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The Spirit of Assessment

It’s mid afternoon and I am taking the case history from a new client; nothing unusual, especially at the beginning of a brand new practice. Also not unusual, my confidence as a therapist was being somewhat tested by my recent entry into the ‘real world.’ I was missing that comfort of having a supervisor around (as in public clinic at school) from whom I could always get assistance with assessing a client. ‘Assessment’ still sounded like something scary. But I am one of those people who likes to have a complete a picture of what’s going on before I proceed.

So, the client and I get down to discussing her chief complaint and, in brief, I hear: “I had a skiing accident last winter, injuring my shoulder, which the doctor at the hospital, and orthopaedic specialist said was a rotator cuff tear. I have been through two bouts of physiotherapy and it really is not any better. I sometimes have my doubts about whether they got it right.” 

When asked to point to where the pain has been coming from she points to the back of her right shoulder around the area of her infraspinatus or teres major/minor tendons. I am thinking ‘right, these specialists could not help her, but somehow I am supposed to figure out what is going on?’ So, since I had no idea how to proceed, I did everything! I had her go through all active ranges of motion for the shoulders, bilaterally, (all the time thinking ‘I am not going to have anything else to tell her …’), doing passive range of motion (assuming no joint involvement) and then proceeded to isometric resisted testing. I was 10 minutes or so into this assessment (thinking ‘she probably is becoming impatient and just wants to get onto the table …’) but I cannot seem to stop myself from at least finishing the resisted testing. Then, confusion and surprise!  Resisted external rotation that should have bothered an injured or dysfunctional infraspinatus or teres minor seemed fine. To my further surprise, resisted extension of the shoulder caused discomfort. When asked to point where she felt the pain, she pointed to that same area of the tendons of the infra and teres. 

Confusion led to internal babbling in my head, and out popped, from somewhere, ‘test long head of triceps,’ which I did by having the client hold her upper arm in slight extension (and I had to really grope around to remember this) and resist my pushing her upper arm into flexion and at the same time resist my attempt to abduct the upper arm. I was just beginning with gentle pressure and building slowly when the client shouted, “That’s it! That’s where it hurts! That’s what I injured.” She points to what I now know is the insertion of the longhead of the triceps at the inferior tubercle of the
glenoid fossa, which lies deep under the tendons of the infra and teres as these pass over to insert on the humerus.

I was standing beside her thinking ‘has her rotator cuff injury resolved, to be replaced by this other injury?’ (I can be a bit thick, or so I have been told, having brilliant complex flights of analytical thinking that take a little time to land me somewhere near the obvious.). All the while the client is telling me, “no one has ever done any of this testing with me, in fact all anyone ever did was ask me a few questions and tell them where it hurt.” I was quite surprised, (I have been told I am quite naive as well). After some further discussion with the client, (since I was reluctant to believe that an orthopaedic physician and two separate physiotherapists missed the mark), I eventually had to bow to the probability that my client originally suffered a severe strain of the long head of the triceps, with the expected concomitant involvement of other tissues nearby and involved with the shoulder joint. While I may have sounded matter of fact and confident whengiving and explaining my assessment to the client, this didn’t cause my head to swell, rather I realized that just by following the basic rules of orthopaedic assessment the answer had just popped out at me. No need for feats of awesome intuition or analysis was required on my part.

After the first treatment (she had 35 minutes left to her original hour), the client felt a great deal of relief and by the fourth visit she was pain free. By following some simple strengthening exercises she went skiing that winter with no problem. A convert was born. The client was extremely happy that I took the time with her, bumbling around and all. She felt that I had listened to her and that by being thorough I had her best interest at heart. It is good for business; I have received literally dozens of clients who have been referred to me by her.

My treatment was specific to her, specific to her injury, and the acuity or state of the tissue at the time I saw her. Though I specifically focussed on her right triceps and particularly the long head and its attachment onto the scapula, I also dealt with all the surrounding tissue and related structures in light of what all of my testing told me. Her injury was unique simply because it was hers. Because the treatment was specific to her it was the most effective treatment she had yet received for her injury.

Assumptions Can Be Misleading
Follow the basic protocol: case history taking; followed, when appropriate, by range of motion testing; then any special or differential testing.

Assumptions can be misleading; leave them aside till the testing is done. One should not go about doing just the testing that would support one’s guess or assumption.

Do not rely on another’s assessment concerning soft tissue injury.  Find out for yourself. Orthopaedic assessment skills help give knowledge that is useful regardless of the techniques employed.

It was good for relationships with other health professionals. Her family physician was impressed and has in turn sent clients my way.

Of late I have come to see the impact of these lessons, in one of those ‘Aha!’ satori-like experiences. I used to tell students that clinical assessment was 50 per cent of our scope of practice: “… to assess and treat …” But, it is not any percentage at all. To assess and treat is one and the same, united and melded into one when working with a client. (I told you I eventually arrive at the obvious.)  

I would like to expand on a few of the items that my ‘triceps experience’ brought forth, make a few comments about the nature of clinical assessment as a whole, take a shot at a few definitions, and outline the basic elements that for some may hearken back to an introductory class during those old school days. And, I would like to talk about massage therapists taking up a skill that is being set aside by others in the health care
system who see technology as the source for answers on questions of soft tissue injury and dysfunction.

What Do We Think We Are Doing?
Over the last several decades in North America, MT has been on a path towards becoming an integral part of the health care system. In doing so, more and more focus has been on developing and refining treatments for ‘soft-tissue’ injury or dysfunction. Though ‘relaxation massage’ and stress management will always be a part of our scope of practice you just need to look at the curriculum of a school to see the growing list of conditions that we as MTs can treat.

This direction in the profession (which in many ways is taking off from where the profession was during the early part of the century) has seen a number of terms bandied about to describe it, such as: medical massage, therapeutic massage, and treatment massage, to name but a few. In turn massage therapists have toyed with different terms to describe themselves: body-workers, deep tissue specialists or soft tissue specialists.

This process of trying to define what we do and the role we are to play within the health care environment has resulted in a pithy statement regarding our “scope of practice,” the kernel of which is contained in the phrase: ‘To assess and treat soft tissue injury and dysfunction …’

In order to be therapists, to treat people and help them recover from injury, help them with their pain, or provide palliative care we need to know not just how to apply the diverse techniques such as Swedish Massage, Muscle Energy, Polarity Therapy, or Craniosacral, applied singularly or in combination. We also need to know when to apply these techniques.

In order to treat a wide variety of conditions we cannot rely on others to provide us with a pre-done assessment that is always correct, or that is thorough enough so that we just perform some memorized routine. In order to use the techniques and manipulation along with the treatment modalities that we have learned we need, above all, to be able to assess for ourselves the injury or dysfunction that the client presents with. All too often, a client comes to us with an assessment that is vague and of little help: e.g. sciatica, a pinched nerve, whiplash, etc.

Proper clinical assessment procedures in no way hinder or prevent a MT from using whatever techniques they wish to explore; if anything, it provides the sure footing upon which such techniques (e.g. Craniosacral, Reiki, Shiatsu, Aromatherapy, muscle energy …) can make you a better therapist. If anything, a strong grounding in physical orthopaedic assessment helps us unite and focus our “intention,” that mysterious ability or attitude that somehow allows us into the tissue when we have it. If we cannot focus our intention we are often unable to be invited into the
tissue and hence are left unable to assist the client with their healing.

Now, many of the “specialized techniques” come with their specific form of assessment: craniosacral rhythms, energy evaluation, Traditional Chinese Medicine pulse diagnosis, and Hara palpation, to name a few. But often they are dependent on either the technique or a specific model of human health or both. However, no matter what techniques you use a basis in clinical assessment can bring focus to client treatment.

Understanding what soft tissue and structures are involved can only help to bring to bear all of our techniques into a cohesive whole and maximize our effectiveness as therapists.

Further, assessment techniques from osteopathic to traditional Chinese medicine need not be seen as outside of classic orthopaedic assessment. They can be employed as “Special Tests” or procedures. For that is what they are: tests designed to test specific structures, energies or balances within the body.

The basis of clinical assessment is active, passive and resisted testing: “range of motion testing.” They are to assessment like effleurage, kneading and muscle stripping are to massage techniques. They can be part of every treatment. Yes, it’s true, they are not as flashy as those “Special Tests” we all had to learn in school, or those “Advanced Techniques” that get
all the attention when we spend hundreds of dollars learning them post-grad. Range of motion testing is like meditation; practice until it is second nature and the reality of our client appears right before our eyes, appearing as the obvious.

There is a danger when making an assumption about the client’s injury during case history taking and testing only for that assumed condition. So, even though a client’s subjective report implies a rotator cuff tear, do not just do the tests specific to a rotator cuff tear.

If you only do a test specific to a tear you may well get a ‘positive’ but that could be secondary to some other tissue or structure that is the ‘real’ primary cause of their pain or problem. Or on the other hand, it may be principally a rotator cuff tear but you do not want to lose the opportunity to see how all of the surrounding or compensatory tissues are involved or responding.

Further, by being thorough you may discover postural or muscle balance issues that may have set the client up for this injury and, if untreated or not addressed, may leave the client prone to re-injury.

Alarms should go off in your head every time you think, “I’ve heard/seen this before … and it’s always been …” You need to resist the temptation to only do the tests that would confirm your guess, or skip the testing altogether.

Often in the face of technology health professionals have acquiesced to employing or relying on a machine, especially in the field of assessment. Are not X-rays, CT-scans, or MRIs the truly objective base for judgements about soft-tissue pain
and dysfunction. The short answer is yes and no. For acute trauma based injury the answer may be yes. For chronic or recurring injury the answer is actually no.

In a 1998 article in Scientific America, Dr. Richard A. Deyo brought together some interesting studies about assessment when addressing the issue of low-back pain. Deyo concluded “that at least for adults under age 50, X-rays added little diagnostic value to office examinations …” Further, referring to epidemiological research it was “revealed that many conditions of the spine that often received blame for pain were actually unrelated to the symptoms … and multiple studies determined that many spine abnormalities were common in asymptomatic people as in those with pain. X-rays can therefore be quite misleading.”

And lastly, “even highly experienced radiologists interpret the same X-rays differently, leading to uncertainty and even inappropriate treatment.” Though hands-on assessments by various health care professionals of the same client can also produce a variety of conclusions, the point is that X-rays are no more objective, and other than in trauma scenarios, add nothing to case history taking and manual assessment skills.

The new toys, CT-scans and MRIs are no better for soft tissue injuries either. In one study that involved looking at pain-free individuals under 60 years of age (who never had a history of either back pain or sciatica) the “MRI found them [herniated disks] in one fifth of pain-free subjects … Half that group had a bulging disk, a less severe condition also often blamed … Of adults older than 60, more than a third have a herniated disk, visible with MRI, nearly 80 per cent have a bulging disk and nearly everyone shows some age-related disk degeneration.”

Another study found a two-thirds of pain-free individuals had disk abnormalities: “Detecting a herniated disk on a imaging test therefore proves only one thing conclusively: the patient has a herniated disk.”

Yet, to this day, if a person complains of low back pain and has an X-ray or imagining scan (often without any manual testing performed during an office visit) and a disk abnormality is found, that abnormality will be said to be the cause of the patient’s pain.

Imaging technology is one reason for the waning of manual assessment skills. Another reason is changes in other professions. Many physiotherapists are becoming administrators of physio-clinics. The same is true of occupational therapists. Paperwork generated by legislation and the health care system is moving them into supervisory roles where assistants are taking on the hands-on work. This distance from the client often means that hands-on testing procedures are overlooked and reliance falls on the assessment the client came to the clinic with from their physician or imaging centres.

As other professions continue to give up manual testing skills and rely on imaging technology, we as massage therapists are in an enviable position. As manual therapists we have the palpatory skills, the knowledge of soft tissue anatomy and, just as important, the time to spend with the client. Who else is better suited or prepared to take up this craft of manual orthopaedic assessment?

As a profession we are positioned to take ownership of these skills and make ourselves an invaluable member of the health care community.

By affirming that assessment is integral to treatment we have a valid claim to the title of ‘therapist.’

For massage therapists, clinical assessment is the means by which we evaluate ‘soft tissue’ and joint injury or dysfunction so that we understand how these physical structures are producing the pain and/or dysfunction that the client presents with. Its purpose and intent is to provide the information upon which we can choose the best way to treat the client, or to refer out if necessary.

Clinical assessment is not “diagnosis.” We do not determine underlying pathologies or organ dysfunction. We are simply assessing or describing the condition of the musculoskeletal structure. We map out ROM, we bilaterally compare muscle strength, length, and we describe the feel of tissue. All the time noting where there is pain or restriction or tension or hyper mobility, etc. We are creating a picture of the individual that is before us so that we can find ways to lessen their pain, free their limbs, or help them cope with disabilities.

Clinical orthopaedic assessment for the massage therapist is the evaluation of soft tissue and the implications this has for posture and function of muscle and joints.

Massage therapists often see the body as an interdependent dynamic whole, we recognize that any change or dysfunction 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.

Orthopaedics means ‘foundation for growth.’ Orthopaedics is concerned with preserving, developing or restoring the healthy form and function of the limbs and spine.

To arrest or stop a dysfunction we must see what tissues or structures are involved and understand the condition of these tissues, and the normal condition for the client, so that we can resolve the pain/dysfunction. We must see our clients as unique individuals with unique treatment needs. This “seeing” is what we call assessment.

In many ways assessment is ‘seeing anatomy.’ When we think through our anatomy we arrive at our manner of assessment. When learning a ‘special test’ for example, like a meniscus test for the knee, if you understand the anatomy, the biomechanics of the tissue and structures, then how to do the test becomes ‘obvious.’ How we think or see anatomy accounts for the variations in testing across the variety of techniques and models that a massage therapist can employ. If you see the body as energy, you see how to assess it as energy. If you see the body as governed by its fascia, then that is how you see to assess. I do not think we need argue about which way of seeing is right or primary. I would rather provide the basis where they can stand together, and work together for the benefit of our clients.

The whole purpose and intent of clinical assessment is to see and think our way into the body so that we may find the cause(s) of the pain/dysfunction, so that we may treat the cause and not just the symptoms.
This is our ideal.

Let’s be blunt. Many acute injuries are obvious in nature: primary injured tissue reveals itself as such by its swelling, redness, heat, bruising, bleeding or loss of function.

Assessment is much more difficult when a condition is chronic or has an insidious onset. At this point assessment is like solving a mystery. When injuries are old or pain is chronic we need to be shrewd and well-trained detectives. There are lots of red herrings, blind alleys, and disguises.

The testing of fresh traumatic injuries or ‘sudden onset’ injuries is often relatively easy compared to the chronic case of lingering or insidious pain or dysfunction.

In the chronic situation there are no easy answers and often no single assessment session is sufficient. It is in these cases that treatment and assessment are most clearly linked.

Over several therapy sessions we can use trial and error in orthopaedic testing to propose possible answers to the client’s complaint, re-testing various structures over several sessions, or re-evaluating the results of our testing. We are palpating every moment that our hands are on the client. We observe endlessly and, by communicating with our client throughout the treatment, our case history taking is an ongoing process. By re-evaluating our previous treatments and the success of the remedial exercises and home-care suggestions we re-assess and re-evaluate. Our attempts to understand their unique pain and their unique reaction to pain are appreciated by our clients. In this way, through our dedication, we can always be successful.

Through our assessment and reassessment we constantly ‘see’ each client anew through their own change, growth and uniqueness and never find ourselves ‘doing the rotator cuff at three o’clock.’

Assessment is not just the boring stuff that comes before the massage; it is the heart and soul of treatment. If we say that we are health care treatment providers but cannot say, precisely, what it is that we are treating our clients for, in what sense are we therapists? We are among the last of the hands-on healers. Our profession and our training allow us the time and the techniques to treat each client as a unique individual by ‘seeing’ each client’s strengths, weaknesses and possibilities.

Assessment really is a remarkable, holistic, meaningful and positive growth process that allows each client to receive the treatment that they need and deserve. When assessment and treatment are two parts of one whole, massage therapists are really holistic healers.