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The Detective
I just posted a version of this on my blog and thought it would be worth repeating here:
Recently a client called me a detective. I liked that description. Connecting the dots.
Good therapy should be about detecting what is not easy to see. Evaluation skills play a big part in this work:
Investigating what is visible and what lies beneath the layers. I
learned the beginning of detecting in my MFR training, but was abandoned
when the rest was left too open ended. Some therapists like to allow
things to unravel, to reveal itself as therapy progresses. I do some of
this, but when something reveals itself, I like to dig deeper.
My physical therapy training certainly blessed me with basic orthopedic evaluative skills and my myofascial
release training delved more into the soft tissue. I think that both
play a role in how I view a client when they come for therapy. But so
much more is the story. Symptoms are a clue, as they tell you where to
begin looking. Find the symptoms, look elsewhere for the pain…some of
the time. Often the symptoms are the cause, just buried where no one
sees them.
A deep model of evaluation should be an integral part of every manual therapy training. Some get it close to
right, others fail miserably (opinion inserted). Connecting the dots
often takes great patience and listening; with your ears, as well as
your eyes and hands. Its all about being a detective.
How are you at connecting the dots? What goes into your decision making?
Walt Fritz, PT
www.MyofascialResource.comViews: 195
Replies to This Discussion
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Permalink Reply by Tracy Seegrist on
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omg Walt, I find I am relating with a lot of things you say. I have told my clients for years that I'm more detective than massage therapist, as it's a matter of the "clues" leading to the "perpatrator" :) and eventually, an "arrest"
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Permalink Reply by Walt Fritz, PT on
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Tracy,
I like that sequence! I don't nail the criminal each session, but eventually I figure it out.
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Permalink Reply by Rick Johnson on
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Walt, it's interesting how often I see a client that has been through the usual doctor, specialist, physical therapist chiropractor route that has not had a resolution to the problem from those experts. And I believe it's only because they may not have "looked" in the right place to begin.By the time I see them, my palpation skills and an open mind, added to whatever assessments may have preceded me, is often the key that opens the door to a fresh and mostly correct perspective."Hands on" is the missing diagnostic.
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Rick,
The "hands on" piece has truly been lost in most areas of medicine. If your practice is like mine, the number of times I've been told by a client that I was the first person who actually touched them is sad.
It just seems to easy not to see or feel the things that seem to be holding clients back. In fairness, I don't see the ones that the Chiro, PT, MT, MD, etc, were able to help.
Walt Fritz, PT
www.MyofascialResource.com
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Permalink Reply by Jason Erickson on
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I relate to this very strongly, Walt. I am a problem-solver by nature, and I love the investigation and reasoning process. Lots to think about in your post... particularly the bit about the story. The client's narrative is always threadbare and missing half (or more) of its pieces. Whole chapters omitted or glossed over until you begin asking questions, drawing out the extra layers of detail and missing information until it starts to make sense and clinical reasoning can fully kick in.
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Jason,
The story is one that is played out in bits; sometimes by choice and other times unavoidable. Items are omitted from the narrative as they were thought to be inconsequential. Others omitted due to their personal nature. And finally, events omitted as they had not been realized.
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Walt, could you walk us through a typical session with a first time patient? As time is usually a factor for an MT, how much time do you give the evaluation process?
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Rick,
I am cutting and pasting from my Foundations in Myofascial Release I course booklet for this. There are additionaly postural alignment photos and pelvic drawings that have been excluded:
Myofascial Release Evaluation
The basics of evaluation are little different from other physical, occupational, or massage therapy evaluation. Collecting the basic demographics, medical and surgical history, past and present therapies, along with a body sketch of pain or issues are similar across the therapy world. I pay particular attention to all surgeries and scars, as well as conditions that the client may not deem worthy of mention. A person referred for neck pain may not consider a pelvic scar important to mention, but often can be crucial. Be probing with your questions.
Postural Evaluation
Fascia has tremendous strength, with a tensile strength of up to 2000 Lbs per sq. inch (Katake, K.: The strength for tension and bursting of human fasciae, see appendix). The tension from restricted fascia can exert enormous tension on our body, pulling it off its center and effecting posture. More importantly, the pulls and asymmetries that we can see are clues to what needs to be treated. Postural evaluation is an integral part of both myofascial release assessment and treatment.
Every client should receive a postural evaluation. From this, you will begin to see how the fascia may be influencing their pain and dysfunction. It is important that you be able to see as much of your client as possible, so it is essential that they wear minimal clothing. When you make initial contact with them, let them know the importance of what clothing you would like them to wear for the evaluation as well as subsequent treatment session. Additionally, myofascial release requires skin on skin contact and your client’s skin must be free of any lotions or oils. Let them know that even lotion applied the day before will still effect treatment if not fully showered off with soap and water.
A thorough postural evaluation is best done when seated or standing a fair distance from your client. If you are too close, you will miss the big picture. Step back and soften your focus slightly. Look for patterns at first, rather than for details. As you begin to collect information, close in on the smaller features. In the photo below, notice the head and trunk offset to the right, the right shoulder elevated, the arms held out from the body and the apparent high arches.
Pelvic Evaluation
While there are many methods to determine pelvic symmetry/asymmetry, this method is one that consistently works well for me. It is essential that you be able to locate the anterior superior iliac spines (ASIS) and posterior superior iliac spines (PSIS), be able to judge the levelness of both iliac crests when viewing from the front or rear, and estimate the pelvic angle (See below and on following pages).
ASIS level is best judged kneeling in front of the standing client and hooking your thumbs just under the ASIS (rather than trying to place the thumb on the apex of the ASIS). Note which side is high or low.
PSIS’s are palpated best by kneeling behind the standing client, placing the hands so the side of the first finger is resting on the iliac crest (palms facing down with the thumbs oriented slightly downward). The starting point for PSIS palpation is where the tips of the thumbs rest. Some clients have dimples in the skin over-riding the PSIS; look for these first. Otherwise, you are palpating for the place where you can hook your thumbs just caudal to the PSIS protuberance. I ask students to look away or close their eyes when trying to locate the PSIS’s, as if you stare at the region you tend subconsciously to try to level both thumbs. Once you hook into the PSIS’s, note which side is high or low.
Accurate palpation of the ASIS and PSIS is a matter of practice; so do not be frustrated on your first attempts. Palpate the landmarks on many different clients to get comfortable with this procedure. Your accuracy will improve with practice. It tends to be more difficult to locate landmarks with heavier clients, ones with pronounced soft tissue tightness, or ones with high muscle mass. Standing assessment is the most accurate, but occasionally landmarks cannot be accurately located in standing. Assessing pelvic alignment in standing allows the influence of gravity to fully act on the body, creating a more accurate picture of where the restrictions lie. You can have your client lie on the treatment table and evaluate ASIS (as well as PSIS) level in this manner. Occasionally your client will show reverse findings in standing vs. supine. It will take more investigation to determine the dysfunction. While you have your hands on the iliac crests, slide your hands over the tops of the crests and compare sides; are the crests level?
Here are some general guidelines on what your findings mean:
- Low right ASIS, high right PSIS, near level crests (common): Anterior rotation of the right pelvis/posterior rotation
of the left pelvis.
- High right ASIS, low right PSIS, near level crests: Posterior rotation of the right pelvis/anterior rotation of the left pelvis.
- Level ASIS’s with high to very high right PSIS and high right iliac crest: Right anterior rotation with a right up-slip.
- High right ASIS with level PSIS’s and high right crest: Right posterior pelvis with a right pelvic up-slip.
The same four possibilities apply to the left side. Remember, pelvic rotations are relative and it is not always necessary to know which side is the dysfunctional side if you are treating them with myofascial release techniques, as you will be treating both sides of the pelvis.
Measuring leg length is a crucial part to this assessment. Have your client lie supine and assure that the legs are in a midline orientation to the trunk and pelvis. Place your palms over the ankles and hook your thumbs under (caudal) to the medial malleoli. Lift the legs slightly and traction, to take out the slack. Return the legs to the table and note which malleolus is high/low. With a pure anterior pelvic rotation, that side will be longer. With a pure posterior rotation, that leg will be shorter. With a right anterior rotation/right up-slip, the right leg will be nearly the same length as the left. With a right anterior rotation and left up-slip, the right leg will be markedly longer. The majority of leg length discrepancies (90-95%) are due to a pelvic rotation, vs. 5-10% due to a true bony difference in leg length.
Seated and Supine Evaluation
Every therapist develops his or her own style of evaluation. What is important for one therapist may have less meaning for another. However, successful Myofascial Release treatment can only be accomplished if the therapist develops an underlying awareness of restriction (fascial and other) within the body. Without this awareness, the therapist is treating blindly. Establishing a sound baseline is vital even though “in the moment” treatment choices are an essential and inevitable part of MFR treatment.
My evaluation sequence has developed and changed over many years and through hundreds of evaluations and re-evaluations. Even with all of this experience, no two evaluations are the same. Every client brings fresh problems to you and your responses will be as unique. There are times when I perform an exhaustive head to toe evaluation, while other sessions will start with a brief evaluation and immediately progress into treatment. I will always return at some point to complete the evaluation and collect the information that I need to make a cohesive assessment. Treatment itself is a part of evaluation, as I need to investigate how each person responds to contact and intervention.
When a client presents with problems or complaints of pain at the shoulders and above, I may alter my evaluation sequence to reflect their concerns. I would strongly encourage any of you who plan to use Myofascial Release as an integral part of your treatment regime to consider taking the Foundations One™ seminar in order to establish a better sense of the whole body. For the sake of this seminar, we will evaluate specifically from the respiratory diaphragm and above.
I will start a client seated on the side of the treatment table. They should be sitting comfortably with their feet resting on a footstool. Stand behind them to evaluate trunk and neck rotation, as well as trunk extension. You should be noting the gross quantity of motion available in each direction as well as the quality of that motion. How must they compensate in order to come to or near end range? When checking trunk rotation, note the equality of motion to both sides through the ribs, spine, and sternum. As you check thoracic extension, note tightness through the anterior shoulders and chest wall, as well as through the thoracic spine.
Next, proceed by having your client lie supine on the treatment table. From the side, assess the mobility of the respiratory diaphragm region, anterior and lateral rib cage, and clavicles/sternum. Traction each arm to determine tightness and restriction as well as possibly reproduce some of their symptoms. Move up to the head of the table and press both shoulders down. Press caudally as well as posterior, comparing both sides for equal play. Compress through the sternum, noting any response up into the neck and throat. Check range of motion in the neck, in side bending, rotation, flexion, and extension. Note whether the motion is full throughout the neck and be aware of any limitations. Gently traction the cervical spine, noting amount of play as well as whether there is more tightness on one side than the other. Check the suboccipital space by lifting your client up onto your extended fingertips. Palpate the anterior neck and throat, including up into the base of the tongue. Note any areas of tightness or reported pain, etc. Evaluate the anterior cervical spine and web space of the thoracic outlet and first/second ribs.
Have them open and close their jaw, noting whether the jaw tracks in a straight line. Lightly lay your fingers over the TMJ while they open and close their mouth, noting any clicking. As appropriate, evaluate the mobility of the pterygoid region bilaterally as well as the tongue. Cradle the occiput with your thumbs on the mastoid processes and evaluate for symmetry. Evaluate eye mobility. Depending on their symptoms, you may wish to sit them up and evaluate eye tracking prior to doing a soft tissue evaluation of the eyes.
Reposition them in prone on the table and check the mobility of the posterior rib cage and thoracic spine. Stand at the head of the table and press through each shoulder, assessing scapular, shoulder, and rib mobility. Press downward through the upper thoracic spine, noting responses in the head and neck.
When performing a full body evaluation, I always start with my client supine and at their feet and work my way to the head. I then repeat the same with them prone. The evaluation summary listed below is a starting point. If you feel density or restriction, or if your touch causes pain or referral of sensation, make note of it and investigate further. What, for the novice, may seem too lengthy a process soon becomes a smooth dance that you move through.
In this section I have listed some general guidelines for evaluation. There may be too much information for some, but over time, it will make sense. No doubt, there will be tests that you will feel the need to add; use this information as a starting point. Please understand that your evaluation will also vary according to your client’s complaints, but I have found that over the years my clients benefit if I perform a complete evaluation. Only this complete approach will allow you to find the deeper reasons for your client’s pain.
Seated
- Compare rotational quality of shoulders, ribs, and spine
- With your knee to their thoracic spine, check spine and thoracic trunk extension
- Thomas Test of hip flexor length
Supine
- Bilateral leg traction and determination of leg length
- Ankle motion
- Kneecap tracking/laxity
- Quadriceps density
- Hamstring length (seldom)
- Pubic symphysis integrity – via knee squeeze
- Re-check ASIS level
- Hip flexor palpation, including across the pelvis
- Palpate abdomen/viscera
- Scar tissue check
- Respiratory diaphragm/rib mobility
- Arm traction
- Shoulder depression/retraction
- Sternal mobility
- Vertebral artery test
- Cervical traction/mobility of the dural tube
- Cervical lift, side bending, rotations
- Sub-occipital mobility
- TMJ mobility
Prone
- Calf/hamstring density
- Quadriceps tightness
- Coccyx alignment/density
- Piriformis and quadratus lumborum tightness or sensitivity
- Re-check PSIS level
- Thoracic spine and rib flexibility
Above material copyright Walt Fritz, PT, 2010
I usually perform this type of evaluation on every client. After sitting with them and going over the written history they have supplied, I'll proceed with the evaluation. Time spent for the eval is usually 10-15 minutes. I always include treatment during any first session (50 minutes total session time).
Walt Fritz, PT
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