Diagnosis

CHAPTER 3 Diagnosis



Chapter contents


General considerations for diagnosis and testing 17

Tests of our aims of exercising 18

Exercise and pain 24

Contraindications 25


General considerations for diagnosis and testing


Diagnosis and examination are fundamental to all medical and therapeutic interventions:


• to design the treatment plan

• to see the improvement, how the patient is responding to treatment

• to adjust and modify the treatment accordingly.

Manual therapists have a special responsibility for diagnosis. During treatment patients seem to become more aware and remember their problems more. Often they tell their therapist what they should have told their doctor or counselor. The manual therapist must be able to guide the patient towards the appropriate diagnostic steps. It is also important to recognize red flags indicating when the patient has to be referred for medical investigation. This is the case if any of the following applies:



abdominal pain, anorexia, bilateral symptoms, bowel/bladder changes, chills, constipation, diaphoresis, diarrhea, dizziness, dysesthesia, dysphagia, dyspnea, early satiety, fatigue, fever, headaches, heartburn, hemoptysis, hoarseness, indigestion, jaundice, nausea, night pain, night sweats, palpitations, paresthesia, persistent cough, skin rash, vision changes, vomiting, weakness, weight loss/gain.



(Goodman & Snyder 2000, pp. 492–493)


Particular care is necessary when there is:


• severe feeling of sickness

• severe night pains

• spasms

• psychological problems

• no history of trauma or injury

• no known etiology

• conspicuous recent changes

• case history which indicates that exercise could cause tissue damage; for example, with fractured ribs be careful not to cause a pneumothorax with exercise

• pain that does not improve with medication, treatment, position, movement, or rest

• any doubt or the feeling that something is not right.

We are not dealing with systemic diseases in this book; nevertheless we should be aware that systemic diseases could mimic neuromusculoskeletal problems due to viscerosomatic reflexes or referral patterns of viscera. Particular care is necessary if the case history shows related signs and symptoms (Goodman & Snyder 2000).


Sammut & Searle-Barnes (1998, p. 136) summarize the important principles of examination:


• understanding what has happened to the various tissues that cause the symptoms

• understanding how the body has reacted locally and globally to these changes, particularly how these have affected the functions

• considering the predisposing and maintaining factors for these tissues and functional changes.

These aspects are helpful for developing appropriate exercises, and changing harmful habits and everyday activities.



Tests of our aims of exercising


From the vast array of tests available we are giving a brief introduction of those that relate particularly to our aims of exercising. The tests indicate which therapeutic aims should be developed, maintained, or reduced. The diagnostic outcome will lead to the appropriate exercise prescription and help patients to understand why these exercises were chosen, how to perform them, and see the improvements for themselves. Many tests are exercises as well, and most exercises can also be considered as tests. Therefore we will give suggestions for tests and refer to suitable basic exercises or āsanas. As soon as patients have developed mindfulness in their approach to exercise, they will be able to see and feel the changes more clearly.


For details of musculoskeletal examination there are many publications to refer to, such as Magee (1997), Sammut & Searle-Barnes (1998), and Goodman & Snyder (2000). For tests referring to motor abilities, see Lederman (2005, 2010).


We will mainly focus on active tests that are most relevant for showing improvement through exercise and can be understood, performed, and evaluated by patients themselves, once the therapist has taught them.


The baseline is the patient’s ability at the start of the exercise treatment. All improvement is measured in relation to this baseline. This individual approach is consistent with the traditional view of yoga, meeting patients where they are. A sensible objective is to tailor the exercise aims to the patient’s needs and expectations, as far as possible. This subjective approach has been useful in the authors’ exercise approach.


A non-specific but highly relevant factor indicating general health and stamina is the overall quality of movement and willingness to move. Experience has shown that any change in range of movement, however small, can improve the patient’s function and well-being. To judge this, mindfulness is fundamental. In itself mindful exercising is an important basis for testing that patients can do themselves.


We have mentioned the importance of testing in the initial diagnosis and observation of improvement through exercising. Particularly important for the patient is the motivation to continue exercising. Therefore tests that enable patients to judge their own improvement for themselves are particularly relevant. With continued practice, mindfulness and the ability to self-test will be increasingly refined.


The following sections suggest a selection of tests, with an emphasis on the close relation between testing and exercising. Results can be documented in different ways according to individual preference. For example, measurements can be taken, or drawings, photographs, verbal descriptions, or a combination of any of these can be used. In this way the patient’s success rate can be observed over a period of time. The baseline indicates where the patient was at the beginning.



The meaning of mindfulness


As explained in Chapter 2, mindfulness is a fundamental aspect of the ancient eastern paths of meditation. Applying this principle to the physical practice of the yoga path leads to the following reflective aspects:


• observing the body’s signals

• cultivating inner awareness from the center to the periphery of the body

• observing and feeling: where awareness can go, which parts of the body can be penetrated with the mind, how long this awareness can last, how long you can be calm in a posture.

In mindfulness the exercise path is entered from both directions. It is a basis for measuring the improvement in all objectives as well as the quality of exercise and the boundary of movements. It is enhanced through continued practice. Improving mindfulness is not restricted by most conditions, nor by aging. Iyengar (2005) emphasizes that we have the capacity to refine our awareness as we get older. It is worth cultivating this. Mindfulness is a strong diagnostic tool that can be applied to all exercises and can constantly be honed.



Mobility and stability


For a successful exercise prescription it is important to consider hypomobility as well as hypermobility and the possible relationship between the two. It is particularly important to understand hypermobility in order to protect the relevant areas and avoid injury through overexercising. We need to distinguish between pathological instability and hypermobility (Magee 1997).


Pathological instability is an excess of the small accessory movements in the joints, such as translation or anterior/posterior shift. A small amount of this joint play is important for painless, good joint function; it is not under voluntary control. Pathological hypermobility is an excess of gross anatomical movements, such as flexion, extension, side-bending, rotation, and circumduction. It is very individual, and is dependent on age, gender, and many other factors. Hypomobility and hypermobility can be generalized or local. Hypermobility is often adjacent to a restricted area and a consequence of it.


Clinical instability of the lumbar spine is frequently discussed (Richardson et al. 1999, Panjabi 2003). When the practitioner can see more pronounced deviations from natural curves during active examination, showing hypermobile segments, the patient often experiences pain. This is an important connection between the testing done by the therapist and the patient. These hypermobile segments also need special care during exercise. If movements at these segments are causing pain, this area may be overworked. The movements should remain in the painfree range or come back to this range if performed too far.


Patients and yoga students who are generally hypermobile are often admired and envied for their abilities and impressive performance of yoga āsanas. Nevertheless, they tend to have pain that does not improve, and sometimes is even worsening despite their regular, beautiful practice. Their muscles, tendons, and ligaments are often overstretched and irritated. They should not go to the limit of their mobility; rather they need to adjust their postures so that the muscles are strengthened and work together in a balanced way. For hypermobile individuals precise alignment is very important. The muscles should be used sufficiently to finetune the movements of the joints and to protect the vulnerable joints. The instructions for both the āsanas and the basic exercises are designed to fulfill this. Very mobile people may need to come away from their limits of movement and use props to support stability first. Details need to be decided on a case-by-case basis.



Standing active examination for hip and spinal mobility


Stand with your feet as close together as possible. Keep the knees straight throughout the movement test. Perform side-bending, rotation, bending backwards, and bending forwards. Find and document the painfree range of movement.


To test yourself you can slide your hands down the sides of your legs for side-bending, and down the backs of your legs when bending backwards. When you bend forwards you can measure the distance from your fingertips to the floor. You may like to use a stick lined up beside your legs: make a mark on this stick to indicate how far you get down, and observe your development over a period of time.


Rotation can also be tested sitting on a chair, turning to either side, and observing the angle of rotation (see Chapter 6, exercise 2.8).


Note that hip mobility and thigh muscle tone influence the result. When testing forward bending in particular it is useful to decide the main limit at the outset. If short hamstrings restrict hip flexion the lumbar spine will be more curved. If the lumbar spine itself is restricted it will show less curve from the side (Sammut & Searle-Barnes 1998).


To test the hamstrings lie on your back and raise one leg, keeping that knee straight (see Chapter 7, āsana Supta Pādāimageguimage imagehāsana). Check the angle of hip flexion.



Tests for the feet


It is essential to observe the transverse and longitudinal arches of the feet during standing and how they change with exercising (see Chapter 6, exercises 10.4 and 10.6).


Active mobility without weight-bearing can be tested sitting with straight legs. Move the feet into plantar- and dorsiflexion, inversion and eversion, and circumduction. Move the toes in all possible directions. Extension of the big toe is particularly important for gait (see Chapter 6, exercise 10.3).


To test these abilities with weight-bearing, stand and invert and evert your feet, then raise the heels and stand on the heels, raising the forefoot (see Chapter 6, exercise 10.9). Toe extension can be tested in squatting with the heels raised. The hands can be supported on a couch.


While wear and tear of the soles of the shoes may not help to judge improvement over just a few weeks, it is a useful diagnostic tool at the outset or over a longer period.



Tests for the knees


Look into the mirror for:


• valgus or varus

• swelling around the joints

• shape and position of the kneecap

Related posts:

Yoga in everyday life Mindful exercising Introduction to yoga Preparatory practice for the yoga art of breathing The basic exercises Selected āsanas for integrating the aims and principles

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Nov 7, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Diagnosis

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