Orthopedic Manual Physical Therapy
The Orthopedic Manual Physical Therapy program at Oakland University is a two-year post professional certification. The program takes current licensed physical therapists and provides them with clinical deductive reasoning, contextual information regarding theoretical principles, and advanced level of manual intervention skills. The two-year graduate level program has 18 credits of coursework and 220 residency hours.
In 1991 Orthopedic Manual Physical Therapy (OMPT) first emerged in the United States as a practice pattern in the scope of physical therapy. Various international leaders in the field of manual therapy met at Oakland University in Rochester, Michigan, to assemble a fundamental approach and find a common thread to which the manual practice patterns in the US could be developed and promoted. Instrumental leaders and developers in the manual therapy field such as Freddy Kaltenborn and Olaf Evjenth from Norway came together to form the American Academy of Orthopedic Manual Physical Therapy (AAOMPT). Together Kaltenborn and Evjenth developed the KE System, a comprehensive approach linking the patient’s symptoms to the functional and structural pathologies. Kaltenborn and Evjenth were influential in the development of the only academic based OMPT program in the US applying the KE methodology at Oakland University. Both Kaltenborn and Evjenth have written books expanding manual physical therapy into what it is today. Today Oakland University continues the development of the KE methodology under the direction of John Krauss using evidence based practice.
OMPT Evaluation Process
The comprehensive approach taken by the OMPT program investigates the relationship between the symptomatic complaints and the mechanism behind the provoking movement patterns. The evaluation is done in order to systematically find the functional impairment and give understanding to the characteristics of the structures involved. Due to the complexity of the body the therapist first generates a differential diagnoses list. This is a list of possible diagnoses that would be consistent with the patient’s symptoms as reported from the history. Irrelevant diagnoses are sequentially eliminated through the use of localization testing.
The philosophy developed by Evenjth and expanded on by Krauss localizes regions, structures, and/or segments. Localization works on the principle of provocation and alleviation of the specific symptoms the patient presents to the clinic with. Therefore replicating or linking signs from the objective testing done by the therapist to the symptomatic movement complaint. Specific detail about the region and structure is interpreted as it is examined. Regional testing is performed if the pain is broad in nature and travels across multiple areas of the body. In order to differentiate regions within the body, the application of the testing either applies or relieves an applied force on one region in order to rule out uninvolved regions.
For example, if there is pain in the base of the neck and into the shoulder, it could be from either of the two regions. If the patient reproduces the painful movement and the therapist applies a stress such as traction to the neck while the patient is in pain and the pain doesn’t change, this would indicate the shoulder could be the involved region. Then the shoulder should be further tested more from that point on.
At this point, the relevant region has been linked to the symptoms and the therapist continues to examine the structures and/or the segments involved (if dealing with the spine) in order to find the primary tissue involved to help determine a working diagnosis. The structures could include muscle, tendon, ligament, cartilage, joint capsular tissue, neural (nerve) and/or soft tissue. Again the primary structure is identified by the replication or alleviation of the specific symptoms. Examination of these impairments looks at the quality of tissues, such as muscle fiber length and feel, nerve irritation, and translatoric joint play. Joint play is precise testing that evaluates the motion that occurs within the joint. This includes characteristics of gliding and rolling within the joint that lead to the primary motion of functional movement.
For example, pain in the shoulder could be from the joint, nerve and/or muscle. Pulling on the humerus separates glenohumeral joint and could lengthen the muscles in the muscles around the shoulder, therefore if pain is reproduced, the therapist would think the joint is not involved and if the nerve testing is negative the therapist concludes it could be the muscles and continues with muscle testing.
Throughout the differentiation process more than one structure may concurrently be involved. Therefore the therapist looks at the specific impairment of that structure as it correlates to the primary structure, function and symptoms. This method of testing gives insight into the symptoms surrounding the whole body.
OMPT Treatment Philosophy
The treatment philosophy of an OMPT is a continuum of the evaluation process, dictating the treatment. The therapist performs a treatment consistent with the impairment findings from the examination. The precise line of testing gives an impression about specific structures and characteristics of the structural deficits. The emphasis of the treatment is elimination of the symptoms, restoration of movement, and training an area that has a pathological dysfunction with expectations of restoring function.
Joint mobilization/manipulation/traction: These are done to improve range of motion, stretch tight tissue, improve circulation, disperse fluid, and improve the pain related to the motion. The goals of traction are to unload the disc, relax muscle tissue, improve a restriction/tight structure(s) and decrease pain. The manual forces used in mobilizations are applied in a straight line into the specific direction and given in a short amplitude. The displacement of a joint(s) is in a desired direction leaving little stress on surrounding soft tissue by proper stabilization. Techniques of the spine are specific to a segment(s) by prepositioning of the spine in order to “lock” (inhibit motion in one area) and/or by manual/mechanical stabilization. This makes the treatment to the specific segment or joint more effective and inherently safe. The OMPT philosophy does not agree with treatments that use gross rotational mobilizations due to its potential damaging effects with unreliable methods. Given the inherent safety of the techniques, slow velocity and high velocity mobilizations are an effective means to treat a pathomechanical dysfunction in nature. Mobilizations can be done concurrently with other treatment as well.
For example, if a patient has low back pain. Traction can be performed to improve circulation, disperse fluid (swelling) out of the area and decrease the load on the disc. When done manually it can be combined with functional massage and other mobilizations for impairments that are found.
Functional Massage (FM): A type of massage that incorporates movements of shortening and lengthening involved tissue during the massage. FM benefits include reduction of pain, swelling, muscle guarding, muscle tightness, tissue adhesions, and improving the gliding between tissues.
Stretching: Is done to improve the length, elasticity, and tone of muscle tissue. The potential benefits include prevention of injury, postural correction, improvement in motion, and decrease risk of damage on other tissues. Tightness of a muscle can lead to impairments elsewhere in the body.
For example, if a hip flexor muscle is tight then recruitment of motion, while walking, can commonly travel up the body and come from the low back. This can irritate the back and lead to other problems.
Therefore we advocate the use of stretching, as suggested by Olaf Evjenth. This stretching lengthens a specific muscle around a joint in a direction that isolates it from other muscles and soft tissue. A common mistake in stretching is referred to as the “hurdle stretch,” which should stretch the hamstring. However, usually the stretch is felt down the entire leg, this usually means that the sciatic nerve is being stretched not just the hamstring muscle.
It is our belief that stretching should be passive, done either static or dynamic/ballistic as in the “bounce” based on the specifics needs of the patient. It is also important to understand that overstretching can have harmful effectives leading to decrease performance. People commonly think of stretching through the extremities, specific muscles in the spine can also be stretched with prepositioning and specific patterns of motion.
Functional mechanics tend to start to brake down with pain and repetitive motion. It is important for the patient to understand the mechanisms that can lead to problems down the line. Many patients’ symptoms are treated based on the symptoms without the underlying cause of the problem being properly understood. An individual’s activity should first be broken down in order to relieve the pathological stress causing the impairment and then gradually work on specific treatment and training applicable to the patient’s functional activities. The components that go into proper treatment, work on inhibiting poor habitual movement patterns while developing strong mechanically proper movements. Proper patient education about effective and ineffective movement patterns are tools that empower the patient.