Dynamic Chiropractic Sept 25, 1995
Ronald Eccles Jr., DC, DABCO, DACAN
Example of a failed orthopedic test
Dr. Clyde Miller for the Graphic!
Editor's note: Part I of Dr. Eccles' article appeared in the
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
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
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:
2) provocative tests
3) motion palpation
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
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,
degree of objectivity to it. It is highly improbable that a
be studied or well-read of Bogduk's work, or would be capable of
scleratomal patterns of pain.
3) Motion palpation: Motion palpation is
often misconstrued as a
chiropractic technique. Motion palpation is a diagnostic tool
utilized by chiropractors to assess dynamics of joint function.
admittedly the interexaminer reliability has not been very high,
intraexaminer reliability is better. Development of clinical
involving motion palpation can help identify the side and level
and assessment for quality of motion intersegmentally can also be
once more experience is attained.
Other Diagnostic Tests
There are several diagnostic tests which are more sensitive in
whiplash trauma. They are:
1) Stress films: In utilization of plane
film radiography, stress
can be obtained of the cervical spine in the extremes of flexion
extension. By utilization of templating, intersegmental movement
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
has been significantly reduced. Under certain guidelines,
can be valuable in assessing dynamic motion of the spine. While
is great in assessing instability and fixation in the sagittal
information has been published for normative data in other planes
3) Diagnostic ultrasound: Diagnostic
ultrasound may be valuable in
assessing acute injury to the musculoskeletal soft tissues.
derived from careful utilization of this procedure is quite
It should be carefully noted that there is no diagnostic imaging
that is sensitive for damage to the zygapophyseal joint surfaces.
postmortem studies reveal a high incidence of damage to these
secondary to motor vehicle accidents, the use of plane film, CT
scan, or MRI has been useless. The most reliable method of
coming from the zygapophyseal joint is the use of medial branch
blocks. Unfortunately, there are few skilled practitioners
performing this differential diagnosis.
The chiropractic physician must use a combination of the history,
clinical examination, and other diagnostic tools to establish the
diagnosis. By understanding the structures which are typically
motor vehicle accidents, and their innervation from the dorsal
begin to look for pain patterns and clinical findings which are
with damaged muscle and tissues derived from the scleratome or
It is mandatory that we rethink our approach to the examination
whiplash patient by emphasizing those procedures which are more
for the lesions involved.
Ronald Eccles Jr., DC, DABCO, DACAN
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