Manipulative Therapy in Physical Therapy - Brent Dodge, PT

Dr. Sechrest: Hello, I’m Dr. Randale Sechrest, your host for eOrthopod.TV. Today I’ll be talking remotely with Brent Dodge. Mr. Dodge is a board certified orthopedic physical therapist. He also has additional training in manual physical therapy. Good day, Brent.

Brent Dodge: Thanks for having me with you, Dr. Sechrest.

Dr. Sechrest: Brent, what I thought we would talk about today is manipulation in physical therapy. I think a lot of people are used to see chiropractic physicians and osteopathic physicians who practice manual manipulation for things like back and neck pain. I think it’s less common to see a physical therapist who uses these manual manipulative therapies. Can you give me a little bit of an idea when physical therapy started using this type of therapy?

Brent Dodge: Well, that’s an excellent question, Dr. Sechrest. I think it’s important just to look at the history of manipulation or manipulative therapy in the United States to get an idea of when physical therapists really began using and embracing manipulative therapy. Beginning in the late 1800s, with Andrew Still, we see the beginning of osteopathic approaches to manipulative therapy, then in the late 1800s, with Daniel David Palmer, you have the beginning of chiropractic thought and approach; and so those guys kind of kicked things off. Then, in 1921, interestingly enough you have the beginning of the America Physical Therapy Association. Shortly afterwards, in 1921, there were 21 journal articles in the Physical Therapy literature as well as book reviews on manipulation, including spinal manipulation, and notably the first president of the America Physical Therapy Association, Mary McMillan, wrote a number of treatises on approaches to physical therapy including the four branches of physical therapy, one of which included manipulation of muscles and joints. So, notably, manipulation has been a part of physical therapy practice since its very foundation. I think it took a while for it to really gain traction. Really, until the 1960s, when you see the emergence of several international leaders of manipulative therapy, beginning with Freddie Kaltenborn from Norway, who we know now as the one who introduced what we think of as the Nordic Approach. He wrote a treatise on manipulative therapy – spinal manipulation – in 1964. Likewise, Geoffrey Maitland, an Australian physical therapist, introduced his school of thought, his approaches to manual and manipulative therapy and wrote a book called “Vertebral Manipulation” that was published in 1964. Stanley Paris is a name that’s also well known. He was born in New Zealand, was trained in Europe, brought a number of approaches and theories in manual and manipulative therapy that he taught both professional and post-professional programs in manipulative and manual therapies. He started the St. Augustine School of medicine in St. Augustine, Florida, and a lot of his work continues as well. So I think as we look back we see the embracement of manipulative therapy really from the foundations of the Physical Therapy Association, the beginning of our profession, and really taking hold with the emergence of several international leaders in the field. With ongoing and current literature, I think we’re seeing a greater use, by physical therapists, of manipulative therapy including spinal manipulation.

Dr. Sechrest: I think that’s fascinating because I do think that it’s relatively uncommon for me, as a physician, to actually refer a patient to a physical therapist for manipulative therapy. So that little history lesson definitely brought it into perspective. A couple of questions, though: 1) Is there any difference between physical therapy or manipulation as practiced by a physical therapist, and manipulation that might be practiced by a chiropractic physician or an osteopathic physician?

Brent Dodge: Well, I do know that there is a lot of overlap when I think of what I do as a physical therapist who uses manipulative approaches. Thankfully, we had the field of osteopathic medicine and chiropractic well in place before the founding of the physical therapy profession, and, I believe as the result of that, we have seen some overlap in the fact that we continue to utilize a lot of the different techniques from both of those professions. Personally, a lot of my background has osteopathic roots, not that the chiropractic approach isn’t effective. I think a lot of times we’re maybe working toward a different end result. But a lot of the times the manual approaches, the positioning, the actual implementation of the manipulation is very identical, very similar between fields.

Dr. Sechrest: Well, let’s talk a little bit about how you actually make decision when patient would be appropriate for manual techniques. When you’re seeing a patient, let’s limit it to low back pain for right now. If you’re seeing a patient who is presenting to your physical therapy practice and he’s been referred, perhaps by a physician who has ordered physical therapy for maybe a first or second episode of low back pain, how do you make the choice whether this person is appropriate for manipulative therapy or whether you’ll use some of the more common physical therapy modalities? For example, exercise physical therapy modality such as TENS units, ultrasound, those sorts of things?

Brent Dodge: I use a classification approach initially. There has been a lot of physical therapy research enter the arena of classification where, if a person is presenting with specific clinical findings, that person might be more appropriate to start with a physical therapy manipulation. That’s not always the case with somebody that has low back pain. In fact, some people that present clinically may show that they have more of a loose joint rather than a tight joint and, therefore, might benefit with a stability training program to help stabilize the joints of the low back. In the classification system, what we determine is that if we can identify a clinical prediction rule or findings that fit within a clinical prediction rule, we would then have a greater likelihood of a very positive result with manipulation. For example, if somebody comes in with acute low back or an acute onset of a recurrent problem, and they come in within the first 16 days after the onset, and they happen to have at least one level of tightness of the joints of the low back, which we test for; they have adequate hip range-of-motion, they don’t have pain radiate below the level of one or more knee, and they are not classified as having an aversion to activity, which we can also identify through various tests; that person, if they can fit all of that criteria, would an appropriate candidate and would expect a great result from spinal manipulation. In fact, the literature would suggest about a 94% or greater result, so you could really get somebody better quickly when they specifically fall within that clinical prediction rule.

Dr. Sechrest: That brings up another thing. What are you trying to accomplish with a manipulative technique? What do you hope that the patient is going to gain if you do a manipulation on that first or second visit?

Brent Dodge: Well, I think we sometimes underestimate it, but the fact that you are actually physically touching someone – there’s a powerful element of touch – where you’re working with and positioning a person by using your hands to position and actually treat that person. I think the second piece is that because the joint or set of joints is placed in such a position and there is a force that’s placed through that joint or joints, you get what we call a high velocity thrust, which can lead to very specific stretching. Sometimes you’ll actually hear a ‘pop’. That’s not always the case, I think it’s better when you do because there is even a psychological effect that, “wow, I got a nice pop or a series of pops” and that seems to be healing and therapeutic to some people. But nevertheless, if that happens you get a good stretching of the structures around the joint, what we call the periarticular structures. I think there’s an improvement in nutrition and lubrication to the actual surfaces of the joint which can be healed. There is also movement and movement can send transmission of information along specific nerve fibers that can lead to a blocking of pain transmission as well as sort of re-setting the nerve system and letting muscles relax and getting muscle spasm out, people begin to move more freely and, oftentimes, they feel better so they have been ready to move more quickly into an exercise-based program.

Dr. Sechrest: Now, in terms of manipulative therapy, is this something you do once or twice and then move on to a more of a functional restoration program, an exercise type program for low back? Or would you consider this something that you would do on multiple occasions, maybe even a long series of manipulations to try to maintain what you’ve gained on the first or second visit?

Brent Dodge: You know, in my practice, when I get in and I get a manipulation, let’s say I’m working at one level and I see some things really start to happen, the person is feeling better, is moving better, I start them on some exercises, whatever those might be; some form of core stabilization, possibly some flexibility work. Basically when they come back I’m going to re-check and just identify is this joint or set of joints now moving better? If not, we’re certainly going to go back through, we’ll make that manipulation again. But, it’s not something I’m going to be doing over and over again. A lot of times we’re going to see results with that. We’re going to see improved joint mobility, we’re going to see improved comfort, better ability to move, better ability to carry out daily activities and exercises; and, in those cases, we’re really going to then start a focused exercise program. We’re going to be educating that client on how the back and how the body works so that they can protect their spine and really start getting back to their activities, whether that be regular activities, getting back to a specific job, whatever the case might be. But it’s not generally long-term, I’m just going to keep adjusting or manipulating the same joint over and over again.

Dr. Sechrest: So what do you do to follow that up, after you’ve had that success with manipulation, what sort of therapy are you going to shift to at that point?

Brent Dodge: I’m going to be really interested in looking at a person as a whole in terms of how they’re moving, their body mechanics. I’m going to be making sure that they’re able to learn how to protect their spine through proper muscle work, stabilization work, the way they move, the way they push, pull, lift, so that they can really protect the back and keep it healthy for the years ahead. It may be that they’ve got some flexibility or muscle imbalances where something is weak, maybe something is tight. We’ll be isolating and really working on a specific muscle or group of muscles for strengthening purposes while maybe simultaneously working on flexibility to make sure that we correct that muscle imbalance and hopefully protect that problem from recurring.

Dr. Sechrest: Well, this is interesting information. I guess, one of the things that I would like to discuss as well is the downsides of manipulation. Do you feel that there are any times where manipulation would not necessarily be the right thing for this patient and could eventually cause harm?

Brent Dodge: Well, I certainly think that somebody comes in with acute back pain and has specific levels of tightness in the low back, there are no real nerve signs or symptoms. In other words, there is no pain that’s traveling down below the level of the knee, there is no muscle weakness when we go through and specifically test the muscles of the low back, the abdominal area, and the lower limbs. They’re not complaining about any type of strain symptom, such as anything with bowel or bladder, particularly any numbness in what we think as the saddle area where they might contact if they were sitting on a saddle. Those are things that might suggest there may be more going on, particularly with the nerve system what we call neurogenic pain, that would lead us to possibly re-think whether we want to do a manipulation. I would probably err, as a clinician, on the side of caution. I don’t have to rush into that. There are a lot of other tools that I have to use as a physical therapist while monitoring those neurogenic symptoms. Because, I think if we get into an acute disc problem where somebody’s got some very acute nerve signs and symptoms, that person is likely not going to respond in a favorable sense to spinal manipulation.

Dr. Sechrest: What sort of training do physical therapists need to actually practice manual physical therapy. I think you mentioned that it’s been a part of the physical therapist’s training for a long time, but you obviously have additional credentials in manual physical therapy. Is this sort of treatment something that we can expect any physical therapist to be able to provide? If we go to a physical therapist should we expect that physical therapist to be able to do a manipulation or not?

Brent Dodge: I would like to think so, Dr. Sechrest, but the reality is that we’ve looked at our training programs, our degree programs in physical therapy; let’s say in over the last 20 years, I graduated in 1991, manipulative therapy was not part of the curriculum at that time and I did not come out of my professional program with the skills or knowledge to do spinal manipulation. That was additional learning that I took on through the North American Institute of Orthopaedic Manual Therapy and really spent a lot of time – we would do 5 and 6 day courses, we would return each year, we would do lots of testing and practicums which ultimately led to a certification as a manual physical therapist that, in fact, was doing manipulative procedures. I think there are other schools now, that as we see physical therapists embracing more and more the value of manipulation and, particularly as we’ve seen the evidence in today’s literature as that body of knowledge continues to grow, there has been a movement in what are now all doctoral programs for physical therapists, to embrace that and learn that as part of their professional curricula. I think more and more that we’re seeing those people come out of the programs ready to go, ready to manipulate, so I’m thinking in these days this should be something that we would expect of our entry level physical therapists, that they would be ready to roll in terms of providing that type of care.

Dr. Sechrest: That brings up an interesting point and, that is, if I’m looking for a physical therapist to provide manual physical therapy, what should I look for either as a physician who is referring patients for manual physical therapy or if I’m a patient looking for a physical therapist that could provide this type of care? What sort of certification should I look for?

Brent Dodge: Well, first of all, I think it would be helpful for anyone who’s looking to utilize physical therapy services whether a physician looking for a physical therapist that does manipulation, that there be either a phone call or conversation, getting on the Internet, looking for a potential CV, resume, of that particular physical therapist to see what their background is or simply to ask the person what their background is? What their training is? And some physical therapists, I think, would tell you “I don’t do manipulative therapies”, and that’s fine. Hopefully that changes as we see the evidence grow and people become more comfortable with that valuable approach. But I guess the thing to do would be to seek it out and really ask people what they’ve gone through, what they’ve done? Do they do it routinely? Is this fly-by-night or is this somebody that really has embraced and utilizes this everyday in the clinic?

Dr. Sechrest: Well, I’m going to put you on the spot here and that is to ask you personal opinion, because you obviously are a physical therapist that has practiced for many years without using manual physical therapy, and now you’ve received this extra training, you’re now using it. What’s the difference that it’s made in your practice?

Brent Dodge: I can’t live without out and I can tell you that my results are far superior to anything I ever used to use. Part of that, Dr. Sechrest, is just that I think, for someone who’s been out doing this for 20 years, you’ve got an eye for when it’s going to work. You’ve looked at the literature, you know what the clinical prediction rule is, you’ve had your hands on a lot of people’s spines and felt where things are tight, where things are loose and having begun to manipulate basically in the mid-90s and really getting on board in 2000 and beyond with some of my advanced training, I’ve seen the results that are far superior, particularly as it relates to neck, upper cervical, situations like that; but particularly as we mentioned before with low back pain, when we get the right patient that’s classified correctly, that person can get stellar results with manipulative therapy, and I think it would be a disservice not for those people to have access to that level of care.

Dr. Sechrest: I think it’s very interesting information and I appreciate your joining us today to explain this to patients. Is there anything that we haven’t discussed as we close, that you think patients should know about either physical therapy in general or manipulative physical therapy?

Brent Dodge: Well, first of all, I think the general public in a lot of cases, now I give them credit because I think there is a lot more awareness now about what physical therapists can do, about the value of manipulative therapy, yet I still think there are a lot of people who get the idea that pain is a natural process, particularly as you age, that you should just kind of expect that things are going to hurt, things aren’t going to work properly, and they just sort of amortize their symptoms as something as being normal into their lifestyle, and I would just really encourage people to realize that the human body is made to move. It’s made to function. If something is not working right it could be that there is some physical therapy or other manipulative therapy that could make a huge impact on how you feel. How you feel when you get up in the morning, what it’s like when you go to work, not coming home with a headache. There are just so many ways that I think people who are doing manual therapy, particularly with those who have an interest in specific therapeutic exercise and training people, teaching them how to take care of themselves. How to take a leg up on being healthy and that means not having pain. Because I think that if the pain is there it’s your body telling you, “hey, there’s something going on”, that there’s a lot of technology and treatment out there that can really help people these days.

Dr. Sechrest: Well, thanks for that advice. I think that’s excellent advice and I think that all of us have heard the term or the saying “Use it or lose it”, and I think pretty much that sums up what you just told us.

Brent Dodge: Yep, I agree.

Dr. Sechrest: Thanks for joining us today, Brent.

Brent Dodge: Thank you for having me, Dr. Sechrest.

Dr. Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopaedic topic, be sure to visit eOrthopod.com. If you’re an orthopaedic surgeon or healthcare provider interested in participating as a guest on eOrthopod TV, you’ll also find instructions on how to apply to become a guest on eOrthopod TV. Thanks for watching.