Assessment Flow Chart for Selecting Therapeutic Interventions

Revisiting a previous post:

CLASSIFICATION OF MOVEMENT PATTERNS

I often am asked “I have _____ wrong, what should I do?” by patients or “How do I treat ______?” by clinicians. My answer is always “It depends”.

What does it depend on? The majority of time it is based on how the person moves. Mechanical pain (pain with movement) is the primary emphasis of our treatments.

I use movement screens to assess my patients. Movement screens let you quickly identify patterns of soft tissue restrictions and poor motor control regardless of where your patient is complaining of pain. I have two standard tests (hip hinge and overhead reach) that I use with every patient. I have a few others (high step march, rolling patterns) that are more specialized depending on specific complaints. Then, especially with athletes, I create some on the spot.

A movement screen does not need to be part of a system; it merely needs to recreate the movement that causes your patient pain.

ACTIVE MOVEMENTS

We are designed to move of our own free will. Active movements are a vital part of the evaluation process:

1) Full Active Range of Motion, No Compensations
If the patient has full ROM without compensations, that movement is not pathological and requires no treatment. Both your and your patient’s time will be better spent on treating a different area or movement pattern.

2) Pseudo Full Active Range of Motion with Compensations
Sometimes, patients will be able to do full range of motion but make compensations for it. A couple common examples using hip flexion:

a) Compensatory movement-the patient is able to bring the knee above 90 degrees but leans backwards in order to do so. This is the result of compensation for tight/short hip extensors and thoraco-lumbar fascia. If the trunk is stabilized, the patient will present with limited hip flexion. Appropriate treatments would include instrument assisted soft tissue mobilization (IASTM), myofascial release (MFR) and post-isometric relaxation (PIR) to lengthen the hypertonic extensors.

b) Avoidance movement-the patient is able to flex the hip above 90 degrees but does not perform it in the appropriate plane. The hip may horizontally adduct or abduct to avoid a soft tissue, joint or capsular restriction. For soft tissue restrictions, the patient will reach end range with a firm end feel where IASTM, MFR and PIR would again be appropriate. To treat the joint and capsular restrictions, indicated by abnormally firm or hard end feel, joint mobilizations would address the dysfunctions.

If the patient has limited active movement, assessing passive movement will help identify the dysfunction.

PASSIVE MOVEMENTS

1) Limited Active Motion with Full Passive Motion
If the patient has restricted active motion but full passive motion, the problem is a neuromuscular issue. The patient lacks either sufficient muscle activation or strength to perform the movement. Treatment should focus on muscle activation via proprioceptive neuromuscular faciliatation (PNF) followed by therapeutic/corrective exercises into the restricted pattern targeting the agonist of the movement.

2) Limited Active and Passive Motion
If the patient has restricted active and passive movements, it tends to be a soft tissue restriction. The antagonist(s) of the movements are hypertonic and too short/tight too allow the movement to occur. The patient will reach end range of motion with a firm end-feel. Treatment should focus on lengthening the antagonists via IASTM, MFR and PIR. Typically, the tone will return to the agonist and the patient will be able to perform the active movement. However, the patient will be weaker in this new range of motion and PNF/Ther Ex may be required.

3) Limited Passive Motion due to Joint Restriction
Soft tissue restrictions may develop due to lack of motion from a joint/capsular restriction. Joint play should be reassessed in any new range of motion and mobilizations if appropriate. Mobilization should always occur in the direction the bone being mobilized would naturally move during the movement. Again, PNF or Ther Ex may be needed to strengthen the agonist in the new range.

Treatment is only as effective as the evaluation it is based on. This is a quick, easy evaluation process to help guide you in selecting the most appropriate treatment to provide fast reduction in symptomatic complaints as well as improving objective findings.