I am not speaking of the force a practitioner needs to provide in order to manipulate a joint, but, the commanding value of manipulation on patients. Let me explain further.
I recently had a past patient of mine call to schedule as he recently (within 2 days) hurt his low back while lifting a small object at home. He described it as giving way and he thought something was ‘out of place’. He was under my care about 6 months ago for a different condition (3 visits for mid-thoracic spine pain) and one of the interventions provided was manipulation, which he enjoyed and attributed to his success.
Now even though in the last episode of care and this one, I combined the effects of manipulation and exercise, the patient’s values and perceptions really played a large role in his successful outcome. I knew deep in my head that he would need more than manipulation to the low back, but it was a factor that would be idiotic to leave out. I would probably say only ~20% of my treatment is manual whilst 80% is assessment and exercise-driven, but that 20% (or if you want to think of simply one manipulation…5%) of the total treatment time when I saw him 6 months ago is what stuck in his head. This is what he remembered. It was possibly the mechanical stimulus needed to get neurophysiological effects and even affect descending signals from the brain, who knows.
Nevertheless, when he injured himself at home, he knew directly who he wanted to see….his physical therapist. Not his massage therapist, chiropractor or primary care physician. The physical therapist.
I don’t normally “use all my tools” (even though I really don’t like this term!) on every patient, it is something to think about when providing an intervention. We do know there are subgroups of individuals who benefit from manipulation (or mobilization, traction, etc.) looking through impairments, but don’t forget the patient preference. That 3rd aspect of evidenced-based medicine may be what is needed. Don’t forget its power.