Physical assessment

Chapter 9 Physical assessment



Physical structure 175
Observation 175

Palpation 177

Posture 178

Gait assessment 181

Assessment of joints 182

Breathing 183
Steps to assessing breathing patterns 184

Tongue assessment 185
Body color 187

Body shape 187

Tongue coating 188

Tongue moisture 188

Pulse diagnosis 188

Face and special senses 191
Eyes 192

Ears 193

Nose 195

Mouth 196

Teeth 197

Skin 197

Fingers and toes 199
Guidelines for assessing the fingers and toes 201

Alignment 201

Color 202

Lines/markings 203

Spacing 203

Size 203

Shape 204

References 206

Further reading 207

The physical assessment follows the holistic intake. The information gathered during the intake provides the subjective view of the patterns of disharmony. The physical assessment provides an objective look at how the patterns have affected the physical health of the patient. Symptoms and diseases are multifactorial, yet they manifest in ways that have a logical pattern and that convey meaning as to the causative factors. The aim of the physical assessment is to correlate the patterns that emerged during the holistic intake with the physical signs and symptoms, to identify the causative factors, and to determine the treatment strategy that is required to restore health.


The human body is an outward display of the internal patterns. These patterns appear on the psychological, functional, and structural aspects of an individual and they always shift together, in varying degrees. For example, you hear it in the words that a patient chooses and how they speak; there are changes on the tongue and in the pulses, in heart rate and breathing patterns, on their face and skin, and in the alignment of the structural body.


Human beings are complex, dynamic, interrelated systems and the physical body displays a single pattern of disharmony in many different ways, in various parts of the body.




There are countless ways of perceiving what is going on with the person who is in front of you and who needs your help and that there are many ways of stimulating healing response (Oshman 2003).


A thorough physical exam includes the assessment of various parts of the patient as each part provides a unique window and highlights a specific function or part of the body. For example, breathing patterns and pulses change in response to acute stressors, whereas the physical structures, alignment of bones, or the movement of toes represent more chronic or ingrained patterns of disharmony. Each assessment method supplements and verifies the others. The manifestation of the same pattern in different parts of the body provides the practitioner with a thorough and more complete pattern of the patient’s condition. For each patient, and each symptom pattern a particular window will provide the clearest view. For example, if a patient has symptoms of joint pain, an assessment of posture will often provide a clearer message than the assessment of pulses or the eyes; if a patient has a range of chronic symptoms, the information conveyed in the eyes and the pulses will often provide a clearer view than a postural assessment.


The body provides many windows for reading the symptom patterns and the more windows that a practitioner looks through, the greater the confirmation of the pattern. The windows, or areas of assessment, provide a range of options for each practitioner, based on their unique skill set and areas of interest. The more that a practitioner studies and practices a specific area of assessment, the greater the depth of information they discover. For example, a practitioner who has mastered tongue and pulse diagnosis will be able to assess the subtleties of a patient’s disharmony through that one window. A practitioner does not have to be master of all the aspects of assessment. What is helpful is for a practitioner to discover where their strengths lie and to develop them, without losing sight of the value of the other windows. I encourage practitioners, especially young practitioners, to initially assessall areas of the body in order to discover the various ways that human beings have of expressing disharmony.


In order to interpret the symptom patterns in the body, a practitioner needs to have a detailed knowledge of anatomy, physiology, and pathology. They also need an understanding of how the qualities and attributes are manifested physically and how the body functions as a complex, dynamic system. As with all parts of assessment, a practitioner needs to have an open mind, maintain the art of curiosity and intrigue, and be able to recognize that health and disease is a puzzle; the more pieces to the puzzle that a practitioner uncovers, the more complete the picture.


During a naturopathic physical assessment a practitioner conducts a conventional physical exam includes laboratory testing; as well as an assessment of a patient’s posture, gait, breathing patterns, tongue and pulse, face, eyes, hands and feet. As there are many books written on the standard conventional physical exam, that information will not be repeated in this book. The emphasis of this chapter is on assessing how the specific attributes and qualities of patterns appear on the physical body.



PHYSICAL STRUCTURE


The physical structure and appearance of a patient is often the first thing that a practitioner observes. This observation provides the practitioner with an indication of the personality and temperament of the patient. The unique qualities that are observed and attributes that they represent can be understood based on the elemental properties discussed in Chapter 5. Figure 9.1 looks at how the elements appear in shape and form in the body.


• Earth build is like an oak tree, strong and firm. Body features have a square shape with definite borders, like a square jaw and shoulders, and a thick, short neck. An earth patient is solid, broad, and big-boned.

• Water build has more cushioning and softness. There is roundness to the physical features and a stout build. You see more fat throughout the body and a larger chest.

• Fire build is muscular and moderate in size. The features are in proportion and the eyes are sharp and prominent. The skin has more of a red tone.

• Air build is like a willow tree, flexible and moving. Air bodies tend to be thin, small boned and without a lot muscle or fat, and they may be underdeveloped. Their features tend to be subtle and their color is usually paler.

• Ether is a reflection of an individual’s presence and vitality regardless of their shape and size.

image

Fig 9.1 Shape of the elements. Air – star shape, appears as symptoms that come and go with no precise pattern. Fire – triangle shape, appears as symptoms that have a sharp edge and that are more pointed. Water – moon shape, appears as symptoms that are more rounded and softer. Earth – square shape, appears as symptoms that are hard, firm, square, definite borders.



Observation


Hippocrates introduced the art of clinical observation as the necessary basis for pathologic diagnosis (Hahnemann 1997). Everything that a practitioner observes holds a meaning. Most of what we observe, in every aspect of our life, is interpreted without our conscious input and awareness of the interpretation process. The mind identifies objects by extracting diagnostic visual cues and matching this information to a prototypical, structural description stored in memory (Biederman 1987, Bar et al 2001) In order to assess the symptom patterns, it is essential to learn and ‘program’ energetic pattern correlations for observed (and auditory) clues into the unconscious mental templates that the mind uses for assessment.


The art of assessment is to separate observation from interpretation. For example, a practitioner might observe that a patient’s arms are crossed, that their breathing is shallow and rapid, and that their brow is tightened; the interpretation is that a patient is frustrated. But that interpretation might be incorrect. How a practitioner assesses the visual clues of the body depends on their internal ‘encyclopedia’. Skilled practitioners are able to pick up detailed information from a patient, sometimes even intuitively, but all information that is picked up should be supported by visual clues.


Many forms of treatment are based on patients becoming aware of how they respond to situations. The more that a practitioner can capture what they are observing the more beneficial it is for the patient. For example, a patient might know that they have anxiety, but they are unaware of the various ways that their body manifests the anxiety, and by becoming aware they have more options and means of treating their condition.


Observation involves having ‘soft eyes’ and ‘open ears’. It recognizes the subtleties as well as the details; the harmony and disharmony that a patient displays. It is about being present in the process, slowing it down, and paying attention. For every aspect of the assessment ask yourself what stands out, what is missing, what seems out of place, and what’s different. Before you look for the details, look and listen for the overall pattern that a patient is displaying, such as an overriding sign of excess or deficiency. Most qualities can be caused by a number of different factors; below is an example of the most common causes of the following symptoms:


• sidedness – Yin–Yang pattern

• symptoms located on the periphery – external pattern

• symptoms located in the core or center of the body – internal pattern

• heaviness – excess of water or earth

• light – excess of air, deficiency of earth

• slow – excess of water or earth, deficiency in fire or air

• sharp – excess fire

• cold – excess air or water, deficient in fire or earth

• hot – excess fire or earth, deficient air or water

• oily – excess water

• dry – excess air, fire or earth, deficient water

• rough – excess air

• thick or dense – excess earth

• soft – excess water, or deficiency of earth

• hard – excess earth, or deficiency of water

• cloudy or milky – excess water

• Yin force causes things to contract, to be heavier, and cold. Yin represents the river side of nature. It represents features that are sunken.

• Yang energy represents the mountain side of nature and hence represents features that are raised and have more strength or substance. Yang has an expansive quality.


Palpation


Observation and palpation are inseparable. Any aspect of the body that displays disharmony needs to be assessed in more detail. If a patient has functional symptoms, such as digestive or breathing concerns, it is important to identify if they are related to structural alterations.


Palpation assessment progresses through successive degrees of attenuation from bone to muscles, to fascia, to fluid, to energy fields (Chaitow 1997). The structure of the body governs its function, and function dictates structure and the movement and freedom of motion of every tissue, organ, and cell is needed for efficient working of the body. Palpation determines the degree to which each part of the body is able to move freely and it is used to confirm and expand on any information that is observed.


Every cell, tissue, organ, and structure of the body is linked as a complex dynamic network. There is an intrinsic nature and organizational matrix within the human body, a connection between the skin, muscles, joints, organs, as well as the emotional state of the patient; each one affects theothers. There is a flow of fluids and energy throughout the body that nurtures and supports each component. An alternation in any aspect alters the whole.


The role of a practitioner is to observe, assess, touch, feel, and learn from the body. The art of palpation is what a practitioner feels, it cannot be learned in books. It is learning to listen – with your hands – to everything that the body is willing to convey. The art of palpation is a very detailed skill that requires an immense amount of practice and silent attention. I recommend that you explore this skill in more detail by studying the works of authors such as Leon Chaitow, in his book Palpation Skills.


The objectives of palpation are to: (Chaitow 1997)


• detect abnormal tissue texture

• evaluate symmetry in the position of structures, both tactically and visually

• detect and assess variations in range and quality of movement during the range, as well as the quality of the end of the range of any movement

• sense the position in space of yourself and the patient being palpated

• detect and evaluate change in the palpated findings, whether these are improving or worsening as time passes.

Palpation also detects changes in energy variations, ‘tissue memory’, and detects differences in tissue texture and quality in various aspects of the body. It involves correlating a patient’s perception of discomfort or disharmony with observational and palpation findings. Palpation provides information as to the qualities of the patterns that are being manifested. For example, muscles overall represent the quality of fire. Too much earth in the fire element shows up as stiffness and increased tone in muscles; a deficiency of earth manifests as atrophy or a lack of normal tone.


Tools such as scans, radiographs and laboratory tests are used by naturopathic doctors and they provide valuable information as to the structural changes in the body, but they do not replace the information that is obtained by observation and palpation.




Although palpation is commonly thought of as a means of accumulating evidence to be used when coming towards an assessment, diagnostic or prognostic position, there exist situations in many areas of manual palpation where there is only a theoretical division between palpation/assessment and therapeutic activity (Chaitow 1997).



Posture


A patient’s posture reveals their sense of inner and outer support, their flexibility, and their openness to external factors. The way a person moves and stands indicates inner characteristics (Mattsson & Mattsson 2002). An aligned posture allows for movement through the full length of the body.


Assessing posture is very important especially when pain and discomfort with movement is a concern, or when you observe structural changes. Posture is the result of the over use, misuse, or abuse of underlying structures of the body, and their respective alignment and positioning both right to left and front to back over time. It is affected by the size and strength of the bones –an earth quality; the fluid within the joint spaces – a water quality; the muscles that attach to the bone – a fire quality; the ease and freedom of movement – an air quality; and the desire to take up space – an ether quality.


Misalignment of posture occurs because of injuries and habitual patterns, such as crossing the legs, or tilting the head while talking on the phone, or an imbalanced stance. Postural assessment determines how posture affects the functioning of the body, and it explores the impact of habits and injuries on physical structure.


When assessing posture, look at the body from the front, the back, and the sides, both when a patient is standing and when they are lying down (Fig. 9.2). It is easiest to see the key features of posture when a patient is wearing as few clothes as is reasonable. A gravity board, plumb line, and grid wall are the easiest ways to properly identify and measure the differences in the posture alignment. Initially assess your patient in as relaxed and natural state as possible. You are looking for how they normally stand and how their weight is distributed. Next have them stand with their heels exactly in line and square to a real or imaginary plumb line running down the center of the body from the head to the feet. The following are the main patterns that are displayed in a postural assessment:


• Lateral or medial deviation. The hands, arms, legs, and feet are body parts that most easily demonstrate lateral or medial deviation which indicate external and internal patterns, respectively. Lateral deviation is when the body parts are pointed or positioned away from the center line, such as patient who stands with their left leg externally rotated (refer to Fig. 5.2). Lateral deviation or movement is due to a patient either pushing away from themselves or being pulled by external situations. Medial deviation is when the body parts are pointed or positioned toward the center line, such as a patient who sits with their knees internally rotated (refer to Fig. 5.3). Medial deviation or movement is due to a patient pulling inward or avoiding external situations.

• Right to left difference. Any difference right to left is a reflection of a Yin–Yang pattern. You often notice one side of the body that is wider and has a more pronounced muscle mass. It is not uncommon for people’s hands and feet to be aligned differently right to left. The presence of other signs and symptoms will reveal whether this is a natural state for a patient or a sign of disharmony.

• Top to bottom differences relate to differences from the hips to the feet, and from the shoulders to the hips on either side of the body. For some people, the difference is all on one side. For others, there is a difference in the upper body on one side and the lower body on the other side; their body is twisted. The upper body has more to do with the interaction between oneself and others. The lower body is more about moving through life.

• Front to back difference. A difference front to back relates to a patient’s center of gravity and by observing the distribution of weight that is in front of the center line and how much is behind it. The front of the body is Yin and represents the sensory aspects of the body; the back of the body is Yang and represents the motor aspects. When the weight is shifted more forward or backward it will often have a corresponding Yin–Yang pattern.

image image image

Fig 9.2 Postural assessment. (a) From the front; (b) from the side; (c) from the back.


The alignment of posture front to back is also indicative of underlying functional changes in the body. For example,



If the head is pulled back, the movement of the neck is restricted and the chest is more fixed and immobile, which means restrictions in exploration and perception of the surroundings. Carriage coincides with a stiff way of viewing the world – rules are followed categorically, fantasy is an obstacle and rigid working-style is favoured (Mattsson & Mattsson 2002).



GAIT ASSESSMENT


A patient’s gait provides information of how the physical body moves within space. It shows how the different parts of the body flow together and the symmetry right to left and top to bottom. Imbalances in gait also highlight structural or functional concerns.


When a patient walks their posture is often different than when they stand: for example they lead with a specific part of the body. If there is a specific part of the body that is leading, look for the symbolism of that body part to provide information on the pattern they are displaying.


When a patient displays an aligned posture and good balance in their gait it implies that they have the ability and strength to preserve the alignment between their head and pelvis. This is important as the center of gravity is in the pelvis.




The arms follow the trunk, giving equilibrium and emphasizing pace. The gaze is directed straight ahead, the head and neck move freely in the vertical line, the eyes and ears readily incorporating necessary information. This way of walking is open and grounded; there are few restrictions (Mattsson & Mattsson 2002).


When assessing a patient’s gait initially do so when they are unaware, such as when they are walking to the practitioner’s office. As soon as you bring a patient’s awareness to their walk it often changes. A patient compensates or exaggerates a feature that they are aware is out of balance. Also, assess their walk in the gait that is most comfortable for them, their natural state. Then ask them to speed it up and slow it down. Notice how they handle the change and what changes in their posture. How a patient walks displays certain qualities and characteristics that relate to the elements and to Yin and Yang.


• Earth walk is slow, steady, and heavy. It indicates a person who stands firmly on the ground and who expresses stability and firmness.

• Water walk is flowing and continuous, like a gentle stroll.

• Fire walking is fast, intense, and with a clear direction.

• Air walk is quick with frequent changes in direction.

• The quality of ether is seen as the ease and ability of walking overall.

• The quality of Yin–Yang is seen when there is a difference between the right and left sides of the body or the top and bottom of the body. For example, you might see that the right arm swings more freely than the left. Or that the legs and hips are very rigid, yet the upper body is more relaxed.


ASSESSMENT OF JOINTS


It is common for patients to have pain or discomfort around joints, as joints are responsible for movement of the structural body. Overall joints represent the qualities of space – ether – that is the freedom to move through life. As ether is the element from which all other elements are derived, the movement of the joints and the location of joint symptoms bring in all the other elements. The joints located in the core of the body, the spine, relate to the freedom of movement that a patient feels with respect to themselves, and their ability to be themselves. The movement of the peripheral joints relates more to the interaction between a patient and their external surroundings. The joints on the upper body also have a corresponding joint on the lower body; for example the elbows and the knees are both air joints, the wrists and ankles are both water joints. The joints on the top of the body refer more to acute or current situations, the joints on the lower aspect of the body often relate more to chronic situations or patterns.


Each joint has a corresponding symbolic meaning, for example the shoulders symbolize giving and receiving, hips symbolize moving forward. The elbow and knee correlate with the qualities and characteristics of air element; the wrist and ankle correlate with the water element (see Fig. 9.3).


• The quality of earth impacts movement of the joints as it relates to structure and support. An excess of earth appears as guarding, stiffness, or inability to move; a deficiency of earth appears as weakness or lack of strength.

• An excess of water impacts joint movement through the presence or absence of fluid and often manifests as swelling or inflammation. A deficiency of water results in a loss of fluid in the joint space. A water imbalance is also apparent when there is a cogwheel aspect to the movement that is, the movement isn’t smooth – it starts and stops.

• An excess of fire results in redness and heat and is one of the main causes of pain. Restlessness in muscles is an indication of excess fire. Muscles are a manifestation of the fire element. Balanced fire is seen in the tone and structure of the muscles themselves.

• The air element controls the nervous system. A lack of nervous impulse for the muscles to move indicates an imbalance in the air element, as in the feeling of ‘pins and needles’, random movements, or twitching.

• Yang energy controls the movement of the extensor muscles. An excess of Yang, for example, would manifest as contraction or issues with respect to the extensor muscles. You might also find an area around a joint that was intensely hot and aggravating. The qualities of heat and contraction are also Yang in nature.

• Yin energy controls the movement of the flexor muscles. The qualities of cold and expansion are Yin in nature. An example of excess Yin would be when the muscles are lax or weak, or there is a concern around the flexion of the muscles.

image

Fig 9.3 Peripheral jonts. (a) Ether joints; (b) air joints; (c) water joints.



BREATHING


Breathing is the first thing you do when you are born and your last breath indicates death. The full potential of breathing is the integration of the body, mind, and spirit; it is a process of experiencing, expressing, and contemplating life.




The function of breathing is said to represent a bridge between the conscious and unconscious – breathing can be controlled by our will, but mostly we breathe reflexively (Mattsson & Mattsson 2002).


Breathing is directly affected by what you are thinking and can affect thinking itself. It is not only essential to life, it is a reflection of life.


Inhalation is an active process where air is brought into the body; exhalation is a passive process where carbon dioxide is released. There is a rhythmic movement between breathing in and breathing out that affects every aspect of an individual. This ebb and flow pattern of contraction, relaxation, and resting is one of the energetic waves of life.


Breathing is quite easy to observe and palpate and carries with it a lot of information. The volume, speed, consistency, location of breath, origin of breath, frequency, phrasing (difference between the inhalation and exhalation), texture (smooth and even or jerky and uneven), depth (deep or shallow) and quality (pneumatic or labored), all provide information about an individual’s health on the psychological, functional, and structural levels.


When patients are dealing with stress, of any type, the initial response of the body, often unconscious, is for the breath to become rapid and shallow. For example, the term ‘anxiety’ has its linguistic root in the Latin word angustio, which corresponds to suffocation. Likewise, when a person feels anxious it will feel as if breathing is obstructed (Mattsson & Mattsson 2002).


The qualities of breathing can be broken down into inhalation, exhalation, and the rest period as described in Table 9.1.



Table 9.1 Breathing

image

Breathing overall is an air element, yet the influences, excess and deficiency of all the elements affect breath. What you are assessing with breathing is thefreedom of the air element to move among and within the other elements. The following is how the energetic patterns manifest in breath.


• The quality of earth is seen in the slowness and depth of the breath.

• The quality of water is seen in a patient’s ability to exhale, to let go. It manifests in the flow of the breath. It appears in the consistency and rhythmic nature of the breathing pattern.

• The quality of fire is seen in the inhalation. It is the impulse to breathe itself. Inhalation has to do with experiencing life, having the impulse to take in from the outside. Excess fire in the breath manifests as a breath that is too rapid.

• The quality of air is seen in the overall breathing pattern. Breath brings in prana or life energy. The act of breathing is responsible for moving energy throughout the body.

• Ether is represented in the body’s ability to breathe itself, having the space and will to breathe. Ether represents the overall quality of the breath.


Steps to assessing breathing patterns


Assessing breathing patterns involves conventional methods, such as auscultation and radiographs to rule in and rule out specific diseases, such as asthma, bronchitis, pneumonia, and lung pathologies. There are many factors that can disrupt normal breathing patterns and assessing the qualitiesof how a patient breathes provides another layer of information that is helpful in determining the causative factors and in deciding on the treatment strategy that is the most appropriate. For example, a sigh is a deep and shallow breath. It is a symptom of fatigue, depression, or grief. The word ‘to sigh’ means ‘to lament, mourn over’. Yawning is a sign of drowsiness, dullness, or boredom. It has the quality of earth. Anxiety, on the other hand, causes rapid, shallow breaths. It is often associated with fire or air imbalances.


The following is a guide for assessing the patterns of breathing:


1 Observation. What was the first thing that you noticed about a patient’s breathing? Was it the sound or movement?

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Mar 24, 2017 | Posted by in NURSING | Comments Off on Physical assessment

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