General (Holistic) Assessment – Why is this so important?
This is important to carry out on every client in order to uncover the primary area of dysfunction that is most affecting recovery of the whole person with any injury. The primary area can either: cause, predispose, maintain or contribute to the symptom picture in some way. The primary area/dysfunction pattern can slow the recovery process.
Remember the patient is the one doing the healing. The Practitioner helps by removing impediments to the healing process so that nature can do its work in a more natural time frame.
For example, if someone cuts their finger – locally, we may apply first aid and clean and bandage the wound. But – what else can we do to help? If an individual has mechanical restrictions in the thoracic outlet, these restrictions can effect flow of blood/nutrition to the injured area or affect venous and lymphatic drainage back to the heart. Likewise restrictions around the sacrum and thoraco-lumbar junction may mechanically (through anatomical relationships) or neurologically (via the Parasmpathetic – S2,3,4 and Sympathetic nervous systems (T5- L2) affect the digestive systems and thus affect gut absorption of nutrients which can then affect flow of nutrients to the damaged tissue and further slow recovery. Poor diet can likewise effect tissue healing. These restrictions may not cause a cut directly but they CAN slow the healing process and thus interfere with the recovery process. This is why different people with the same injury/illness recover at different rates. It is also why the manipulative therapist may get the best changes in one case where as the dietitian/naturopath may help more in another. It all depends what else is happening in the whole mechanism of the individual concerned (and how many components of the whole are involved in the recovery from the presenting symptoms – directly or indirectly). There are numerous other examples to illustrate this and I have included some case studies and material (at end of notes) which should help to illustrate the importance of holistic individualized assessment further. Please read this information and reason it through.
How are we going to identify these potentially involved relationships in any individual patient’s case unless we take a thorough history and perform a good General Screening Process?
Note: The following information is taken from Chapter 1 of Wholistic Integrated Assessment, A Teacher-Student Guide (12 DVD Set and Manual – See bibliography section). The How to do all of this is discussed in this publication. The goal of this information is simply to reinforce the importance of holistic assessment and give you a feel for how I approach patients with health care issues.
HOLISTIC ASSESSMENT means: – To assess the WHOLE person (even if we don’t know how, or choose not, to treat the whole). A problem/injury does not walk into our clinic, a person does. This person has a history of many previous experiences, stresses, traumas, accidents, injuries, etc as well as certain training, beliefs, feelings and attitudes to life – all of which may help or hinder the rehabilitation process.
COMPONENTS of the whole can be divided into Internal and External Influences and the problem often involves an inner predisposition (e.g. postural imbalance) in combination with an external agent (e.g. overtraining, gravity, trauma, etc) that leads to stress on the symptomatic area and will thus lead to the manifestation of symptoms. A person may have many internal and external influences that happen to be contributing to his/her problem pattern in some way – either as causative, contributing or maintaining factors – each of which may slow or hinder the healing process to some extent if not identified and treated.
A focus on a problem area or part of this person alone may not lead to successful recovery unless these contributing components are identified and thus integrated (in some way) into the management/rehabilitation program – either through personal management (using the combination of our awareness of the condition, anatomical & physiological relationships and whatever treatment modalities/techniques we happen to have available) and/or referral to the appropriate health care professional.
The GOAL of the Holistic Assessment Process is: – To identify key components present in a person’s inner and outer environment that may be contributing, in some way, to the problem or holding pattern.
INTERNAL INFLUENCES: – Refers to any of the components within the human mechanism (Spiritual, Psychological, Physical Anatomy and Physiology) that may be contributing in some way to the problem pattern in its entirety.
EXTERNAL INFLUENCES: – Refers to any of the components outside of the human mechanism that may be contributing to, or influencing, the problem pattern
HEALTH: – Means all components of the whole are functioning in harmony with one another. There is a healthy balanced FUNCTION and a balanced relationship between all components. This means there is no difference in the functional relationship (although there is in structure or form) between the various tissues or components of the whole. Thus, when using any of the tools of diagnosis (mentioned later) all tissues/states would feel even and balanced (i.e. symmetry, balanced motion and healthy tissue texture tone) with respect to each other and the whole.
To recognize Health we look for areas that reflect and radiate balanced symmetry, motion, light, vitality, and tissue texture tone, etc. In fact if we look for these areas first we will automatically notice problem areas because they are simply areas that do not (in a minor or major way) reflect these qualities – they don’t look/feel quite right. Seeing Health first allows us to notice the edges and boundaries of the dysfunctional areas in their entirety. Around (and even within in some cases) all problem areas are healthy areas (see concepts of finding health and dysfunction).
DISEASE (DYSFUNCTION) – implies an area or component is out of harmony (balance) with the whole. There is no longer healthy FUNCTION (EASE) but rather a DYS-FUNCTION (or DIS-EASE). Thus Disease means one or more components have separated themselves from Health and have began to function in a separative and less than ideal way. There is no longer a UNITY (one Whole) but rather fragmented sections that are no longer in a balanced relationship (communication) with one another. In this state there is a difference and now when we apply our diagnostic tools we will begin to detect imbalances, not only between two or more areas/components but, more importantly, between Health and Disease.
It is important in the general assessment process to identify the areas of greatest difference (from and compared with health) as these areas tend to have a marked influence on a person’s ability to recover from illness or injury. This implies that we notice the healthy areas first.
A PRIMARY AREA OF DYSFUNCTION: – Refers to that area of the Whole that is most out of harmony with Health and which is maximally hindering the function of the person as a whole. This is the area (comprised of often numerous components) that is slowing recovery and that is preventing the body’s self-healing mechanisms from doing their work efficiently.
SECONDARY AREAS OF DYSFUNCTION: – Are all other areas of the human mechanism that have been forced to adapt/compensate to maintain homeostasis (balance) as a whole. These areas may themselves, over time and with continued stress, become dysfunctional (often in combination with the forces of gravity, further trauma, etc) and thus create stress and further compensation in other areas and so on, extending the chain of cause and effect until the body cannot adapt anymore and thus manifests symptoms – often in remote areas from the initial disturbance.
Primary components with respect to the primary area refer to those tissues/layers that are holding that area in a dysfunction pattern. With respect to the symptomatic area, the primary components are those tissues/layers that are manifesting the symptoms.
Secondary components refer to the tissues/layers surrounding the primary tissues/layers involved that have been forced to accommodate/compensate in order to maintain overall balance, both in the local area and in the whole.
When the human mechanism cannot heal/resolve a disturbance (on any level), it will compensate in order to maintain an optimal balance in the whole. The general screening process and the ability to gain meaningful and useful information from this process are vitally important in order to uncover the causes lying/hiding beneath the effects (or compensatory patterns – which are often more noticeable).
Knowing this information, our management becomes much more effective in helping the human mechanism to remedy a situation it was unable to heal when the injury first happened. Local assessment only deals with effects or symptoms and unless the cause happens to be in the same area as the symptoms, little long-term results will occur.
DIFFERENTIAL DIAGNOSIS: Refers to a list of possible conditions a person may be suffering or a list of possible tissues causing symptoms. If we know our anatomy and we know the area in which a person has symptoms, we should have a reasonable idea as to what tissues are possibly contributing to the symptoms. This list is a list of options considered after taking a thorough History (but being also open that it could be something else unconsidered at this stage). Hopefully, after our assessment and layer palpation we would be able to narrow down this list (or possibly expand it to include other options in some cases) as we confirm more precisely what is going on.
WORKING DIAGNOSIS: Refers to what we feel is going on as a whole after taking a History and performing a thorough Assessment, backed up possibly by our special tests and other investigations. It is an attempt to tie together all of the inner and outer components, uncovered so far in our investigations, that may be contributing to the symptom picture. It includes any causes, contributing or maintaining factors in the posture of the whole patient, any external influences such as diet, training and the effects of gravity on the symptomatic area as well as a description of what is going on at the symptomatic area itself.
E.g. A sacral and pelvic imbalance (with key restrictions in the right S-I joint, mid lumbars and Right Q.L.) combined with the effect of running on uneven surfaces (sloped track) and the effects of gravity have placed increased demand on the right Achilles tendon with the subsequent development of an Achilles Tendinopathy.
This sets the stage for a more comprehensive treatment and rehabilitation program that can address all of these components and not just the part suffering the symptoms.
ACTUAL DIAGNOSIS – Is the actual or real diagnosis based on the fact that all relevant clues have been discovered through the assessment process. This is what IS actually happening and not merely what we think or guess is happening.
In some cases our working diagnosis will be the actual diagnosis and in other cases it will not be because we may not have uncovered enough clues from our assessment at any given moment to put the whole puzzle together. However the goal of the assessment process is to make a number of unknown factors known and thus even if we do not have all of the clues, we can still form a working hypothesis based upon all the clues we have to date – keeping in mind that more clues may emerge as we proceed with assessment and treatment. This makes our work safe because we never have to treat anything we have not uncovered in our assessment. We only treat safely and within limits those components that we have uncovered so far. Because we know what tissues are involved, as far as our experience and skills enable, we can treat these effectively using the wide range of treatment techniques and options available.
NOTE: – The General Assessment process does not identify DETAILS – this is the role of the regional and local assessment process. The General Assessment process simply identifies the areas of greatest difference. Differences must be acknowledged before we focus on details, otherwise we may prematurely hone in on regional or local details only to find later that we have wasted time on effects rather than causes (see primary and secondary areas) as well as failing to relate properly the details at the symptomatic area with the details at the causative, contributing or maintaining areas of the whole (see local assessment).
NOTICE DIFFERENCES BEFORE HONING IN ON DETAILS.
Try the following self awareness exercise:
1) Create a problem in your right thoraco-lumbar (upper low back) area. Extend, side bend right and rotate around this dysfunction and then straighten your heads so that your eyes are level. Holding this crooked posture, notice where you feel the strain in your body (e.g. upper body, back, legs, etc)? Then walk around in this posture and imagine how you would feel at the end of the day if you walked around, held in this pattern? Do you feel pain or discomfort in the problem area or elsewhere?
This should illustrate how the problem area affects other areas, and also the individuality of each person’s compensatory mechanisms (when you do this with groups of people). It also illustrates that the pain is often felt at a distant site to the original problem – thus emphasizing the importance of needing a holistic assessment.
The reason each person feels discomfort in a different area is because each has a unique life history of previous strains, stresses, etc (which practitioners can pick up in the tissues) and a unique way of compensating to stress. Thus, when a further stress is placed upon the mechanism, previous areas that haven’t been loaded enough, as yet, to show dysfunction, now begin to show symptoms. The pain is felt in whatever area or structure is under the most stress with weight bearing forces, be it bony, tendinous, muscular or otherwise. This is especially the case with overuse injuries or injuries with no onset of acute trauma, although these predisposing dysfunctions may have an influence even in acute injuries (by setting the stage).
These are some examples to illustrate the possible relationship between the internal and external influences and the symptomatic area.
- A pelvic imbalance (internal influence) under the influence of weight bearing forces (gravity) and running/training (external influences) may lead to increased stress being placed upon the knee, ankle or foot with the subsequent development of a knee problem (e.g. patellar tracking disorder), an ankle problem (e.g. achillis tendinopathy) or a foot problem (plantar fasciitis/mid foot pain or a first metatarsophalangeal joint problem, etc). It all depends on where the gravitational forces primarily act in combination with the internal postural imbalance and the demands of the sport.
- A patient has recurrent left knee problems (pain and swelling due to cartilage damage) from an old injury almost 2 year ago that never fully recovered. Examination revealed some minor asymmetry at the knee, the cartilage damage and poor flow of blood/nutrition/energy to the knee itself. It also detected some tension and imbalance sacrum/pelvis which itself was due to a restriction in the right lower abdominal quadrant. This area had a similar congested, bound and devitalised feel. On further questioning he revealed that he did have some digestive trouble and that he had received an operation on his appendix many years earlier in the restricted area. Due to the restriction and internal scarring that resulted from this operation (which you could feel) this was affecting the motility of the bowel and affecting nutrition/energy flow to the tissues, especially the knee that was already compromised because of an old injury. It was also creating a twist in the pelvis by locking up the right Sacral area, forcing the left side to roll out and work harder thus placing a little more stress on the left knee. His knee had received numerous local treatments with no improvement. The major clue was the similarity of palpatory feel to the bowel/sacrum and the knee, the observable findings and the feel that the knee wasn’t getting the free flow of blood and removal of waste that it needed to heal. Balancing the pelvis and freeing off the restriction in the lower abdomen relieved the knee pain in one visit. The self-healing mechanisms improved the nutrition and energy to the knee, once the maintaining factors above were dealt with, allowing the knee the environment it needed to heal.
- A middle-aged/elderly lady, on a volunteer horse ride, had received several musculoskeletal treatments for general aches and pains by a student the past two years running. The student was frustrated that the tissues were not improving despite her best efforts. Standing back for a moment, we observed the patient from a distance and noticed that she exhibited the hunched posture of a depressed patient. This hadn’t been noticed before due to a focus on the musculoskeletal system, not the patient as a whole. Noticing this allowed us to recognise the general depressed/devitalised state of the tissues as a whole. By tuning in to the tissues on palpation, we could sense the depressed feel, as if the weight of the world were on her shoulders. We asked the patient if this was what she was feeling and she said “oh yes”. Simply by us/and her acknowledging this, the emphasis moved from looking for a physical cure back to the level it originated. She realised her emotional state. The light switched on as she realised this (and what ever other realisations that occurred in her mind in relationship to this) and her posture physically lifted a little, the tissues manifested increased vitality – all perfectly observable to everyone watching. The next day when we saw her she reported feeling somewhat better than she had in years, although there was still a long way to go. In this case, how she was feeling affected her posture and the aches and pains were an effect of this slouched posture.
- A middle-aged woman presents complaining of pain in her wrist with no apparent cause (gradual onset for no apparent reason). Her myo-therapist referred her because she had treated the upper back, shoulder and arm several times and there was no improvement in symptoms. On examination I found the following: A uterine dysfunction (I can’t remember why exactly this was the case now) had locked up the sacral and pelvic area creating a twist in her posture, pulling the right shoulder down via the latissimus dorsi. The right shoulder was thus inferior, forward, anterior gliding and internally rotated, causing the forearm to compensate by rolling externally and the wrist to roll in. The little bit of asymmetry and tension in her wrist locally were relatively minor when compared to these other findings. This was my working diagnosis on examining her. It may not be the actual diagnosis (and there may be other explanations) but it fitted all the findings so it’s my working hypothesis. Treating the primary area (pelvis/uterine area) allowed her mechanism to adjust on its own in such a way that a couple of days later while she was playing golf the pain simply disappeared and didn’t return. Note: not all patients respond this quickly. I’m just selecting cases where there is an easily identifiable predisposing/maintaining factor in order to illustrate the importance of assessing the whole person. If the correct areas are addressed, improvement happens a lot quicker.
- Another woman presents (in her mid thirties) with tension around the neck and shoulders. She doesn’t respond quickly to treatment but on assessment you notice a long thin posture with a midline tension right along the entire spinal cord (occiput to sacrum). Her shoulders are hunched, pulled up and held medially, with a lot of myofascial tension present in this area. There is neurological and membranous tension present (the membranes attach, more solidly, to the skull, C2/3 and S2). She also gets some headaches. She worries a lot and can’t sit still for a moment. She concentrates too hard (you can feel the tension in her forehead) and is always a few steps ahead of herself. She is very anxious and her body is generally tight overall. This case displays a hyperactive mind and nervous system (central and sympathetic). Unless these components are recognised and dealt with somehow (maybe through learning how to relax if she is willing) little response may occur with massage or joint treatment (being an effect of the mental/neural state).
- A young man eats very poorly and is very lazy and sluggish in his general nature. He presents sometime after a lengthy recovery from septic arthritis (infection) in his right knee, which he obtained from a minor fall onto his knee. On examination his tissues and fluids are generally very sluggish (like him) and not flowing – especially through the abdominal, middle to lower back and pelvic area and right leg. In these areas it feels like “a stagnant pond” and what happens to the water in a stagnant pond after a while? (It becomes susceptible to infestation). It was no surprise to find out he had septic arthritis given the texture of the tissues. Diet, probably lifestyle (attitude maybe), circulation and lymph flow are key elements here, in addition to any mechanical compromise placed on the knee due to postural factors.
- A painter complains of shoulder pain on overhead work. It came on about a week after he slipped in a puddle of paint and had a near fall. It was his right leg that slipped. Examination reveals tightness in his right erector spinae, quadratus lumborum, and latissimus dorsi (and T8 to L3), holding his posture in right side bending (these muscles tightened up to prevent injury to the body when he nearly fell). This joint and muscle imbalance is affecting scapular position, thus influencing scapulo-thoracic movements. The acromial arch is not elevating properly with overhead movements and thus he is getting symptoms and signs of impingement.
- A twenty year-old woman is suffering moderately severe right knee pain with weight bearing. It came on for no apparent reason and has worsened over time. She now can’t walk on it. It is held in a flexed position and is painful on movement. After failing to gain improvement by treating locally in the first visit (I neglected to assess wholistically), I decided to reassess the whole on the second visit. I discovered a restriction in the right liver region (springing and tissue texture here was not very good) and I asked her if she had ever had any trouble here. She said she had cirrhosis of the liver about a year ago. There were a lot of adhesions and sluggishness in her liver. Once this was noticed, her whole pattern became clear. The restriction in the liver was holding that section of her back in extension and side bending right. The psoas was involved creating a compensatory hip flexion and subsequent knee flexion. With the effects of daily activities and weight bearing in this posture the knee has become strained and thus created the symptoms. Treating the liver area allowed a 95% recovery by the time she presented the next week.
The above cases should all illustrate the importance of examining the whole prior to honing in for local treatment.
Once problem patterns are found, there are two general approaches in Osteopathy which may help;
1) A more direct structural approach: this consists of techniques such as massage, manipulation, articulation and muscle energy technique.
2) A more gentle indirect approach; using cranio-sacral or Biodynamic Osteopathy which works with the subtle energies, rhythms and movements within the body and with the health within the body to help bring areas of difficulty back into balanced function with Health, so that the person can function as an integrated whole. It is very gentle yet may be very deep, integrative and helpful in achieving long term health benefits.
What is My Approach?
I take a holistic approach (based upon the above principles and incorporating both of the above approaches) but use primarily the cranio-sacral approach especially for helping to resolve difficult and complicated health issues as well as in acute situations to settle things down when more direct techniques cannot be used due to pain. This approach helps towards restoring balanced relationships between all conflicted tissues and organs of the body, including relationships with the mind, emotions and between past issues or trauma patterns (stored in the tissues) and the presenting issue. Patients are also educated on Self-healing and other rehabilitation exercises to support optimal recovery.
Turner, P. (2010). Wholistic Integrated Assessment, A Teacher-Student Guide (12 DVD Set and Manual). Melbourne: Paul Turner Publications and Osteopathy.