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Steven George: Hello and welcome to this PTJ podcast. Today we're highlighting the article "Orthopedic Manual Physical Therapy: A Modern Definition and Description." And we're very fortunate to have with us the lead author Jason Silvernail. Doctor Silvernail is affiliated with the Graduate School at Baylor University in Texas, the San Antonio campus.

So welcome Jason to the podcast. And I wanted to start off by congratulating you on this article. It's a great contribution to the literature, and it's my understanding that it garnered quite a bit of attention when it was published. Before we get into some of the particulars that may have attracted this attention, I wanted to start with some very foundational questions about this article for you.

Jason Silvernail: Hey, great. Thanks, Steve. It is great to be here. I had a just a tremendously positive experience with PTJ. I'm excited to be here and talk about this paper that my co-authors and I worked very hard on for a very long time. And one of the things I should say before we get started is because I'm still on active duty as a U.S. Army officer is that everything I talked with you about today is my personal opinion and commentary on the basis of my authorship on this paper and does not reflect the official policy or position of the US Army, the Department of Defense, or the United States government. So there's no U.S. government here. It's just me. So since we're bound now down to just me, I'm. I'm happy to take questions. Thanks again for the coming offer.

George: Great. Yeah. And I understand the, you know, the need for that disclaimer and appreciate it, but I mostly thank you for your service. I've had the fortune to collaborate with several, you know, military affiliated researchers and the one thing I'm always struck by is just how mission-oriented people are that are directly in the military, in, in your role. So I thank you for your, for your service. And you know, we really appreciate you taking the time to meet with us.

So quick transition, you know this this was a this was essentially an All Star author team that we was put together for this paper. And you know I am curious about how that all came together and what it was like being a lead author for that for that group of co-authors on this particular paper.

Silvernail: You know, I remember growing up as a little kid and, you know, you'd watch these educational programs and then they would sing this song. And one of the programs, one of these things is not like the other, one of these things is not the same. You look at this author list and you think, my goodness, what is Silvernail doing there? Geez. So I think it really was true. This really is kind of a All-Star list of some of the people who have who have published some of the most groundbreaking and influential literature in in orthopedic physical therapy and in orthopedic manual therapy. And so this this project was grown out of an effort from the American Academy of Orthopedic Manual Physical Therapists Board of directors. And they saw a need to update the definition and an explanation of what we do in OMPT as a subspecialty.

And they took some people that they know were supporters of the direction we were trying to go. And in academia, you look at that author list, you've got expert clinicians, you've got career academics. You've got career researchers. You've got people who don't do any of that and primarily just take care of patients and do policy stuff like me.

So I think you've got a real diversity of people who do different things in physical therapy and who are looking at this important topic in a different, potentially through a different lens. And I think that was a real strength of the of the authorship team. And this definition represents AAOMPT's definition of what OMPT is, and especially in their role as our member organization for the International Federation of Manual Therapy. And so it was. It was just a tremendous experience. I mean, how do you go through and talk about which articles to cite and how do I have a disagreement with Julie Fritz or with Chad Cook or with Carol Courtney or Josh Cleland. Or, you know, it's just it was. It was pretty amazing and it was a – it's definitely it has been a career highlight for me so far.

George: Great. And I think that's, you know that's a good perspective on how teams like that come together. And I think don't underestimate yourself or your or your role. I mean I think you know, there's a reason why groups like this come together and I'm sure if we had some of the, the other folks on here they would certainly point out you know, some things that maybe, you know would surprise you to hear, hear about, you know what, what it takes to lead a group like this so. But I think it's very interesting to hear that how that comes together and I guess I can say not too surprising to hear. You might disagree with Julie Fritz or Chad Cook. I can pick on those two because I work with Chad and know Julie quite well. But in all seriousness, it's great to have a group that can like you said, have kind of high level consideration and but keep the keep the main goal and focus and keep moving and I think that's really apparent from the from the product.

Can you talk a little bit about how PTJ ended up being a target for this article? I think you know manual therapy to me is a really interesting topic because there's just so many outlets for articles because it cuts across, you know, orthopedics, there are some manual therapy, specific journals. Obviously there's some provider types that manual therapy is a core skill. So you know I'm not expecting you to expose any trade secrets, but I'm just curious about, you know, how PTJ ended up being kind of lucky enough to be the disseminator of this article.

Silvernail: Yeah. When I think about who we wanted most to communicate with about what OMPT is and what that's updated definition consists of, I think we really wanted to reach as much of a generalist audience as we possibly could. I  don't, I don't really think at the top of my mind was let's go to a manual therapy type, orthopedic manual therapy type journal. I think our my thought was like I want your average clinician or researcher or faculty member to have a clear understanding about when we say something is OMPT, what do what do we mean when we say that? And I think the best way to do that is to go to a journal that has a large and wide reach for that kind of generalist audience that we were most trying to meet and PTJ just met everything that we were looking for and we just had a tremendously positive experience with the editorial team and much of the a good portion of the improvement of this product, the final product, as you mentioned, you know really with thanks to the editorial team for their assistance, too.

George: No, that's good to hear. And I like, you know, I like to hear you thinking about who you want to communicate with because I think that's one of the means that sometimes authors, I don't know if they put as much thought into that or but that really is what it boils down to. And you know, I could see an orthopedic journal or a manual therapy journal that's not being potentially as impactful or maybe a little bit of an echo chamber effect either. And I always think. OK. Mm-hmm. You know as someone who has tried to communicate between different worlds, sometimes that when you can explain it to a generalist group, that's when it becomes really powerful, because you're not talking to people that are already maybe familiar with these terms and maybe will be a little more skeptical in a healthy way about where you're where you're trying to go. So I'm glad to hear that that was at the forefront is who you want to communicate with because I think that's such a key decision and thinking about the journal and the audience that you want to get in front of.

Silvernail: Yeah. For us it's a. It really was all about the audience. And I think that also a special, of special importance I think is that there are so many of these, the themes and concepts that we talked about have a lot of overlap. I mean a lot of times when people share with me experiences they've had with manual therapy, it's obvious that me, to me that they're not talking about orthopedic manual physical therapy. They're talking about some other, you know, method or approach to manual therapy. And that I think that's all perfectly good. And I support those things. But that's not what I do.  

It's not what I teach and it's not. It's not the program that I graduated from. And I think understanding the difference between who's in entry-level practitioner and physical therapy, who is like a postgraduate learner, who's doing like a CME course or something like that, who's a resident to get a specialization like an orthopedics, sports or Women's Health or anything else, and who is going to a subspecialty fellowship program. Those differences to us are important and we needed to and we wanted the opportunity to put these ideas out to a generalist audience.

One of the things that we did in addition to that is and our editorial team was kind enough to work with us on an additional supplement that is a patient case, so that as people read this, the definition, if some of it looks a little bit, you know, maybe too much like definitions or, you know, lists of things that it sometimes it's hard to figure out. Well, you know, how does this really apply in the clinic and how would I notice this if I saw somebody do it in clinic?  Putting that patient case in there and showing the connection between the definitions and explanations that we made conceptually and how that would transmit sort of practically to the patient, I think that's a key, a great opportunity that we're pleased to be able to have, too.

George: No, I agree. And you know again thanks for pointing out some aspects that you know I think support the main article too because I think you know this is hopefully just the beginning. I think we've danced around this, but I do want to ask you directly about because I understand there was a there was a charge to this, but why do you think this was the time, you know, to provide this definition of OMPT as a subspecialty and then you know related to that were you were you surprised that this issue hadn't already been addressed? It seems like one that maybe should have.

So why now? And you know, as you were looking through the literature, where did it surprise you that it hadn't been hit kind of head on like this?

Silvernail: Well. Let me let me break it sort of a cardinal rule of the of the interviewee and ask and answer the second question first. So what we ended up doing is we built on the definition of OMPT that IFOMPT had provided in the IFOMPT constitution and relevant and I think relevant to the OMPT world and the manual therapy role, I think there's just been a lot of attention lately on better describing what people mean when they say those things. And so I think that while IFOMPT was exploring some of those things, we took that opportunity to take that great definition that IFOMPT had. If you look at the IFOMPT Constitution and you read their definition, basically we've just sort of expanded what that was without any sort of radical altering one way or another. And in terms of like why we wanted to do it. You know I think that for a lot of us, it involved being in the back rooms of clinical practice guidelines or systematic reviews, and I would say for my part, I've been in those rooms where people decide how we organize and how we classify a body of work and how we produce a translational clinical document like a clinical practice guideline or a systematic review. And we noticed a persistent dichotomization of studies.

So this is kind of how the discussion went. So here's the study that has exercise therapy and education. Oh, great. We're going to put that in the exercise therapy, physical therapy bucket. Wonderful. Here's one with exercise therapy and manual therapy. We're going to take that, and we're going to put that over here in the manual therapy bucket. And along with the manual therapy bucket, it wasn't just OMPT. It was sort of any old kind of hands-on technique that you might think of all went in that same bucket.

And I thought, well, wait a minute. What? Why are you putting this exercise trial in the exercise physical therapy bucket and that exercise trial in the manual therapy bucket? Well, because that had a hands-on technique like, well, we don't have an education bucket where all these studies involved in educational effort for the patient and or self-management plan, why don't we have a self-management bucket? And then you know, you can sort of mentally insert the sound of crickets chirping at that point. Right.

And so it seemed to me that people really didn't understand why they wanted to dichotomize hands-on trials in a certain way and in a way that I thought had the effect of watering down the impact of some of the quality trials that do exist especially in OMPT, and I think that we use several examples in the paper. If you're looking for a treatment for a common problem that our patients have, that can be done in about 6 visits and gets you about a 50% improvement that is durable out from 6 to 12 months. Like how many things do we do that work that well that reliably with that few visits? Not a lot.

And, but that's what OPT does for knee osteoarthritis, for example, and the impact of those trials was getting watered down by the way people were classifying it and the way people were dichotomizing the hands-on approach. And I think that it came from a desire from some people to really sort of hair split and separate into as many possible small elements complicated things that we were doing with our patients that were known, known, helpful.

And so you mentioned before that that, that paper got quite a bit of attention when it came out. And oh, Steve, I was ready. I had my thumbs ready to, to, to jump into the social media fray. I certainly did that. And you know, so one of my interlocutors sort of said, hey, you know, you've got all these things you're doing with the patient, how do you know it was the manual therapy that, that, that worked? How do you know it’s not just free riding on something else that you're doing. And I said, well, I guess I'm not making a claim about those individual things like I. If I'm not feeling well and I open a can of chicken soup, I don't really worry, is that celery doing anything good for me? Maybe the celery is just free riding on the chicken broth or the salt, or the carrots or but, but I don't have to worry about that. I have on the shelf prepackaged in a can chicken soup. All I have to do is open it and eat it. I don't have to. I don't have so my this sense of we need to split everything into as many tiny possible pieces, patients don't care about that. I don't think payers care about that. I don't think our fellow clinicians care about that. I think a small number of people who want to pick and choose different things out of this total package I think those are really the people that care about that kind of splitting up. So I think it's that kind of dichotomization, and we talked about that a good bit in the paper, helps explain why we wanted to make the definition now and define it the way that we did. And I think if people follow through and look at the patient case that will help illustrate that as well.

George: Yeah, definitely. And um, can have a little bit of, you know, memories of, of working through some of this for the CPGs on low back pain because essentially trial and almost no trials that were in our updated search were unimodal treatments. You know, everything is some combination of something, so certainly can relate. So it'll be interesting to see, you know, if other areas kind of adopt this type of framework to talk about, you know what, what does it mean to have, you know these multicomponent interventional approaches but also being able to explain in a way that it is prepackaged so you can make sure you're getting you know once you find Progresso or whatever it is, by the way we don't we don't endorse any particular brand of chicken soup but Progresso happens to be what’s in our cabinet and you know and it's got good carrots and all that.

But I can go to it again and again, and that's kind of what you're setting there with OMPT. Along those lines, you know, it's pleasantly, pleasantly, maybe not surprised knowing the people that worked on it, but it was nice to see health coaching in there because I think that is something that you just see different reactions to by provider types.

You know, I think some people have more enthusiastically embraced, you know, what health coaching can be. Whereas I think other folks have maybe pushed away a little bit that it's not a quote unquote skilled that which I disagree with for the record. So can you talk a little bit about, you know, did that meet much resistance or where was this group as a whole kind of enthusiastic about endorsing health coaching as part of this OMPT definition?

Silvernail: Yeah. You know, one of the things that pleasantly surprised me the most about working with this team, I mean you look at these authors, I mean they, they're from all different parts of the country. They're teaching in different programs and some people would say, well, those people must not do OMPT the same way. They must do it a different flavor or, you know, with the different paradigm. It was amazing how little disagreement we really had and how much all of us almost immediately agreed on what the big picture items were that we thought were important and the way in which we teach our students and fellow. And I think that health coaching piece, although I'm going to take you know, 60% credit for using for making sure that that term stuck in, I would say that I think that's kind of in the DNA of people who are OMPT trained.

And I think about the, the, the people on whose shoulders we collectively stand, especially when in the outpatient, orthopedic and hands-on care community and physical therapy. I mean these are a lot of these folks were private practitioners, knew who kind of hung out a shingle for PT and they were not making successful practices on the basis of what an insurance company would pay for. They were really making successful practices on the basis of the long term relationships they built, they built with their patients and how they help their patient over the over the long-term continuum of their life.

And I think that, you know, especially for me, when I came out of OMPT training, one of the things that it instilled in me is like a great sense of humility about what medicine can accomplish and about what I can accomplish in PT and a sense of one of the things that I really needed to do is help my patients stay as functional as possible, as healthy as possible for as long as possible. And what I was doing with him in the clinic did not support something that they could do for the next 10 to 15 to 20 plus years to stay healthy, but I was probably going in the wrong direction. And so I think that's sort of a long term patient-centered mindset, I think that is a big focus of what we do.

One of the things we did is we set out, you know, 5 distinguishing characteristics. These are characteristics of how you can recognize OMPT in the clinic and you can follow through in the patient case and see it, which is advanced subspecialty training, and focus on clinical judgment, expertise in examination, expertise and treatment, and a patient-centered long term mindset. Now part of that involves a couple of actions that you take and one of the actions that you take is activity and health coaching and it's precisely to get that kind of long term mindset.

You know, I heard somebody once say, you know from the personal training world, say I don't care how much you can dead lift in six weeks. I care what your blood pressure is in 10 years and I think that like that is definitely the thought process we have in OMPT when we when we see patients. We we're looking for long term positive changes in health.

George: No, that's great. And I think that's why, you know, that's such an important, you know, part of the model and also like you said, I think it does it, it's relatively it should be relatively easy to differentiate use that as a way to differentiate from the type of care you're describing versus you know maybe some of the other things that you've seen in the literature and clinically.

So we're nearing the end. I hate to bring this up at the end, but maybe it's good because we could go on and on and on about it. But I am curious about your thoughts of dosage, especially after hearing, you know, obviously you're not, you don't come across as a reductionist. You know, where we have to, you know, know each but. But I am curious, you know, that has always been a challenge especially for manual therapy and even exercise, but especially manual therapy, how do we talk about dosing and you know some of the visuals I think get across that issue conceptually.

But we still, you know, we struggle to have kind of a duration frequency, intensity model. And so I'm just wondering what if you know if you feel comfortable you know ending with a few thoughts on dosing or future thoughts on dosing or is it, is it even important if we monitor the patient's response is that ultimately what matters and maybe the amount that we put in, maybe it's not a physiologic you know, relationship that it is in some other system. So I'm just curious, I'm sorry, it's a open-ended horrible thing to ask, but I was when I looked at the paper again and preparing for that, you know, that was one of the things that I kind of caught my attention and wondered if the group had thought about that or if you have any thoughts?

Silvernail: Yeah, yeah, I think well. Well, I think there's this sort of the big picture thought about that and then there's the more, more detailed one and I guess I'll start with the big picture one. You know, I think when people think about dosage of care or an episode of care, you know, especially in the outpatient therapy world, you know, I think what we're talking about is, you know, number and frequency of visits. So you know, if you look across the different OMPT trials that we that we quoted and cited in the article and you think like how many times is an OMPT practitioner seeing a patient?

Well, it's 4 to 12 visits or so and it's over, you know, couple of months. So I think one way to look at dosage is just maybe that's sort of superficial look. I think we're talking about, you know, 6 to 8 visits or so over, you know over about two months or so and that's one way to look at dosage.

Another way to look at dosage is like how much physiological load or strain are you putting through the through the tissues and that I think is going to depend in large part on the patient response. So I think it depends a lot on sensitivity. But you know actually a long time ago published an article called "Biomechanical measures and Knee Joint Mobilization." And one of the biomechanical variables that we tracked over time was like the total amount of time that in an oscillatory mobilization you were pressing into resistance. And I used that as one possible, you know, way to conceptualize dosage and especially for the manual technique part. So as we're characterizing that that load and so I think that if somebody wanted to think about manual therapy dosage, you know at the at the risk of being that guy who wants to talk about his other presentations or publications in a  podcast about another one I guess I'm that guy now, but you can go and you can go and check out biomechanical measures of knee joint mobilization and get a sense of what that of what that looked like.

So I think that mostly in the outpatient world, when we talk about dosage, I think that's what we're getting at. We're getting that number of visits over what kind of time and therefore that tells us a lot of useful things that gives us a sense of what is the time commitment for the patient. It gives you a sense of what is the financial commitment from the payer, what is the skill investment for the provider. Calculating dosage like that I think does a lot of very practically useful things for the health care system. As we think about centering what we do around best practice.

George: No, that's helpful. And I think it's a good perspective because you do have that you know, like you said, that biomechanical background and then transitioning to what, you know my words, not your words is maybe a more pragmatic way to think about, you know, dosing. So and like I said, this could be a whole lot of other topics so I appreciate you just kind of sharing a little bit of thoughts and obviously it's not a main thrust of the paper, but I it did. It is something as I was revisiting  it that I wanted to make sure we talked a little bit about and.

Silvernail: Yeah, no dosage is interesting. You can see dosage is forced time integral, which is how I described it you know way back when or you can see it in you know number of visits and you know length of time or something too and.

George: Right, yeah.

Silvernail: I think both of those are have value in terms of describing the kind of dosage we're talking about.

George: Yeah. And I think that's the challenge. You know, when you follow a kind of a classic model where there aren't as many opportunities to represent that you know it, it dosage becomes so prime. But in our field, I think it's it really is it's kind of you know there's layers of it of how it can be expressed and that's a challenge sometimes. But it's also opportunity.

So I like I said I appreciate your sharing your thoughts and you know I also appreciate you joining us and sharing you know a little bit more behind the scenes on this article, and especially for your leadership and putting this team together and you know, leading the way on what we hope is a really informative article and hopefully we'll provide some you know, kind of foundational definitions and things for people to build on and like you said, it would be nice if we see some of this permeate into practice guidelines so that we can maybe you know better discern when the treatment is meeting these types of characteristics versus when it's, you know, used in a more haphazard manner. So. So thank you so much for joining us and thank you for thinking of PTJ.

Silvernail: You’re welcome. I mean, I think one of the one of the other things that, that, that has come up with as I've talked about this other places is the opportunity to describe what subspecialty training look like and I think about the kind of skills and competencies you need to graduate from an OMPT fellowship, and I think that those skills and competencies are broadly similar to the skills and competencies that you would need to graduate from any other subspecialty fellowship in physical therapy.

So I think that, you know, I think this potentially provides a model for other people who are into, you know, subspecialty education to consider how they define their practice and how they can use a patient case to convey the value of subspecialty training in their field and how we can better articulate some of those specifics that I think really do make big differences for our patients. Thank you very much for having me.

George: Yeah, no, great point to end on and thanks so much for joining us.