Is manual physical therapy distinct from physical therapy clinical practice? (Letters to the Editor).

To the Editor:

We were both surprised and disappointed to learn of the categorical deletion of research involving the use of manual physical therapy from the Philadelphia Panel Evidence-Based Clinical Practice Guidelines. Manual physical therapy is actively practiced in the majority of clinics in the United States and Canada, is part of the Guide to Physical Therapist Practice, (1) is included in the normative model of physical therapist education curriculum, and is a large part of mainstream physical therapist practice. Therefore, it is perplexing that the authors of the Philadelphia Panel reported "one RCT was excluded because manual therapy was used as the comparison intervention." (2(p1681)) This statement is notably ambiguous. The exclusion could be due to a categorical bias against manually applied physical therapy. Alternatively, the authors could have been concerned about the inability to separate the effects of passive movement imparted by the treating therapist from the effects of active and passive movement performed by the patient. The first possible explanation is the least acceptable, as bias is no more appropriate in systematic review research than in original research. The second possible explanation is academic hairsplitting that is more likely to foster debate than better patient care.

Although attempts to isolate individual effects are desirable in basic research, applied clinical research questions are often better answered by studying realistic clinical treatment regimens. Most of our practice remains undefined thanks to a slavish adherence to the reductionist approach. Physical therapist researchers have labored in vain to tease out the effects of each form of modality, exercise, or technique without capturing the measurable clinical benefit of the appropriate combination of' therapy tailored to the impairments found in the individual patient. We must study the effects of physical therapy as it is practiced in the clinic.

The insistence on a reductionist approach simply misses the point that physical therapy can never be practiced without a combination of effects at the system, tissue, cellular, or behavioral level. The effects of rehabilitation interventions are multifactorial in nature; a reductionist approach to clinical research by its very nature excludes the often powerful interaction effects realized using a combined treatment approach. A logical progression for clinical research would be for an experienced provider to observe consistent clinical benefit with a specific form of treatment. A case series could help the provider determine whether those results are reproducible in multiple patients. The next step would be to subject the intervention to the rigors of a randomized controlled clinical trial. If the treatment as performed in the clinic is determined to have substantial benefit, subsequent trials could tease out the relative contribution of each treatment or stimulus to the significant overall treatment effect.

When a randomized controlled clinical trial with an intention-to-treat analysis and a 1-year follow-up is selected for publication as the lead article in a prominent medical journal, it is suggestive of scientific merit. When that same article is selected for Mosby's Yearbook of Medicine and positively reviewed by the Journal for Evidence Based Medicine, the American College of Physicians Journal Club, the Journal of Bone and Joint Surgery, The Physician and Sportsmedicine, and the Journal of Family Practice, it would seem to be a credible study of clinical importance. When that study is awarded the Rose Excellence in Research Award for 2001 by the Orthopaedic Section of the American Physical Therapy Association, it suggests the research merits recognition and is of importance to the practice of physical therapy. Given the overwhelmingly positive reviews in other venues, we find it disappointing that this study (3) was excluded from consideration in the Philadelphia Panel

Evidence-Based Clinical Practice Guidelines.

Even more confusing was the exclusion of another study (4) that clearly did separate the effects of manual physical therapy combined with exercise from exercise alone. If the former study was excluded based on the inability to determine the respective contribution of exercise and manually applied treatment, this study would seem to have been a logical choice for inclusion in the Philadelphia Panel Evidence-Based Clinical Practice Guidelines.

In summary, we are perplexed that clinically meaningful research that ranks high on the evidence hierarchy, (5) that includes patient-focused outcomes, and that has been largely embraced by the medical community can be categorically discarded for the purposes of this review.

COL Gail Dean Deyle, PT, DPT, OCS,
FAAOMPT
Chief Physical Therapy
Brooke Army Medical Center
3851 Roger Brooke Dr
San Antonio, TX 78218

COL Nancy E Henderson, PT, PhD, OCS
Chief Physical Therapy
Madigan Army Medical Center
9040A Reid St
Tacoma, WA 98431

MAJ Matthew B Garber, PT, DScPT,
OCS, FAAOMPT
Director, US Army-Baylor University
Postprofessional Doctoral Program in
Orthopaedic and Manual Physical
Therapy
Assistant Professor, Baylor University
Graduate School
Brooke Army Medical Center

MAJ Robert L Matekel, PT, DScPT, OCS,
FAAOMPT
Faculty, US Army-Baylor University Postprofessional
Doctoral Program in
Orthopaedic and Manual Physical
Therapy
Assistant Professor, Baylor University
Graduate School
Brooke Army Medical Center

Michael G Ryder, PT, DScPT, OCS,
FAAOMPT
Faculty, US Army-Baylor University Postprofessional
Doctoral Program in
Orthopaedic and Manual Physical
Therapy
Assistant Professor, Baylor University
Graduate School
Brooke Army Medical Center

Stephen C Allison, PT, PhD, ECS
US Army War College
122 Forbes Ave
Carlisle Barracks, PA 17013

References

(1) Guide to Physical Therapist Practice. 2nd ed. Plays Ther. 2001;81:9-744.

(2) Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions. Phys Ther. 2001;81:1629-1730.

(3) Deyle G, Henderson N, Matekel R, et al. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee: a randomized controlled trial. Ann Intern Med. 2000;132:173-181.

(4) Bang M, Deyle G. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther. 2000;30:124-137.

(5) Guyatt G, Haynes B, Jaeschke R, et al. Introduction: the philosophy of evidence-based medicine. In: Guyatt G, Rennie D, eds. Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. Chicago, Ill: AMA Press; 2002:3-12.

Editor's Response:

The authors of both of these letters take the Philadelphia Panel to task for the omission of articles dealing with manual therapy, an omission acknowledged in the special issue that carried the panel report. There is a suggestion by the letter writers that this omission is even more harmful because this report appeared to them to define physical therapist practice. There is no basis in fact for such a conclusion. The special issue did not, and was never meant to, define physical therapist practice. The panel was interdisciplinary, and its report specifically focused on the issue of selected interventions that had evidence to support their use in rehabilitation--not just in physical therapy. I emphasize the term "selected" because the authors did state which types of articles they included in their analysis and the word was used in the titles. In addition, there was no linkage, stated or implied, to the Guide to Physical Therapist Practice. (1)

Flynn and associates state that in reference to manual therapy techniques: "Is it little wonder that physical therapists use these interventions at lower-than-expected rates when our own reviews fail to include these interventions?" I am not sure how they define "our own reviews." The panel report does not belong to the profession, and that was made clear in the articles. It dealt with rehabilitation interventions that can be used by many types of practitioners. Our Journal was honored to be chosen as the preferred venue for carrying information that the authors believe should govern the practice of all health care professionals, including physicians and chiropractors, in rehabilitation.

The panel report consisted of materials sent to the Journal for peer review, materials that dealt with rehabilitation interventions. I see no basis for Flynn and colleagues' contention that harm was done to the cause of manual therapy because "our professional journal publishes practice guidelines that appear to indicate that such treatments are not a part of our practice." Harm is done when accusations are made without foundation and when defensiveness leads to ignoring of facts. Misrepresenting what the panel did does not add to evidence-based practice but rather to an atmosphere in which nonconstructive criticism replaces meaningful dialogue.

Manual therapy was not given the kind of consideration many of us would have preferred in the panel report. The limitations and focus of the report were acknowledged in the text and titles, just as they should be in any such report. Clearly, not all possible interventions were considered. Again, I wish they had been, but an editor's wishes are rarely met, and the articles, in the opinion of our peer reviewers, were highly credible for the topics they covered. There were limitations, as is the case for almost all articles we publish.

I learned a long time ago that the best way to get your topic studied is to conduct the research yourself. In this case, that means there is ample room for others to enhance the panel report by conducting systematic reviews that include interventions omitted by the Philadelphia Panel. The Journal does not demand that authors do what its editors or reviewers would have done. Our job is to determine whether submitted materials are credible, meaningful, and contribute to our knowledge and whether there is proper characterization of limitations.

Jules M Rothstein, PT, PhD, FAPTA Editor

References

(1) Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81:9-744.