Conventional assessment vs functional assessment

Anthony Lombardi
May 02, 2014
Written by
The conventional assessment of musculoskeletal injuries has traditionally been one-dimensional. A chiropractor treating a patient with shoulder pain typically performs shoulder orthopedic testing, while a patient with low-back pain undergoes an exam that focuses on straight-leg raise and sacroiliac joint tests.

Convention to function  
   
Conventional assessment approaches often lead to incorrect interpretations of diagnostic imaging and conventional orthopedic testing. When injuries are assessed in a vacuum, there are often discrepancies among the different diagnoses.

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As clinicians, we are presented with injuries and different clinical presentations that challenge the way we assess our patients. Several landmark studies have shown tissue tears revealed on imaging are very common in patients who are completely asymptomatic. For example, a study by Dr. Richard Worland in 2003 focusing on rotator cuff tears determined that approximately 40 per cent of asymptomatic patients over the age of 50 have full-thickness rotator cuff tears. Another research paper, published by Zanet Oschman in 2007, reported the high incidence of asymptomatic tears in the study group indicated rotator cuff tears can be regarded as a natural correlate of aging and that bilateral tears are common.                               

As chiropractors we see this lack of causal relationship almost daily in cases of low back pain. A New England Journal of Medicine study (Jensen, 1994) revealed that in a MRI examination of the lumbar spine, many people without back pain have disk bulges or protrusions. Given the high prevalence of these findings, the discovery of bulges or protrusions by MRI in people with low back pain may often be – just coincidental. There is an overreliance on single orthopedic tests, which can be unreliable when assessing musculoskeletal dysfunction.

It is necessary to look further into what is happening on a musculoskeletal level and look to adopt more functional approaches when patients are experiencing pain and dysfunction.

With the advancement of manual therapy, we have learned and developed a multitude of standardized treatments – yet almost every chiropractor assesses their patients differently. In light of the research and the need for something better, athletes and chiropractors are turning to functional musculoskeletal assessment as a means to provide more consistent clinical outcomes.

Put simply, functional assessment is the art of locating and restoring mechanical dysfunction without focusing on the area of pain. This was born out of the premise that manual and rehabilitation therapists never actually “fix” musculoskeletal injury – they simply apply interventions which allow the body to adapt so the patient can function at the highest level possible.

Patient-centered assessment
Functional musculoskeletal assessment has risen in popularity because of its patient-centered philosophy. It focuses on giving patients what they want in a reasonable and attainable time frame.

There are several functional methods being used today. Dr. Alejandro Elorriaga, who specializes in sports medicine, teaches Advanced Functional Approach geared toward finding the underlying cause of the dysfunction. While chiropractors, Dr. Mark Scappaticci and Dr. Mike Prebeg, created FIT – functional integrative therapies – which focuses on restoring the body’s lost “adaptive potential.” I, myself, founded the EXSTORE System, which finds and fixes motor muscle inhibition within a few minutes. These functional approaches are designed to improve performance for every one – from professional athletes to plumbers.

Athletes who play at the highest level require the type of treatment results that keep them at their best. 

Chicago Bears receiver Chris Williams and New York Jets linebacker Garrett McIntyre share their thoughts on why they felt functional assessment played a significant role in the NFL.

“Because the NFL is so competitive, it is very important to locate the problem area as fast and as efficiently as possible so that treatment can begin. The goals of treatment during the season are much different than in the off-season, because you only have days to recover,” says Williams.

 For New York Jets’ McIntyre, his chiropractor’s functional approach enables him to play at his best. “Throughout our grueling season your body gets out of balance. My chiropractor’s functional approach keeps my hips and glutes firing all season which for me is the key to staying healthy and to preventing more serious injury.”

Ultimate Fighting Championship (UFC) fighter-turned-coach Jeff Joslin also provided his perspective on functional approach. “Top UFC level fighters train two to three times per day. As a rule, they overtrain which puts their muscular system in jeopardy of becoming weak from trauma and injury. Having something as specific as functional assessment does not interrupt our training since you are essentially making functional adjustments with the chiropractor between training sessions.”

Patient-centered benefits

1. Patients get results they desire
The goals of treatment are important for patients, especially high-level athletes – since those results influence their performance. With functional assessments, patients see tangible results after one or two visits.

2. Reduces radiology use
The Hamilton Family Health Team in Hamilton, Ont., houses primary care physicians and nurses and serves approximately 280,000 patients. They asked me to teach functional assessment to their medical doctors (MDs), nurse practitioners and nurses last year. Dr. Ravinder Ohson utilizes the assessment system in his own practice with his nurse practitioner and he found he used less radiology. “I have used functional assessment and found it to be an efficient way to localize the cause of the dysfunction. This has saved me time as well as reduced my reliance on radiology to give me the diagnosis,” he says.

3. Sharing is caring
When patients validate your treatment, they will refer you to others. Strive to provide patients the results they want in a way they are not used to. Getting results after the first couple of visits as opposed to the eighth or ninth visit will get patients telling others about you, which will not only generate more referrals but you will be able to help more people in need.


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.

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