Selective Reassessment

[Barrett Dorko]

As some of you know, I have a different take on evaluation than many of my colleagues. Okay, some call it heresy. You can read what I’ve written about that here (http://www.barrettdorko.com/articles/end_of_evaluation.htm) and in the Five Questions (http://www.somasimple.com/forums/showthread.php?t=2404) thread on this site.

What I wanted to discuss here is the issue of reassessment. Often I’m struck by the number of ways therapists try to figure out whether their care is taking the patient in the direction they would prefer. Too often, I think, these questions and/or maneuvers may be premature or irrelevant. I feel certain as well that some tests and questions that might prove quite revealing simply aren’t done.

The more I think about it the more complex this issue becomes, so I’d like to start with a few questions in an effort to order the topic, realizing full well that these questions might serve to do little more than organize my own ignorance.

What are the most important attributes of any test or question?

When is the best time to ask a pertinent question or request a maneuver?

When is it appropriate to reproduce via a passive movement the patient’s complaint of pain? How about an active movement?

I’ve my own ideas but will save them for a while. If somebody says something especially insightful I will simply claim that I had already thought of that but hadn’t said it yet.

[Diane]

I'll bite:
>What are the most important attributes of any test or question?

To obtain information about the state of the organism, and changes in output, and how the human organism feels about or perceives its input/output.

>When is the best time to ask a pertinent question or request a maneuver?
Throughout.. any time, but not right when a desired change is happening.

>When is it appropriate to reproduce via a passive movement the patient’s complaint of pain?
Never. I think that's called a provocation test.

>How about an active movement?
Rarely. Depends if you mean active movement produced consciously or nonconsciously.

[emad]

Well, the best reassessing test and its timing is the test does not provoke/detriorate complaint .

Emad

[nari]

Reassessment is done on the basis that objective measures of improvement, no change or deterioration can be recorded. So if one measures ROM or strength pre-technique; immediately reassesses and finds improvement, it is taken to mean this method works. OK so far. But as we know, pain is not related to ROM or strength, so this reassessment could be just a temporary and misleading thing. I think the emphasis on reassessment is way overdone.

What are the most important attributes of any test or question?

I can't go past Diane's reply. The organism, not the leg or the finger or the neck...

When is the best time to ask a pertinent question or request a manouvre?Anytime - but observe how the organism is responding first. May take a while.

When is it appropriate to reproduce via a passive movement the patient's complaint of pain?
Rarely ever. If the patient is conscious, the control must come from the patient.
How about an active movement?
Depends on what sort of active movement. Needs to be functional, and linked to the movement/s that produced pain in the first place. A nonconscious active movement is useful; a conscious, cautious movement can be unhelpful and misleading.

Nari

[BB]

Barrett,
I can't wait to see where this one goes. I think it is a great follow up to the 5 questions thread.

What are the most important attributes of any test or question?

That it actually tests what it intends to test, or brings about an answer that will provide the information needed.

When is the best time to ask a pertinent question or request a maneuver?

In terms of reassessment Jules Rothstein (http://www.ptjournal.org/cgi/content/full/83/5/455?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=rothstein&searchid=1&FIRSTINDEX=20&sortspec=relevance&resourcetype=HWCIT) would have said, I believe, at a time when you would have expected to see the answer or change you desire. He also would have recommended to check for signs along the way that would lead you believe the right direction was being followed. I would also add, when you believe the wrong direction is being followed.

When is it appropriate to reproduce via a passive movement the patient’s complaint of pain? How about an active movement?

I have a more difficult time coming up with an answer with this. My knee jerk response would be to say never. But, I do find it useful in the clinic, as a threat reducing tactic, to have a patient show themselves a movement that was painful 2 minutes earlier is no longer painful. In this case, the test maneuver is meant to create a baseline for the patient in their working memory of a movement, upon which a novel stimulus can be added in a non-threatening manner and then compared to the baseline.

[Barrett Dorko]

I like the “assess the organism and not the part” answer. Of course, many reading this will probably want to know specifically how that might be done. Personally, I feel that when working with the essential diagnosis of an abnormal neurodynamic isolated joint motion reveals very little about change in the system – with one exception, and that’s the hip. Combinations of adduction and internal rotation here distinctly alter widespread areas of the peripheral nervous system and I don’t think it makes a whole lot of difference whether these movements are active or passive.

Cory’s comment about how we can, in effect, “set and reset the baseline” with a certain motion done before and after therapeutic intervention looks just like what I already do. Now I have a better way of explaining it.

As to when things should be reassessed, well, that’s tricky. Some things change with remarkable speed and others only as processes and time accumulate. The problem for me is that I simply don’t know which of the defects in the system will change in what sequence or exactly when. I find it helps to probe gently, both in my questioning and my requests for and about performance. I ask about warming but I’m patient with this. I wonder aloud about frequency and intensity and duration of discomfort, not just its presence. Together, the patient and I witness the change without distinct expectation of when something comes about but with a mutual agreement regarding what changes are important.

I’m a fan of TV shows that feature detection. There are a few about the use of that art and science in medicine but there are many more about crime. I notice that every detective begins with a theory of the crime, developed soon after they initially observe the crime scene. Phrases like, “the victim knew her attacker” and “this wasn’t a mugging” or “this was personal” are commonly heard as certain things are observed (in these examples, no forced entry, watch and rings still on the body and twenty blows to the head). On Law and Order SVU this is about half the dialogue.

The theory of the crime then leads the detective toward an investigation of a certain sort. They’ll look at acquaintances and family members if the door wasn’t broken into. If the victim was strangled they’ll suspect the spouse immediately. (I’m just kidding here, I think) Anyway, you get my point.

When many therapists reassess in a rote manner they seem not to have a “theory of the crime” in the body, so to speak. Their tests aren’t relevant to the tissue most likely involved and their questions don’t address the physiologic processes you’d expect to change as improvement ensues. It is as if they found a victim bludgeoned in a cottage in Wyoming, their wallet missing and the window smashed. They then immediately go to question the victim’s distant cousin in Poughkeepsie.

It seems to me that this detective is unlikely to close the case.

[Luke Rickards]

I think that the most important attribute of a test or question is its ability to lead to an essential diagnosis. Of course, as Diane points out, the organism's perception of and response to this shouldn't be ignored.

I use a similar approach to reassessment as you Cory. I may not use the painful direction though, especially where they are highly irritable. Often movements that previously felt stiff only, or basic ones like active cervical rotation or Barrett's passive assessment of the hips will suffice to impress how easily their 'baseline' can change. For some patients we will go through this at the end of the session, and for others frequently throughout the session.

One thing I've found particularly useful about SC is that active reassessment is often occuring as you treat. A quick comment about the movement that has just emerged or question about how it feels to now be in a position that 2 mins ago they couldn't achieve often works wonders.

[Barrett Dorko]

Luke,

I agree entirely.

There is a conceit in "orthopaedic" cases that isn't often spoken of but I think it has retarded our progress as diagnosticians. It is that we should be very close to determing precisely what's wrong before we proceed with any form of care. The massive and intricate evaluative forms we are compelled to fill out are supposed to reveal the problem as if it were some sort of algebraic equation.

They don't.

But we know that internal medicine doesn't approach patients in this way. After a brief but appropriate eval the physician will often say, "More tests might prove necessary, but I'd like you to try this (whatever) for a while and see what changes. We'll know more about what's going on after we watch your response to some form of care."

The Five Questions and Simple Contact are distinctly similar to this. Thinking in this way, we make the patient's response part of the equation, and we understand that the equation is nonlinear, thus reminiscent of those used when calculating the consequences of chaos.

[Luke Rickards]

It is that we should be very close to determing precisely what's wrong before we proceed with any form of careIf we were to hold to this, considering that much our testing is so unreliable we would rarely treat anyone.

[Barrett Dorko]

Luke,

Exactly. I've met thousands of therapists "frozen" at the point where treatment should have begun because they remain so ambiguous about what it is they think they might have discovered both during and at the completion of their seemingly thorough eval. At Paris' courses the evaluation is raised to the level of ritual sacredness.

Not a good idea.

[EricM]

When a patient tells me at the outset, it hurts whenever I do this 'this,' I have no problem inviting them to try doing 'that' to see if we're getting anywhere. Often the problem will resolve before I think it has and the patient will try the once painful movement out without any invitation from me. When this happens I'm pretty sure we've created a good and probably lasting change.

Back to that hip thing for a moment...Barrett I have observed another pattern quite frequently in the lower extremity in which the knee on the painful side may be more flexed than the opposite one. This of course tends to force the hip into relative external rotation when lying supine (unless they are really sore and are holding everything flexed). So I'm learning to look both at knee and hip resting position.

eric

[EricM]

So as not to distract from this thread, I've started another titled Tenderness on Palpation (http://www.somasimple.com/forums/showthread.php?p=25438#post25438) to discuss the use of palpation in assessment.

eric

[emad]

Eric ,

I think External rotation put less load over the Sciatic. I do not know how about the femoral ?I noted that with very senstive degress of pain at knee and sciatica .

Cheers
Emad

[nari]

Extensive evaluations at the start of the first session often impresses the patient (the doc never did all this) and when pain increases (that's the pain!) but it doesn't mean the therapist is impressed as to what to do next. Some PTs use lengthy evaluations to exclude certain conditions; but there is no certainty this is so.
Generally, as we in Oz do not take much notice of Paris, the initial evaluation is short, and largely subjective. It is more along the lines of the doctor's style of evaluation mentioned by Barrett; we are aware that lengthy probing and stretching is quite provocative and likely to be unproductive. Unless, of course, the patient is so impressed by the PT's tenor that it ends up not provocative at all....:)

Nari

[Chancellor Mobley]

I may be off target and not be in a position to ansewer these questions not being a PT. "what are the most the most important aspects of any tests or questions?" I would first suggest being clear about the differences of tests and questions. To test is different than to question, I believe.

"When is the best time to ask a pertinant question or request a maneuver?" I'm not sure when the best time to ask a pertinant question is but I find that the ones that are not contrived are the best ones. I like to ask for maneuvers that are able to be accomplised.

In "the five questions" thread, to paraphrase, I believe Barrett asks the patient what he/she does, what she can do and what she wants to do non-verbally. Correct me if I'm wrong but I imagine that these questions are continually being asked throughout the sessions and are in a sense a reassessment. Is it not an art as too the timing of these questions?

Chance

[Barrett Dorko]

Chance,

I don't think you're wrong at all, and the way you've described what I propose we do (and certainly do myself) looks very familiar to me. As you've indicated, the Five Questions thread makes all of this intricate process as clear as it can.

I would say also that tests and questions are certainly different but that they are often intertwined and necessarily so.

Nari,

I agree – again, and found myself looking at the word “tenor” in your post. In fact, I looked into the synonyms for it on my Word program. Among others are the words “mood, “meaning” and “intention.”

Whatever else might be said about the mechanics, timing and sense of reassessment, I think we have to remember that mood, meaning and intention are implied and acted upon continually as well. Controlling these within the tester may be difficult, impossible, inappropriate, helpful, confusing or all of these at one time or another unpredictably. All of these qualities might be assigned to the patient as well with an equal amount of randomness.

To me, this is just another argument in favor of testing as little as you can, reducing the rituals that surround assessment and respecting the limitations of our consequent knowledge once a test has been completed.

[nari]

I like using the word 'tenor' - with respect to literature, I take it to mean the emotional effect prose or poetry delivers to the reader, which is variable according to the person exposed to the literature. Somebody also exhibits 'tenor' when chatting or lecturing to a group; and it will be interpreted variably, depending on whether it's Tuesday or last year.

So how we interact with patients can never be measured to a point where consistency can be a golden rule (whatever that is); and that further places doubt on the need for the complexity of evaluations that PTs seem to have adopted in general.

Chance, can I ask if you are not a PT, what is your bread? (Aussie for one's occupation)

Nari

[Chancellor Mobley]

Hi Nari,

I practice Structural Integration(rolfiing). That's my bread.

Chance

[nari]

Thanks, that is interesting; and will go and look up more on SI.

Timing can be crucial, and it seems to depend on rapport and understanding being established very early in the piece. If that does not happen, and it sometimes doesn't, especially when the patient requests a method that is out of my expertise or just ineffective, it gets a bit sticky from there on in.
It is an art; just as explaining pain is an art as well as a science.

Nari