PT 714 OMPT Lecture 2025

What is Orthopedic Manual Physical Therapy (OMPT)?

• Subspeciality of physical therapy

• Examination and intervention approach

• Emphasizes hands-on or manual skills to identify musculoskeletal impairments

• Impairments addressed with manually applied interventions, typically also with reinforcing exercises 

• Main goals of OMPT

  • Relieve pain

  • Restore movement

  • Optimize function

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“Orthopedic manual physical therapy is a subspecialty of physical therapy featuring a systematic active approach to the management of a broad spectrum of physical disorders.  Based on a patient-centered advanced clinical reasoning model taught in fellowship training, OMPT has key distinguishing characteristics that include expertise in hands-on iterative examination and treatment strategies inclusive of thrust and nonthrustmanipulation.  Essential to OMPT is a focus on continuous reassessment, through all aspects of care, synergistic application of carefully designed and dosed exercise, and a patient-centered long-term mindset driven by the available scientific and clinical evidence, and the biopsychosocial framework of each individual patient.

Army-Baylor Doctoral Fellowship in OMPT

• One of the first AAOMPT-recognized residencies in 1996

• Approved as a Doctor of Science degree program in 2001 by Baylor University

• Re-credentialed as a clinical fellowship in 2004

• Australian approach with exposure to MDT and Mulligan Concept

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Different from most fellowship programs … dual purpose … clinical fellowship and terminal doctoral degree program

150 hours of clinical mentorship

OMPT Interventions

• Joint manipulation (thrust manipulation)

• Joint mobilization (non-thrust manipulation)

  • Physiologic movement

  • Accessory movement

  • Muscle energy techniques

  • Mobilization with movement

• Soft tissue mobilization

  • Manual

  • Instrument-assisted

  • Dry needling

Well tolerated strategies for managing knee OA: article

• Reassessment: within & between sessions

• Exercise “dose” … FITT factors

• Prescribe minimal effective dose

  • Compliance decreases with complexity

  • Compliance increases with perceived value

• Attempt to prescribe exercises that have multiple effects

  • Reduces overall time to perform program

  • Improves compliance

• Home exercise timing

  • Perform active movement early in the day for reduced symptoms and reinforcement of improved movement through day

  • Perform strengthening later in day so patient isn’t fatigued by daily activity

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With the person sitting next to you, what are the key 1-2 take-aways from this article?

1. Doing the minimal but effective dosing – not doing more than we have to (minimleffective dose)

2. Tailoring the activity to the individual –

3. Choosing exercises with multiple effects (making sure that their HEP exercise can accomplish multiple goals so they are more compliant)

- what Dr. Crowell picked: paying it forward type stuff: concept of the reassessment – use it to know the overall treatment is working but it also shows what is giving the most benefit so you can do more of that than the useless stuff

Important concepts of the article

- reassessment

- minimally effevctive dose

- exercise with musciple effect

- develop a clear plan – ask them how they exercise then incorporate that into the program; if they don’t exercise add daily activities like getting up out of their chair at work

- you don’t need the complicated exercises to get extra benefit – simple is good

Evidence for Joint Mobilization/Manipulation (CPGs): lower quarter strong recommendation

• acute low back pain

• chronic low back pain

• hip OA

• acute ankle sprain

• chronic ankle instability 

• Plantar heel pain

Evidence for Joint Mobilization/Manipulation (CPGs): lower quarter expert opinion

• achilles tendinopathy

• non-arthritic hip pain

Clinical Prediction Rule for classifying patients with low back pain who demonstrate short-term, improvement with spinal manipulation

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3 treatments … initial, 2-4 days later, 2-4 days after 2^nd

*** Probability of success with 4 and 3 predictor variables present

This is a clinical prediction rule which shows the characteristics of the people that get better in a study. The found these 5 things (predictor variables)

Clinical Prediction Rule for classifying patients with low back pain who demonstrate short-term, improvement with spinal manipulation: predictor variables

• Duration of symptoms < 16 days

• FABQ work subscale score < 19

• At least one hip with > 35° of IR ROM

• Hypomobility in the lumbar spine

• No symptoms distal to the knee

Success = 50% reduction in ODI

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3 treatments … initial, 2-4 days later, 2-4 days after 2^nd

*** Probability of success with 4 and 3 predictor variables present

This is a clinical prediction rule which shows the characteristics of the people that get better in a study. The found these 5 things (predictor variables)

Clinical Prediction Rule for classifying patients with low back pain who demonstrate short-term, improvement with spinal manipulation: BEST RESULT

*** Best result when providing manipulation to those (+) on CPR

Exercise group = low stress aerobic and lumbar spine strengthening program.

Explain table …

What is clinically meaningful for knee OA

*** OMPT clinically meaningfully better than sham PT for knee OA

What is clinically meaningful for knee OA

*** OMPT (in-clinic) clinically meaningfully better than PT HEP only for knee OA

What is clinically meaningful for knee OA

*** OMPT clinically meaningfully better than steroid injection for knee OA

Detailed interview and physical examination to determine impairments and functional limitations + manual therapy techniques and reinforcing exercises

• Impaired movement

• Reduced strength

• Reduced flexibility

• Impaired motor control

• Manual therapy techniques and reinforcing exercises

  • Primary: knee region

  • Secondary: L-S, hip, foot/ankle

Evidence for Joint Mobilization/manipulation (CPGs): Upper Quarter moderate recommendation

• Acute Neck Pain (T-S mobilization)

• Chronic Neck Pain

• Rotator Cuff Disorders

• Lateral Elbow Tendinopathy

Evidence for Joint Mobilization/manipulation (CPGs): Upper Quarter weak recommendation

• Acute/Subacute Neck Pain

• Adhesive Capsulitis

• Carpal Tunnel Syndrome

*** OMPT no different from corticosteroid injection for subacromial impingement

*** Both groups with large, clinically meaningfully improvements in function

manual therapy to improve flexion/elevation or to improve external rotation

*** OMPT better than usual care for mechanical neck pain

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Manual therapy was better than usual care for mechanical neck pain

Interpretation of Manual Therapy Frequency & Duration

2x per week

3-6 weeks

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This is the actual answer for the past slide. This is for MANUAL THERAPY ONLY

Only need about 10-12 visits of manual therapy

Review of Manual Handling Basics (3 things)

• Expose areas to be examined

• Use your hands to feel throughout the examination and treatment

• Use your eyes for additional information

• Use appropriately slow and confident movements

• Use soft but as firm as required hand contact pressure

• Use large skin contact areas and padding as required

• Avoid pulling skin or hair, folding of skin, or putting pressure through your or the patient’s jewelry

• Do not put manual pressure over or through clothing

• Keep your fingernails trimmed short and filed

SINSS

SINSS: Severe/irritable what do you tell the patient

• Severe/Irritable

  • Tell the patient: “move until pain increases”

  • Limit examination

  • Examine to the first onset or change in pain

  • Select provocative special tests carefully

  • Be alert for red flags.

SINSS: Non-Severe/Non-irritable what do you tell the patient

• Tell the patient: “move as far as you can”

• Provide sufficient overpressure to determine end feel, note their pain onset and change through range and the quality of “end feel”

• If symptoms are not reproduced with the above tests, the objective examination can be taken further

  • Repeated movements or sustained movement

  • Combined movements

  • Functional tests

Reliability of manual exam 

Pain is more reliable than stiffness

Specific and purposeful treatment approach

ignore the red

Treatment decisions: my typical treatment sequence for most patients:

My typical treatment sequence for most patients:

• Initial evaluation: treat primary source of symptoms & reassess

  • Manual therapy

  • Reinforcing exercises (become home exercise program)

• Quickly address contributing factors

  • Therapeutic exercises (may add to initial home exercise program)

• Quickly address secondary problems

  • At subsequent visits

HEP

Home exercise program:

• Should directly compliment/reinforce your initial in-clinic treatment.

• Consists of 2-3 exercises that will maximize benefit.

Reassessment: what is reassessed? when are they reassessed?

• What is reassessed? à ASTERISKS

• When are asterisks reassessed?

  • WITHIN SESSION: immediately following application of the intervention and/or immediately following the treatment session

  • BETWEEN SESSIONS: prior to starting the next treatment session

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Example … low back pain … pain with running & pain with sitting

Special tests … straight leg raise

Assessment of change

• within-session change

• between-session change

• treatment decision

“Dosage” in physical therapy: exercise variables: to improve mobility

To improve mobility

• Sets & repetitions

  • More is better

• Load/resistance

  • Low-moderate

• Frequency per day

  • Frequently

• Total volume

  • High

• # of exercises

  • More is better

“Dosage” in physical therapy: exercise variables: to improve muscle force production

To improve muscle force production

*** Depends on the goal

• Endurance vs strength vs hypertrophy vs power

• Tissue loading

• Sets & repetitions

• Load/resistance

• Frequency per day

• Total volume

• Speed

• # of exercises

“Dosage” in physical therapy: manual therapy variables

• Sets & repetitions

• Grade of movement (load)

• Combined movement

• Compression/distraction

• # of techniques

Grades of Mobilization/Manipulation

Grades of Movement: other photo

Logical Line of Reasoning

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May have more than 1 logical line of reasoning for a patient … different components of the same disorder …

Manual therapy: small to moderate clinical effects, outcomes independent of, select procedures based on patient/clinician 

When administering spinal manipulative therapy to patients with nonspecific low back pain, targeting treatment to selected vertebral levels does not increase the overall effect compared to nontargeted spinal manipulative therapy.

Absolute Contraindications to Manual Therapy

• Systemic or localized infection (e.g., osteomyelitis)

• Acute circulatory condition

• Malignancy

• Open wound or sutures at the treatment site

• Recent fracture

• Hematoma

• Hypersensitivity of the skin

• Inappropriate end-feel (spasm, empty, and bony), or evidence of joint ankylosis, or joint hypermobility

• Advanced diabetes

• Rheumatoid arthritis (in a state of an exacerbation)

• Cellulitis

• Constant, severe, or extensive radiating pain, including pain at rest or that disturbs sleep, indicating that the condition is likely to be very irritable

• Any condition that has not been fully evaluated

Relative Contraindications to Manual Therapy

• Joint effusion or inflammation

• Rheumatoid arthritis (not in a state of an exacerbation)

• Presence of neurologic signs

• Osteoporosis

• Pregnancy, if a technique is to be applied to the spine

• Dizziness

• Steroid or anticoagulant therapy

Multiple effects

-Central nervous system

-Peripheral nervous system

-Musculoskeletal tissue

-Neural tissue

continue the current manual treatment, but reinforce need to perform HEP 

increase dose of current dose