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1st Jun

2018

The Key to Treatment Success: Comprehensive Diagnostics and Tissue Analysis

When my patients have previously been treated by other physical therapists, much too often do I get the same report: Very little was offered in the form of diagnostic evaluation by the clinician.. This is very unfortunate, since treating without having a proper tissue and movement diagnosis, is like fumbling in the dark. You may occasionally get lucky and do it right, but most often, you do little to help your patients or you may even make them worse. Having a paper with a medical diagnosis, or X-ray/MRI results, is not nearly enough, as I will explain.

What I will refer to here, is musculoskeletal pain or dysfunction, not caused by internal organ or systemic disease, which must be cleared by the physical therapist through the evaluation process (who should promptly refer the patient to a physician, if suspecting this).

Muskuloskeletal pain is essentially mechanical and chemical in nature, and most often a combination of both. Mechanical pain means that pain nerve fibers (nociceptive fibers) embedded in the affected tissues are being stimulated by either stretch or compression, or both. Chemical pain is caused by certain nerve fibers responding to inflammation in the tissues. Signs and symptoms tell us whether the pain is predominately mechanical or chemical in nature, and to what extent.

Mechanical pain can be brought on by certain movements or activities, which put stress on the compromised tissue, but it lets up quickly after such movements have been stopped. On the other hand, chemical pain tends to linger after a certain activity has been performed. The longer it lingers, the more inflamed the tissues typically are. We call this irritability of the tissues. It is essential that the physical therapist understands this, since treatment is very different for the person with primarily mechanical pain, than for the individual with much more chemical pain and tissue irritability. This is a difficult skill to learn, but extremely important to get good treatment results.

Some people with chronic pain which has been present for at least several months, develop a state of sensitization in their central nervous system, i.e. involving the brain and spinal cord. They often report similar symptoms to those with a high level of chemical pain, or inflammation, even though they have little signs that indicate such inflammation. Their pain is caused by a completely different mechanism, with its root in the nervous system. Again, these people must be treated differently, than those who do present with much inflammation after an acute injury, otherwise treatment results will be poor.

Establishing a correct diagnosis for the purpose of providing effective physical therapy treatment, is like putting together a puzzle. Almost half the pieces can be found in the history taking and attentive listening to the patient. The rest come from performing objective tests, all with a specific purpose, while the clinician forms a tentative diagnosis hypothesis, with each subsequent test helping to prove or disprove such a hypothesis. It is important to resist the temptation to jump to conclusions before all pertinent tests have been performed.

Close observation of the person with and without movement throughout the examination, can offer clues as to what is wrong, and where. Carefully performed tissue provocation tests, while putting specific tissues on stretch or compression, can be effective in differentiating between various tissues causing the pain or other symptoms. Every tissue, such as ligaments, tendons, muscles, joint cartilage, spinal discs, or nerves, etc can be provoked by specific tests and positions, based on their function and anatomy.

This can be done in a three step approach, performing active movements, passive movements, and resisted tests in different positions. By this time, usually 80% or more of the puzzle pieces have been fitted in.

A precise neurological exam is important, especially whenever symptoms such as tingling, numbness, weakness or “electrical-like shooting pain” exist. This is to determine if any nerves have been compromised, which must take high priority when designing the treatment program.

Palpation, which means touching and pressing on tissues, can follow at this point, to confirm previous findings, and localize the problematic area, as well as offer other diagnostic findings. However, basing your diagnosis primarily on palpation for tenderness, gives you false positive results in at least 9 out of 10 cases. This is a mistake commonly made.

Special clinical tests can then be performed, which in research studies have shown a good correlation with certain specific conditions or injuries. Most often, one test by itself tells you little, but in combination with previous tests, they can help in making the diagnosis more precise. Medical lab tests and radiology tests, such as X-rays and MRI scans can be looked at here as well, to correlate with clinical findings. If they do not correlate, they may be irrelevant to the patient’s symptoms. At this point, we also want to look at potentially contributing factors, such as flexibility, and muscular balance.

Finally, the orthopedic manual physical therapist wants to specifically test joint mobility through motion palpation (a skill learned over many years) both locally and in surrounding and even distant areas, to determine if joints are moving normally, insufficiently, or excessively. The manual treatments, and design of the exercise therapy program require this specific information, in order to be performed safely and effectively.

Only when all pieces are put together, can a good treatment plan be designed. As you can see, this is a process which cannot be rushed through, and typically takes at least 60 minutes on the initial visit, but it’s worth it. Anything less is guess work, usually a result of either lack of training, insufficient time allowed for the evaluation, or even arrogance, in my opinion.

As I have said many times in the past, we (orthopedic manual physical therapists) certainly don’t have all the answers, and cannot help every person or condition, but a thorough evaluation at least gives us the best possibility of having a successful treatment outcome, and it can also tell us if we should refer the patient out for other treatment or medical testing.

With best wishes for a nice summer and good health,

Gunnar

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