#14 - Quadrant Movement Analysis - Taming the Clinical Grey Area With Dr. Pape, Part 1

Factor, spelled F-A-K-T-R, stands for Functional and Kinetic Treatment with Rehabilitation. Over the past decade, this unique approach to treating pain and dysfunction has been utilized by healthcare providers on 6 continents. Serving as a framework that guides clinical decision-making in patient visits around the globe on a daily basis. With this podcast, our goal is simple: to bring the best and brightest in clinical education to the forefront and empower practitioners with cutting-edge, evidence-based content that improves patient outcomes and inspires healthcare providers to continually evolve their approach to treatment. In each episode, we will feature a training or interview with some of the top minds in healthcare. In a short format that is easy to digest, with actionable information that you can implement into practice right away. Let's get started. Hi guys, welcome to a new episode of The Factor Podcast. I'm your host, Jessica Riddle. If this is your first time tuning in, welcome and thanks for listening. In today's episode, we feature a brand new training titled Quadrant Movement Analysis. Taming the Clinical Gray Area with Dr. Rob Pape. Dr. Rob Pape is a longtime innovator in clinical evaluation and treatment instruction. He created Quadrant Analysis, which combines a subclassification system with theoretical-practical biomechanics. Quadrant Movement Analysis, as it's formally called, improves and simplifies patient assessment, breaking the body down into traceable patterns that chiropractors can then utilize to get better and faster patient results. Dr. Rob is a 1996 graduate of Life Chiropractic College West and has been in successful practice ever since. His clinical approach is full body and generally combines joint and soft tissue work with movement therapy. So what exactly is quadrant analysis, you might be asking? Well, to put it simply, QA is a framework that practitioners can use to collect data for problem solving. From as many angles as possible. Now, anyone in clinical practice can attest to the fact that there are often many contributing factors for a patient's pain or dysfunction. With quadrant analysis, you have a framework for assessment that assists you in zeroing in on where to begin with treatment, and then how to continue triangulating these different data points throughout your process of reassessment so that you can adapt your treatments as necessary. If it sounds like this is a great tool that you can use in practice, stick around. This 2-part training is a goldmine of great information. Let's dive in.

First of all, I'm really happy to be here. Thank you to the good folks at Southeast Sports Seminars for having me. It's an honor, quite honestly, to work with them. Secondly, I hope everybody is safe and healthy during this incredibly weird time, and it's very weird to be talking to you through this box. I know you're out there, and I'm talking to you through this box at this time. I look forward to us all being able to get together in person like we did in the before times, right? Anyways, for today's talk, we're going to be talking about quadrant analysis, or sometimes we call it quadrant movement analysis. And we're going to be talking about it because there are a certain amount of continuing education units going up with the Southeast Sports folks on their site. And so we want to give you a preview of what it is so you understand it. And if you're into it, cool, then you can take some of the courses, right? So here we go. Let's see if this works. Boom. So come on along with me and let's see what we get. So our learning objectives for today. Are that this is a subclassification system that we're looking at. It combines practical mechanics and a subclassification system. That's the basics of quadrant analysis. There's also this buried treasure map to find what we call villains. Villains are those areas away from the area of chief complaint that might be driving the chief complaint. So those are the 3 main things that we want to go over today. That's not the All of quadrant analysis, but it's the big meaty parts. I think the best part of this— I'm going to hopefully give you quality throughout this 40 minutes and then the period afterwards for questions. Hopefully you'll get some nuggets along the way. I want this to be practical for you. I want you to be able to take at least a couple of things away from this that will change the way you think a little bit and change the way you work a little bit. Maybe when you go back into your— into treatment assessing this afternoon, Or tomorrow, or whenever it is that you're back at work. About me. So I've been doing this, I'm going into my 25th year as a chiropractor, practicing the whole time. I've taught a bunch on the side, and I've taught this quadrant analysis stuff for a couple of years now to small groups. I've been sort of beta testing it all the way along. I came out of Life West, right? And Life West looks like that and that. That's all I came out with. I was a good adjuster coming out of school, and I don't want to poo-poo adjusting because it's an amazing tool to have. If you don't adjust, well, then you're missing that tool. But what I found was trying to close that safety pin on folks, maybe 30, maybe 40% of the people that I was seeing that first year out in school, I was getting them where they wanted to be. They told me in school, find it, fix it, leave it alone, and everything's going to get better. Well, that's not really how it works, and you probably know that if you're watching this. So I realized pretty quickly that I was evidence-based. I wanted to see my people getting better in real time. I wanted to see their goals being achieved in real time, and I wasn't seeing that so much, and I had to figure out what I was missing. And this is the mid to late '90s. This is before the internet. This is before we had all of this. I couldn't just get online to a community and look stuff up. I was working in Oakland, California, which just had a bunch more people from Life West around me. I didn't know where to go, what to do, who to look to. So I just started reading a bunch of books from different professions and collaborating with different professionals to try to figure out what they were looking at. And if this GIF would work, and it's not going to, it would say that we were looking for data. I needed to figure out what data I needed to know In order to improve my chances of getting my patients better and getting them to reach their goals. And that in the end is what quadrant analysis is. I've spent the last 5 or 6 years trying to codify it at the request of a student who came to see me in my practice one day. He's watching me, he's like, look, man, I've been shadowing lots of docs. That's what I do. I try to shadow somebody at least once a month, a couple of times a month. I've been shadowing people in school. I don't know what it is you're doing, but could you teach that? And I went, well, yeah, probably. Which was probably the dumbest thing I've ever said. Because trying to reach inside your brain and figure out what it's doing and watching yourself do it, not as easy as it sounds. It was not a comfortable ride along the way to watch myself do my own work and then try to codify it, write it down. But I did. And here we are. And I think it's pretty interesting stuff. I think, look, most of it, 99% of it, is stuff that I've taken from other people, right? We all have mentors. We all have people who've taught us. I've just packaged it in a way that hopefully— when I packaged it, I was thinking really about the new practitioner coming out of school. School helps you pass the boards. You get out of school, you're thrown to the wolves. You get out of school, most chiropractors— I mentor a lot of young chiropractors, and the words I hear are, I feel like a fraud. I feel like I have to fake it. I don't know what I'm doing. I've made a big mistake, blah, blah, blah. We've all been there. I was there that first year in school too. We're all there those first few years. Hopefully quadrant analysis packages things together and gets you to think in a different way so that you can start to see pattern, patterns in terms of your patient presentation, patterns in terms of mechanics, and you can use those patterns, that pattern recognition to make better decisions. We had titled this the Taming the Gray Area. I just got an email from, I practice in New York and I got an email from one of the district board groups there and they're having the president of LifeWest come and speak to them or by Zoom in their next meeting. And the taglines, the things that they were saying to get you to register for this were, get clarity and get certainty. And what I'm here to tell you is there ain't no clarity and there ain't no certainty, not 100%. It just doesn't exist. Schools should be teaching us to embrace uncertainty, that n equals 1, that gray area. If you can get comfortable in the gray area, if you understand the right questions to ask, That's where you're gonna find your success. That's where we live, really. And the fact that we're trying to teach on one end this just adjust and everything will get better, that's crazy to me. And again, I love adjusting. I teach adjusting. I'm good at adjusting. I think it's an amazing tool. I think it's the most powerful tool I have in my kit, but it's just one tool. But then we have this other end of the profession. When I finally connected with chiropractors online through FTCA and other groups, what I found was that on the evidence-based side, There was this— if we're not diagnosing a medical issue and then applying a treatment protocol to it, then we're not doing things right. Like, that's the other extreme end. And good stuff on both ends, but most of where we live is in the middle. And if, if that pop and pray doesn't work, and if that cookie-cutter strategy doesn't work, that, that treatment protocol strategy doesn't work, what are you doing? What are you left with? And hopefully quadrant analysis helps you to bridge that big chasm in our profession. People ask me, they're like, so this is like a technique where A leads to B leads to C? No, it's not a technique. I am not a technique person. This is the opposite of the technique, quite honestly. There are no rules to this. Quater Analysis has no rules. It is a thought framework. It will help you to think a little differently, hopefully. And that is at the end of the day, if you get one thing out of this, hopefully it changes your thinking a little bit. And to the new docs, what they taught you coming out of school hopefully is working for you out in practice. But you need to have a thought framework, you need to have a way of processing information with your patients. And quadrant analysis is one example of that. There's plenty of examples of it out there, I'm sure. This is just one way. And I'm not saying my way is the only way or the right way or the best way. It works for me, it works for the people I've taught it to. So your mileage may vary. And that guy would dance. That would be a dancing guy if we had GIFs. Overarching idea with quadrant analysis is it's concepts over rules. It is malleable, fungible, changeable all the way along. It's kind of like when Bruce Lee talked about martial arts towards the end of his career. He's like, yeah, you got to study all the forms. You got to study all the katas. But in real life, those things fade away and you've got to apply all of them in the moment and potentially move in and out, blend them together, change from one to the other or make up your own. So hopefully when you understand the concepts, and I think most docs who have been out in practice for at least a few years, whether you know it or not, you have this, you're doing this to some extent. You might have some holes in it. I know I still have holes in mine. I'm 25 years out. I learn new things all the time. But if you're building your concepts into a framework, then you have a way to flow in and out. If you have 10 different patients who come in with the same sort of presentation, the same chief complaint, you might need to do 10 different things with them. So that just adjust or cookie-cutter approach, it's only going to get you so far. It might— maybe it'll work really well with 3 or 4 of them, but what do you do with the other 6 or 7, right? So having concepts driving your game, driving your analysis, driving the way you treat and retest, this is an important thing. What I'm teaching you It should not supersede anything that you already know. If you understand the things that Quadrant Analysis is trying to show you, then you just seamlessly blend it with what you already know. In our profession, and we might have physical therapists, I have massage therapists, trainers who utilize this stuff. My wife is a personal trainer. She's got her master's in exercise science and rehab. She uses Quadrant Analysis. She uses it in the most movement way possible. This is fungible, like I said, and it should blend with what you already know.

Today's episode is brought to you by Southeast Professional Education Group, formerly known as Southeast Sports Seminars. For over a decade now, we've been pushing the envelope to raise the bar on professional continuing education within the healthcare space. If you like what you hear in this episode, I encourage you to continue your learning with Dr. Pape's virtual Quadrant Analysis of Movement course. This curriculum combines a subclassification system with practical biomechanics to simplify patient assessment. In this course, you'll learn to break the body down into traceable patterns, which you can then utilize to build a successful treatment plan. CE credit is available for chiropractors and physical therapists in many states. Please visit online.sports-seminars.com for details or visit the sponsor link in our show notes.

Oh, I miss GIFs. So another thing that people ask me about Quadra Analysis right off the bat usually is, well, when is it appropriate to utilize this analysis? And the answer is, it depends, right? N equals 1. I utilize aspects of this with all of my patients, every single one. But with an acute antalgic lean lumbar disc patient, how much data am I getting from this and how much of this evaluation can I do with that person versus somebody who has a chronic low back problem that doesn't seem discy and isn't antalgic. The world's a difference. So it could give you a very little bit of data and a very little bit of it may apply, or it could give you everything you want to need and everything— there's a spectrum. It will give you data points that you have to decide are appropriate to look for. Based on what your patient is presenting with. So again, QA, quadrant analysis, quadrant movement analysis is 3 things. It's a subclassification system. We want to subclassify our patients and try to put them in the right little box to see if we can start in the right place with them. The subclassifications are as follows: something we call pattern breaks that we will go over a little bit later, hypermobility and hypermobility-related disorders, which we should know about. Abdominal, which is in quadrant analysis, sort of systemic inflammation sub-classification. Motor control, dynamic stability, and then straight-up mechanical dysfunction. Quadrant analysis tries to define mechanical dysfunction in ways that are very practical, very applicable. If you ask people what mechanical dysfunction is, you'll probably get a bunch of different answers. You know, most of the time in our world, it's a stuck spot, right? Well, why is it stuck? How is it stuck? What's going on with the muscles, with length-tension relationships and these types of things? Quadroanalysis is going to try to explain that a little bit more practically. And there it is, practical mechanics. Honestly, as a chiropractor and someone who works alongside acupuncturists, dietitians, trainers, co-managers with physical therapists and medical doctors, some of us in these professions should really be owning mechanics. And my personal bias is that we should understand movement and we should be able to use our hands to assess mechanics passively better than anybody else. And when you own these practical mechanics from a quadrant analysis standpoint, honestly, you have unlimited treatment possibilities. I will never tell you how to do anything. I will tell you how I do things, maybe give you examples, and we can certainly chop up possibilities. There's no one right way to do the thing. If you understand the mechanical situation in front of you, if mechanics matter in this patient presentation, if they're the thing you have to address, which is a whole nother question, right? Mechanics aren't always primary. We know that. Sometimes they're secondary, sometimes they're tertiary. But if you're going to address mechanics, you should be able to come at the thing that you're trying to address and affect a dozen different ways. At least you should be able to reason those ways out. They should make sense to you. And then the third thing, the buried treasure map. Now this is the pattern breaks. Back in when I was in school, I remember the old-timey chiropractors, they'd say, well, and the old-timey chiropractors to some extent were a lot more like, I think most manual therapists combine a little bit of movement therapy chiropractors are today. The old-timey chiropractors weren't, at least the ones I knew back in California, a lot of them were really smart and thoughtful and they were trying to figure out how to get people well as fast as they could. They knew that people mainly came to them for musculoskeletal injuries, and they were trying to get people better, out of pain, moving better, as fast as they could. But they would talk about trying to find that primary subluxation. And I don't mind the word subluxation. I don't care if you use it, if you call it mechanical dysfunction. I tend to call it mechanical dysfunction because I talk across professions, but subluxation, chiropractic subluxation, same thing to me. Dr. Todd Riddle wrote this really cool essay About— and this is kind of how I was introduced to him, I believe— about trying to find the villain instead of treating the victim. It's a insightful essay. And from my standpoint, the villains— when I read that, I went, oh, he's talking about what I call pattern breaks. And so we'll talk about pattern breaks a little more as we go along here today. And here's the goal. This is always the goal for me. I'm playing a game with myself. I'm trying to solve puzzles. I'm trying to get people where they want to be as quickly as I can get them there. And I'm trying to increase my odds of success at all times. It keeps me interested. It keeps me loving what I do. The gray area is, is the best part of being a chiropractor to me. The best part of being a practitioner. I don't want certainty. I want to have to figure out the details that get me to the end result that works for my patient. That's the best part. So this gray area is everything. Here is a picture of part of an infographic we have for quadrant analysis subclassifications that will be in the course. And again, why subclassify? Here's my thing about subclassification that I think this describes it as best as possible from my standpoint. I love medical diagnosis. I sucked at it for a really long time. I'm pretty good at it now. Not nearly as good as some of you, I'm sure, because I didn't come from that world. But a medical diagnosis is telling me what's happening. It's gonna be a picture of the end stage of a process. I wanna know how that process came about. I wanna understand the physiology and the mechanics that led to that end stage boo-boo that we are calling this thing, this medical diagnosis, right? Medical diagnosis is helpful, but it doesn't tell me how to treat the thing. 'Cause again, 10 people can come in with the same medical diagnosis and I might need to do 10 different things. So the subclassification— why do I subclassify? Because I want to have something actionable. And just having a medical diagnosis from my standpoint isn't actionable enough. I need more information. And again, here are the subclassifications: pattern breaks, hypermobility, abdominal, which is the systemic inflammation one, motor control, and mechanical dysfunction. Here is a really bad picture of the evaluation form that I offer here in Quadrant Analysis. Again, this evaluation form is malleable. It is fungible. If you're a rule follower and you want to follow this as rules, go for it until you understand it really well, and then you'll change things up. Dr. Liebensohn is famously quoted as saying, and I don't know if this was his or he took it from somebody else, but I've heard it from him more than anybody else, He says every movement is a test. That's true, every movement is a test. And if you understand the concepts that underpin what this evaluation is doing, then you can change up the movements to create new tests. Easy enough, right? And then down below here, we have some very general treatment considerations. So for each evaluation, for each test, I give you, well, if you find this, you might consider doing this. If you find that, you might consider doing that. So it gives you a little bit of like a head start in Oh, well, Apley's 1 was really decreased on the right side versus the left side. Let me see what Rob says maybe he would do there. And again, general, very general, not rules, possibilities. Here is another schematic from the coursework. This is our workflow with starting ruling out red flags, evaluating for yellow flags. If there's some mechanical possibilities here, we evaluate, blah, blah, blah. And then it gives you the flowchart of How I tend to sometimes prioritize the subcategories or the subclassifications. Again, not always. Sometimes. It's just an idea. And then with some possible treatment approaches at the bottom. Some ideas. All right. So now let's talk about pattern breaks. Pattern breaks are areas of abnormal dysfunction within normal dysfunction patterns. And we'll talk a little bit about normal dysfunction patterns coming up here in a second. But mechanical dysfunction is normal. We'll start there. There is a normal type of dysfunction that we'll see. And then there are outliers from that normal dysfunction, abnormal dysfunction. Pattern break might be that. It's oftentimes an area where somebody had pain previously and it just went away. And very often they do not check this off on their intake form. Honestly, the subclassifications, they exist mostly because people don't check things off on their intake forms. Right. You'll get a lot from history, right? You'll get 80, 90% from history with a lot of people. But some people, when they go to the chiropractor, they're like, oh, I just came to get my back cracked. They don't know who you are necessarily the first time. They don't know what you're looking for. So the subclassifications exist to make up for, to some extent, the fact that they're not going to give you everything on the form. So yeah, where pain just went away before. Oh yeah, doc. You find this area of dysfunction, you ask them about it. I used to have pain there. It was really bad for like I don't know, about 2 months. And then it just went away. And you go, well, did you get treatment? Did you see anyone?

No, no, no.

It just went away on its own. Hmm. Okay. That's a clue. Oftentimes, and most commonly, pattern breaks are what we call packed on evaluation. The muscles are short. The soft tissues have shortened up on both sides of the joint. That's the classic pattern break presentation. There are other pattern break presentations, but that's the classic one. And again, these are the potential villains to the victim that is the chief complaint.

All right, guys, that's all for today's episode. Be sure to tune in for part 2, where Dr. Pape will discuss patterns of mechanical dysfunction and how they can lead back to the chief complaint. We will also discuss short muscles versus long muscles and explore what pattern breaks are and why you should pay attention to them. You won't want to miss it. Episode 15 drops in 2 weeks, or 1 week for our Patreon subscribers. You can subscribe to The Factor Podcast on Apple, Spotify, iHeartRadio, or the podcast app that works best for you. Please be sure to give us a 5-star rating to help us grow the show. Every little bit helps. And last but certainly not least, please also visit the show notes for a link to download the PDF of today's full presentation, As well as get more information about Dr. Pape's Quadrant Analysis of Movement online course. We'll see you next time. Hey guys, if you like what you heard today, I encourage you to visit our website at factor-store.com. That's spelled F-A-K-T-R-store.com to find out more information about all that we have to offer. We have a variety of online offerings as as well as our hands-on Factor Rehab System course scheduled in cities around the globe. Be sure to also check out our event calendar and bookmark any of these upcoming live webinar dates coming up in the near future so you can join us live. And of course, the biggest compliment we can receive is for you to help us spread the word to your friends, colleagues, and classmates. You'll find all the important links as well as info about our sponsors in the show notes, so be sure to check those out.