Features Research
Essentials of Assessment: Spring 2006

Pain and dysfunction can lead to asymmetries in the body. These asymmetries can lead to further symptoms of pain and dysfunction, which can in turn lead to further asymmetries. For example: a C-curve in the lumbar spine produces a rebalancing C-curve in the thoracic or cervical spine, (making an S-curve overall).

The body’s need to compensate for pain and dysfunction, potentially leads to a complex chain of asymmetries. This can complicate any assessment process, and is like the chicken or egg experience for the therapist.

The therapist could be presented with a situation where the patient’s original pain and dysfunction (“the lesion”)
has actually been resolved, and the patient is presenting with discomfort and dysfunction developed from the compensatory process. By the time the patient comes to see you the original cause of their pain and dysfunction may well be undetectable. (All you see is the S–curve.)

So where does your assessment begin? Of course, asymmetries are 1. the result of the body’s attempt to compensate for pain and dysfunctions, and 2. these asymmetries will require the body to also compensate for them (further producing more asymmetries); for example:

One of the most used means of assessment is the observation of asymmetry; observed either by eye or palpation: Asymmetry seen and felt through the body twisting, bending, and compressing or lengthening. Asymmetry seen and felt in the tension and positioning of musculature and joints. All of these can be observed statically or with the body in motion. Such imbalances require not only thoroughness in assessing, but also in prioritizing the goals of each stage of the treatment process. As each treatment goal is accomplished a re-assessment is required.

Ongoing assessment involves three stages:

1. Initial Assessment – includes health history;
2. Pre & Post-treatment Assessment – performed after a treatment and before starting a subsequent treatment; 
3. Re-Assessment – following a series of treatments.

Certainly the client’s chief goal is the removal of pain and dysfunction they are presently experiencing. This requires us to focus on the principle area of complaint. None the less, we know that often what we are treating are the symptomatic compensatory responses in the musculoskeletal system arising from; other pre-existing and predisposing conditions or from underlying pathologies that require referral to a physician.

Following treatment addressing the most noticeable symptoms, we are now required to uncover the “hidden” dysfunction that the complaint, is in fact the result of.

With respect to the progression of ongoing assessment, we first seek to locate the clearly noticeable dysfunctions and those postures or movements that reproduce the pain and discomfort. Most MTs will investigate the common causes of referred pain, i.e. patterns resulting from Trigger Points. 

In this sense our primary assessment might be considered “triage.” Establishing the mechanism of injury, (if not initially self-evident). Seeing, for example, 1) which rotator cuff muscles are most acute and contributing the greatest to shoulder pain and dysfunction, 2) which thoracic-shoulder muscles are most acute 3) what is occurring with both the muscles intrinsic to the arm and the scapular-thoracic-cervical muscles. With the information gathered, the therapist can prioritize the tissues to treat and the appropriate modalities to apply.

Pre & Post-treatment assessment is performed twice. Immediately following the treatment and prior to the
commencement of the second (return visit)

Here the therapist should revisit some testing after the initial treatment to gauge the treatment’s effectiveness and to suggest some self-care for the client to do between appointments.

Upon seeing the client again, we assess, however cursory, to see to what degree the first treatment helped and, to establish the now present acuity and make any modifications to the imminent treatment.

A progression of assessment begins. (pre and post treatment assessment). Here the therapist assesses, by exploring, the body’s own predisposing musculoskeletal condition and how that may have contributed to the initial complaint. How may pre-existing muscle imbalances could be setting the client up for injury? (shortness here, tautness there, stretch weakness in the opposing muscle). And, what about those not-quite-successful compensations the body may be attempting because of some motion restriction coming from some distal joint limitation? Did these pre-existing asymmetries, causing change in muscle length and strength, possibly contribute to a client injury?

The above can be thought of as taking the assessment globally. This could require more hands-on assessment.
It is an ongoing “thinking through” of the information constantly flowing in, through talking with the client, palpating and treating (and so further palpating), observation, etc.

At this point we move from a ‘restricted’ assessment –  one that centred on the obvious presentation seen through the signs and symptoms of the chief complaint and their concomitant impairments found through initial testing, to a more global view. The whole body becomes the focus:  the search throughout the whole body for the compensations to pre-existing asymmetries, imbalances, restrictions in range of motion, and tissue texture changes.

The larger view should be utilized as soon as possible, acuity permitting, especially if treatments are not providing or sustaining the results expected. Unfortunately, when results are achieved through specific and regional treatments, the client may say “thank you” and not seek further treatment, thinking that all is well.

The therapist needs to begin speaking to the client about a global view even during the initial “acute-phase” or during their initial treatments. The client should be informed about the possible established asymmetries etc that may be predisposing factors to their present complaint. Often after discussing the client’s complaint from this larger point of view, the client begins to remember other pains and dysfunctions they may have suffered from previously that fit into this new global view.

Even if the client does not want to follow up on these issues, taking the time with each client to view them globally with respect to their presenting impairments gives us invaluable information to add to our personal store of knowledge.

Eventually, we find ourselves correcting that unilaterally rotated ilium, for example, as we address that stubborn shoulder problem. With improved and lasting results for our clients.

This more global view harkens back to the use of postural assessment. This global view helps us organize and progress our treatments and remedial exercise. Knowing what to lengthen prior to strengthening; knowing what is already too long and needs tightening; or, making sure before you increase or decrease ranges of motion of a complaining joint that the joints above and below are not hypo- or hyper-mobile.

We need to remember to balance the global view with specific treatments; that is to say, to balance the treatment of asymmetries with the treatment of pain and dysfunction.  Some people say you need to only address the imbalance to resolve the pain and dysfunction. Though I may agree with the sentiment of this as a principle, I do believe that specific treatment of tissue that is fibrosed or contractured, is still very necessary.

Patients do require relief from pain. In fact, relief from pain, and the physiological changes achieved in the specific treatment of the lesioned tissue can actually hasten the progress of treating the pre-disposing or perpetuating asymmetries.

We need to be aware of each of the imbalances present in the body in order to bring out the health of the individual fully. This is done by hands-on progressive treatments and by the client carrying out a progressive remedial exercise regimen. The progression is charted out, assessed, by seeing specific tissue problems (pain and dysfunction) within the context of the symmetry and asymmetry of the patient as a whole.

To find these imbalances we need to carefully assess and re-assess the client. Which means that we should move back and forth from; the global view (symmetry/asymmetry, or, general health and fitness) to; the specific view (painful and dysfunctional tissues), and back to; a revised global view, as we move through the healing process.

To treat only the specific lesion, the “chief complaint,” and not to take this larger view of the patient usually means that the therapist will see them again as soon as they present with new symptoms, caused by the body’s inability to sustain the compensations and the asymmetries, left untreated.

By re-assessing, we can ensure that the client does not develop new, unnoticed, and subsequently untreated, asymmetries.