Comprehensive Comprehensive

Orthopaedic Orthopaedic

Assessment as Assessment as

Palpating Living Palpating Living

Anatomy Anatomy

David David

ZulakZulak 1Coming in 2009!

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‘‘ClassicClassic’’ Orthopaedic Testing.Orthopaedic Testing.

•• James James CyriaxCyriax – the father of orthopaedic medicine. Developed this through the 1930

and up into the 80’s.

- Developed the basic protocol of Active Free (AF), Passive Relaxed (PR) & “Passive Forced” (PF, or “overpressure”) and Active Resisted (AR, or

isometric) Range of Motion TestingRange of Motion Testing. The so-called “Special Tests” are those that have been developed to test specific structures like the meniscus in the

knee, or nerve entrapment in carpal tunnel.

- The purpose was to find the cause so that it could

be treated, not just the symptoms 2

‘‘ClassicClassic’’ Orthopaedic Testing.Orthopaedic Testing.

• In general, this testing procedure that Cyriaxdeveloped was based on “provocationprovocation” -

provoking symptoms. He released the simple fact that when tension is put through an

injured or dysfunctional tissue it would

‘complain’ – It would be felt as pain by the client and/or affect the function (i.e., range of

motion etc) of the soft tissue or joints of the musculoskeletal system. Thus identifying

what tissues are injured and to what extent. – Find the cause in order to treat the cause. 3

‘‘ClassicClassic’’ Orthopaedic Testing.Orthopaedic Testing.

• This way of testing has remained the principle way that allopathic medicine

(MD’s, and many PT’s, Kinnesiologist’s, AT’s and MT’s) investigate musculoskeletal

tissues.

• However, imaging technologies (x-rays, CT

scans, MRI’s) are taking over as the preferred way of investigating soft tissue &

joint injury. This is a huge error when searching for answers concerning chronic

conditions. 4

‘‘ClassicClassic’’ Orthopaedic Testing.Orthopaedic Testing.

• So now hands on testing is used primarily

by manual therapists.

• As massage therapists we spend all day

palpating tissue; who is better trained by the very work they do then us to take

ownership of hands on testing?

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““Deep PalpationDeep Palpation””

• We can think of many orthopaedic tests as

“deep palpation”.

• The tests are designed to help us use the client’s own body to palpate deep structures

that are not directly available

– For example “McMurry’s Meniscus Test”.

• Thinking of orthopaedic’s “special tests” as “special palpation techniques” may help

some MT’s view orthopaedic testing more favourably. 6

7From: http://www.straightfromthedoc.com/50226711/

New Developments in the How to Employ New Developments in the How to Employ

Orthopaedic TestingOrthopaedic Testing

• The “Impairment Based ModelImpairment Based Model”:

– Does not search for a “condition”, a “diagnosis”or even some “principle cause” or “key lesion”.

– With respect to identifying the condition troubling the client, or searching for the cause of the

client’s pain or discomfort, these are routinely never found. The cause of low back pain, for example, is identified in only 10 to 20% of cases.

– If we always need to know the cause of our client’s pain or condition prior to treating the

client we would often find ourselves with nothing to do. 8

“Impairment Based ModelImpairment Based Model”:

– Is still assessing by means of range of motion testing, along with special tests, and observing which movements or actions are impaired.

However it does not then try to “jump to the conclusion” about the cause.

– It understands which tissues are involved by having a good grasp of anatomy, along with good palpation skills, and seeks to assess their function.

– When testing the function of tissue we can create a picture of what tissues are ailing in that unique

individual client that is there before us.9

Impairment Based Assessment:Impairment Based Assessment:

– Impairments often show up as symptoms: asymmetry of posture and movement, losses

in range of motion &/function; changes in tissue(s) and their environments (like edema); as pain, or altered sensation.

– Classic procedures of orthopaedic assessment such as case history taking,

observations and basic range of motion testing provide the bulk of information about the impairments a patient presents with.

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Impairment Based AssessmentImpairment Based Assessment

– These impairments can usually be matched to techniques or modalities in massage therapy.

• Edema → drainage techniques like effleurage, vibrations...

• Shortened tissues → petrissage, muscle stripping, stretching...

• Fibrosis/adhesions → petrissage and frictioning...

• Pain → ‘stroking’, grade 1 joint mobilizations, ‘rocking and shaking’/rhythmic mobilizations...

– Thus we are constructing our treatment plan as we

find the client’s impairments.

– This is certainly an improvement over the condition-

based model of assessment11

-- Is this impairment based Is this impairment based

assessment and treatment assessment and treatment

procedure all that we need as procedure all that we need as

massage therapist?massage therapist?

-- The short answer is no.The short answer is no.

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The Longer Answer...The Longer Answer...• The impairment (“disablement”) models that have been

developed are not changing orthopaedic testing procedures, but rather, are changing how we interpret our findings of such testing.

• However, orthopaedic testing does not serve us well when we need to evaluate the:

– joints of the spine, especially the ‘facet’ joints

– sacroiliac joints

– innominates (hips)

• And orthopaedic testing as it has existed to date has a tendency to get lost in the detail and lose the big picture.

• Further, it relies on provoking symptoms such as pain or dysfunction.

• What is missing? 13

What is Missing...What is Missing...

•• Motion palpationMotion palpation is the first thing that is missing

– especially for assessing the joints of the spine...– After all, most of our client’s come in with back pain – low

back, mid & upper back, and the neck

– Without being able to assess the synovial joints of the spine how can we claim to be able to adequately address the client’s chief complaint of back or neck pain?

– We have the palpatory skills to do this sort of testing but many of us lack the knowledge of how to do this simple task.

– No longer will we need to give away our clients to other manual therapists, like chiropractors etc.

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•• Motion palpation Motion palpation techniques specific to the assessment of the spine and sacrum:

– those that especially come from Osteopathy are particularly suited for massage therapy.

– It is the landmarking and palpating of structures while the client moves their limbs and joints

during Active Free testing as well as in Passive Relaxed (with or without overpressure).

– Assessing through palpation & sight the quality & quantity of motion, (and because almost every joint in the body is paired), looking for

symmetry/asymmetry of motion.

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LandmarkingLandmarking......

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Motion palpationMotion palpation

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Vertebral segments functional in flexionVertebral segments functional in flexion Vertebral segments functional in Vertebral segments functional in

but but dysfunctionaldysfunctional in extensionin extension extensionextension, but , but dysfunctionaldysfunctional in flexionin flexion

But they may present on palpation as the same! They require motiBut they may present on palpation as the same! They require motion palpation in on palpation in

order to differentiate them, and so that they can be treated apporder to differentiate them, and so that they can be treated appropriately!.ropriately!.

flexion

extension

X

X

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From Fred Mitchell From Fred Mitchell JrJr’’ss Muscle Energy ManualMuscle Energy Manual vo.1vo.1--33

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Motion Palpation is Motion Palpation is

not Just for the Spine!not Just for the Spine!

Motion Palpation...Motion Palpation...

• By adding motion palpation to our skill set in

orthopaedic assessment we are then not just taking a static ‘snap shot’ of our client, but

rather it is more like taking a moving picture.

• This motion picture provides us with invaluable information about the nature of

many impairments of the limbs and spine that may be troubling our client.

• By helping us to assess all of the joints of the

body we can now truly get a holistic view of our client: get the complete picture 21

What is also Missing...What is also Missing...

• Is a broader scope of assessment techniques that can be included under the category of

“special testing”: (for example)– Cranial bone motion testing

– Energy technique assessment protocols

– Shiatsu or acupuncture point/meridian assessment, along with “pulse diagnosis”...

• A comprehensive form of orthopaedic assessment does not by definition exclude any

testing that seeks to explain changes in the musculoskeletal system, directly/indirectly

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Thinking Anatomy Thinking Anatomy • This expanded, more comprehensive view of

orthopaedic assessment I describe as ‘thinking anatomy’:

– Thinking through the structure and function of the body’s anatomy.

– Thinking anatomy while observing through palpation helps us to visualize and see into the tissues and observe how well they function.

– It helps us understand and solve specific impairments or tissue damage as possibly

compensations due to detrimental postural consequences.

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– And performing such an assessment with a client is what is meant by “palpating living anatomy”

• This is a way that massage therapists can understand & use orthopaedic testing that will be specific to our profession.

• This understanding of assessment enables us to remain true to the principles that massage therapy has had for over a century:– That massage therapy employs a whole body

approach– That healing occurs on many levels– Massage therapists are most effective when

treating specific problems within the context of the whole person..

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Thinking Structure & FunctionThinking Structure & Function

• Assessment is “thinking through anatomy” & by

this thinking through the implications of the structure and function of the musculoskeletal

system we can re-create any orthopaedic test, and moreover, create others as needed. We

could also re-invent any treatment modality, and create more of these.

–– For that is how it was done originallyFor that is how it was done originally.

Clinical assessment is a way to see how the Clinical assessment is a way to see how the

““living anatomyliving anatomy”” ––the body the body -- is functioning and is functioning and

how it is how it is dysfunctioningdysfunctioning..25

Therefore Therefore ComprehensiveComprehensive Orthopaedic Orthopaedic

Assessment is:Assessment is:

•• An impairment oriented approach to the assessment An impairment oriented approach to the assessment

of soft tissue and jointsof soft tissue and joints.

• This is meant to be very specific, while at the same time keeping a ‘global’ view regarding impairments.

– Specific in that we want to know of all the tissues involved in any impaired function.

– It is not to looking for conditions or dysfunction themselves but rather it is to search out the impairments that constitute any condition or dysfunction.

– And it is about seeing how each tissue presents itself that day, each tissue within the context of the region, and this region within the context of the whole body.

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Comprehensive Assessment is...

– About how these impaired tissues are affecting the whole body, and in turn, how they are being affected by the whole body.

– About seeing how the tissues we are investigating are moving. We are in fact investigating the life of the tissues, as they live in their world - in their environment – in their body.

– To see how the whole body may be involved in predisposing or in creating the unique injury (dysfunction) and its component impairments that are troubling that specific client.

We are creating a complete motion/We are creating a complete motion/‘‘livingliving’’ picture of picture of

the individual living being that is before us.the individual living being that is before us. 27

Comprehensive Orthopaedic Comprehensive Orthopaedic

Assessment ...Assessment ...• Is an organized testing procedure (protocol)

that flows from case history taking, through observation, range of motion testing and

special testing (when appropriate), and naturally carries us into our treatment plan.

• The movement of each step to the next step in the protocol provides us with a clearer

and clearer picture of that individual’s state of musculoskeletal health.

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ActiveResisted

Movements(Isometric)

ActiveActive

ResistedResisted

MovementsMovements(I(Isometricsometric))

Active Free Movements

Active Active

Free Free

MovementsMovements

Special

Tests

SpecialSpecial

TestsTests

Differential Muscle Testing

Differential Differential

Muscle TestingMuscle Testing

MyofascialTrigger Points

MyofascialMyofascial

Trigger PointsTrigger Points

Neurological Testing:Dermatome/Myotome

Scleratome/DTR

Neurological Testing:Neurological Testing:

Dermatome/Dermatome/MyotomeMyotome

ScleratomeScleratome/DTR/DTR

Specific/SpecialTissue Tests

Specific/SpecialSpecific/Special

Tissue TestsTissue Tests

Physical Examination

Physical Physical

ExaminationExamination

Case HistoryTaking

Case HistoryCase HistoryTaking

ObservationInspection

ObservationObservationInspectionInspection

Passive Relaxed Movements

Passive Passive Relaxed Relaxed

MovementsMovements

Comprehensive Orthopaedic Assessment Comprehensive Orthopaedic Assessment

Review of ProtocolReview of Protocol

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Comprehensive Assessment Comprehensive Assessment

is Meant to be is Meant to be ‘‘HolisticHolistic’…’…

• As massage therapist we see the body as an interdependent dynamic whole. We recognize that

any change or impairment in any part of the body will in a short time be seen to affect other nearby structures, and if not resolved, will eventually affect

the whole body.

• From this perspective, Clinical Assessment for the

massage therapist is the evaluation of soft tissue and joints and the implications this has for the structure and function of the body as a whole – for

“posture and movement” . 30

Comprehensive AssessmentComprehensive Assessment……

Or, to put it another way: comprehensive orthopaedic assessment is the evaluation of the

static and the dynamic relationships of muscle, connective tissue and joints in the living body.

Hence, the purpose of comprehensive

assessment is not just to find a specifically

injured tissue, but rather, to also discover how the region is in compensation and even how the

body as a whole is accommodating the strain.31

Occiput is extended;

So the Upper CervicalVertebrae are held in

Extension, while the lowest cervical and

upper thoracic are held

Flexed.Chin moves forward

into protrusion.

Shoulder rolls forward, or

is protracted.

Kyphosis will beginto exaggerate.

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Comprehensive TreatmentComprehensive Treatment

• Treatment of individual impairments or

dysfunctions without looking at the

whole only provides limited relief at

best.

• Treating impairments or dysfunctions

within the context of the whole body

provides the possibility of sustained

relief and resolution of the precipitating

& perpetuating factors.33

Thanks for Listening!Thanks for Listening!

Coming in 2009Coming in 2009!

www.mt-publishing.com34