A review of Thrust Joint Manipulation Skills For The Spine
Who: The authors are Emilio Puentedura (affectionately called “Louie” by almost everyone who knows him) and Bill O’Grady. Both gentlemen are seasoned veterans in the realm of orthopaedic manual physical therapy (OMPT). Louie and Bill have received, as well as given, extensive education in basic to advanced OMPT technique. Here are their bios, as they appear on Baylor and UNLV DPT programs’ websites:
Louie Puentedura is full time faculty in the Baylor University Doctor of Physical Therapy Program. Dr. Puentedura is a seasoned clinician, he completed a Bachelor of Applied Science in Physiotherapy (1980) and a Graduate Diploma in Manipulative Therapy (1983) from La Trobe University in Melbourne, Australia. Since arriving in the USA, he completed a post-professional Doctorate in Physical Therapy (2005) at Northern Arizona University in Flagstaff, Arizona, and a PhD in Physical Therapy (2011) at Nova Southeastern University in Fort Lauderdale, Florida.
Dr. Puentedura has been an ABPTS board-certified Orthopaedic Clinical Specialist and a Fellow in the American Academy of Orthopaedic and Manual Physical Therapists for three decades. He completed 10 years on faculty as Assistant and then Associate Professor of the Doctor of Physical Therapy Program at the University of Nevada in Las Vegas. Dr. Puentedura has taught physical therapists and physical therapy students for more than 25 years and has published more than 60 scientific papers since 2010.
Dr. Puentedura has received several awards including the Rose Excellence in Research Award from the Orthopedic Section of the American Physical Therapy Association, the John Medeiros Award from the Journal of Manual and Manipulative Therapy, and presentation awards at the American Academy of Orthopedic Manual Physical Therapists Annual Conferences in 2012 and 2016. Follow Dr. Puentedura on Twitter and other social media @AussieLouie.
Dr. William (Bill) O’Grady earned his Bachelor of Science in physical therapy from California State University, Long Beach during 1972; his master’s from the University of Southern California during 1977; and his doctorate at the University of St. Augustine for Health Sciences in Florida during 2001. He completed three-year fellowship in manual therapy with the North American Institute of Orthopaedic Manual Therapy during 1995.
He has served on the board of directors of the orthopedic section for the American Physical Therapy Association, chaired the orthopedic specialty council and was an original item writer for the specialty exam. He was chairman of the board of examiners for the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT).
Dr. O’Grady has received many honors for his contributions to the profession including the John McMennell Service Award from AAOMPT, the Paris Distinguished Service Award from the Orthopedic Section, the Lucy Blair Service award, and the Catherine Worthingham Fellow of the American Physical Therapy Association. Dr. O’Grady retired from the U.S. Army in 2002 as a full colonel after 38 years of service. He was the first “Life Fellow” of the AAOMPT, and is a diplomat of the American Academy of Pain Management.
I have known of Louie and Bill for a number of years through literature and continuing education organizations. However, I first met the two of them at a pre-conference course for the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) in which they assisted Laurie Hartman DO, PhD. The course was on Osteopathic Manipulation. Dr. Hartman was the lead instructor, with Louie and Bill aiding in lab supervision and then providing instruction on technique and drills for practice. While their skills were evident from the get-go, their sense of humor and camaraderie with each other and the students were perhaps the most impressive. These “two amigos” are quite the pair. You can hear my previous conversation with Bill O’Grady here.
What: This book, as it’s name implies, is about thrust joint manipulation (TJM), also known as high velocity low amplitude thrust (HVLAT), for the spine. It includes seven chapters reviewing almost every relevant aspect regarding TJM for the spine.
Forewords were written by Laurie Hartman and Joe Farrell. Laurie is recognized internationally as one of the best manipulators in the world (at least, that is my impression) and has taught for close to 60 years on Osteopathic Manipulation. Joe Farrell is a physical therapist in the United States that is also a highly skilled, and highly respected clinician, that has dedicated his career to passing on knowledge and skills that he has developed over time. Both of these gentlemen are highly regarded among their peers as fantastic manual/manipulative clinicians and educators. To have them provide the initial words for this book says a lot about the content the reader is about to dive into, and sets the stage for what is about to come…
Chapter 1 – the focus of the initial chapter is history, plain and simple. Louie and Bill make great efforts to ensure the reader is aware the the practice of TJM does not belong to any one particular person or profession. Detailing how historical records indicate that TJM was utilized in ancient civilization to improve a persons pain/function. Other authors have detailed the founding of the osteopathic and chiropractic professions, and their use of TJM as the only means to “cure” the patient. However, Louie and Bill provide a much more detailed history of physical therapy (or physiotherapy outside the U.S.) and its use of TJM. As well as bringing the reader up to date throughout the 20th century in terms of who the key players were with instruction of TJM when it pertains to the physical therapy profession. Not just in the United States, but world-wide.
Chapter 2 – Do you like to read research and review literature? It is really tough to do sometimes, unless that is your thing. This chapter presents relevant literature (and there is a lot) related to the use of TJM. While that may be a turn-off for some readers (am I lumping myself into this category?), you need to not skip this! Louie and Bill really highlight where some research and literature have done well, but just as important, where many pieces of literature have come up short with their findings. Not only that, but what they could have done to be more beneficial for clinicians. It is important to understand on a basic level, the research that supports the use of TJM. In addition to this, validated (and some not validated) clinical prediction rules are reviewed to help the reader understand who may benefit from the use of TJM. One great way for an apprehensive clinician to gain confidence in using TJM is to first have a basic knowledge of who would likely benefit from it in the first place! Luckily, Louie and Bill take care of that here.
Chapter 3 – Safety should always be our first concern when delivering any intervention with patients. TJM is no exception to this. Bill and Louie do well to mention “Primum Non Nocere”, the phrase first mentioned by Hippocrates that means “First, do no harm”. Given the amount of publicity there is regarding thrust joint manipulation gone awry, it behooves any practitioner to learn about indications and contraindications. Here, large amounts of research are presented for the risks and side effects associated for each area of the spine (cervical, thoracic, and lumbar). This is a huge bonus and unique feature for this book because it significantly puts into perspective what could go wrong with TJM in each region of the spine. While catastrophic events related to TJM are horrific for both patient and clinician, the odds are insanely low of something like that actually happening. One of my favorite parts of this chapter is the “Putting the Risks of Spinal Manipulation into Perspective” section. A simple table illustrates how exercise (pick any form) and taking NSAIDs create a significantly higher risk for an adverse event when compared to TJM of any region of the spine.
Chapter 4 – Clinical reasoning is the focus in this chapter. Clinical reasoning, clinical decision making, and whatever else you want to call it are topics that have been significantly focused on in terms of graduate and post-graduate education. The way I think about it and have told others is “Hey, I can teach a monkey to do what we do… but it’s the why and when to do it that matters most”. That is just to say, that the reasoning behind what we do as TJM practitioners is as important as the performance of the techniques themselves. Louie and Bill give an impressive summary of research on the possible effects of TJM and why it works the way it does. For example, they report on the following in regard to clinical reasoning with TJM: a research evidence approach, biomechanical approach, neurophysiological approach, patient expectation approach, and pain neuroscience approach. In my opinion (not that you want that…) the truth as to why TJM works is likely a combination of all of the above. Bill and Louie do a nice job of not showing any bias in their presentation toward one approach or another, and just lay all the information out there for the reader to consume.
Chapter 5 – I affectionately call this chapter the “drills for skills” chapter. You really won’t see content like this in any other text or manual on TJM. Skills to improve hand speed, teaching the reader how to use large muscle groups to generate speed with small amplitude, and proper body position for different techniques are detailed here. For clinicians that have previous exposure and practice with TJM, but feel a bit “rusty” at times, this is the perfect adjunct to improve your skills without having a live patient in front of you.
Chapter 6 – This chapter focuses on various tests to perform prior to TJM. Some are tests that are performed on a routine basis, such as pre-manipulative holds, palpation and motion testing, and spring testing. Appropriate research is cited and discussed throughout the chapter. Another part of this chapter discusses “special tests” that may or may not be performed on a routine basis, but are important to perform in certain circumstances. These are broken down based on the region of the spine discussed. While there are special tests that are not included in this chapter (honestly, you could make an entire book on special tests throughout the spine), the ones mentioned are important and pictures accompany each test.
Chapter 7 – While this is likely a section that many readers may skip to because it describes and shows each technique in great detail, they would be doing themselves a disservice. The earlier chapters were so well-written and well-presented that the reader may “miss the forest for the trees” type of thing. What separates (again) this TJM text from others is how each technique is described. It’s not just a “here’s how to do it” description. No, many different details are included to help the reader problem solve any issue they may have with performance. Suggestions of what muscle groups dominate the TJM application and a section of “keys to success and fine tuning” are quite refreshing to see in a book of this magnitude. To accompany this section, the publisher (OPTP) has on its website video recordings of all the techniques. Two videos exist for each technique, one is a real-time recording as performed in the clinic, the second is a recording with voice-over detailing each step of the TJM performed. The videos and sound are high quality and are another great adjunct to this book.
Chapter 8 – The last chapter does well to bring this journey of TJM to a close. Bill and Louie go to great lengths to mention how the TJM technique does not belong to any one profession, nor should it! Thrust joint manipulation is a tool to help improve outcomes for our patients. In reality, it has never belonged to any one profession when you look at the history of it. Hopefully, readers will gain valuable insight from these chapters and use them in a safe and educated manner to improve the quality of life and overall function for their patients.
When: In regard to the question of when… the answer is undoubtedly NOW! Bill and Louie make a marvelous case that the skills taught within the pages of this book are designed for the young clinician, up to the seasoned clinician. For myself, having an interest in TJM ever since my initial education in DPT school, I’ve acquired a large number of books (both old and new) dedicated to this subject. I can certainly say with the utmost confidence that this book is truly unique in its presentation and content.
Where: Thrust Joint Manipulation Skills For The Spine can be located exclusively on the OPTP website at the following link – https://www.optp.com/Thrust-Joint-Manipulation-Skills-for-the-Spine
Why: The least selfish answer to the question of “Why should I bother buying and studying this book?” is easily answered early on in the book. Louie and Bill make a good case that patients benefit more when TJM is utilized, where appropriate. Need there be another answer when the most obvious one is that patients’ outcomes are better when TJM is employed (again, when appropriate)? Well, I’ll try and mention a few others. Not only are the types of techniques presented effective, but the manner in which they are presented is impressive. Particular detail has been given to ensure success for the reader. Next, the “drills for skills” presented in chapter five do a rather impressive job of answering the age-old question of “what can I do to get better?” TJM is a psychomotor skill that requires a lot of practice. Now, armed with the strategies from Louie and Bill’s book… that question is pretty darn close to being answered once-and-for-all.
How: No book like this is worth reading unless the person reading it has an idea of “How do I get good at doing what is in here?” Since TJM can require a lot of skill, as well as confidence, before utilizing as an intervention with a patient, practice is key. Luckily, the drills presented (as mentioned earlier) are a perfect place to start. Also, thanks to the extensive list of literature in chapter 2, the reader has a good idea of exactly which patients will benefit from TJM. Therefore, confidence is automatically built-in for the clinician-patient that TJM will be beneficial… so less apprehension on the clinician’s part. However, the reader would do well to fully understand who NOT to use TJM with… it just so happens that Louie and Bill include an entire chapter on this subject. Again, to help the reader gain confidence in using TJM for the benefit of their patients. Now, further equipped with drills to improve technique, knowledge of who will benefit from TJM, and knowledge of who NOT to perform TJM on, the reader should be much more comfortable utilizing the techniques presented in the book.