What inspired you and Gregory Johnson, PT to develop Functional Manual Therapy®?
Early in our careers, Gregg and I realised we wanted to really take on those patients who did not get better in other places. We challenged ourselves to consider if there was more that we could understand about the functioning of the human movement system to better serve our patients. This introspective thinking drove us to develop a clinical reasoning system – FMT™—in which knowledge of science, anatomy and physiology is applied with intuition developed from pattern recognition.
I have heard you speak of pattern recognition. How is this concept incorporated into your patient care and the FMT™ clinical reasoning system?
“The intention to notice creates a library of reference which leads to pattern recognition.” (Saliba 2007). When mentoring and teaching, Gregg and I challenge each Physical Therapist to really consider how much you intend to notice about each patient that comes in every day. Are you absorbing as much information as possible about how they sound, feel, look and move like, and filing that away in your library with proper categorisation?
Every interaction with a patient should tell me something; what is not moving, what muscles are not working, what is driving the dysfunction, and how the brain is processing movement strategies. Then this information is filed in my brain. With repetition, a pattern recognition begins to develop. The more information the therapist can organise, the more it can be used when needed. A master or advanced clinician develops the intuition of pattern recognition and moves beyond the use of pattern matching.
What is the difference?
Pattern matching basically means A+B=C. Therapists learn pattern matching during Physical Therapy education so that they can match symptoms by acceptable methods of practice which require little experience to use. Pattern matching allows a new graduate to practice basic PT with little experience.
But many patients have complex problems that require more than basic skills. Our profession has grown so much in the last 60 years, integrating more science and research into our practice. Only using pattern matching is actually more like being a technician—as physical therapy was practiced in the 1970s and 1980s.
Developing pattern recognition requires repetition and utilisation of new techniques embedded within sound clinical reasoning. As a physical therapist learns and applies new ideas and techniques, he or she maintains the safety net of pattern matching but also develops a library of reference for pattern recognition. That equips them to make those “blink”–intuitive–decisions required for the treatment of more complex patient dysfunctions.
Even before we understood the science of pattern recognition, Gregg and I looked beyond basic interventions and challenged ourselves to see patterns that could guide us with more complex patient care. This focus on seeing patterns while applying knowledge and current science and research that drove the development of Functional Manual Therapy®. That is how the FMT™ system developed.
How has FMT™ expanded on the norm of PT care?
Throughout our career, Gregg and I have challenged the norm of physical therapy to continue to incorporate new understanding and knowledge into accepted treatment protocols. In the 1970s, before any other PTs were even considering the myofascial system, Gregg introduced Soft Tissue Mobilisation or the assessment and treatment of the myofascial system into the PT profession. Now is a standard of patient care. Likewise, we have led the way in training PTs to consider and apply the knowledge that alignment of structure dictates function. Building on years of clinical and empirical research, I developed and published the only valid and reliable postural classification system.
How did you do this?
We developed and published the Saliba Postural Classification System (SPCS) after a series of randomised control trials in which we showed that the SPCS has both reliability and validity. Reliability means when I assess your posture, there is a high statistical chance of assessing the same thing about this posture every time if you present the same alignment and I do the same correction every time. There is also high probability that other clinicians will assess your posture with the same classification. This reliability ensures that any therapist using SPCS will implement a similar postural treatment and intervention. Though there will be nuances in the art of the application, the clinical reasoning will be similar.
The validity of the SPCS was shown by demonstrating which alignment allowed the most efficient weight transference through the body onto a force plate without postural disturbance. With this validity and reliability, the six classifications in SPCS have made it very easy for clinicians to assess, and quickly realise what needs to be done and treat patients.
That leads to the basics of FMT™…
Yes. Simply put, we have three systems we treat in FMT™. One is the mechanical system which is how the body moves. The second is the neuro-muscular system which is how muscles function, whether they can contract, have strength endurance and can they let go. And finally, there is the motor control system or how the brain centre organises and controls that movement.
FMT™ addresses all three of these systems within every treatment. The ability of our joints and soft tissues to move is directly related to our brain’s ability to use the right muscles and the muscles responding appropriately to the brain’s signals. That is why we call FMT™ an inter-dependant systems approach. Each patient is treated with an understanding of the influence each system has on the other. All three systems are interdependent in order to be efficient, and their symbiotic relationship drives our analysis and understanding.
When we treat each patient with this understanding, our intervention ensures a more effective outcome. Many therapists teach patients how to cognitively change what they are doing, FMT™ facilitates a more automatic incorporation of efficient posture and movement into daily activities.
What is the difference between cognitive and automatic?
There are three stages of learning: cognitive, associative and automatic. We very often make patients do things or do something to them—that is, we give them cognitive tasks. But we don’t develop an associative relationship on a kinaesthetic level, an awareness of what they are doing. They should do things automatically like riding a bicycle or picking something up.
Too much of physical therapy does not even consider that associative stage, and keeps it cognitive—just instructions to the patient rather than getting them to feel it. That is more prescriptive rather than a process of helping the patients to get to the associative state that promotes automatic motor control. We focus on the associative learning stage.
What does a Physical Therapist trained in FMT™ do differently?
We teach our therapists to gather data by that “intention to notice”. Even when they just touch a patient, they gather information and use that to know immediately what intervention to do. We teach them to feel and identify efficient motion, whether it is passive, active and resistive, and know appropriate postures and movements.
We develop their communication skills so that they can get patients to have more efficient CoreFirst® strategies by showing them how it feels when they are doing something right or wrong. Communication skills coupled with great manual skills ensures the patient becomes a more active part of the team.
So that connect is crucial?
In FMT™, we really promote active patient participation. Our therapists dig deep to find a way to get patients to relate to something they feel, so that it connects. Once that connection happens, then the patients have an association with what we are trying to do. Then they can go home and practice, and reproduce it when they are not with us.
Until therapists make that connect, proreceptively, kinaesthetically, auditorily and visually, they cannot expect that patient to understand what and why they are doing what they are. Once that association happens the fact that FMT™ is different becomes evident to our patients!
The foundation of FMT™ Functional Manual Therapy® is a clinical reasoning system that directs the Physical Therapist to utilise advanced handling skills, advanced understanding of movement, and advanced mobilisation techniques to offer comprehensive treatment and care for any patient care, especially complex patient diagnosis.
How does FMT™ tie in with the orthopaedic versus neurological approach?
In neurological impairments, the primary dysfunction is driven by either a problem in the central nervous system (CNS) or the peripheral nervous system (PNS). PNS is the system that carries impulses from the brain and spinal cord to the muscles to help them do their job. So any impairment there is very different from a problem in the CNS which is the brain and spinal cord. MS and Parkinson’s are diseases of the CNS; PNS diseases include diabetic neuropathy. The question is, what do we do to address the needs of such patients?
The FMT™ trained Physical Therapists at Vardan dig really deep to discover a neurologically impaired patient’s potential. And then they utilise their skills to maximise the patients’ potential to live more efficiently.
What is FMT’s approach to neuro patients?
We treat neuro patients as orthopaedic patients with a neurological dysfunction. We improve their mechanical system first, then their muscles are strengthened so that the brain can communicate with a more efficient body again. Our PTs will watch how any patient functions and then decide on the intervention.
So the validity and simplicity of FMT TM makes it the right choice?
Yes! One Institute of Physical Art (IPA) senior faculty once said that “FMT just makes sense! Why were we not doing this before?” The simplicity of FMT™ actually allows the complexity. When something is in itself very complex there is no room for manoeuvrability and change. But if it is simple and there is strength in its system, there’s a lot of space to be creative within that structure.