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Assessment bred in the bone

Assessment is a way of looking at anatomy with our hands. Teaching assessment can be a way of teaching more than tests, we can teach living anatomy through palpation. We can teach how to have X-ray vision, to see the motion of bones through flesh.

Starting a clinical assessment course at the very beginning of a massage therapy program has the benefit of immediately getting the student thinking in those terms.

Some of these benefits include:

• Even as they begin their introductory course/lab on Swedish techniques they are already in a mindset of observing and gathering information about tissue texture, symmetry/asymmetry, temperature.
• As they are learning physiology, and other similar courses, they may begin to understand how these sciences relate to massage.
• If students have some assessment background prior to public clinic experience, they will begin their clinical experience with an awareness of the importance of assessment and be able to make it part of their practice right from the beginning.

The more a curriculum can show the relevance of the sciences to the practice of massage therapy the better.  

Common objections to introducing clinical assessment early in a program is that it is too technical, it relies on first having significant grounding in other information to be understood, and it is just too much information to add to students’ already substantial load. This is a mistaken view.

The content of an assessment course should not be seen as completely new information that gets heaped onto the student, but rather, a way of integrating and absorbing much of the information the first term student is already receiving.

If the anatomy course follows, by and large, a region-by-region approach assessment can complement and reinforce this anatomical information. I have often characterized clinical assessment as “thinking anatomy.” If you think through the nature of the structures and functions of any region of the body, it is possible to re-invent the appropriate testing. This reinforces learning of both anatomy and assessment for the student and demonstrates how integrated they really are.

For example, when teaching the regional anatomy of the lower leg, ankle and foot, a parallel assessment course can allow students to palpate the boney landmarks of the skeletal anatomy, use differential muscle testing to palpate muscles from origin to insertion, review the range of motion of the joints, palpate the end-feel of joint movement. This allows for a review of the attachments of ligament and how they “steer” movement within the joint, as can the shape of the joint capsule along with the shape of joint surfaces.

The most important way many of the assessment skills will re-enforce anatomical knowledge is that it can present this information in a different mode of learning or in a different learning style, through touch and motion. The more ways that we approach a topic, the more senses we use to learn with, the more likely we are to remember it, because it gives us different ways/places to store this information in our memory.  

Many of the so-called “special tests” (such as McMurry’s Meniscus test) can be described essentially as deep palpation, as a way to palpate deep structures (the meniscal pads). By placing tension on specific tissues through positioning and movement, one can often access deeper structures. In McMurry’s, you are using one or other of the very condyles of the femur to feel, to palpate, the surfaces of either the lateral or medial meniscal pads of the knee. The examiner attempts to feel, while holding and palpating via the knee’s epicondyles, for irregularities of movement – bumps, skips hesitation and the like – while moving the knee several times through a series of movements.

Motion palpation of first the osseous elements of the shoulder girdle and then over the various muscular components actualizes into tangible knowledge of the conceptual view of integrated motion of the shoulder girdle elements. Having palpated this on several people who have more or less normal motion, the student now has a powerful assessment tool when they encounter an injured or otherwise impaired shoulder.

Motion palpation of the spine likewise aids a student of anatomy to see and concretely understand the integrated movement patterns of the spine, which enables them to find group dysfunctions of several spinal segments or to locate a specific impaired spinal segment. Enabling massage therapy students to understand and assess the spine from the occiput to the pelvis is critical to our profession. After all, though we do treat all areas of the body, the bulk of our clientele who come seeking relief from pain or dysfunction are doing so for back and neck issues. If we do not understand and cannot assess the spine competently, how are we expected to help those clients?

In both of the above examples, the shoulder and the spine, new information is certainly being given, but that is built on and comes out of unifying, demonstrating and seeing the seemingly endless lists of joint types, structures, muscles and their attachment points in action – in the flesh.

What is bred in the bone comes out in the flesh.