Some people think that manipulation is one of the hardest skills to obtain in physical therapy education. I would like to challenge that and say that clinical reasoning is one of the hardest skills to achieve. When I teach, I often use the example of my eight-year-old. Believe it or not, I have taught him how to manipulate my sacro-iliac joint and my talo-cural joint! Yes, even at his young age, he can perform the skill quite well. What he can’t do is discern when to perform the skill.
So let’s look at an example of where good clinical reasoning was better than good hands.
I periodically do consulting work for an acro-sport team that is on the other side of the country from where I live. The coach will often call me and ask me questions about his athletes. More often than not, these athletes will have already seen one doctor, if not more. Our most recent phone call went something like this:
“I have this 18-year-old old male athlete with complaints of intermittent testicular pain. His pain is so bad that at times he cannot get out of bed. The only thing that helps to decrease his pain is to curl up in a ball and lay perfectly still in bed.”
This athlete had seen a primary care doctor, an orthopedist, and a urologist. He has had blood work, x-ray, MRI, and CT scans done—all of which were inconclusive for anything of significance. No one could tell him what was wrong. Someone even suggested removing a testicle to help decrease pain.
So I asked a few questions about recent medical history and it turns out that this athlete had a sprained ankle a few months prior. He had been walking in a brace for 6 weeks and it was shortly thereafter that his testicular pain started. I had the coach take the patient through an AROM scan and the patient was lacking left thoracic rotation. He was also lacking what appeared to be left sacro-iliac joint posterior rotation.
Now we all know that decreased sacro-iliac motion in a healthy 18-year-old old male is unheard of so I was a bit skeptical that it was truly “stuck.” Upon further inspection (through skype and the phone) it was determined that the patient’s lack of sacro-iliac joint motion was actually due to neuromuscular facilitation of the quadratus lumborum not allowing the joint to move in its correct plane of motion. What caused this? Maybe it could have been the fact that he had an uneven gait pattern for six weeks, while walking in the brace.
Quadratus lumborum attaches to the 12th rib, which articulates with T12. The facilitation of the quadratus lumborum could have caused altered movement or neuromuscular control of this area. A common referral pain pattern of T12 is to the testicles. I gave the coach some ideas on how the athlete could use a form roller and exercises to restore motion and decrease the facilitation of the quadratus lumborum.
On my one- and two-week follow up calls, the athlete had been pain free through all movements—and very thankful that he was not having a testicle removed.
In a case like this, the patient did not need someone with amazing hands to perform some great manipulation. He needed someone who was able to put the pieces of the puzzle together. I often hear students say they are frustrated that they cannot “feel” what they think they should be feeling on a patient. I tell them that it can take eight to ten years to develop a good sense of touch. I was two years post fellowship before I felt like my clinical reasoning and my hands merged—with my hands taking longer than my brain. So yes, I really do feel that anyone can learn to manipulate—but it takes much more skill to determine who to manipulate.
Interested in developing your clinical reasoning? See what courses are coming up in your region in 2019.
-NAIOMT Instructor Stacy Soappman, PT, DSc, COMT, FAAOMPT.