My first month off following graduation was spent interviewing for travel positions. I was looking for a way to pay off some of my six figure loan debt effectively, and travel PT provides that opportunity. I ran into some interesting situations during the interview process.
Many companies wanted to know what skills I could bring to the table (i.e. what hands on skills [i.e. what manual skills]). I may have fumbled through one or two interviews when asked this question, feeling the need to impress my interviewer with the limited yet slightly more advanced manual skill set I possess compared to the likely average new grad. However, looking back, I wonder what’s the point? Actually, I felt that way immediately after the interview. I was actually frustrated. My ability to get the position I was interviewing for was hampered by something that is practically made up and devoid of true scientific grounding (at least in the way most schools teach it.*)
My skills are in differential diagnosis, scientifically/evidence based treatments, communication, being a reflective practitioner, and critical thinking.
Yes, I have learned some helpful manual skills for specific body parts, and I do use them in the right context (Episode 3 of the NAF Physio Podcast), but the question arose in my mind, “what’s the big deal if I know more than I do now?”
If I know one manual technique for every body region, do I need to know more? Is there any benefit to having an array of placebo based interventions vs one placebo based intervention?
And what about down the road? Likely, patients won’t know the difference. The only perceived benefit to obtaining more manual skills is that I get some variety. I won’t be as bored providing these treatments (again, in the right context), if I have a variety of them to choose from. But that’s not really a good motivator for choosing continuing education courses, is it?
So what’s the point?
I guess I’m writing this because I wish I had told that interviewer that my manual skills were sufficient to induce placebo based pain relief on par with those of any of the other PT’s in that clinic; and that more importantly, providing the right context to the patient, I could manipulate any body region for pain reduction in any other body region (if I chose to be so deceptive).
I guess I’m also writing this because, as a new grad, it seems apparent that what employers are looking for is skills sets and all of those skill sets are focused on the intervention side. Sure, the ability to correctly diagnose and communicate are valued, but theres no metric for them..and they are largely intangible items. There’s no good way to impress an interviewer with my skills in these areas. It’s all about “what can I see that you can do for me?”
With this, I still have many questions. Should I spend money on continuing education in manual therapies which will potentially be phased out or largely marginalized in the future? What does our profession’s preoccupation manual skills and loosely science based interventions say about us to the rest of the (informed) healthcare community? Will we ever overcome this hurdle of the 20 year information gap for evidence being incorporated into practice? Will I continue to encounter professionals who have never heard of the BPS model and neuromatrix theory of pain?
–Spencer
PS- Listen to that podcast. It will explain what I mean by “I use manual therapy in the right context.”
*My university taught histological and neurological sciences in regard to these topics above. We were encouraged to think independently and critically about the subject material and never accept information at face value without first questioning its validity. PT programs are hamstrung by CAPTE in regards to what information they teach, and there is certainly limited educational hours available. Many programs willingly or unknowingly forgo the opportunity to impress the best current understanding of evidence in regards to topics of manual therapies and pain science to students. I am fortunate to say my university did not, often at great personal time and effort expense.
PTbraintrust 
Spencer,
I enjoyed reading your post, so thank you for that. I can empathize with your frustration as a new grad PT trying to navigate the real world clinical challenges that are out there. I want to address some of the specific questions you brought up: However, as a manual therapy residency and fellowship trained PT, I clearly have a bias when it comes to manual therapy, so take from it what you will.
You stated that your skills are in scientific/evidence based treatments? Are you implying that manual therapy is not one of them? In fact, there is a huge amount of scientific and clinical evidence out there supporting the use of manual therapy. The mechanisms of manual therapy are biomechanical to a small degree, but mostly have neurophysiological and psychological effects. (To be sure, psychological is different than placebo). One resource I would point you to is Bialosky et al Man Ther 2009. Secondly, the combination of manual therapy plus exercise has been shown to produce better outcomes than either intervention alone in almost every study that has been done on those variables.
Do you need to know more than one manual technique per body part? Answer–you better. What if the only technique you know for cervical rotation involves the pt laying supine and you have a pt who cannot lie supine. What then? You need to know techniques that you can perform in multiple positions. What if the one technique you know is not comfortable for the patient? Can you modify it in any way? Can you do a completely different technique? I imagine the latter would be a little challenging if you only know one technique. And what if the one technique you know doesn’t work for YOUR pt? Just something to consider.
As I wrote earlier today in a response to a PT who commented on one of my posts, knowledge is power. More education ALWAYS helps. Although having too many options can sometimes lead to “The Paradox of Choice,” knowing more and increasing your skill set will give you the opportunity to provide interventions that work well for each individual patient.
Regards,
Andrew
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I really enjoy reading your posts so keep writing sir! As a new grad you base everything on research because that’s what is taught in school. If you never stray into “the fringe” where there is anecdotal evidence (not totally off the reservation with pixie dust and hummingbird wings) and you live in the safe zone of RCT’s I would argue you’re the one living in the past not those that are innovating ahead of the lumbering, slowly moving research field. Research is valuable I think you just opened a can of worms with manual therapists comparing all our work that does help people to a placebo which is false as noted above. By the way how does an interview now test communication skills? Keep writing man just check your facts on all fronts first….
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Spencer, I enjoyed reading your comments and appreciate the dillema you describe and your perspective on the issue. Where I think your argument falls short is the assumption that somehow the integration of manual therapies is something contrary to the ability to incorporate a BPS model, pain sciences education, and the like . The question is not whether to focus on one or the other but both! Manual therapy and hands on care in general is one of the most effective tools you have to establish credibility with the patient, get some immediate improvements in pain, and open up entire conversations around pain education that otherwise simply don’t happen as effectively otherwise. I hear way too many clinicians these days want to cling to a so called BPS model presumably as if touching the patient is unnecessary and a waste of time. Manual therapies give you an entrance to the patient’s heart and so, which is foundational for pain sciences education to have a chance of shaping a patient’s perspective about their pain. Only novices make it an either/or decision. Experts almost always go for both. Thanks for the post. Good food for thought.
John
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John, thanks for reading and commenting. I actually agree with your comments wholeheartedly. I suppose I could have clarified more; but this was, indeed, a quick and slightly frustrated post with the with the current loan debt situation I and all other new grad students are in.
I do like to employ manual therapy techniques with patients, given they appear to be appropriate candidates. And I often perform manual therapy techniques while explaining their likely cause for pain relief (i.e. non-specific), then often use that as a basis to transition into pain education. I suppose my big question was, while attempting to look into the future, what is the benefit to paying to learn more techniques than those I have already learned? I admit I am no seasoned or well versed master of manual therapy techniques; but if I know one or a few techniques per body region, should I pay to learn more? This..is an honest question, not intended to be rhetorical per say; but more specifically, not intended to imply I see no benefit in learning or using manual therapy.
Thanks again for reading/commenting.
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A thoughtful posting – thank you.
There seem to be some strawmen being erected in the comments; perhaps if you had bolded the section that explicitly states, “Yes, I have learned some helpful manual skills for specific body parts, and I do use them in the right context…”, readers would have greater difficulty trying to further slant their reading of your posting to thinking that it is opposed to manual therapy at large.
Additionally, I read your use of the term “placebo” to refer to non-specific effects, not to disparage all therapists out there who use manual therapy techniques, which you (yourself) employ. I hope this is an accurate reflection of your thoughts.
It might also be helpful if you could expand on, “If I know one manual technique for every body region, do I need to know more? ” It reads as a rhetorical question, but makes it seem that if a therapist knows only a single upper-thoracic HVLA manip, that should suffice (e.g. for cervical/thoracic pain) and that is all that they need in their manual therapy repertoire (this seems a bit over-the-top and I assume you mean something different, but cannot make assumptions based on this posting alone).
Again, thanks for writing.
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Keith, excellent comments. Your interpretation of placebo as non-specific effects is correct (perhaps I could have substituted that phrase instead, but of course… I did not imply any negative to the term placebo). I agree, bolding “…I use MT techniques/skills in the right context…” could have prevented some of the hostility that occurred following the post. I do perform them on the right patient population, I explain to patients what is going on in terms of localized stimulation being sent to the brain, the brain receiving movement in a non-threatening environment, I try to perform pain education while I perform them to hopefully provide something with long term benefit; but of course, you already seemed to understand that (so that is more for the other readers satiation).
I guess to expand on “knowing one technique for every body region, do I need to know more?” I was being slightly hyperbolic. To clarify, I perhaps could have stated, “in addition to what MT techniques I learned in school.” I do think there is benefit to possessing an array of approaches for treating patients, even within the subset of manual therapy. I suppose I just simply question the true benefit of knowing, for instance per your example, more than one manipulation for the thoracic region. Again, I don’t discredit the reality of patient preference, realizing many patients will naturally respond differently to different approaches..even within the subset of manipulative therapy. However, regardless of the brain activity that is measured, there’s no study (to my knowledge) that has examined the difference in outcome relative to each manipulation approach for the thoracic region. Big caveat, I did not even attempt to look up that topic in the research. Perhaps there is; I would be impressed.
To try to summarize that last thought, how do I know that performing one manipulation has benefit over another manipulation (other than patient preference)? And it still seems logical to me that, given the current best understanding of benefit for manipulative therapy (i.e. neurophysiologic, non-specific, placebo), painting the right context around any form of manipulative therapy could be the cause for the effect produced (whether it’s the context of current pain education/BPS models and helping the patient to return to pain-free movement, or the old model of realigning bones and restoring “natural flow”). Anyway, I have no qualms with learning techniques from colleagues willing to share their knowledge and skill with me, but I do wonder what benefit there is to me spending money on such endeavors..at least in the long run or at least for now.
Thanks again for reading Keith, and thanks for the level headed critique/questioning. It’s always helpful and welcome.
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Spencer
It is not about the techniques, it is whether they can be applied to the appropriate patient and or altered to fit your specific patient. There is more than one way to skin a cat. Understand that manual skills can be acquired down the road with proper mentoring, residency, fellowship programs and some con ed courses. As an owner of a 2 PT clinics, what I look for in my employees is whether or not they are eager to continue learning and is that in stilled in them. To be a master of something one must love being a student at heart. Thomas Jefferson never believed that one would ever be a senior in education that is why at the Univ of VA you are referred to as a first or second or third year and so on. What you should have told those employers is that you would be willing to acquire those skills and show them in your interview that you are a life long learner. There are so many OLD new grads out there–you definitely don’t want to be that.
I thought I would take a different tangent on this post since you had already awoken the sleeping giants defending MT and exercise as interventions in PT on previous replies. Make sure you do your homework before making such random statements–your blog is out there and you don’t want to be putting out errant information with out knowing all the facts. You let your emotions and frustrations get the best of you–but for good reason. Spencer, the bottom line here is as an employer myself, I look for dynamic, outgoing PT’s that connect with their pt’s on a whole different level. You can really be a mediocre PT — but when you really connect with your patients on a whole different level and they realize you really care about them, by listening to them, understanding why they are seeking your services and establishing that awesome rapport with them continually promote positivity — it is amazing how much better your outcomes will be.
PS: Why waste your time with traveling PT–find a place where you can be mentored in becoming a well groomed PT in all aspects so you are managing your patients correctly. Sorry that you debt is driving you job decision making but totally understood and respected.
RON MASRI
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I agree with some of the statements made above (globally) and at first skim this post can seem quite inflammatory. I read this as Spencer telling his interview story: He was looking for jobs, doing interviews. He mentions to the employer that he has had an 8 week clinical with a FAAOMPT clinical instructor and learned techniques, enough to do the job. He has manipulative and soft tissue skills and uses them in the right context. The employers say (interestingly enough to him) we need more manual therapy credentials or skills. From here you get the question. What’s the point?
I am in line with Keith’s interpretation of the word placebo here. The neurobiological “placebo”, not the clinically inert sham “placebo.” Anyway, the question remains valid. How much of a thing do you need? (apparently more in this employment situation.) The questioning of spending money on a technique that may be proved ineffective is also a valid question. We don’t have a bunch of $$ to throw around, we want to make it count. I don’t personally think MT a waste, but I ask myself that question when pursuing CEUs (as do most of us). And heck, Spencer could be right… MT (fairly sure he is specific to manips?) may be extinct in 20 years, I don’t know how progress and scientific advances will take us… and no one does. I am fully ready to be laughed at by future students when I tell them I’m about to attempt pain education with a patient.
Bottom line: good thoughts… progression through reflection
-Matt D
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