In a previous post (Back to the basics…) I mentioned how important our knowledge of anatomy is when considering characteristics of what makes someone a “master” clinician.
This time, I want to mention a another characteristic of what makes someone a “master” of manual therapy (especially mobilization/manipulation of joints)… and that is the understanding and application of biomechanics. Now, I know that I am speaking from a position of bias because I believe understanding biomechanics of the human body is of huge importance when talking about the subject of manual therapy. This bias comes from some of my manual therapy training and previous mentors, which emphasize this understanding. Perhaps it can be summed up best by paraphrasing an explanation from one of my instructors along the way… the safest and most effective manual therapy techniques (be it mobilization or manipulation) take into account the movements that the body does naturally. In order to understand what the body does naturally during any given movement, a knowledge of osteokinematics and arthrokinmaetics is vital.
If you would indulge me for just one explanation. Take, for example, the most dangerous manipulation that we hear about in literature and public conversation… a high velocity low amplitude thrust (HVLAT) technique to the atlanto-axial motion segment. One thing that is perfectly clear in the literature across multiple professions is how end-range, rotational thrusts to this segment cause the most damage in the arterial structures that pass by them. Now, certainly there are plenty of clinicians that utilize this technique successfully and their patients do not get injured. However, if you have a good understanding of the arthrokinematics of this area… why would you choose to mobilize/manipulate in such a way when it is proven to be harmful to so many people? In my humble opinion, a much safer way to go about improving movement at this segment would be to perform the HVLAT along the direction of the joint glides (arthrokinematics): either an antero-inferior or postero-inferior direction. That way, when combining appropriate locking techniques, you minimize stress to the surrounding structures because you are thrusting in a direction that the segment normally goes in to. In the first technique (end-range, rotational thrust), it is performed essentially as an osteokinematic movement (rotation) that is dis-regarding the arthrokinematics of the segment. Therefore, placing undue strain on very sensitive tissues.
That technique is perhaps the most important reason why biomechanics and a good understanding of them, matters! If clinicians are educated in mobilization/manipulation to some degree or another and have not been presented with such a technique mentioned above as an option, there are plenty of organizations that teach this. Heck, I might just do a short video on the arthrokinematics of this area at a later time, just to show you here. However, if you have been educated on a much more appropriate and safer technique… and then choose to continue using a more potentially dangerous technique (as stated in literature), then one could easily argue that those clinicians are negligent!
Wow, let me take a step down from my soap-box for a few moments. Whew!
All of this is not to say that there aren’t good manual therapists out there that do not routinely think about the biomechanics of whatever part of the body they are treating. I mean, can any of us give a detailed explanation of the biomechanics of fascia in any particular part of the body? This is certainly an area of manual therapy that is fascinating, yet not understood completely (however, there are amazing amounts of research coming out every year about the fascial system). I know amazing therapists, with gifted hands, that rely more-heavily on “end-feel” when using manual therapy techniques, and do not think much about biomechanics. So, can you be a very skilled manual therapist without “using” biomechanics of osteo- and arthro-kinematics? Sure, definitely! However, I would argue that you wouldn’t be as effective and safe as you could be (for reasons mentioned above).
For another example… we all have patients that have limited mobility of the hips, right? I’m sure everyone reading this post and following this blog have found limited movement with hip extension. An appropriate part of your treatment plan would be to improve that mobility for the betterment of that patient’s function. Okay, do we all agree on that so far? Now, how would most of us normally go about improving that movement? We could perform different stretch techniques (whether passive, active, resistive), soft tissue techniques to the hip flexors, or even mobilization techniques to the hip joint itself. All would likely improve the movement of hip extension. I’ve done all of those before and been successful, as have all of you. Although, not until recently did I better understand how mobilizing (with a good application of biomechanics knowledge) the hip for improving extension range, can actually be more effective at improving mobility of the hip itself. Because, unless you are a perfect clinician and everything you do works as you plan, you have to admit that there are times when we’ve tried the above techniques and it didn’t work like we thought it would… I know I have! I’ve done all the soft tissue mobilization on psoas, anterior thigh, abdomen, etc. Done all the mobilizations and stretches for the hip too, in many different directions and planes. For those patients that didn’t respond by gaining the significant range that I expect… oh well, it must be just a really stiff hip! Now that I’ve been taught (and finally learned how to apply it) what the hip joint does during this movement (hip extension), my mobilization to regain it has been much more effective. And yes, I still use all the other techniques mentioned above to improve this movement! So… stayed tuned for a video explaining this technique and what I am talking about!
I once asked a friend and mentor of mine, who were the best manipulators that he has known or seen? He named four people. Three of whom have/had an extraordinary knowledge of biomechanics and how to apply them to different regions of the body. The fourth person has a good knowledge of this subject and utilizes it to some degree for their techniques, but chooses to focus their teaching on other aspects instead of the biomechanics. All four also have a great sense of touch. I use this as an example to say that, again, biomechanics and a good understanding of them are important. They are a basic knowledge that we are taught in school. And, from what I’ve seen and encountered… the “masters” have a good knowledge and understanding of this subject. More importantly though… the masters know how to APPLY their knowledge into their techniques!
What do you think? Would love to hear your thoughts below…