It’s been a week since I got back from #IFOMPT2016 and I purposely waited this long to write my review of the conference because I needed some to time to take in the plethora of information that I was exposed to. I won’t dive too much into any one specific talk because the fabulous SoMe team did an excellent job doing detailed reviews of all the keynote lectures for you to read at your leisure. This will be my personal thoughts about the weeks events.
First off, I am so proud to call myself a physiotherapist. The amount of brilliance that lies within this profession both locally (Go Canada!) and abroad is astounding. The shear number of PhD physiotherapists breaking down walls and answering the question of “why does what we do help? (or not help)” is astounding. IFOMPT had researchers talking about such things as best practices for those with knee OA, to ischemic pain from static postures, to the psychosocial elements of pain. There is a shift in our profession and I think if you keep reading below you will begin to understand what I mean.
Dichotomy within the profession: Hands on vs. Hands off
IFOMPT is a conference with the term ‘manual therapists’ in the title. By this fact alone one would assume there would be a huge contingency of manual therapy presentations at this conference. This couldn’t be further from the truth. In fact, to my knowledge there was not one talk out of the 5 days that focused specifically on and only on manual therapy. I did not hear the words PIVM, PAIVM, or PAM once while there. There was no talk on rotated innominates, shifted ribs, or fixated joints. Well, there was but only to say that these are not diagnosis’s we should be giving to our patients.
Here is a perfect explanation of the dichotomy of opinions at this conference: Brian Mulligan vs. Lorimer Moseley
On the final day of the conference I attended a 90 minute workshop hosted by Brian Mulligan. This is a man that created mobilizations with movement and at the tender age of 83, was still as passionate and exuberant about his techniques as I’m sure he was when he first started. His talk was standing room only, meaning delegates has to be turned away at the door because of the amount of people who wanted to hear him speak. His presentation was very pathoanatomical in nature. He had one guy come up with a 20+ year history of back pain who had pain with extension. After a few quick spring tests to determine the joint levels at “fault” he did literally 3 minutes of mobilization with movement to open up the facets (which he diagnosed as the pain generating structure) and then re-tested extension, which was in fact much better then before. The crowed clapped and he was labelled as a miracle man by the man who was now out of a 20 year history of back pain. There was no talk of any psycosocial factors, no discussion around this man’s beliefs around his pain and no real differential. Suffice to say, those in attendance were quite impressed…well, some were. It was essentially a smoke and mirrors show to wow the audience.
I noticed the vast majority of younger PT’s (like myself) spent that morning at Mulligan’s course, while the older facet of the profession was at a more academic talk on the mechanisms behind the manual therapy we provide. It became apparent that there were many new grads in attendance who simply want to “fix” people. They want to provide an immediate result to the patients chief complaint, which is usually pain. Brian Mulligan did a very grand before and after show, bringing up live patients (including myself) to the front to demo techniques that he assures will fix pain problems within minutes. To quote Brian “I don’t need any rubbish study to tell me what I’m doing works, all I need are the testimonials of my patients”. This sentiment resonated with many in the very full room he was teaching in.
On the other hand, there were several talks by prominent PhD Physiotherapist Lorimer Moseley who discussed the biopsychosocial nature of pain, how complex it is, and how many different treatments have very similar effect sizes when done under randomized control trial. He spoke about the brains capacity to determine what is threatening to the body and what isn’t. He mentioned how discs cannot slip, pelvis’s cannot up slip or down slip and that thoracic rings cannot shift. And if they could, we would be pretty bad at detecting it with any reliability. Basically, he used actual data to explain why perceived anatomical abnormalities are not always pain generating issues. This was a stark contrast to the Mulligan talk about jammed facet joints and rotated innominates causing sacroiliac pain. Is it any wonder the novice clinician is confused?!
We went into this profession to help others. I will speak for myself when I say that I firmly believed going in that if I learned the right techniques of assessment and treatment I could use my hands to fix peoples pain. I would be a star! I even did a fellowship in manual and manipulative therapy in order to boost my ‘manual game’. I fortunately learned, quite begrudgingly I might add, that my hands were not “magical” as I so desperately wanted them to be. IFOMPT’s central theme was that listening to our patients, understanding their goals and concerns, and applying our hands to facilitate independent movement and not to align anything is what has been shown effective to date.
However under the radar this opinion was, there was still a huge subset of delegates who want desperately to believe that they can use their hands to detect joint faults and correct them to aid in pain reduction. I honestly believe many were scared to voice their pathoanatomical beliefs because of how ridiculed that model was being made out to be at the conference. What I did find funny was that the biggest theme of IFOMPT was the BPS/neurocognitive approaches to treating pain, yet the 2 big award winners were primarily manual therapy based clinicians/studies (Josh Cleland for this study and Brian Mulligan). There seems to be the knowledge that our hands aren’t doing what we think they are, but we are desperate to believe manual therapy can fix people’s pain. I think we are in a bit of a identity crisis within the profession….if we can’t fix people using our hands, then why are we labelled manual therapists? No one will admit it, but many still hold MT as the central keystone in their treatment intervention and are unwilling to let that go. That was evident by all the 1-1 chats I had with delegates around the conference.
The last thing I wanted to touch on was the fact that no one discussed the economic realities of practice that underpin much of what was discussed at the conference. The time it takes to employ a BPS model, desire for repeat business (elephant in the room), need for cultural authority in the msk domain are realities that I still feel are too taboo to be discussed at such a prestigious conference. I believe a HUGE barrier to widespread implementation of a more BPS model has to do with the fact that clinicians do not want to make the patient feel 100% independent with their problem. Many physiotherapists are business owners and if all their staff are seeing patients only 3-4 times and mainly giving exercise and advice to self manage conditions, a lot of money stands to be lost. I am genuinely curious if the economic impact of the implementation of a BPS has been studied. It’s much more lucrative to tell someone they need weekly therapy to fix their imbalances then to reassure someone and tell them to do generalized exercise for their pain on their own.
IFOMPT 2016 was the biggest and most evidence backed conference I have ever been to. The calibre of the keynotes combined with the fantastic social program makes me giddy for what IFOMPT 2020 in Melbourn, Australia has in store. I for one will not be missing it. I suggest you try and do the same.
Signing off from my blogging duties for now. I hope to meet many readers in 4 years time.
Enjoy being a physiotherapist, it’s still one of the best gigs in town!