One of the concepts we like to teach at Optim Manual Therapy is developing hypotheses of sources of injury. As soon as you see the script (if you get one) or the location of pain on the intake form, you should immediately have several hypotheses for pain. I recommend at least 5. For example, if someone comes in with lateral ankle/foot pain, my initial hypotheses may include:
This list is not all inclusive as there are other potential sources of pain, such as a fracture. Additionally, this list is not mutually exclusive. For example, when someone rolls their ankle, a lot of times they have ligamentous disrution, strain of peroneal tendons, cuboid dysfunction, and intermediate dorsal cutaneous neural tension. Walking abnormally for awhile after injury can then lead to back issues and potentially S1 radiculopathy. Now this is an extreme case, butwe want to be able to narrow down our hypotheses in order to better manage the patient. Following the subjective interview, we should be able to eliminate a couple hypotheses and each remaining one should have some sort of reasoning behind it. Finally, we can use our objective testing to further narrow down our hypotheses to a final PT diagnosis. While we call it final, it doesn't have to be. Sometimes, throughout our treatment, our diagnosis changes based on a patient's response or lack of response to treatment.
While we like to challenge our COMT and Fellowship participants to identify possible structures of injury, it is important to remember the involvement of the central nervous system. There are many cases where it is not truly a structural issue and instead we need to focus on retraining the nervous system, especially in chronic pain patients. In these types of patients, it is essential that a non-structural assessment is taken into play and instead is shifted towards a functional assessment. We worry less about pain, other than re-educating the patient on pain science, and more about improving their livelihood and activity.
-Dr. Chris Fox, PT, DPT, OCS
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