• Implementation
• Evidence based

Orthopaedic manual therapy (OMT) has advanced in recent years. A great amount of research accompanies this advancement. This has led to a shift from a paternalistic biomechanical paradigm to a patient-centred, biopsychosocial (BPS) paradigm.1 ,2 The IFOMPT defines OMT as “a specialized area of physical therapy for the management of neuro-musculoskeletal conditions based on clinical reasoning, using highly specific treatment approaches, including manual techniques and exercises”. Second, the IFOMPT states, “OMT also encompasses, and is driven by, the available scientific and clinical evidence and the biopsychosocial framework of each individual patient”. Nowadays, manual therapists are often master of science (MSc) and are trained to serve as role models and educators.3 ,4

In physical therapy, as in many fields in life, not everyone adopts to changes the same. Different types of ‘adopters’ can be described by the timing and motivation for adopting a specific change.5

• Innovators: Innovators are adventurous. They ‘gamble’ at new developments and are first to adopt change. Although they can lead the change, and serve as an example, they may also change the direction before any goal has been achieved.

• Early adopters (EA): EA are often young and pay attention to innovators’ developments. EA are enthusiastic and often charismatic about change. EA communicate mainly in positive ways about the change. EA often focus on the improvements of the new versus the old. However, this might be a utopian version of reality.

• Early majority (EM): EM are patiently waiting until it is clear that the change is useful to them. EM look at the change and try to see the benefit for their own situation, carefully evaluating whether or not the baby will be thrown out with the bathwater. The EM are likely to adopt change according to the benefits.

• Late majority (LM): LM are sceptical about a change. The LM are not likely to adopt changes according to the benefits, when there are still obvious threats.

• Laggards: Laggards are not likely to adopt change. Laggards generally are confident about their situation and comfortable with it. They are satisfied and content with the current state and context they are in. Unless there is an external force, such as a law or guideline policy present, they will not change. Although content and satisfied, laggards are hard to move and do not respond to rational arguments.

Although some physical therapists may be seen as innovators in a specific field, they may be laggards when adopting a BPS paradigm.

The nature of evidence-based practice is to start a rational debate about change. Much of the debate on a patient-centred BPS paradigm has been adopted from a theoretical point of view. Sceptics state that there is a gap between theory and practice. They seem to point out to the fact that the ‘why’ might be clear, but it is unclear how to change.6 This indeed is a real threat to incorporating a BPS framework.7 As the EM and LM are looking up to innovators and EA to lead by example, the debate seems to go on about the theory to get the laggards to implement a BPS paradigm. For example, a recent editorial in BJSM refers to laggards as ‘dinosaurs that should become extinct’.8 On popular and social media, the draft of the NICE guidelines on low back pain mainly referred to things that ‘are not to be done anymore’ or ‘people should exercise’ without any reference to the BPS framework. The recommendation to use the BPS-oriented ‘STarT Back screening tool’ for risk assessment and stratified care was hardly mentioned.

Continuing a debate about change with laggards seems ineffective. After all, laggards lack internal motivational forces to change and will only adopt change according to appropriate external forces.5 A common ground and a common starting point of a debate with laggards are lacking. Role models and educators should realise that an ineffective debate will create the perception of the entire profession being unable to make an evidence-based paradigm shift. Although the debate between laggards and role models continues, the majorities remain unable to put theory into practice. Therefore, we risk failing the implementation of a BPS paradigm. Educators and role models need to start informing, inspiring and facilitating majorities to put theory into practice.3 ,4 Educators and role models should exemplify and educate about patient empowerment, behavioural approaches, communication skills, motivational approaches, self-management skills and pain education skills in physical therapy. Educators and role models should develop evidence-based courses, start writing case reports and perform trials to exemplify and describe the skills in specialised physical therapy and disseminate these to the EM and LM. A true change is unlikely to be made, unless the majorities learn skills on how to change, not just knowledge on why to change. Only after creating such a change in the standards of care, external forces can be created for laggards to adopt change.