How I treat: situational care, multimodal care, wellness care

Situational Care:

Although people are all built to the same plan, they are highly varied in their development, histories, and how they use their bodies. Situational care means looking at each patient and each case as unique. As a result every person has to be assessed as an individual.

Janet Travell was a White House physician to John F. Kennedy and helped him a great deal with his back pain. She was also a pioneer in the non-surgical treatment of problems of the neuro-musculo-skeletal system. In her autobiography she wrote: “Complexities in the diagnosis and treatment of painful stress disorders of the skeletal musculature begin to be apparent if one considers how many words can be made from twenty-six letters of the alphabet. The parts of the human body are moved by more than [four] hundred muscles, and the combinations of muscular strains that can be created by internal and external forces are infinite. In addition, each person may be imagined as representing a different language or dialect.”

Multimodal Care:

In light of the above it stands to reason that a therapist who treats only in one way will be truly successful only if their method meets the right condition. Historically a number of different professions have been involved in the care of neuro-musculo-skeletal (NMS) system and even within them are many subgroups based on particular techniques. Unfortunately many therapists only have one approach– they may manipulate joints, or may emphasize one form of soft tissue manipulation, or stretching, or exercise, or use guided movements. The many specific forms of manual, kinetic, and manipulative therapies can be used to various ends, depending on the situation and goals of the patient. It is a combination of methods best suited to each person that works best.

Putting the two together: comprehensive care

Some therapy is very narrowly focused on areas of pain or other symptoms. Sometimes this is appropriate if the problem is very limited, like a jammed finger. In other cases, when symptoms keep coming back limited symptom based interventions are not the answer. The symptoms (what the patient experiences) may be due to other things they are unaware of (shoulder or back pain due to poor posture, for instance).

True success means having a progressive effect on the patient’s condition, not simply maintaining their symptoms at a minimum level. Many people will improve somewhat no matter what is done for them. But after an acute episode people may, as Dr. Travell put it, “tolerate the second rate state of average health.” Average, as she says, is not normal. Average is not necessarily ill but people in this state often put up with things they don’t have to.

Situational and multimodal care begins by becoming acquainted with the patient in the ways that are relevant to their problem. Patients know things about their problems too, although they may not always realize the significance of what they know. In a sense the doctor is a guide and is always learning because every patient + case is different.

For this to happen enough time must be allowed during each visit for communication between the therapist and the patient. In internal medicine the diagnosis is often the end of the process except for the prescription itself. In rehabilitation it is only the beginning. Conditions of long standing may represent a serial unfolding of adaptations the body has made to try to remain functional. It is not usual for such problems to be simply in one spot, a muscle or a part of one muscle. There has to be time in each visit to address different factors that may be parts of the problem.

This makes therapy sound very involved. It need not be. Many nagging, long established problems can have rather simple causes and only need the right therapy. What I have discussed here applies mostly to rehabilitative care. Acute phase care is discussed on page three under What I Treat.

Patients have different goals and these matter. Some people want limited, symptom oriented care. Some people are limited by finances or pressed for time. I encourage patients to bring up any treatment issues before therapy begins or during it rather than feeling they have to go along. If there are forks in the road we can discuss trade offs and options. In the end every one is responsible for their own health.

Therapy can be uncomfortable but nothing is done beyond the patient’s ability or willingness to tolerate it. Patients are free to decline any procedure or request a modification of approach.