Moving Manual Therapy Forward – Building from Maitland’s Pioneering Work

After my Decline of Manual Therapy Skills blog I received some constructive criticism on the post.  My brief touching upon “traditional manual therapy” and incomplete explanation of OMPT seemed to ruffle a few feathers. It was brought to my attention that Maitland was speaking of biopsychosocial issues way back in the 70s as evidenced by his text.  As I have studied Geoff Maitland in Fellowship I recognized that he was, like a lot of pioneers in our profession, way ahead of his time.  In my opinion, he brought the patient to the forefront of manual therapy treatment and made it about them and their experience with pain.  His chapter on communication remains one that I think any physical therapist should read to develop their communication skills with patients.

I was also pointed to a passage in one of his past texts that described “Psychological Factors”

This passage represents the entirety of what I have found discussing more of a biopsychosocial thought process in a 500 page book.  It likely has been my own experience with reasoning strictly based on Maitland’s books, and seeing those who masterfully apply it, that has made me realize that it was grossly inadequate for complex pain states.  Our profession is recognizing it and those who practiced directly with Geoff Maitland recognized it.  This is not meant to downplay the amazing contributions of Geoff Maitland but to simply say the knowledge at the time of him creating his reasoning method was limited in the biopsychosocial and neuroscience domains.  Louis Gifford has an amazing set of books, his Aches and Pains series, where he spoke to his experience with Maitland himself applying the reasoning model.  I saw myself and my own experience in manual therapy speaking to me from these pages (page 43 of his 1st book in the Aches and Pains series).

Of course physiotherapy has progressed since this time and I think (and hope) exercise has become more of a hallmark in our care.  I am thankful to clinicians such as Tim Fearon who pushed me to recognize the power of exercise.  In Gifford’s book he discusses many of the positives of the Maitland reasoning style.  He highlights the communication and listening pieces that are a hallmark of his clinical reasoning and actually have a huge amount of neuroscience to support them.  It seems that despite the lack of knowledge and science at the time that Maitland saw the power of good communication and listening.  Adriaan Louw had a great editorial titled the neuroscience of the Maitland concept that really did a fantastic job giving examples of how Maitland was a pioneer and there is a lot of neuroscience that supports a lot of what he was doing in the clinic.  We need to be eternally grateful to Geoff Maitland for pushing us to listen and better communicate with our patients, but we also need to recognize that, despite his immense contributions to our field, he also had failures and his model has been shown to not adequately encapsulate the entirety of the experience a patient in pain has.  Authority bias and the Asch effect are cognitive biases we must guard against in our critical thinking and reasoning if we truly want to move forward and build upon the work of such pioneers as opposed to camping out in theory that science is passing by.

Will our profession continue to be satisfied with the continuous coming and going of patients’ pain that Gifford discusses above? Doing this surely will keep schedules full and bills paid, but I feel we can and must become something much greater.  Surely there are patients who will respond beautifully to mechanically delivered treatments.  No one is saying we lose the skilled application of technique, but we may need to broaden the definition of what skilled performance truly is.  The context we create around the masterful technique and the admiration from our patients for our virtuosic performance must be considered.   Do we truly think that a robot who is taught the ability to produce the “perfect” performance of technique will create the same outcomes as a living, breathing, empathetic, and interacting human being?  Are we willing to ask ourselves if we are simply just temporarily modulating pain versus truly creating change that results in behavior change outside the 4 walls of the clinic?  My training and experience in physical therapy has shown me that creating change in the clinic is easy.  It is the change that remains present in the context of a patient’s life that is the truly hard and difficult work we must focus our practices on.  This goes well beyond the expert performance of technique.

Our clinical reasoning needs to stay up to date with science.  We have an absolute duty as professionals to keep our practice up to date with science even if it conflicts or brings us discomfort as we challenge our current practice patterns.  This especially applies to those who teach manual therapy coursework.    A big reason I teach with EIM is the fact that clinical reasoning and pain science are huge components of their fellowship program and we have people like Jason Steere who are leading a charge to integrate the two. This integration is the result of the science pushing to realize that we can no longer just tell a narrow mechanically-dominated side of the story in theory and application of manual therapy.  We need to be better than continuous comings and goings of pain that Gifford saw in Maitland’s practice.  Let’s be honest and recognize that we ALL have patients who wallow in our clinics.  There are variables that a physical therapist, and sometimes anyone else for that matter, is unable to affect that are serving to reinforce the pain and behaviors we see in the clinic.  Often we are quick to cast stones at fellow physical therapists or other professions whose clinics we feel patients are wallowing in but are we living in glass houses?

Mark Kargela

Mark has been practicing physical therapy since 2003. He spent the his career pursuing expertise in manual therapy treatments. When he recognized that manual therapy had limited success in chronic pain he began intense study of pain neuroscience and advanced training. He practices in Glendale, Arizona where he is a Clinical Assistant Professor and runs Midwestern University's Physical Therapy Institute. He also teaches nationally for Modern Pain Care and lectures across the country on spine care and persistent pain.