Pattern Recognition and Streamlining Evaluation

Changing from a mechanical/postural model to one with more plausibility has entailed numerous modifications to both evaluation and treatment. Myofascial release is traditionally based in the mechanical/postural model, with treatment following from an evaluation based on said mechanical/postural (MP) findings. While my conscious shift away from this model started less than six months ago, I had been experiencing a shift away from MP evaluation for the past few years. It was not a purposeful shift; rather it was one built on outcomes. Evaluation always guided my thought process for pending treatment. But after so many years of treating based on the MP findings, I believe that I moved into a more automatic assumption-based treatment. Nearly every one of my clients presented with forward shoulders, for instance, so why test for it? If the norm was asymmetry, how can it matter? In actuality, it often doesn't matter. A vast percentage of us have marked asymmetries that do not necessarily create issues/pain. (Note the "not necessarily", as occasionally the asymmetry does seem to create a problem). We are complex beings and determination of "cause" is often so complex a concept that we alone cannot get to the cause. But we can make educated and experienced-based observations and, yes, guesses, to at least start the treatment process.

When I was first presented with treatment concepts that stated that posture and symmetry did not matter, I was troubled. I had previously evaluated posture and symmetry, determined that things were out of balance, corrected them (or so I believed), re-evaluated, and found that the problem lessened or went away. This created a reluctance to move away from my original base of knowledge. The model seemed to work perfectly. But there came occasions when a patient presented with lower back pain, for instance, accompanied by a severe pelvic torsion. Previously I would have included what is termed "pelvic balancing" into my treatment. This would take the shape of pelvic wedging to move the pelvis back into a neutral alignment, as well as treatment to the soft tissue to correct fascial tightness patterns (pardon the now abandoned describers). But on certain occasions I left the pelvic asymmetry alone, treating only elsewhere. Voila! The pain was reduced in the same fashion as if I had done pelvic correction. This would seem to be in conflict, but I don’t believe this is so. It is plainly obvious that there are many ways to skin this therapeutic cat and I've long resolved myself to not have to know everything.

If treatment from the PM model was not necessary, why spend so much effort in evaluation from this model as well? Was it true that I had transcended treating from the PM model, or had I simply made certain therapeutic assumptions, casting aside superfluous techniques and thoughts? Had treatment become so automatic that I found less need to look into certain mechanical minutiae and simply move right past them? Therapeutic knowledge/assumption is not witchcraft, ancient wisdom, or intuition, but is simply hard-earned knowledge and experience. We do learn patterns and trends that can apply to a group larger than a single person.

In the past, my "standard" evaluation could easily take 30 minutes, if I felt the need to be thorough. That is quite a bit of time out of a typical 50-minute session to spend before applying any treatment. I firmly believed that this was time well spent (and still do at times). I continue to teach this thorough, in-depth model of PM evaluation at my Foundations in Myofascial Release Seminars, but now I insert a caveat: all of this MAY not matter. How unsettling is that? How can a therapist, new to my form of Myofascial Release, determine what is necessary and what is superfluous? Experience and time are what will make the difference, and both of them are great teachers.

Diane Jacobs, PT, to whom I am deeply indebted for sharing her knowledge and patience, said something in her DermoNeuroModulation Seminar (DNM) that resonated. In essence she said that we all use our unique set of pattern recognition skills to identify issues from our own unique frame of reference. I may palpate for tissue density while she may palpate for something completely different, but we both identify a disruption in the desired or ideal, me which seems connected to the pain; this seems universal and should be what we strive for in any form of bodywork. What pattern recognition skills do you utilize?

I had a new client the other evening that presented with acute right shoulder pain. My client believed that a few years of sedentary lifestyle followed by what she felt was an excess of yoga seemed to bring on the pain. After talking for a bit, taking her history, etc., I stood her up and went through the first portion of what used to be my standard evaluation. "Face me, turn right, turn left, face away" all the while I am dutifully making note of postural asymmetries. My client's shoulders were pulled forward and if I looked hard enough, the right shoulder may have been even more anterior, but I stopped the observation there. I could have asked her mother, who was out in the waiting room, to stand up for postural evaluation and I would have probably found similar findings, but without the symptoms. Look around at your family, friends, colleagues, or just folks walking past you. Check out their posture; I can guarantee you that most of them will have varying degrees of forward shoulders, with further asymmetries as well. But question them; do they have shoulder pain? Some may, most will not. So instead of completing my PM evaluation, I moved my patient right to the treatment table and spent some time palpating for tissue quality, which is the primary means that I utilize to connect with pain. I discovered characteristic tissue density in the anterior shoulder region and when I put added pressure or skin drag into this area, my client confirmed that this engaged her pain. How simple can it get?

Let me return to my past dilemma for a moment. Had I seen this client for the first time a few years ago, I would have done the full PM evaluation, finding forward shoulders, right >left, and treated her based on these findings. I would have done a cross-handed "release" across both shoulders, feeling what I thought was fascial restriction all along the way. She would have most probably improved. But she improved the other evening, too, but from a different therapeutic mindset. In her session I spent a good amount of time performing a simple skin stretch (DNM). Yes, I drop a bit deeper than I was taught, at times, but don't we all develop our own style? I used Dycem, my latest obsession, to improve my tactile awareness. I then engaged my client with some basic pain education, explaining possible causes of pain from a neuroscience perspective. I also taught her simple skin stretching. Skin stretching, as it was taught, strives to find a direction that lessens or eliminates pain. I add a 180-degree twist; if the skin stretch brings the pain to their awareness, you have found another reason to hold the stretch. (Note, this does not mean that the stretch increases the pain, it simply makes one aware that they have connected with it.) Pain which lessens or is made more distinct; hold the stretch. She left with much greater ease of movement and diminished pain. She also left without re-visit scheduled. I believe in empowering my clients to keep the gains we made during the initial session, taking it even farther on their own. She may return, if for nothing else but to clean up the remaining loose ends, but she has the power to make that determination, not me. Skipping my past complete evaluation caused no negative outcome. Each time this occurs I feel more empowered to seek a more streamlined approach to evaluation, one that diminishes the reliance on the PM model. There are times when pelvic symmetry SEEMS to matter, and I acknowledge this. I've not figured it all out yet, but give me some time. Take your time in all of this, as there is no rush.

As I asked above, what pattern recognition skills do you use to determine dysfunction?

Enjoy.

For now,Walt Fritz, PT