February 18, 2005

This article is entitled "The 10 Steps of a Proper Assessment". This is a valuable tool to incorporate into your practice. At the very least, it's an excellent review of the steps to take when formulating your treatment plan.

Alfie Vente, RMT, IN TOUCH

Orthopedic assessments are important because it can help the therapist formulate a plan to assist clients in their healing. It is important to note that there are 10 steps to performing an effective assessment:

1. Observation by the therapist is very subtle. It can include observations of how a person walks, talks, sits, stands or even a motion like taking their jacket off. Some of the things you may see include an antalgic gait, carrying of one arm in an abnormal position, leaning to one side when they sit and even articles of clothing that may contribute to a persons condition such as shoes (are they high heels, do they look worn, etc).

2. After the person has filled out the case history it is time to ask a few questions. These will mostly be questions about their pain, such as, location, intensity, duration, frequency and characteristic (dull, achy, sharp shooting, stabbing, burning, etc.) At the onset what aggravates it, what makes it better, length of time and have they used any other therapies? Other questions that you may ask are: are you on any medications (this includes herbals and nutritional supplements)? Are there any foods you cannot eat? Do you have any other sensations other than pain and does the client have any previous injuries?

3. The postural assessment is next. The best way to assess a client's posture is to use a plumbline. The second best thing if you don't have access to a plumbline is by "eyeing" your client. All observations must be taken from 4 different views; two lateral views, anterior and posterior. Note of any gross observations such as shoulder heights, pes planus, genu varum or valgum etc. As mentioned above, the therapist should observe any gross malformations, changes and differences. You are not looking for minute observations such as a minimal height difference of shoulders.

4. Active free range of motion testing is to help the therapist determine the client's ability and/or willingness to move. This form of testing should be specific to a joint and its cardinal planes of movement such as flexion, extension, lateral rotation, medial rotation, abduction and adduction.

5-6. I put passive relaxed and active resisted testing together because it all depends on what you think might be causing the client's pain. Is it contractile tissues (muscles and tendons) or is it non-contractile (ligaments, joint capsule)? To determine what you should do first, consider what you think clinically might be the cause of a person's pain. The most painful of the two tests should be done last. The final anatomical movement that causes the person the most pain should be done last also. To give you an idea what your thinking process should be, consider someone who, from all your testing and questioning shows an injury to contractile tissues of the hamstrings. Your final test for this section should be active resisted knee flexion. The therapist should test bilaterally and above and below the given joint that is affected.

7. Specific muscle tests including length and strength testing, will help you to determine which specific muscles are affected. Length testing can also give you positional information about a body part or joint. For example, someone with very tight and shortened iliopsoas and rectus femoris muscles may show an anterior pelvic tilt.

8. Special tests are only used when steps 1-7 have not given you any good answers. Special tests help you determine if there are any compression syndromes such as carpal tunnel syndrome, they can also determine where along the length of the nerve/neurovascular bundle the compression may be arising from. Special tests can also help assess of any ruptures, such as, the drop arm test for a supraspinatus tear or Thompson's test for a tear of the Achilles tendon. Some special tests, such as, the vertebral artery test (it tests of any blood flow insufficiency to the brain) must be done in the beginning to help determine whether a client is fit enough to be treated.

9. Palpatory tests can help assess tone, texture, temperature and tenderness. They can be used before, during or after your treatment. It can give you clues as to what particular hydrotherapy should be used, and if there are any restrictions, adhesions or trigger points that need to be worked on.

10. As massage therapists we cannot diagnose but we can assess. After all of these steps are taken we must make some conclusions (not diagnoses). For example, on your intake form instead of writing down "the client has an Achilles tendon rupture," you may write "From my assessment it seems like this client may have a rupture of the Achilles tendon." From your assessments you should be able to determine whether a referral is necessary.

Posted by Ralph at 05:32 PM | Comments (0)

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This article discusses a Harvard study examining the role of gene decline with age. The findings create more questions than it answers - but they do illustrate that genes pertaining to learning and memory are more susceptible to damage from oxygen free radicals than other genes. This could be an important step towards understanding and preventing degenerative brain diseases.

By James Bakalar and Anthony L. Komaroff, M.D.
Newsweek
Are the changes in the brain that accompany aging caused by damage to the underlying genes involved in functions such as learning, memory and the transmission of nerve impulses? Exciting new research suggests that they may be, and the findings could eventually help predict and prevent degenerative brain diseases like Alzheimer's and Parkinson's.

A research team at Harvard Medical School studied changes in gene activity in the preserved brains of people who ranged in age from 26 to 106. Examining tissue from the prefrontal cortex, a center of higher mental functions, they uncovered some surprises. While most of the genes did not show changes with aging, about 4 percent became either more or less active. The differences in gene activity were caused by damage that occurred mainly in the regions of DNA that turn genes on, which are known as promoters. In most cases, the damage was caused by oxygen free radicals-hyperactive molecules released by the chemical reactions that power cells. Prominent among the genes that lost their youthful vigor were genes that affect learning and memory, cellular energy production and the transmission of impulses between brain cells. (To compensate for this oxidative injury, genes that protect tissues from oxidants and genes that repair DNA had become more active.)

The gene-promoter damage observed in the study began surprisingly early in life. While gene activity was similar in most brains from people in their 20s or 30s, problems became apparent in some brains as early as age 40. Also, the activity of learning and memory-related genes dropped faster in some people than in others, suggesting that each human brain ages in its own way. And occasionally the variations could be quite striking: one 71-year-old brain showed as much gene activity as that found in 30-year-old brains.

The biggest question raised by this study is why, in the course of normal aging, certain people are more vulnerable than others to age-related damage from oxygen free radicals. A second question is why genes important to memory and learning appear to be more vulnerable than other genes. Finding the answers could one day allow physicians to identify people at greatest risk for this kind of damage and to prevent it.

A better understanding of this normal aging process may also shed light on the beginnings of degenerative brain diseases like Alzheimer's and Parkinson's. "Looking at a brain afflicted by Alzheimer's disease is like looking at a battlefield after the war," says Dr. Bruce Yankner, a Harvard Medical School professor who led the study of brain-gene aging. "So much has been affected that it is difficult to know how it started. But by studying how the normal brain ages and comparing it with early cognitive decline, we hope to obtain clues to the earliest events in these diseases."

Bakalar is editor of the Harvard Mental Health Letter; Komaroff is editor in chief of the Harvard Health Letter.

Posted by Ralph at 04:32 PM | Comments (1)

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This article describes a study done in Sweden on the effectiveness of massage on those suffering with chronic pain. This sizeable study (117 participants) is done from a subjective perspective and would be a great source of information to relate to a client who is tentative about trying massage for chronic pain.

Massage significantly improved self-rated health, mental energy and muscle pain in people with chronic musculoskeletal pain, according to a recent study.

"A Randomized Clinical Trial of the Treatment Effects of Massage Compared to Relaxation Tape Recordings on Diffuse Long-Term Pain" was conducted by staff at the Uppsala University Department of Public Health and Caring Sciences, in Uppsala, Sweden.

One-hundred-seventeen subjects with long-term, diffuse (spread out) musculoskeletal pain participated in the study. Each subject had pain that had lasted for at least three months and was not caused by a specific disease or condition.

Participants were randomized to either a massage or relaxation group. Subjects in the massage group received anywhere from six to 10 massages, each lasting 30 minutes. Subjects received the massages one to three times per week. Participants received an average of seven massages. One person administered all massages, and each session was adjusted to meet subjects' individual pain thresholds.

Subjects in the relaxation group listened to a relaxation tape twice a week for five weeks. The tape instructed them to tense and relax the muscle groups and breathe slowly and regularly.

Questionnaires regarding the subjects' age, gender, smoking habits, country of birth, marital status and profession were filled out before, immediately after and three months following the study. A self-rated health questionnaire and rating scales for mental energy and muscle pain were also administered at these times.

Results of the study showed that, during treatment, there was a significant improvement in self-rated health, mental energy and muscle pain for subjects in the massage group as compared to those in the relaxation group.

"For all three outcome measures, massage was significantly more effective during treatment, even after controlling for other possible factors," state the study's authors.

However, at the three-month follow-up evaluation these improved scores had reverted back to their initial levels.

"This lack of long-term benefits could be due to the short treatment period or treatments such as these do not address the underlying causes of pain," state the study's authors. "Future studies of long-term pain should include longer treatment periods and post-treatment follow-up."

- Source: Uppsala University Department of Public Health and Caring Sciences, in Uppsala, Sweden. Authors: Dan Hasson, Bengt Arentz, Lena Jelveus and Bo Edelstam. Originally published in Psychotherapy and Psychosomatics, 2004, Vol. 73, pp. 17-24.

Posted by Ralph at 04:20 PM | Comments (2)

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This article contains information that could have a significant impact on many massage therapists practices. There is a legal debate currently going on regarding the safety of the relatively new class of painkillers, Cox-2 inhibitors. If these drugs are taken off the market, it's going to greatly affect our clients with arthritis or chronic pain. In addition, knowledge of the possible cardiovascular risks associated with these painkillers could prove to be of great value to the massage therapist.

By RANDOLPH E. SCHMID Associated Press Writer

WASHINGTON (AP) - The maker of Celebrex and Bextra says the two prescription painkillers are safe, even as an official of another company that makes a similar drug says he believes all drugs in the same class may pose heart or stroke problems.

Merck & Co., pulled Vioxx from the market after a long-term trial indicated that users of the popular pill could have a variety of problems from stroke to irregular heartbeat to heart attack.

Officials of Pfizer Inc. told a joint meeting of two Food and Drug Administration advisory committees on Wednesday that they believe the company's Celebrex and Bextra remain safe and effective treatments for chronic pain.

When Merck withdrew Vioxx on Sept. 30 the company acted because it feared some problem with the drug itself was leading to the strokes and heart trouble.

But Dr. Ned S. Braunstein, senior director of Merck Research Laboratories, told the panels that since then studies suggesting similar problems with Celebrex and Bextra have changed his mind.

"The data strongly suggest it is a class effect" for all drugs of that type, Braunstein said.

The drugs, designed to help people in chronic pain from conditions such as arthritis, are known as Cox-2 inhibitors. At least two other Cox-2 drugs are awaiting approval from the FDA, Arcoxia from Merck and Lumiracoxib from Novartis Pharmaceuticals. The panels planned to discuss those drugs Thursday.

The Cox-2 drugs have become blockbuster sellers over the past 15 years, offering relief from chronic pain without causing the stomach and intestinal troubles that plague many other pain killers.

The advisory committees are holding a three-day session to gather data on the safety of Cox-2 inhibitors and to make recommendations regarding their future use.

Recommendations could range from limiting these drugs to people not known to be at risk of heart problems, reducing the dose or duration of use, requiring tougher warning labels and even taking the drugs off the market.

A panel of federal judges on Wednesday assigned all pending Vioxx product liability lawsuits against Merck to U.S. District Judge Eldon E. Fallon in Louisiana. Fallon is experienced in major pharmaceutical litigation.

An FDA health official told the panels there were preliminary indications of heart problems with Vioxx before it was withdrawn, but it was difficult to sort through conflicting data.

Dr. Lourdes Villalba, medical officer responsible for Vioxx at the FDA's Center for Drug Evaluation and Research, said a study done in 2000 comparing Vioxx with the painkiller naproxen showed a higher rate of heart problems with Vioxx, but other studies had conflicting results. In discussions with Merck officials, she said, the company suggested naproxen might have a heart protective effect.

Nonetheless, in 2002 the agency required an added warning on the Vioxx label urging caution in prescribing it for people with heart conditions.

"We never bought the naproxen theory," she said.

Dr. Kenneth M. Verberg, Pfizer vice president for inflammation and immunology, defended Celebrex as safe, though he said there is little data on use of the drug for more than one year. Further long-term testing of Celebrex is needed, he said.

Merck's Braunstein said the biggest increase in heart problems occurred after 18 months of use.

Dr. Steven Galson, acting director of FDA's Center for Drug Evaluation and Research, reminded the committees that the drugs in question are important painkillers widely used by people in chronic pain. It is important to balance the risks of drugs with their benefits, he said.

A drug that has a positive risk-benefit balance for the population as a whole, Galson added, still may cause serious problems for some individuals.

The meeting's chairman, Alistair J.J. Wood, assistant vice chancellor of Vanderbilt University Medical Center, commented that "it's worrisome when a drug that is supposed to produce a safety benefit is producing an increase in mortality."

Recommended Study
Pharmacology and Massage

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