The Thinking Practitioner Podcast:

Episode 171: The Most Skipped Step in Assessment and Why It Matters Most (with Whitney Lowe)

Whitney Lowe  

Welcome to the Thinking Practitioner podcast,

Til Luchau  

a podcast where we dig into the fascinating issues, conditions, and quandaries in the massage and manual therapy world today.

Whitney Lowe  

I’m Whitney Lowe,

Til Luchau  

and I’m Til Luchau.

Whitney Lowe  

Welcome to The Thinking Practitioner. Thanks for joining us here today. I’m Whitney Lowe, and we are excited to welcome Jane as a new sponsor of the Thinking Practitioner podcast. If you know us, you know that we are selective about who we partner with. We want sponsors whose values align with ours and who genuinely serve this community, and Jane certainly fits that bill. They are a practice management platform built specifically for health and wellness practitioners, which is simple enough for solo practitioners, but powerful enough for clinics and groups. What really caught our attention is Jane’s reputation for customer service, real humans available by phone, email, or chat, even on Saturdays. That kind of support is increasingly rare, and it says a lot about a company. So, if you’re looking to simplify the business side of your practice, check them out at a dash t dash.tv/jane that’s a dash t.tv/jane And thinking practitioner listeners can get a free first month by entering the code THINKING1MO at checkout. So, thanks for joining us here today. 

Whitney Lowe  

Til is off again this week, and I’m going to be doing a solo episode today, and I wanted to focus on some key aspects of treating pain and injury conditions, and look specifically about the role of the history, the role of that intake that we have with our clients, because this is so critically important. So, we’re going to take kind of a deep dive on some key issues related to how do you take a really effective history, why the different parts of it matter so much, and what kind of excellent information we can get for this, that’s going to help us become a lot more effective with our treatments when we’re working with our clients, and one of the things that gets overlooked a lot is how important and detailed that history needs to be.

There are various parts of our assessment process, and sometimes I see some practitioners focusing almost exclusively on the physical examination components of the assessment, and even speaking about assessment as if saying, like, oh, I’ve done my assessments with my, with this client, meaning what they’re really talking about is they’ve done a bunch of tests or physical examination tests with them, but the reality is the most important part of that assessment process is really the subjective information that you get from your client, that initial history, and so this is what we want to zero in on, is like, how do we take a good history? What kind of information do we get from that, and where can we really use this to benefit ourselves much more effectively as we make our clinical practice aimed at treating these various people who are coming with so many pain and injury complaints for us to address. So, here’s where we see one of the problems kind of getting started: a lot of the therapists will sort of begin treating their clients, just, you know, maybe focusing, just asking some basic questions at the beginning, and maybe your client says they’ve got shoulder pain, or maybe they say they got a pain down their upper extremity into their hand, and so then your attention goes to those places, and you just start working on where it hurts, but really we want to be asking a different question, not so much just where it hurts, but why it hurts. What’s the reason going on there? Because this can make a big difference in where the problem is really originating from. What is the nature of that problem? How is it going to respond to the work that we do? How might we actually aggravate that problem with the work that we’re doing?

Also, these are all critically important questions that we’re going to try to identify here, so with the various parts of that assessment process again, as I essentially wanted to, I want to sort of zero in on the history taking process, and we’re going to use a framework, or introduce a framework today called the OPQRST model. So this is taking a big sort of alphabet soup chunk of letters of the alphabet, but this is an acronym, and we’re going to look at each of these different component parts of the OPQRST framework, and one of the reasons I like this framework so much is, you know, oftentimes I would talk to students about the critical importance of history taking, and they would say, like, well, you know, I don’t know what kind of questions to ask, I don’t know what kind of things I should be asking my clients. And then the other really important part of this is, like, what do their answers mean? So, if they say, for example, I’ve got a, you know, a dull throbbing ache that just wakes me up at night on my shoulder, what does that tell us? What kind of things does that mean versus something that might be a real sharp kind of sensation that they would feel, so we’re going to zero in on what this framework tells us, and how this helps us design and implement a much more effective history-taking process that will then guide our treatment most effectively. So one of the big things that this history tells us is a lot about red flags, and what that means is. Some safety things that we need to be aware of, there are often very concerning conditions or problems that somebody might present with that they might not realize is a concern or a caution or possibly even a significant contraindication of the things that we might be doing with massage, and if you just kind of glance over and skip over a few things in the history, you might miss some of these really important red flags that would indicate the necessity for a referral or for somebody to be seen by another particular practitioner.

So this is a really distinct advantage of having a bit more of a structural framework to your, your history taking, because it, it helps you zero in on some of those things that might be critically important here, so let’s take a look at this. This whole history-taking process. One of the things I want to just emphasize, first off, though, is we talk so often about the therapeutic alliance and the ability to connect with your client, and how critically important that is, and this is one of the things that happens by building a really comprehensive history-taking framework is you have a great opportunity to really enhance that therapeutic alliance and develop a great deal of confidence and communication with your client, and that has tremendous therapeutic power. So, there’s a tremendous amount of benefit that comes from developing that communication and rapport with your client that happens just through a well taken history.

So, let’s look at that OPQRST framework. Here we’re going to start with the letter O, and this is for onset. So, this tells us how, how did that condition come about? Was that a sharp, sudden, acute injury, or was it a gradual condition over time, and maybe there was a, like, if it was an acute injury, they heard a loud pop, or there was a snap, or a sudden jerking pain sensation, or something like that. This tells us some key things about the nature of the tissue and how it was injured. If this was an acute injury, in particular, we want to sort of zero in on biomechanical forces that might have led to overloading that tissue, was it a muscle strain from excessive eccentric loading, or was it a compressive injury from too much force jamming into a joint, or what were those factors that might have led to the initial onset of it? If it is a chronic problem, we are looking at a different set of factors. There may be similar mechanical challenges to a particular area, but there may also be bio psychosocial factors or nociplastic pain sensations that have developed over time just from chronic inflammation or chronic irritation of certain structures. So we want to try to zero in on some of those kinds of questions. When did it start? How did you feel that? So, if you say, for example, you know a client says something like they felt a sharp pain in their shoulder when they were reaching over the back seat of the car, and there was a pop associated with it, that sounds like an overload tissue injury, maybe you know, straining muscle tendon unit, or possibly even a ligament sprain or joint capsule injury to that area, whereas if they reported instead a gradual stiffening over the course of months with no specific injury that they can recall, that would point towards something like a more chronic evolving condition, like adhesive capsulitis, for example, or possibly even rotator cuff tendinopathy, so knowing the nature of some of these problems and how they occur also helps us generate what are going to be our most effective questions in there as well, as well, and keeping in mind the nature of that tissue injury is going to govern a great deal about how we’re going to go about treating it. The next part is provocation and palliation, two big words, basically just meaning what makes it feel better, what makes it feel worse. So, for example, if there’s a pain somebody feels when in their spine, when putting on their shoes, you know, bending over, putting on their shoes, or sitting, and then it’s relieved by standing or walking, we see that pattern oftentimes suggestive of disc pain or disc-associated things that help from movement. So, movement is making it feel better. Sitting still makes it feel worse. Conversely, you might see the reverse type of thing in an instance where somebody says there’s pain increased when they’re standing still or walking downhill, that’s relieved by sitting, or they often call this the shopping carts sign, where they lean over, put their arms on a shopping cart, and can walk leaning over the shopping cart, that feels better, that is telling us some specific things about the mechanics of that low back region, for example, that might be joint-related pain to the facet joints in that second instance, where they were having increased pain with standing still or walking downhill, but it’s relieved by sitting, maybe, and even sometimes slumping over forward or leaning in a forward direction that takes the load off. Of those facet joints, so this is where we want to frequently look at how we compare the signs and symptoms from these different various possibilities. When we get that kind of information from our client, next we’ll go to cue or quality. This is the nature or quality of that pain. What is it? What does it ideally feel like? How would they describe it? 

And here I often want to encourage people, try not to put words in your client’s mouth by asking them, like, is that a sharp pain, because that’s a yes or no question, or might be a little bit more difficult for them to kind of tune in and identify, try to get them to give you recommendations or determine or descriptions of this pain in their own words as much as possible. Sometimes you might make some suggestions of how that might feel like. Would you say that is a burning or tingling or sharp or dull ache, or give them a number of different words to choose from, instead of just giving them one thing to look at, so one of the most common examples that we have here is the burning or tingling electrical shock kind of pain sensations that comes from neuropathic injuries or nerve injuries. So this is almost always an indicator of some type of neural involvement. This could be the nerves being mechanically irritated by compression, or it could be even chemical irritation of nerves, or something else indicating some type of irritant to the nerve structure, but it does indicate some type of nerve problem, as opposed to a muscle tendon, or ligament, or some other tissue that might be not producing those same kind of electrical sensations. Now, also, when we talk about those, the type of sensations, it’s really important to note where that location is, and this is kind of getting us a little bit into our next letter, the R letter, but let’s just stick with it right here for a moment. There’s a. you’ve probably heard numerous times the essential rule of real estate, which is location, location, location, and that is also an important rule in orthopedic evaluation when you’re looking at the nature of where those sensations are felt, for example, a person might say, I’ve got a sharp shooting electrical kind of pain in my hand. Well, many of us will immediately start thinking about median nerve entrapment in the carpal tunnel, because that’s the most common nerve entrapment problem in the lower extremity, or excuse me, in the upper extremity, and so when we have that carpal tunnel type of, or median nerve type of irritation in there, that could likely be a compression of the median nerve in the, in the carpal tunnel region, but what if that location is not in the distribution of the median nerve, but is instead in the distribution of the ulnar nerve out toward the edge of the hand. Zeroing in on that location is going to be critically important when we track down what is the quality of that pain. So, consequently, if somebody says, instead, well, this is just kind of like a dull, deep kind of ache in my hand as I’m doing various movements, and it’s really stiff in the first part of the day, and then it gradually gets easier, that sounds like arthritic type of pain, or maybe something associated with joint stiffness that gets improved by gradually doing movement over and over again, so the quality and nature of that pain description is going to lead us to looking at some of those various different factors as well. 

Whitney Lowe  

Let’s take just a quick moment to hear some notes from one of our other new sponsors. Here, we would like to welcome Deep Roots Massage and BodyWork in Keene, New Hampshire, as a new supporter of the Thinking Practitioner podcast, Deep Roots is a massage practice that’s expanding into continuing education for massage and bodywear professionals, and, like us, they are drawn to the art and science of evidence-informed practice, and they’ve built a reputation for hosting carefully crafted hands-on workshops with some of the fields leading educators, and they keep their class sizes small, so you can actually get more individualized instruction, and the kind of substantive group discussions that really enhance your practice, so you can get individual, individualized attention, and we really enjoy that kind of practice environment. As educators, I can say that this year’s lineup includes Advanced Myofascial Techniques for whiplash and acute injuries. Also, there’s a visceral anatomy and manipulation class, Thai massage, and a Leg, Knee and Foot masterclass with my partner, Til Luchau. So, to see the full schedule and register, visit Deep Roots mb.com that’s d e e p r o o t s m b.com and use the code thinking at checkout to save 10% on any of the upcoming workshops. 

Whitney Lowe  

Okay, jumping back into our framework again, we’re on the. Our word now, which is referral and radiation. We kind of touched on this a little bit in the last one we were talking about, but this is where we’re identifying, like, is this pain necessarily right here or is it referring somewhere else? And this is where we’re looking at things like Myofascial trigger points that may refer pain to other sensations as well as nerve entrapments or nerve compression problems, like we talked about earlier, you know, pain client might say something like, I’ve got pain out here on the lateral side of my hip. One question I always like to ask clinically, that can you point to and press on something that makes it worse? Usually, if they can point to impress on it and zero in on it with a single finger that’s indicative of some type of localized irritation right in that area. Oftentimes our referral pain, they might say, like, well, you know, it’s like going on down my arm, or it’s kind of a dull diffuse ache, maybe, or they can’t quite put their finger on it, that would be potentially more indicative of something like on the lateral hip region, maybe you know a bursitis or greater trochanteric pain syndrome, where there’s an irritation of the the tendons of gluteus medius and minimus, so interestingly, to you know, a lot of this is just an interesting little clinical thing that a lot of the lateral hip pain that gets blamed on bursitis, where people can put their finger right on, they might think it’s a local tissue right there that is a bursa, because that’s gotten a lot of attention in recent years, but some of the recent research has indicated that problems or inflammation in that trochanteric bursa is nowhere near as common as we once thought it was, that more commonly we might be seeing problems with tendon compression of the hip abductor tendons as they cross over the greater trochanter, there, so that’s again something that would be making a difference in how we choose to treat that particular problem. So we’re looking at some other types of pain that might be potentially referring down the whole lower extremity if it’s not right where they can put their finger on it. Again, this could be nerve entrapment problems referring myofascial trigger point pain patterns, and this is going to make some significant difference in how we choose to treat that.

For example, we treat myofascial trigger points with some moderately deep compressive forces, and possibly even stripping techniques and things that might be done during active movement, along with the contraction forces of those muscles, but we don’t want to do that kind of thing with a nerve entrapment problem before pressing directly on an irritated nerve, because that could definitely increase the pain problems or the pain sensations that the person is feeling, so this is something we want to keep, keep, keep it attuned to is what really is, is the primary cause there.

So, next letter we’ll jump to is our S O P Q R, and now we’re on the S. This is severity, and looking at the functional impact of that. So, you might have something, let’s say maybe we’re talking about a knee problem, and a client reports their pain is like eight out of 10 on a one to 10 scale when walking, but they can still squat and climb stairs, so that’s not necessarily a problem for them, that could indicate, you know, something where they’re really having a, an issue with walking, or maybe an acute non-structural inflammatory type of problem that’s going on there, on another person, they might say, for example, they report their pain is three out of 10, but that the knee really gives way, and that they can no longer bear weight on it, and to walk, and so a lot of times this is indicative of a completely different type of injury, like a ligament injury, where there’s instability, or, or what we call reflex muscular inhibition, where something is stopping them, the quadricep muscles from contracting to give them support and stability around the knee during the activities that they’re doing, because there’s pain avoidance, or is there a sudden pain or sensation in there. So these are different strategies that will go about trying to identify what is the root cause of that problem, and how we’re going to best go about and get it, and so lastly is our T, our timing, and this is when do they feel the predominant aggravation of these symptoms. So, is it are they waking up with this example, for an example, within the spine and neck region, for example, if somebody says they wake up with intense stiffness in their neck and back, and that sort of that eases after a hot shower and movement, they start walking around doing some things, and that gets a little bit easier, that would suggest maybe some kind of arthritic problem, or just general muscle stiffness and tightness and hypertonicity that gets worked out through some additional activity levels, but conversely, a person, maybe, who’s saying that they, they wake up feeling good, but by 4o’clock in the afternoon, after a long day at work at their desks, they had this heavy crushing headache, and you know, their back feels like a knife stuck in it. And there’s their neck is just screaming at them, so that would suggest chronic postural fatigue and muscular muscle trigger points, or some type of tension type headaches based on the long term cumulative cervical load issues in there. So this timing helps you decide like what kind of interventions you might make, and when the timing is going to be ideal for making those interventions. So, again, we’ve got this framework, the Op QRST framework. There’s a lot of different kind of things, but if you’re going through the history-taking process with your client, I would encourage you to think along the lines of this framework and say, you know, have I asked a question about the onset, have I asked them a question about, is there any referral, or is what’s the timing associated with that? If you maybe kind of, when you’re first getting used to doing this, you maybe even use kind of like a sort of a check-off process to determine, like, am I getting each of these different component parts of the questions answered, so am I, did I, did I ask about this? Did I ask about that? That will help you structure a really good, effective client interview. One of the other things that I encourage people to think about is, you know, I hear practitioners say a lot about, you know, like, well, I just, I kind of, I talk to my clients a little bit, I really just like to follow along what my hands tell me to do. Just remember, your ears and your brain are just as important as your hands in this evaluation process. Your hands can tell you a lot, but understanding and making some determinations about the nature of what’s going on in there is also critically important. And you know, I’ve noticed another thing too, with a lot of practitioners who seem somewhat reluctant to delve into, or take a lot of time delving into, this comprehensive history-taking process. Part of that is because you may not have a really good understanding of what kinds of questions to ask, and this OPQRST framework can certainly help you do that, but a lot of times it’s like, well, my client just wants to get on the table and get going, and remember that there’s different reasons that clients might be coming to you, if they’re coming to you just for general relaxation massage, and they just want to get relaxed, there’s not necessarily an imperative for a long detailed interview process, but if they’re coming for you, coming to see you for some type of specific injury complaint, for example, that they want to try to address. Then that’s something which is going to potentially require you to take a much more detailed interview process. And I like to talk to them in the, in the, at the outset, say, like, you know, what are your real goals? What are you really looking for here today? And, like, if they are trying to get you to address some type of pain or injury complaint, let them know we’re going to do some more comprehensive and detailed assessment process here to determine our first of all, are there any true contraindications, cautions, or red flags that I need to be aware of, but more importantly, you know, is massage or soft tissue work here really appropriate for this type of thing that you might be doing, and if so, what kind of things am I going to do that are going to be most effective in there? So, that’ll help us make some of those determinations. So, just remember, don’t rush this interview, it’s really critical, it’s really important, and you know, think about, you know, I know it does take a part of your client time there, but again, if you’re, if you’re doing this with your client, with an understanding at the outset that this is really important information that’s going to help them get them, get much more out of that session.

That 10 minutes you spend on the OPQRST format might make you more effective in the rest of your entire treatment, more so than just jumping in and doing more, more work right off the bat. So do remember there’s a critically important value in doing that, and use this to structure the rest of your framework. There again, I just want to also emphasize, and I hope this kind of goes without saying, is understanding our our key scope of practice and how this fits into that. Remember, as massage therapists, we’re not doing all this stuff in order to diagnose conditions for clients, because that is, of course, outside of our scope, but what we’re doing here is that this is helping us organize and structure the treatment plan, and have a much more comprehensive and robust understanding of what we might be doing, and in directing how our physical evaluation methods are going to most effectively structure what types of techniques and methods and strategies are we going to employ with our clients that are going to get the best benefits for them? So that’s a critical, important part of what we’re doing, is to have a good understanding of what’s happening, so we can determine what’s going to be most effective. So, thanks for hanging out with us again today. 

Whitney Lowe  

And I just want to remind everyone that the Thinking Practitioner Podcast is proudly supported by ABMP, Associated Body Work and Massage Professionals, the premier association for dedicated massage and body work practitioners like you. When you join ABMP, you’re not just getting industry leading liability insurance, you’re getting practical resources designed to support your career from free top tier continuing education. And quick reference apps like Pocket Pathology and Five Minute Muscles, ABMP does equip you with the tools you need to succeed and grow your practice. Also, note that ABMP is committed to elevating the profession with expert voices, fresh perspectives, and invaluable insights through their CE courses, the ABMP podcast, and massage and bodywork magazine, which features industry leading authors like my co-host Til and myself, thinking practitioner listeners like you, can get exclusive savings on ABMP membership at abmp.com/thinking. So join the best and expect more from your professional association. Again, we would like to say thanks to all of our listeners and to our sponsors. You can stop by our sites for the video, show notes, transcripts, and any extras. You can find that over on my site at AcademyofClinical massage.com and over on Til’s site at Advanced-trainings.com We’d love to hear from you with your ideas or input about the show, so please feel free to email us at info at The Thinking practitioner.com or you can look for us on social media and on YouTube. You can find that at Til site, he’s at his name, Til Luchau, L U C H A U, and also you can find that for me on my site as well. You can find me on social media under my name, Whitney Lowe, as well. Again, thanks so much for joining us here. We really appreciate it. If you would, wouldn’t mind taking just a quick moment out to rate us on Spotify, Apple Podcast, or wherever you help to, you happen to listen, that actually does help people find the show, and then helps keeping us going here. So, please take a few moments to do that. We sure would appreciate it. Thanks again, as always, for sharing your time with us, and why don’t you tell a friend, share the word, and we’ll see you on the next one. Bye.