Specificity of diagnosis = specificity of treatment = specificity of results
With recent advances in manual medicine, treatment options for practitioners are growing in number. Various new techniques have emerged both in the literature and in the everyday practice of chiropractors, physiotherapists, massage therapists, and athletic therapists. Each of these particular techniques (Active Release Techniques® [ART], Trigenics®, Graston®, electro-acupuncture, Kinesiotaping®, myofascial release, muscle energy techniques, laser therapy, etc.) offers a particular approach to dealing with specific tissue pathology, and/or mechanical dysfunction. For example, ART acts to remove soft tissue fibrosis or scarring, whereas electro-acupuncture is utilized for neuro-modulation and reduction of pain and inflammation.
As with other more established forms of therapy, such as spinal manipulation, mobilization, and stretching, even the best management techniques will fall short if the evaluation is not thorough enough to delineate the exact deficits. But are our methods of tissue evaluation and examination specific enough to correctly select the right technique to accomplish its intended purpose?
Most manual practitioners have limited access to diagnostic advances in imaging methods. In terms of orthopedic examination, most procedures are designed to determine the extent of “macro” injuries to tissues; however, a large majority of conditions seen in a manual practitioner’s office are “micro” tissue injuries such as repetitive strain disorders, which are often not reproduced with these tests. Even in situations where an orthopedic test elicits a patient’s symptoms, little information is forthcoming to assist in the selection of appropriate treatment. As an example, positive shoulder impingement signs do not delineate the exact structures that are causing the pain. These signs simply indicate that the location of the painful structure is the subacromial region, which can represent various diagnoses, including:
• supraspinatus insertional tendonopathy
• long head of biceps tendonopathy
• long head of biceps tenosynovitis
• subacromial bursitis
• glenohumeral joint capsular tear or capsulitis
• internal impingement (posterior-superior glenohumeral impingement)
• subscapularis tendonopathy/ impingement
Many of the above possibilities differ in terms of histological causes (inflammation, collagen degeneration, angiogenesis, ligamentous tear, etc.) and symptomatology (pain, swelling, stiffness, etc). Most importantly perhaps, they also differ from a treatment perspective, in terms of structural location.
Considering the many current treatment possiblilities in manual care, a diagnosis of subacromial impingement is insufficient for selecting from the most suitable modalities. Such a diagnosis lacks the specificity to determine exactly where the practitioner inserts the acupuncture needle and to what depth, or where a myofascial release technique is performed, or which joints need to be mobilized and in which direction. Thus the manual practitioner is often left with just their hands and their knowledge of anatomical structure to determine the cause of a patient’s symptoms.
Though human anatomy is para-mount in the training of manual practitioners, instruction in palpatory and functional anatomy frequently is overlooked by institutional curricula. Anatomy is typically taught in a classroom setting, and testing is often restricted to the regurgitation of anatomical fact (i.e., origin, insertion, innervation) though some academic institutions are equipped to offer the experience of cadaveric dissection. While anatomical pedagogy is undeniably important, the art of soft tissue palpation with live subjects will ultimately determine the practitioner’s ability to locate and assess musculoskeletal pathology.
Functional Anatomic Palpation Sys-tems© (FAP) is a guided systematic approach to soft tissue palpation in which the practitioner delineates, feels, and then assesses specific anatomic structures. The approach is summarized by the following: specificity of diagnosis = specificity of treatment = specificity of results©.
A diagnosis of “groin sprain,” for example, is subjected to further examination in order to determine the location of the lesion, be it in the adductor longus, brevis, or magnus, the pectineus, or obturator externus, each of which is palpable and distinguishable via palpation.
FAP offers advanced instruction in soft tissue palpation to chiropractors, physicians, physiotherapists, massage therapists, osteopaths, acupuncturists, and athletic therapists. In addition to hands-on palpation and discussion of treatment alternatives and current research, the training also provides a review of clinical and functional anatomy.
The course is divided into three seminars based on anatomic region (upper limb, lower limb, and spine). Anatomical structures are reviewed onscreen with visuals courtesy of the Primal 3D anatomy series by Primal Pictures in which overlying structures are peeled off to uncover the target muscle, ligament, or tendon. Time is allocated for participants to practise their palpatory skills.
Even the best management techniques will fall short if the evaluation is not thorough enough to exactly delineate a patient’s deficits. The FAP system gives practitioners the opportunity to hone their palpatory and diagnostic skills, and this will translate into a more specific application of treatment modalities.•
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