Defining Orthopedic Manual Physical Therapy with Jason Silvernail

Few things will stir up blood pressures and social media fervor more than a post about manual therapy. I've not been innocent of criticisms of some of the dated and non scientific approaches to hands on care. For me, I am just as appalled by what goes on out there in the fringes of manual therapy practice as that is not in any way, shape, or form similar to how I was trained to apply manual therapy as an orthopedic manual physical therapist. It became clear to leaders in OMPT training and education that a clear definition of orthopedic manual physical therapy practice needed to be published so clinicians and patients could better understand the identify research and practices portrayed in the media that better represented OMPT practice versus all hands on care being lumped into one big old manual therapy bucket.

It's important to for, I think for everyone to know that we're not here to define manual therapy. We're here to define orthopedic manual physical therapy. That is what is represented in some of the best trials, not only in terms of. quality, but in terms of outcomes for our patients are in the orthopedic manual physical therapy model.

This is what prompted Jason Silvernail and his coauthors to publish a definition that really encapsulates the training and key characteristics of OMPT practice. So someone can make their own educated decision on practice versus. Allowing social media outrage and clickbaiting to be their only source of information. It has become increasingly frustrating to those of us trying to use manual therapy in an evidence based, critically applied and patient centered mode of application to be grouped with anybody out there providing hands on care.

And I know that you see crazy manual therapy out there from other professional groups or other, other systems of, of care. What does that have to do with OMPT? Well, it's got nothing to do with OMPT.

Jason and I also spoke to the criticisms that manual therapy training is elitist, which has always puzzled me as the people I've encountered in OMPT training have been some of the most humble, generous, and kind individuals out there.

Some folks just don't like the idea that as humans, we develop systems of, of training and education, and we do create hierarchies of competence. In those systems. Right. And so I think it's interesting the areas in which that really seems to bother people and the areas in which it doesn't. So nobody at my brother's work site thinks he's elitist. They know the training he's been through and they know he's the kind of guy they call to call it, to, to fix difficult, complicated problems. And one of the things that fellowship training teaches you is how to manage difficult, complicated problems.

It's hard to find well reasoned discussions around manual therapy on social media. If you want a well reasoned explanation of what orthopedic manual physical therapy practice is so you can make your own educated decision on if it seems like a good path for you, then this episode is for you. We are about to open the doors to our ModernPainPro community where we're having discussions, workshops, and giving support to clinicians to excel in their practice. If this sounds like something you'd be interested in, then make sure you check out our community at ModernPainCare. com forward slash community. On to the episode.

This is the Modern Pain Podcast with Mark Kargila.

Welcome to the podcast, Jason. Hey,

Mark. It's great to be here. Thank you so much for the invite.

Always good to have you here. You've been on the podcast before. I think last time we had you in the podcast, we were live in San Diego at CSM and now we're, we're, we're back virtual mode as we've, we've been in the past, but excited to have you here. Always enjoy discussions with you. I think you bring a nuanced and well reasoned approach to what you discuss and, and things you put out there on social media. What stimulated this discussion today is your, your release of the OMPT kind of standards definition paper of kind of what OMPT orthopedic manual physical therapy for those of you who aren't sure what OMPT means. Um, we're going to talk to that a little bit, but Jason, I know you. Uh, if you don't mind introducing yourself for the audience, letting folks know kind of where you're at and what you're all about. Thanks. I'm,

I'm very excited to be here. My, my name is Jason. So Bernie, I've been a physical therapist since 1997. Um, and I've been on active duty in the U S army for a long time. I've got over 25 years experience PT. Uh, I've got my doctorate physical therapy degree on board certified in North I'm an orthopedic, uh, orthopedic therapy, um, certified strength and conditioning specialist, fellowship trained in, in manual and manipulative therapy. I'm also an officer in the U S army where I currently hold the rank of colonel. Uh, and because I'm in the army, I got to say everything I say with you today is my personal opinion. Commentary does not reflect the official policy or position of the U S army, the department of defense or the United States government. And having said all that, I'm excited to talk about, uh, you know, our recent paper, which Uh, orthopedic manual physical therapy and modern definition and description, which I did with, um, what I think can truthfully be called a, um, just an unbelievable dream team of authors who are just, uh, tremendous academics, researchers, and clinicians who come from all different kinds of backgrounds from the sort of full spectrum of different approaches to OMPT. And we all kind of came together. And put together what we, what we believe is like a modern definition and description of what OMPT is, because I think people need that. I think that when we have some of these big timeless principles, um, I think that often we believe. Everyone understands what they are and why they're important. And I think that these things need to be reinterpreted and explained a new, in a way that, that matches each generation, not, not strictly speaking each generation of people, but just every so often these, these things need to be refreshed in a way that ensures that we are. faithful, not only to the original teaching of what we're all involved in, but also in a way that puts it into context and makes it make sense in the current, in the current day. And that really is what we tried to do. Uh, and I think we were pretty successful and I'm really excited for people to read the paper and give us some feedback.

It's a great paper really gets into the nuts and bolts of what it really means. Cause I think it gets misrepresented. You know, I think we generically take things manual therapy and, and we know in social media, sometimes that can be a, a, a, Topic that brings all sorts of vitriol and discussion and criticism and again, maybe based on some rightful criticisms of some examples of maybe not the best Um definitions of what manual therapy is But this paper obviously serves to really give a good definition of what it means to have expertise in this kind of focused mode of study of interacting with a patient through, you know, manual therapy approach. What have you found? Like, where did you feel this really fits in? I know you kind of spoke to this already a little bit, but like, where do you, what prompted this and where do you feel this kind of fits to kind of address maybe some of the misunderstandings that exist out there that you see across the social media landscape, but also elsewhere, just in general healthcare, um, of misunderstanding what that means to be an orthopedic manual physical therapist. It's important to,

for, I think for everyone to know that we're not here to define manual therapy. We're here to find orthopedic manual physical therapy. That is what we teach. That's what we practice. That what, that's what it was sort of historically passed down to us as a method, uh, from people that came before us. That is what is represented in some of the best trials, not only in terms of quality, but in terms of outcomes for our patients are, are, um, are in the orthopedic manual physical therapy model. And I think that oftentimes people. Uh, get confused about what that mode of care or method of care is versus other kinds of hands on care And I think I see this in kind of two two different streams And I think that the first stream is is sort of how it's interpreted sort of like, um In modern medical culture or in therapy culture where there's a real Misunderstanding or a conflation of all of these things and the other one is is the way that it's taught and understood in the academic world so for example in clinical practice guidelines and reviews and and Having published in literature before having published in clinical practice guidelines before I will tell you that some of the discussions that that I end up Having with some academics are are pretty interesting in terms of the way in which they see it, especially if they're not familiar with these, with these methods. And let me give you an example. One of the things that, that, um, many of us found, uh, who were in, who are in the OMPT world have found that when we look for high quality randomized trials. About how people can handle common conditions. Our patients have some of those, some of those trials that show the best outcomes. Or in the OMPT model, yet those trials are often excluded from reviews and excluded from practice guidelines because of the way that the care is categorized. And having talked to a lot of these academics and researchers myself, oftentimes they'll go through and they'll read a trial and they say, Oh, Well, they did a hands on technique. We're going to take it out, and we're going to put it in this bucket that says manual therapy. So, anybody who touched a patient with their hands or moved something, we're going to call that the manual therapy bucket, and we're going to put everything in there. Now, what's kind of funny is that we don't do this for exercise. We don't say, Oh, wait. They did a stretch, let's pull it out and put it over here only in the stretching bucket and not put it in the exercise bucket. Or, well, here's the strength training. We, we have to have this in the strength training bucket. We can't put that. And so it gets a little bit reductive. We, we've, I think we feel like we need to sort of slice and dice a lot of these things into ever tinier pieces. Yeah. Uh, and that in, in, in that reduction, uh, you know, we miss a lot. I had a, I had a long conversation on social media about our paper when it first was released, uh, published ahead of print, which is where it currently is now, as we're waiting for the full, for the full journal publication to come through. And one of my, uh, discussion partners was saying something like, you know, the problem with doing different things with patients is you don't know which one of those things work. Some of those might be effective and the other things are sort of just free writers. And I don't know why I thought about this, but I thought, you know, it's a little bit like getting sick and you eat a can of chicken soup and you see, you feel better. Like with these same people think, well, which part of the chicken soup helped you? I bet that celery is not helpful. Is it? That's celery is questionable. Nobody likes celery, Mark. Do they? Nobody likes celery, especially if there's no peanut butter with it. I bet that celery is a free rider. We're gonna put this in the celery soup bucket. And not in the chicken soup bucket because it's got celery in it. And that like, that really is the substance of that discussion. That that's not hyperbole. That is not me, you know, oversimplifying or trying to be difficult. That is the substance of actual conversations I've had. Both in public and behind closed doors with researchers and academics about how we interpret this. And one of the things that we try to convey with, with this paper is how to understand that OMPT is a process of care. It is a. It is a treatment model that has, um, a conceptual model, meaning things that we do that are consistent with the description of advanced specialty practice public that published through the American Academy of Orthopedic Manual Therapy, which is connected to IPHOMPT, which is the international manual therapy, physical therapy, bottled body that that sort of supports all countries with their with manual physical therapy. And it also has distinguishing characteristics, ways to recognize it so that when we go and look at our trials, we can say, is this a trial that includes manual therapy? Or is this an OMPT trial? Because there are, those two things are different. And we wouldn't say this is an exercise therapy trial, but not a strength training trial. Like we would, we would have no problem describing clearly. The interventions and processes when it doesn't, for some reason, when it doesn't involve manual therapy, but for some reason, when it involves hands on care. That that really seems to bother some people and I have to be honest with you. I'm really not sure why

you bring up great points about the reductionist kind of way. We try to piecemeal it. So the carrots are free riding

the carrots in the chicken soup. Mark, the carrots aren't doing anybody any good. That's just extra stuff they threw in.

I'm a carrot man. I'm not a celery guy. I mean, unless you got some, unless you got some ants on a log with the raisins and chocolate chips actually take

Oh, nice. I got to try that one.

Yeah, definitely worth your time, worth your time. Uh, I'm wondering if you can speak to because I, you, you and I both went through fellowship training. We've been fortunate to go through that process and really kind of, I mean, it was a huge source of growth for me, mainly how to think and reason through this stuff. And, and when you see people like on social media, we had Seth Peterson, who's a great physio, went through similar training, um, and, and talked on the podcast, how like some people on social media, like, yeah, when I do manual theoretics, check out my brain. Which I'm like, Oh my God, that is the exact opposite of like how I was trained to apply manual therapy. It was very thoughtful and very, you know, reasoned approach with it. I'm wondering if you can speak to maybe and maybe reflect it within your own experience of your growth and development within your training of how. Manual therapy is something that is a very cognitively active process and granted it's cognitively changed with some of the new science as any technique should that is kind of maybe reconceptualize how what we're doing and how maybe the mechanism behind it, but still the thinking and reasoning remain. I'm just maybe you can kind of head shed some light for the audience of like, yeah. How that whole development and process is more than just checking your brain out and putting your hands on somebody.

Yeah, that's a great question. 100%. I think this really kind of touches on this issue of active versus passive care. I'm not really sure where this dichotomy came from, but kind of like all dichotomies, it's um, it's often not so helpful. So, Um, we understand that many people learn manual therapy differently or experience it differently, either from a colleague or as a patient or from reading a paper. And we understand that it can be hard to sort through all these things. Just as if you're not used to doing physical things, it might be difficult to read a paper and figure out what is a mobility exercise versus a strength training exercise versus, you know, something like that, right? So some, that sort of similar process might be a play. And so one of the things we did with our definition paper is we didn't just Provide the paper itself. We actually included a patient case where that it, that sort of walks you through literally what is going on in the mind of someone who has OMPT training and helps explain why they make the decisions they make when they make them and how they are constantly adjusting or changing what they do based on the patient's response to the care. And there's just no way that that can be passive. There's no way that can have a Uh, checked out brain, kind of a, kind of a process to it. And I know that there are other kinds of manual therapy that aren't like that, and that's perfectly okay with me. But that's not orthopedic manual physical therapy, and that's really what our paper set, set out, um, to define. And I think, uh, We are hopeful that when people read the paper and get interested, they'll say, let me check this patient case out. Let me see what's going on with all this stuff. And we tried very hard to be clear about what that thought process looked like.

Yeah, no, and I think you all laid out a very good, I think the patient case component was, was very helpful because I think it, It brings it to a real world versus more theoretical and in print and things can be misconstrued. But when you see it applied to a real case, I think for sure. Do you see any issues with the consistency, I guess, of OMPT training where, and I think this exists across all professions, I'm fortunate to work with some osteopaths and there's discussions in their profession of like, man, there's some, some sex of the different parts of the osteopathic. Profession that probably need to like bump things forward a little bit. They're operating under some, some maybe dated models. Do you think that plagues a little bit of what we deal with orthopedic manual physical therapy and, and, uh, you know, how do folks, I guess, deal with that as, as they're considering, you know, as OMPT something. Um, they may want to pursue as a clinician. Yeah,

no, that's great. Um, well, I think the short answer is yes. And the long answer is that anything that human beings do there, you're going to see variants and how it's done. And there's nothing that any one person or one group can do to make everyone see things exactly the same way or do things in exactly the same process. And that that is not unique to manual therapy. There's variation in the way that we train physical therapists. There's variation in the way medical schools approach education or optometry schools or nursing schools. There's differences in the way that. Um, people who, to study mental health and who are behavioral health providers, there's differences in the way that they do talk therapy. There's different kinds of talk therapy that you can do for people. There's acceptance and commitment therapy. There's the big umbrella of cognitive behavioral therapy. Um, there's all sorts of different options to pursue there. I mean, there's motivational interviewing. All of those things are are different, but they're all talk therapy. And there's variation between those things. The standards that we use for orthopedic manual physical therapy require of programs and require of program directors and the curriculum that they change in response to evidence. And what we're not going to see is we're not going to say everyone changed in exactly the same way at exactly the same time. But I would say that the, Progress we have made in bringing more evidence based methods to OMPT has been extraordinary over the past 15, 20 years, and I think you would be hard pressed to find another group of people in medicine who is as Who is as interested in updating things as we are in OMP.

In the paper, you kind of speak to some of the distinguishing characteristics. Because I think you're, you're right. You've, you spoke to the fact that it just gets lumped in with manual therapy and, and you know, somebody does a paper where they check out their brain and just poke. You know, do whatever. I'm not going to name specific techniques because then that gets, it gets ugly. But I'm, I'm wondering what you find. And you've again, defined them nicely in the paper, but for folks that maybe haven't read it yet, I will link it in the show notes, the publication in print, and then obviously soon it'll, it'll hit the real, the imprint status. But what do you feel like are the major things, especially as you've seen it in your own development as a, as a physical therapist that really distinguishes OMPT training from like, you're just basic, you know, from other maybe manual therapy forms or, or ways of treating.

Yeah. So we've laid out five distinguishing characteristics of OMPT. These are, these are ways that you can look at a trial or look at a treatment process and recognize OMPT to be able to describe it. Right. And so the first is it's advanced subspecialty training. So there are elements. Of OMPT elements of reasoning elements of techniques that are taught in entry level PT programs. There are more elements of those things that are taught in residency training, which is the next level up. And then OMPT is really designed to be fully applied at the fellowship training level. And these are people, you know, in the United States, these are people with a doctor of physical therapy degree. who are already board certified in their specialties. That makes them a top 10 percent person in the profession. And then we put them through this training process and similar to what the feedback that you gave me earlier today, uh, right here is that it made a significant difference in your ability to manage complicated patients and to make better decisions. So that advanced subspecialty pipeline is one way you can is the first way you can measure. Uh, uh, or recognize OMPT with the distinguishing characteristic. The next is that there's a focus on clinical judgment, not the things that you do, but why you make the decisions you make and how to, and how to conduct yourself and, and structure the, the visits with the patient such that you're making the best decisions you can make at any given moment to get the patient the best outcome. So it's a focus on clinical judgment. The next one is an expertise in examination. Now, that might be hands on examination that, that looks kind of like manual therapy. It might be more orthopedic or musculoskeletal examination skills. It might be the history taking and the questions that you ask, uh, you know, incorporating some of the, uh, motivational interviewing or behavioral methods to try to elicit the right information from the patient that will help you help them the way they need. Uh, and that's expertise in examination. That's it. The third, the fourth one is expertise and treatment. Now that can include hands on manual therapy, but it also can include things like exercise therapy, mobility, strength, training, um, uh, activity and guidance on, on resuming their, whatever their physical activities were or, or finding ways so that they can do things well in the longterm. You know, and speaking of longterm, the last distinguishing characteristic is a patient centered longterm mindset. Now it's the goal of the OMPT to help the patient. understand their disorder enough to feel better from it, and then understand enough about what they can do so that the activities they choose are well tolerated for them and keep them as healthy as possible in doing what they want to do as long as possible. So those are our five distinguishing characteristics. Advanced subspecialty training, focus on clinical judgment, Expertise in exam, expertise in treatment, and a patient centered long term mindset. And Mark, this might be a surprise to you, but when this paper first came out, and we started talking about this, nobody was upset with me. That I included focus on clinical judgment. Nobody thought it was a terrible idea that I was talking about a patient centered long term mindset. The only thing people were upset about was whether or not there was manual therapy in the treatment. And maybe that, that kind of, that kind of comes to the, you know, to maybe some, some discussions, you know, of bias or, or, or where the culture is with manual therapy and physical therapy, you know, at this moment in 2020. You bring up a great point because I think there's this in rightful criticism, right? When we get these folks that, you know, on social media that, that portray like, or like, well, show, look at what's going on here. And we can all see it's just pseudoscientific garble, like, like that makes zero sense whatsoever. When, when people got wooden hammers and are whacking things and you know, the, all the just strange things you see. Yet, when I look at my own PT training, I don't, I mean, techniques were part of it. I'm not going to say it wasn't. And I think there's some definite need to upskill your technical components, your craft. But the biggest things that caused me to critique manual therapy, traditional man therapy was my fellowship training. I had pain science that really opened my eyes like, well, yeah, we need to look, you know, Bigger picture and have some of these psychologically informed interventions and, and then, uh, you know, why manual therapy works, you know, I, I was fortunate. I had Steve George and Joel Bielosky who were really stimuli like men. I know. I mean, I, again, these are two of like the authority figures as far as manual therapy mechanisms. So, but I, I do think there's this. Portrayal of like manual therapy technique. And again, it's probably fair when you look at the worst cases out there. Um, and then if you lump OMPT within that, yes, I, I, if I'd be mad if I thought OMPT was that, but I don't, I just don't. Again, I haven't been through it and done it. I just, that is, OMPT would be the first in line to criticize that non reasoned, non evidence pseudoscientific approach to, to putting your hands on somebody. What, what do you see? I mean, it's probably cultural social media, but where do you think that major disconnect is? Yeah, I think some of that's hard for me to say. I will say that, um, it's trivially easy to go online or to go to any social media platform and look at people doing. Some kind of crazy exercise in a gym somewhere where they're almost like it's a, it's a funny little video clip. This is look at the way this person is doing this crazy thing. What, what does that have to do with physical therapy and our exercise prescription? Well, it has nothing to do with us, but it's nothing to do with us, right? Um, so you might see somebody examining a patient or talking to a patient and just being Like being very rude and judgmental and difficult and not being welcoming to the patient and sort of coming across like they're not really interested in helping. And I knew, I do know that happens. What, what does that have to do with me or with OMPT? Well, it has nothing to do with it. It's not related. That's not what we do. And I know that you see crazy manual therapy out there from other professional groups or other, other systems of care. What does that have to do with OMPT? Well, it's got nothing to do with OMPT, that that's just not what we do. I, I can't be responsible for any and all manual therapy or exercise therapy or discussions with patients or history taking. I, I can't accept responsibility for what people do outside an OMPT model. I can only describe accurately what experts in the field, including program directors, feel represents orthopedic manual physical therapy. And the Journal editors and review team, arguably one of the most prestigious journals in our profession, approved that for publication and it made editors choice. So somebody thinks that this is valuable information and thinks that this is, um, this is something that the readers of the physical therapy journal would really like to read. And, you know, I hope people take advantage of that too. I mean, there's, there's, People drink and drive all the time. What's that got to do with the way I drive my car? Well, that's nothing. It's not related to me. And I really feel like a lot of that is true there. I don't have any trouble criticizing drunk drivers, but that doesn't mean that I have to take any responsibility for. I don't get behind my car, the wheel of my car and go, Oh gosh, I'm driving. And some people don't drive well. Oh no. I mean, I just don't have those feelings inside. Maybe other people do, but, uh, but that's definitely not how it works for me. We, we are here to define and describe. Orthopedic manual physical therapy, kind of no more, no less. And if the description wasn't super clear, we did provide a patient case example that walks through what that looks like. And I think people will find that pretty helpful too.

I'm wondering too, like based on maybe your experience going through, I think you went through Baylor's fellowship. What do you feel like in within fellowship training? And you've defined it a bit in the paper, of course, but like, what do you think really kind of, um, really was the big. impact for you personally as a clinician or professionally as a clinician that, because I think there's this belief that, and I know when I went into fellowship, I truly, before I really understood what fellowship was about, I thought, oh man, I'm going to be so much more skilled with technique. And again, that's part of it, right? But I really, that was like the smaller, probably the smallest component of it was How fancy my techniques became. It, I'm wondering if you can talk about that, of what your, what your experience was in that

I had the same experience. I would tell you that like, for me, it's distinguishing characteristic. Number two, it's a focus on clinical judgment. I, I was a pretty well educated dude. I'm a pretty smart guy and I was a pretty well educated dude by the time I went to fellowship training, you know, and, um, I don't think I really learned how to think critically. Until I went to fellowship training. I think that I thought I understood that, but I didn't really understand it until I went through fellowship training, kind of one on one honestly, every time I've seen somebody really change their practice, it's never been the result of a weekend. It's never been the result of reading a book. Or going to a seminar, it's only been the one on one clinical mentorship that you in the example of that is what you get in, you know, in an OMPT fellowship, you can get lots of other places too. But it's that kind of model that really changes, right? You know, sitting across seeing a patient and sitting across and looking at Dr. Gail Deyle, look at me like. Okay. Now, what do you think? And I just thought, Oh gosh, I don't, and he really taught me and the other people there taught me really how to be a, how to be a very clear, critical thinker, how to rigorously organize my thoughts in a way that was consistent across every judgment I made. And the result of that was that I was able to make better decisions. Then most other people, most of the time, and I didn't really learn that until fellowship training, and I found that the critical thinking that I learned there was broadly applicable to all sorts of other different things. It gave me that ability to critically think. So. So I'm, I'm in Afghanistan. It's 2013 at three o'clock in the morning. And I'm on a, I'm on a call on a military, um, communication network with our brigade psychologist who has got, she is not sure if she needs to get one of our soldiers out of Afghanistan. The theater of combat and evacuate them back to the States because of their mental health status. And she is sort of agonizing about that decision about she's just not sure which way to go. Right. And so she calls me asking for advice and I talked her through the clinical reasoning model that I learned at OMPT that helped her make the decisions she needed to make in her line of work. To make the right decision for that patient. And so when I think about the benefit of fellowship training, that is the big part of it. It's really learning to critically think and really very, very closely scrutinizing everything you say and do to a level that is beyond what I understood I was getting into, but that profoundly changed me as a person after in a positive way.

Definitely echo your thoughts with that. I, I, I also remember going into fellowship feeling very similar. Like I'm, I've been in this game for a bit. I figured I've read a lot. I feel like I'm a, a smart guy. I remember we had our first fellowship virtual rounds and I'm like going to present this case, right? It's going to knock everybody's socks off. And it was the probably single most humbling experience in my entire life. Cause it was professionally just absolutely shredded. Cause I didn't have this process. I thought I had a. process, but it was just so exposed of like the lack of like this rigorous methodical thinking process and really, and all those things. So Tom Denninger and Jason Steere, if you're listening, you know, we, we still, we still have some PTSD from it in a good way. Right. You know, in a way that really, it, it, it sharpened us, it made us so much better and, and just really, um, the, the ability then to help. Pay that forward. And I've been fortunate to mentor students and mentor, um, some fellows in training and things. And it's, it's always fun to see that, you know, discomfort that, Oh man, I remember that feeling. And Hey, I've been there, you know, we can kind of all relate to that thinking journey, but I agree. That's just a misunderstood component because everybody just wants to default to the technique, the technique, and then, you know, and all the things that again, when we try to lump OMPT and with all of the things that are out there, that may not be the most. evidence based, you can, it, it loses again, the essence of what I think maniotherapy is. And I think I agree that second part, your clinical judgment piece is what, to me, separates, uh, OMPT from, from, and again, there's other fellowships within sports medicine and other things where they're taking that clinical, uh, Critical thinking and, and think to similar levels to, to really hone their practice.

One of the things we said in the paper is that the end result of fellowship training in OMPT produces, produces, um, a practitioner that is on par with someone who is fellowship trained in another, right? So if you take a fellowship trained women's health specialist, a fellowship trained sports medicine, as fellowship trained OMPT, Like for the problems that we are, we are handling in our clinical care, we should have substantially similar expertise. Right? So one of the things that I sometimes hear from people when, when they talk about additional skills and training is that people are. I think there's something about getting additional training. People feel like it shouldn't make someone better, which is a little confusing to me, but, um, or they'll even say, well, people are being elitist by, you know, going to get more training. Well, if we really put through someone through a focused formal training process, they really should be better as a result of that. Right. But it, it's funny how it provokes that sort of feeling. Like, um, so. My brother does some pretty dangerous work. He's a master mechanic and he did. He works on large diesel engines that pump natural gas into people's homes. It's kind of that kind of that low carbon way to heat houses and produce electricity and stuff like he's the guy they fly out to the drilling platform in the ocean to fix things. Nobody else can fix. That's what my brother is. And so, as you can imagine, he's gone through a lot of different training and certifications to be able to do that. You make a mistake on some of those engines, you can die, and so can the other people who are working it with you. And so, one of the things that nobody questions there is nobody says, Well, well, he's just elitist, or he's not any better than anybody else, or he's just turning a wrench. I know how to turn a wrench, aren't I? Just as good as he is. And I think that, um, we see some of those insecurities come out in people sometimes when they see and talk about, um, advanced training. I, I would say that in our paper and, and in the thoughts of, of those of us who were writing generally, what we're trying to convey is we're not trying to compare OMPT fellowship grads to anybody else. We're just saying that going through that training process makes people better. And people like you and me who have been through. The training, that is the feedback that we provide to the programs. So it isn't something that we are sort of inventing from the profession. It's something that the trainees tell us. And I think that's a, that's an important part of this too.

Agree. When we hear this discussion and this maybe accusation of this elitist way that A manual therapist or portrays himself. Do you think there's any substance to that argument? Uh, you know, I, I look back to maybe some of the really old traditional ways where it was like maybe one person who was the named head of this approach and it became kind of maybe A little bit what humans do, we tribe up and we kind of get a little confirmation by us kicking into gear, which is just again being part of the human condition that we're all part of. Do you think there's any substance to that elitist mindset? And how do you feel like OMPT? Because I don't personally see it there anymore. I mean, granted, there's probably some examples of maybe some folks that are a little still. Very narrowed into maybe one person's view of the way, you know, you know, hands on care dealers deserves to be delivered. But, uh, what are your thoughts on the substance of that, that, that elitist, you know, discussion that gets thrown at, uh, you know, this type of training, I really, I

really would like the opportunity. To go a little bit deeper when somebody says something like that, because when people say that's elitist, I guess, I don't think I know what that means. I have in my mind what I think they're trying to convey, but I don't know that that's what they mean. And I don't want to misinterpret what they say. But I'll tell you that. Uh, my, my lay person's understanding of what EL means in this context is they're saying somebody is making themself out to be more competent or higher status than they deserve. And, and I guess that when people say EL is, that's kind of what I think what I think of. Right. And I think some of the most. You know, humble and unassuming people I've met in physical therapy are manual therapy fellows. I I don't make any claim for being able to speak for the all manual therapy fellows in physical therapy. I I wouldn't do that. It wouldn't be appropriate. I had they had the same variance, you know as anyone else does. But I think it's a real sense that we, some folks just don't like the idea that as humans, we develop systems of, of training and education. And we do create hierarchies of competence in those systems. Right. And so I think it's interesting, the areas in which that really seems to bother people and the areas in which it. So nobody at my brother's worksite thinks he's elitist. They know the training he's been through and they know he's the kind of guy they call to call it to, to fix difficult, complicated problems. And one of the things that fellowship training teaches you is how to manage difficult, complicated problems also. Uh, so. I really feel like we've got to pull the elitism idea apart a little and better understand what people mean if they're mad that some people have got greater expertise when they get more training. I'm not sure there's any I can say that's going to make them feel good about that. Like, I mean, a lot of people drive cars. I drive, I drive a car too, as you might imagine. Um, the army sent me to a couple of courses on defensive driving, right? Yeah. And that training made me a safer driver. It did. I, and I, and I think that my accident record and my conduct on the roads shows that pretty well. And if somebody thinks that that's elitism on my side, then, you know, I'm just going to have to leave them to their opinion.

Well, well said, I think. I agree. I think I don't know what forms that I just sometimes maybe there's folks that are portraying themselves or pushing themselves and maybe denigrating others who don't. I mean, but I agree. I haven't met any ortho fellows who are like, you don't have this training. So you're less of a PT. I mean, granted, I think that, Hey, I might have a skill set that could help you. And then maybe, you know, mentor you and things like that. I've seen more of the kind of, Hey, can I help type mindset, but I haven't seen. This this this elitist and maybe there's other things and again, I can't speak for the experiences of others who've kind of had that kind of perception of it, but it's been unfortunate. It's not been my perception. I guess maybe traditional like if you're not this therapist, then you're not. I've seen some of that maybe a little bit. But again, I, um, when it comes to OMPT, I haven't experienced that within the OMPT fellows, which is again, helpful that we, Okay. Define what that is, right? Because there might be some other fringe manual therapy approaches that don't ascribe to these values.

Well, I do think in physical therapy, there are other kinds, there's other systems of thought in manual therapy that are not OMPT, and I think that's great. I don't have any problem with that at all. But that's not what OMPT is, right? You know, as social animals, one way to increase your own status is to pull down the status of another member of the tribe who's seen to be higher. And I don't know if that's part of that elitism process, but I think that's worth thinking about. I mean, I think people talk about bias a little bit too. I had a long conversation. Um, Uh, as I, as I sometimes do on the X platform about, um, about our paper and, you know, people said, well, I think you're biased towards manual therapy. And I think a lot of people use those words like elitism or bias. And they think that just using the word is an argument, but that's not an argument, right? That's just, that's just a name. That's just name calling. Right. When I said, well, well, how do you mean I'm biased? Well, you're biased because you're a manual therapist. Yeah. But how am I biased? Like you. I want you to make an argument. I might be I'm biased about things all the time. Maybe I'm biased about this too. Tell me make the argument so that we can consider it. And so, well, what do we mean when we say somebody's biased? Well, they're treating something in a differential manner without good reason. That's kind of what biases. That's just my, you know, my. Um, you know, lay persons kind of take on what, on what bias is, uh, somebody's with the dictionary right now yelling, that's not what the dictionary says. Great. Well, you got the dictionary out. Here's another word for you. Pedant. Uh, so, so while, while we think about bias, right? And I said, well, you know, I might be biased for manual therapy, but I might be biased on a patient centered, long term mindset. But nobody accuses me of that. I might be biased toward focusing on good clinical judgment. Never got accused of that. I might be biased about examining and treating people carefully with high standards of evidence based practice. Nobody ever accuses me of being biased that way. In fact, manual therapy was singled out. As something that somebody might be biased or elite about without a good reason. That's bias. Somebody's biased in that conversation, but so far, I don't think it's me.

Very good points. Um, I agree. I think it's just when we look at the foundations of what, when we're trying to describe OMPT and break it down, it's just to me, if we expose that to the people that are making this, Argument that there's this bias and elitism. I mean, to me, I think most people who see these values that we, you know, live by and ascribe to would be all on board with, but because it's some sort of, yeah, I don't know.

I think it's helpful also to think that, you know, every time, every time you do something, there's going to be a small percentage of people who are really angry about it. And, and really, I, I'd like to spend most of my time on talking to most regular people in our profession. Who are not who don't go on long Twitter rants about things, uh, and who aren't animated like that. And they might be thinking, you know, I'm thinking about advanced training for at least for me and maybe for you. I ended up being interested in manual therapy fellowship training because I was. I would leave a patient interaction where I felt like there was something there I wasn't getting. I felt like, I think that somebody, if I was better, I could have helped them. Not, not in a general sense, but in a very specific sense that this was just a problem that is figureoutable, but that I couldn't figure it out. And that I recognized that I wanted, um, an ability to be able to help more people like that. And that's part of what it is. Pushed me into pursuing that. So if people are out there and they're interested in thinking about an OMPT fellowship and what that involves, I think reading our paper under helps, but I think also that reading that patient case and following step by step through those distinguishing characteristics. And how we get to make the decisions we make and why, why we decide to do the things that we do when we decide to do them. I think that will provide great insight into what OMPT training might offer them and whether it would be a good fit for them. Uh, you know, in their clinical practice,

there's papers out there, there's one by Baker and colleagues. I think that laid out the script format of like clinical reasoning for the foundation, I think was laid by

those, those kinds of papers for, for us to follow up and do this definition.

And we'll link it because I think it does lay out a lot of the kind of the complexity of the reasoning process and the critical thinking that goes into it versus just this, check out your brain and, and, um, just go to it with manual therapy. I'm wondering what you see, like with, with OMPT training, do you think there's been some challenges with the, especially in the current atmosphere or the current culture where social media just wants to go on the attack oftentimes? And, and as we've mentioned, probably. Not well informed and this paper serves to inform a attack manual therapy, but that's not what I practice, you know, MPT sure You know This is what we're about and I think if you want to attack that then I think we all probably need to look in the mirror a little bit but I'm wondering what you see is like are there challenges out there to because are we risking with sometimes the generalization and you know Maybe uninformed Um, you know, rock throwing at OMPT and other things that it puts a risk at a lack of development of these skills and critical thinking and then pursuit of this, maybe in a clinical practice where, you know, a clinician who could possibly benefit of it because social media is bombarding them with all these, you know, vitriol and negative messaging around things that they may miss an opportunity to kind of grow their, their own, uh, practice in their own professional skills. Well, I

think that I'm focusing on what I have the most control over. And I have the most control over on what I think and what my behavior is. And so I'm really trying to act in a way and talk in a way that helps people understand what I believe the value of OMPT is in general for our patients. That's mostly. From randomized trials. So that's not my opinion. That's the published data. Uh, and I'm interested in sharing with people why we feel like it's valuable and why all all of the authors and people who are trained in this way, why we get value from that and letting people make their own decision. People in our profession are very intelligent. Um, you know, you have to be very smart to go to physical therapy school and get a doctor of physical therapy degree. And I trust. People in our profession to make their own decision about what is best for them and what is best for their patients. And I want to put my best foot forward about what, what. What we think OMPT is to see if that's a good fit for them and to, and to take, take away from some of the, um, some of the discussions and social media that often generate more heat than light and actually throw light on something and let people make their own decision. I'm happy with that. I'm not interested in convincing anyone of anything. I'm interested in just making sure that everyone fully understands what OMPT is and what OMPT is not, how to recognize it, how we can start recognizing it when we go to do clinical practice guidelines and we go to recognize it when we do systematic reviews so we can classify it appropriately. So we're not missing out on quality care for patients. In, in that whole shuffle of papers. And it really is for us. about providing the best possible care for patients, lower costs, lower risk, noninvasive care that works and is cost effective. And if we're going to keep that available for patients, and that's where all of us have a passion for, and I know you do too. We have to get out there and describe what it is we're doing and why we think it's important and whether somebody agrees with or likes it. That's for them to decide. And I'm perfectly, once we've done that, I'm perfectly happy to let the chips fall where they may.

Yeah, and you've all put a great description and really shed light on what it is to help the general physio, up and coming physios and other folks who are, Deciding what trajectory they want to make their career to see if this is a good path for them. I agree. I don't think, um, trying to bang your fist in and convince anybody anything that's, that's probably going to eternally frustrate most folks involved in that whole process.

So I trust people to make their own decision. I mean, I'm, I'm trying to give them good information and I trust them to make a good decision that's for them. Now that might be patients that might be PTs that might be, um, other professional groups who work with us, nurses, physicians, whoever. I mean, these are smart people and I trust their ability to make good decisions. I'm just focused on making sure they have accurate information, uh, and from which they can make

their own judgments. And those of you listening, I would just, or watching here on YouTube, I just, just check out the paper. If it's something you've kind of had, maybe some misconceptions or some struggles with manual therapy, or maybe not sure. I think it's worth a read to kind of see what it's all about. And then obviously once you read and get all the information, you can make your own judgment for yourself. Like Jason, Jason has nicely put. Jason, I want to respect your time. I want to thank you and also all of your coauthors for putting together a great paper that really puts a clear, um, Definition of what it means to be OMPT. I hope it does shed some light on it. So some, some clinicians that are deciding where their career needs to go can make some good informed decisions. So thank you all for all your work and thank you for what you're doing.

Thank you. And thanks to the AON for trusting me with this project and for trusting this, uh, truly this dream team of amazing authors who taught me so much in this process also, um, I'm happy to see the next step and what comes next. Thank you again.

And thank you for always being a well reasoned voice on social media. It's always very nice to see when you're having these discussions, uh, a very well reasoned approach to having discussions and, and really just kind of getting to the, to the, the nuts and bolts of it without the, you know, the emotions and, and I always appreciate your well reasoned approach. So So thank you for that. All right. For those of you who are listening, we'd love if you could subscribe wherever you're listening to this podcast. For those of you who are watching on YouTube, if you can hit the subscribe and maybe like so we can spread this information to other maybe physical therapists who are trying to decide if OMPT is right for them or not. We'd greatly appreciate that, but we'll leave it there this week. We will talk to you all next week.

This has been another episode of the Modern Pain Podcast with Dr. Mark Kargela. Join us next time as we continue our journey to help change the story around pain. For more information on the show, visit modernpaincare. com. This podcast is for educational and informational purposes only. It is not a substitute for medical advice or treatment. Please consult a licensed professional for your specific medical needs. Changing the story around pain. This is the Modern Pain Podcast.