by Terri Gorman O.T.R.
In an earlier blog post I have written, “Significance of Objective Measurements for Positive Treatment Outcomes” I established my beliefs regarding the importance of using objective assessments. I outlined my journey as an OT student realizing why there was such an emphasis on assessment and evaluation in the therapy world when treating patients. In this article, it is my intent to convey methods that I utilize when selecting relevant objective assessments for each individual client, as well as how I integrate those objective assessments into individual treatment plans, and then use those tools to guide and facilitate positive treatment outcomes. I will be speaking from the perspective of treating my OT and CranioSacral Therapy (CST) clients, not only by outlining some of the same principles I use for OT clients, but expanding on that reasoning and those connections.
As an occupational therapist, I have used standardized objective assessments for as long as I have treated. Initially, when I began performing CranioSacral Therapy (CST) treatments I did not use any objective measurements to quantify results/outcomes from the bodywork. I still do not always use objective measurements for my bodywork clients, but the numbers of those who receive treatment from me who participate in at least one objective assessment, are beginning to rise. The reasons for this are many, and include the fact that many individuals who seek CranioSacral Therapy (CST) are dealing with issues that are often difficult to measure. Due to the subjective nature of issues such as chronic pain, headaches, migraines, sleep disorders, neuropathy, etc. progress can often be occurring, yet the client may not always recognize the progress being made because of the hyper-irritation aspect of the nervous system and the lack of integration of the BodyMindSpirit.
Oftentimes, individuals seeking CranioSacral Therapy (CST) have already tried many other types of therapies, counselling, traditional medical routes, herbal alternatives...on and on…and have come seeking relief for a process (or processes) that he/she have been plagued with for months, years, decades or a lifetime. Sometimes, clients tell me they are “trying” CST “as a last resort.” Some individuals begin telling me all about their problem(s) during the initial contact (by phone, text, Messenger, etc., etc.) to schedule an appointment, while others are vague (almost secretive) during scheduling and even during completion of their medical history intake form upon arrival at my clinic. More times than not, and even when the client has been someone who readily divulged their interpretation of the reason for seeking treatment, I discover additional pertinent issues and medical history information during subsequent treatment sessions, and often while the client is on the table, with the client usually stating “Oh, I forgot to tell you about that.” All of this leads me to believe that oftentimes, people do not realize what their real issues are, let alone how to effectively address their real issues, so…why in the world would I think they would be able to realize progress towards issues of which they are unaware? This idea was reinforced for me strongly after I listened to a great webinar by another CST practitioner and CST coach, Sharon Desjarlais, titled “Craniosacral Expansion: Learn How to Complete the Biological Process That Attracts New Clients Who Consistently Invest In Their Deepest Transformation.” During the webinar Sharon stated that clients have no idea what they need, and suggests that the CST therapist should “blend all your modalities into a personal protocol for each client.” This made such great sense to me, and the idea was further reinforced that objective assessments are vastly important when treating the craniosacral therapy client.
I have a medical history intake form that my clients complete at their first visit, and I review the intake form with the client briefly before we proceed to the treatment room. Again, wide variation exists in the completion of this document (which is in constant revision to accommodate new and different scenarios), particularly in the area where I ask the client to identify the problem for which he/she is seeking treatment. However, with some verbal dialogue to complement the written form I am usually guided to identify and select 1 to 2 objective assessment(s) to establish baseline functioning before the client gets onto the treatment table for the first session. Because of the wide variety of objective assessments available, one of the most difficult tasks is narrowing down the best ones that can accomplish the goals of guiding treatment, as well as clarifying objective progress made from that treatment. My intention in writing this article, is that the reader will increase ease in selecting & integrating appropriate objective assessments.
I will use examples from recent clients to illustrate selecting & integrating objective assessments. Client A presented with an initial contact via my website which allows the client to send a message. In her initial contact, she stated she was having sleep issues, and in fact was sending the email during the middle of the night and was currently experiencing back and jaw pain. Upon receipt of this email, I was already able to ascertain the need for objective assessment(s) that would measure pain and sleep, and that the pain assessment(s) would need to measure pain in more than one area of the body. At clinical presentation, the client declared also having 2 mood disorders to include anxiety and depression, that she had degenerative disc disease, and that she grinds her teeth at night. Visually, this client presented with a slumped posture and with her shoulders rotated forward and her chest somewhat caved in. Based on these initial impressions, I chose a back pain assessment called the Oswestry Low Back Pain Disability Questionnaire (1), which is designed to give information as to how back or leg pain is affecting ability to manage in everyday life. So, this questionnaire is a very functionally oriented assessment, which also calculates a percentage based on the answers, and categorizes the levels of disabilities associated with the answers into minimal, moderate & severe disability, crippled and bed-bound. It should be noted that there is also an assessment called the Oswestry Neck Pain Questionnaire that I use frequently also. I chose a posture assessment called the Reedco Posture Score Sheet (2), designed to be an easy to administer tool for diagnosing a patient with poor posture, and is a task performance exam. The patient is observed standing in several predetermined positions and is scored based on 4 posture conditions, forward head, dorsal kyphosis, trunk inclination, and lumbar lordosis. The numeric scale assigns 0-Poor, 5-Fair and 10-Good, with a possible 100 points. Next, I chose the Beck Anxiety Inventory (3), which is another numeric scale that lists common symptoms of anxiety and the client circles the corresponding numbers that equate to how much he/she is bothered by the particular symptoms, with the categories being 0=Not at all, 1=Mildly, but it didn’t bother me much, 2=Moderately, it wasn’t pleasant at times, 3=Severely, it bothered me a lot. The columns of the assessment are totaled and the corresponding sum total analysis indicates if the person demonstrates “very low anxiety,” “moderate anxiety” and “potential cause for concern.” To assess the sleep issue, I chose a scale by Clark L. Jennings, M.D., called the Sleep Assessment Scale (4), which is a 17-item questionnaire that again categorizes sleep difficulties into 5 categories, 0=Not at all, 1=A Little bit, 2=Moderate, 3=Quite a bit, 4=Extreme. The selections are totaled, and I used this scale to more closely determine poor sleep patterns and for discussion with the client for suggestions to remedy poor sleep. Now, I have baselines established for back pain impacting function, posture which may be contributing to pain, anxiety which may be contributing to pain and poor sleep, and actual sleep patterns, which may be contributing to any of the above. After establishing these baselines, I am ready to begin treatment. As treatment progresses, rather than the client only identifying that he/she “feels some better,” “thinks he/she may be sleeping better,” and/or “thinks he/she may be having less anxiety,” I am able to facilitate the client’s objective and measurable outcomes by performing reassessment(s) and the client becomes mentally aware of positive outcomes in a most productive way—functionally, emotionally and spiritually. In this way, the client is also able to identify progress, which is extremely gratifying and empowers the client to further invest in good health practices.
Other recent clients have presented with cognitive impairments. Many excellent cognitive assessment(s) exist, which are far too many to mention in this short article, but I will mention a couple that I frequently use due to the ease of administration, as well as functional information given from the results. My favorite is the Allen’s Cognitive Levels (5), of which there are many types of assessment kits and programs available. This program was developed by Claudia Allen, who is an OT, and the reason it is my favorite is because it focuses on remaining cognitive abilities rather than disabilities. I frequently use the LACLS, which is the Large Allen’s Cognitive Level Screening a/k/a the “leather lacing.” This assessment measures attention, sequencing, problem-solving and safety awareness—all important aspects of safe cognitive functioning. Another short cognitive assessment that is a brief screening scale is the Short Blessed Test, which is a 7-item question/answer scale. This is a screening test to determine the possibility of early dementia processes, and the interpretation states that although it is highly predictable of early processes, it is a screening test which should be followed by more extensive testing when scores determine Questionable Impairment and/or Impairment consistent with dementia. I have found this screening assessment to be extremely reliable and valid when followed by more extensive testing.
In summary, objective assessment(s) are numerous and readily available for each and every type of client presentation, and I am continuously finding new ones as different diagnoses, syndromes and other labels are advancing. The key to selection is to determine the client’s needs for functional progress, then allow the assessment(s) to guide the client observations and experiences, while the craniosacral therapy process unfolds. And---stay grounded, neutral, curious….and have fun while doing so.
1. Hudson-Cook, N., & Tomes-Nicholson, K. (1988). The revised Oswestry low-back pain disability questionnaire. Bournemouth, Eng.: Anglo-European College of Chiropractic.
2. Reedco Posture Score Sheet. (n.d.). Retrieved from . www.greatseminarsonline.com/course_documents/gait/scale.pdf
3. Beck, A. T. (n.d.). An Inventory for Measuring Anxiety: Psychometric Properties. Retrieved June 4, 2017, from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.471.4319&rep=rep1&type=pdf
4. Sleep Assessment Scale. (n.d.). Retrieved from http://www.jenningspsych.com/downloads/SleepratingformV2.pdf
5. Allen, C.K., Austin, S.L., David, S. K., Earhart, C.A., McCraith, D. B, & Riska-Williams, L. (2007). Manual for the Allen cognitive level screen-5 (ACLS-5) and Large Allen cognitive level screen-5 (LACLS-5). Camarillo, CA: ACLS and LACLS Committee.
6. Katzman, R., Brown, T., Fuld, P., Peck, A., Schechter, R., & Schimmel, H. (1983). Validation of a short orientation-memory concentration test of cognitive impairment. American Journal of Psychiatry, 140, 734-739.