Power of assessment: Breaking down components for best outcomes

Caleb Fenton
October 15, 2018
By Caleb Fenton
Preparations for empty can special test: The angle can also place pressure of the tendon of the long head of the biceps as it attaches on the supraglenoid tubercle of the scapula.
Preparations for empty can special test: The angle can also place pressure of the tendon of the long head of the biceps as it attaches on the supraglenoid tubercle of the scapula. Photos: Courtesy of Caleb Fenton
Assessment, often only practised on initial treatments, is a powerful tool to have, as RMTs answer not only our own questions, but the client’s as well. Assessment and orthopedic testing reinforce that we are professionals and informs the public and other health-care professions that we have knowledge and understanding of human anatomy and are able to differentiate conditions from serious pathologies.1

Assessment gives you the power to determine the best course of treatment, while staying focused on the client’s goals. If a client’s goal is different than a therapist’s, then assessment is a tool used to show the client why we think treatment goals should be changed.

Biomechanics change as we begin to adapt and manipulate soft tissue – we can make changes to how a joint is moved in its plane and change how strong a muscle activates. But how do we determine these changes if we don’t have a way to measure before and after the treatment? If we are busy chasing localized symptoms, we generally forget to chase the problem that can only be discovered through a thorough
assessment.

A client’s symptoms of pain can’t truly be measured like changes to a joint’s mobility. Though a client’s symptom of pain may be present post-treatment, we may have changed the client’s ability to move that joint.

Assessment can be broken down in several ways to help us determine the cause of the symptoms the client is dealing with:
  • Questions
  • Observations/Palpations
  • Gait analysis (if necessary)
  • Range of motion testing (active, passive, resisted, assisted)
  • Joint play (not covered here)
  • Orthopedic tests
Line of questioning
Asking simple questions like “where is the area of concern?” sets a solid foundation of why clients are being treated in the first place.

(Side note: We have all had a client that has given us a bucket list of problems, and almost expects you to treat everything in one session. My suggesstion for responding is to simply say: “There’s plenty to cover in this treatment, however, if you could choose the area of greater concern, we can focus on that for today.”)

In some practices, the area of concern is treated generally in hopes the client feels better.  The amount of times we have a high-risk client, where massage is completely contraindicated is very rare, that much is true, but a generalized treatment affects the representation of the profession. Thoroughness in questioning alone may give your client a high level of trust and respect for your objective approach towards their concerns and subsequent treatment.

Questions can also reveal a completely different condition. For example,  carpal tunnel syndrome could also be symptoms from a neurological or vascular impingement issue found in the neck and shoulders, like thoracic outlet syndrome. Even more local to the forearm can be cubital tunnel syndrome or ronator tere’s syndrome. One symptom, four possible conditions.

As we start out with investigative questioning, we move towards a final goal that the client may not yet understand. These questions aren’t definitive in a diagnosis, but point us in the direction we may need to go. They help determine what kind of issue we may be dealing with and gives us a greater understanding of how the injury happened, when it started and when it bothers them most. We can get very specific with questions as some other professionals have documented in what they call the “magnificent seven”2
  • Location: Where is the pain now? Where was the pain at onset? Does it radiate or go anywhere else?
  • Onset: How did the pain start? Over what period of time? Was onset sudden or gradual?
  • Duration: How long has the pain been present? Has it been intermittent or constant? Have there been similar episodes in the past?
  • Severity: How bad is the pain now? How bad was it at onset? What was the maximum level of pain? (Use a pain scale.)
  • Quality: What type of pain is it? How would you describe the pain? What does the pain feel like? (Burning, achy, throbbing, pinching, sharp, etc.)
  • Associated symptoms: Are there any other symptoms besides pain? (Ask questions specific to the chief signs and complaint as listed on the documentation templates. For example, ask if the patient has abdominal pain; if so, ask about symptoms: nausea, vomiting, diarrhea, etc.)
  • Modifying factors: Does anything make the pain better? Does anything make the pain worse?
Thoroughness may cost time with the actual “hands-on,” but it will make up for how effective the treatment will be.

Posture observations and palpations
Posture observations can be paired very well with palpations. Observations and palpations are a great way to initiate contact with the client, and with proper consent of assessment, we can begin to see the effects of pain and how the body begins to adapt and compensate its injuries, whether reoccurring or acute. As massage therapists, I believe we often skip palpations because we are “hands-on” with the client for the remainder of the treatment time. But going back to not trusting symptoms, we could simply palpate the area of discomfort, and if minimal discomfort is felt, it further reinforces that the problem may be elsewhere. In addition, muscle tone feels different when a client is standing or sitting opposed to a rested prone position.

With observations, there are plenty of ways we can observe. They can be postural like looking at symmetries, muscle mass differences and the client’s antaglic expression. Or, it can be posture along with other generalized effects like redness, swelling and bruising. We can
explain to our client what we see, maintaining professionalism involving the client in treatment.

With palpations, we begin the more objective clinical approach as we feel muscle tone differences. It’s important to check the muscles in different postures. For example, if they sit for prolonged periods, check the muscles sitting and palpate the differences when they stand. It’s always important to palpate both sides – to feel the differences from one muscle to its twin on the other. While you’re palpating, you can ask your client if they feel “pressure differences.” Gentle pressure is key to dermatome testing, and you can clear neurological conditions while your palpating.

Once practiced often enough, observations and palpations can take 30 seconds to a minute to complete, depending on the complexity, and establishes a very strong objective foundation.

Gait analysis
Gait analysis involves simple observations.3 If a client’s posture demands the observation of gait, do so, as it can only take a few seconds. You can simply watch the client walk into your room – because even though it’s third on the list, you can start with this. See how client steps, and you should also observe their ability or inability to stand from a seated position. Watch how muscles contract and the mechanics of the hips. By consistently analyzing gait, you may be able to assume the symptoms a client is currently experiencing before they tell you, surely surprising them. By utilizing gait analysis, you are now not only observing the mechanics of the body, but also examining a local problem and how it affects the body systemically.

Range of motion
Range of motion testing is the beginning of dividing the subjective from the objective. We begin to view the plane of movement of the joints, how the functional tissue begins to contract and elongate as the movement is accomplished. We are also applying several other assessment principles, observing movement and the client’s facial cues for any discomfort. We can also apply palpations, by simply placing our hands over the tissue that is contracting, the folds of the skin begins to buckle under the superficial fascial pull. An important practice is to “do the most painful movement last.” When we perform a movement that is uncomfortable first, we potentially compromise the rest of the movements. Also, cue the client: While completing active range of motion, ask them to stop when there is discomfort and to explain what they feel and where it is located.

Sometimes the location of discomfort is completely different to where the client’s original concern was when we have the client move. What do we do? Generally, we no longer attempt the movement and move forward with the rest of the motion testing. However, we can continue with that same movement by applying two other types of motion: active assisted and active resisted. We are taught (at least I was) to apply range of motion through an active state, through the passive, then to a resisted state to check strength. But, what we can do is add all motion principles to one plane of movement.

As an example, if a client is requested to preform horizontal extension (or abduction) and they experience tension in the anterior deltoid, that is opposite to the muscles we are contracting. We can assume that possibly the attachments of the subscapularis, latissimus dorsi or teres major are causing discomfort. (Also, muscles like the coracobrachialis, pectoralis major and short head tendon of the biceps.) But how can you come to this quick conclusion with little
evidence?

If we assist the client through the range, does that remove strain off those muscles, helping the muscles of extension or does having the client resist horizontal flexion (or adduction) create a different symptom? Or what about resisting horizontal extension? Do we notice how the client’s arm is angled during the movement? Does it feel better if we rotate the thumb down or up or palm up or palm down?

To further the foundation of understanding anatomy and the actions of muscles and the nerves that innervate them, if a muscle is unable to fully contract, doesn’t that mean the neurological innervation has been compromised (little to no resistance) or a potential tear in the muscle tissue (pain with resistance)?

There are so many different variables for us to use and different specific muscles to focus on.

We begin to measure changes and re-test at the end of the treatment. Yes, the client may still have discomfort, but they went from moving their arm from 45 degrees to 90 degrees. Are we as massage therapists only to help fix the subjectiveness of pain?  The lack of movement is the cause of pain, it’s called “disuse pain.”4 Even though you are assessing your client’s range of motion, you’re treating them.



Orthopedic tests
Orthopedic tests are on the far side of objective information and should be preformed last, as it can be invasive to the client and is the final nail in the coffin of the problem we believe the client has. A protocol we should follow is to never assume a correct diagnosis from one positive test. We should do three to four special orthopedic tests to rule other underlying pathologies targeting different structures:
  • Musculoskeletal
  • Ligamentous and capsular
  • Neurovascular
We should note specifically which test is positive, as well as the research differentials to further pinpoint the problem, assuring the best outcomes in future treatments for our client’s. Testing also helps separate the line between indicated and contraindicated, and when referring your client out to another health-care professional, you’ve established a foundation that a referral is the best option for your client.

Another protocol to note is not to inform the client where the area of discomfort may be located. You may establish a physiological barrier which can include the physical. As you are performing the test, communicate with your client to tell you when they feel discomfort and inform you where it’s located to further dilute false positives.

Your practice involves how you practice, and as you do your due diligence in pre-treatment assessment, you will begin to have more clients respect your knowledge and allow you to work the way you do.

Resources:
  1. See Dr. Nakita Vizniaks Academic Charts, https://prohealthsys.com/blog/medical-education/what-everyone-ought-to-know-about-doctors/
  2. The Sullivan Group, sullivangroup.com and UT Health Science Center: San Antonio, som.uthscsa.edu/studentaffairs/MSIVLabSession.asp
  3. https://www.physio-pedia.com/Gait
  4. https://www.spine-health.com/blog/relationship-between-chronic-pain-and-inactivity-disuse-syndrome, and https://www.arthrosurface.com/fitnesshealth/inactivity-causing-damage-joints


CALEB FENTON, RMT, SMT (cc) has been a massage therapist for nine years and graduated from the Professional Institute of Massage Therapy with honors. He currently practices in a busy multiple disciplinary clinic with other RMTs, physiotherapists and chiropractors in Steinbach, Man., where he lives with his wife and two kids. He has mentored and tutored several massage therapists, and helps with local sports teams to assess and treat athletes. Fenton is currently developing his own seminars to teach massage therapists to find confidence in clinical understanding and practice.

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