In clinical practice, there are many ways to skin a cat. Why is that? Because there are many different types of cats with many different types of ailments! Our job as clinicians is to use solid clinical reasoning, good investigative questions, and tests to try and determine which levers to pull or inputs to provide to accelerate recovery.
It has never made sense to me that people argue whether we should be using manual therapy or exercise, a hands on or hands off approach etc. Doesn’t it depend on the individual patient we are working with? As clinicians, shouldn’t we strive to understand the human body as much as possible to maximize our methods of creating positive change? Over the years I have prioritized education with some patients and specific therapeutic exercise with others. General conditioning guidance is at times top priority while an extra moment of active listening and empathy may be the fastest opening for positive change in others. Manual therapy can facilitate quick changes in function and at times moves to the top of the list of possible levers to pull. Each individual patient needs a different input or combination of inputs to create their optimal healing environment, and it is our job as clinicians to solve this puzzle.
In order to best serve our patients we need to:
1. Have a solid framework for information gathering and organizing to understand our patients and categorize them to the best of our ability.
2. Use that information to determine which inputs might resonate best with the individual in front of us and use every lever possible at our disposal to facilitate the fastest recovery.
3. Educate our patients on their role in this process and teach them the most effective methods available for self-care.
After listening to our patient’s story, we need to decide if they would benefit from physical examination and how extensive this examination should be.
- Does their problem sound musculoskeletal?
- Are there contraindications to examination and treatment?
- Is the patient highly irritable (symptoms come on easily, are quite painful, and remain long after the aggravating activity ceases?) or non-irritable?
- What is their most painful or limiting movement or function (Client Specific Impairment Measure (CSIM))?
- Do you consistently apply a solid structure like this to your Subjective examination?
Would you voluntarily choose to disregard any information you gathered? Of course not - using all known information is essential, and gathering solid subjective information with as few biases as possible is one very important tool in formulating the most efficient plan.
Having a test-retest framework of clinical reasoning is also essential for understanding which levers to pull with different patient types. What works for the goose many not work for the gander. Assessment – intervention – then re-assessment proves the value of your treatment. But what if we could use an assessment and treatment paradigm that gave us immediate, feedback regarding its effectiveness?
What if we could assess the value of a particular input in real time, during the performance of the specific functional movement that bothers the patient the most?
The Mulligan Concept™ and Mobilization With Movement™ (MWM) allows us to do just that!
We can understand whether an input is helpful within a couple of minutes! Using good communication skills while applying various clinician or patient directed forces, we can determine if a manual therapy input is appropriate, needs more or less force, and in which direction the force must be applied to facilitate the best response. This increases the precision of our forces, and our chance of success with manual therapy.
Using all the tools available is essential!
With Mobilization With Movement™, patients can see and feel improvements in their function immediately, which alters their perception of their own problem consciously and subconsciously. Patients become actively involved with their treatment both mentally and physically, in the clinic and outside the clinic. Using active, pain free Mobilization With Movement™, we tap into multiple body systems at once providing manual therapy, therapeutic exercise, and neuromuscular re-education simultaneously. If you could eliminate a patient’s pain with their specific chief complaint, would you choose not to use this skill? Of course not, using all the tools available is essential, and with real time feedback on whether MWM’s are helpful – why not pull this lever?
Empowering patients to improve their own condition is also our responsibility. Educating them on the nature of their problem and showing them ways to speed recovery outside the clinic must be part of our intervention. With the Mulligan Concept™ we have options to maintain the successful manual therapy inputs we have discovered in our patients’ everyday life. Application of tape and self-directed MWM allows our patients to repeatedly reproduce pain free movements between visits. Using familiar, active, pain free movements as a home program allows patients to experience more normal movement once again, desensitizing their system. If your patient could move in the exact way that previously bothered them without symptoms as part of their HEP wouldn’t you want to use that input as often as possible between visits?
Why would we not pull this lever?
Patients become motivated to participate in their home program very easily when they immediately experience its value. Our job as clinicians is to discover and provide what each individual patient needs to the best of our ability. Accurate data collection, solid clinical reasoning, and using as many effective inputs as possible is what our job demands. When we have a manual therapy system that demonstrates the value of an input in real time, why would we not pull this lever?
As Brian Mulligan likes to say:
“Could you do it?”
“Should you do it?”
“Would you do it?”
I think we should all answer Yes! Yes! Yes!
Mark Thomson PT, DPT, OCS, FAAOMPT, CMP, MCTA