Each time I have the opportunity to take a student physical therapist, I have daily reminders of, in my humble opinion, one of the most important concepts that instructor should impart on developing professionals: the “so what factor”. This is a concept that lacks simplicity. It doesn’t fit in a box. It envelops the concepts that guide history taking, efficient utilization of special tests, decisions regarding the need for specific ROM and strength measurements, use of standardized evaluation procedures and, you guessed it: what to do with that information.
I realize that current PT programs emphasize the efficient data gathering piece (history taking, MMT, etc. with minimal positional changes), but the common theme that students report is that they feel inadequate with the selection of effective treatment strategies. The reasons for programs limiting such instruction often stems from poor evidence supporting specific treatment approaches.
What I’ve learned from my years of pursuing continuing education is that several treatment approaches, (for instance, those that are based on standardization of assessment and treatment approaches- SFMA, McKenzie, use of CPRs, etc), in many cases efficiently bridge the gap between treating impairments (pain abolition and increased ROM/ movement patterns) and reducing disability. Unfortunately, research is often limited in outcome measures. Specifically, the outcome measures may be too broad, or the methodology is poorly based on movement science, specifically studies that use exercise interventions in supine or other limited weight bearing postures in the interest in reducing pain and disability during standing activities (1). Additionally, studies may not clearly demonstrate in some case that spinal manipulation cures back pain or has long term reductions in disability (2). However, short term effects on ROM (3) and motor control (4) have been studied. Additionally, it has been demonstrated that back pain may affect movement kinematics during typical movements encountered with daily life (5).
Evidence-based instruction leads to broad brush application of literature review that states that treatment “x” and “y” don’t work for back pain, or for whatever pain syndrome. However, as movement experts, our “so what factor” should encompass the studies linking pain to aberrant movement, spinal manipulation to motor control (and short term resolution of aberrant motion), the effect of Trigger point pain on movement and motor control, and how utilization of standardized movement assessment tools can correct kinematic faults and lead to improved body mechanics during the activity that may have contributed to the original or recurrent pain syndrome (even if evidence doesn’t clearly show that one small piece of the puzzle in developing a treatment plan is the “key” to the “cure”). I’ll be the first to admit that there is severely limited evidence of the validity or reliability of the SFMA, among other tools. Honestly, however, if therapists can draw on movement science and motor control literature to get someone lifting their child properly off the floor without pain in 3 sessions when they began unable to bend forward and touch their knees or extend the spine without pain, all parties involved are satisfied. Perhaps, in the short term it becomes less important to demonstrate with statistical significance that touching the toes in standing is a valid measure of ROM. Instead, if we are using corrective exercise and manual therapy aimed at improving ROM with that pattern as a precursor to something functional (proper lifting kinematics), then whether it is valid for assessing ROM from a normative perspective becomes less important.
1. Hayden J, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD000335. DOI: 10.1002/14651858.CD000335.pub2.
2. Gross et al. 2010, Manipulation or Mobilization for Neck Pain, a Cochrane Review. Manual Therapy 15 (2010). 315-333.
3. Martínez-Segura R1, Fernández-de-las-Peñas C, Ruiz-Sáez M, López-Jiménez C, Rodríguez-Blanco C., Immediate effects on neck pain and active range of motion after a single cervical high-velocity low-amplitude manipulation in subjects presenting with mechanical neck pain: a randomized controlled trial. J Manipulative Physiol Ther. 2006 Sep; 29 (7):511-7.
4. Marshall and Murphy, The effect of sacroiliac joint manipulation on feed-forward activation times of the deep abdominal musculature. J Manipulative Physiol Ther. 2006 Mar-Apr; 29 (3):196-202.5. Esola, Marcia A. MS, PT*†; McClure, Philip W. MS, PT‡; Fitzgerald, G. Kelley MS, PT‡; Siegler, Sorin PhD. Analysis of Lumbar Spine and Hip Motion During Forward Bending in Subjects With and Without a History of Low Back Pain. Spine 1996 Jan 1;21(1):71-8.