By Michael Hurley
By Michael Hurley
Whether we are students learning in a classroom setting, or health-care practitioners building a patient base, we need clarity when initially assessing new patients.
Whether we are students learning in a classroom setting, or health-care practitioners building a patient base, we need clarity when initially assessing new patients. In school, we are taught a variety of orthopedic tests that are supposed to form the foundation of our assessments. Having been through the classes, we finally start to treat patients – but we soon discover, and studies tell us, that frustration sets in when traditional orthopedic tests don’t give us consistent results. (Contant, 2003)
For instance, picture this brief scenario: A patient complains of low back pain. You have them perform range of motion tests, a straight leg raise and Kemp’s test. All tests point to everything being normal. Ten minutes of testing goes by, and you are still no closer to finding the cause of your patient’s discomfort. I am sure most practitioners have been in this situation at one point or another.
It was this type of frustration that made me seek out a system that would be time efficient and allow me to accurately diagnosis dysfunction in my patients. This is when I came across Exstore, a comprehensive assessment system developed by Dr. Anthony Lombardi, a chiropractor from Hamilton, Ontario.
How it works
The biggest mistake made by practitioners in manual medicine is spending too much time focusing on the area of pain, which may not be specifically localized to the area of pathology. Assessing the patient using the Exstore system allows the practitioner to find the cause of the problem rather than focus on where it hurts.
The assessment system employs two steps that thoroughly and accurately diagnose the cause of dysfunction in a network that is based on three major foundations of the skeletal system: the vertebral column, the scapular girdle and the pelvic girdle. Hamill (2006) describes the girdles as foundations of human movement. These girdles serve as attachment sites for muscles and are constantly adapting to movements of the upper and lower extremities.
The first step is palpation. It is key to understand and recognize how tissues feel. Devor (1999) states that fibrous tissues form palpable, taut muscle bands and trigger points; such muscle dysfunction and spasm lead to compression of blood vessels, and decreased blood flow, leading to increased pain stimulation and decreasing joint mobility.
The second step, which is the key to the entire system, is assessing motor inhibition of the tissues around the scapular and pelvic girdles. Le Pera (2001) describes muscle motor inhibition as the inability of the peripheral nerve to contract the muscle due to chemical or physical trauma. This motor muscle inhibition can be cause by three different factors: nociception, pain and arthrogenous changes.
Why inhibition matters
Portenoy (1994) described nociception as the neural processes of encoding and processing noxious stimuli. It is the afferent activity produced in the peripheral and central nervous system by stimuli that have the potential to damage tissue. Nijs (2012) concluded that chronic nociceptive stimuli result in cortical relay of the motor output in humans, and a reduced activity of the painful muscle. Nociception-induced motor inhibition might prevent effective motor retraining. In addition, the sympathetic nervous system responds to chronic nociception with enhanced sympathetic activation. Not only motor and sympathetic output pathways are affected by nociceptive input – afferent pathways (proprioception and somatosensory processing) are influenced by tonic muscle nociception as well.
Svensson (1996) studied people suffering from jaw pain and concluded that sensory-motor interactions can be explained by a facilitatory effect of activity in nociceptive muscle afferents on inhibitory brain-stem interneurons during agonist action.Thus, generated movements have smaller amplitudes and they are slower which most likely represents a functional adaptation to experimental jaw muscle pain.
Finally, studies have shown the presence of arthrogenous muscle inhibition. Sedory (2007) found arthrogenic inhibition of the hamstrings muscles bilaterally and facilitation of the quadriceps muscle ipsilateral to the involved limb were noted in subjects with unilateral chronic ankle instability.
The Exstore assessment system allows the practitioner to determine the inhibition of the patient’s dysfunction in a systematic and efficient manner. The system is simple to apply in practice and is ideal for chiropractors and manual therapists who use acupuncture and myofascial release as part of their treatments.
Unlike most assessment systems, Exstore is also very effective in helping patients and athletes prevent injury. This system has been used on many professional athletes as a means of pre-screening and treating before any serious injuries can occur. Exstore is useful not only in helping elite athletes but also can help practitioners be more specific and time efficient while helping patients from all age groups and levels of activity.
Not just for chiropractors
Since this system was created, it has been taught to chiropractors, physiotherapists, occupational therapists, massage therapists, athletic therapists and medical doctors for use on all of their patients.
The Hamilton Family Health Team in Hamilton, Ontario, which houses primary care physicians and nurses and serves approximately 280,000 patients, has asked Dr. Lombardi to teach Exstore to its MDs, nurse-practitioners and nurses.
Dr. Ravinder Ohson, an MD from Hamilton, utilizes the assessment system in his own practice.
“I have used the Exstore system and found it to be an efficient way to localize the cause of the dysfunction,” says Dr. Ohson. “This has saved me time as well as reduced my reliance on radiology to give me the diagnosis. I would suggest this system to any primary care provider in the assessment of a musculoskeletal disorder.”
Exstore has changed the way I approach patients daily. It has given me the confidence to accurately diagnose and treat any musculoskeletal complaint and I feel it would be a welcome system in any clinical practice.
Editor’s note; Dr. Hurley does not work for, or have any interests in, Exstore or Dr. Lombardi.
Sources Used In This Article
Hamill (2006). Biomechanical Basis of Human Movement. Baltimore: Williams & Wilkin.
Contant. (2003). The Efﬁcacy Of Lumbar Spine Orthopedic Testing.
Le Pera et al. (2001). Clin Neurophysiol, 112(9), 1633-1641.
Devor (1999). Evaluation and Treatment of Chronic Pain. Baltimore: Williams, & Wilkins.
Portenoy RK, Thaler HT, Kornblith AB, Lepore JM, Friedlander-Klar H, Coyle N, Smart-Curley T, Kemeny N, Norton L, Hoskins W, et al. Symptom prevalence, characteristics and distress in a cancer population. Qual Life Res. 1994. Jun; 3(3):183-9.
Nijs J, Daenen L, Cras P, Struyf F, Roussel N, Oostendorp RA. Nociception affects motor output: a review on sensory-motor interaction with focus on clinical implications. Clin J Pain. 2012 Feb;28(2):175-81. doi: 10.1097/AJP.0b013e318225daf3. Review.
Svensson P, Arendt-Nielsen L, Houe L. Sensory-motor interactions of human experimental unilateral jaw muscle pain: a quantitative analysis. Pain. 1996. Feb;64(2):241-9.
Sedory EJ, McVey Eric D, Cross Kevin M, Ingersoll Christopher D, Hertel Jay. Arthrogenic Muscle Response of the Quadriceps and Hamstrings With Chronic Ankle Instability. J Athl Train. 2007 Jul-Sep; 42(3): 355–36.
Dr. Michael Hurley is a 2011 graduate of New York Chiropractic College. He is the owner of Middlesex Spine and Sport Clinic in Mount Brydges, Ontario. The clinic is a multidisciplinary office that offers chiropractic, physiotherapy, massage therapy and naturopathic medicine. www.middlesexspineandsportclinic.com , email@example.com