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MPACe l eb r a t i ng 40 yea r s

1 9 6 6 - 2 0 0 6

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APA MissionThe APA is the peak body representing the physiotherapy profession in Australia. We advocate for equitable access to quality physiotherapy and optimal health care for all Australians. We assist our members to provide quality physiotherapy through professional excellence and career success.

MPA MissionTo be a world-recognised leader in the field of musculoskeletal health.

APA VisionAll Australians will have access to quality physiotherapy, when and where required, to optimise health and well-being.

MPA VisionTo advance the health and well-being of the community through our leadership, knowledge, skills, and expertise in the field of musculoskeletal physiotherapy.

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C o n t e n t s

Celebrating 40 years (1996-2006) 2MPA National Chairman, Michael Ryan considers the past and future of MPA.

A revolutionary era 4 MPA members, Dr Dale Larsen and Associate Professor Pat Trott, reflect on the proud history of musculoskeletal physiotherapy and MPA, and acknowledge the pioneering physiotherapists who have contributed to their development.

MPA Distinguished Members 7We celebrate our MPA Distinguished Members’ contributions to musculoskeletal physiotherapy and MPA.

Balancing the art and the science 10MPA members, Darren Beales and Dr Darren A. Rivett look at the balance of art and science in musculoskeletal physiotherapy whilst discussing where MPA has come from, where it is, and where it wants to go.

MPA Celebrating 40 years 1966-2006MPA Celebrating 40 years 1966-2006 is

an official commemorative magazine

of Musculoskeletal Physiotherapy

Australia (MPA), a National Special

Group of the Australian Physiotherapy

Association. All materials in this

publication are covered by copyright

and must not be reproduced without

written permission.

Cover: Elizabeth Moorfield and

Helen Boursinos

Editor

Amanda Wilson

Design

Perry Watson Design

Prepress

CJM Graphics

Printing

M Print

Published by Musculoskeletal

Physiotherapy Australia, Australian

Physiotherapy Association.

Level 3, 201 Fitzroy Street

St Kilda Victoria 3182

Tel (+61 3) 9534 9400

Fax (+61 3) 9534 9199

mpa@physiotherapy.asn.au

Copyright © 2006

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The history of manual or manipulative physiotherapy in Australia dates back to the early years of its worldwide evolution in the 1950s.

However, it was not until the mid 1960s when the formal education of manipulative therapists began, under the guidance of Geoffrey Maitland and his colleagues. It was also during this decade, in 1966, that the Manipulative Therapists’ Association of Australia (MTAA), later known as the Manipulative Physiotherapists’ Association of Australia (MPAA) and now known as Musculoskeletal Physiotherapy Australia (MPA) was formed. Created by those physiotherapists with a special interest in the management of neuromusculoskeletal conditions by way of manipulative therapy, admission to the MTAA was permitted only after completion of a clinical examination or the formal course at The University of Adelaide. From the beginning a focus on quality was evident and acknowledged as critical for the development of the profession and our group.

Over the years, standards of education, of clinical and profes-sional practice, and programs of mandatory peer reviewed continuing

education have been established, monitored, and redeveloped by our group. Clinical research and the publication of documents such as the Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders and the various Evidence-Based Clinical Statements have continued with strong MPA involvement, with their international appeal and relevance testimony to their inherent quality and to the robust international position of MPA.

The history that records our achievements is indeed a proud one: our international recognition, the many professional and clinical developments, and the ongoing relevance of membership to one of the largest special interest groups of the APA is due essentially to the

people involved within MPA. Our history as a group is not born of a significant, or ‘dramatic’ incident, but instead is one of evolution. This is thanks to the ongoing

C e l e b r a t i n g 4 0 y e a r s ( 1 9 6 6 - 2 0 0 6 )F o r e w o r d b y M i c h a e l R y a n

This ye�r sees Musculoskelet�l Physiother�py Austr�li� (MPA) cele�r�te 40 ye�rs.

Perh�ps fittingly, given the long �nd proud history of our group �nd the signific�nt

w�ys in which we h�ve contri�uted to the �ro�d evolution of our profession

�nd to the Austr�li�n Physiother�py Associ�tion (APA) �s � whole,

we cele�r�te this milestone �s the APA cele�r�tes its centen�ry.

The first ye�r of the Gr�du�te Diplom� M�nipul�tive Ther�py Course �t Cum�erl�nd College of He�lth Sciences, University of Sydney, �979.B�ck row L – R P�m S�v�ge, Lyn H�rmond (lecturer), G�et�no Mil�zzo (lecturer), Jo McCormick, Ro�yn Brewster-Jones, Trish McIntosh, Mel� Cook, P�m Ro�erts.Front row L – R Jenny Pynt, P�ul H�wkins, Adel� Mills-D�vis, M�rg�ret M�tthews.

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commitment and dedication of many individuals. It is because of these individuals that our group has grown, progressed, and flourished to the point where we can be self-indulgent enough to celebrate 40 years. It is with our appreciation that we quite rightly celebrate this significant milestone. Many of the tremendous and important developments in our profession and indeed in the discipline of manual, manipulative, or musculoskeletal physiotherapy have resulted from the endeavours, input, involvement, and leadership of MPA members and volunteers. Many of those individuals to whom MPA owes this debt of gratitude are acknowledged in this publication, but others are not.

I think it a natural corollary to consider where one is going when one takes the time to look back at where one has been. One can argue that it is in fact because of this strength of history, and of course because of the ongoing and omnipresent goodwill of many passionate MPA volunteers, that I feel very confident that our future will be as exciting and proud as our past. MPA stands at the coal face of development in our profession, now as then. The critical issues facing the physiotherapy profession are those facing MPA and our members. Issues of work force and staffing demands, the development of the Extended Scope Practitioner role, and its many

applications, the development of specialisation within our broader profession, and within its disciplines, the ongoing challenges of ensuring our persistent place and relevance in the Australian health care setting, and the need to contribute to ongoing reliable and relevant research are all exciting and important matters in which MPA continues to be involved, in the proud tradition of those who have gone before us. It is this pioneering spirit, ubiquitous in the history of MPA that continues to guide us in the development of our profession.

The years roll on and, as becomes increasingly obvious, times change. What has not changed throughout the 40 year history of our group, is an underlying commitment to quality. Whatever MPA is involved in, whether it is helping physiotherapists ensure the best of care for their patients, ensuring and contributing to relevant representation within and outside the profession, or assisting with broad professional development, MPA now, as then, is committed to quality. In this year of our 40th birthday we salute and give thanks to those who have gone before us, acknowledging their commitment to quality, and the steadfast shoulders that they have provided on which we can stand, and look confidently into the future.

Gr�du�te Diplom� M�nipul�tive Ther�py students, University of Sydney, �980.L – R G�et�no Mil�zzo (lecturer), Lyn H�rmond (lecturer), Neil Munro (student), Bri�n Edw�rds (ex�miner) �nd P�ul Kelly (student).

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The emergence of manual or manipulative therapy as a discipline within Australian physiotherapy occurred in the late 1950s. During this time, early

tuition was provided for physiotherapists by medical practitioners, such as Dr James Mennell (UK), Dr James Cyriax (UK), and Dr Charles Hembrow (Australia). Dr Cyriax broadened the teaching of manipulative techniques in England, and conducted teaching courses in both Australia and New Zealand. Several international doctors and physiotherapists whom he educated returned to their home countries to instruct colleagues in manual therapy techniques. These physiotherapists included Freddy Kaltenborn from Norway, and two Australians, Jeanne-Marie Ganne and Marie Hammond, both of whom returned to teach manual therapy at the School of Physiotherapy at The University of Adelaide. They were later joined by the revolutionary musculoskeletal physiotherapist, Geoffrey Maitland.

It was at The University of Adelaide in 1965, where the development of Australian manual therapy education began. This saw the introduction of an annual three-month course in spinal manipulation, conducted by Geoffrey Maitland under the auspices of the APA. This course later evolved into a 12-month postgraduate diploma in manipulative therapy, which was first offered by both the Western Australian Institute of Technology and the South Australian Institute of Technology, in 1974.

A r e v o l u t i o n a r y e r aB y D r D a l e L a r s e n a n d A s s o c i a t e P r o f e s s o r P a t T r o t t

As Musculoskelet�l Physiother�py Austr�li� (MPA) turns 40, we commemor�te

its proud history �nd �cknowledge the pioneering physiother�pists who h�ve contri�uted to

its development. From its origin �s the M�nipul�tive Ther�pists’ Associ�tion of Austr�li� (MTAA),

MPA h�s evolved to �ecome one of the l�rgest N�tion�l Speci�l Groups within the APA.

With � current mem�ership close to �,000, it h�s in�rgu��ly e�rned � position �s � recognised world

le�der in developing st�nd�rds for musculoskelet�l educ�tion, pr�ctice, �nd rese�rch.

Dr Ch�rles Hem�row. Freddy K�lten�orn.

A�ove: L – R Je�nne-M�rie G�nne, Ruth Gr�nt, �nd M�rie H�mmond.

Left: Geoffrey M�itl�nd with P�t Cosh, He�d of School, Lincoln Institute (now L� Tro�e University).

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The development of such manual therapy education was groundbreaking as these were the first postgraduate manipulative therapy programs to be conducted by tertiary institutions in the world. It was not long before this phenomenon grew and within a decade similar postgraduate programs were offered by the Lincoln Institute of Health Sciences in Melbourne, Cumberland College of Health Sciences in Sydney, and The University of Queensland.

Throughout the late 20th century Maitland’s concepts continued to profoundly influence the development of manual therapy within Australia and internationally. Many of his pupils including Gwen Jull, Pat Trott, Ruth Grant, and the late Brian Edwards made significant physiotherapy contributions and led educational programs in their respective states.

The Maitland approach was characterised by an emphasis on careful and comprehensive examination, continuous assessment, and evaluation of the patient as well as the use of a highly sophisticated art of joint mobilisation. This assessment, with its focus on the identification of soft tissue or joint restriction as a source of dysfunction represented a substantial change for the profession, which had previously relied on the use of palliative modalities (e.g. shortwave diathermy) and general exercises. The relative gentleness of Maitland’s passive mobilisation techniques, compared with the thrust methods espoused by Dr Cyriax, promoted the acceptance of mobilisation into both under and postgraduate programs in the Schools of Physiotherapy.

It was Maitland, along with Brian Edwards, Pat Trott, and Roger Wilson, who was responsible for the formation of the MTAA in 1966. Qualification for entry was based upon successful completion of either The University of Adelaide’s three-month course in spinal manipulative therapy or a challenge examination. These requirements ensured all members held a high standard of competency in manipulative therapy.

Entrance requirements changed over the years. In 1980, at a time when postgraduate manipulative therapy programs were available in all Schools of Physiotherapy, MTAA membership required the successful completion of a 12-month postgraduate program that included peripheral as well as spinal manipulative therapy.

Today we are witness to further changes. All physiotherapists in Australia, who are members of the APA, are able to join MPA through three levels

of membership: Level One, Level Two, and Level Three. Requirements for Level Two membership consist of having completed an approved Masters level postgraduate manipulative or musculoskeletal program, or the Alternative Pathway to Title Program. Level Three membership is restricted to APA Musculoskeletal Physiotherapists who have successfully completed the requirements for admission to the Australian College of Physiotherapists.

Entrance requirements were not the only thing to change throughout the years, with the MTAA altering its name twice. Shortly after becoming a National Special Group of the APA in 1970, the MTAA adopted the name Manipulative Physiotherapists’ Association of Australia (MPAA) before being renamed

Musculoskeletal Physiotherapy Australia (MPA) in 2001.As the education of manual therapy evolved in

Australia, so did its practice. This was highlighted by the MTAA being instrumental in the formation of the International Federation of Orthopaedic Manual

Therapists (IFOMT). Following much debate (and determination on the part of Stanley Paris in the USA), detailed documentation requesting the formation of the group was approved at the World Confederation for Physical Therapy (WCPT) Congress held in Montreal in 1974. The

three IFOMT consultants who had deliberated over these negotiations were Gregory Grieve (UK), Geoffrey Maitland (Australia), and Freddy Kaltenborn (Norway). In 1978, IFOMT became the first Special Interest Group of the WCPT; a status that assisted member nations gain greater acceptance for manipulative therapy within the physiotherapy profession.

Prior to the formation of IFOMT, there had been comparatively little exchange of manual therapy knowledge at an international level. The leaders within the profession who had developed their own concepts quickly became regarded as ‘gurus’ and there was considerable animosity between practitioners who adhered to different schools of thought. With the emergence of more sophisticated educational

‘ C o n f e re n c e d e l e g a t e s, i n c l u d i n g t h e p re s e n t e rs, f e l t t h e y w e re a t t h e f o re f ro n t o f p ro g re s s i n g

t h e k n o w l e d g e a n d c l i n i c a l p ra c t i c e o f m a n u a l t h e ra p y.’

St�nley P�ris.

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programs and regular international meetings, the opportunity for manual therapy knowledge developed, where new concepts could be presented and challenged. Bob Elvey and later Gwen Jull became the Australian representatives on IFOMT. Bob served two terms as IFOMT President and made a significant contribution to the standards of academic and clinical practice. In 1980, Australia was one of the first countries to be granted full membership status of IFOMT; a reflection of the high standard of practice embedded within MTAA membership.

Throughout the past 40 years, the maintenance of academic and clinical standards has been a high priority for MPA. From the MTAA’s inception, an Academic Standards Committee was incorporated into its organisational structure with academic leaders, with a passion for maintaining high standards (Brian Edwards, Pat Trott, and Mary Magarey) elected as chairs. Further commitment to these standards was shown through the development of a formal mandatory continuing professional development program introduced in 1983, outlining requirements to maintain membership.

The inaugural professional development conference of the MTAA was held in Sydney in 1978, with 98 per cent of the MTAA’s membership base attending. Thirteen papers were presented followed by the Annual General Meeting (AGM). Conference delegates, including the presenters, felt they were at the forefront of progressing the knowledge and clinical practice of manual therapy. And indeed they were. The success of this conference ensured they would be held biennially, with Adelaide to host in 1980. The MPA Conference has developed over the years to offer high quality concurrent programs, with an excellent mix of scientific research that underpins the practice of musculoskeletal physiotherapy, and workshops demonstrating and teaching the application to clinical practice.

The patient examination and management skills currently taught at such conferences and in musculoskeletal physiotherapy, have evolved from the established concepts of neuromusculoskeletal management proposed by many physiotherapists, medical practitioners, other musculoskeletal

practitioners, and authors. These include those from overseas such as Dr James Cyriax, Alan Stoddard, Gregory Grieve, Freddy Kaltenborn, Robin McKenzie, Brian Mulligan, and Shirley Sahrmann. Within Australia, Geoffrey Maitland has made the greatest contribution to the field of clinical assessment, but significant advances in the management of neuromusculoskeletal dysfunctions are attributed to the works of Dr James Cyriax, Gregory Grieve, Freddy Kaltenborn, Alan Stoddard, Robin McKenzie, Brian Edwards, Bob Elvey, Gwen Jull, Jenny McConnell, Brian Mulligan, Ruth Grant, Pat Trott, Mark Jones, Carolyn Richardson, Julie Hides, Paul Hodges, Gregory Schneider, David Butler, Peter O’Sullivan, and Shirley Sahrmann. This list is not exhaustive and does not include those researchers who have chosen to investigate the efficacy and effects of musculoskeletal physiotherapy that arose as a consequence of the ideas and concepts proposed by the physiotherapy pioneers of manual therapy.

Upon reflecting on our proud history, we anticipate what the future holds. Those who have practiced before us have provided us with a strong base from which we can continue to grow and flourish. We, as contemporary primary contact practitioners dealing with clients with problems attributed to disorders of the neuromusculoskeletal system, must be accountable for our clinical decisions. We must do so in an environment that presents competing demands and constraints, including evidence-based practice, an information explosion in the health sciences, funding restrictions, and ethical issues.

For the discipline of musculoskeletal physiotherapy to remain viable in the 21st century and beyond, practitioners must be cognisant, and adaptable to new knowledge from basic and applied research. We need to be critical of the available evidence yet at the same time remain reflective of the way in which various treatment hypotheses and protocols are presented and evaluated. In this environment physiotherapists have a necessity of becoming more holistic in patient care. Our pioneers have established a solid foundation of skilled clinical reasoning, enabling us to practise autonomously, to make clinical decisions collaboratively, and to apply new knowledge to support sound patient-centred clinical practice.

In our 40th year, we salute those who have gone before us, thank them for their hard work and foresight, and look forward to what the future holds for our profession.

A full list of references w�s supplied for this �rticle �nd �re �v�il��le from MPA upon request.

Gwendolen Jull with P�ul Hodges, upon his receipt of the Young Austr�li�n of the Ye�r Aw�rd �997.

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M P A D i s t i n g u i s h e d M e m b e r s

Since MPA’s inception 40 ye�rs �go, titled mem�ers of MPA who h�ve m�de �n outst�nding �nd

distinguished contri�ution to musculoskelet�l physiother�py, �nd to MPA, h�ve �een �w�rded

Distinguished Mem�ership (formerly known �s Life Mem�ership) of MPA, �y their fellow mem�ers.

We �re delighted to p�y tri�ute to these MPA Distinguished Mem�ers.

Geoffrey Maitland has made an unparallel contribution to musculoskeletal physiotherapy in Australia and internationally. Geoffrey’s

practice and teaching of careful and thorough patient assessment and the application of gentle passive oscillatory techniques to reduce pain and to restore joint mobility were largely responsible for manual therapy being routinely taught to under and postgraduate students in many countries. In 1965, he developed and taught the first three-month program in spinal manipu-lative therapy in Adelaide, and the following year was one of those responsible for the formation of the MTAA.

In recognition of his leadership and service to musculoskeletal physiotherapy Geoffrey has received many awards, with highlights being a MBE in 1981, and the Mildred Elson Award, bestowed by WCPT for outstanding international leadership in physiotherapy, in 1995. Further achievements include the publication of two seminal works, Vertebral Manipulation, and Peripheral Manipulation, and the honour of being the only physiotherapist to hold two fellowships of the Australian College of Physiotherapists (Fellowship of the College by Monograph, 1979 and Fellowship by Specialisation in Manipulative Physiotherapy, 1983).

Geoffrey’s work has contributed immensely to the knowledge base of our profession and countless students will be forever grateful to him for revolutionising their careers.

The late Brian Edwards is remembered for his vision and dedication to the development of manipulative physiotherapy in Australia and internationally.

He developed a method of manipulative therapy called Combined Movements — a system of examination and treatment that married the basic sciences of spinal movement, mechanics, and pain to clinical application. This technique is now used worldwide and considered a vital component of any manual spine examination.

Brian was responsible for setting up the first physiotherapy course at The University of Notre Dame and was instrumental in making the first manipulative therapy tertiary program in the world, Postgraduate Manipulative Therapy at Curtin University of Technology, world-renowned. Some of his other firsts included becoming one of Australia’s first three APA Musculoskeletal Physiotherapy Specialists, by examination, and working as the first physiotherapist at both the Subiaco Football Club and the West Coast Eagles. He was also involved in establishing the MTAA.

During his career, Brian received many accolades: the Order of Australia Medal (OAM) in 1992, for his contribution to physiotherapy and Legacy and an Honorary Doctorate of Science by Curtin University of Technology in 1995, for his services to education.

He also took on the roles of National President of the MPAA (1968-1971), Standards Committee Chairman of the MPAA (1981-1983) and Fellow of the Australian Council of Physiotherapy (1984).

Geoffrey MaitlandAwarded MPA Distinguished Membership, 1991

Brian Edwards (1941-2003)Awarded MPA Distinguished Membership, 1993

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Pat Trott has played an important and sustained role in musculoskeletal physiotherapy and MPA. Pat spent 40 years at the School of Physiotherapy,

The University of Adelaide, where she climbed the academic ladder to become Associate Professor, and Head of School. During these years she developed the curriculum and taught the musculoskeletal program of the undergraduate course. It was here, with Geoffrey Maitland, that Pat developed the curriculum of the Graduate Diploma in Advanced Manipulative Physio-therapy (later converted to a Clinical Master program).

Pat’s list of achievements are extensive including: founding the MTAA; National Vice President of the MTAA; National Academic Standards Committee Chair; National President of the APA; Chief Censor and Secretary/Treasurer of the Australian College of Physiotherapists; and Director of the Physiotherapy Research Fund.

Pat retired officially in 2000, but continues as an Adjunct Associate Professor supervising PhD, Masters and Honours students in her areas of research expertise, namely vertical spinal creep and thumb disorders related to the practice of passive mobilisation.

Robert Elvey, now retired, has made quite an impact on musculoskeletal physiotherapy and MPA through his many roles, including:

President of the MTAA (1981-1983); APA representative to IFOMT (1981-1984); President of IFOMT, for two terms (1984-1992); Senior Lecturer and Co-ordinator, Master of Manipulative Therapy, at Curtin University of Technology (1990-2003); and, Member of the Professional Services Review Committee (1995-2004).

Over the years, some of Robert’s educational interests focused on the ability to recognise and describe the primary pathology leading to a disorder, disorder diagnosis and classification, and intervention delineation basing a clear distinction between treatment and management.

He was also involved in the research of intracapsular pressure gradients of the lumbar zygapophyseal joint with passive movement as a means to hypothesising the affects of passive mobilisation procedures of treatment, and the primary role of the peripheral nervous system in very selected and specific disorders of regional pain and movement dysfunction of the periphery.

Ruth Grant has made an important contribution to musculoskeletal physiotherapy in Australia and internationally. Throughout her career,

she has held academic and clinical appointments in Australia, Canada, and the United Kingdom.

She has performed various roles including: Chief Physiotherapist at The Alfred Hospital in Melbourne; Senior Lecturer, Head of School, Dean of the Faculty of Health and Biomedical Sciences; Pro Vice Chancellor of the Division of Health Sciences, and Vice President, Health Sciences at the South Australian Institute of Technology (SAIT) — now known as the University of South Australia. At this University she supervised the school’s first PhD student to successful completion, was the inaugural Co-ordinator of the Honours

students, and taught research methods to postgraduate physiotherapy students. Some of her greatest achieve-ments whilst at SAIT were being awarded a personal chair in physiotherapy, in the process becoming the first female professor in the University’s 100 year history, in 1989, and being bestowed the title of ‘Professor Emeritus’ for her outstanding contribution to the University and her profession, in 2002.

Her research interests concentrated on the area of blood flow in the vertebral arteries and the effects of it on neck position and cervical manipulation. It was as a result of this research that she, with help from others, developed a protocol for ‘Pre-manipulative Testing of the Cervical Spine’, which was endorsed by the APA. (The Clinical Guidelines of today had their genesis in that early protocol).

Ruth retired in July 2002, but continues to make a significant contribution to physiotherapy nationally as Chair of the Australian Physiotherapy Council and locally, through her Chairmanship of the Physiotherapists Board of South Australia.

Pat TrottAwarded MPA Distinguished Membership, 1993

Robert ElveyAwarded MPA Distinguished Membership, 1997

Ruth GrantAwarded MPA Distinguished Membership, 2005

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Gwendolen Jull has made her mark on musculoskeletal physiotherapy and MPA. Over the years Gwendolen has held many roles

including: National Vice President of the MPAA (1980-1984); President of the MPAA (1985-1987); Chairperson of IFOMT Educational Standards Committee (1990-2004); and President of the Australian College of Physiotherapists (1998-present).

Over the years Gwendolen’s principal areas of research have concentrated on the field of spinal pain, particularly the cervical spine including headache and whiplash associated disorders. Her research has ranged from the pathophysiological mechanisms in the cervical motor and sensorimotor systems to the development and testing of research based management methods.

Throughout her career, Gwendolen has also contributed to national and international journals, text books, and conference presentations in the field of musculoskeletal physiotherapy.

Greg Schneider has maintained a prolonged contribution to MPA through clinical practice, education, research, and committee

involvement. Throughout his career, Greg has amassed almost 40 years as a private practice principle. He has spent over 22 years imparting the philosophy and practice of manipulative physiotherapy through his role as a clinical supervisor and lecturer, by delivering papers at MPA and IFOMT Conferences, and to the Spine Society of Australia. In 1998, he was awarded Specialist Title, and in 2002, membership of the Spine Society of Australia.

Greg’s research aims were to define a subgroup of the low back pain population that could be identified clinically, and correlated with a biomechanical basis. Research over 15 years established these criteria for lumbar instability, with the work culminating in a Masters of Medical Science, and a 2005 publication in Spine. Greg is currently enlarging this work. He has also commenced research into the stiff painful shoulder, for which ethics approval has been granted.

APA Musculoskeletal Physiotherapy SpecialistsFor many years, the pinnacle of physiotherapy achievement in Australia has been the attainment of Specialist status, through fellowship by specialisation or monograph of the Australian College of Physiotherapists. Currently five of the current 13 members of the College are APA Musculoskeletal Physiotherapy Specialists. MPA pays tribute to these members by recording their names and year of fellowship below.

Geoffrey Maitland, 1979 and 1983Pat Trott, 1983Brian Edwards, 1983Gwendolen Jull, 1988Greg Schneider, 1998Peter O’Sullivan, 2005

MPA Honorary MembersMPA recognises those persons who are not eligible for MPA membership, but who have nonetheless contributed significantly to the field and/or knowledge base of musculoskeletal physiotherapy. These persons, often of a distinguished position in their own field, have been awarded Honorary Membership (formerly known as Honoured Membership) of MPA.

Nikolai BogdukArthur BurnellBrian CorriganMarie HammondEdward ScullLance Twomey

Gwendolen JullAwarded MPA Distinguished Membership, 2000

Greg SchneiderAwarded MPA Distinguished Membership, 2003

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B a l a n c i n g t h e a r t a n d t h e s c i e n c eB y D a r r e n B e a l e s a n d D r D a r r e n A . R i v e t t

As we cele�r�te 40 ye�rs of Musculoskelet�l Physiother�py Austr�li� (MPA), it is timely to reflect upon

the ��l�nce of �rt �nd science in our profession, not just �y looking ��ck on where we h�ve come from,

�ut �lso �y �cknowledging where we �re, �nd envis�ging where we w�nt to go.

Physiotherapy is inextricably linked to science. We require a science degree to be registered to practice. Arguably, however, physiotherapy is a ‘soft’ science

where there are few, if any, real absolutes. This is where the art of clinical practice begins.

The dark agesThe origins of musculoskeletal or manipulative physiotherapy practice are rooted in the ‘cookbook’ approach. Condition A required Treatment X. Conditions B, C, and D also needed Treatment X. Heat and massage, heat and massage. This is no slur on the practitioners of that time. This was simply how things were done. There was generally little need for art or science as the wisdom of the referring doctor obviated any such need. One ‘cookbook’ constituted the physiotherapy library of clinicians and students in these simpler, but unenlightened, times.

The renaissanceThe shortfalls of the ‘cookbook’ approach, combined with a groundswell of inquisitive minds, led to a fundamental shift in the practice of musculoskeletal physiotherapy. Practitioners began to develop more advanced communication and interview skills, facilitating higher levels of interaction with their patients. An inevitable consequence of this was a greater emphasis on the analysis of the patient’s subjective status. Changes in communication occurred not only in the verbal domain, but also in the physical. There was a proliferation and refinement of hands-on assessment techniques, with physical communication between the patient’s spine and the therapist’s hands whilst performing passive intervertebral motion assessment an outward display of this. Some hands-on assessment

techniques were gathered from around the world and other disciplines. Others were conceived by Australian manipulative physiotherapists of that time, many of whom are now rightly considered visionaries of the profession. Treatment techniques progressed in a similar fashion. Re-evaluation became more critical in determining the clinical value and role of each intervention.

Concurrent with these changes, clinical reasoning skills underwent a ‘growth spurt’. Practitioners applied a more critical approach to all aspects of patient management. Hypotheses about elements of clinical management were developed, tested, and refined both within and between patients. As an offshoot of these practices, diagnostic and treatment decisions became more specific and based on the patient’s individual clinical signs and symptoms. The art of manual therapy came of age. The ‘cookbook’ began to gather dust.

In retrospect, two events stand out as landmarks of this time. In 1964, the first edition of Geoffrey Maitland’s, Vertebral Manipulation, was published.

Geoffrey M�itl�nd (right) with Greg Schneider, Sydney �980.

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This seminal work championed a high level of clinical reasoning prowess as well as a new level of technical proficiency. Its impact on manual therapy specifically, and musculoskeletal physiotherapy in general, has been immeasurable both locally and internationally.

The second event was the congregation of a number of like-minded clinicians which culminated in the formation of the group now known as MPA. A primary function of this group during its formative years, which included Geoffrey Maitland, Brian Edwards, Pat Trott, and Roger Wilson, was to foster the growth of this new clinical approach. In short, it was a forum with the goal of nurturing and disseminating the art of manual therapy. However, these forbears were not blind to the need to rationalise their approach. The art was also to evolve with a scientific basis.

The industrial ageAnd so we went to work, blending the art, and the science. Many fine examples of this fusion exist. If you have observed some of the messes entry-level physiotherapy students produce when learning patella taping, you would have come to the realisation that taping the patella is an art. Jenny McConnell utilised all the aforementioned skills in developing a new approach to anterior knee pain. Now we have the science in the form of mechanistic studies, and randomised control trials (RCTs) that support this approach. In New Zealand, Brian Mulligan’s SNAGs, MWMs and other acronymic techniques evolved from this mixture of advanced clinical reasoning, high level technical skills,

innovation, and dare we say perhaps with the help of a small ‘miracle’. The science is following: neural tissue pain provocation testing, motor control interventions in the lumbar, and cervical spines. The list goes on.

The information ageWe now find ourselves entrenched in the era of evidence-based practice (EBP). External bodies now mandate this. Fortunately the foundations of musculoskeletal physiotherapy, led us in this direction long ago, along with some ‘gentle prodding’

from one of our Honorary Members, Nikolai Bogduk. This has placed our profession in a strong position to negotiate the requirements of the present climate. However, we must tread with caution and not throw the baby, that is the art of manual therapy, out with the bathwater, that is those procedures that lack unequivocal scientific evidence. But has this era already resulted in the pendulum swinging too far: away from the art, past a balance of art and science, to rest on the science?

Unfortunately the term EBP has become synonymous with RCTs, systematic reviews, and meta-analyses. The limitations of these methodologies are becoming more apparent. However, in some quarters contemporary practice of musculoskeletal physiotherapy has arguably already become distorted by such a strict interpretation of EBP. As a case in point, a physiotherapy student with little or no clinical experience vehemently questions the clinical supervisor’s choice of mobilisation technique, stating there is no evidence in the form of a RCT for the use of that technique. This might seem extreme, but does appear to be occurring. In another example, an insurance company employee dictates the number of treatment sessions (found in an evidence-based ‘cookbook’?) a musculoskeletal physiotherapist is permitted to manage a patient with low back pain, a very common practice in other regions of the world and starting to appear in this country.

It is enlightening to learn that a systematic review of RCTs published in the British Medical Journal failed to find any evidence to support the assumption that parachutes prevent death and major trauma. The authors concluded that, ‘Everyone might benefit

MPA Honor�ry Mem�er, Nikol�i Bogduk.

Bri�n Mullig�n.

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if the most radical protagonists of evidence-based medicine organised and participated in a double-blind, randomised, placebo-controlled, crossover trial of the parachute’. We cannot help but agree with this conclusion at times. What these protagonists fail to recognise is that most patient problems are multifactorial and RCT results are unlikely to match a given patient presentation sufficiently to use in a prescriptive manner. Even Sackett, the guru of EBP, states that, ‘Without clinical expertise, practice risks become tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient’.

Where does this strict adherence to EBP leave us? Would our esteemed colleagues of ‘The renaissance’ been able to stimulate the development of the profession in such an environment? Will adherence to EBP limit our thinking and close the avenues to new approaches? Is this environment counter-productive to the development of advanced manual therapy technical and clinical reasoning skills? Will the proud Australian ‘art’ of manual therapy survive?

The futureNevertheless, there is good reason to be optimistic about the future of musculoskeletal physiotherapy and MPA for the next 40 years. Musculoskeletal conditions are

the result of complex interactions between physical and non-physical factors. As such, every clinical presentation is unique. Patients will respond to the same intervention in varying ways because of the interaction of physical and non-physical factors. Also, it is quite likely that there is a genetic predisposition for response to treatment. Certainly pharmaceutical companies are pursuing this line of research. Recognition of individuality of clinical presentation and treatment response necessitates the survival of the art of musculoskeletal physiotherapy.

For this to occur, and for musculoskeletal physiotherapy to continue to flourish, the pendulum must be balanced between the art and the science. This is acknowledged in the APA Vision for Physiotherapy 2020, ‘Evidence-based management is integrating individual clinical expertise with the best available external clinical evidence and patient values’, i.e. balancing the art and the science. And importantly, ‘The best available external evidence is not restricted to randomised controlled trials and meta-analyses’.

This indeed then is our challenge as MPA reaches middle-age. A challenge spelt out by an artist, albeit an artist in a different field:

‘Every child is an artist. The problem is how to remain an artist once he grows up’.

(Pablo Picasso)

A full list of references w�s supplied for this �rticle �nd �re �v�il��le from MPA upon request.

MPA National Chairs honour board

Brian Edwards 1969-1971

Daniel Rosen 1971-1973

Paul Kelly 1973-1975

Peter Smith 1975-1977

David Neill 1977-1981

Robert Elvey 1981-1985

Gwendolen Jull 1985-1987

Tony Grace 1987-1989

Chris Gaughwin 1989-1991

Judy Furey 1991-1993

David Malone 1993-1995

Cameron Lawson 1995-1997

Trudy Rebbeck 1997-1999

James Schomburgk 1999-2001

Debra Shirley 2001-2004

Michael Ryan 2004-