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…
A great short video from Tim Flynn about the opioid epidemic. Please watch and comment with your thoughts below!
Welcome to our first technique video!
The talo-crural distraction thrust is a technique that is utilized often for patients with ankle dysfunction. However, have you learned the biomechanical rationale and reasoning as to why this technique works? Or, what types of patients it will benefit the most? Dr. Thomason demonstrates which patients are appropriate for this technique and little modifications of patient positioning to make it more safe. Please comment or reply with your thoughts below!
Welcome to our second interview! This time, we speak with Erl Pettman. Erl is a former senior lecturer and chief examiner for the Orthopaedic Division of the Canadian Physiotherapy Association (CPA). He is also a co-founder of the North American Institute of Orthopedic Manual Therapy (NAIOMT), for which he still serves as senior instructor and chief examiner. In addition, Erl is an instructor for the post-professional Doctor of Science in Physical Therapy Program (DSc) at Andrews University, Berrien Springs, Michigan.
During our interview, we learned of Erl’s influences from a young person to pursue physiotherapy as a profession and how he got involved into manual therapy. Erl is a passionate individual for his profession, not just for treating patients, but for instructing other therapists as well. If you have not had an opportunity to learn from him, please consider as he has a wealth of knowledge not often seen in manual therapy. His approach to manual therapy is one that consistently uses biomechanical principles and functional anatomy to create the safest techniques of mobilization/manipulation, while being gentle and highly effective.
If you would like to learn more about Erl, please visit his website at http://www.erlpettman.com. On there, you will find a book that he has written on manipulation (DVD included). If you haven’t come across this book yet, check it out! I would highly recommend purchasing one to have in your clinical library (I do). Also, you could find out where he is teaching next on http://www.naiomt.com.
I hope you enjoy this interview. As always, please reply if you have any comments or questions!
Ever hear of the saying “The masters do the basics well”? I’ve certainly heard it quite a bit over the years. However, have you ever thought… ‘well, what are the basics?’
To me, the basics have to start with anatomy. We’ve all heard it, “you’ve got to know your anatomy!” If there is ever a common theme of all the expert clinicians that I have ever taken a course from, met personally, or heard speak… it is this one. Several points could be made about this, but one of the biggest reasons for knowing your anatomy well is that it helps your clinical reasoning.
For example, if you know your anatomy well enough, you could differentially diagnose the “carpal tunnel syndrome” patient that was referred to your clinic with an actual C7 radiculopathy; or recognizing the signs or symptoms of a basic posterolateral disc protrusion and prescribing McKenzie passive extension exercises (which will argubaly benefit them the most in the long run) at the initial visit; or perhaps even more important, understanding that the patient in front of you is not demonstrating a usual musculoskeletal presentation, and you are able to recognize this quickly and refer them back to their physician!
Please don’t misinterpret this post as lecturing readers as if I have a vast amount of knowledge of anatomy. I will be the first to tell you that I am no expert in it. However, I can say that I have a decent knowledge of anatomy. Also, I can tell you some of the habits that “experts” have in our field, so that hopefully you can be inspired to incorporate them into your own life.
First, everyone reading this post should own a Gray’s Anatomy. I do NOT mean the Gray’s Anatomy that is in some special collector’s packaging and is sold for $30 down at the local Barnes & Noble. That is an old version (the last American version made actually, circa mid-1910s) and is obviously outdated. No, the version I’m referring to is the British edition. It is in it’s 41st edition at this point and can be found here (https://www.amazon.com/Grays-Anatomy-Anatomical-Clinical-Practice/dp/0702052302/ref=sr_1_3?ie=UTF8&qid=1495605232&sr=8-3&keywords=gray%27s+anatomy). If you only have one anatomy book… this is the bible. While we are on the subject of books, I much prefer the Atlas of Anatomy by Theime over Netter’s. The pictures, information, and clinical pearls are much more helpful to me. You can find the latest edition of that book here (https://www.amazon.com/Atlas-Anatomy-Anne-M-Gilroy/dp/1626232520/ref=sr_1_1?ie=UTF8&qid=1495605330&sr=8-1&keywords=atlas+of+anatomy).
The second thing I’ve learned from those much smarter than myself is that they study anatomy every week, about two to three hours each week. For those who don’t want to do the math, that’s less than 30 minutes per day… doesn’t seem so daunting of a task now, does it?
Third, they usually subscribe to multiple journals, or check the content of their favorite journals and have ways to access articles. If you are wondering how to get access to articles for cheap, go down to your local library for goodness sakes and start there. If you live near a Universtiy… even better! If not, most alumni associations from our graduate schools have some sort of perk where they can get you articles pretty easily (usually they charge a small fee like $5 per article though). Not too bad if you REALLY want to check out something important.
Fourth, if they run into something that is puzzling them in the clinic… they go back to their anatomy books! Or, they search things out on journal search engines (remember Pubmed from school?). This may not be too earth-shattering as I’m sure a lot of us do this, but how many of us actually go back to look into anatomy texts and read information versus going to look at an atlas because it’s easier to just see a picture? I know I’ve certainly been guilty of this one!
Lastly, the great clinicians I’ve met so far are always thinking about what the anatomy of a given individual means FUNCTIONALLY. As an example, it’s of little use to know the origin/insertion of a muscle if you don’t understand it’s true function… let alone how to properly rehabilitate it. Take the hip abductors… is their main function to move the leg away from midline in an open-chain (in the coronal plane)? Many clinicians give patients sidelying hip abduction exercises, or even standing hip abduction exercises to work this muscle. That may certainly help improve the strength of it, if the patient can do it correctly. However, wouldn’t it make more sense that these muscles function in weight-bearing? Therefore, wouldn’t it make more sense to exercise it in weight-bearing through something like eccentric hip abduction? I didn’t figure this out on my own, but had to learn that from a mentor, but it has certainly changed how I think since then!
I know that most of you reading this post have already agreed with me that our knowledge of anatomy is paramount and that we could (and should) ALWAYS learn more. However, my purpose in bringing this up is to make suggestions for ways to achieve that if you haven’t already thought about it. Or, if you are a new clinician fresh out of school beginning to feel overwhelmed by the patients you are seeing. Again, I am no expert in anatomy… yet. But I have learned how to better myself. The rest is just putting in the work to read, listen, and learn.
What are your thoughts? Do you have any suggestions that I have not mentioned? Would love to hear from you!