NOTES ON RECORDING FINDINGS FROM POSTURE ASSESSMENT:
(NOTE: these were some notes I thought I would share from my past clinical supervision teaching to aid write up of assessment findings and clinical reports. See also other post on case study example for a patient with shin splints in “Assessment aids 1″ for a visual example)
for a report/summary it’s always good put an intro..E.G. “A …… (Age)Yr old ……(M/F), …………..(occupation/sport, etc) presents with”……. (symptom picture). Then go into all the relevant history details (including general health questions, other issues elsewhere and past history of accidents, injuries, opperations, etc – to get a sence of what else could be setting the stage for, or slowing recovery from, injury/illlness).
ONLY observation at this stage – of TEXTURE AND SYMMETRY (STATICALLY – WHAT YOU SEE) – DRAW/Shade in on postural diagram (with written notations if needed) – for the whole person (not just the part with symptoms). It’s good to draw symmetries (e.g level lines where levels are equal) as well as asymmetries for contrast.
Only Palpated Asymmetries and Texture findings (generally, regionally and IN DETAIL/landmarks soft tissue and Bony – To I-D key tissues in trouble in both symptomatic and other key areas of the whole person contributing) – (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. 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 healthy – or vice versa (which influences meaning and interpretation of findings).
4) Motion Testing
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 Needs to have Details – e.g. what regions of the spine are actively restricted in QUALITY of movement (E.g. L1 – sacrum) – as well as which movements and directions? These need to be further clarified with PASSIVE AND ACCESSORY Movements – in both the Primary and secondary areas (e.g. 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 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 Q.L – but passive lumbar movements might be easier indicating that the actual joints are ok but it’s the SIJ and soft tissues – i.e. the Q.L that are 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 assoc muscles (pec.min 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 WDX – (see below).
To record – write in and on the posture chart you need to circle in areas of active movement restrictions (e.g. whole lumbar pelvic region) and cross off the segments actually tight passively (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 (this is what the patient feels only) – YOU NEED TO DESCRIBE WHAT YOU FEEL/SEE also in order to give meaning to the painful feeling (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). Pain simply means something is not liking the movement – not why?
5) Working Diagnosis & Discussion of Results
In addition to what you learnt, missed, realisations, etc. you need to describe how your ACTUAL findings all LINK in the form of a working diagnosis (pattern of cause to effect) and not just say effect, symptoms or include vague general findings with no real understanding of the relationship between these findings.
It ideally should be something like this:
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 …………………………. 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 posture and then say, this is maintained by key dysfunctions in ………… (list primary findings )………….placing stress on …………………(other secondary areas/tissues) and thus pain/symptoms.
Then add contributing and maintaining factors could include; overweight, poor postural or work/sport habits/techniques, repetitive activities, work (e.g. sitting all day, lifting heavy weights) or environmental stresses, emotional and mental stress (describe), lack of sleep, lack of stretching, etc.
E.g. for 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:
a) A primary restriction in the sacrum (held in backward and left tilt) and Left SIJ and right Q.L is holding the pelvis in a posterior rotated and Left tilt 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 sidebending/rotation is placing increase stress on the right thoracic outlet (with key symptomatic restrictions in the right scalenes, Pectoralis minor, 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)
Can you see how this will significantly help understanding and the formulation of a sound and logical treatment and rehabilitation plan addressing all of these findings/contributing factors?
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 ones instrument of investigation – our minds and senses – are also adequately trained to pick up the clues in the first place from out assessment processes – if not the process itself alone will not work)
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 (i.e. special tests are not a substitute for good postural assessment).
By Paul Turner www.turnerpublications.com
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