Promoting orthopedic manual therapy(omt) in north america:
In 1968, Stanley Paris, a physical therapist, recently immigrated from New Zealand, wanted to promote manual and manipulative therapy in the United States. He set about forming the North American Academy on Manipulation Therapy. In attendance at the first organizational meeting were Cliff Fowler and John Oldham, Canadian co-founders of the Canadian Orthopaedic Division of the Canadian Physiotherapy Association. Interest in manual therapy was growing and in 1971, Paris and Oldham invited Freddy Kaltenborn to the United States and Canada. Now, in addition to the Paris and Canadian courses, enthusiastic therapists interested in expanding their manipulation skills and knowledge base could participate in courses offered by Kaltenborn as well1.
One such therapist was Erl Pettman. Pettman qualified as a Physio Therapist after completing his education at the Nottingham School of Physiotherapy (England) in 1972. He moved to North America in 1974 with his wife and settled in British Columbia, Canada where his journey into the world of manual therapy began. Although he had a deep grounding in anatomy and biomechanics, he had no experience in manual therapy and no Level I knowledge such as basic assessment concepts, selective tissue testing, and referred pain, etc.
Erl took his first orthopedic manual therapy (OMT) course from John Oldham in 1975. John Oldham, Cliff Fowler and David Lamb were huge contributors to the world of OMT as founders, instructors, and examiners of the Canadian Orthopedic Division of the Canadian Physiotherapy Association. They had recently (1972) created Upper and Lower Scanning Examinations using Cyriax's philosophy as their framework. John was amazed that Erl had no knowledge of Cyriax. Having just bought the newest edition of Cyriax's 'Textbook of Orthopaedic Medicine', John gave Erl the book (still in its wrapper) and said, "This will change your life and career". He was right. The book was the epitome of anatomical and clinical logic. It was the seed that would help Erl develop concepts in Clinical Reasoning. Erl had further courses over the next 3 years from Cliff and Dave. These three men were his original mentors and the four became lifelong friends.
Erl continued to advance his clinical skills with newly arrived Freddie Kaltenborn and Olaf Evjnth in what was known as the Nordic OMT system. He ate up their biomechanical model and their manual precision, especially in manipulation. It was their emphasis on safety and localization of techniques that made him a skilled enough manipulator to feel the confidence to later write his book “Manipulative Thrust Techniques”.
THE NORIDIC OMT SYSTEM:
Although the Kaltenborn-Evjnth Approach was just being introduced in the United States and Canada, it had been developing over the last 30 years. Freddy Kaltenborn had been trained as a physical educator, athletic trainer, and then a physical therapist in the 1940’s. His training included mobilizations, primitive manipulative thrusts, and exercise. However, many of Kaltenborn’s patients reported they got better results when they sought chiropractic care. However, because chiropractic concepts were not part of the traditional practice of medicine, the doctors at that time would not support it in physical therapy. Therefore, Kaltenborn started to look elsewhere for further training. He found two doctors in London who were unusual in that they were committed to training physical therapists in manual medicine. These were Dr. James Mennell and Dr. James Cyriax. Dr. Mennell had written several books on physical treatments and joint manipulation. Dr. Cyriax had written on an approach to soft tissue discorders with a specific evaluation and treatment system. Kaltenborn observed Dr. Mennell’s mobilization techniques and studied with Dr. Cyriax for 2 years. Upon returning to Norway and demonstrating his skills, the Medical Association for Physical Medicine cosponsored him to teach the Cyraix approach in 1954. 2
Cyriax came to Norway in 1955 to examine the therapists who had completed instruction with his approach. Kaltenborn and the therapist that he had taught formed the Norwegian Medical Manipulative Group. 2The regional and nonspecific treatment techniques used by this group changed significantly in the 1950’s with the contributions of Albert Cramer and Alan Stoddard(whom Stanley Paris also trained with). They were medical doctors who also had chiropractic and osteopathic training respectively. They taught specific spinal techniques. After studying under Stoddard, Kaltenborn became an instructor certified in both Chrioropractic and Osteopathy. Cyriax, Stoddard, Cramer, and Kaltenborn worked together pulling evaluation and treatment tools from osteopathy, chiropractic, and orthopedic medicine, to determine which techniques should be taught in the Norwegian Medical Manipulation Group. 2
Kaltenborn then began incorporating his own techniques and theories into this system and it became know as the Kaltenborn Method. Some of the specific ideas that he brought to the system was the concave-convex rule, the emphasis on translator(linear) joint movements in relation to the joint plane during evaluation and mobilization treatment, using grades of movement, using three-dimensional positioning prior to joint movement, protecting the joints around the specific segment being treatment, ergoniomin principles for protecting the therapists, and teaching self-treatment. Kaltenborn emphasized biomechanics and functional evaluation of the locomotion system. He added treatment techniques aimed at pain relief, stretching connective tissues(of joints and muscles), and relaxing muscle spasms. He started teaching all these ideas in his courses in 1960 to therapists in the Nordic counties. 2
KALTENBORN-EVJENTH APPROACH:
In 1968 Olaf Evjenth, OMT, another skilled clinician from Norway, joined the group. Evjenth’s training was in physical education, athletic training, and physical therapy. He expanded the concepts with specialized techniques for muscles stretching and coordination training. He believed in more intensive training that assessed performance. He put strong emphasis on developing equipment for home treatment, but also for egonomic innovations that allowed for more effective treatment, while being less stressful physically for the therapist. He also modified exercises so patients could do mobilization, stabilization, and stretching independently at home. Evjenth also introduced symptom provocation testing and symptom alleviation testing as a method to help localize lesions and improve the specificity of the evaluation. The Kaltenborn-Evjenth Concept also taught that multiple techniques could be used in the same treatment session, as well as how to sequence those treatments for the best outcomes. 2
Central to the Kaltenborn-Evjenth approach is the emphasis on restoration of the gliding component of a normal joint and a treatment plane is defined as the plane across the concave joint surface. Manual translatory techniques include traction, compression, and gliding techniques. Traction and compression are performed perpendicular to this treatment plane, whereas gliding techniques induce movement parallel to this plane. Mobilization and manipulation techniques are used to reduce pain and increase ROM. In this system, joint restrictions are classified as periarticular, articular, intraarticular, or combined in etiology. Periarticular restrictions owing to adaptive shortening of neuromuscular and inert structures (including skin, retinacula, and scar tissue) and articular structures (capsule and ligaments) are treated with sustained mobilization techniques. Periarticular restriction due to arthrogenic muscle hypertonicity is managed with neurophysiologic inhibitory techniques including thrust techniques. Intraarticular restrictions are best treated with (traction) manipulation initiated from the actual resting position. 3
Kaltenborn always felt that it was a good philosophy to incorporate useful tools from other approaches and acknowledges that benefits of the many contributions of physical therapists and physicians around the world. In 1974, Kaltenborn, Maitland, Stanley Paris, and Gregory Grieve found the International Federation of Orthopedic Manipulative Therapy (IFOMT). Through the forums held by IFOMT, the Nordic OMT System has been able to continue to expand with contributions from other representatives from other systems, and encompass a complete arthro-neuro-muscular approach to manual therapy.2
THE DEVELOPMENT OF THE CANADIAN SYSTEM:
Erl Pettman took this same integrated approach. While under the mentorship of John Oldham, Cliff Fowler, and David Lamb, he studied with Kaltenborn, and Evjenth. Erl was also professionally influenced by James Cyriax, Alan Stoddard, Fred Mitchell Jr., Greg Grieves, Geof Maitland, Robin McKenzie, Stan Paris, Wendy Aspinal, Bob Elvey, Dave Butler, and Nick Bogduk. From his mentorship, training, studies, Erl formed an eclectic system incorporating what he felt was the best of the best from each of these systems, along with developing his own theories and techniques such as the manubrial test, the figure of 8 testing for cervical spine integrity, and homer’s test for the knee. Using everything he'd been taught, he was able to realize that many conditions, especially chronic ones, did not occur in isolation. Rather, patterns began to emerge that pointed to the highly integrated connections between regions. For example, shoulder problems that originated from lesions in the neck, or breathing dysfunctions, thoracic lesions, and jaw dysfunction associated with poor posture.
At the request of many colleagues, Erl began teaching OMT courses in Canada in 1977. Erl’s goal was to assist new, as well as experienced therapists, in acquiring, enhancing, and applying manual and manipulative therapy, in a safe, efficient, and effective manner. His emphasis was on the application of biomechanical principles and clinical reasoning skills in the enhancement of assessment and treatment techniques.
Erl went on to produce Canada’s first eclectic OMT course in 1979, The Upper Quadrant Course, where he linked postural and spinal dysfunction to upper limb dysfunctions. Erl presented the Upper Quadrant course in front of the faculty of the Canadian Orthopaedic Division of the Canadian Physiotherapy Association. Among the attendants were David Lumb, Cliff Fowler, Anne porter-hoke, and John Oldham.
A year later, he went on to introduce the Lower Quadrant course along similar lines and with a similar emphasis. Erl managed to convince his colleagues in the Canadian Orthopeadic Division, that after teaching the Level I course, they should switch to Level II and III quadrant courses, reflecting their new grasp of neuro-musculo-skeletal pathology. This new structure became the basis for a three-month manual therapy course in Western Canada. These two courses would become the precursors to the Level III Upper and Lower Quadrant Courses taught today by both the Canadian Orthopaedic Division, the North American Institute of Orthopaedic Manual Therapy (NAIOMT), and ASPIRE OMT. In 1981, utilizing the ‘Quadrant’ concept as its theme, Erl constructed and organized Western Canada’s first long-term OMT course with clinically supervised practice. Erl also managed to convince an up and coming therapist, Dianne Lee, to teach these courses. Dianne Lee would become an internationally known, and well respected, therapist.
THE FORMATION OF NAIOMT:
Increasing interest in the ‘Canadian System’ of OMT from a number of American friends saw Erl, Dave, and Cliff teaching increasing numbers of courses for U.S. manual therapists. Erl decided he needed to come up with a more inclusive name for the system that respected it presence on both sides of the boarder. So, Erl developed the North American Institute of Manual Therapy, or ‘NAIOMT’. As the system rapidly grew in popularity, he recruited Jim Meadows to teach with him. To help teach and develop a proper curriculum, along with a policies and procedures manual, they then recruited Ann Porter Hoke. Gradually, as numbers continued to swell, Erl began to develop a faculty. Among the first were Bill Temes, Steve Allen, Kent Kyser, Kathy Stupansky, and Gail Malloy. This core group became the shareholders when they incorporated NAIOMT in 1992. It continues as a leading light in US post-professional education, one of the few that can bestow its graduates a Fellowship in the American Academy of Orthopedic Manual Physical Therapy (AAOMPT).
PROFESSIONAL RESPONSIBILITIES:
Erl became an Examiner for the Canadian Manual Therapy Examinations in 1980 and he was Chief Examiner from 1982-2002. Erl has also been a certified manual therapy instructor for the Olaf Evenjth system since 1990. His chapter on Upper Cervical Instability was published in Modern Manual Therapy, 2nd Ed 1992. Furthermore he has presented papers at IFOMT Proceedings in 1984, 1988 and 1992. In 2006 Erl published his first book….’Manipulative Thrust Techniques’. Since 1994, Erl has served as adjunct faculty for Andrews University. Erl’s relationship with Andrews University began when Kathy Berglund asked him to help teach an Advanced Master’s degree, which he was extremely happy to do. Very quickly, this program was converted to a DSc degree. In 2019, with great honor, Erl accepted an Honorary DSc from Andrews University for his years of outstanding contributions to the field of manual therapy.
THE FORMATION OF ASPIRE:
After 28 years within the NAIOMT system, there were many changes that were taking the institute in a direction that was outside of the initial goals. Erl decided to establish a new institute that was more faithful to his original ideal.
ASPIRE was formed in 2020, during the covid-19 pandemic. Erl established a system where the many instructors he had mentored over the years, could join him in formulating this new venture. He wanted to empower them to bring this system to the next generation of students and clinicians. His goal was for each instructor and student to feel valued, appreciated, and mentored to continue to grow as clinicians, educators, and to allow the passion for manual therapy to flourish.
Erl has not only been influenced by his instructors and mentors, but by his students as well. He welcomes questions and discussion that keep him digging deeper. He encourages his students to become life-long seekers and innovators. His faculty, students, and colleagues alike appreciate his dedication to passing on the torch as a clinician, instructor, and mentor. In his book ‘Manipulative Thrust Techniques’, Erl quotes Isaac Newton as saying “If I have seen further, it is by standing on the shoulders of giants”. ASPIRE faculty strive to carry on this sentiment, by both appreciating our mentors, and by mentoring the next group of aspiring manual therapists.
FACULTY REFLECTIONS:
Erl Pettman has always been much more than a NAIOMT and ASPIRE founder, faculty instructor, examiner and mentor. He has brought his personal touch into every course weekend and cared wholeheartedly about the students learning, as well as about their families, and other important personal life matters. His distinct mastery for blending storytelling, the finer particulars of applied anatomy, and the intricacies of clinical reasoning are beyond any other professional learning experience I have encountered. Erl’s principles of a comprehensive examination followed by the ‘art & science’ of OMPT blended into precise manual techniques have brought years of clinical success stories under his wonderful guidance. I am eternally grateful and enthusiastically give my sincerest thanks and support to Erl Pettman and his faculty comrades that opened their arms as mentor, guide, and friend to me along this most successful professional journey. - Bruce A Franke Jr
Relationships. If there was a class titled Relationshipology, Erl Pettman would certainly qualify as the Distinguished Professor for the course. Over the past 4 decades he has studied the intimate relationships between anatomical structures and their contribution to the functional movement of the human body. Erl’s insatiable hunger to understand the biomechanical and neuromuscular relationships throughout the “whole person” is unparalleled. His comprehensive understanding of embryology allows him to expound on the life-long relationships throughout the human body, which are formulated at the stage of the embryo, when life begins. For decades, Erl has explained the “relationships” (now coined Regional Interdependence) between these structures drawing students and colleagues, alike into exploring this design. At the age of 72, he continues to build upon the knowledge, uncovering yet more relationships, which are often biomechanical or neurophysiological in nature. Every finding, undoubtedly confirms that the neuromusculoskeletal system of the human body was magnificently created to “work together” purposefully and intentionally.
Sitting in Erl Pettman’s course is life-altering. He unquestionably challenges the status quo. He welcomes the engaged student questioning “why” over the compliant student. He inspires the participants to use the relationship between their mind, eyes and hands. Minds that seek truth by utilizing specific analytical skills and clinical reasoning based on foundational knowledge with eyes engaging in careful observation and hands trained to palpate movement. Yet, perhaps the relationship most difficult to explain isn’t actually how a forward head posture could lead to a second metatarsal stress fracture, rather how a teacher could believe more in you than you actually do in yourself. Great teachers and leaders, like Erl, foster relationships to help others see their true potential which propels them further down a path than they dared travel alone. A respected mentor believing in students more than they believe in themselves is counter-cultural in today’s society which is self-promoting.
Anyone can take an online course and get knowledge but without that relationship, that mentoring and the empowerment that you can do it, the knowledge is USELESS. However, if you take a course from Erl, he gives you the knowledge and equips you in the belief that YOU CAN DO IT while offering life-long mentorship. Erl Pettman has an open invitation to a community of empowerment where individuals who ASPIRE excellence are equipped with the tools, as well as the confidence that together they can accomplish far greater than ever imagined alone. - Valerie Coolman
I met Erl 25 years ago in Canada during my manual therapy training studying from many amazing therapist , Diane Lee, Cliff Fowler. But it was him where I felt I was instantly hooked, it was a combination of wisdom , knowledge a sense of humor and last, but not least his caring loving personal way of teaching. When he had his hands on my neck demonstrating a technique I realized how less is more and precision is more important than force.
The Canadian system is a blend of many other systems from around the world without any dogma. I believe that ASPIRE is also follows this tradition and aiming to be a constantly evolving system. Anybody who has a chance should experience Erl’s class and teaching. I can only hope to ever be half as good a teacher and clinician as he is. - Erika Fabian.