C. D. Dorine van Ravensberg, PhD
Rob A. B. Oostendorp, PhD, PT, MT
Lonneke M. van Berkel, MSc, PT
Gwendolijne G. M. Scholten-Peeters, PhD, PT, MT
Jan J.M. Pool, BSc, PT, MT
Raymond A. H. M. Swinkels, MSc, PT, MT
Peter A. Huijbregts, DPT, FAAOMPT, FCAMT
Abstract: This study compared socio-demographic characteristics, health problem characteristics, and primary process data between database samples of patients referred to physical therapy (PT) versus a sample of patients referred to manual physical therapy (MPT) in the Netherlands. Statistical analysis indicated that that the MPT sample was significantly (P<0.01) different from the PT samples with regards to the socio-demographic data in that the patients in the MPT sample were younger, had attended post-secondary education to a greater degree, and were more often gainfully employed. The MPT sample was significantly (P≤0.01) different from the PT samples in that health problem data in the MPT sample indicated mainly acute, non-surgical orthopaedic or neurological, spine-related complaints of recent occurrence. Recurrence was significantly (P<0.01) more common and complaints were significantly (P=0.01) more often non-traumatic in the MPT sample. MPT referrals were significantly (P<0.01) different from PT referrals in that the MPT referral originated more frequently with a general practitioner but not with a medical specialist and that referral occurred within three months of occurrence. Primary treatment goals and interventions are discussed, as are study limitations, suggestions for future research, and relevance to the international situation.
Key Words: Manual Physical Therapy, Physical Therapy, Patient Characteristics, Sociodemographic, Health Problem, Primary Process
Since the inception of the profession, manual therapy is and has been an intervention used by physical therapists1,2. Early manual physical therapy (MPT) could hardly be called sophisticated, but neither were manual interventions in other health care professions3. Manual therapy training for physical therapists starts in the entry-level professional program with specific manual therapy and related foundational courses and continues with post-professional educational opportunities in the form of continuing education seminars, clinical residency and fellowship training, post-graduate academic and diploma programs, clinical mentorship, and manual therapy certification programs4,5. Both at the national and international level, educational guidelines, criteria, and standards have been developed to standardize entry-level as well as post-professional curricular content6-8. Physical therapists have significantly contributed to technique and concept development and description9-18, research19, and guideline development in the field of MPT, and have, when compared to other manual therapy practitioners, a superior safety record in the clinical application of manual therapy4,20.
Compared to the international situation described above, the MPT education and reimbursement environment in the Netherlands is somewhat unique. In contrast to the situation in the United States, for example, where entry-level education over the years has placed an increasing emphasis on manual therapy curricular content including thrust techniques21-24, entry-level education in the Netherlands deals almost entirely with non-thrust manual techniques. To become a registered manual (physical) therapist, therapists have to successfully complete one of five different post-graduate programs all conforming to IFOMT standards8,25. Manual physical therapists enter into capitated care contracts with insurance providers separate from and at a higher reimbursement rate than physical therapists. In the Netherlands, physical therapists use thrust and non-thrust manual interventions at a high frequency in clinical practice26, yet only registered manual physical therapists are reimbursed at the higher MPT rate. This unique education and reimbursement environment has resulted in a sharp delineation of MPT from physical therapy (PT) in the Netherlands with an almost separate professional identity for MPT versus PT. As discussed above, this is quite unlike the international situation where MPT remains firmly integrated into the PT profession as a whole.
Indications for PT and MPT overlap, for example, for patients with non-specific low back and neck pain, but they also clearly differ: e.g., neurodegenerative and internal diseases may present an indication for PT, but not MPT. In the overlap area, both the physical therapist and the manual physical therapist have expertise with health problems involving movement dysfunction. In the Netherlands, professional profiles describe and delineate PT and MPT scopes of practice. A comparison of the Physical Therapist Professional Profile27 and the Manual Therapist Function Profile28 shows that the MPT primary process (i.e., examination, evaluation, diagnosis, treatment planning, and intervention) emphasizes evaluation and treatment/improvement of joint function, especially of joints in the spine and pelvis. To this end, the manual physical therapist uses knowledge, methods, and techniques considered unique to MPT. In daily clinical practice, PT and MPT are often less distinct, because the same person, i.e., the physical therapist with a specialization in MPT, provides both PT and MPT. This seems to result in a treatment continuum where the switch between what is considered MPT or PT occurs whenever indicated. Despite the implicit logic of said continuum evident in clinical patient management, the question regarding PT and MPT distinctiveness remains. For the primary process, this distinctiveness is described in the above-mentioned professional profiles27,28. However, a practical distinction can be hard to make. Which patient with low back pain (LBP) would benefit more from MPT intervention and which one would be more appropriately treated with PT? General practitioners (GP) also make use of implicit referral criteria, but they frequently ask for more explicit criteria with regards to appropriate patient selection for referral to either PT or MPT. For now, there is no answer to this question. Review of the relevant international literature has provided no data on referral criteria to help the GP identify patients, who might benefit more from a PT or an MPT referral. The Dutch Society for Manual Therapy recognized this problem and contracted with the Dutch Institute for Allied Health Care for a descriptive and explorative study. The questions we meant to answer with this study included:
- What is the distribution of patients referred for MPT with regards to socio-demographic characteristics, health problem characteristics, and primary process data?
- Is there a difference in socio-demographic characteristics between patients referred to MPT and those referred to PT?
- If so, is the distribution of patients referred to MPT or to PT different with regards to health problem characteristics after correction for the differences in socio-demographic characteristics?