very specific, nor all that reliable between therapists. These studies also showed the large impact of a patient’s beliefs on their outcome.

Now, clearly, not everything is wrong with OMPT. Some impairment measures appear to be very useful in selecting appropriate treatment (such as lumbar PA mobility) and there is little doubt that for connective tissue injuries, skill in a manual examination and clinical reasoning process is critical. To the degree the OMPT paradigm does that, it will achieve (and has achieved) success. However, there are large numbers of patients whose primary complaint of pain cannot be traced to dysfunction in the strength, mobility, or joint kinematics of a connective tissue structure or structures. These patients will continue to *not improve* with traditional OMPT care, because that paradigm is not designed to examine or treat non-connective tissue structures.

There is a very large and growing body of scientific research describing in detail the essential problem these patients might have (it is neural), and what we can do about it as therapists to facilitate their recovery. People like Michael Shacklock, and David Butler are two of these names, though names like Lorimer Moseley, Alf Brieg, and others should be acknowledged as well.

Patients who traditionally fell through the cracks of PT/OMPT care would end up with what can be described charitably as “fringe” practitioners. They and their legion of invented treatments (myofascial release, neuromuscular therapy, craniosacral therapy, reiki, etc) found occasional success but were hamstrung by their adherence to outdated and patently untrue assumptions and statements about the basic physiology of the human body. We desperately need a scientific paradigm for guiding the examination and treatment of these patients, and we ought to be embracing *anyone* who takes a carefully-examined scientific road toward this goal. We also need to *not worry* that they may not examine or treat using methods that are traditionally familiar to us.

We need change for this group of patients, and we ought to be content following the scientific method to get there, and not allow our discomfort with new terms and theories to prevent us from rational inquiry.

The more I practice and think, the LESS CERTAIN I become about everything. I thought that’s how every scientist felt, but the smug certainty shown sometimes by those defending the OMPT paradigm can not be backed up by either the existing data or a spirit of scientific inquiry.

[Barrett Dorko]

Jason,

Perfectly clear. I know how it felt to write this and hit the "send" key. There's nothing else like that.

An astounding post to place before those who think we're crazy as well.

[Diane]

Wow Jason, that is one rigorous position paper.

I think you managed to:

1. put your finger on the precise problem not just in PT but in all manual therapy by whatever designation

2. shake down the fakey bravado of OMPT

3. identify the entire raison d'être of SomaSimple, brilliantly

4. demonstrate your remarkable skill for succinctness in the process.

All in one fell swoop.

[Luke Rickards]

Wonderfully put Jason.

We need to 'Sticky' this one.

[BB]

Jason,
Outstanding. It will be interesting to see a defense of OMPT for non-pathology to your clearly laid out concerns.

[Crazy Pole]

Jason,

Thank you for sharing the wonderfully thought-out stance.

You label yourself as "having a lot of opinions". I think that's great, especially since they are backed by solid reason. Thanks for taking the time and effort to share them.

Wes

[rfairbanks]

I received the lecture series "Biology and Human Behavior: The Neurological Origins of Individuality" by Robert Sapolsky for Father's Day. I listened to the first lecture yesterday and what he says is relevant to this discussion.

From the lecture notes: "typically, we think categorically, as with colors, coming up with labels and explanations, but categorical thinking has its advantages and its limits"

"This course's goal of noncategorical thinking about behavior is critical. Little can be explained by merely thinking about genes alone, or brain chemicals, or hormones, or early experience, or any other single factor"

He then outlines the factors that effect behavior as expressed by the nervous system, modulated by environmental triggers, hormones, and fetal development, related to genetic attributes and continuing back to the effect of natural selection.

He discusses famous scientists who thought only in one category (think Behaviorism and John Watson).

It seems to me that the OMPT construct that Jason has so expertly critiqued is an example of categorical thinking. The proponents of this construct are trying to categorize patients as we were taught in PT school. In reality we need to see all of our patients in a noncategorical way that makes us aware of all of the factors involved in their painful problem.

The group on this discussion list is the reason I have been able to move from categorical thinking to seeing the big picture. I am very grateful to each of you for your generosity in sharing your ideas, your resources and your passion with me.

Rich

[Jason Silvernail]

Thanks for your post, Rich. I have that same audio course waiting for me on my bookshelf.
Glad to hear it's so helpful.
You've gotta love The Teaching Company.

[pht3k]

this is so true.
ompt is working really well... with i would say an half of my patients
but the other half is not responding or partially responding.
the problem is that it is not easy to know which patient will respond well to ompt.
a patient might seems very logical, empiric, not troubled by some psychologic concerns, and finally does not respond to ompt treatment.
an other patient seems hysteric and finally all pain is gone after a single treatment.
central pain doesnt seems to follow any logical pattern.

but going away from ompt is somewhat abstact to me.
i am here exactly to try to learn about all this.
i attended butler and moseley courses.
i loved thoses courses.
hopefully i will learn much more here at somasimple
thanks jason to share your thoughts.

[nari]

Jason,

Good stuff.
I would also say that a focus on OMPT would be successful about 50% of the time, for the average patient without a heap of neurally-based baggage, some of which includes "psychological" factors.
De-categorising thinking goes some way towards management; this helps to look at the person and not just the orthopaedic problem presented.

The little involvement I had with orthopaedics demonstrated one thing (among many): A 76 yo frail woman with a TKA was treated by PT essentially in the same way as a nervous 35 yo male with a TKA following trauma. The protocol never differentiated between them.

Nari

[ginger]

well thought through and written jason, i enjoyed your piece very much. I suspect we may yet differ on some aspects of your concerns about some methods , but overall it is clear and speaks a language I engage in often. Which is , to question the construct that supports the pathology first "medical" paradigm, along with a willingness to open up to alternate cause/effect models.

[Jason Silvernail]

Ginger and Pht-
Thanks for waking this thread up. This is an important issue, I think.

[kongen]

This needs bumping.

[ptim]

Jason
very well written
If you're willing, I'd be interested in a thread on 'The Probklem with the McKenzie Method'

[John W]

ptim,

Jason is up to his ears in full-time residency training work, so I'm not sure that he'll have the time to wax nostalgic on the McKenzie/MDT method.

However, I think it's safe to say, that many of the underlying constructs of MDT fall squarely within the biomechanistic/mesodermal meme that was the theme of his original post in this thread.

I will say for the McKenzie-ites, though, that they do seem to be shifting their thinking more quickly and resolutely than some others in the OMPT realm.

Feel free to tell us what you think about McKenzie/MDT.

[Jason Silvernail]

As I'm in an OMPT Fellowship now, I'll be writing at some point on "The Future of OMPT". I've written plenty on the old MDT models as well, on myphysicaltherapyspace.com.
Thanks for your comment

[smikolic]

Jason....this is amazing, awesome...well thought, and perfectly put.

I am reading it to my "mesodermal" collegues....great conversations ensue following. I love this place.....wow.

Thank you for your frustration, your guts, your devotion to your patients and the profession, for advancement of scientific knowledge and understanding, your passion....whatever got you to place that post here.

Steph

[Diane]

I'm going to go ahead and post that entire post #1 to facebook Jason. It's convenient for me to do it right now, strike while the iron is hot, all that. I'll take it off if you have any objection. Deal?

[Jason Silvernail]

The "problem" one?
Go ahead.

[smith]

Should be mandatory reading for all medico's involved with management of these conditions. As always, great Post JS. Keep us abreast of your fellowship. Dumb it down for me though.

I was once at a conference where a PT explained the McKenzie approach. A surgeon was sponsoring the conf. so we could get educational units. The sx's impression of McKenzie was that there was too much movement for someone who already had LBP. Do these exercises, and if you get increased pain in the back but decreased pain in the periphery that's supposed to be good? Sx must have been a defense over defect guy. He finished by saying maybe he's old, and just doesn't get it. The pt sure get's it though.