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Defending Subjectivity

February 17, 2021 by gordon browne

Where to Look?

 

We should include subjective criteria in a PT musculoskeletal evaluation, and movement quality can be assessed as ‘good’ or ‘bad’. What do you think of these statements? Are they self-evident? Or do they seem vaguely heretical?

 

We can sometimes misinterpret calls for evidence based practice as meaning that every item on your assessment list needs to be quantifiable and objective.

 

  • Measuring ROM at a joint.
  • Evaluating individual muscle strength (an illusion, but not the topic for this month).
  • Counting how many times someone can move from sit to stand in a minute.

 

Good stuff, good info for traumatic injury recovery especially—but incomplete, particularly when it comes to repetitive stress injuries and degenerative conditions. Since many of these kinds of conditions feature hypermobile joints and hypertonic muscles, resorting to goniometry, manual muscle testing or any activity involving a stop watch is going to be of limited benefit,.

 

Like & Feel are not Unscientific

 

But there is a subjective aspect to rehab-related evaluation of common musculoskeletal conditions—an aspect that asks ‘what would I like to see here’. And it’s probable that you are already assessing ‘subjectively’ as illustrated by these examples:

 

    • Rather than measuring lumbar ROM with low back pain, we get better actionable information by assessing distribution of movement.
      • I would ‘like to see’ free and easy hip and thoracic mobility, with no ROM limitations that could contribute to lumbar hypermobility stresses.
    • Rather than testing quadraceps strength with patellar issues, we get a bigger picture when we assess proportionality of effort.
      • I would ‘like to see’ the big hip extensor muscles doing their fair share with stairs or sit to stand.
    • Rather than counting sit to stand reps with plantar fasciitis, we identify the mistake by watching for sub-optimal skeletal alignment.
      • I would ‘like to see’ the feet bear weight as centered tripods instead of collapsing into pronation.

 

Video Examples

 

For the rest of this blog, we will defer to the magic of video, where we will use two examples to illustrate this concept of looking at musculoskeletal evaluation and optimal movement assessment through the lens of ‘what I would like to see’.

 

    • Observing the ‘mistake’—a qualitative judgment—helps us to identify the ‘pattern at fault’ or the ‘directional stress’ for that particular condition.
    • Establishing a ‘target’—also a qualitative judgment—helps us to list our clinical goals for that particular condition.
    • Practicing the ‘target’—turning goal into exercise.
    • We will use two common examples to illustrate these ideas further:
      • Trochanteric pain syndrome.
      • Patellar tracking or anterior knee pain.

 

Video BL-15: Assessing with Subjectivity

Filed Under: Blog, News

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