Why Become a Manual Therapy Fellow?

This post was originally found on Jesse Awenus' blog. I often wonder now, being skeptical (but not as skeptical as Jesse), if I would go though an entire fellowship all over again. The answer changes often. Do I think it's worth it, yes! Knowing what I do now about the over abundance of passive assessments and treatments and lack of educational strategies, including Therapeutic Neuroscience Education, would I do it all over again? Most of the times, I answer yes, as long as the program had the right content. Thanks for the post Jesse! - Dr E

Lets face it, going through the community based level system run through the Orthopaedic Division or through either Western’s or the newly formed McMaster masters program in Manual and Manipulative Therapy is tough. These are structured programs that require many months of study, practice, exams, and mentorship. Let’s also not forget all the associated course/tuition fees and lost income from time away from work to finish these programs. I finished my advanced diploma in 2015 and it took me about 5 years to get through it all. I recall having to say no to many weekend getaways during the summer of my advanced exam as I would be at home hunched over my desk studying anatomy, biomechanics, pathology, and everything else the people reading this know all too well about. It was quite the onerous process to say the least.

So why do we do this to ourselves? What posses a physiotherapist to take on this extra burden after already completing 6+ years of university study to become a registered physiotherapist. While I’m sure this answer differs for many, I think it comes down to a few key concepts. First off, physiotherapists by nature have a thirst for knowledge and betterment. I know this because year after year the Allied Health Professional Fund (AHPF) in Ontario consistently states that we as physiotherapists use up our funding much quicker than every other listed profession combined! (We sure do like our continuing education). We strive to do better for our patients and figure out exactly why we fail to help a portion of the patients who seek us out. Second, physiotherapists love a good challenge. Despite all our bitching and moaning about the process of becoming an FCAMPT, we enjoy the ride and the community it builds for us both professionally and socially. I can’t tell you how many amazing physiotherapists I wouldn’t have otherwise known had I not done all my levels. The professional networking at these courses cannot be understated.

Other reasons for gaining fellowship may include increased status within the profession, monetary gain from clinics/bosses who provide additional payment for course completion, and for self satisfaction. I’m sure people reading this have their own reasons for taking a level course or doing another masters program.

I would be remiss if I said everything I learned and studied was based on solid evidence and I would be doing a disservice to my skeptical nature if I didn’t have grievances on how the program is taught. While this article isn’t a commentary on the current state of manual therapy education in Canada, I do think it’s prudent to point out that many of the pathobiomechanical models that are routinely taught within the CAMPT program don’t follow suit with emerging evidence. I distinctly recall being made to feel inept when I couldn’t feel thoracic spine passive intervertebral motion (PIVM) as well as the person instructing me. If I’m to be honest, I recall leaving class some days feeling more stupid and incapable then when I entered.  It was later on in my career that I realized that was simply not the case and that there have been repeated studies concluding that identifying lesions by motion palpation are not reliable (Huijbregts et al 2002, Nyberg et al 2013, Seffinger at al 2004).  I began to worry that the physiotherapist down the street from me would be better able to help a patient in pain because they were able to be more specific in their treatment selection and delivery then me. Fortunately, I realized this was also not the case. There are now a number of studies showing similar benefits among patients receiving “therapist selected” and “randomly selected” mobilizations or manipulations. Both groups seem to show equal short-term improvements as long as they receive any form of manual intervention (Donaldson et al 2016, de Oliveira et al 2013, Chiradejnant et al 2003, Aquino et al 2009).  I learned through many hours of reading research that manual therapies can be very effective for nociception reduction, but the exact mechanism for this is till up for debate. If you can keep these ideas in mind as you go through the CAMPT program, I think you will enjoy it much more.

It may seem like I’m saying that becoming an FCAMPT was a waste of time, but that couldn’t be further from the truth. The program I was taught gave me a much more solid foundation in differential diagnosis, screening for red flags and understanding anatomy at a much deeper level. I feel better off for having been through the system and I am glad I stuck through it. There are rumblings that when the new manuals come out next year there will be less emphasis on motion palpation and biomechanics and more emphasis on neuroscience education and a more current model explaining the possible reasons why our hands can help make people feel so much better. I welcome these changes and hope to see more made in the future to keep our program relevant in light of all the emerging evidence surrounding manual therapy. I am a proud FCAMPT and I encourage anyone with any questions about it to contact me. I would be happy to help in any way that I can.

Jesse Awenus B.A Hons (Kin), MSc.PT, Dip.Manip.PT, FCAMPT
Registered Physiotherapist
www.JessePhysio.com

References:
Aquino RL, Caires PM, Furtado FC,. Applying Joint Mobilization at Different Cervical Vertebral Levels does not Influence Immediate Pain Reduction in Patients with Chronic Neck Pain: A Randomized Clinical Trial. J Man Manip Ther. 2009 Apr 1;17(2):95–100.

Chiradejnant A, Maher CG, Latimer J, Stepkovitch N. Efficacy of "therapistselected" versus "randomly selected" mobilisation techniques for the treatment of low back pain: a randomised controlled trial. Aust J Physiother. 2003;49(4):233- 41.

De Oliveira RF, Liebano RE, Costa LC, Rissato LL, Costa LO. Immediate effects of region-specific and non-region-specific spinal manipulative therapy in patients with chronic low back pain: a randomized controlled trial. Phys Ther. 2013; 93: 748– 756

Donaldson M, Petersen S, , et al A Prescriptively Selected Non-Thrust Manipulation Versus a Therapist Selected Non-Thrust Manipulation for Treatment of Individuals With Low Back Pain: A Randomized Clinical Trial. J Orthop Sports Phys Ther. 2016 Mar 8:1-29.

Huijbregts PA. Spinal Motion Palpation: A Review of Reliability Studies. J Man Manip Ther. 2002 Jan1;10(1):24–39.

Nyberg RE, Russell Smith A. The science of spinal motion palpation: a review and update with implications for assessment and intervention. J Man Manip Ther. 2013 Aug;21(3):160–7.

Seffinger MA, Najm WI, Mishra SI, Adams A, Dickerson VM, Murphy LS, et al. Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature. Spine. 2004 Oct 1;29(19):E413–425.

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