The Failure of Standard Orthopedic and Neurologic Tests, Part II
 
   

The Failure of Standard Orthopedic
and Neurologic Tests, Part II

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:
   Frankp@chiro.org

NOTE: This article is reprinted with the permission of Dynamic Chiropractic
No reproduction of this article is permitted without permission of the publisher
 
   

Ronald Eccles Jr., DC, DABCO, DACAN
Dynamic Chiropractic Sept 25, 1995

Whiplash Series


Example of a failed orthopedic test
Thanks to Dr. Clyde Miller for the Graphic!

Editor's note: Part I of Dr. Eccles' article appeared in the September 1,1995 issue of "DC."

In the last article I covered the rationale of why typical orthopedic and neurologic examinations fall far short of being sensitive for tissues lesioned in a motor vehicle accident.

Now having a better understanding of the innervation of the cervical muscles, the posterior zygapophyseal joints, and the ligaments and connective tissue which are typically injured in motor vehicle accidents, we can begin to see that the dorsal ramus should be the focus of our evaluation.

In the previous article I claimed that the majority of patients involved in motor vehicle accidents rarely present with radicular-type symptoms. Although from my experience this is true, it does not dismiss the responsibility of the chiropractor to still evaluate for this possibility. The chiropractic physician should pay careful attention to de-emphasize these testing procedures which we would expect normally to be negative, and create emphasis on those testing procedures which tend to be more sensitive.

More Sensitive Examination Procedures

Tests which I believe are sensitive to the whiplash-injured patient can be divided into two categories: those which are listed by physical examination, and those which are listed by other diagnostic tests.

Examination procedures which are more sensitive to the tissues innervated by the dorsal ramus include:
1)   palpation
2)   provocative tests
3)   motion palpation


Physical Examination

1) Palpation:    The palpatory examination is the hallmark of the chiropractic exam. It is in this area that chiropractors seem to have excelled above their counterparts treating similar conditions. For a proper palpatory examination, the chiropractor should document areas of tenderness which admittedly have a high degree of subjectivity. Although palpatory findings have been called into question as based on their subjectivity, certain findings in this part of the examination have a high degree of objectivity. Palpated muscle spasm should always be reported since it is not easily faked. Myofascial trigger points which refer pain into predictable and reproducible areas (non-radicular) and that reproduce the chief complaint should be carefully documented and considered highly valuable.

2) Provocative tests:   I have used compression maneuvers in an attempt to provoke tissues which are injured in CAD trauma. I normally challenge the cervical spine by compressing it in the neutral position, in right and left lateral flexion, in extension, flexion, and in the combined movements of extension, rotation and lateral flexion to one side. Instead of performing these tests and reporting whether they are positive or negative, the chiropractic physician should carefully provoke the cervical spine and record concisely and clearly what the patient reports.

A Typical Example

Let's take, for example, a typical whiplash victim who suffers with lower right cervical spine pain radiating to the right shoulder blade and tip of the right shoulder. During the provocative testing portion of the examination, the patient's neck is put into right lateral bending, and then compressed with about 10 pounds of pressure. The patient is then observed for facial grimacing, or guarding, as a result of provoked pain. The patient is also asked to describe what they experienced. If the patient reports pain, the doctor should note the pain's location, the area pain is referred, and the approximation of the severity of the pain. Remember, pain in this position can be produced both ipsilaterally and\or contralaterally.

By provoking the cervical spine with compressive maneuvers in different positions, the physician can clearly assess the region, distribution, and quality of pain. This will help identify whether the pattern of pain is more similar to pain from a scleratome/myotome, or that kind of pain which would be produced from a radicular involvement.

It is my contention that this testing, when reported accurately, has a high degree of objectivity to it. It is highly improbable that a patient would be studied or well-read of Bogduk's work, or would be capable of identifying scleratomal patterns of pain.

3) Motion palpation:   Motion palpation is often misconstrued as a chiropractic technique. Motion palpation is a diagnostic tool and should be utilized by chiropractors to assess dynamics of joint function. Although admittedly the interexaminer reliability has not been very high, the intraexaminer reliability is better. Development of clinical skills involving motion palpation can help identify the side and level of lesion, and assessment for quality of motion intersegmentally can also be derived once more experience is attained.

Other Diagnostic Tests

There are several diagnostic tests which are more sensitive in assessing whiplash trauma. They are:

1) Stress films:   In utilization of plane film radiography, stress films can be obtained of the cervical spine in the extremes of flexion and extension. By utilization of templating, intersegmental movement can be assessed for hypomobility or hypermobility.

2) Videofluoroscopy:   Videofluoroscopy, in the past several years, has advanced to the level where the amount of radiation exposure to the patient has been significantly reduced. Under certain guidelines, videofluoroscopy can be valuable in assessing dynamic motion of the spine. While its value is great in assessing instability and fixation in the sagittal plane, little information has been published for normative data in other planes of movement.

3) Diagnostic ultrasound:    Diagnostic ultrasound may be valuable in assessing acute injury to the musculoskeletal soft tissues. Information derived from careful utilization of this procedure is quite objective. It should be carefully noted that there is no diagnostic imaging modality that is sensitive for damage to the zygapophyseal joint surfaces. While postmortem studies reveal a high incidence of damage to these structures secondary to motor vehicle accidents, the use of plane film, CT scan, bone scan, or MRI has been useless. The most reliable method of assessing pain coming from the zygapophyseal joint is the use of medial branch blocks, or joint blocks. Unfortunately, there are few skilled practitioners capable of performing this differential diagnosis.

Conclusion

The chiropractic physician must use a combination of the history, clinical examination, and other diagnostic tools to establish the appropriate diagnosis. By understanding the structures which are typically injured in motor vehicle accidents, and their innervation from the dorsal ramus, we can begin to look for pain patterns and clinical findings which are consistent with damaged muscle and tissues derived from the scleratome or myotome.

It is mandatory that we rethink our approach to the examination of the whiplash patient by emphasizing those procedures which are more sensitive for the lesions involved.

Ronald Eccles Jr., DC, DABCO, DACAN
Sarasota, Florida



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