DANGER SIGNS: Contraindications of the Orthopedic Examination
PERSPECTIVE
Andrew M. Rodgers
DC
The chiropractic examination has evolved from the days of just analyzing the spine for subluxation and subluxation listings to include ruling out pathologies by performing a comprehensive history and orthopedic neurological examination. Of course, all of it must be documented in a special format, or it could be deemed not done by the courts, insurance companies, and state licensing boards.
You should always take a patient’s history prior to the examination. The results of this history may result in not even performing the examination because it might injure the patient. The gold standard of the initial case history begins with documentation of visualization as the patient first enters your office. Even at the initial stage, a prudent chiropractor can stop and refer out for other treatments or diagnostics, even performed elsewhere. An example would be when an antalgic patient within crying 10-out-of-10 pain complicated by 10-out-of-10 leg pain, or worse, bilateral leg pains accompanied by urinary and or bowel dysfunction. Extremity muscle weakness is a good referral-out sign for further diagnostics prior to any other interactions with a patient. Such a patient presentation may not even be a candidate for any type of manipulation or even a provocative orthopedic examination, which could cause injury to the patient. Knowing what you are dealing with before going forward with every stage of the deductive medical protocol procedures to reach a diagnosis and treatment plan or a referral is paramount for a preventative riskmanagement profile.
I hope we all have been taught the proper history protocol, or have and continue to learn the best practice history techniques. Besides the OPQRST mnemonic (onset, provocation or palliation, quality of pain, region and radiation, severity, time/history) and the PFSH or PMHA mnemonic (past medical and social history review of past illnesses, operations of injuries, falls, traumas, or accidents), all the prior radiographic and imaging studies must be gathered. Best practice dictates reading the films yourself even if not taken in your office. In my over 40 years of practice and number of seminars, Eve learned that nocturnal pain and nonpositional pain is an insight to sinister visceral pathology that might just be mimicking musculoskeletal symptoms. These could be life-threatening.
I wrote a scientific manuscript for the Journal of Chiropractic Medicine (volume 16, number 3, September 2017) titled, “Thoracic Schwannoma in an Adult Male Presenting with Thoracic Pain: A Case Report.” I sent the patient for an MRI, which showed a tumor, so I then immediately sent him to the neurosurgeon, who operated the next morning. His life was saved.
We must review all systems for symptomatology and adverse reactions (for example, looking for cauda equina syndrome or other sinister pathological comorbidities). It is so important also to look for a fever or for infection of spinal structures. How about the patient that complained to the chiropractor for six months of extreme calf pain, but the chiropractor told him it was from sciatica from a prior motor vehicle accident? That turned out to be a deep vein thrombosis (DVT) and no differential diagnosis was performed, so the patient lost his leg and could have lost his life. How about three chiropractors referring to each other trying to correct an idiopathic scoliosis on a 12-year-old child who ended up with instrumentation rather than a Milwaukee brace, which had helped her mother when she was a child? I was the plaintiff expert witness in a Rochester Hills, Michigan case where that occurred. There was a multimillion-dollar judgment against three chiropractors trying to correct congenital idiopathic scoliosis on a young 12-year-old girl who suffered irreversible spinal damage.
When you perform the history and examination, it is prudent to rule out any risk factors, contraindications, or present comorbidities that would interfere with the success of your chiropractic treatments. All the signs and symptoms already previously mentioned in this article are a good list to start.
Documenting the functionality of the patient’s activities of daily living throughout the history and examination will help dictate treatment, but paramount to that is even if they are a chiropractic case. A chiropractic case is one that you will not harm the patient or postpone proper medical diagnosis and or treatment.
So even before the history, you might need to refer the patient out for diagnostics or another medical specialty, such as pain management, physical therapy, orthopedic, neurologist, or neurosurgeon. They refer other patients when they are educated to the fact that you work with the medical providers of your community. They even know that you recognize there is more than just manipulation for patient care in our community. Chiropractic is not a panacea of all conditions, and not every condition is a treatable chiropractic case. Everyone needs chiropractic, but not everyone can receive or tolerate it.
Now that we passed the first two entry points to accept the patient as a chiropractic patient, we are ready for the examination. By the way, patients really appreciate your honesty and recommendations. Beware of the orthopedic examination because you could injure patients while examining them. Doing proactive orthopedic testing, such as a Lasegue straight leg test, can stretch the sciatic nerve. A foramina compression test shouldn’t be performed if there is a degenerative joint disease. Spurling’s or Jackson’s tests shouldn’t be done when there is myelopathy, spondylosis, or bone spurs. We have come across these injuries when there is spinal stenosis or facet arthrosis. So what about the patients who have all of the previously mentioned issues? They could have arthrosis in the foramina transversaria and even doing hyperextension vertebral artery dissection testing could be dangerous, even ranges of passive range-of-motion testing. It is recommended to start with easy active ranges of motion because patients are restricted to what they can tolerate. This should be done before the passive ranges of motion and any examinations.
If imaging is available, read the report and interpret the films yourself. This would be the best medical practice and the best way to avoid injury during the orthopedic examination. There may be “danger signs,” contraindications, risks, and complications to passive range-of-motion and orthopedic testing. Any provocative orthopedic testing including range-of-motion testing could injure a patient. Patients have been injured by not being aware of these precautions and end up being defendants in negligence malpractice cases for causing disc damage, spinal nerve damage, and even cerebral vascular problems among a myriad of other conditions.
The deductive process of reaching a diagnosis and prognosis through the history and examination is essential prior to the decision making to treat or refer. Knowing that there are “danger signs” to the orthopedic examination is a crucial and a prudent warning in risk management. Once we have ruled out these and other risk factors in the visualization, history, and examination process, we may proceed carefully and confidently with our chiropractic services. We are responsible for all that we do and don’t do.
References:
1. Ronald Evans, D.C. FACO, FICC , Illustrated Orthopedic Physical Assessment Second Edition copyright 2001 Mosby, Inc.pages 138 thru 141
2. Thomas A. Souza, D.C. Third Edition , Differential Diagnosis and Management for the Chiropractor Protocols and Algorithms; Jones and Bartlett Publishers copyright 2005 pages 56 thru 60
3. Scott Haldeman, D.C. Third Edition, Principles and Practice of Chiropractic McGraw-Hill Medical Publishing Division, copyright 2005 pages 569 thru 571
Dr. Andrew M. Rodgers, Chiropractic Physician, continues his active clinical chiropractic practice in Fort Lee, New Jersey for over forty years. He is a BS, in Pre-Med, MS in Biology, DC from NYCC 1974. He has completed diplomate courses in forensics and orthopedics. He was a Distinguished Alumni of NYCC in 2011. He has opined on over 120 plaintiff and defense malpractice, fraud and disability cases. He continues to serve as an advocate for Chiropractic and Chiropractors.
