Orthopedic Special Tests

Summary: Til interviews Whitney about his use of Orthopedic Special Tests. Topics include the promise and the reality of special tests, pros, cons, and controversies, when to use them, and when not to.

 

Til Luchau:

Til Luchau here. Books of Discovery has been part of the massage therapy education world for over 20 years. Thousands of schools around the world teach with their textbooks and digital resources. In these trying times, this beloved publisher is dedicated to helping educators with online-friendly digital resources that make instruction easier and more effective in the classroom or virtually.

Whitney Lowe:

I’m Whitney Lowe. Books of Discovery likes to say, “Learning Adventures start here.” They see that same spirit here on The Thinking Practitioner podcast and they’re proud to support our work knowing we share the mission to bring massage and bodywork community enlivening content that advances our profession.

Whitney Lowe:

So check out their collection of e-textbooks and digital learning resources for pathology, kinesiology, anatomy and physiology at booksofdiscovery.com, where Thinking Practitioner listeners save 15% By entering, “Thinking,” at checkout. Hello, Til. How are you today, sir?

Til Luchau:

I am very good, Whitney. Thanks. Nice to be here with you. How are you doing?

Whitney Lowe:

I’m doing okay, doing better. I’ve been ill for the last week or so. I had a very unusual case of pneumonia that I am coming off of.

Til Luchau:

Yeah.

Whitney Lowe:

Yeah. I had an interesting little experience with that-

Til Luchau:

I’m glad you’re well. What was interesting about it?

Whitney Lowe:

Well, it was interesting… Always interesting going to the doctor and doing things and watching the healthcare system work and watching my own symptoms and things like that. I was just extremely ill for about five days with very high fever, very serious chills, fatigues, aches, body aching all that kind of stuff. I went to get a COVID test thinking like, “God, this is just weird,” these symptoms I was having. Went to urgent care and it came back negative and still sick a couple of days later. Went back again and the doctor started running a group of tests and ended up with pneumonia without cough, no running nose, no sore throat, no upper respiratory symptoms at all, which was weird.

Whitney Lowe:

That was really interesting. He said yeah, he had been humbled by that condition numerous times of seeing it act weird. So that was an interesting and fascinating little process to go through there.

Til Luchau:

No fun, though. Yeah, I can take all kinds of ones like that]. I mentioned that I have some history getting over that too. I’m glad you’re able to join us today. I’m glad you’re on-demand and feeling better. I’ll try to take it easy on you today.

Whitney Lowe:

Please do. Please.

Til Luchau:

All right. Be nice.

Til Luchau:

Okay. Because you proposed an interesting topic, you wanted to talk about orthopedic special tests. Did I get that right?

Whitney Lowe:

Yeah. Yeah, it’s been an interesting topic, bandied about quite a good bit across social media and some other platforms as well and I thought we should handle this a little bit here, too.

Til Luchau:

We should and especially like how it relate to the hands-on manual therapy, massage therapy world that we talk about?

Whitney Lowe:

Yeah.

Til Luchau:

Let me just launch in. I’m really looking forward to, by the way, just picking your brain about this. What do you mean or what do we mean by special orthopedic tests or orthopedic special tests?

Whitney Lowe:

Yeah. These are tests that are usually designed to increase our likelihood of recognizing a particular orthopedic pathology, be that carpal tunnel syndrome or tennis elbow or whatever it is. There’s a lot of ways that you might just see if someone has wrist pain or somebody has elbow pain but you do want to try to narrow that down as much as possible. Over the course of the last, I don’t know, when the first special orthopedic test ever came up, that’d be an interesting trivia question for somebody to figure out.

Whitney Lowe:

But over the last decades, there have been hundreds and hundreds of these tests that have been developed with… The key thing is a great deal of them, in my opinion, go back to the original theoretical models of James Cyriax with something that he called selective tissue tension paradigm, where you try to selectively apply a force to a local tissue in some way and see if it elicits pain, indicating that there’s a particular problem with that tissue.

Whitney Lowe:

They took that idea with special orthopedic tests and just found out well, what kinds of things stress the involved tissue in carpal tunnel syndrome when it’s present? They found a number of different procedures would do that on a really regular basis. After a while, they found it being frequent enough that this person would decide to say, “Okay, I’m going to call this after my name,” or whatever and name it the Phalen’s test or the Tinel sign or the so and so test, the Thomas Test.

Til Luchau:

The Thomas Test. Those are examples of special orthopedic tests that… And those cases are used specifically to try to assess or identify carpal tunnel issues.

Whitney Lowe:

Yeah, yeah.

Til Luchau:

Gotcha.

Whitney Lowe:

I’d really like to say… They tend to be used to try to identify those things frequently. This is something we’ll talk about in a good bit more detail. I think they’re important to try to rule out or further refine your understanding of things.

Whitney Lowe:

But what’s come to pass is that frequently, they’ve been used to shortcut a lot of the other evaluation process and jump to an understanding or jump to a suspicion about something being there when the evaluation isn’t actually as thorough and comprehensive as it could be.

Til Luchau:

Okay. You’re saying maybe having a test could shortcut or cause you to abbreviate some of the other things you do to learn about what’s going on in a way that may not be helpful?

Whitney Lowe:

Yeah, absolutely.

Til Luchau:

Okay. You mentioned the Tinel sign, Phalen test. I’m thinking of the Lasègue test or the straight leg raise, there’s just some classics out there in the literature. You said there’s hundreds and hundreds and hundreds of them. Do you think it’s important for massage therapists to learn these? We’re quoting these right out of physiotherapy, orthopedic medicine. How about massage therapists and manual therapists? They have a place for us?

Whitney Lowe:

I do think they have a place for us. I’ve sort of debated about a lot of this stuff for decades myself. Really, kind of backtracking on this a little bit, I think I may have told the story on the podcast before of how I kind of got interested in this stuff. But it started for me probably six months into my massage practice. I opened a practice in a medical office building because we were told, “If you really want to start getting into the healthcare system, start networking with doctors and that sort of thing.” So I did. I opened up an office there in this building and I was very young and green and did not really know what I was doing a lot.

Whitney Lowe:

Of course, my training was pretty limited at that time. It was just six months out of massage school but in any event, I gave brochures to all the doctors in the building and all that kind of thing. This woman came down to see me one day. She said she had been sent down by one of the doctors, the general practice doctors up there who he said like, “Okay. Well, let’s send somebody to this guy and see if it helps.” She came in and she was obviously in a tremendous amount of pain, back pain.

Whitney Lowe:

I started going through the whole interview thing with her, filling out the form and things like that. I was trying to tell her to get undressed, get on the table and I would come in and start doing it. And she’s looking at the massage table and looking back at me. I could see what’s going through her head like, “How am I going to get on that table?” I’m recognizing that this is going to be a real challenge here.

Whitney Lowe:

She did find a way to get onto the table. What I didn’t allow her to hear, the words and the phrase or the rotating thing going on in my head was, I have no idea what’s wrong with this woman. I don’t know if I’m going to help her. I don’t know if I’m going to hurt her. But I need this client really badly because this doctor just sent her to me. It’s the first person he’s ever sent down here and I can’t just send her back.

Whitney Lowe:

It’s like… I don’t know what’s going on here. My treatment goal for that day ended up being to let this woman leave my office without worse pain than she came in here and I will definitely consider that a success. As soon as she did, I started… I was like, moments later into the books. I’ve got to figure out what back… How do you figure out what somebody’s back pain was? It was at that time too that I also ran into Benny, Benny Vaughn. He was the first person who had been teaching continuing education workshops that I had attended that ever started talking about assessment.

Whitney Lowe:

That just clicked with me as something that was really relevant for us to learn how to figure out what was wrong with somebody. And so back to your original question about special orthopedic tests, in many instances, they have a great deal of value because they can certainly rule out a lot of red flags and help you refine a direction of understanding what’s happening.

Til Luchau:

Okay. So they can rule out red flags, so you can help us understand what’s happening. But just back to your story for a second, because I think that’s emblematic in a way of the way our field is evolving, where yeah, most of us weren’t trained rather in that deductive process of trying to figure out what’s happening with the client or patient.

Til Luchau:

Most of us were trained in protocols and routines of some sort and we just apply that. I’m remembering my own beginning stories of finding myself in a room with somebody with a fairly serious situation. And like, “Okay, which routine do I use now?” And really pulling out of the hat or just trying to even guess. Thank goodness, so many of them worked that that allowed me to have enough encouragement. But you said that really drove you to hit the books and really start to understand these things.

Til Luchau:

It’s also making me remember, that’s basically how I met you. Because I was scheduled to teach a class on the shoulder and someone said, “Okay. It’s good.” You focused around conditions of the shoulder, which was actually kind of a radical idea. Because otherwise, I was just thinking, “Yeah, shoulders are cool. Let’s talk about shoulders or something. Oh, the condition of the shoulder? Like reasons clients would actually be coming to see us. That’s a cool thought.”

Til Luchau:

This would be the middle ’90s or something like that. I just started searching the literature I probably… I don’t even know if it’s Google we had back then. Maybe it was Yahoo or something, but I was just doing an internet search. A suggestion came up with your name and like, “Oh, wow, here’s this massage guy who actually wrote an article about…” I think it was carpal tunnel or something. Maybe it was thoracic outlet. It’s one of those. And I thought, “Okay, this is pretty good.” This guy, Whitney, is finding things in the orthopedic world and helping translate them to our manual therapy world. That’s pretty great. I think it was actually through you that I got introduced to some of those back then.

Whitney Lowe:

Yeah. Certainly, my background was a bit unusual compared to a lot of other massage therapists in terms of learning environments because I spent a lot of my early years in an orthopedic clinic working side by side with orthopedic physicians and physical therapists, and that sort of thing.

Whitney Lowe:

So I learned a lot of what they were doing, simply by watching them and following them around and asking a ton of questions. And so recognizing is thinking, “Hey, this could really be relevant for massage therapists,” and that, maybe not.

Til Luchau:

Well, you’ve really made a unique contribution and found a niche for yourself in standing for that process of critical thinking, of using assessments to think it through because again, that wasn’t part of our tradition for many of us.

Whitney Lowe:

Yeah.

Til Luchau:

And so it’s really interesting that you’re talking about these now, from this point of view and you’re dialing it down to where you see them being useful at ruling things in, ruling things out. Is it time to talk about… Any other pros before we get into the cons?

Whitney Lowe:

Well, yeah. One thing I would like to mention in terms of this and this is kind of touching base, you and I just got through participating in a panel discussion on critical thinking and sort of reasoning processes. This is one of those places where I think it really shines the value and the necessity of developing some types of critical thinking and reasoning skills in relation to orthopedic assessment tests, special orthopedic assessment tests.

Whitney Lowe:

For example, I wrote this article back in 19… When was it? I’ve got to look this up here. 2008. Yeah, it was 2008. Wrote this article in 2008 for a Journal of Bodywork and Movement Therapies on suggested variations on standard carpal tunnel assessment tests. Where this came from was me working with a number of people and finding in a standard orthopedic assessment test like a Phalen’s test, where in the Phalen’s test, if you’re not familiar with this procedure, you just place your backsides or your hands together and press them against each other and that bend in the wrist right over the carpal tunnel-

Til Luchau:

Like a reverse prayer position?

Whitney Lowe:

Exactly.

Til Luchau:

Fingers are pointing down, the back of my hands are together and I press them together.

Whitney Lowe:

Yeah.

Til Luchau:

Okay.

Whitney Lowe:

In that position, that presses on the median nerve in the carpal tunnel and usually will exacerbate and aggravate their symptoms indicating carpal tunnel involvement. But let’s say your carpal tunnel is not really as severe yet. But maybe there are certain things that you do that might make those symptoms come up. Well, at the same time, I was really heavy into exploring David Butler’s work on neural mobilization and Michael Shacklock’s work and all that kind of stuff about well, what if we modify some of those standard carpal tunnel assessment positions, for example, with the Phalen’s test position, instead of holding the hands in front of the body with the rest of the upper median nerve relaxed, what if you did that with your arm all the way stuck out to the side and your head bent to the opposite side, which puts tension through the whole neural structure?

Whitney Lowe:

What I found is that then, those carpal tunnel symptoms often would show up or they wouldn’t show up in a standard carpal tunnel assessment test.

Til Luchau:

You were stressing the nerve a little bit with the position, like a neuro-dynamic kind of tensioner. You were using that as a kind of assessment to see if that nerve sensitized.

Whitney Lowe:

So I’d use the Phalen’s position with the hand bent all the way out to the side with the rest of the nerve tension that way and then take the tension off by bending the hand back to neutral and see if the wrist pain stops. Often it would and so thinking through how might I vary this standard assessment procedure helps me pinpoint if there is some type of local tissue driven nociceptive problem there like inflamed median nerve getting compressed or is this maybe a large scale neural sensitization issue somewhere else?

Whitney Lowe:

From that instance or knowing some basic orthopedic special tests to start with and alter those positions is really valuable. That’s why I still think it’s really helpful for massage therapists to know some of these procedures and then to be able to use them appropriately.

Til Luchau:

Okay. Great. Yeah. If you hang out with physical therapists or physios at all, that’s their bread and butters. Most of them are very well trained in the conventional repertory of them. Even if there’s debate in that field about their usefulness, most of them are still getting tested on it. That becomes the working vocabulary of a lot of physical therapy at least in the US. I don’t know about other countries. But yeah, these tests become the collective wisdom of that set. Are we ready for some of the ways that they’ve come under scrutiny or people are questioning their usefulness?

Whitney Lowe:

Yeah, I think that’s a good place to jump into next here.

Til Luchau:

Yeah. What are some of the cons of those? Or why are they perhaps being questioned or controversial?

Whitney Lowe:

Well, a couple of things come to mind. Several things are outlined really well in a nice little editorial piece that was in the British Journal of Sports Medicine in 2017. Its name caught my eye and I had just like… I’ve got to read this to see what it is about. The paper is called Orthopedic Special Tests and Diagnostic Accuracy Studies: House Wine Served in Very Cheap Containers.

Whitney Lowe:

I thought, “What in the world are they talking about? I’ve got to go look this up.” But the analogy that they…

Til Luchau:

Chad Cook, by the way and co-authors-

Whitney Lowe:

Co-authors of an excellent orthopedic assessment text. They’ve been doing this stuff for just years. They’re heavily into it. But they put together some really good concepts and ideas in this piece. First of all, they were saying orthopedic special tests have become house wine. And the analogy they use is like, when you go out to dinner, you could go down the wine list and start thinking, “What would pair well? I’m going to have lamb tonight. What’s going to pair well with the lamb? I’ve got to think through this and figure out what’s going to work well.” Or I could just order the house wine and that’d be the easy way around it.

Whitney Lowe:

This is what happens a lot with the special orthopedic test is that people say… Somebody comes in with shoulder pain and they just start going through a bunch of shoulder tests with them without going through the other pieces first, that really need to happen for a comprehensive evaluation.

Til Luchau:

For example, what’s some of the other pieces?

Whitney Lowe:

So for example did they go through active and passive movement and resistive testing of numerous positions and find out certain of these things hurt during active movement, but not during passive movement? Or what was the pattern? Like they hurt during abduction? But not during external rotation or something like that.

Til Luchau:

Specific movement variations.

Whitney Lowe:

They didn’t look for some of those specific patterns that would point to something else that might be happening in there and they jump to using these special orthopedic tests as a means of identifying something rather quickly which is very helpful in the healthcare system when you’re a physician who only spends an average of seven minutes with a client to do some of this kind of stuff just rapidly and it’s, “Yep. Got it.” That’s what you’ve got.

Til Luchau:

Right. They become probably so ubiquitous because they do really lend themselves to defining something, giving it a name, which is something you’ve got to write down with your ISDN description, whatever it is. They help you just have the feeling like you know what to do. Okay, now I know what it is and now I know what to do. That’s the premise. But some of the critiques in this paper were, “It’s like house wine, it’s one size fits all.” Is that the critique basically?

Whitney Lowe:

Yeah. That it allows you to skip over the other parts of making decisions that you really shouldn’t be going through and just go for the easy answer.

Til Luchau:

Which also might include history, some medical circumstances, personal circumstances, all those kinds of factors as well.

Whitney Lowe:

I’ve seen this a lot in terms of the way these procedures have been used in the massage therapy world is in a similar fashion, when people learn some special orthopedic tests, they’ll jump right to doing some of these tests and skip over those other important parts of the evaluation process which I think often illustrate or make something show up that doesn’t show up at all in the orthopedic tests.

Whitney Lowe:

The other part of this problem is many of these tests aren’t actually that reliable. When they started doing some of the evaluation studies for how accurate these tests really were across a broad spectrum of the population with certain conditions, they didn’t turn out to have such great accuracy.

Whitney Lowe:

That’s one problem and another issue that they brought up in this little editorial pieces that the accuracy studies that are often run on these orthopedic tests are compared against some other types of gold standards which oftentimes aren’t themselves that accurate. Now, you’re trying to make something determine how accurate it is.

Til Luchau:

Yeah, this is… Yeah. Well, that’s… The validity of a test is a big topic. You’re saying that some of the critiques in this paper, maybe in general, are that one, they may not be that accurate. Maybe they don’t really reliably show what they say they show. And then even when they do, what they’re compared to might be complex too.

Til Luchau:

I read the figure, I’m just playing it out of my memory, but I think it’s somewhere between 4% and 7%. I think it’s… Chad Cook had four, someone else had seven, in terms of the number of standard orthopedic tests that could be said to be absolutely reliable and compared to something that could be validated another way.

Whitney Lowe:

Yeah.

Til Luchau:

It’s a really low percentage, these things that actually have an evidence base behind them it turns out/

Whitney Lowe:

Right. But that becomes a problem if you’re putting a whole lot more of your eggs in that basket in your evaluation process and not doing a bunch of other things. Now, if you’re using that test as a piece of the puzzle, and you’re using that as only a small percentage of your evaluation thought process and you’re recognizing that it has accuracy limitations, then there’s still value in having that be part of your evaluation process.

Whitney Lowe:

But the trick is and the seductive trick is they tend to be things that make us think that we really nailed something down when we may not have.

Til Luchau:

You’re bringing to mind a debate that was very much alive in my days, at the Rolf Institute when I was teaching at the Rolf Institute and it’s probably just a fundamental paradigm clash in our ways of understanding things. But on one side of this debate was the idea that what we’re learning is essentially mysterious and acquired through experience and is so complex and multi-causal that trying to reduce it to cause and effect is bound to fail.

Til Luchau:

That basically, you couldn’t reduce something like manual therapy down to a bunch of tests that say if I do this, then I’m going to know exactly what to do, because it’s just too complex. That’s one side of the debate. The other side of the debate was all of us who are trying to learn this stuff going, “Okay, so given that, what the heck do I do? How do I even know where to start? Give me something that I can try so that it will give me a sense of what needs to happen next.”

Til Luchau:

I remember the teachers there at the institute, at some point were identified as being in one camp or the other and eventually that led to a kind of split, political split in the institute. It was painful for the people involved but the ones with one point of view went to one school, the ones with another point of view ostensibly went to another school, but of course it’s not quite that simple.

Til Luchau:

But this is a really fundamental schism in our ways of understanding. Can we reduce it to simple, “If I see this, then I do that.” And then is using multiple tests enough? Because that’s often the caveat that’s given. Is like, “Okay, so learn these tests, but do several because that’ll help cover it.” But you’re saying there’s another level of complexity too, which is really understanding the context and the history and some other factors around that.

Whitney Lowe:

Yeah. Now, let me introduce another thought into this which I have found interesting to ponder because I began thinking about this when I was looking at all this stuff, questioning some of the value of these tests over the last couple of years. You and I had an interesting podcast discussion about this when we were talking about client expectations and outcomes.

Whitney Lowe:

I don’t remember our episode number that we did that with, but that was… We had some fascinating discussions about how client expectations can really enhance the outcomes. Now, the idea when you start going in-

Til Luchau:

23, sorry. 23.

Whitney Lowe:

Excellent.

Til Luchau:

Yeah. Sorry. I just looked it up.

Whitney Lowe:

I’m glad you did, because I want to be able to reference that. Who’s our guest that we had for that discussion? It was?

Til Luchau:

That was Mark Bishop.

Whitney Lowe:

Mark Bishop, right. Yeah. Mark’s wonderful research that he’s done on these whole issues around client expectations. And so you start going through a number of orthopedic tests with somebody and it’s kind of like, “Hey, this kind of… I suppose this guy knows what they’re doing.” They’re asking me all these questions, because I will tell you, numerous, numerous times clinically, I have had clients ask me, “How come nobody ever did this with me before?” When we’re going through the assessment and the evaluation process, because I do a really thorough and comprehensive assessment.

Whitney Lowe:

I think that has a lot of benefit for client outcomes, for people feeling greater confidence in what I’m going to be doing with my therapeutic interventions with them as well. That’s another potential benefit that they may have, that’s not often recognized and not often talked about.

Til Luchau:

Mm-hmm (affirmative). Yeah, well. There’s a process of listening and methodically working through with someone that has an effect in and of itself of just getting the details there, getting the story established. So taking the time to do that, I can see being really therapeutic in its own right as well.

Whitney Lowe:

Yeah. Mm-hmm (affirmative).

Til Luchau:

Well, okay. Say some more about what could be the most effective ways to use these. Anything else we want to check off? How should we use them before we do more about how not to use them?

Whitney Lowe:

Yeah. I just want to encourage people, if you are going to use them to basically don’t use them in a vacuum by any means. Let them be a comprehensive part of a bigger picture puzzle that you use in your evaluation process. I don’t agree with just… I’ve heard some very prominent educators say some things like, “I don’t do any of that kind of stuff anymore. I just start working with my client’s sense of discomfort and work from there.” That’s okay, if that’s your approach. That’s not what I find to be most effective for me.

Whitney Lowe:

I still think there’s a lot of value in certain types of conditions, finding instances where it’s potentially beneficial to do this and have it really help somebody by finding the nature of what’s going on with him. I think there’s a lot of benefits and ways that this still can be done here.

Til Luchau:

Great. How should we not use them? I don’t want to throw in the diagnosis word in there too. Because it’s… How is this different than diagnosing if we use a special test and say, “Oh, yeah. Positive for pain. Carpal tunnel, I got it.” How’s that different than diagnosing?

Whitney Lowe:

Yeah. That’s something we haven’t touched on here and it’s a really important distinction because there is that seductive temptation for a lot of practitioners is to get into the thought process of using them in that way. I will also say that in watching a lot of the social media discussions about these topics, a lot of massage therapists will just jump back in and say, “No, I don’t use these tests because we don’t diagnose.” That reveals a fundamental misunderstanding of what they’re used for because there is a big difference between assessment and diagnosis.

Whitney Lowe:

Assessment is a systematic process of gathering information. That’s what we’re doing with this test. Now, if you take that Phalen’s test and you tell your client, “See, you’ve got pain in your wrist, you’ve got carpal tunnel syndrome.” Now you’ve crossed the line because you’ve told them a particular condition and named it and that’s giving it a diagnosis.

Whitney Lowe:

You may think in your head they have carpal tunnel syndrome and you say, “You’ve got pain there. Okay. Well, let’s see if we can work with some of that discomfort with the manual therapy that we’re going to be doing here.” You don’t ever have to tell them any particular named condition. But that’s a seductive place that people often get into and often misunderstand how to use those procedures and end up doing that kind of stuff. You can end up getting yourself in trouble by doing that as well.

Til Luchau:

Well, getting yourself in trouble. But also, it’s enormously complex to tell someone they have something. Or even that their positive test means that it’s a likelihood that they “have something.” There’s some really good reasons why most of us have injunctions against doing that. Just because of that communication process can be… It can be helpful or it can be harmful to be told you’ve got something going on.

Til Luchau:

I’m with you, Whitney. We are all, as practitioners, we’re gathering information, we’re making guesses, working hypotheses all the time for ourselves that guide our work and we can dialogue about them with our clients and patients. But yeah, the difference there being I’m not telling them what’s going on with them, I’m using these as starting places or working hypotheses that I go check and test for myself.

Whitney Lowe:

Yeah. Yeah. That’s a really key thing for people to remember is how you do that and how you frame it and how you look at those kinds of procedures. Because you can give people really, I don’t want to think damaging, but let’s just call it detrimental nociceptive messages about things going on with them by saying, “Well, you’ve got a positive Phalen’s test. That definitely means there’s something going… Your nerve is compressed here.” We don’t know that for sure, actually. We could say, “You’ve got increased pain there, so let’s look at this. There could be a number of different factors that might be producing that.”

Til Luchau:

We don’t look for them for an absolute diagnosis. We don’t use them in isolation and if I see this, then absolutely, I do that. The other things we don’t do with special tests?

Whitney Lowe:

I think those are the big don’ts. I would say too, don’t put so much weight on them. This is painfully obvious that this is not a… This is not a beneficial business perspective for me to say don’t put so much emphasis on the stuff that I spent a whole bunch of years writing a book and selling it everywhere to people with these special orthopedic tests and everything.

Whitney Lowe:

But the reality is, I don’t do that anymore to the same degree either. I really have moved away from a lot of that stuff that is in the book that way and don’t put as much emphasis on it as I used to for sure.

Til Luchau:

Wow. Okay. I think we’ve kind of filled out why but say a little more about that was like for you over the years. Because yeah, you put a lot of energy into cataloging and clarifying and building a model on these. Tell us about what that’s like for you now.

Whitney Lowe:

It’s challenging. It’s very challenging for me, because there’s that quote that has been bandied about on the internet quite a bit about. It’s hard to get somebody to change their understanding when… What is it? When their income depends on it or something like that. I can’t remember exactly the way it goes. I’ve seen that with a lot of people having difficulty making significant paradigm shifts around the models that they’ve taught for years. That’s one of the ways in which that’s been challenging for me which is that I’ve been all about assessment for… Not all about assessment, there’s a lot of emphasis on the treatment that follows through with that, but assessment has been a big, big, big part of my focus in my business.

Whitney Lowe:

And also introducing and teaching massage therapists a lot of these special orthopedic tests. I spend a lot of time learning about them. I spent a lot of time learning them in these different environments. Yeah, that’s been in one of those rugs pulled out from under the feet kinds of things to cause me to reframe a lot of what I’m doing and a lot of what I’m talking about.

Whitney Lowe:

But it has also led me to refocus more on what I think are really the valuable things that people need to be learning and what are more valuable things they need to be getting from things. Because I saw this happen a lot in the classroom, in the education world there’s a lot of emphasis on just trying to learn these tests and that’s trickled down into entry level training programs where they’re teaching a lot of these orthopedic tests and some of these entry level training programs now.

Whitney Lowe:

Man, students are so overwhelmed with the amount of information that they need to know for their licensing exams. What you’re doing is teaching them these tests without really developing the complex clinical reasoning that should come before you even perform the test. You’ve got to figure out what’s happening. What you end up doing is teaching them to memorize things that just become a process or procedure that they don’t really understand.

Til Luchau:

As well as I’m just thinking too, about the subtle distinctions between specificity and sensitivity and all of the things that a result can mean or not mean and how to use those, how to take it beyond just if I see this in the test, then I should do this. All the considerations around that are really a large undertaking to understand all that. You’re saying that, yeah, maybe they don’t belong in entry level education or at least if they are there, what do you think?

Whitney Lowe:

Well, this has been a really hard question for me as well. Again, I sold my book to schools for years for programs to teach that stuff. But I really don’t support that idea any longer, that those things should be taught in entry level training programs.

Til Luchau:

Okay. Cool.

Whitney Lowe:

For those reasons that we just talked about is like… A lot of this actually for me comes from me studying a lot about education and recognizing things about cognitive load and curriculum development and how to put together things where people can sequentially actually get something and keep it and have it last and recognizing there’s a big difference between information dumping and educational experiences that tend to be more long lasting.

Til Luchau:

Well, we’ve been talking about it, but let’s just take a second to name it. What should people be learning instead? Where will people’s energy go instead?

Whitney Lowe:

Here’s where it shouldn’t go instead, in my opinion, is, and this comes from also watching this in teaching assessment and continuing education workshops for several decades now, which is that we start going through some basics and I’ll say, “Hey, I want to go through some exercises here about basic range of motion practices, active motion, passive motion and manual resistive tests which are very simple ideas. Most practitioners are taught this kind of stuff in their entry-level training programs. I’ll ask a question, “How many people know how to do these procedures?”

Whitney Lowe:

Probably 90% of the hands will go up in the classroom. It’s like, “Great. All right. Good, so we don’t need to go over that a whole lot. So let’s put this into practice.” I’ll give him a worksheet and I’ll have them go through this worksheet. I’ll say right now, “Do these procedures: active flexion of the shoulder, passive lateral rotation and resisted medial rotation. Now, if your client has pain with the first two of those, but not the second or something like that,” I’ll make up this pattern, “What does that mean?”

Til Luchau:

In terms of the muscle involved or something like that?

Whitney Lowe:

Yeah. Yeah. They will struggle with this, it will take them long periods of time to go through that. You can see the frustration of like, “We never learned how to do that.” It’s like that’s what you should be studying. By the time we go through this whole worksheet, there’s these light bulbs are going off and people thinking like, we learned how to do range of motion in school but I never really understood how to use it and what does it really mean. This is what I think-

Til Luchau:

How to use it to deduce or get a hypothesis about which structures might be involved and where I want to go.

Whitney Lowe:

Yeah. Even just very simple, going through those processes. What does it mean if it’s painful when you do this and painful when you don’t do that. You will probably recall back when we did the Shoulder Jam, there’s part of my presentation, I showed a bunch of these charts that we use that are just what happens to these… What I did is I ended up going back and I did this for our online program is make these tremendously detailed charts of what tissues are stressed when you do active shoulder flexion and what tissues are stressed when you do passive shoulder flexion, what tissues are compressed, what tissues are stretched, what tissue are elongated.

Whitney Lowe:

What would possibly cause pain when you do all these things? Now, that’s where I encourage people to put their attention. If you want to really do this, take a look at some of those kinds of charts and start saying, “How would I figure these things out?” Like in a simple evaluation with my client and look through what procedures causes sensations and then maybe you can just quickly look it up in the chart and say, “What might be involved here?”

Til Luchau:

The basic skills there are really pretty fundamental. It’s a clinical reasoning process that asks the question, let’s find out what’s going on before we start throwing techniques at it. Let’s use specific movements, active, passive, etc, resisted, unresisted. And then, you’ve done all this work on your charts, where we can actually just go look up and say, “Okay. So if this is the movement, then this is probably the structures involved.”

Til Luchau:

People with an instinctual understanding of anatomy can get there on their own too. But you’ve done a lot of the hard work there. I’m going to put a link to that shoulder jam presentation in our show notes, I think, because that was… You really excited people there I remember in the gym too because people go, “Wow. You mean I can do these simple movements and then look it up in Whitney’s chart and see what structure is involved.”

Whitney Lowe:

Yeah.

Til Luchau:

That’s so great.

Whitney Lowe:

Yeah. That again, is another elaboration of thinking through from an educational perspective of what’s really information that’s relevant and how do I pull something like that out of there? Because the truth is, the complexity of looking at those patterns is not easy. It takes understanding a good bit of biomechanics, kinesiology, anatomy and all those things put together to put some of those concepts and ideas together. But if you want to get good at looking for local tissue involvement when that’s the cause, that’s a good way to do it.

Til Luchau:

Well, the complexity there makes it really tempting to say, “Oh, I don’t diagnose, so I’m not going to do that.” Or, “I work intuitively, not cognitively so I’m not going to do that.” Or, “I kind of know what works, I’m just going to go do that.”

Til Luchau:

All those reasons we come up with, not to have to think things through. I just want to make a pitch for it. It doesn’t have to be so complicated. You have done a lot of the hard work in there and basically, it’s some really simple principles. You’re using those as pain provocation tests. You’re finding out what makes the troubling sensation happen and then reverse engineering it or even using those combinations of movements to come up with a treatment strategy.

Whitney Lowe:

Yeah. Thank you for saying that because that is absolutely true that it doesn’t have to be hard in many instances. In many instances, it’s not that difficult. This is just the way that I work mentally, I like having a framework to sort of organize my thoughts of what happens with the results of these different procedures. That just happens to be how I work. Other people work in different ways. That’s the beauty of the world. But I do think that there is… Especially when you’ve got the clients that are really trying to nail down like, “I can’t get anybody to help me figure out what’s wrong with my shoulder or my neck or whatever.”

Til Luchau:

Yes.

Whitney Lowe:

That’s when it’s particularly helpful.

Til Luchau:

Yeah.

Whitney Lowe:

It allows you to really drill down into those kinds of details.

Til Luchau:

Well, I see it getting interesting to people at some point in their career too. Maybe some people would never find it interesting, but many people after five years in, 10 years in, whatever, start to realize okay, my routine, my shotgun routines are throwing everything at the wall and seeing what sticks routines help a lot of people but maybe I could get even more efficient, more specific and even better by getting methodical or getting very intentional in ways I’m using these things to determine my best guess treatments.

Whitney Lowe:

Yeah, yeah. Absolutely.

Til Luchau:

Okay. We’ve talked about some good things. Anything else you want to make sure we cover before we wrap it up for the day?

Whitney Lowe:

Yeah, I think we’ve hit that pretty thoroughly there on the things that I wanted to kind of call up. I would encourage people to take a look at some of those things that we’ll mention in the resources. The article, the Cook and Hegedűs article was a really good piece.

Whitney Lowe:

You had asked too about where do people learn some more about, tests, so some of these different tests and how to evaluate whether or not they’re good or not.

Til Luchau:

I can tell you. But I can just hear this student in my class at this point, saying, “Okay, you’ve told me all the reasons why tests, I don’t need them. But now, which test should I use? Where do I get this test? They sounded pretty interesting to me.” What would you say to that person?

Whitney Lowe:

There’s a couple of good resources out there. We mentioned Chad Cook, for example, he’s got a really good book out there, Orthopedic Physical Examination Tests. That’s a good one out there. It’s a really comprehensive thorough assessment book that David Zulak did, Clinical Assessment For Massage Therapy.

Whitney Lowe:

David’s a practitioner out of Canada and this is a Handspring publication. Really thorough comprehensive recourse in there. Again, very few rarely do you get these comprehensive orthopedic assessment resources aimed at massage therapists. This is a really good thorough one he did there.

Til Luchau:

Well. I just want to wave your flag. Of course, you’re still offering that whole repertory of tests that you’ve put together over the years and you’re evolving. It’s still available, isn’t it?

Whitney Lowe:

It is. In fact, that stuff is all inside our online program. All of those orthopedic tests are in video in there now which I think is so important because a lot of these procedures, you see them in the textbooks with pictures and descriptions but you may not even understand exactly how to move the person through the test just the right way. That’s why I felt like the videos were so important.

Whitney Lowe:

I really cut the number of tests down that I wanted to emphasize people to learn because I didn’t think it was necessary for them to really go and memorize hundreds and hundreds of these tests. I really kept it to the ones that I thought had better accuracy levels and also were really pretty, pretty relevant.

Til Luchau:

Can you name some names? Are you willing to name some tests that you’ve found useful enough to leave in there? Reliable enough to leave in?

Whitney Lowe:

Oh, yeah. Sure. Some of the ones that are particularly viable like the straight leg raise is almost always included for people as a really valuable thing.

Til Luchau:

Lasègue. Test of Lasègue.

Whitney Lowe:

Yeah. I’ve gotten a lot of benefit from the upper limb neurodynamic tests that have been developed, that focus on the upper limb, on neural pathologies in combination with looking at some other things. There are some other things that are particularly valuable in sort of nailing down some… Making some discriminations between things, some of the patellofemoral tests that just basically have people squatting down, which is considered a special orthopedic test.

Whitney Lowe:

Again, this is one of the places where I get to talk about changing the way you do a standard testing procedure because I found doing palpation of the extensor retinaculum, while you move the knee into flexion with a load on it is a really good valuable way to reproduce and see if that’s causing those kinds of pains.

Til Luchau:

If that’s the place of trouble, that’s the process of doing compression or friction or something. That’s great.

Whitney Lowe:

Yeah. A lot of those kinds of things are particularly helpful and valuable. Especially, things like the straight leg raise test and some other things that might help you really pull out something that’s a serious red flag that needs to go be seen by somebody else.

Til Luchau:

There you go. There you go.

Whitney Lowe:

Yeah.

Til Luchau:

Well, you’re just helping me appreciate too, how important a role those tests have played in my own development to go beyond for myself. I’m just applying routines or recipes into really being able to tailor what I do to what the client’s coming in with. How it’s so important to remember, they’re just one factor, but they can help me begin that process of a biomechanical narrowing or biomechanical hypothesis that then I can go experiment with and work from.

Whitney Lowe:

Yeah. Mm-hmm (affirmative).

Til Luchau:

But I’m going to go ahead and put a link to your online program too in the episode resources. I think that’s really a great one for people.

Whitney Lowe:

Yep. All right.

Til Luchau:

Anything else you want to cover today?

Whitney Lowe:

I think we’ve done a good job of tailoring a discussion on some of these key things to think about around the special orthopedic tests.

Til Luchau:

That’s great. Me too. This is Episode 52. And you know what that means?

Whitney Lowe:

52.

Til Luchau:

  1. Now we’re playing with a full deck, finally. Or you could say… Yeah, exactly. Or you can say at this point, all we need is a couple of jokers and then we’re going to be good.

Whitney Lowe:

I think we’ve had a couple of Jokers just from the start.

Til Luchau:

Pretty good. 52 episodes, it’s been a pleasure.

Whitney Lowe:

Indeed it has.

Til Luchau:

I’m looking forward to the next 52 or however many we do.

Whitney Lowe:

Yeah. This episode, what’s the air date on this episode?

Til Luchau:

Yes. You never know what’s going to happen but slated for the 17th of November 2021.

Whitney Lowe:

I can’t remember… I think he did put on the schedule there. We were getting up really close on our two year anniversary.

Til Luchau:

Yeah, that’ll be an episode or two later, where they do an anniversary episode. Yep. Winding down.

Whitney Lowe:

Cool. All right. Well, thank you very much for that discussion today for all those great questions. As you can tell, I love talking about this stuff. I hope that’s helpful for some other-

Til Luchau:

No, I’ve enjoying it now. And thanks for sharing all that you have and having the time today to go over that. I want to thank our sponsors, all of them. But our closing sponsor is Handspring and just about them in particular, like we mentioned, they actually have a great book on orthopedic testing. We’ll put the link in the show notes.

Til Luchau:

But when I was looking for a publisher for a book I was wanting to write, this is many years ago, I ended up with two offers. One from a large international media conglomerate and the other from Handspring. A small publisher in Scotland run by four great people who love great books and love our field.

Til Luchau:

To this day, I’m glad I chose to go with them, Handspring, because not only did they help me make the books I wanted to share, The Advanced Myofascial Techniques Series, but their catalog has emerged as one of the leading collections of professional level books written especially for body workers, movement teachers and all professionals who use movement or touch to help patients achieve wellness.

Whitney Lowe:

Handspring’s Move to Learn! webinars are free 45 minute broadcast, featuring their authors, including one with you Til. Do head over to their website at handspringpublishing.com to check those out and be sure to use the code TTP at checkout for discount. And thanks again Handspring. And thanks to all our sponsors, once again, and we offer a special thanks to all of our listeners.

Whitney Lowe:

We thank you all for hanging out with us again here today. You can stop by our sites for show notes, transcripts and any extras. You can find that over on my site at academyofclinicalmassage.com. Til, where can they find that for you?

Til Luchau:

The episode show notes etc on our site are under advanced-trainings.com. If there are questions or things you want to hear us talk about, email us at… Well, it’s [email protected] or look for us on social media, just under our names. My name is Tim Luchau, what’s your name?

Whitney Lowe:

My name today is Whitney Lowe. You can find that on my social channels there as well. If you will, follow us on Spotify, rate us on Apple podcasts. That does help people to find the show. Please go follow over there. And then wherever else you have to listen to, Stitcher etc. Whatever happens, listen and do tell a friend.

Til Luchau:

If you go to one of our sponsors, tell them that you heard about them on us. Because that helps everybody too. That helps us realize that we’re helping spread the word in a helpful way.

Whitney Lowe:

That does. Sponsors like to know that, when that’s certainly very helpful for them as well. Of course, if you’re unable to find us in any of those locations, you can grab a flashlight, a transistor radio and find a local cowboy and strap them to their saddle and you can pick us up on satellite radio. We’re available there as well. Okay.

Til Luchau:

Thank you Whitney.

Whitney Lowe:

All right, sir. Enjoyed it. We’ll talk to you again here soon.

Til Luchau:

See you later.

Whitney Lowe:

Okay.

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