All right,
welcome back to another exciting
episode of Orthostatic,
the podcast from the
Academy of Orthopedic Physical Therapy.
Today,
we have a guest who's as dynamic as
he is distinguished,
hailing from the land down under.
He's made his mark in Australia, Canada,
and now here in the United States,
not only an associate
professor at the University of Florida,
but also a leading light in
the management of musculoskeletal pain.
When he's not shaping minds
in the classroom or
mentoring PhD students,
he's unlocking the mysteries of pain
through manual therapy and exercise.
Let's welcome to the show,
Dr. Mark Bishop.
All right.
Thank you very much.
All right.
We'll get the hard questions
out of the way first.
We'll give you the nice broad one.
Mark, what's manual therapy?
That can't be a simple question.
Maybe I should say it's not
an easy question.
It's a simple one.
And then we'll back it up.
Why is it important in this
area of orthopedic physical therapy?
How would you answer that one?
Well,
manual therapy is a group of ancient
techniques, actually.
So with thousands of years
of history of people
performing manual therapy interventions,
which are essentially
skilled interventions for
which you and I use our
hands to deliver some sort of treatment.
And so historically,
we look across multiple
different cultures and
multiple different eras.
There's always been manual
therapy as part of
healthcare and health improvement.
I'd say the more modern
definitions that you'll
read about is like series
of skilled passive movements.
So types of things where I'm
using my hands to perform
very specifically
goal-directed activities,
and those can be directed at the joints,
the muscles and soft tissues,
neurovascular bundles.
kind of broadly,
and they're used mostly to
manage neuromuscular conditions.
And I'd say that one of the
definitions I really like
about it is that it's an
approach that uses clinical reasoning,
highly specifically
directed treatments that
include both manual
techniques with my hands
combined with exercise.
And so for me,
that's the definition I like
the best for this.
And I think why it's important,
we certainly,
you talked about tangents before,
we can go off on plenty of tangents.
I think that one of the
reasons that manual therapy
is very useful as a system
is that it's a systematic
approach for me to deal
with someone's
neuromuscular health condition.
And for that reason,
I think my opinion is the
approach is important in orthopedic PT.
We can certainly debate,
and I know there's plenty
of debate about which
approach is most effective, but for me,
the systematic application
of manual interventions and
exercise has been effective
in my career and I think
overall effective across
pain in particular,
but broadly lots of
different orthopedic conditions.
All right, so next question is,
how does it mix?
How does it play well with others?
How does manual therapy
integrate with other treatment modalities,
or should it be all or one?
Once again, you get plenty of debate here.
I would say that I think it
has to be integrated.
It's not a standalone.
Certainly,
my preference mark bishop's
preference is I've trained
in a manual therapy system
so that that's my original
bias for thinking about how
we uh look at how you're
moving what uh what is
happening so I use my hands
a lot for that um and but
when it comes to actually intervening
I certainly may do some manual techniques,
but it has to be part of
the bigger picture.
So it has to include things
related to other systems,
movement systems, cardiovascular system,
as well as a bunch of other things.
So you have to do the manual
therapy part in conjunction
with the exercise.
You may include other modalities in there.
I personally don't use a lot
of other modalities,
but certainly it has to be
combined with everything.
Don't know of any examples
where it's just effective
only to do the manual
therapy part for broader recovery.
I might just be able to do a
manual therapy intervention
and make some sort of change,
but I don't think that's
going to help the broader
recovery of a health condition.
Yeah.
Now,
if you ever looked or try to find
misconceptions,
you don't have to go very
far because people will say,
take something with this
internet thing that we have.
And typically it'll be a
game of telephone.
So what are some
misconceptions about manual
therapy that you come across?
And then, you know,
what would you say to those things?
What are the frequently
misconstrued ideas?
Well, I'd say probably first and foremost,
one of the things I think
is that you have to be very,
very specific with a
particular biomechanical model.
be effective I think that's
a misconception certainly a
lot of our historical
theories about how manual
therapy may actually
improve someone's health
condition were based on
very complex biomechanical
models that as they've been
studied haven't necessarily
stood up under all
circumstances so the idea
that I have to very
specifically push or move
something in a very
specific direction at a
very specific frequency may
not actually affect me
I think another
misconception is that one
particular system is better than another.
I don't think we've seen that either.
I think that when you look –
when I have looked more
broadly at systematic approaches –
And by that I mean it
doesn't matter what system,
if I'm an advocate for a
McKenzie-based system,
a mechanical diagnosis and
treatment system, I mean,
or a Maitland-based system,
it's the system that's important,
not necessarily the
specifics of the technique.
But the more systematic my approach is,
the more likely I am to get
a comprehensive picture and
make a good decision.
with with that being said it
sounds like there's there's
no one best but it's better
to have a process and
follow that process so I
was going to say you know
what are some of the best
uh trainings required in
your in your mind to
perform manual therapy
effectively but it sounds
like it sounds like I don't
know if I should even ask
that question because it
sounds like the answer is
it depends which we love in
pt I think it does depend
and where I have ended up
on that personally
is that we, in our own research,
have done a few things that
indicate that there's an
intersection between what
you want as a patient, what you prefer,
what I prefer as a provider,
be that manual therapy, be that exercise,
be that whatever.
And there's an interaction
that occurs when these
things happen that helps improve outcome.
It's not responsible for all outcome,
but it certainly helps
improve the outcome.
And so the way we kind of
interpret that is the type
of system that I endorse is
perhaps not as important as
how much I've practiced that system.
The relationship that
develops between you and I
as patient and provider in
part is driven by your
perception of my competence.
your perception of my
competence is in part
driven by my self-efficacy
and my confidence in my
ability to do an exam and
do an intervention that's
going to help you.
That confidence comes from
practice regardless of system.
So if I find a set of
techniques or a set of
interventions or philosophy
that I really endorse and
then it behooves me to study that well,
become good at that system.
That improves my confidence in that system,
which then helps drive your
perception of my competence
and helps build these interactions.
So that's kind of where I've ended up,
that as long as I endorse a system,
and I've practiced that,
then that's going to
improve the outcomes that we have.
And I think as I have talked
to other people,
that certainly there's not
many people just in my
circle of acquaintances and
peers that endorse just a single system.
There's many of them that
will use elements of
different theories and philosophies.
They practice those,
perhaps trained with the
developers of those,
and become confident in using them.
So I think I kind of danced
around your question there
about is one system better than another.
I think you just choose what
system that you really like
and get good at that by
studying practice.
Now,
most of what we've been talking about
is ideas and concepts, but is there a,
this is all around people, right?
I mean,
you study these things to be able
to help and make a
difference in people's lives.
Is there a particular case?
Is there something that
comes to mind where if you
had to show the benefit of
manual therapy and the
techniques you've studied
has made a significant difference?
Is there something that
comes to mind that you
could actually put a face to?
There's a couple.
I'd say two.
When I think about this,
the person that I remember the most,
that's part of the bias
with this sort of recall stuff,
is I remember the people
who did really well,
I remember the people who did not do well,
and there's a group in the
middle that I don't really remember.
But a person I remember doing really,
really well had headaches
and a facial pain,
and we were doing a few things,
and then it wasn't until I...
did a upper cervical manual
technique that that
particular person
experienced or at least
reported great relief to the orofacial.
And I remember that that
happened decades ago.
And just remember that sort
of person getting up off
the table and say, oh,
that feels so much better.
We went on to do lots of other things,
but it was just that
particular technique that we did, I think,
met a bunch of different
needs and caused a big difference.
Another person, if I may,
that I remember a lot is a
A colleague of mine had had, I don't know,
long-term neck and thoracic pain.
She got some shoulder pain,
and she'd been going to see
some people for a set of
interventions that weren't
working for her.
And, you know,
I had the benefit of her telling me, well,
I've tried this, I've tried this,
I've tried this.
And so I could say, well,
we won't do those because
you've tried those.
Let's do this.
It turned out it was some
simple sort of assisted movements,
some thoracic patterns,
some passive physiological motion.
And she got up and said, oh my God,
that's the best I felt in months.
Um, and so those, those two stick with me,
but like I said,
that's a big recall bias.
Um, uh, but there are two examples that,
uh,
people found really good immediate
short-term relief and then
didn't need a lot of
follow-up manual treatment after that.
And we were able to move
into doing other things.
Now, Mark, you work with students,
and students always come
with a lot of these things
called questions and insecurities.
If they're still listening right now,
if you've got some either
students or new grad PTs in
the first three to five
years of their career,
where would you send them to start?
They've got to start somewhere.
You mentioned finding a paradigm,
and the goal is to find
something that works for you.
It doesn't necessarily
matter what it is necessarily,
but where would you send them to start?
What would your suggestion or advice be?
I'd say to a mentor or a
senior PT at wherever they're working,
talk to that person about
what works for you.
How did you make those decisions?
Why did you choose that?
And then the next step is to
learn a few different things.
I'd say my own journey, if I may,
we studied in Australia and
our focus was on
Maitland-oriented manual
therapy techniques.
Then I had the opportunity
to go and work in Canada
where the techniques were
different and they were
doing a lot of
post-isometric holds and
movements and some muscle energy things.
And then it came to the
United States and there was
a whole group of soft
tissue mobilization things
that I had never encountered before.
And so I took some of those courses.
I'd say over that,
couple of years um I found
my favorite my favorite
stayed with my base
training which was the
maitland and and stuck with
that but I think if you
have the opportunity to to
try a couple of different
philosophies can find one
that conceptually said aha
that makes a lot of sense
to me then that would be
where I would get you to start yeah
that's a pretty big difference, right?
That's international.
I think a lot of the PTs,
especially in the United States,
aren't necessarily exposed to that.
It sounds like you might
recommend that because it's so different.
I think I would.
Philosophically,
the Norwegian manual
therapists are going to
think a little bit
differently from people who
have developed their own
system here in the United
States versus the osteopathic origins of,
say, Grieve or Maitland.
And so each of those comes
with a different set of
sort of background philosophy,
but we can debate about the
accuracy of those.
But their approaches are
then a little bit different
for how they do the techniques,
combine the exercises with
those techniques.
And then you sort of find,
it sounds as if you're saying,
and find the things about
those varied things that
may align with you, work for you,
and that's how you find
your own skill set.
Absolutely,
I think you know Stanley Paris
did a lot for manual
therapy in the United
States and has some great
courses if people are
interested in sort of joint
focused things here in the United States,
that's a somewhere they
could start certainly the
Norwegian PTs have a
presence here in the United
States the neurodynamic
approaches Dave Butler and others
of thinking about
neurovascular bundle as a
potential source of these
type of things those are
all available here in the
united states for people to
to try uh last thing we do
on orthostatic is call
words of wisdom is there
something you want to leave
the audience with either a
soapbox statement or
something that uh that you
use as your mantra what do
you want to leave with the
audience as we exit
Care about your patients.
That's what I think.
I think if some of our
outcome is related to our relationship,
then it behooves me to
think about that
relationship and truly care
about the person in front of me.
I don't know if this
resonates with anybody,
but I can tell if I'm not into it,
if I'm maybe not having a great day,
don't feel like talking,
then my outcomes that day
are just not as good.
I don't feel good at the end of the day.
The people I've seen don't
necessarily feel as good.
And so if I can just focus
on being present,
care about the person in front of me,
then that goes a long way.
Yeah, great words.
Dr. Mark Bishop,
thanks so much for stopping
by on Orthostatic.
You're welcome.
Pleasure.