MOJ eISSN: 2374-6939 MOJOR

Orthopedics & Rheumatology
Volume 3 Issue 2 - 2015
Redefining Role of Manual Therapy in Orthopedics and Rheumatology
Bhojan Kannabiran*
RVS College of Physiotherapy, India
Received:August 17, 2014 | Published: August 26, 20155
*Corresponding author: Bhojan Kannabiran, Physiotherapy Department, RVS College of Physiotherapy, Coimbatore, India, Tel: 919487968169; 919894151846; Fax: 04222687603; Email:
Citation: Kannabiran B (2015) Redefining Role of Manual Therapy in Orthopedics and Rheumatology. MOJ Orthop Rheumatol 3(2): 00088. DOI: 10.15406/mojor.2015.03.00088
Keywords: Manual therapy; Low back pain; Cost-effectiveness; Manipulative sports Physios


The exact nature why Orthopedic Manual Therapy benefits many conditions has given rise to contradictory theories and intense argument. Justifications drawing the complete picture why manual therapy is advantageous have ranged from the scientifically valid to the mysteriously strange explanations. Though theories stay proposed, has involved research that were unwell premeditated, or were primarily promoted by individual judgment, there are plenty of postulates driven largely by investigators and doctrinaires in physiotherapy, osteopathic, chiropractic and massage-based body work involving spinal, cranial, visceral and fascial manipulations.

One day in clinical practice, I was confronted with an ethical and business challenge that is symbolic of the social and economic encounter the country is facing regarding health care. The cost of health care in India is becoming expensive-it accounts for a major share of the Indian economy, and it is perhaps the greatest threat to the long-term wealth of our State and Central governments.

We are probably hearing about this in some form over the past few years, but the reality of the problem is striking when a patient is sitting in your clinic. I evaluated a young software engineer in my office outside of Coimbatore who was suffering from low back pain for past few years which he developed after joining the software industry. The history suggested a sciatic pain radiating to the lower back, who had multiple consultations and did quite a number of MRI’s which showed no red flags with multiple disc bulges and was suggested physical therapy trail of four weeks which fails he may require a surgery. The physical examination confirmed the diagnosis with neural sensitivity (non-disruptive syndrome). Our discussion turned toward the manual therapy, movement impairment and reestablishing motor control of the spine and the rehabilitation process considering the effect of disc pathology and neural sensitivity.

Simply by routine I converse with patients regarding who referred to manual therapy before manual therapy procedure. There was an adamant agitation in the exam room as we discussed the why he was referred late and how he preferred manual therapy and what delayed manual therapy treatment. I soon learned that the family was depending on this guy who is the bread winner and a spine surgery would be an expense out of their budget. The low back pain created an unexpected budget crunch for the family, and the cost of treatment for the lesion would equal the cost of a semester at college for his brother. In India, the past 5 years have witnessed a quiet yet dynamic shift in health care benefits provided to patients by specialist physiotherapists. Maybe in an effort to compete in a worldwide economy while preserving effectiveness, many are shifting towards the conservative health care straight.

There has been an astonishing proliferation of high profile conservative treatments and cost-effective treatments that cover low back pain solution. These changes have created paradigm shift price sensitivity in the health care marketplace. Patients are now searching for value and acting like true consumers. Simultaneously, the implementation of the spinal, cranial, visceral and fascial manipulation techniques catalyzed the explosion of new types of treatments among health care providers, and patients.

 The debate regarding the conservative spine care has focused primarily on who is in need, what treatment techniques or approaches should be provided, and who should recommend for it. While the public attention has been drawn to the sharp discussion and struggle regarding the new form of advanced spinal pain management, one of the most crucial components conservative treatments in orthopedic ailments and rheumatology has quietly gone unnoticed. The new insights move away from a traditional medical model that is followed historically to the new holistic model of considering the various aspects of the growing science including paradigm shifts from biomechanical aspects to neurophysiology has rewarded volume and the provision of more results incorporated in modern evidence based manual therapy approaches.

 Total Value worth = Results/Budget

Praiseworthy agreements are gaining momentum throughout the country, and unlike health care reforms earlier, it appears that there is no working back at this fact. In this way the modern manual therapy, both the referral practice and walk in patients, are acting like consumers much like my low back pain family. The good news is that orthopedic manual therapy, especially sports medicine, is in advance of these changes in health care distribution. We as manipulative sports Physios have been a front-runner among the other medical specialties in defining and reporting our results, and we have developed validated patient-reported outcome measures. It is clear-cut that on the result side of the total value worth equation we have performed well. Our presentation on the result side of the total value worth equation, however, requires a more thorough exploration, and the majority of health care practice settings are not able to accurately determine the total cost evidence based care.

For example, the development and fast distribution of new and innovative treatments in the earlier decade has been an integral component to the success of orthopedic manual therapy and our excellent patient outcomes. However, there are many examples of non-innovative treatments being still in practice that simply add an addition cost to each patient without improving the outcome. We are now threatened with a practically impossible task: ‘‘turn the referral arc’’ and provide those same superb outcomes, but at a reduced cost. That’s creating value at the individual patient level. There has been a paucity of manuscripts in various orthopedic & rheumatology journals regarding value, outcomes, and cost. We should now start to publish articles reporting outcome measures such as quality worth non recurrence life years, the worthy - value exploration, and the incremental cost effectiveness ratio.

 This makes us feel a bit sore, it should. I have immersed myself in this field over the past several years while updating myself with various advanced form of manual therapy procedures including basic and advanced osteopathy, spinal, cranial, visceral& fascial manipulation from various prestigious institutes around the globe, but I feel much more contented discussing the tones of manual therapy dimensions in common ailments . I assure that current concepts will continue to focus on manual therapy in orthopedics and rheumatology, but as health care delivery moves from capacity to worthiness, we will also be at the lead of popularizing the values of manual therapy in orthopedics and rheumatology.

Returning to my patient, he had an orthopedic manual therapy session followed with corrective exercises to regain motor control in movement impairment perspective scientifically justified. I used a session of visceral manipulation for the stiffness at the low back and a one session of fascial manipulation on selected centers of fusion. We can only provide value to one patient at a time, but like minded professionals working in hospital or clinic settings, and working across the globe, have the potential ability to redefine value of manual therapy in orthopedics and rheumatology.

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