Turner Publications & Osteopathy

Assessment Aids 3: Help Tips for Recording Findings from Posture Assessment

SELF-HELP TIPS ON RECORDING FINDINGS FROM HOLISTIC POSTURE ASSESSMENT:

Introduction:

The following example of how to better record findings is an attempt to correct an Issue I have noticed in the past observing students in Osteopathic teaching clinics.  I noticed that many of the students did not use the posture diagrams to their full potential (and often didn’t use them at all). They tended not to routinely explore and notice the PRIMARY PROBLEMS elsewhere (“the what else”) from their general postural assessment simply because the assessment process itself did not routinely reinforce the general assessment part of clinical examination.  Thus, they rarely recorded findings elsewhere because these findings were ‘out of mind – out of sight’ so to speak).   It was not surprising therefore that many students had trouble observing and understanding the relationship between the “what else” (PRIMARY ART’s) and the tissues causing symptoms.   When assessing, they instead tended to jump straight to the region with symptoms and try to work it out from there rather than first observe the whole for the bigger picture and obtain clues about ‘what else’ needs also to be investigated (for primary problems elsewhere, which, if present, and are observed and felt for, provides context for the presenting issue.   This is not the students fault however, because they are only following the protocols set out in today’s education.   The reductionist biomedical model seems to be emphasised to the extent that the holistic elements are often neglected, without anyone even realises they have been missed.   This can be easily remedied however but simply reinforcing the importance of a holistic assessment process and including it back in for context.

Although a history often starts with the presenting complaint and then we ask questions about the background whole person (life history, general health, lifestyle etc), I have found that the assessment process itself works much better if we start by assessing the the background whole and then, once important factors in the whole person are noted first, HONE’ in on these key areas and their relationships in more detail.  In this way vital factors contributing, if elsewhere are not missed.  This holistic assessment therefore inevitably results in us uncovering investigating (in more detail regionally) at least two regions of the whole person (unless primary and effect are in the same region):

1. For the “what else” behind the scenes setting up the symptomatic tissues, maintaining them and or otherwise slowing the healing process by interfering with the ‘self-healing mechanisms and preventing them from doing their work efficiently.  This can include relationship imbalances between any aspect of the whole person (Spiritually, mentally, emotionally, energetically, and physically, and can include other factors such as diet, relationships with other people, environment, sport, work etc).   The physical manifestation of all of these relationship imbalances manifest in the physical body as Area (or Areas) of PRIMARY A.R.T. (Asymmetry, Range/Quality of Motion Abnormality and Tissue Texture Changes.  NOTE: THIS IT THE TRULY OSTEOPATHIC PART AND WHAT WE SHOULD BE GOOD AT DOING IF WE ARE TRUE TO OUR PHILOSOPHY AND PRINCIPLES;  I.e. are helping to remove impediments to the natural healing process).  We don’t heal the body.  We set it up to heal itself more efficiently but to do this we need to get good as assessing and noticing findings in the whole person first.

2.  The Area comprising the tissues causing symptoms.   This is what is usually explored but without the context of the background whole person, on its own , doesn’t tell us very much about how the tissues causing symptoms came to be in the mess they are in to begin with.   The better we understand the context for them being in trouble the better and more safely we can treat. WHY? because we understand what we can actually treat to help take stress of the tissues causing symptoms and thus support optimal recovery.

Furthermore, the students were encouraged to come up with a symptomatic diagnosis and then list any contributing factors which may be present.  But – because the whole person was rarely “consciously’ noticed they tended to make up the contributing factors from the history or guesswork (regional case study reasoning perhaps) rather than from actual tissue findings.  It makes more sense to describe the pattern from ’cause to effect’ rather than ‘effect to cause’ (although if all the relevant findings are present we can trace it either way) as this helps with understanding of “WHY THINGS CAME TO BE” and thus provides “CONTEXT” for the presenting issue.  The focus was more on what was causing the pain than what was going on behind the scenes setting the symptomatic tissues up.  Because General posture assessment for primary ART’s was not mindfully performed (with awareness of why it is so important), the natural result was that findings were not noticed and recorded properly on the examination forms.    In my opinion we should not start with a symptomatic diagnosis but rather end with it.   If we follow a simple process of A = Observing, Palpating and Motion testing; B = Generally, Regionally and Locally and repeat C = Standing, Sitting and Lying, and make a comment about symmetry, texture and motion in each posture – noticing similarities and differences in A.R.T in each posture for both the primary and symptomatic areas also – then we can’t fail to get good at assessment.

One student I recall did just this and by the simply following this process and practising it on every patient for a whole semester he did become a more confident and competent practitioner.

So because effect comes after the cause it should be documented that way also.   Our working diagnosis is simply storey starting at the beginning and reaching its logical conclusion in the effect.    It should describe the whole person and not only a part of a person.  A benefit of this approach also is that after, when we reassess, if we have done a good job, the whole person will look, feel and move in a more balanced way telling us exactly how effective our treatment has been.  How do we know if our treatment has a local (temporary perhaps) effect or a more global (long lasting one perhaps) unless we know what was there to begin with?

As such the following is some suggestions I have for both performing and recording your findings from a mindfully engaged holistic postural assessment,   I hope you find the following helpful.

The STEPS

1. HISTORY

or a report/summary it’s always good describe essential details in storey form. G. “A …… (Age)Yr old …… (M/F), …………..(occupation/sport, etc) presents with”……. (symptom picture).  Then go into all the relevant history details (local, regional and general including past life history of ‘anything else’ and general health screen information as this gives us an indication of what people have been through in their whole life (i.e. what else) which may be setting up or contributing to the presenting issue or otherwise slow its recovery – and thus give clues to potential complexity and prognosis).

2. OBSERVATION:

Describe/Draw ONLY observation findings (for now to develop receptivity to visual clues) at this stage – of TEXTURE AND SYMMETRY (STATICALLY – WHAT YOU SEE) – DRAW/Shade symmetry & texture in on postural diagram (with written notations if needed). It’s good to draw symmetries as well as asymmetries for contrast.

3. PALPATION:

Describe/draw only Palpated Symmetries, Asymmetries & Texture findings (generally and regionally – healthy and unhealthy for contrast) and IN DETAIL/local landmarks; soft tissue and Bony – To I-D key tissues in trouble – (STATICALLY – WHAT YOU FEEL). DRAW/Shade in both on postural diagram (with written notations if needed).  This will enhance/reinforce and clarify what you have already SEEN from observation.  Contrast healthy and unhealthy areas if possible (and symmetry/asymmetry – note an area may be asymmetrical and can even have altered texture but still be ‘functionally and textually’ healthy – or vice versa (which influences meaning and interpretation of findings).

4. MOTION TESTING

Describe/Draw MOTION TESTING findings (DYNAMICALLY – WHAT YOU BOTH SEE AND FEEL). This adds the ‘quality of motion’ element to the already observed and palpated “Areas of both” Asymmetry and Texture change): Recorded findings need to have details – e.g. what regions of the spine are actively restricted in QUALITY of movement (E.g. L1 through to the sacrum) – as well as which movements and directions of freedom/limitation?  These need to be further (later) clarified with PASSIVE AND ACCESSORY Movements – in both the Primary and secondary areas (e.g. which in relation to the case below, the primary region is the sacrum/pelvis and the primary restriction to passive movements would be at the left Sacro-iliac Joint (SIJ) and actively the whole Lumbar side bending left may, most likely, be restricted if compressing the Left SIJ and  also due to the stretching of a tight right Quadratus Lumborum muscle (Q.L.) – but passive lumbar movements might be easier in quality indicating that the actual joints are OK but it’s the SIJ and soft tissues (i.e. the Q.L specifically), that are primarily limiting its movement.

Can you see how this detail helps?

There may be secondary restriction also at the C/T junction, 1st rib, clavicle and associated muscles (pectoralis minor or scalene for example) – limiting certain movements – All which will link to observable/palpable findings actually uncovered.  All this needs to be in the findings, in addition to GOOD OBSERVATION AND PALPATION findings – in order to formulate a good Working Diagnosis (WDX) – see below.

To record – write/describe the levels/regions/segments involved on the posture chart and/or it may be helpful to circle in areas of active movement restrictions (e.g. whole lumbar pelvic region) and cross off the segments actually tight passively within this active region (e.g. Left SIJ) – in the primary area and also in the Symptomatic area.

Also – DON’T JUST WRITE – MOVEMENT PAINFUL with no further comment because this is what the patient feels only and can distract from what you feel/see.  YOU NEED TO DESCRIBE WHAT YOU FEEL/SEE also in order to give meaning to the felt experience (e.g. it could be painful because hyper-mobility or hypo-mobility, due to over stretch or compression).  The feeling gives you more meaning and understanding (about why perhaps which QUALITY of motion may clarify).  Pain simply means that something is not liking a movement – not why it’s in trouble to begin with?  Note: If a tissue is limited in one posture but completely free in another then is is likely a compensation and not a primary dysfunction.

5. WORKING DIAGNOSIS & DISCUSSION OF RESULTS

This can include after, in addition – what we learnt, missed, any realisations we may have had when trying to relate the ‘what else’ elsewhere to the tissues causing symptoms, etc). Here = we need to describe how your ACTUAL (observed, felt and motion quality) findings all LINK up – explaining the relationship between what else (i.e. the primary ART’s) and the tissues causing symptoms – in the form of a working diagnosis (pattern of cause  – or ‘what else’ – to final effects) and not just describe the effect, the symptoms or include vague general findings with no real understanding of the relationships between the involved findings.

A Working Diagnosis, ideally, should look something like this:

  1. a) Primary problems in …………. tissues (list and describe) are holding this area in ………………….position, creating compensatory …………………….positioning in structures elsewhere/above/below (describe) which is placing stress/compression/traction/stretch on …………………………. (involved) Structures (describe effects on these, often secondary structures, based on local findings at the symptomatic area) – causing …………………………………..(key differential diagnosis, if applicable) creating ………………(symptoms/pain, etc).

Or b) if you are not sure what the primary tissue are – describe the overall posture and then say, this is maintained by key dysfunctions in ………… (list primary findings or ‘what else’)………….placing stress on …………………(other secondary or symptomatic areas/tissues) and thus pain/symptoms

Then add  other contributing and maintaining factors which could could include; overweight, poor postural or work/sport habits/techniques, repetitive activities (e.g. sitting all day, lifting heavy weights) or environmental stresses, emotional and mental stress (describe), lack of sleep, lack of stretching, etc.

For example: a problem in a 24 yr old university student with right sided neck pain and tingling in the right arm and hand, a Working Diagnosis could very well be something like this:

  1. a) A primary restriction in the sacrum (held in backward (counter-nutated position) and left tilt) and left sacroiliac joint and right (shortened) Quadratus Lumborum muscle is holding the whole pelvis in a posterior rotated and Left tilted position with a slight rotation left also – resulting in the trunk above compensating by a) flexing in the Lumbar and Thoracic spine resulting in an upper cross type posture and forward head carriage creating in increase stress at the C/T junction. And b) This together with a compensatory rotating and side bending right to the trunk above, is dropping the right shoulder, placing further imbalance and stress on the right C/T area and upper ribs with associated hypertonic scalene and pectoralis minor muscles – contributing to a Right thoracic outlet problem and resulting in neck pain and tingling in the right arm and hand.

Other Contributing factors are – poor sitting posture at school (sitting slouched all the time), carrying a bag always over the right shoulder, mental and emotion stress (further effecting neural tension) and doing a lot of writing (being right handed) related to studies (further placing tension and strain on the right arm/shoulder, etc).  

Or, if not clear of order – b) The patient has a slouched type (trunk flexed) posture with associated anterior head carriage.  This together with a left pelvic tilt/rotation and an associated right trunk side-bending/rotation is placing increase stress on the right thoracic outlet (with key symptomatic restrictions in the right scalene & Pectoralis minor muscles, C/T junction and first rib) with resultant symptoms of thoracic outlet syndrome.  Key maintaining restrictions holding this postural pattern were noted in the Left SIJ, and Right Q.L.  Other contributing factors are…(as above)

With this in mind it should be easier to see how  a holistic working diagnosis (explaining the whole pattern of dysfunction) will significantly help understanding and the formulation of a sound and logical treatment and rehabilitation plan addressing all of the involved findings/contributing factors?

 

Conclusion

BASICALLY – A GOOD WORKING DIAGNOSIS REQUIRES GOOD EVIDENCE GAINED FROM A COMPREHENSIVE ASSESSMENT PROCESS.   The answer virtually, in most cases, presents itself and guesswork is thus minimised.   One needs a good Assessment PROCESS to have any chance of good ASSESSMENT FINDINGS (assuming one’s instrument of investigation – our minds and senses – are also adequately trained to pick up the clues in the first place from our holistic assessment processes.  If not, the assessment process itself alone will not work as nothing will be noticed in response to the processes themselves).

Note: active resistant and special tests can also be included to help you rule in or out the key differential diagnosis you should already have uncovered from good postural assessment (But remember – special tests can help rule things in or out but are not a substitute for good postural assessment and in fact – if you observe and feel the tissues symmetry, texture and motion this will enhance correct interpretation of any special test performed and thus will help derive more meaning from them).

Note: We (as a class) once recorded all the findings from each stage of a holistic postural assessment in a class for remedial therapists once and the results I have included in another post (CASE STUDY FOR PATIENT WITH SHIN SPLINTS – CLICK TO SEE POST).  So… this post goes through some (simplified) steps and the other one illustrates the results.   Observing the results immediately makes apparent that any clinical case study which does not include the whole person (for ‘what else’) is more limited and reductionist in scope (exploring the relationship between tissues/conditions causing symptoms and the symptoms itself and is not truly holistic (exploring the relationship between ‘what else and the tissues/conditions causing symptoms), and is thus (in our case) not truly an Osteopathic case study (and would hold true for any holistic profession).

I hope you have found this article helpful.

Best wishes,  Paul Turner www.turnerpublications.com

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