I have a juicy, thought provoking guest post today about The Exstore System from a fellow chiropractor in Canada. This tool is all about his structured way of looking at, assessing and treating patients.
I love systems, they make life easier. When it comes to the human body I believe we develop patterns of compensation which, at times, become painful signalling to the brain, “Hay you know what lets stop this body moving”. You may come in to see your local chiropractor with a low back pain, but why is he looking at my feet, ankles, knees and hips, did he not hear I said the pain is in my lower back? To find out more take a read below to see why the site of pain is not everything.
EXSTORE: A New Way of Thinking & Assessing
by Doctor of Chiropractic, Anthony J. Lombardi
Manual medicine is in need of a standardized system for the assessment of musculoskeletal injuries to help ensure consistent quality clinical outcomes.
Conventional assessment of these type of injuries have traditionally been performed in a vacuum. A doctor tending to a patient with elbow pain typically performs exclusively elbow orthopedic testing, while a patient with low back pain undergoes an exam that focuses on SLR’s and SI joint tests. Patients with non-traumatic knee pain undergo every knee orthopedic test imaginable until the doctor derives his or her own conclusions. Another error conventional assessment approaches yield is the incorrect interpretation of diagnostic imaging they have ordered.
When we assess injuries in a vacuum, we are often faced with several differential diagnosis. So, we order x-rays, US, MRI etc to help bring some clarity to the condition. Thus, we look for and expect answers in the imaging because our assessment wasn’t specific enough. In my experience, practitioners use the results of the imaging to bring clarity to their diagnosis though their interpretation of the imaging results are inaccurate. For example, someone with shoulder pain may have 6 positive shoulder orthopedic tests and doctor refers them for a US which discovers a supraspinatus tear. So, the doctor determines the supraspinatus tear is causing the pain.
In my opinion, conventional orthopedic examination is uni-dimensional and backwards. The biggest mistake practitioners make during musculoskeletal exams is that they initially assess or focus on the area of pain. Focusing on the area of pain first, puts practitioners in a pigeon-hole and narrows their clinical mind. Barring direct traumatic injury, the area of pain should be the last place to be assessed.
Pain is a consequence – not the cause of the patients’ problems. It is a consequence because nociception can be stimulated from different areas via a combination of local factors like myofascial, or periosteal trigger points, regional factors like neuro-metabolic segmental articular dysfunction, and global factors like autonomic nervous system dysfunction. Therefore assessment must be multi-dimensional at all times.
EXSTORE is born
The emergence of contemporary minds is changing the way we do assessments. Sedora et al, Gribble et al (2005) observed that our musculoskeletal system is made up of basic skeletal foundations: The scapular girdle and pelvic girdle, which become inhibited during injury or dysfunction . All soft tissue and peripheral nerves connect to or interact with these skeletal girdles. Also the kinetic chain of movement in our extremities begins in one or both of our skeletal girdles.
Therefore, longstanding elbow pain cannot be present without some degree of shoulder girdle dysfunction and/or longstanding shoulder pain cannot be present without some degree of elbow or wrist dysfunction. Injuries related to soft tissue can no longer be isolated to one area or one joint. It has to be understood that a shoulder problem carries elbow and wrist dysfunction (Horre 2006). Conversely, very often low back pain and sacroiliac pain is associated with dysfunction of the tissues that support the pelvic girdle and stabilize the lumbar spine.
A directed musculoskeletal assessment system is required to assess global mechanical function of the body. This system will provide information about the nature of the dysfunction, the adaptability of the tissues and the origin of nociception . By doing this, our treatment can be focused on correcting mechanical dysfunction which will consequently address the chief complaint.
In this directed assessment system, the first thing that must occur is movement analysis. Musculoskeletal assessment should never be performed without analysis of gait and functional movements. Watching how the system (body) interacts with gravity is necessary when dealing with these types of injuries. Secondly, a palpatory exam is an integral part of a focused exam. This allows us to find and appreciate areas of trophic change, and areas of trophedema. These regions are products of neurogenic inflammation from the sensory axons, which can trigger plasma extravasation that leads to abnormal collagen scar tissue formation.
These changes are present months or even years prior to the patient begins experiencing pain, stiffness, etc. Lastly, the largest component is the assessment of the skeletal foundations (shoulder girdle, pelvic girdle) and the local assessment of tissues along the kinetic chain of movement.
The most important thing to understand in assessment is that the body is in a constant state of adaptation. We must understand how the body works on both a mechanical and a neuro-metabolic cellular level. This way we can learn to appreciate the nature of the dysfunction and how to correct the problem.
We must realize that no issue is uni-dimensional. Neck pain has contributions from neck and shoulder dysfunction while shoulder pain can be a product of neck and shoulder limitations with associated upper extremity adaptation, and elbow pain causes adaptations in the scapular girdle and in the cervical spine. The reason why conventional assessment fails our patients is because it cannot take into account the kinetic mechanical adaptation of the musculoskeletal and peripheral nervous systems. The value of a focused assessment examination is worth exponentially more than any amount of treatment. It is priceless.
The EXSTORE assessment system is actively being taught to chiropractors, physiotherapist, massage therapists, and medical doctors in North America and Europe.
- Sedora et al, Journal of Athletic Training 2005 v.42 (3) Jul-Sept 355-360
- Gribble et al, Journal of Athletic Training 2005;40:S-28
- Horre, Osnabruck 2006, The Influence of Joint Dysfunction on Muscle Function
Dr. Anthony J. Lombardi is a chiropractor in Hamilton, Ontario, Canada who uses manual techniques and medical acupuncture to improve performance and reduce pain in patients with neuro-musculoskeletal disorders is the creator of EXSTORE, can be contacted via email at firstname.lastname@example.org or on twitter @exstoresystem.