Chapter 2 Naturopathic diagnostic techniques
INTRODUCTION
The diagnostic process should flow from an extensive case history and physical examination to a differential diagnosis that lists possible alternatives for the presentations within the patient. An awareness of different types of pathology that may lead to particular signs and symptoms will assist the naturopath to narrow down the list of possibilities and select the most likely hypothesis.1
Further investigations, including pertinent biochemical evaluations, should then be performed to point to a more definitive diagnosis. This diagnosis, along with any other health issues that may have presented during the investigation, should all be used to address a patient from a holistic perspective and develop an adequate management plan. Clinical methods of diagnosis are best used in combination, and when interpreted alone possess definite disadvantages. Physical signs in conjunction with dietary and biochemical methods may provide a clearer picture of the physiology or pathophysiology at play in each individual. This chapter provides an overview of a variety of physical examination techniques such as anthropometric data, body signs and symptoms, gastrointestinal palpation and iridology, as well as an outline of dietary assessment methods and biochemical evaluations via a variety of pathology testing methods. Some of these types of assays have robust scientific bases, while others that have not been so extensively studied have
been included as an overview of available techniques. The chapter then concludes with some useful traditional Chinese medicine analytical methods that have been adapted for naturopathic diagnostic purposes. A section on factors that affect nutritional status has also been included as a tool to assist with identifying potential confounding variables that should also be taken into consideration.
EVIDENCE-BASED CLINICAL DIAGNOSTIC TECHNIQUES
Physical examination
Naturopathic physical examination should be systematic and precisely recorded, while relating particular signs to standardised definitions. Assessment of a patient begins as soon as the consultation starts. A person’s disposition, facial complexion and expression, body size and shape, mobility, gait and posture, as well as the way they conduct or hold themselves, may provide important clues in relation to their mental and physical states.1 A general inspection of the whole body may reveal external evidence of a disease, for example obesity, wasting, arthritis, abnormal stature or development, presence of pain, jaundice, pallor or cyanosis.2
Warm, sweaty palms on the initial handshake may indicate an overactive thyroid due to increased circulation with blood vessel dilation. In contrast, an underactive thyroid may cause the hands to be cool and dry in texture.3 Persons with alcohol dependence may attempt to conceal their addiction; however, certain signs may provide indicators such as plethoric faces, rhinophymic noses and alcoholic aroma. Smokers may also be revealed by their scent or nicotine-stained fingers. A person’s facial expression may portray psychiatric illness such as depression, while conversation may alert to an anxiety disorder. In developing countries, malnutrition with subsequent wasting and loss of weight is a relatively common occurrence; however, when these signs appear in more developed populations, naturopaths should be alerted to potential underlying pathological conditions such as diabetes, thyrotoxicosis, malabsorption syndromes or chronic infections.4
Anthropometric data
Height and weight should be determined to assess if a person is over- or underweight. Waist to hip ratio (WHR) is the most useful predictor of cardiovascular disease mortality while body mass index (BMI = weight (kg)/height (m2)) may be a better predictor of increased mortality from raised blood pressure (see Table 2.1).5
Table 2.1 Data that predict increased mortality from cardiovascular disease and raised blood pressure5
| FEMALES | MALES |
|---|---|
| WHR > 0.8 | WHR > 0.9 |
| Waist circumference of > 88 | Waist circumference of > 102 |
| BMI > 25 | BMI > 30 |
Some form of body composition analysis, whether via skin fold or BIA, should also be performed to determine lean mass or protein sufficiency. Protein insufficiency may have widespread ramifications. Hypoproteinaemia can cause deviations in circulating levels of certain micronutrients, such as iron,6 zinc, copper7 and potentially selenium.8
Body signs and symptoms
Physical signs may be important aids in identifying nutritional dysfunction, though care should also be taken during case taking as particular signs may not be specific and may relate to non-biological factors (such as injury or excessive sun exposure). Signs may also differ between populations and may also vary over time periods within a population.9 Any findings suggesting an abnormality should be considered a clue rather than a diagnosis. Table 2.2 outlines a variety of signs and symptoms as documented in research literature.
| SYSTEM | SIGN | POSSIBLE NUTRIENT DEFICIENCIES |
|---|---|---|
| Biliary | Fatty liver deposits | Omega-6 EFA10 |
| Cardiovascular |
Bioelectrical impedance analysis
Bioelectrical impedance analysis measures the impedance or opposition to the flow of an electric current (usually 50 kHz) through the body fluids contained mainly in the lean and fat tissue. This is generally low in lean tissue, where intracellular fluid and electrolytes are primarily contained, but high in fat tissue. In practice, a small constant current is passed between electrodes spanning the body and the voltage drop between electrodes provides a measure of impedance. The resulting impedance reading is proportional to the total body water volume. Prediction equations are used to convert impedance to a corresponding estimate of total body water.127 Lean body mass is then calculated from this estimate using an assumed hydration fraction for lean tissue. Fat mass may then be calculated by subtracting lean mass from total body weight. Although commonly accepted as a measure of these markers many naturopathic practitioners adopt novel conclusions from this technique that are yet to build an evidentiary base.
Gastrointestinal palpation
Palpitation of the abdominal area may reveal various underlying organ pathologies such as liver disease or gall bladder insufficiencies (see Figure 2.1a):
Figure 2.1 (a) Normally palpable abdominal structures (b) Palpating the liver
Source: Adapted from Jarvis 200764
Palpation may also locate a mass. If so, it must be distinguished from a normally palpable structure or enlarged organ and note must be taken of its location, size, shape, tenderness, consistency, surface, mobility, pulsatility and tenderness. Gastrointestinal palpation may also be used in conjunction with other abdominal physical examinations, such as auscultation and percussion, to elicit required information. An example of this is that a fluid wave indicates ascites, which may occur with heart failure, portal hypertension, cirrhosis of the liver, hepatitis, pancreatitis and cancer.64
