American Academy of Orthopedic Manual Physical Therapy (AAOMPT): History, Advocacy, and Education

John McM. Mennell Service award recipient October 19, 2007

I want to thank the Academy executive and those who nominated me for this award and for the opportunity to address you today. I also want to thank my wife Janet for being here today and for being supportive of my professional goals. Although professional mentors have opened many doors for me, Janet's support and encouragement over the past 19 years has given me the courage to walk through those doors. Besides being an audiologist, a speech language pathologist, a clinical faculty member, and a PhD student; Janet is a wonderful mother to our 2 children, William (age 13) and Emma (age 9). My family keeps me grounded and brings tremendous joy to my life.

It is a great honor to receive an award that is named after Dr. John Mennell, a physician from the United Kingdom who educated many physical therapists in the United States in the science and art of manual therapy through the 1960s, 70s, and 80s. Dr Mennell, who passed away in 1992, was well respected by the Founding Fellows of the Academy, and they chose to honor his memory by naming this service award after him. Although I never met Dr. Mennell, I have been privileged to listen to all 12 of the previous Mennell service award speeches, and I am humbled to have my name included among such a dedicated, prestigious group of physical therapists.

The only thing that can make you feel older than to receive a service award, which typically occurs towards the end of one's career, is to be told that you are appreciated because you provide a “historical perspective”. I developed an appreciation for the history of our profession from my mentor and one of the Founding Fellows of the Academy, Dr. Stanley Paris. I would not be here today if not for Dr. Paris.

History

I have become the unofficial Academy historian over the past few years, not because I am old, but because my career has followed a similar timeline as the Academy. For instance, I started the University of St. Augustine manual therapy fellowship program just a few months before the first meeting of the Founding Fellows of the Academy in the Summer of 1990. Dr Paris kept us informed on the development of the Academy as it was occurring during our weekly residency meetings.

In 1992, Dr. Paris organized the International Federation Orthopaedic Manipulative Therapists (IFOMT) congress in Vail, Colorado. Since I was still his resident at the time, I was given the privilege to provide free labor at the conference. My primary job, along with fellow resident, Elaine Lonnemann was to check the name tags of all of the participants to assure that they had paid for that day's conference programming. We were under strict orders to turn back anyone with an invalid name tag. On the first day of the conference, I was at my post at the front entrance to the exhibit hall, and an older gentleman, without a nametag, was walking toward me from the registration desk. As I stepped forward to enforce the nametag rules, Dr. Paris came running across the hotel lobby to pull me back and promptly introduce me to Freddy Kaltenborn. (I learned that nametag rules don't apply to individuals such as Freddy Kaltenborn).

The Academy was accepted as a full voting member of IFOMT at that meeting; I was part of the first group of physical therapists to join the new organization; and after meeting and interacting with international leaders in our field at this conference such as Geoffrey Maitland, Mariano Rocabado, David Lamb, and Gwen Jull, I was hooked on attending manual physical therapy conferences.

In 1994, I completed the University of St. Augustine Fellowship program and was accepted with the first class of new Fellows into the Academy, and in 1995, I attended the first meeting that new fellows were invited to attend, which was held in a hotel room during the APTA combined sections meeting in Reno, Nevada. While at that meeting, Dr Paris nominated me for the executive position of Member at Large and Ola Grimsby nominated Jim Rivard for Treasurer. We were both about 29 years old and suddenly elected into the inner circle of this new professional organization.

In the mid-1990's, the Academy executive committee communication between bi-annual face to face executive meetings was challenging. Typically, when an issue arose, the president would spend hours on the phone calling each member of the executive, or we would use the fax machine, which also involved the lengthy process of sending the fax to one person at a time. Things became easier a few years later when we upgraded to the use of dial up e-mail and conference calls.

Despite these obstacles to communication, we made progress on a number of issues including building positive working relationships with the APTA and the orthopaedic section, development and implementation of a residency recognition process, representing the United States in IFOMT, establishing a home office in Gulf Port, Mississippi, putting on very successful annual conferences, and working with the APTA to create the Manipulation task force to address regulatory, legislative, and education issues related to manipulation in physical therapy practice.

Advocacy and Education

The areas of service that I am most proud of are the contributions the Academy has made regarding advocacy and education. Legislation and education are intimately related, and I have had personal experiences that illustrate this point.

In 2001, the Illinois Prairie State Chiropractic Association filed a complaint with the Illinois department of professional regulations that the Northern Illinois University Physical Therapy program was teaching “chiropractic techniques” and thereby violating the PT practice act. Since I was the primary orthopaedic physical therapy faculty member at NIU at that time, I was invited to attend a hearing conducted on this matter in which I presented arguments that what I taught was within physical therapists' scope of practice and was in full compliance with physical therapist academic program accreditation guidelines. The chiropractors argued that since Illinois law prohibited physical therapists from performing “chiropractic techniques” that, physical therapists should not be allowed to perform and teach high velocity thrust manipulation. “Chiropractic technique” is currently not defined in Illinois law, and we argued that physical therapists can not possibly teach or practice “chiropractic technique” because we do not receive the full training in chiropractic philosophy that chiropractors receive in their professional education.

We were able to successfully defend our position because of the resources provided by the Academy and APTA manipulation task force and because we used the “professional education” argument. This is a very common strategy in legislative and regulatory turf wars between professional health care groups. The typical approach is to argue that the public is at risk of harm if legislation is passed to expand the scope of practice beyond the professional education. While I was legislative chairman for the Illinois Physical Therapy association, in a two year span we successfully used this argument with the athletic trainers, massage therapists, and occupational therapists.

However, since only about 40% of the Physical Therapists Professional Education programs in the country were teaching the entire continuum of manipulation techniques in 2001 including thrust manipulation¹, many of us feared that entry-level professional education could become the achilles heel in our legislative conflicts with the chiropractors.

In 2003, the Academy established a goal to work to enhance the level of instruction of manipulation in physical therapist professional education and worked with the APTA to put together the manipulation education committee. The result was development of the Manipulation Education Manual (MEM) designed to provide resources for physical therapist educators on how to enhance the professional curriculum on manipulation including thrust². The committee also worked with the APTA committees revising the Commission on Accreditation of Physical Therapist Education (CAPTE) Evaluative Criteria³ and the Normative Model for Physical Therapists Education⁴ to clarify in the 2005 revisions of these consensus documents that both thrust and non-thrust manipulation for the spine and extremities must be taught in physical therapist professional education programs. The committee members also provided educational programming at professional meetings and a 2 day continuing education course to bring the contents of the Manipulation Education Manual to the attention of physical therapist academic and clinical educators.

Evidence of the positive impact of the Manipulation Education Manual occurred in Illinois earlier this year when the Illinois Chiropractic Society, with the support of the Illinois Osteopathic Medical Society, proposed legislation to define … “chiropractic technique” as a “manipulation” that is … “equivalent to GD Maitland's range of movement scale grade V”⁵.

Since physical therapists in Illinois are prohibited from performing “chiropractic technique”, this definition would prohibit physical therapists' ability to practice thrust manipulation in Illinois and also prevent physical therapists from calling a thrust a Grade V mobilization/manipulation.

Illinois Physical Therapy Association President Peter McMenamin and I had an opportunity to meet with the lobbyists and leaders of these two organizations to explain that mobilization/manipulation including thrust have been an integral part of physical therapists' scope of practice since the inception of the profession and are taught in physical therapist professional education programs. The osteopathic physician listened to our arguments, but wanted to check our claims for him self. His research included contacting a physical therapist professional education program in Illinois; the director of the program, who is a pediatric specialist, was able to explain to the osteopathic physician that manipulation, including thrust, is taught in their program and gave him the website where he could access the Manipulation Education Manual. The next day the osteopathic physician called Peter McMenamin to say that he was impressed with the Manipulation Education Manual and was satisfied that physical therapists were being well educated and trained to perform thrust manipulation. The osteopathic society withdrew their support for the legislation, which combined with physical therapists' lobbying efforts, killed the legislation.

In this case, the education helped to defeat the legislation.

Recommendations for the Future

This was a very satisfying victory; but, our work is not done; there are challenges to our scope of practice, professional autonomy, and ability to be paid for our services in every legislative session.

It is time for the Academy to take our advocacy to the next level. We need to train our members to advocate on issues that are important to manual physical therapy at both the state and national levels as representatives of the Academy. In the past, we have worked through APTA channels, but now it is time to consider standing along side APTA to advocate for our profession. We need to develop the necessary training materials and programming to assure that there are Academy members ready to testify in every state when the need arises and to develop liaison relationships between the Academy members and the APTA state chapter legislative committees to assure that experts from the Academy are consulted when issues related to manipulation arise in the state legislature.

In the future, the Academy should also consider hiring our own federal lobbyist and developing a true political action committee fund that could raise and distribute funds to support political candidates that are supportive of physical therapy issues. In this way, we can become a stronger partner with the APTA to push the physical therapists' legislative agenda.

Our work in education is not done. Many members of our profession are not following evidence-based guidelines in their daily clinical practice and do not understand evidence-based principles. Not to mention that many of our colleagues are fearful of learning and performing manipulation. We spend far too much time teaching our students outdated and unproven treatment procedures. Many of the continuing education courses our colleagues attend provide unscientific, unproven, and inappropriate approaches to patient care.

We need to incorporate evidence-based principles in our teaching, writing, and clinical practice to move the profession forward, and use media and public relations strategies to get simple, evidence based messages out to the public and our colleagues on a continual basis. Although the Academy has begun doing this and in many ways is a leader in this area, I feel that we could do more. The Academy should also consider development of a review and recognition process of professional continuing education course providers to assist in guiding our colleagues to attend courses that meet evidence-based, education, and clinical standards.

We also need to recognize that we do not live and work in a vacuum. We should work through the international channels of IFOMT to educate our international colleagues that the words that they use to describe mobilization, manipulation, and manual therapy in their professional writing and teaching impact public opinion, the media, and legislative issues in the United States. This includes bringing our profession of physical therapy with us in all descriptions of manual physical therapy procedures and consistently using the Guide to Physical Therapist Practice ⁶ definition of mobilization/manipulation in our daily clinical practice, education, and research activities.

Through the Academy, we have been able to create a synergy of research, clinical practice, education, and advocacy. To truly become an autonomous profession, we need to continue to push the boundaries of these four pillars. Let's learn from our history to build on the solid foundation provided by our predecessors. It will take the time, money, energy, passion and service from every member of our profession to attain our common vision for the future.

Thank you for your attention and thank you for this award.