The Whole-Body Assessment

by Kevin Haussler, DVM, DC, PhD and Debranne Pattillo, MEEBW

We believe that practitioners who have been trained in a diverse array of assessment techniques can all provide unique clinical insights, but those assessments must be based on a whole-body approach and be as detailed as possible.

Veterinarians and human-trained chiropractors, osteopaths, and physical therapists are taught, during their extensive training programs, thorough physical examination protocols that guide their treatment plans. These licensed practitioners know how critical it is to take the time and have the necessary resources to conduct a comprehensive evaluation – not only for that initial client visit, but also to assess the patient’s longer-term response to care.

If we neglect to take the time to establish a well-defined baseline of clinical parameters (relative to the individual practitioner’s scope of practice), then how can we build a sensible treatment plan? Or provide any realistic updates to the client of significant improvements provided by our clinical services, or justify our fees or continued treatment?

Another key reason why physical assessment is of critical importance is that treating an animal, without first taking a complete patient history and performing a thorough assessment, can be harmful to both patient, owner, and practitioner. Dr. Haussler’s January blog post, Recognizing Red Flags, discussed the importance of screening patients for infectious, contagious and zoonotic diseases, and avoiding contact or doing immediate referral of potentially affected animals.

Another example: Applying chiropractic treatment to a horse with ataxia due to spinal cord compression or a primary limb lameness due to a hoof abscess would be issues of great concern if treatment was applied without any consideration of the cause of the clinical complaint or diagnosis.

The assessment training gap

For practitioners who have pursued training or certification to work with animals – chiropractors, osteopaths, physical therapists, massage therapists, bodyworkers, acupressurists, – the same standards for training in physical examination procedures is expected, which implies that graduates of these programs are taught to routinely perform a thorough assessment of their patient before proposing a treatment plan or applying any therapy.

Unfortunately, some training or certification programs for animals do not provide any or only limited didactic or practical course content on assessment techniques. Despite this fact, these training programs are often considered to be reputable because their curriculum provides extensive training in treatment techniques (i.e., how to apply the techniques), requirements for externships, case studies, and hands-on validation of the student’s work. This implies that the graduates of these programs would theoretically know how to do the treatment work but would not know if the patient standing before them has any specific clinical indications that could inform their treatment plan or whether that patient might be harmed by having specific manual therapy techniques performed.

And what about the training or certification programs that have lower standards or fewer requirements for the length of study, quality of instruction, or a lack of oversight or hands-on training? Have graduates of these programs learned the value of taking a detailed history and conducting a whole-body evaluation? Or have they recognized some of the shortcomings of their initial training and then pursued additional training to develop their assessment skills?

For animal bodyworkers, learning and then applying a whole-body assessment is essential for recognizing discomfort, improvements, and to know when referral for veterinarian intervention is required (as outlined in the Recognizing Red Flags blog post). Graduates of various programs may be unaware of the need for comprehensive assessment guidelines since they simply do not know what they do not know.

Why the lack of assessment?

There are several possible explanations why assessment techniques might not be taught or are only a minor component of a certification or training program, or are not completed on every patient at every visit:

General application – A belief that every living being has issues somewhere in their body and finding the exact location or affected tissue is not that important – just applying a treatment somewhere will help the patient.

Lack of time – As some of these training programs are offered over a weekend or limited to less than 100 hours, there may not be time enough to cover all the needed topics. Therefore, the focus is on the technique or training method itself and less on the evaluation procedures.

Lack of expertise – The instructor lacks the awareness or may not have qualifications as they were not taught how to do detailed whole-body assessment techniques during their own training.

Difficulties in translation from human – Many of the techniques that we use with animals have been transposed from use in humans. However, human-based techniques may not wholly translate to the quadrupedal, nonverbal, haired, animal patient. Similarly, human-trained instructors may find it difficult to effectively shift their teaching methods from the human to animal patient.

Client resistance – Bodyworkers report that they sometimes encounter resistance from clients because of the additional time and associated cost required to collect a complete medical history and conduct a comprehensive physical examination – sometimes the client just wants a “quick fix”. It can be helpful to explain to clients why the information needs to be collected and to demonstrate a full-body assessment. If they still resist, then there is a possibility that they may not continue to be a client.

Scope of practice and assessment techniques

It is important to note that assessment techniques vary according to an individual’s scope of practice and the different modalities or manual therapies that are applied. Practitioners vary in their training and individual area of interest or focus and therefore may not perform the same physical evaluation procedures.

Certain clinical or diagnostic techniques are and should be reserved for veterinarians or other licensed practitioners trained in those specific methods. For example, a massage therapist with training focused primarily on myofascial issues is not qualified to do a cranial drawer test on a dog’s stifle and should not be discussing how to manage a ruptured cranial cruciate ligament rupture. It is important to have a clear understanding of our scope of practice and specific training, and what assessment techniques we should and should not be performing.

Practitioners also need to be aware that in navigating the complexities of veterinary regulatory language, they face potential pitfalls. State veterinary practice acts wield considerable authority, with terms that if used by non-veterinarians could easily be construed as infringing on the practice of veterinary medicine. While some practice acts provide clarity on the roles of practitioners, many do not. Therefore, it is crucial for practitioners to use terms that align with their scope of practice, to avoid legal repercussions.

For instance, in Texas, animal bodyworkers received cease and desist letters for using terms such as “evaluation”. The veterinary medical board cited codes from the definition of veterinary practice (§ 801.002.):

(5) “Practice of veterinary medicine” means:

(A) the diagnosis, treatment, correction, change, manipulation, relief, or prevention of animal disease, deformity, defect, injury, or other physical condition, including the prescription or administration of a drug, biologic, anesthetic, apparatus, or other therapeutic or diagnostic substance or technique.

Diagnosing is strictly prohibited for unlicensed practitioners. Instead, they can facilitate communication between owners and the managing veterinarian or advocate for veterinary examination when issues arise.

While terms like “treat” are generally accepted in the human massage therapy realm, caution is advised as interpretations by a particular veterinary medical board may vary. Opting for terms such as “address” or “do a session” can mitigate risks.

Similarly, practitioners should refrain from using terms like “physical therapy” since this is a licensed title for human Physical Therapists. Even veterinarians use designations like “animal rehabilitation therapy” instead of “physical therapy”.

Certain terms, such as “chiropractic,” are also restricted to individuals with relevant qualifications. Practitioners must respect these boundaries and refrain from using terms like “manipulation” or “adjustment” unless properly authorized.

Despite the intricacies, awareness of these nuances can safeguard practitioners from accusations of overstepping their scope of practice.

Using SOAP notes for a clinical approach

SOAP notes, a widely used method of medical record keeping and documentation for healthcare providers, can be a helpful way for practitioners to make sure that we are taking a clinical approach to our work and not skipping over important steps in the data collection process. SOAP is an acronym for Subjective, Objective, Assessment, and Plan.

Here is how veterinarians use SOAP notes:

  • The Subjective components include information collected from the owner or trainer such as the signalment (age, sex, breed), presenting complaint, and medical and performance history.
  • The Objective parameters are data collected by the veterinarian and may include vital signs, physical examination, laboratory tests, and diagnostic imaging.
  • The Assessment then involves the process of synthesizing the subjective and objective information to form a diagnosis.
  • The Plan is then based on the diagnosis. So, if we do not do an assessment or only do a partial assessment, we are not able to place much confidence in our diagnosis. We did not do the work – if we have no gas in our car, then we can’t expect to go far. If we do not have a diagnosis, then how can we build a plan?

S leads to O leads to A leads to P.  Results in focused and effective treatment for your patient.

P (treatment) without S or O or A.  Results only in P (pee).

Space does not allow us to provide here an extensive list or detailed description of the subjective and objective outcome parameters needed to fully assess, for instance, the appendicular and axial skeleton in horses. However, here is a general outline of points that should be covered in a detailed musculoskeletal and neurologic evaluation:

History

  • Signalment – age, sex, breed, athletic discipline, exercise
  • Presenting complaint, review of body systems
  • Medical-surgical-performance history, current medications

Observation

  • Static – environment, behavior, conformation, posture, body condition, symmetry
  • Dynamic – in the stall, at liberty in paddock, in hand, on lunge, tacking up, mounting, ridden

Palpation

  • Soft tissue – hair, skin, superficial fascia, deep fascia, ligaments, tendons, muscle, vasculature
  • Osseous – landmarks, prominence, size, shape, spacing

Mobilization

  • Soft tissue – skin, fascia, muscle, tendon, ligament
  • Articulations – low vs. high motion, types of articulations (hinge, complex), arthrokinematic vs. osteokinematic

Neurologic assessment

  • Cranial nerves – mental status, behavior, head tilt
  • Sensory – light touch, pin prick, stroking vs. pressure, posture, proprioception
  • Motor – strength, coordination, spasticity, tail pull, tail tone
  • Reflexes – deep tendon, spinal (sternal elevation, lumbosacral flexion)

Because non-veterinary practitioners do not “diagnose”, they typically adapt SOAP notes to their needs. Although different practitioners may use different session forms, these forms should all include the initial history (signalment including the client’s concerns and goals) plus static and dynamic observations that map how the horse presents regarding any asymmetries in structures, muscles, or movement. For soft tissue palpation, the “Four Ts” of bodywork are employed – which include comments regarding tone, texture, tenderness and temperature.

Here is how non-veterinary practitioners often interpret the SOAP acronym:

  • The Subjective section of the session form includes the practitioner’s impressions and opinions based on personal experience.
  • Findings from the static and dynamic assessments are included in the Objective section, with no personal impressions added.
  • Remember that practitioners must avoid diagnosing. For example, instead of stating that the cranial swing phase of the right forelimb is shorter than that of the left forelimb – which is a fair and objective comment – if the practitioner then adds “because of possible navicular syndrome,” that would be considered diagnosing.
  • The “A” section is often interpreted as Action, i.e., what the practitioner did during the session, including reassessment at the end of the session, to note improvements.
  • The Plan section of the form includes recommendations to the client for exercises, plus the practitioner’s thoughts regarding future sessions with that animal.

It goes without saying that when a horse is under active veterinary care, the session should be cleared first with the veterinarian to make sure the work is appropriate for the animal. Any suggestions by the practitioner for animals under active veterinary care should also be discussed with the managing veterinarian.

Measuring outcomes

Our March blog post and Community Gathering, on the effectiveness of manual therapies, will address how we can measure the success of our work. Suffice it to say here that unless we adequately assess our patients prior to treatment, we will not have a baseline or reference point with which to compare our results (i.e., measure our effectiveness). Specific performance indicators can be used to assess our treatment efficacy, which will vary according to our intent for providing care. More on that next month…

In closing

From a veterinarian perspective, the treatment is only as good as the diagnosis, and the diagnosis is only as good as the assessment. For all practitioners, the quality of our assessment defines the quality of our patient care.

If you are a practitioner who has been taught appropriate assessment protocols, this blog post may serve as a gentle reminder of the importance of always taking the time to perform a thorough assessment and of constantly reassessing your work.

If your training did not provide sufficient methods to allow you to complete a whole-body evaluation, then we encourage you to seek out additional educational opportunities. One practitioner currently pursuing training in advanced assessment techniques reports that this realization caused her to take even more precautions with her bodywork.

If you are contemplating training as a manual therapist, make sure that you contact the certification programs you are considering to ask about the breadth and depth of the assessment protocols that they teach in the didactic or practical portions of their course.

If you are an animal owner, always ask the practitioner to perform an appropriate assessment prior to working with your animal and to explain their findings. Although non-veterinary practitioners are not legally allowed to use the term “diagnosis” – this term is reserved for veterinarians – they should absolutely be willing and able to share their “findings” and their treatment plan. And, of course, advise you if they think that your animal needs to be referred to a veterinarian, a different practitioner, or other member of the animal’s care team.

Do you always thoroughly assess your patient prior to treatment? If you do not, what obstacles are preventing you from doing so?

Were you taught a whole-body assessment protocol during your training? Does it provide you with a framework or methodical approach that then leads you to an effective treatment plan?

Do you build your treatment plan based on SOAP notes or some other means of assessment? How is that working for you?

Community Gathering with Dr. Haussler and Debranne Pattillo on March 11th.

Resources

Haussler, Kevin. Spinal Evaluation Module (free with free Basic Membership at vetspine.orghttps://vetcompendium.org/diagnosis/

Pattillo, Debranne. Anatomy of Equine Bodywork, The Equinology® Approach. See assessments pp. 295-332 and dentistry pp. 671-690. https://www.equiinkpublications.com/

Equinology Inc. Initial History Form (2020) [PDF]

Equinology Inc. Initial Static and Dynamic Observations Form (2017) [PDF]

Crabbe, Barb, with Debranne Pattillo. Introduction to Equine Conformation – Evaluation and Analysis Considerations [PDF]

Mitchell-Golladay, Ruth. Facilitated Healing Through Myofascial Release. See subjective and objective assessment forms at beginning and end of book. Info: animalmfr@gmail.com

Interested in learning more?