Global perspectives on functional assessment, part 2 of 2
Functional assessment from the practitioners’ viewpoint, part 2 of 2
By Anthony Lombardi
Since the popularity of functional assessment and treatment is growing, I wanted to learn and understand how doctors and therapists from around the world used this approach in their practices and how they apply it clinically to see if there were any fundamental differences from the way it is done here in Canada.
In part 2 of this series our expert panel answer the last two questions. Our expert panel includes: chiropractors Dr. Timothy Scherz from Quito, Ecuador, Dr. Joseph Armou from South Carolina, Dr. Montgomery Harrison from Macquaire University in Sydney, Australia, Dr. Edward Jarvis from Quito, Ecuador, and Dr. Cyril Fischhoff from the Island of Mauritius; massage therapists Richard Lebert of Ontario and Ken Ansell of Saskatchewan; occupational therapist Jason Lomond of Nova Scotia; medical doctor in sports medicine Dr. Hugo Pinto from Portugal; and chiropractic students from New York Chiropractic College Kyle Neagle and Steve Martinow.
How do you use functional assessment/treatment in your practice?
Pinto: I only use it in my practice because it allows me to assess the cause, not only the consequences, of the dysfunction (pain), even if that is the main reason that brings the patients or athletes to us. I would not use any other approach, because the results are never what I want.
Lebert: I use the functional model in my practice when I am working with athletes that compete at a high calibre. A functional approach allows me to offer athletes a treatment approach that focuses on improving motor recruitment, which helps athletes use their body more efficiently. In addition to athletes, I use the functional model with chronic pain patients or patients that suffer from fibromyalgia. When working with chronic pain patients, the therapist and patient may be left with more questions than answers when using orthopedic assessment.
Ansell: I now use functional assessment daily in my practice. Where I would previously start with the traditional orthopedic testing and progress from there, I now get more accurate results starting with a functional assessment and progress to orthopedic tests as needed. My training in functional assessment has streamlined both the assessment and treatment processes where the problems are quickly and accurately assessed and my treatment outcomes have become more successful.
Harrison: Functional assessment is applied in order to narrow down my diagnosis of tissues in lesion. I apply multiple functional assessments to confirm or rule out dysfunction. Treatment is applied according to the diagnosis. I pick the best treatment in my toolbox to correct the dysfunction. I recheck the failed functional assessments immediately following my treatment to look for improvement in overall mechanics. If my treatment did not provide adequate change, this means I may have treated dysfunctional tissue, but not necessarily the relevant ones involved. I then recheck my diagnosis, and apply tests, treatment and retest until I’m satisfied that adequate gain has been accomplished.
Lomond: A combination of approaches: assessment of participation limitations (OT theory), Exstore, advanced functional assessment – as taught through McMaster University, and neurobiological approaches (i.e. Butler).
Fischhoff: All the dynamic assessments are functional (rehab school, Exstore, dynamic imaging, gait analysis). The more we combine all this information, the more we have a better idea of the global dynamic context.
Martinow: When I start practising, I envision my assessments to include a detailed history with accompanying neuro and ortho testing to rule in/out any serious pathology, and then proceed to a functional exam. Depending on the region this can include the squat, balance test, range of motion tests, Apley’s Scratch test, hip extension/abduction to name a few. I will correlate my ortho findings with my functional assessment and base my treatment on what I find in the functional assessment. I think it is very important to add in corrective exercises at the appropriate times during the healing phases. I believe core exercises are extremely important in rehabilitation.
Armour: I use functional A-T daily in my practice, which helps me quickly evaluate and identify the patient’s dysfunction or adaptive changes. I then typically target these areas with medical acupuncture or soft tissue techniques. I have found the Exstore program is by far the most effective and fastest at locating dysfunction/motor inhibition.
Neagle: As far as approach, I like to apply what I have learned from Dr. Craig Liebenson’s Magnificent 7, some of Gray Cook’s Selective Functional Movement Assessment, McKenzie’s lumbar assessment, Dr. Stu McGill’s input on spine biomechanics and loading, and of course the work of Vladimir Janda. As long as I am continuously working on patients, I don’t think I will be able to say what my exact approach is. I will be constantly refining what I feel is an adequate functional assessment throughout my time in clinic and in practice. One thing I know for certain is that almost all of my functional assessments will have some form of squat in it (unless absolutely contraindicated upon patient presentation). It is such a crucial movement in everyday life, but also, from a clinician standpoint, the squat tells so much about a patient.
Jarvis: I use information gleaned from patients during the history, muscle strength testing and pain location to focus types of treatment on a patient. I feel that spinal and extremity adjusting, contemporary acupuncture and myofascial muscle work are very important in removing musculoskeletal sources of chronic and acute pain in patients.
Scherz: I prefer to use the Exstore system in clinical practice.
- Recheck the failed functional assessments immediately following your treatment to look for improvements in overall mechanics.
- Tissues that are inhibited will not respond to exercises until that neuromuscular junction of the inhibited tissue is restored using manual techniques or acupuncture.
- Find a system you like and use it with consistency.
Do you think schools will begin to include functional assessment/treatment approaches in their curriculum?
Scherz: I believe learning functional assessment approaches would be another great tool that students could learn in school. I believe the limiting factors are that if you just use functional assessment as part of your examination you may miss very important findings that you would find on palpation and other forms of clinical assessment such as diagnostic testing.
Ansell: I think that schools will eventually include some fundamentals of this functional assessment and treatment in their curriculum but the more progressively thinking schools will see the increased benefits to treatment success and adopt these principles quicker than others. I think that limiting factors of using functional a/t in the school curriculum will be clinical experience. Functional assessment and treatment is more successful, I think, when the clinician has some clinical experience to draw on.
Lomond: Already is, to a certain degree (OT school uses functional assessment).
Pinto: Being a medical doctor gave me a general view to almost all of the pathologies afflicting people. Unfortunately, in regards to neuromuscular, myofascial and even some organic dysfunctions, it did not give me the tools to properly assess the patient, and investigate the cause of these types of pathologies, and only gave the tools to treat the consequences. This approach should be mandatory in all health schools in the world – medical, physiotherapy, chiropractic, nursing, massage therapy and others – because it focuses on properly assessing the individual on his/her environment to truly look at the probable causes that led to the problem the patient presents to you. The limiting factors are the marasmus present in all these schools, with all the teaching and non-clinical staff ruling the way the students should be reached. We should learn clinically and not theoretically.
Armour: It appears the trend is heading more towards a functional A-T model, although I personally feel that it will not become part of the schools’ curriculums. Unfortunately, even though the majority of chiropractic schools do a great job covering a full range of topics, they are often focused on teaching a curriculum that is more focused to the board exams or a more generalized curriculum rather than specific assessment and treatment techniques.
Lebert: It may be a couple of years before schools start to explore the functional approaches, but I would love to see them taught to students. Limiting factors could be instructors that are not yet confident in their ability to teach and explain a functional approach.
Jarvis: Chiropractic and contemporary acupuncture schools are closing their eyes and still teaching future healers with dogma. While spinal and extremity misalignments are heavily influenced by the muscles that act upon the joint. In fact, muscle contraction may be the cause and source of many chronic pain syndromes. Tight muscles protecting a joint or segmental level after the source of perceived or real tissue damage has disappeared may make it impossible to adjust or mobilize. Traditional physiotherapies in treating taut muscles disappoint, as does the use of muscle relaxants. Dry-needling muscles is an important adjunct to SMT or osseous adjusting.
Harrison: Functional assessments are already being included in the Macquarie University Chiropractic course. Limitations of functional assessment: it takes time to learn/master, and one must look at many people to get an idea for what’s normal and abnormal. The major issue that I observe in class is that we only get to perform the tests on each other (18- to 30-year-old healthy specimens). The movements don’t have meaning until you start using it on real patients who have biomechanical problems.
Neagle: As of right now, we have some younger generation clinicians and teachers that support and have introduced many of the students to the functional assessment and treatment approach. At NYCC, there is little resistance to this type of mindset. Many students here are biomechanically based and strongly support the idea of coupling chiropractic adjusting and functional rehabilitation to have an astounding effect.
Fischhoff: They already teach it, but in the “functional family” there are many systems of analysis (or assessment/treatment), from active release to dry needling, so probably all the schools do not teach the same.
Martinow: At NYCC we are introduced to functional assessment and treatment briefly. I think with active care becoming a more prominent role in chiropractic, schools will start emphasizing functional assessments and treatments more vigorously. There may be some limitations to overcome with curriculum planning because every school needs to meet certain accreditation and standards. In time, I believe it will be a very important aspect in the curriculum.
- Students need to learn clinically and not theoretically.
- Schools have curriculum planning issues because they need to meet certain accreditation and standards.
- Instructors may not be confident in their ability to teach and explain a functional approach.
Anthony Lombardi, DC, is consultant to athletes in the NFL, CFL and NHL, and founder of the Hamilton Back Clinic in Hamilton, Ont. He teaches his fundamental EXSTORE Assessment System and conducts practice-building workshops to health professionals. Visit www.exstore.ca for information.