Clinical Reasoning and Treatment Choice
As many of us function as educators directly or indirectly working with clinical students, interns, graduate assistants, etc. it seems relevant to share some of our more interesting interactions in this realm. I was asked today by clinical students something along the lines of, 'how do you reconcile thinking in terms of the Selective Functional Movement Assessment (SFMA) with the treatment options we learn at University of Idaho, particularly when you have mentioned that any treatment has the capability of affecting more than one dysfunction classification?' My students and I proceeded to the white board and wrote down a sampling of the treatment techniques they had been exposed to in their academic careers and developed the following hierarchy of primary effects, secondary effects, and tertiary effects based on the SFMA classification system. While the following is not an exhaustive list, it is representative of the experiences of UofI MSAT students both in their program and in my clinical practice.
| Treatment | Tissue Extensibility Dysfunction | Joint Mobility Dysfunction | Stability & Motor Control Dysfumction |
|---|---|---|---|
| Maitland Joint Movilizations | 2 | 1 | 3 |
| McKenzie Method of Mechanical Diagnosis and Therapy | 3 | 1 | 1-2 |
| Mulligan Concept MWN | 3 | 1 | 2 |
| Total Motion Release | 2 | 2 | 1 |
| Positional Release Therapy | 1 | 2 | 3 |
| Primal Reflex Release Technique | 1 | 1 | 3 |
| The MyoKinesthetics System | 1 | 1 | 1 |
| Instrument Assisted Soft Tissue Mobilization | 1 | 2 | 2-3* |
| Dynamic Neuromuscular Stabilization | 2 | 2 | 1 |
1 = Likely primary effect of treatment.
2 = Likely secondary effect of treatment.
3 = Likely tertiary effect of treatment.
* = Likely treatment effect application dependent
What one may notice is that this isn't an up and down 1-2-3 rating system. For example, in the case of The MyoKinesthetics System (MYK), we have 1, or primary, listed for all three dysfunction classifications. This is based on the proposed mechanisms of action of the applied treatment. Typically, MYK treatments include the passive manipulation of soft tissue (TED - 1), and joints (JMD - 1), while including active range of motion (SMCD - 1). When considering MYK one may come to the conclusion that all three of these are potentially equal actions included in the typical MYK treatment. A potentially clearer example may be Mulligan Concept (MC) Mobilizations with Movement (MWM). With MC MWM, alterations in joint positioning is achieved via manual manipulation of joint articulations (JMD - 1) typically with active range of motion (SMCD -2), likely resulting in changes in length tension relationships in soft tissue (TED - 3). When we consider Instrument Assisted Soft Tissue Mobilization (IASTM), alterations in soft tissue length/tension dynamics (TED - 1) likely change joint position (JMD - 2) with application of treatment potentially including, but not requiring, active motion, altering the secondary or tertiary effects of treatment, (SMCD 2-3). While this is in no way a definitive cross referencing of dysfunction classification and treatment application, it was a fun thought experiment to engage my students in while exploring some of my clinical reasoning processes.