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Hi everyone. Since I’ve always been challenged w/my size vs that of my patient, I have had to use creative strategies to achieve my goals to maximize my treatment choices and still protect my body and/or the patient w/manual therapy techniques I choose. This article hit home for me b/c until I did my fellowship training, I thought certain techniques were just not an option for me to perform. Luckily after better understanding of patient anatomy and biomechanics and the way to use my body size as a benefit not a barrier, I was able to improve my creativity and technique outcomes. I think the other thing to consider is that even if you do have a biomechanical advantage over a patient but they present with other complications, have other body parts affected or cannot sustain certain postures, you will HAVE to use creativity and choose alternate options to reach your goals. When we teach you new manual therapy techniques, the goal is to have you become proficient in the “gold standard” means of performing it but after you understand the goal of the technique and the joint or soft tissue you’re looking to mobilize, you can use creativity to achieve your goal.
I would be sure that each of you has encountered some barrier to performing a manual therapy technique that you previously learned or one you’ve been taught during your residency. Can you share either a technique you need advice on ways to better perform based on barriers you’ve encountered or share with the group or way(s) you’ve updated one that has been successful for you/the patient? Also, it would be great to consider ways to maximize the manual therapy technique you’ll be reviewing at the next weekend course to share ideas with your classmates in case they encounter certain barriers? Be sure to discuss any suggestions you plan to make to the group w/your mentor FIRST before suggesting things to the group!
KK -
Hi Kristin, thanks for the unique article. I would say that in the past I definitely have been guilty of choosing other options instead of a particular manual technique in deference to the patient’s size. Obviously this might be a disservice to a large portion of the population and a very large portion of the orthopedic patient population depending on your clinic’s demographics. As someone with low back pain that has affected my ability to practice already I think this article was helpful in highlighting the need for creativity to work around practitioner or patient barriers.
I’ve not had this issue but I would love to hear how anyone has modified the long axis hip distraction manipulation to a patient that is larger.
One issue I have noticed with assessment and also applies to treatment, but what have people done for lumbar PPIVMs for larger patients? Are you utilizing more rotation and lateral flexion to get facet opening/closing versus straight plane flexion and extension?
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As someone who is also challenged with my size versus patient size, I found this article to be very insightful. I know that over the duration of several weekend courses, I have been practicing my manipulative techniques. I have found that lowering the table to get my body weight over the patient and issuing verbal cues to better inform them of what position I would like them to maintain has helped my overall success with the technique. I believe I still struggle with some larger patients when utilizing the supine thoracic manipulation technique because I am unable to maintain my hand position to adequately create a barrier of resistance. When this happens, I tend to revert to the prone technique. I am always interested in modifications that I could utilize to perform techniques such as this more successfully.
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Brett showed me a way to perform the supine technique from the ipsilateral side for those patients with a larger BMI and/or chest circumference. I have also had some success with using a keltenborn wedge in supine for larger patients that were unable to tolerate prone or assume prone due to excessive soft tissue. I don’t like that technique as much because I’m unable to make those small movements with my hand to increase/build the barrier.
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Kristin, I think I may just need more practice feeling those movements in general, as single leg with a patient with more soft tissue in that area results in me having a fairly poor sense of the quality and quantity of the movement. Your point is a good one though: making modifications can be very helpful, but you do not absolutely need to perform every technique on every patient.
Would it be possible in the next course weekend for you to show us some of the modifications you find most helpful with larger patients? Like you said in the end it comes down to biomechanical advantage, but I think some additional examples from someone who has had experience with modifying techniques would be helpful to get us thinking more about this topic.
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