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Physiotherapists are not corn
  1. Laura Ritchie
  1. Correspondence to Laura Ritchie, Orthopaedic Division, Canadian Physiotherapy Association, London, Ontario N6L 0C2, Canada; orthodiv{at}shaw.ca

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It turns out I am a terrible physiotherapist. If you practise in a ‘Hands On’ manner and believe everything you read online, then you might come to the conclusion that you are too. Such is the vehemence of opinion in the ‘Hands On-Hands Off’ debate on platforms such as Twitter, it seems to echo the polarising political discourse that is now so common.

Now, we know we are not terrible therapists. We know that as physiotherapists who include manual therapy in our treatment approach, we are part of a network with a long, proud history of excellence in clinical knowledge, techniques and reasoning. But lately it seems that special interest groups such as the Orthopaedic Division of the Canadian Physiotherapy Association (CPA) are facing some serious challenges. There has long been a perception that we are all about mobilisations (‘mobes’) and manipulations (‘manips’) but this has been amplified recently through social media. The potential impact of this negative rhetoric is worth considering, even if you are not active on social media yourself. Will recent graduates continue to study manual therapy-based curricula when faced with the plethora of alternative educational opportunities in conjunction with obdurate voices on social media? Similarly, in the face of the naysaying, will some therapists lose faith in their training and think twice about instructing in orthopaedic or manual therapy courses? The net result could be that therapists of all levels of training develop an ortho identity crisis.

A clear professional identity is important. It guides our path and it gives us strength when facing challenges. The identity of our profession has been and continues to be evaluated in different ways. Pat Miller, Vanina Dal Bello-Haas and Chantal Lauzon are finalising the core professional values of the CPA through a Delphi process.1 Dave Walton and the Physio Moves Canada team connected with physiotherapists nationwide about opportunities and threats they face.2 Publication of these results, and those from broader international arena, will help form a clearer idea of what is needed to ensure our profession continues to thrive.

Certainly for that future to be successful, we need patients and third parties to have faith in our profession. Thus, they need to know who we are and what we do, at least in broad terms. Public bickering in the Twitterverse about out-of-context minutiae will not help our case. It will more likely drive patients to seek help from professions that seem to have their professional act together, leaving us ‘eating ourselves until we are no more.’3 The Canadian Academy of Manipulative Physiotherapy has already taken steps to promote a clear brand and the CPA’s Orthopaedic Division has also recently undergone rebranding, including the blog for which this article was originally written. This rebrand emphasises excellence in advanced orthopaedics (not manual therapy specifically) within the context of a peer-supported network and a rigorous, globally recognised evidence-informed education and examination curriculum.

As the rebranding continues to be rolled out, this is a good time to think about our ortho identity, whether you are part of the Canadian Orthopaedic Division or another special interest group. How do we see ourselves? How do others see us? They are complex questions and not ones to answer definitively here but they are certainly worth considering because in the face of change, we really are Stronger Together, the tag line of the 2017 symposium hosted by the Orthopaedic Division and the Canadian Academy of Manipulative Therapy. Let us take a moment to consider some factors so we can continue to say it loud and proud: we are ortho.

I can type in all caps better than you can

Social media is great for knowledge translation, for sharing findings and facilitating discussion. Downsides include decontextualised information, user bias and negativity. Sometimes it seems a competition of who can SHOUT THE LOUDEST or cite the most articles to prove the ‘other side’ is woefully unsupported. Manual therapy and at times the Orthopaedic Division come under fire for being ‘Hands On’ in a way that is a bit baffling. Does anyone practise entirely hands on or hands off? Presumably most of us follow the middle course, varying treatments based on the patient in front of us. Yet, to voice this reasonable approach in a public forum can feel like a losing battle, assuming you are brave enough to wade into the quagmire.

But what is the alternative? By avoiding opposing voices, we risk barricading ourselves in an echo chamber, listening only to opinions matching our own. There remains the need for informed debate, so in that spirit, let us talk plainly about the Canadian Orthopaedic Division, some of which may relate to other orthopaedic or manual therapy groups.

The big bad (and old) Orthopaedic Division

One criticism is that the Orthopaedic Division curriculum is based on an outdated biomechanical model. The Orthopaedic Division has been around as a special interest group since the ‘70s and when the Extremities Vertebral course syllabus was created around that time, the biomechanical model was the accepted framework (email to the author from B Padfield, April 2018).4 Some early instructors (eg, David Lamb, Cliff Fowler, John Oldham) were Cyriax trained in the UK and the original courses were based on their own notes but as new evidence has been published, it has been incorporated into OD courses.4 Yes, we still learn about biomechanics (joints do move, after all) but also about the neurophysiology controlling joint and muscle function, movement screening, pattern recognition, pain science and exercise dosage. We are taught to clinically reason, to think in terms of the biopsychosocial model and to treat according to those influencers. It certainly isn’t all mobes and manips. The syllabus has come a long way.

When it comes to the syllabus course manuals, most involved in the syllabus would probably agree they have needed updating for a while. Compilation of those manuals started around 2001 while the most recent version was completed in 2009 and we all know how quickly printed information becomes outdated (emails to the author from B Padfield and J MacMillan (April 2018). The update is now under way and the new manuals will be released in early 2019. Would it have been nice to have them sooner? Sure, but the OD is a large not-for-profit organisation, founded and run by volunteers—it is a big ship to turn around. This perhaps puts it at a disadvantage compared with smaller newer educational outfits but that should not discount the decades of experience, knowledge and expertise at the heart of the OD.

The reality is that the OD provides a layered educational system that works for many people in terms of time commitment, cost and structure. It provides a solid framework with which to approach clinical interactions, starting at the tissues and working through whole body regional interdependence. It has a great network of instructors and mentors to help develop sound clinical reasoning for choosing how and when to treat. And yes, the curriculum continues to teach and hone manual skills, with an emphasis on the mechanisms behind why manual therapy may work for specific populations and when it can be an effective tool with the right patient in the right context.

Physiotherapists are not corn

Words are important, with the power to persuade, prejudice and pigeonhole (among many other things). Perhaps part of the problem with the ortho identity is labelling; by identifying as a Manual Therapist or, say, a Fellow of the Canadian Academy of Manipulative Physical Therapists, maybe there is an inaccurate expectation that you always practise with a focus on manual skills. But even those that identify as Manual Therapists will have taken courses that are not related to manual therapy—physiotherapists do love a varied toolbox! No two physiotherapists are alike in terms of their training, practice setting, funding model, clinical experiences, even life experiences, so we cannot expect everyone to treat in the same way. Nor should we—patients are not identical therefore they will not respond identically (or, as Dave Walton memorably put it during a keynote presentation last year, we are not corn).5 An approach that works well for you maybe does not work for me with my patient—and that is OK! That is why we have that diverse toolbox.

A possible downside of this variety is spreading ourselves too thin. With continuing education, it is important to pick one thing and take the time to get really good at it. For people currently taking or having completed postgrad training such as the Canadian Orthopaedic Division syllabus, advanced orthopaedics is what they chose to focus on for that period of time. Afterwards they may develop an interest in additional skill sets but they will always have that solid orthofoundation to complement the other skills in their toolbox.

For physiotherapists who do not necessarily identify as Manual Therapists, phrases like ‘manual therapy’ and ‘hands on’ can still be problematic due to certain assumptions, but even Peter O’Sullivan (often held up as a proponent of the Hands Off approach) states that he places his hands on all his patients. However, he also states: “What I DON’T do is use ‘HANDS ON’ to tell the patient that I am ‘fixing’ their ‘dysfunctions’ and ‘instabilities’…or to reinforce dependence on passive therapies.”6 Certainly we should be careful with the words we use with patients. If we are aiming to empower them to maximise their health and function, then we should correspondingly minimise the creation of fear or dependency through our words and our explanations of our proposed treatment.

Perhaps we should also think about the words we use in relation to the orthopaedic physiotherapy community, not just to patients. Should we talk less about ‘manual therapy’ and more about ‘advanced orthopaedics’? After all, this is what the OD curriculum actually encompasses. Manual therapy is only one component of a broader orthopaedic framework and of course orthopaedics is only one area under the physiotherapy umbrella. We can seldom, if ever, think of orthopaedic issues in isolation so maybe our own word choices lead to some of the pigeonholing we experience. Renaming the syllabus is in fact a change that the executive of the Canadian Orthopaedic Division is considering as part of the rebrand.

Ultimately, we should encourage and celebrate diversity of education and practice in the orthopaedic physiotherapy community, recognising that at the core of that practice is a solid foundation of advanced orthopaedic knowledge, techniques and clinical reasoning. An optimal outcome for the patient in front of us is more important than the means to achieve that outcome. One size does not fit all,7 whether therapist or patient.

Ending the identity crisis: our window of opportunity

Given the diversity among physiotherapists, what then are our commonalities within the orthopaedic physiotherapy community that show who we are? How about:

  • Evidence-informed, patient-based practice?

  • Strong therapeutic relationships, built on connection, trust and frank discussions about treatments?

  • Positive word choices that empower our patients and instil resilience?

  • Optimal outcomes that are truly meaningful to the patient?

  • Pride in our established yet evolving approach to advanced orthopaedics that includes manual therapy when appropriate?

These may indeed be some qualities that underpin orthopaedic physiotherapy organisations but perhaps too much of a mouthful. The Canadian Orthopaedic Division’s new tag line more succinctly encompasses these ideas: ‘The Community for Advancing Orthopaedic Physiotherapy’. Whichever way we practise individually, we are part of this community so let us take the opportunity to promote our community’s brand whenever possible by:

  1. Walking the walk. Take a moment to reflect on your treatments, clinical reasoning, potential biases, word choice and outcomes. Does your practice currently advance orthopaedic physiotherapy or is anything in need of a refresher or update to stay abreast of the orthopaedic physiotherapy community?

  2. Talking the talk. Let us positively engage in reasoned debate in person, on social media, everywhere! Talk with entry-level physiotherapy students, students undergoing postgrad training and other health professionals to emphasise the value of advanced orthopaedic education in contrast to negative rhetoric.

In this way, the orthopaedic physiotherapy community will continue to thrive with engaged students, members and instructors, who are all proud to say, we are not corn, we are ortho.

References

Footnotes

  • Contributors With gratitude to Jasdeep Dhir, Angela Growse, Jennifer MacMillan and Bev Padfield for providing background information on the Orthopaedic Division and its curriculum for this article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Author note A slightly different version of this article originally appeared in a blog hosted by the Orthopaedic Division of the Canadian Physiotherapy Association in June 2018. Representatives of the Orthopaedic Division gave permission for reproduction of the article here and it was modified to its current format at the request of BJSM editors.

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