Holistic Assessment – The next step in the development of Bowen Therapy

Holistic Assessment – the next step in the development of Bowen Therapy : As Published in ‘In Touch’, the quarterly, in-house journal of the Bowen Therapist Professional Association (BTPA), U.K. May, 2013

Graham Pennington N.D., Grad Dip (Acupuncture)

Graham is the principal of Warrnambool Natural Medicine Centre in Victoria, Australia.  He has practiced Bowen Therapy, Naturopathy and Acupuncture for more than twenty years. He is the author of A Textbook of Bowen Technique – A Comprehensive Guide to the Practice of Bowen Therapy.

INTRODUCTION 

In 1986, Oswald Rentsch commenced what was to be an amazingly successful campaign to promote and teach his personal interpretation of Tom Bowen’s approach to therapeutic bodywork.  Although Rentsch has undoubtedly succeeded in placing ‘Bowen Technique’ on the map of remedial bodywork, this success has come at a cost.  Rentsch’s interpretation has come to be viewed as representative of the way Bowen actually worked[1], yet there is ample evidence that this is not so.

Whether or not Rentsch’s systematised, recipe version of Bowen Technique serves to illustrate the majority of Bowen’s moves and procedures is debateable but it is certain that the repetitive, sequential application of learned procedures is not indicative of Bowen’s approach.

One of the major differences that exists today, between the clinical approach used by Tom Bowen and those who follow a derivative of Rentsch’s approach, is that the latter do not apply the therapy in accordance with a system of holistic assessment.  Applying the recipe style of treatment is a symptomatic approach: no holistic assessment is required and the therapist administers a similar treatment to each case, regardless of individual presentation.

If we are to remedy this situation the Bowen Therapy profession must embrace holistic assessment methods.  This involves a simple addition to the existing knowledge base – an addition that enables the therapist to customise each treatment according to individual presentation.  In this way, every treatment varies because it is targeted to the needs of each patient.  Of course this approach leads to better clinical outcomes.

BACKGROUND

Tom Bowen left no formal training notes about the type of therapy he practised.  To understand and define it, we must rely on accounts of the people who claim to have watched him work.  It is widely acknowledged that at least six men claim to have done so over the twenty-three years he was in practice (1959-1982).  Interestingly, each of those who observed him developed a different interpretation of his work.  Oswald Rentsch, has taught his interpretation widely, whilst others have only taught their interpretation of Bowen’s work to a handful of practitioners.  Consequently, a Bowen industry has emerged where most published authors and treating practitioners have been exposed to only one individual’s interpretation of Bowen’s work.

At least two of the six men who observed Bowen have publicly rejected the recipe style approach.  Instead, they use a style of Bowen Technique in which treatment is applied based on a holistic assessment of the patient and is targeted to specific dysfunction, in accordance with individual presentation.  In addition to making a holistic assessment of each patient, they apply the Technique in a holistic manner, recognising some of the complex interrelationships existing within the body.  They also use reassessment techniques to measure the effectiveness of their treatments as they apply them.

Questions are now being posed regarding the basic assumptions of those teaching the popular recipe style of the technique.  Romney Smeeton, a chiropractor, and one of Bowen’s observers in the seventies and early eighties, writes

‘I should state I am at odds with much of the current teachings of Bowen’s work, primarily because they lack a system of individual assessment and are nearly all based on a systematized use of standardised recipes and this was not Bowen’s approach’.

Kevin Ryan, an osteopath, and another of Bowen’s observers, told the BTFA (Bowen Therapists Federation of Australia) conference in 1998 that Bowen based his treatment interventions upon his assessment of the patient and that

‘Tom Bowen never did a move unless he had an expectation of what effect it would produce.’

Interestingly, according to the transcript of proceedings of the Committee of Inquiry into Osteopathy, Chiropractic and Naturopathy, in 1973, Tom Bowen said, ‘I average 65 patients per day’.  This allowed him around five minutes for the treatment of each patient.  The recipe style of treatment widely taught and practiced today simply cannot be applied in this time frame.  It is clear that Bowen did not routinely apply the recipe style approach that currently bears his name.

HOLISTIC ASSESSMENT

Many Bowen Therapists can and do perform assessments of isolated muscle groups or individual joints, much like a physiotherapist or a myotherapist.  These assessments are helpful in providing a baseline level of function from which to measure progress, but they do not embrace holistic principles, or encourage therapists to view the body as a complex interrelated whole.

A holistic assessment is one that assesses the body for areas of dysfunction from a systemic viewpoint.  Holistic assessment procedures allow the body to be viewed in its entirety, allowing the therapist to assess central nervous system (CNS) function, for example, whilst simultaneously recognising some of the complex interrelationships which might influence it.  Importantly, it allows the therapist to identify primary sites of dysfunction rather than secondary sites – applied in this context, treatments are less ‘symptomatic’.

The few Bowen Therapists who do use such an assessment techniques claim it enables the Bowen treatment to be targeted and goal-directed.  Treatment goals can be assessed along the way, thus the use of holistic assessment procedures can help to achieve better clinical outcomes.

Holistic Assessment – Discussion

If the Bowen Technique is a holistic therapy should it not embrace holistic assessment methods?  A holistic profession is one that recognises the body as being ‘more than the sum of its parts’.  A holistic profession is one that recognises the importance of complex interrelationships that exist within the body.   Osteopathy is such a profession.  We know that Bowen called himself an osteopath and he did so because he embraced the underlying principles of osteopathy (and these are certainly holistic[2]). By utilising the recipe approach to treatment, some Bowen Therapy practitioners may be ignoring the very principles upon which the technique is founded.

The good news is, holistic assessment techniques can be easily learnt and applied to provide a more targeted, effective, goal directed Bowen Therapy.

Holistic Assessment – Techniques

At the beginning of every treatment Tom Bowen made an assessment of tonal symmetry on each patient.   All Bowen Therapists still do this at the beginning of every treatment although many of them may not realise they are doing it.  A general rule that all therapists learn is that a treatment should always be commenced with Moves 1 & 2 of the Lower Back Procedure – the reason for this is to assess tonal symmetry.

Tonal asymmetry is an expression of the patient’s dysfunction[3], so as therapists, our first objective must be to identify the side of ‘tightness’.  The tight side is synonymous with the side of the functional short leg.  The functional short leg acts as a signpost pointing the therapist to the dysfunction that is the source of the patient’s problem.  A simple premise applies here: if we exert an influence upon that dysfunction, then the short leg will change.

The use of simple tonal assessment methods allows the therapist to identify relationships within the body and to measure the effectiveness of any therapeutic input.  For example, if there is a functionally short right leg that does not change after the piriformis move, one can assume the patient’s dysfunction is not associated with piriformis.  If the leg length corrects following the Temporomandibular Joint (TMJ) Procedure, one can recognise the patient’s dysfunction was associated with the TMJ.  Indeed, one could use this method of ‘move and re-assess’ to determine whether any individual move in the TMJ Procedure (or in any other procedure) had actually corrected the dysfunction.  For the therapist, such a process is both educational and empowering.

Recognition of Interrelationships

Tom Bowen was, like many good therapists, aware of interrelationships which existed between different areas of the body.  Those who watched him work have claimed he attributed special significance to a few areas of the spine.  The notion expressed is that Bowen placed particular emphasis on restoring function to the sacroiliac joints, the coccyx, the cervical spine and the TMJ[4]. Bowen understood that a patient’s sciatic pain could be related to TMJ dysfunction and that the patient’s migraines could be related to coccyx dysfunction[5] etc.  The significance of this for the Bowen therapist is that a patient’s primary dysfunction can be quite a long way from the site of symptoms, thus making the need for holistic understanding and assessment even greater.

Screening Procedures

As therapists, some of these interrelationships can be used to our advantage through the use of some simple screening procedures.  The Cervical Turn Test is one example.  Once a functional short leg is identified, the therapist can have the patient turn their neck to the left and then reassess the functional short leg.  The process can be repeated with the patient turning the neck to the right.  If the patient’s tonal asymmetry is associated with a problem in their neck, turning the head to one side should result in a correction of leg length.  When this test returns a positive finding the therapist can confidently focus on locating and correcting the problem in the patient’s neck – this is the case regardless of whether the symptom presentation is idiopathic knee swelling, headaches or asthma.

There is also a useful screening procedure to indicate sacroiliac joint dysfunction.  The Sacroiliac Joint Test[6] is carried out with the patient prone.  The short leg is identified and the patient’s knees are flexed to ninety degrees.  A positive test result (indicating sacroiliac dysfunction) is found when the short leg crosses over and becomes the long leg.  A positive indication of sacroiliac dysfunction would then send the therapist in search of the appropriate treatment (possibilities include piriformis move, sacroiliac procedure, pelvic procedure etc.).  Reassessment could then be used to confirm restored sacroiliac function.

Holistic assessment techniques used in four cases of right sided hip pain

The following case studies serve to illustrate the principle that symptom presentation does not give a good indication of the source of dysfunction.  Dysfunction in one area of the body can lead to symptoms in another area.  These principles were well understood by Bowen.

Case 1:  A 62 y.o. male patient presents with a ten day history of right sided hip pain.

This patient reports significant discomfort in his right hip following recent gardening activities.  Lying prone the patient is assessed and the right leg is found to be functionally shortened.  Moves 1 & 2 of the LBP are performed and the right paraspinal tissue is found to be tighter than the left. Screening demonstrates a positive Derifield finding.  The therapist administers a move to the left piriformis muscle to assess its tenderness (using this as a control) and then the same move is applied to the right piriformis.  The patient reports increased tenderness on the right side.  Immediate reassessment indicates a return to almost equal leg length.  A two-minute wait is applied followed by reassessment.  Tonal symmetry has returned and leg lengths are now equal.  There is no longer a positive Derifield finding.  Follow up in one week reveals the patient was significantly improved following the treatment and has been completely pain free for the last 5 days. Assessment at follow-up reveals tonal symmetry indicating no further treatment is necessary.

Case 2:  A 22 y.o. male patient (a football player) presents with a five week history of recurrent right sided hip pain which is worse with exertion and gets better with rest.

Moves 1 & 2 of the LBP are performed and reveal elevated tension in the paraspinal tissue on the left side.  Tonal asymmetry is assessed revealing a functionally short left leg.  Screening reveals a positive Cervical Turn Test.  Realising the patient has a primary issue affecting his cervical spine the therapist moves quickly through the Lower & Upper Back Procedures (no waiting necessary) and turns the patient.  Tactile assessment of the neck reveals significant spasm on the right side from the level of C1 – C4.   Moves of the Neck Procedure are used to address this spasm and a two-minute wait is employed.  Upon reassessment, tonal symmetry is evident.  Follow up in one week reveals the hip pain has significantly improved following the treatment and the patient reports he has successfully completed a training session since the treatment.  Assessment at follow-up reveals minor functional asymmetry which corrects upon cervical rotation, indicating some further treatment is necessary.

Case 3:  A 17 y.o. female patient presents with a two month history of recurrent right sided hip pain which is worse with exertion and gets better with rest.

Moves 1 & 2 of the LBP are performed and reveal elevated tension in the paraspinal tissue on the left side.  Tonal asymmetry is assessed revealing a functionally short left leg.  Screening is unremarkable.  The therapist moves thoroughly through the Lower & Upper Back Procedures ‘searching’ for abnormal tensions that may be associated with the presenting asymmetry.  No such tensions are identified and therefore no waiting periods are necessary.  Upon turning the patient, tactile assessment of the neck reveals nothing abnormal.   Suspecting an adductor issue, the therapist compares the tension of the left and right adductors, finding the left to be in a state of tension.  Moves of the Pelvic Procedure are used to address the adductor after which a two-minute wait is employed.  Upon reassessment, the patient demonstrates equal leg length. Further enquiry reveals the young patient is an avid horse rider who regularly competes in dressage events.  She is counselled on looking after her adductors. Follow up in one week reveals the hip pain has significantly improved following the treatment but some asymmetry remains.  Further treatment is required.

Case 4:  A 40 y.o. female patient presents with a ten day history of right sided hip pain.

This patient reports significant discomfort in her right hip which began several days after planting 60 trees.  Lying prone the patient is assessed and the left leg is found to be functionally shortened.  Screening procedures are negative.  Tactile assessment reveals tension and tenderness of the paraspinal areas on the right side of the first lumbar vertebrae. The therapist administers Move 1 of the Psoas Procedure[7] to the right paraspinal tissue and immediate reassessment indicates a return to almost equal leg length.  The Psoas Procedure is completed and a two-minute wait is applied. Upon reassessment tonal symmetry has returned and leg lengths are now equal.  Follow up in one week reveals the patient was significantly improved following the treatment and has been completely pain free for the last 3 days.  Assessment at follow-up reveals functional symmetry indicating no further treatment is necessary.

FUTURE DIRECTIONS

The recipe system may have placed Bowen Therapy on the map but it is self limiting.  As each patient presents, rather than using our own intelligence to solve their problems, we are urged to work in robotic fashion, following strict predetermined treatment protocols.

The future of Bowen Therapy lies, not in the repetitive application of learned procedures but in processes which enable the therapist to identify dysfunction, guide the intelligent application of treatment and then confirm that the treatment was effective in restoring function. Such processes must be heavily focused upon holistic methods of assessment.

Thirty years have passed since Tom Bowen left his legacy in our care. It is now time for the profession of Bowen Therapy to move forward and adopt holistic assessment techniques.