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Tool-Based Versus Assessment-Based Interventions

From my perspective, there is currently a fundamental problem in the manual therapy community. Manual therapy is predominantly a tool-based intervention strategy; consisting of many variations of tools and techniques. As a result, practitioners take the particular tool they’ve been educated in and apply it to the presentation of the client.

Being a former race car mechanic, I liken this analogy: If I purchase a brand new shiny 10mm wrench, am I going to go around the car and look for fasteners it might fit? That doesn’t make a lot of sense, does it? Let’s dive a bit deeper.

We see a plethora of technique-based courses being offered in our profession. There are many reasons why we need to have an array of tools available to us. However, the tools themselves often distract us from finding the causation of each unique presentation. When we are simply applying a tool to a problem to see if the problem changes, we are guessing. This has the potential to be negligent. 

I recognize that the statement that a tool-based intervention is potentially negligent is a bold statement. Let’s build some context that supports the statement. We need to consider two specific variables in an individual’s presentation.

Adaptation

Adaptation is a learned coping strategy. Understanding why that coping strategy was implemented by your client’s nervous system is the primary consideration. That person’s experience has biopsychosocial factors that influence how their nervous system chose to cope with and adapt to the changing environment around them.

Compensation

The  combination of symptoms based on a nervous system’s chosen adaptive strategy, is not consciously chosen. It is instead a function of the survival-based nervous system. Adaptation is mostly unconsciousness behavior. However, there are exceptions when we consciously add elements to our environment for beneficial change — like changing one’s diet or engaging in a fitness plan. Maladaptive compensations are often driven by our unconscious, even if it seems like we are making conscious choices.

Here’s  a hypothetical presentation that illustrates how a tool-based intervention can be negligent. Let’s use an example of regional interdependence, where one region of the body compensates for another region of the body not participating. For example, a client comes in with sacroiliac pain. The function of pelvic sacral stability is diminished in some way. Using the model from Lovett Reactors, the therapist traces the instability to the jaw. The therapist then treats the jaw. 

There is a fundamental problem with this. While the pelvic sacral stability issue is a symptom of the jaw, more times than not, the jaw is a symptom of something else. That something else is related to an experience, which became an association that has an array of emotional responses. The symptoms we are seeing in the jaw is related to a past experience and a limbic association. Effectively, what the therapist has inadvertently done is remove the coping strategy of the limbic system. The potential for this to blow up is pretty high.

Now let’s look at a real life example. This occurred in a seminar that I attended several years ago. A combat veteran was getting a neurological treatment from a colleague to correct a movement dysfunction. Unbeknown to the therapist, that movement dysfunction was related to a combat experience. The person on the table had a full blown PTSD incident while being treated. Afterward, he became suicidal and had to be on suicide watch while his limbic system reorganized to find a new coping strategy to compartmentalize the traumatic event.. This kind of response can happen on a spectrum from mild to full blown PTSD flashback like this example.  When we are treating symptoms, we are potentially creating a vulnerability in the coping strategy of the nervous system.

There is a solution to this problem of tool-based therapeutic intervention. The solution is an assessment-based process that determines the root cause of the individual’s presentation. That assessment process must consider each aspect of the presentation as a potential symptom. The symptom-causation relationship must be traced to the driver of those symptoms. That driver is the root causation. That assessment process must take into consideration the entirety of the biopsychosocial model. The down side of this is when the causation of the individuals presentation gets out of our scope of practice. This is when our referral network becomes very important.

As therapists, we can do better. We can advance from being the hammer and seeing every problem as a nail. Instead, we can hone our assessment strategies to derive the appropriate tool that is needed — see The Five Tenets of DNA™ to learn more. We can determine if it is safe to use that tool. We can live up to the first rule of the Hippocratic oath: Do No Harm.

Learn More About the Biopsychosocial Model

https://www.urmc.rochester.edu/medialibraries/urmcmedia/education/md/documents/biopsychosocial-model-approach.pdf

http://www.enniscentre.com/Presentations/Gatchel-Biopsychosocial%20Approach%20to%20Chronic%20Pain.pdf

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Five Considerations for Your Assessment Strategies

By streamlining assessment via the considerations outlined in Dynamic Neuromuscular Assessment™ Seminars, you can save yourself and your client a lot of time and energy. Let’s illustrate this with several of the considerations that make DNA™ unique.

First Consideration: Keeping the container safe

DNA™ teaches us effective ways to monitor the response of our client’s nervous system in order to keep the container safe.  Our nervous system chooses adaptation strategies as a protection mechanism. These strategies have a priority. There is the primary compensation and the potential for multiple secondary compensations. These secondary compensations boost the primary compensation. If we indiscriminately remove a secondary compensation, we are inadvertently creating a void in the container of our client’s coping strategies. The nervous system then must adapt to not having that available element. What the nervous system chooses to fill that void with may potentially be more maladaptive than the original coping strategy. This can happen in all three categories of the trine in Applied Kinesiology: movement and structure, physiology and subtle body energy, and limbic associations and emotions. The danger here is that if we kick out the leg in a three-legged stool…something is going to crash. This can become a big problem if the nervous system chooses to utilize the energy system from our physiology or limbic associations to bolster dysfunctional movement.

Second Consideration: Manual Muscle Testing can and will produced skewed results

Protocols we utilize in Dynamic Neuromuscular Assessment™ allow us to recognize when the false negative and the two false positives show up in MMT. There are two causes for this. First, the practitioner may have unresolved issues in their mind/body. As practitioners, we affect the outcome. Our expectations and projections, conscious and unconscious, have an impact on the testing results. The second cause is the response we are getting from the client. There are two false positives and one false negative that are constantly showing up in our MMT. If these are not vetted, our correlation of relationship and causation will be skewed. We need a specific process, or protocol like what is shared in DNA™, to double check when the movement response gives us faulty data.

Third Consideration: Global / Local / Global

Global assessment in DNA™ evaluates the ability of the nervous system to respond using feed-forward assessment. This allows the nervous system the opportunity to utilize the primary compensation. Then we can further vet the dysfunction by looking at the local components. The first global assessment gets us in the right neighborhood, the local components, or building blocks of movement, gets us to the right house. As we continue with the process we end up in the right room, in the right house in the right neighborhood. After we have vetted the primary driver, restored normal response, we can insert that back into the global movement for re-evaluation. The global local global approach is much faster at vetting the primary compensation. This is the opposite of the hit or miss strategy of relying on local assessment to resolve a presentation.

Fourth Consideration: Secondary compensation leads us astray from the primary driver

When we are evaluating movement, every dysfunction has the potential of multiple pieces. How we trace, or map, the dysfunctional components in DNA™ makes a difference in the outcome for your client. We must treat each piece as a potential symptom and completely vet the presentation before we employ a corrective strategy. This relates back to the first consideration and is a major tenet of DNA™, we do not want to remove a secondary coping strategy as that creates vulnerability. The mapping process specifically vets the dysfunctions to arrive at the primary dysfunction. Initially this may seem like the tortoise and the hare approach. The hare would be treating what they find as it presents itself. The tortoise looks at the complete presentation before using laser focused corrective strategies that have the most impact with the least amount of intervention.

Fifth Consideration: Specific Adaptation to Imposed Demand, the SAID principle is our ally in efficiency

DNA™ radically optimizes your assessment by implementing the SAID principle.  The SAID principle has two primary ways it affects the outcome of our work. The first is the preliminary steps we take during the evaluation process. Does the process complete the map of the presentation? When it does, we can then cue the nervous system to all the elements that correlate to the primary dysfunction. When we employ a corrective, then the nervous system has an understanding of how these pieces interrelate. We then get the most value from the least amount of work. The second way the SAID principle affects the outcome is related to the corrective strategy itself. If we have not cued the nervous system appropriately, then the nervous system must interpret what, how and why the pieces fit together. Often, the nervous system is unable to fill in the missing pieces. When this happens, our corrective strategy will be temporary at best. This is why clients will return with the same presentation over and over. The nervous system is not getting enough information to make a sustainable change. Instead, when the environment load increases beyond capacity, the nervous system returns to a familiar coping strategy.

Let’s look at how these five considerations weave together in an evaluation process. This is an excerpt from a recent DNA™ Module One practicum.

Intention: Assessment of the breathing apparatus

Global Skill: QiGong Posture

Visual: appears that the diaphragms move out of alignment creating a lack of integrity in the core cylinder

MMT: Functional Dysfunctional Response: Correlation to Limbic Association

Local Components:

Sacrospinalis / multifidus –  normally responsive

TVA –  normally responsive

Pelvic Floor –  functional dysfunctional

Vet Pelvic Floor:

Structural – L sub-occipitals TL

Vet L sub-occipitals – functional dysfunctional

Structural – R jaw TL

Vet R Jaw – functional dysfunctional

Limbic Association TL- same association as the global movement association

Double check our work:

Client TL’s the R Jaw

Retest PF and L sub-occipitals

Normal Response

Corrective:

Cue the associated movements into the nervous system (order matters)

Limbic hold on the Bennett points (a generic cranial hold while observing the breath)

Retest: (in the same order)

PF normal response

Sub-occipitals normal response

Jaw  normal response

Re-insert local components back into the Global Movement

Normal Response!

Summary:

Using Dynamic Neuromuscular Assessment™ our first consideration is the safety of our client’s nervous system.  We then add stability into the system. We did not remove coping strategies creating vulnerability. The old paradigm would indicate that we would have released sub-occipitals. If we would have tried to correct a dysfunctional component that is correlated to a limbic association, potentially the volume of that limbic input would increase. That would have essentially kicked the third leg out of the three-legged stool.

Limbic associations can have multiple layers mirroring the template of compensations with primary and secondary/s. We toned down the association. We did not necessarily remove or clear. We tone it down so that the nervous system can appropriately respond to the environment. There may be more work needed to effect sustainable change.

Using only one corrective – in the DNA™paradigm – we restored movement function to all the local components and the initial global assessment. That could not have happened if we did not utilize the SAID principle in our assessment and correction.

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Ask The Right Question to Optimally Engage the Nervous System

There are a few misconceptions in the movement/bodywork community about manual muscle testing. The first being the term itself. Manual muscle testing is not testing muscles. Manual muscle testing is asking a question. Can the nervous system/structure respond appropriately to a particular stimulus. This is having a conversation with an input / output feedback loop.

The manner in which we engage in the conversation makes a difference. I like to think of the conversation as having two separate aspects. The first aspect is the conversation with nervous system. We are engaging the proprioceptive feedback loop. Can the nervous system respond to the stimulus at the periphery? The second aspect of the conversation is structure. Can the various connective tissue structures respond to vector, load, and duration?

Nervous system response and structural durability are interdependent. Without the nervous system’s capacity to respond appropriately, durability would be compromised. Motor control and neuromuscular coordination are tangible responses of our body’s ability to cope with a changing movement environment. When we feel safe during movement, we have the capacity to optimally thrive.

There is a specific attribute of the kinesthetic conversation that occurs during movement. When we appropriately cue the nervous system to the neurological disorganization of maladaptation, the opportunity to learn, or upload input /output response becomes available.  There are optimal ways and less than optimal ways this happens.

I’ve created a progression – Dynamic Neuromuscular Assessment™ — for the therapist to learn an optimal process for engaging with the nervous system of their client. There are three layers to this process.

The first layer starts with deconstructing and refining manual muscle testing. Movement assessment has the potential to accurately interpret the input/output of nervous system response. This has several sub levels and nuances.

The second layer is mapping. Mapping is a format to understand the unique presentation of our client. The symptom / causation relationship is investigated to arrive at the primary causation, or the primary layer to start employing a corrective strategy.

After we have the global picture mapped of our clients, we can employ the third layer of the DNA™ process, corrective strategies. Caution must be used when employing corrective strategies. Keeping the container safe is a primary concern when “do no harm” is the imperative. We cannot apply a corrective technique until we understand the causation and its source. If we remove a coping strategy or compensation, the nervous system will fill that void in the container. That something will more than likely be maladaptive. Instead, we need to displace a maladaptive compensation with a positive adaptive coping strategy.

Engaging the nervous system is a process of inquiry. As therapists we are learning to ask the right question.  When we ask the right question, the nervous system can be appropriately cued to the symptom causation relationship. This keeps the container safe so that the potential for change is fully realized.  Dynamic Neuromuscular Assessment™ is an assessment protocol that allows the therapist to optimally utilize the corrective techniques they already have by asking the right questions.