Manual Therapy Forum
Inspiration, Education, and Empowerment
Application of biomechanics to hip extension mobilization
In our latest video, Dr. Thomason explains biomechanics of the hip joint for sagittal plane motions (i.e. a pure spin). Then he demonstrates a highly effective mobilization to regain loss of hip extension using this biomechanical knowledge. Watch and add your comments below to tell us what you think!
So you’ve just taken a con-ed course… now what?
Have you ever taken a continuing education course and wondered… now what? Learning different or new assessment/treatment techniques and seeing the benefits of them during a weekend course can be simply life-changing to some. But let’s face it, your partner over the weekend isn’t normally like the patients you are going to be seeing on Monday when you return back to work. So, for some of us, doubt starts creeping into our minds of “can I really do this with the type of patients I see?”
The answer is of course, YES! Some of the instructors I get to teach with always end the course with suggestions of how to retain the titanic amount of information that was taught over the weekend, and how to continue practicing and refining your skills with new concepts that were learned. The following are suggestions that have been helpful for many over the years.
First, when it comes to assessment techniques (i.e. PIVMs, position/motion assessment, joint glides, functional tests, neural tension, etc.) choose something… anything. Dedicate just a few minutes of your appointment time with EVERY patient for the next day or two and perform that assessment on all of them. You don’t have to treat anything, just see what you find. That way, you get a ‘forced practice’ time on many different people in a short amount of time. After that day or two, pick another technique and do the same thing. Write down your findings somewhere for each patient. If you repeat this habit pattern, pretty soon, you will have gone through the entire weekend course material and have re-practiced it all! In case you are wondering whether a patient will say anything as to why you are assessing a part of their body that seemingly has nothing to do with the reason they have been attending your treatment… explain how important the ‘kinetic chain’ concept is for their diagnosis (which is not a lie and is in all likelihood a true statement), and you want to see how it could be effecting their dysfunctions.
Second, during your coursework, if you were also taught how to use different forms of mobilization (or even manipulation), educate your patient as to what you found in your brief assessment. If it is appropriate, and they agree, perform the technique to correct the dysfunction you previously identified. You already explained to them how important this is in helping improve their function, so hopefully they will be on board. After treating a dysfunction, see how many different things it effected for that patient. For example, see how treating their ankle effects their gait, how treating their pelvis can change their shoulder range of motion, or how treating their coccyx can change their neck range of motion (yes, this can happen). Again, over days and weeks, you will have practiced virtually everything you learned during your continuing education course.
Third, one thing that really helps advanced clinicians is pattern recognition. The ability to recognize common patient presentations and relate them to past experiences can really speed up your clinical decision making. Create (and write out) typical patterns of presentation, whether you have seen these patients or not. If you haven’t seen a particular diagnosis, look up in textbooks or online resources those typical patterns. That way you can develop a bank of clinical scenarios that you can play mental gymnastics with (or perhaps ‘clinical calisthenics’ would be a more appropriate term?) [Pettman]. As you review these cases and their usual presentations, pattern recognition will be much easier for you in the clinic (again… even if you have not actually seen the condition yourself).
Fourth, think back on previous patients you have had (i.e. reflection). Do more ‘clinical calisthenics’ with those patients and what you may have done differently with them, with your new knowledge. It’s always a good idea to look back on your successes (and failures) in the clinic to see what your clinical reasoning was, why you made the decisions you did, was your technique performed correctly… and what could you have done differently that may have given your patient a better outcome.
Lastly, if the clinic you work at has inservices, present some of the material you learned at an inservice. If you don’t have inservices, take charge and start organizing some! Choose topics that you are more comfortable with presenting and do that once every week, or every other week. That way, you are able to practice, but you also will have to review it enough to present the topic to your colleagues. Again, over time you will have reviewed the whole weekend course. And, it really makes you learn and practice your topic. Because, in order to teach something effectively, you have to be somewhat skillful at it!
In summary: yes, you can incoporate new material you learned over a continuing education course into your every day practice; yes, it will take time to get comfortable with it (and good at it); and yes, you will actually have to practice these things to get good at them. Think of it this way, if you are willing to spend your time and money (whether you pay for it, or your employer does) away from home for a few days to learn something new/different… I hope you would devote further time in or outside the clinic to develop the skills that were taught to you. Otherwise, why go in the first place?
Professor Laurie Hartman DO, PhD
Our latest interview is with Professor Laurie Hartman. Laurie is Associate Professor of Osteopathic Technique at the British School of Osteopathy, and has been teaching osteopathic and manipulative technique and manual therapy since 1964. He has taught and lectured in 17 different countries with osteopaths, physiotherapists, medical manipulative groups and chiropractors. Laurie has also authored the book “Handbook of Osteopathic Technique”, one of the best books on manipulation that you could find.
In this interview, we get to learn how Laurie decided to become an osteopath and enrolled in the BSO at a very young age! In addition, Laurie discusses his earliest mentors and how he got into teaching. Laurie also brings to light his approach and thoughts regarding manipulative techniques (plus advice he would give to any and all practitioners of manipulation).
If you would like to learn more about Laurie, please visit his website at http://www.lauriehartman.co.uk. On his website, you will find his book and DVD series regarding the techniques that he teaches. As much as I had recommended Erl Pettman’s book on manipulation, I would equally recommend this one (as well as the DVDs since they detail every technique in the book)! And yes, I do own Laurie’s book/DVDs as well.
Hopefully, you will enjoy this interview as much as I enjoyed it! Please, leave any comments or questions you may have below!
Cheers!
Matt
Back to the basics… again
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…
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A great short video from Tim Flynn about the opioid epidemic. Please watch and comment with your thoughts below!
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