Practical Assessment in Orthopaedic Care Series

K. Jeffrey Miller, DC, FIANM(us), MBA K. Jeffrey Miller, DC, FIANM(us), MBA Chiropractic Orthopaedist

Dr. Jeff Miller is an Assistant Professor at the University of Missouri School of Medicine. He practices as a Chiropractic Physician in the Departments of Orthopaedic Surgery and Physical Medicine and Rehabilitation at The Missouri Orthopaedic Institute (MOI).

Dr. Miller has been a Doctor of Chiropractic for 33 years and a chiropractic orthopedist for over 27 years. He is a prolific writer having published over 250 articles, 9 books and serves as a columnist for Dynamic Chiropractic and The Columbia Daily Tribune. A sought-after speaker in the US and abroad, Dr. Miller has presented over 300 postgraduate programs in 38 states and several countries. Practical Assessment in Orthopaedic Care Series Clinical Documentation E & M History & Examination

K. Jeffrey Miller, DC, FIANM(us), MBA Pyramid of History Focus

PFS ROS HPI History Component

• History of the Presenting Illness

– Often referred to by the abbreviation OPQRST

– Onset/mechanism, palliative/provoking, quality, radiation/referral, severity, timing

– CPT-E&M HPI = location, quality, severity, duration, timing, context, modifying factors and associated s/s History Component Review of Systems (ROS)

– 14 Total systems based on CPT-E&M

• Constitutional symptoms, • Musculoskeletal

• Eyes, • Integumentary

• Ears, Nose, Mouth and Throat • Neurological • Cardiovascular • Psychiatric

• Respiratory • Endocrine

• Gastrointestinal • Hematological/lymphatic

• Genitourinary • Allergic/Immunologic History Component

• Past Family, Social Histories

– Surgeries/Procedures – Hospitalizations, – Immunizations, – Injuries, – Illness (short/long term) – Pregnancies – Allergies – Occupational history is included in Social History Past, Family and Social Histories (DOT Example)

Documentation Statement

-Mode of Onset

– “A specific event or situation is not currently recognized as the causative factor.”

Clinical Examination Categories Clinical Examination Categories Pyramid of History Focus

What we need PFS The way we think ROS HPI Ahh…But the patients don’t know this

• You know it is going to be a long visit when the patient starts the history with…”It all started 25 years ago when I…” Pyramid of History Focus

Inverting what we need HPI The way the patients think ROS PFS ”It all started 25 years ago when I…”

• You cannot treat “25 years ago” • You can treat “Now” • To get to the point, I frequently try to direct the patient toward the answers to the following past history questions. – Have you had the current problem before? – When was the first time? – Has the problem been constant or intermittent? – Have you had surgery for the problem? – Have you had chiropractic care for the problem? Moving Beyond Standard History Components

The Pyramid of History Focus • The 5 Ds And 3 Ns – Let’s get to NOW – Stroke Recognition

• Patient Health Survey • Questions with New Emphasis – Ten Foot Pole Patients – Suicide, Abuse

• Daily Questions • 20 Questions – Checklist Manifesto – Prompting Information/Cooperation

• “When you hear hoof beats think horses not zebras”

• But it is the zebras you should worry about!

• Rule out all the things that could kill them first!

• Signs and symptoms of all the stuff that could turn out terrible

• The form is designed for “Yes” to stick out

• Also designed to catch the patients trying to skip steps/not cooperate

Daily Questions Checklist Manifesto

• The Checklist Manifesto – Routine Safety Procedures • Pilots • Short day-to-day checklist example: – Pregnancy, Implanted Devices, The Ds and Ns – It is especially helpful to have a list if you provide coverage for other doctors. The same applies for new associates. – Associates, The “July Effect”

Always Tell the Doctor if You

• Have any concerns

• Have any implanted medical devices, especially any implanted devise that is electrical, or uses a battery i.e., pacemaker, stimulator or pump.

• Are or could be pregnant.

• Have pain (scored 0-10) – 0 = No Pain – 10 = Terrible pain (you cannot drive, work or attend school etc.) Always Tell the Doctor if You

• Have experienced changes in your symptoms – No change – Symptoms have improved – Symptoms have moved – Symptoms have increased Always Tell the Doctor if You

• Have limited your activities due to your condition (changed your work, job or household activities)

• Are having trouble following home instructions

• Have allergies to Latex, adhesives

• Are afraid of needles

• Have been injured since your last visit Always Tell the Doctor if You

• If you have seen another doctor since your last visit, and why

• Are having trouble with bladder of bowel functions

• Are having thoughts of suicide

• Don’t feel safe at home

• Are being verbally, physically or sexually abused. The Five Ds And Three Ns

The 5 Ds The 3 Ns

– Diplopia • Ataxia

– Dizziness • Nausea

– Drop Attacks • Numbness

– Dysarthria • Nystagmus

– Dysphagia Questions with New Emphasis Suicide, Abuse… – Suicide: (Thoughts and/or Attempts)

– Abuse: Mental, Physical and/or Sexual

– Smoking

• Surgery

– Smokers have failure rates 5x higher than non-smokers for joint surgery

– 16 weeks smoke free for surgery

• I designed this to get information out of patients who are poor historians

• It focuses on situations and events instead of conditions.

• Have you ever been treated in an emergency room? – As an adult? Child? • Have you ever been transported by ambulance? • Have you ever called a doctor after hours? • Have you ever had to see a doctor while out of town? • Have you ever had emergency dental care? • Have you ever had an allergic reaction? – Food, Drug, Insect, Substance, Plants 20 Questions

• Have you ever carried/do you carry medication in case of an emergency? – Nitroglycerin, Glucose, Insulin, An inhaler, Epi Pen • Have you/do you warn any type of medical alert jewelry? • Have you ever had to have a tetanus shot? • Have you ever received stiches? • Have you ever been fitted for a special brace, worn a brace or worn a cast? 20 Questions

• Have you ever been admitted to a hospital? • Have you ever been anesthetized or had a body region numbed? • Do you have any implanted medical devices or embedded foreign objects from trauma (pace maker, bullets) • Have you ever been x-rayed? • Have you ever used a cane, crutches, walker, wheelchair? • Have you ever undergone a series of injections? 20 Questions

• Have you ever been diagnosed as having a permanent condition?

• Have you ever been disqualified from participation in any of the following:

– A job

– The military – A sport • Have you ever been denied medical or life insurance? 20 Questions

• If I were to add to this list I would ask, “Do you have any significant or unusual scars?” Practical Assessment in Orthopedic Care

Evaluation and Management Coding Changes for January 2021

K. Jeffrey Miller, DC, FIANM (us), MBA History of E & M

• Prior to 1995 the time spent with the patient was the key factor in examination coding • In 1995 the key and contributing components guidelines were implemented. It was revised in 1997. After the revisions doctors could chose to use either the 1995 or 1997 guidelines. Doctors could use the guidelines that matched their field of practice. • The changes for 2021 are the first in 23 years. History of E & M

• Centers for Medicare and Medicaid Services (CMS) initiated new guidelines for 2021 • The American Medical Association (AMA) became involved because it is their system and Medicare wanted to bundle some examination codes. • CMS and the AMA reached a compromise Components of Out Patient E&M Codes

3 Key Components 4 Contributing Components

– History • Coordination of care – Referrals, additional tests, gathering other records etc. • HPI • Review of systems • Counseling – Report of Findings • Past, Family, Social • – Examination Nature of the illness – Brief, limited, severe • Bullets (exam procedures) • Time – Medical Decision Making – Face to face time • Degree of complication • “Doctor to Patient”

• In the current guidelines, two of the three key components, history and the exam/bullet system are the two primary focus.

• The focus is changing to Medical Decision Making and Time

• Despite the change in focus, History and Examnation are still vital to the process History and Examination History Categories

HPI Review of systems & PFS

• The standard OPQRST • 14 Systems

• The foundation of every examination • Past History code, it is a part of all new patient E&M • Family History codes and most established patient E&M codes • Social History – Occupational History • There must be one HPI per complaint being addressed

• There have always been problems with the bullet system

– I estimate that 50% of chiropractors don’t understand or use the system

– Many doctors aren’t really performing the procedures. They list the required content in templates but perform only a version of what is listed.

– This was one of Medicare's complaints and the reason they wanted to bundle exam codes. Examination Procedures/Bullets

• There are no specific examination requirements or bullets in the guidelines. • The new guidelines state that examination content must be “clinically relevant” • Clinically relevant is not clearly defined, and that appears intentional. Examination Procedures/Bullets

• The new guidelines allow greater flexibility in examination content, especially for chiropractic. – There are no chiropractic bullets. We have been using a combination of the musculoskeletal and neurological bullets – Analytical procedures for Chiropractic Technique Systems vary greatly – Analytical procedures for Chiropractic Technique Systems may be easier to include with confidence. • NOTE: Flexibility isn’t license to slack off, cut corners or stop performing a good history & examination. – An exception to the flexibility is the mandate to perform a PART examination for Medicare documentation. Medical Decision Making and Time A Change in Focus

• Medical decision making is a key component in the current guidelines and time is a contributing factor.

• Medical decision making remains a key component and time is moving from contributing to a key component. Medical Decision Making

• Medical Decision making is related to: • The degree of history recorded • The extent of the examination rendered. • The degree of information gathered during the examination process • The number of diagnoses rendered • The ordering of additional tests • The need to refer for concurrent care • Obtaining and reviewing external records • Producing reports • In short, how complex the case will be

• The only significant rule for time in the current guidelines: the doctor must spend the entire time associated with each examination, face-to-face with the patient. Time

• In the new guidelines, time spent with the patient is a significant factor. • And, an important modification is occurring in the face-to-face time rule. The doctor is not solely responsible for face-to-face time. Time spent with patients by staff members will counts as part of the required face-to-face time. Time spent with a patient by the doctor and staff are thus, combined to meet the time requirement for each examination. – For example: Time spent by an assistant/nurse/intern/resident recording the patient’s history counts toward the required examination time. – This was Happening anyway (another problem) From the AMA Website for 2021 Guidelines

• “Office or other outpatient services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination is determined by the treating physician or other qualified health care professional reporting the service. The care team may collect information and the patient or caregiver may supply information directly (eg, by portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in selection of office or other outpatient services.” Time Requirements for Specific Codes

• Established codes:

– 99213 20-29 minutes

– 99214 30-39 minutes The Total Number of Codes

• Instead of bundling codes, the new patient code 99201 is being dropped – No one uses 99201 anyway • Chiropractors cannot use 99211. It is called “The Nurse’s Code” and it is used for examination procedures that do not require/involve a doctor. – Example: Blood Pressure Monitoring • Stop using these codes if you have been. Evaluation and Management Codes - Development

Level New Patient Exam Levels Established Exam Levels Bullets Patient Bullets Highest 99205 Comprehensive + 99204 Comprehensive 99215 Comprehensive + 99203 Detailed 99214 Comprehensive 99202 Expanded Problem 99213 Detailed Focused 99201 Problem Focused *99212 Expanded Being Dropped Problem Focused Lowest Never Use This Code 99211 Problem Focused

Blue = Definition & Documentation Problems + = to fullest extent (example, vitals) * and Yellow = with adjustment

Practical Assessment of the Chiropractic Patient

K. Jeffrey Miller, DC, FIANM(us), MBA

Dr. Miller has been a Doctor of Chiropractic for 33 years and a chiropractic orthopedist for over 27 years. He is a prolific writer having published over 250 articles, 9 books and serves as a columnist for Dynamic Chiropractic and The Columbia Daily Tribune. A sought-after speaker in the US and abroad, Dr. Miller has presented over 300 postgraduate programs in 38 states and several countries. • “Specializing in Spine and Nerve Rehabilitation”

Lower Motor Neuron Testing

• Right or Left Handed • Ambidextrous • Shoulder Height-levelness – Dominant side lower • Grip Strength – Dominant side stronger by 10% – Female grip strength is 50% of males

• Impairment Rating – Non-dominant often rated lower • Side Posture Adjusting – Farfan’s Torsion Test – Side of handedness up • Pseudoambidexterity

Pseudoambidexterity

• Both ambidextrous and multilingual, 20th president James Garfield could write Greek with one hand while writing Latin with the other.

• Quick Assessment of Lower Cervical and Upper Thoracic Nerve Root Motor Function

• C5-T1

• Flexion of the Shoulder-C5 • Extension of The Elbow and Fingers-C7 • Extending the Thumb-C6 • Spreading the Fingers-T1 • Bringing the Fingers Together-T1 • Flexing the Fingers-C8 • Wrist Stabilization-C6/C7 • Shaking (flex and extend the elbow)-C5/C7

• Shoulder Flexion and Elevation to reach for the Handle Bars-C5 • Spreading and Extending the Fingers Preparing to Grip the Bar-T1/C7 • Bringing the Fingers together and Flexing them to Grip Bar- T1/C8 • Using the Throttle-C8/C6 • Using the Clutch or Brake- C7/C8

T1 Finger abduction C8 finger flexion

C7 Finger Extension C7 Wrist Flexion

C6 Wrist Extension C5 Arm Flexion

• C7 Arm Extension

• For adduction…squeeze method could bring finger flexion into play and skew results, use Rosenbaum card or similar

• Note the spring response for abductors

• Test distal to the joint without crossing the next joint • Hold for 5 seconds • Do Not pump the muscle/joint • Grade the contraction • Differentiate between true weakness and reflexive weakness due to pain • The examiner can place a muscle in a mechanical disadvantage to detect subtle losses

Objective Grade Qualitative Description Observation Range of Motion 5 Normal Antigravity plus Full range of motion resistance 4 Diminished Antigravity plus some Full range of motion resistance 3 At least antigravity Antigravity only Full range of motion 2 Poor Gravity omitted Full range of motion 1 Trace Evidence of activation Partial range of motion 0 No activation No evidence of activation N/A *This scale provides ordinal information Grip Strength

• Test for Motor Function Of Nerve Roots L2-S2 and Lower Extremity Range of Motion (hip, knee and ankle) • Alternate Version

Motor innervation for lower extremity movements performed during deep knee bends Movement Nerve Root Level HIP flexion L2-L3 extension L4-L5 KNEE extension L3-L4 flexion L5-S1 ANKLE dorsiflexion L4-L5 planar flexion S1-S2 9/17/20 MillerCopyright 2002-2017 Hoppenfeld

• Gluteus Maximus (S1)

– S1 strength is usually WNL if the patient can move from sitting to standing without using the hands to push up

• Snapping • Crepitus – Repetitive – Non-repetitive • Trochanteric Bursitis • Ober’s and Noble’s Tests

• Marching in place on the heels

• Stabilize

• Space considerations

• 25 Bilateral Repetitions – McNab • 15 unilateral – Hoppenfeld • Hop on foot – Manual? • Stabilize • Space Considerations

Toe Raises Heel Standing/Marching

• Foot Dorsiflexion L4

• Great Toe Extension L5

• Toe Flexion S1-S2

Upper Motor Neuron Testing

– Jean Alexandre Barre’ described Drift

• Barre’s Test (some confusion here because there is a Barre’s test for the cervical spine/vertebral artery assessment. It is essentially the same maneuver as the rotation/extension maneuver in George’s Test) Miller 2002 9/17/20 MillerCopyright 2002-2017 Drift Drift

• Basic Life Support (BLS) – Acceptance due to uniform use in medicine – American Heart Association – Cincinnati pre-hospital stroke • Scale (one positive) – Arm drift – Abnormal speech – Facial drooping • (DDx)

Miller 2002

• F.A.S.T. Stroke Screening – Face – Arms – Speech – Time

– The FAST was developed in the UK in 1998 by a group of stroke physicians, ambulance personnel, and an emergency department physician and was designed to be an integral part of a training package for ambulance staff. The FAST was created to expedite administration of intravenous tissue plasminogen activator to patients within 3 hours of acute stroke symptom onset. The instruments at this time with most evidence of validity were the Cincinnati Prehospital Stroke Scale (CPSS) andMiller the 2002Los Angeles Prehospital Stroke Screen (LAPSS). – http://stroke.ahajournals.org/cgi/content/full/34/1/71

• Names – Drift – Pronator Drift – Spontaneous Drift – Barre’s Test (some confusion here because there is a Barre’s test for the cervical spine) • Jean Alexandre Barre’ first described the sign

• Positive Indications: – One hand rolling from supination to pronation is a positive – Typical sign is the hand rolling from supination to pronation with the arm dropping toward the floor – The arm drifts laterally (outward) in cerebellar lesions • These lesions are unilateral – The arm drifts upward in Parietal lesion • These lesions are contralateral

• Positive Indications:

– Movements are slow and may take a few seconds to initiate

• The reasoning behind holding the positions 15-30 seconds – Tapping the hand or arm may help initiate movement

– Both arms drifting is not significant

• Vertebral Artery Test • Doctor Should Position Patient’s Head • Eyes Must be Closed • Held 15-30 Seconds Each Side • Drift – Objective – Validity by Common Use

• This is a side note

• Confirmatory Test to Upper Extremity Drift (UMN)

Miller 2002

• This is a side note

• Are the eyes closed?

• Does it matter?

& Arm Rolling • Test for UMN

• Eyes closed

• Roll forward and backward • Satellite Motion is abnormal

• Pathological Findings – Finger Rolling • The pathological finger remains stationary or wobbles a little while the non-pathological finger rotates around it like a satellite. – Finger Rolling is more sensitive than Arm Rolling – Arm Rolling • The pathological arm remains stationary or wobbles a little while the non-pathological arm rotates around it like a satellite.

• 0.33 Finger Rolling • 0.33 Rapid Alternating Movements • 0.24 Forearm Rolling • 0.22 Pronator Drift – Specificity of each test was 1.0 and the combination of the four detected 50% of patients with lesions 0.33 Specificity

0.24 Specificity 0.22 Specificity Investigative Progression of Physical Examination

Progression → Further Structure/Function History Observation Baseline Testing Evolvement of Evolvement of Pathology ↓ Testing Testing Lower Motor • Patient • Muscle • Hand shake • Strength • Dynamomete Neuron reports loss atrophy of testing r testing of strength the upper individual Upper Extremity • Patient extremity/ha muscles Motor Strength reports nd dropping Grip Strength items Upper Motor • Patient • Possible • Drift • Referral Neuron reports Spasticity • Arm Rolling • EMG Strength weakness • Finger Rolling

Progression → Further Structure/Function History Observation Baseline Testing Evolvement of Evolvement of Pathology ↓ Testing Testing Lower Motor • Patient • Muscle • Heel and toe • Strength • Dynamometer Neuron reports loss of atrophy of walking testing testing strength quad, • Heel individual Lower Extremity • Patient hamstring, standing/toe muscles Motor Strength reports calf raises • Sit to Stand difficulty musculature • Quick test Test raising from a • Going from chair sitting to • Patient standing reports difficulty with climbing/desc ending stairs Upper Motor • Patient • Possible • Drift • Referral Neuron reports atrophy • EMG Strength weakness • Spasticity

MSR and Pathological Reflex Testing

• There has been a shift from using the description deep tendon reflex (DTR) to muscle stretch reflex (MSR) in recent years as DTR does not correctly reflect the mechanism of the reflex phenomenon • Myotatic reflex is another currently acceptable term but, to a lesser degree Muscle Stretch Reflex Significance

• Muscle stretch reflexes are only significant if correlated with the following circumstances; 1. An absent reflex is identified along with other signs of lower motor problems 2. An exaggerated reflex is identified along with other signs of upper motor problems 3. Reflex strength is asymmetrical 4. The reflex is unusually brisk when compared to reflexes from higher spinal levels

– Malanga and Nader: Musculoskeletal Physical Examination; an evidence-based approach, Mosby/Elsevier, 2006 Eliciting a Muscle Stretch Reflex

• Hammer selection – Weight handle length – Firm strike • Stiff vs flexible handle – Accuracy (practice), both hands, dimes on the desk – The use of other instruments or manually stimulation to evoke a MSR • Striking the patient – Multiple taps – Tendon – Muscle belly – Examiner’s finger/thumb • Jendrassik Maneuvers Wexler’s Scale for Grading Muscle Stretch Reflexes “Record Keeping” Grade Response Lesion Grade 5+ Sustained clonus Upper Motor Neuron Grade 4+ Clonus Upper Motor Neuron Grade 3+ Hyper-reflexia Upper Motor Neuron Grade 2+ Normal Neither UMN or LMN Grade 1+ Hypo-reflexia Lower Motor Neuron Grade 0 No reflex Lower Motor Neuron

Also known as the National Institute of Neurological Disorders and Stroke (NINDS) Scale This is a Strange Scale = Normal is in the middle of the scale This scale provide ordinal information

• Age

• Endocrine changes

• Anxiety and tension

• Medications-drugs

• Diseases (muscle diseases)

• Injury to the muscle or tendon Muscle Stretch Responses

• A muscle with lower motor dysfunction may have one good reflex response. For this reason more than one blow is necessary, typically 3-5. Responses to the remaining blows determines the rating for the reflex. Clonus

• Clonus = More than one reaction-movement as a result of the strike of the hammer – Each movement is referred to as a “beat” – Clonus = 3-4 beats – Sustained clonus = the beats continue – Beats usually occur at a rate of 5 to 8 Hz • Clonus can be seen in any muscle group but is most common in the muscles moving the ankle. – The knee, wrist, jaw and elbow are other common sites. Hammer Selection

• Dejerine Hammer

• Berliner Hammer

• Queen’s Square Hammer

• Taylor Hammer (Looped Handle) • Queen’s Square Hammer

• Traube Hammer

• Taylor Hammer (Solid Handle)

• C5- C6 • Radial Nerve • Strike tendon or muscle • Symmetry • Multiple Taps

– Inverted Supinator Test

Identify the muscle belly Lateral border of the cubital fossa

• STRIKING THE BELLY

• C7 • Radial Nerve • Strike tendon or muscle • Symmetry • Multiple Taps

• L2, L3 & L4 • Femoral Nerve • Strike tendon or muscle • Symmetry • Multiple Taps

• S1-S2 • Tibial Nerve • Strike tendon or muscle • Symmetry • Multiple Taps

Miller 2002 9/17/20 MillerCopyright 2002-2017 Wexler’s Scale for Grading Muscle Stretch Reflexes (MSR) “Record Keeping” Grade Response Grade 5+ Sustained clonus Grade 4+ Clonus Grade 3+ Hyperreflexia Grade 2+ Normal Grade 1+ Hyporeflexia Grade 0 No reflex

• Biceps Musculocutaneous C5-C6

• Brachioradialis Radial C5-C6

• Radial Radial C5-C6

• Triceps Radial C7

• Patellar Femoral L2-L4

• Achilles Tibial S1-S2

• Extensor Hallucis Longus Deep Peroneal L4, L5, S1

• Pec Major (Pectoral) Med/Lat Pectoral

– C5-C6 Clavicular Head, C7-C8, T1 Sternocostal head

• Medial Hamstring Sciatic L5, S1

• Masseter (Jaw Jerk) Trigeminal (CN V)

• Test for UMN Lesions • Upper Extremity Equivalent of Babinski’s Sign • Application of Stimulous Must Be Firm – Caution: • Fake finger nails • Partially amputated fingers

• Hoffman’s test can be added to Lhermitte's test when the head and neck position is sustained or with the patient repeatedly flexing and extending the head and neck. Dynamic Hoffman’s Sign

• Test for UMN Lesions

• Most Common UMN Test

• Application of Stimulus Must Be Firm

• Present or Absent

– Up Going or Down Going

Progression → Further Structure/Function History Observation Baseline Testing Evolvement of Evolvement of Pathology ↓ Testing Testing Deep Tendon • Biceps C5-C6 • Re- • Advanced Reflexes NA NA • Brachioradialis enforcement imaging C5- C6 • Additional • Referral • Triceps C7 Reflexes • Other types • Patellar L4 for tests for • Achilles S1 the same root level

Pathological • Hoffman’s • Additional • Advanced Reflexes NA NA • Babinski’s pathological imaging reflexes, • Referral upper and lower extremities

Neurological Testing

• It isn’t just the fact that the patient finds/touches his nose…

– It must be done repeatedly and the movements must be smooth and on target

• Cerebellar Test – Coordination • Eyes Closed • This isn’t Just Touching the Nose – Fast, Smooth and on Target

Heel to Shin test

n Cerebellar Test – Coordination n Eyes Closed n Tandem stance is Harder than Tandem Walking or Romberg's tests due to the testing position having a more narrow base – Magee, Dutton • Also referred to as Sharpened Romberg’s Test or Tandem Romberg Test • You can also grade this = partial tandem

Progression → Further Structure/Function History Observation Baseline Testing Evolvement of Evolvement of Pathology ↓ Testing Testing Upper Extremity • Finger to nose • Finger to finger • Advanced Coordination • Patient reports • Poor • Rapid alternating test imaging a decrease in handwriting movements • Past pointing test • Referral hand • Lack of coordination coordination • Drift in arm • Arm rolling movements • Finger rolling Lower Extremity • Tandem Stance • Romberg's Test • Advanced • Patient reports • Ataxic gait • Tandem Walk imaging a loss of balance • Walking with a • Heel to Shin test • Referral wide stance

Neurological Testing

Progression → Further Structure/Function History Observation Baseline Testing Evolvement of Evolvement of Pathology ↓ Testing Testing

Sensation • Patient reports • NA • Sensation scan • Tissue • Sharp and dull numbness (run hands • Tooth picks • Light touch “dead” areas down arms and • Vibration • Patient report legs) • Proprioception an inability to • Two point feel his feet discrimination • Hot/Cold • Graphesthesia • Stereognosis • Advanced imaging • Referral

• Spinothalamic Tract Pain & Temperature

• Posterior Column Proprioception & Stereognosis & Light Touch • Spinocerebellar Tract* Proprioception

• Corticospinal Tract Motor Function

• The only tract that does not cross over

Primary Modalities Cortical Modalities

• Pain* • Two point discrimination • Stereognosis • Light touch* • Graphesthesia • Pressure

• Temperature

• Proprioception • * = Most commonly tested • A key factor in most sensory testing… • Vibration the patient’s eyes being closed

• Spinothalamic tract • Test along the course of dermatomes/peripheral nerves • Wattenberg Pin Wheel • Problems with safety – Sanitation – Breaking the skin • Pointed vs cutting ends

• Problems with safety

– Sanitation

– Breaking the skin

• Pointed vs cutting ends

• Use Tooth picks

• Dermatomes = Dermal pain • Myotomes = Muscle pain • Sclerotomes = Ligaments (joints) pain • Viscerotome = Organ pain roots • Angiotome = Pain from vascular tissues • Neurotome = Pain from neurological tissues

• If any of these tissues share the same level of innervation…pain can refer

• Why test these locations?

• Dermatome tests are my least favorite neurological tests- subjective

– Dermatome and Peripheral nerve innervation of the skin is highly variable

• Usually spared in unilateral cord lesions

• If pain and proprioception are intact then light touch will not likely be effected

• So only test light touch if deficiencies of pain and proprioception are found

• Posterior Column

• Tissues for Light Touch

– Readily available

– Cheap

– Clean-disposable

• Pressure is not typically a large concern. Dysfunction of other modalities usually takes presentence • An algometer can be useful in testing • Pressure's role in testing other modalities, vibration • Pressure may be present when pain isn’t felt

• Travels in the Spinothalamic tract with pain

• If pain is intact hot and cold usually will be as well

• Tubes of hot and cold water

– Cold of warm metal instruments work well

• Position sense: knowledge of where body parts are in space

• Unilateral dorsal column that crosses over in the brain stem

• Test distally and move proximal if necessary

• Drift, arm rolling, finger rolling, Romberg’s test, tandem stance are depend upon proprioception but also vestibular and cerebellar function • Individual testing isn’t always immediately necessary in chiropractic clinical practice. When it is it will usually be for patient’s with head injury, cerebral/cerebellar ischemia or the elderly in general

• Use a 128 Hz tuning fork with weighted ends • Testing locations • Testing locations continued – Great toe – Spinous processes – Metatarsal heads – Sternum – Malleoli – Clavicle – Tibia – Radius/ulna styloid processes – Anterior superior iliac spine – Finger joints – Scrum

• This is a sensitive test as the nervous system must perceive, transmit and interpret rapidly changing stimulus

• A lack of the sensation indicates peripheral nerve and/or posterior column path

• The purpose is to access if the patient can differentiate between being touched by one or two different points of contact • Multiple tools are available • The test can be performed static and/or moving. Moving is considered more accurate

• Any number of sensory pathologies central or peripheral can cause positive findings. Peripheral pathologies more common • The most common concern is diabetes • Posterior columns, medial lemniscus

• Tip of the tongue 1 mm • Lips 2-3 mm • Finger tips 2-4 mm • Dorsum of the fingers 4-6mm • Palm 8-12 mm • Back of hand 20-30 mm • Dorsum of foot 30-40 mm

• Used frequently with diabetic patients

• Compare to two point discrimination

• The ability to identify objects and textures by touch and/or differentiate objects by touch

• Palpation/Braille

• Posterior column-Parietal Lobe Function • Depends on intact lower neurological functions

• Can only be tested at the hand

• The ability to recognize letters or numbers written on the skin with a pencil, dull pin, or similar object • Parietal Lobe Function • Depends on intact lower neurological functions • The patient should be able to identify the written letter/number right side up or upside down • Must use dissimilar numbers and letters

• Remember –You are not really drawing the letters/numbers with ink etc.

• Facial Sensation CN 5

– A lesion will likely effect all three branches of the sensory nerve.

– Over 90% of lesions effect the maxillary branch

• Tuning form for hot cold comparison

– Near heating/cooling vent if possible

• After I published the first edition of Practical Assessment I was frequently asked, “What do I do if the patient cannot move or every tests is painful for the patient?”

• Upper motor • Sensation • Lower Motor – Sharp/dull • Coordination – Light touch • Pathological Reflexes – Hot/cold • Vibration • Stereognosis • Proprioception • Graphesthesia

What can be tested at the hands and feet?

• Upper Extremity – Motor C5 – T1 – Sensory C6, C7 & C8 • Lower Extremity – Motor L4 – S1 – Sensory L4 – S1

Practical assessment of the Chiropractic Patient

K. Jeffrey Miller, DC, FIANM(us), MBA

Neurological Testing

• Informed Consent • Mood • Emotional State • Pain Identification • Pain behavior • Examination findings/coding – Bullets

• Orientation – Person – Place – Time • Mood – Pleasant, Agitated, Corporative, Nervous, Friendly etc.

• General Information • Spelling – World-dlrow • Numbers – 100 back by 3’s – Seven Digit Number (office #)

• Orientation – Person • Who are you? • Who am I? – Place • Where are we? – Time • What is the year, season, month, day?

• General Information

– Current Event

• News items

• Popular songs

• Current movies

• Spelling

– Spell the word “world” forward and backward

– Why backward

Miller Copyright 2002-2017 Mental Status • Numbers – Use especially if the patient cannot read – People who cannot read are often able to use numbers • From 100 backward by 3’s • Repeat a 7 digit number (office #) – Don’t use 867-5309

• Zero through Ten Pain Scale – The Numeric Pain Rating Scale (NPRS) – Ask for a verbal rating/response to the question, “Please rate your pain using the numbers 0-10 with 0 being no pain and 10 being the worse pain you can imagine?” – It is good to give reference points • 1-2 = You notice it but would not take an aspirin • 9-10 = You cannot work, drive, go to school etc. – Ask for: • current level of pain • a range from lowest to highest • average for the last 24 hours. Rating Pain

• The 0 – 10 scale is not the “Visual Analog Pain Scale” – Visual Analog Scale = The patient marks a point on a blank line that represents the path from lowest to highest on a diagram/instrument. This is then compared to a line on a separate diagram/instrument that is divided into the numbers 0 through 10. The numbered line serves as the scale for scoring the patient’s response. • The scale is said to be more accurate/objective than the 0-10 scale. Visual Analog Instrument

• I don’t know anyone who uses this method Range of Motion Instrument

• I don’t know anyone using this either…but I want one… Jury Duty Rating Pain

• Pain Factors

Wong-Baker Faces Scale

Numbers Descriptions 0 It don’t hurt 1 Oh…it ain’t nothing/much 2 It hurts a tad bit/smidgen 3 It bothers me some 4 Somethin’ ain’t right 5 It hurts right smart 6 I’m sufferin’ terrible 7 It hurts like far (fire)! 8 It’s killin’ me! 9 I’m ‘bout ta die! 10 Just shoot me!

• Pain Factors

– Facial expressions of pain and apprehension are good indicators of mental status and mood

Frontalis: Fear Surprise

Corrugator Supercilli: Pain

Dental Training

Miller Copyright 2002-2017 Miller Copyright 2002-2017 Miller Copyright 2002-2017 Miller Copyright 2002-2017 Miller Copyright 2002-2017 Miller Copyright 2002-2017 Miller Copyright 2002-2017 Cranial Nerves

Neurological Testing

• CN 1 – Olfactory Nerve

– Sensory only-sense of smell

– Usually not tested routinely

– Why?

• Rosenbaum Chart

– Used from 14 inches

– For Refractive Problems

– Near Vision • #Snellen – Far Vision

Direct Pupillary Light Reflex Indirect Pupillary Light Reflex

Miller Copyright 2002-2017 Miller 2002 Miller Copyright 2002-2017 Cranial Nerves • CN 3 – Oculomotor Nerve – Motor only-eye movements, pupil reactions and blinking – Tests • Cardinal Planes of Gaze • Papillary Light Reflexes

• Ptosis

• CN 4 & 6 - Trochlear & Abducens Nerves – Motor only-eye movements – Tests • Cardinal Planes of Gaze

• Cardinal Planes of Gaze

– Patterns

• The letter H

• Circle

• CN 5 - Trigeminal Nerve – Motor and Sensory – Tests • Motor – Muscles of mastication • Sensory – Facial sensation • Motor/Sensory – Jaw Jerk Reflex

• Muscles of mastication

• Facial Sensation • Toothpicks • Tissue • Many Daily Activities Involve Facial Sensation • Maxillary is primary – Involved 94% of pathologies

• CN 7 – Facial Nerve – Motor and sensory-muscles of facial expression and taste – Tests • Facial expressions – Smile (show teeth), raise eye brows • Taste (Shared with CNs9-10)

Smile Raising the brow

Miller Copyright 2002-2017 Cranial Nerves • CN 8 - Acoustic Nerve – Sensory Only-hearing and balance – Tests • Watch/Finger Rubbing • Forced whisper at no less than five feet • Webber/Rinne • Hum Test • Audiometer

• Finger Rubbing

• Webber – Patient humming is the same with the exception of the method of vibrating the head • Tuning fork • Voice box

• CN 9 & 10 – Glossopharyngal &Vagus Nerves – Motor and Sensory-muscles of the pharynx and taste – Tests • Motor – Gag reflex – Swallowing • Sensory – Taste (shared with CN 7)

– Touch the uvula/soft palate

• Swallowing Test – History of Dysphagia – Osteophytes or DISH

• CN 11 - Spinal Accessory Nerve

– Motor only-shoulder and neck muscles

• Trapezius - shoulder shrugging

• SCM – head rotation

– Tests

• Trapezius and SCM movement and strength

Trapezius Testing SCM Testing

• CN 12 - Hypoglossal Nerve

• Motor only-Tongue movements

– Tests

• Tongue protrusion (Tongue points to pathological side)

• Articulation of Speech

Tongue Protrusion Normal Abnormal

K. Jeffrey Miller, DC, FIANM(us), MBA

• Orientation – Person: the patient writes and signs his own name, demographic information – Place: the patient showed up at the correct office, answers health questions – Time: the patient dates the forms correctly, knows the date of onset for his condition, knows past and family history

• Short Term Memory – The patient knows the date of onset for his condition, the mechanism and the details of the HPI • Long Term Memory – The patient knows past and family history • Spelling – The patient completed paperwork (there are exceptions) • The use of numbers – The patient knows dates and phone numbers

• CN 2 – The patient was able to see: the paperwork, read office signs, where they are going • CN 3, 4 & 6 – Eye movements: move together, all ranges • CN 5 – Facial sensation: if there is a loss of facial sensation the patient will note it while washing their face, brushing their teeth, shaving, applying make-up – Muscles of Mastication: the patient will notice problems chewing – They will report these abnormalities

Miller Copyright 2002-2017 Indirect Assessment • CN 7 – Facial expressions: can the patient smile, frown, blink, raise the brow, annunciate • CN 8 – Could the patient hear you, answer questions appropriately • CN 9 & 10 – Phonation: voice changes – Swallowing-difficulties reported – A lesion of CN 10 is rare

• CN 11

– Can the patient shrug his shoulders

– Can the patient rotate his head

• CN12

– Articulation of speech

• There are times when the patient is too young to be the source of information and/or cannot completed paperwork etc. Patents or guardians must provide information and complete paperwork. • There are also times when a patient’s degree of literacy may interfere with the assessment of mental status through completion of paperwork. • An altered mental state is known/documented and consent to care is solely determined by a guardian. • The advent and continuance of patient generated information in EMR systems, i.e. kiosks, iPads…

• The patient is oriented times three. Demographic and history information provided by the patient included the patient’s full name and showed the patient is aware of being in a healthcare facility. Signatures and dates were provided accurately. Spelling and the use of language are within normal limits and appropriate.

• The first cranial nerve was not tested. The patient was able to see and complete paperwork. Eye movements during the history and examination process were within normal limits. No reports were made of abnormal sensations or numbness of the face. Problems chewing are not reported. TMJ and temporal pain are not reported. Facial expressions are within normal limits. The patient responded to questions appropriately and did not ask for questions or information to be repeated. Difficulties with swallowing and voice changes are not reported or observed. Shoulder and head movements are within normal limits. Movements of the tongue and articulation of speech are within normal limits.

• Look at and listen to the patient. • The observations are important aspects of diagnosis and clinical decision making and they become intuitive. • It must be remembered that these observations can and should be documented.

K. Jeffrey Miller, DC, FIANM(us), MBA K. Jeffrey Miller, DC, FIANM(us), MBA Chiropractic Orthopaedist

Are you familiar with….?

• Maximal Foraminal • The Slump Test Compression Test • Sphinx Test • Bonnet’s Test • Prone Knee Flexion Test • FAST • Brachial Plexus Stretch Test • Cincinnati Prehospital • Fortin’s Finger Sign Screening Test • Aberrant Range of Motion • Drift • Arm Rolling • Tandem Stance • Finger Rolling • Vanzetti’s Test

• The following examination procedures are the author’s best recommendations for the profession based on his education and experience. The procedures do not establish a standard of care for the profession

4/3/16 2002-2016 K Jeffrey Miller DC, MBA The Oldies but not so Goodies

• A few of the procedures discussed in this program are fading in their usefulness and application. They were included because they retain some usefulness, primarily for differential diagnosis. Consider the following: – At some point for each procedure, a physical sign or reaction was noted to be associated with a specific pathology. The relationship was then documented and named. – Despite the passage of time and the development of newer testing options, a patient’s body does not know there are newer and better ways. The body does not know it should only react to the most evidence based diagnostic procedures. This means the physical signs and reactions associated with the fading tests can still occur during physical examination. – We should always be aware of all the physical reactions associated with the pathological conditions of the tissues we are testing and their possibilities of occurrence.

• Discussed does not equate with recommended Disclaimer

• The following procedures ARE NOT the encouragement of short

cuts or skipping important procedures. THEY ARE designed to make the examiner efficient by gathering more information in a shorter period of time to improve diagnosis, plans of care, treatment and ultimately prognosis

4/3/16 2002-2016 K Jeffrey Miller DC, MBA Non-Technique Specific

• The following procedures are independent of examination procedures utilized by individual chiropractic adjusting techniques

4/3/16 2002-2016 K Jeffrey Miller DC, MBA Non-Technique Specific

• The doctor can combine any of the exam procedures and concepts described here with his or her choice of technique(s) and the

technique's analytical procedures

4/3/16 2002-2016 K Jeffrey Miller DC, MBA Important Concepts

• Observation; Many clinical findings related and unrelated to the test being performed can be observed during performance of that test

Miller 2002 4/3/16 2002-2016 K Jeffrey Miller DC, MBA Important Concepts

• Everything Moves;

• In a midline test for example…

– If you flex the cervical spine…The bones, ligaments, disks muscles, the cord, blood vessels, the trachea, the esophagus etc., all move

Miller 2002 4/3/16 2002-2016 K Jeffrey Miller DC, MBA Important Concepts

• Everything Moves;

• In a bilateral test…

– If a structure on one side is compressed the same structure on the opposite side is often stretched

Miller 2002 4/3/16 2002-2016 K Jeffrey Miller DC, MBA Important Concepts

• The body does not know which test is being performed Important Concepts

• Replication; many tests have the same mechanism of performance but have different pathological meanings

Miller 2002 4/3/16 2002-2016 K Jeffrey Miller DC, MBA Important Concepts

• Combinations; orthopedic and neurological tests can be combined to improve efficiency and differential diagnosis

Miller 2002 4/3/16 2002-2016 K Jeffrey Miller DC, MBA Important Concepts

– There are five methods for combining tests

– 1. Testing by Indirect Method

– 2. Same Mechanism/Different Pathology

– 3. Different Mechanism/Same Pathology

– 4. Sequential Testing

– Clusters

Miller 2002 4/3/16 2002-2016 K Jeffrey Miller DC, MBA Testing by Indirect Method

• Examples

– Pulse and Respiration Rates

– Orthopedic Tests and Range of Motion

Miller 2002 4/3/16 2002-2016 K Jeffrey Miller DC, MBA Same Mechanism/Different Pathology

• Examples – Soto-Hall and Lindner’s – C6 Motor Function and Cozen’s Test

Miller 2002 4/3/16 2002-2016 K Jeffrey Miller DC, MBA Different Mechanism/Same Pathology

• Examples – SLR and Lindner’s – Brudzinski’s and Kernig’s

Miller 2002 4/3/16 2002-2016 K Jeffrey Miller DC, MBA Sequential Testing

• Examples

– SLR and Bragard’s

– Cervical Compression and Cervical Distraction

Miller 2002 4/3/16 2002-2016 K Jeffrey Miller DC, MBA Cluster Testing

• Using a specific group of tests for a specific pathology

– Strength in numbers

• The higher the number of positive tests in the group the greater the chance that pathology is present Neurodynamics

• Sensitization = Applying a stress to the nervous system prior to performing a test to make the structures more sensitive to increase the chances of detecting dysfunction. • Summation = Adding stresses together to increase the chances of detecting dysfunction. • Sequencing = stressing tissues from proximal to distal, distal to proximal or beginning in the middle. Important Concepts

• Patient Position; Orthopedic and neurological tests have traditional patient positions but most can be performed in more than one position.

– Tests depicted in photos may vary slightly from the recommended examination procedures for demonstration purposes…Why?

Miller 2002 4/3/16 2002-2016 K Jeffrey Miller DC, MBA Important Concepts

• Space Considerations: There are instances where a test may replace another when examination room space is limited

Miller 2002 4/3/16 2002-2016 K Jeffrey Miller DC, MBA Combination Drift and Maximum Foraminal Compression Test PROCEDURE ONE

• Drift is a test for upper motor neuron lesions • Maximal Foraminal Compression Test is for radicular problems emanating from the cervical spine

• Basic Life Support (BLS) – American Heart Association – Cincinnati pre-hospital stroke • Scale (one positive) – Facial droop – Arm drift – Abnormal speech • Acceptance/Reliability

• F.A.S.T.

– Face

– Arms

– Speech

– Time

• Positive Indications:

– Movements are slow and may take a few seconds to initiate

– Tapping the hand or arm may help initiate movement

– Both arms drifting is not significant

• This is a side note

• Confirmatory Test to Upper Extremity Drift (UMN)

• The eyes

Miller 2002

• This is a side note

• Are the eyes closed?

• Does it matter?

• Max Cervical

– Upper Extremity Radicular Symptoms on the side of rotation

Head Rotation

• The lesions identifiable by Drift are present regardless of head position

• This allows the test to be performed with the head rotated and allows the test to be combined with other tests

• Upper Motor • Lower Motor – Spastic Muscle Weakness – Flaccid Muscle Weakness – Hyper-reflexia – Hypo-reflexia – Pathological Reflexes Present – No Pathological Reflexes Present – Superficial Reflexes – Superficial Reflexes are Present Diminished/Absent – Localization – Centralization

• While the examiner will not be palpating the radial pulse during the examination recommended, the patient may report TOS extremity symptoms with this head position

• S/S on side of head rotation=Adson’s

• S/S on the side opposite of head rotation=Halstead’s

• Vertebral Artery Test • Doctor Should Position Patient’s Head • Eyes Must be Closed • Held 15-30 Seconds Each Side • Drift – Objective – Validity by Common Use

• George’s Functional Maneuver

• Worth Mentioning – Another side note – Unterberger’s Test • Hautant’s combined with marching in place – It tests for the same pathology – While we like combinations, stability is a question here – Unterberger’s Test without head rotation is a Fukuda test • The test is for balance and the positive indicator is the patient rotating has he marches

• Worth Mentioning – Interesting Clinical Information – Drop Attacks – Anxiety • Two curious experiences • The fighter pilot – Amaurosis Fugax • Internal Carotid Artery • DDx – Migraines – temporary unilateral visual impairment

• Radicular arm pain to the side of rotation • TOS symptoms in either arm • Symptoms associated with an established lesion in the cranium similar to or the same as vertebrobasilar pathology • Symptoms of Vertebrobasilar Pathology – Tinnitus, visual disturbances, vertigo, numbness, nausea, nystagmus etc. Brachial Plexus Tension Test PROCEDURE TWO

• Brachial Plexus/Nerve Root Test • Upper Extremity Equivalent of SLR • Built in Confirmatory Test • Nerve vs. Muscle

Tests Replicated or Observed During Brachial Plexus Testing

• Shoulder Depressor Test

• Don’t Whip the Head to the Side!!

• Brachial Plexus Test

– Nerve vs. Muscle

– Head Stabilization and Shoulder Motion (Depression)

• Facet Syndrome/Lumbar Disc Pathology

• Seated Over Standing?

• Medial vs. Lateral Disc

Tests Replicated or Observed During Kemp’s Test

Antalgia Sign

Scheplemann’s

• Correlate with medial vs. lateral disc • Can be seen standing or seated – In some cases lying down • Also Known As – Vanzetti’s Sign

• Pain possible on either or both sides

• Intercostal Neuralgia of Rib Cage Strain/Sprain

– Other rib pathologies

• Tests for Neuromeningeal Tract Tension

• The Most Complicated Yet Most Productive Test

• Soto-Hall • Tripod • Lindner’s – Hamstring Tension • L’Hermitte’s • Kernig’s • Brudzinski’s • Bragard’s • Seated Adams • Fajersztajn’s • Compression Fracture • Homan’s • Bechterew’s • Dejerine’s • SLR / Lasegue's – Valsalva’s • CSLR • Fortin’s Finger Sign

• Maitland, GD. The slump test: examination and treatment. The Australian Journal of Physiotherapy. 1985 • Miller, KJ. The slump test: application and interpretations. Chiropractic Technique. November 1999

• The Slump Test – The Original Description • Five Steps – The Slump, Cervical Flexion, Leg Extension, Foot Dorsiflexion, Cervical Extension – Miller’s Modifications • Three Steps – Simultaneous Leg Extension. Simultaneous Bilateral Foot Dorsiflexion, Cough

• Note the tension and direction of pull on the cord and Sciatic nerve

• Soto-Hall • CSLR • Lindner’s • Tripod

• L’Hermitte’s – Hamstring Tension • Brudzinski’s • Kernig’s • Bragard’s • Seated Adams • Fajersztajn’s • Compression • Homan’s Fracture • Dejerine’s • Bechterew’s – Valsalva’s • SLR / Lasegue's • Fortin’s Finger Sign

• Primary Maneuvers • Secondary Maneuvers – Cervical Flexion – Lumbar Lateral Bending – Spinal Flexion – Hip Flexion – Hip Internal Rotation – Knee Extension – Hip Adduction – Foot Dorsiflexion – Great Toe Extension – Increased Intrathecal- Intradiscal Pressure – Patient Position

• Lying on Back • 30kg/cm2 • Standing • 70kg/cm2 • Walking • 85kg/cm2 • Twisting • 90kg/cm2 • Sitting • 100kg/cm2 • Coughing • 110kg/cm2 • Jumping • 110kg/cm2 • Straining • 120kg/cm2 • Laughing • 120kg/cm2

• The Majority of Disc, Radicular and Sciatic Tests are Performed – Lying on the Back-30kg/cm • Bechterew’s - Slump are Performed – Seated-100kg/cm • Supine vs. Seated MR Scans

Recumbent MRI Seated MRI

Standing - XR Supine – MR Scan Stability – Standing Vs. Sitting

Standing X-ray Supine MR scan

Disc Pressure

• Lying on Back (SLR) • 30kg/cm²

• Standing (Neri’s) • 70kg/cm² • Walking • 85kg/cm² • Twisting • 90kg/cm²

• Sitting (Bechterew's) • 100kg/cm²

• Cough (Dejerine's) • 110kg/cm² • Jump • 110kg/cm²

• Strain (Valsalva’s) • 120kg/cm² • Laugh • 120kg/cm²

• Dejerine’s Triad = ADL (cough, sneeze, strain, laugh)

Escalating Pressure in the Disc

Neri’s Bowing Standing then bending 70-120 kg/cm2 in the disc

SLR-Lasegue’s Lying 30 kg/cm2 in the Disc

• Very General Test • Cervicothoracic – Subluxation – Disc – Sprain – Strain – Fracture • Rib Fracture, The Compression Test

• Lower Extremity Radicular Complaints

• Tethered Nerve Roots

• Electrical-Shock Like Sensations in One or More Extremities • Spinal Cord-UMN • Performed either with quick flexion of the head and neck or the head and neck can be flexed and the position held to see if systems develop

• Hoffman’s test can be added to Lhermitte's test when the head and neck position is sustained or with the patient actively flexing and extending the head and neck. Dynamic Hoffman’s Sign

• Meningitis/Head Bleeds

• Bacterial vs. Viral

• What are the Odds of Seeing This?

• Scoliosis • Seated vs. Standing • Why do both? Compare to Kemp’s

• Be careful! – A reason for allowing the patient to move into a testing positioning • Localized pain and possible angular deformity with short transition

• The same or different? – They both use hip flexion and knee extension – The only difference is the order the two motions occur • Seated Vs. Supine

Start Normal

Abnormal

• Movement of the Good Leg Hurts the Bad Leg

• Medial vs. Lateral Disc

• The majority of disc lesions protrude lateral to the left or right and then lie either medial or lateral to the nerve root. • Medial and lateral refer to the relationship of the disc lesion to the nerve root. • Disc protrusions that are lateral to the nerve root are the most common presentation

• Antalgia Sign/Vanzetti’s Sign

• SLR / Braggard’s

• CSLR / Fajersztajn’s

• Kemp’s

• Slump

• Side Posture – Lateral Disc Protrusion = Adjust with the side of leg pain up – Medial Disc Protrusion = Adjust with the side of leg pain down • This works with the antalgic posturing of the patient and the biomechanics of the pathology

• Ambidextrous • Shoulder Height-levelness – Dominant side lower • Grip Strength – Dominant side stronger by 10% • Impairment Rating – Non-dominant often rated lower • Side Posture Adjusting – Farfan’s Torsion Test – Side of handedness up

• Alternating Layers of Fibers

• Twisting/Sports; Right Handed vs. Left Handed Individuals

Miller 2002 MillerCopyright 2002-2017 Miller 2002 MillerCopyright 2002-2017 Farfan’s Simplified • After studying Farfan’s reasoning and torsion test you will discover that the entire concept can be boiled down to knowing if the patient is left handed, ambidextrous or right handed • Just ask the patient – Guess and impress!

• Radicular Pathology vs. Hamstring Tension?

• Tripod Name?

– Flip Test

• Recliner Sign (Miller)

• Tripod Sign Related to Lung Disorders

• Pain and/or restriction resulting in Tripod Sign – Radicular - unilateral and below the knee – Hamstring - bilateral and above the knee • Prone evaluation (second photo) • Pseudo Lasegue’s (not shown) – Replicates Proprioceptive Neuromuscular Facilitation (PNF) stretching of the hamstrings

• Note the leg not being tested moved!

The leg being tested cannot straighten The Opposite leg flexes at the hip and knee

• Palmer is to chiropractic what… • Don’t perform this test fast – Bring the leg to the testing position and hold – Clonus • SLR – Lateral disc

• …sterling is to silver

• Is testing speed as important here?

– Clonus

• CSLR

– Medial disc

• DVT • The knee is key • Efficiency – If Supine • SLR • Bragard’s • Lasegue’s Differential • Homan’s • The combination can be performed sitting

• Space Occupying Lesions – Disc, tumor – Head and/or Spinal Symptoms • Cough, Sneeze, Bear Down (Valsalva’s) • Easiest to perform?

• Space Occupying Lesions

– Disc, Tumor • Part of Dejerine’s

Tests Replicated or Observed During the Modified Slump Test

• Pain • Obese • Pregnant – Do the original version of the Slump Test in steps • Try Maximum SLR

• Soto-Hall • CSLR

• Lindner’s • Tripod – Hamstring Tension • L’Hermitte’s • Kernig’s • Brudzinski’s • Bragard’s • Seated Adams They can All be • Fajersztajn’s recorded based on • Compression performing the one • Homan’s procedure ! Fracture • Dejerine’s • Bechterew’s – Valsalva’s • SLR / Lasegue's • Fortin’s Finger Sign

• You can back up or fall back to Maximum Straight Leg Raising if you wish to confirm the Slump test or need and alternate test

• SLR • Braggard's • Lindner’s • Dejerine’s Cough • Bonnet’s • Piriformis

• Tests Lumbar Extension and Extension of the Spine Above this Level • Narrows the Spinal Canal • Combine with Pheasant's test

• Sphinx • Pheasant Test • Nachlas Test • Femoral Stretch Test • Ely’s Test • Quadriceps Tension Test

• L/S and/or SI Joint Pathology

• Note approximation of the heel to the buttocks

• Hip Flexion Contracture

• Note; hip flexion with heel approximating the buttocks

• Same position as Nachlas

• Femoral Stretch creating paresthesia in the anterior thigh and/or lower leg

• Note the distance between the heel and the buttock • Normal quadriceps flexibility is being able to touch the heel to the buttocks

• Tests for Anterior SI Ligament Sprains

• Replicates Gaenslen’s and Lewin-Gaenslen’s Tests and Psoas Sign

• Tests for Femoral Never Irritation • Replicates Gaenslen’s and Lewin- Gaenslen’s Tests and Psoas Sign

nGaenslen's (supine)

nLewin-Gaenslen's (side posture)

nPsoas Sign (side posture)

• Tests for Hip Joint Pathology Early and SI Joint Pathology Late • Better than Patrick’s Test – Why? – Internal vs. external hip rotation • Obturator Sign

Hibb’s Patrick FABER

Note the location of the knees

• Obturator Sign

PROCEDURE EIGHT

• Like Vertebral Artery Tests You Are Screening by Simulating the Adjusting Position

• Cervical Range of Motion • Thoracic Range of Motion • Lumbosacral Range of Motion

• Extension 70° Max For../Sphinx

• Rotation 70-90° Max For Comp

• Lateral Bend 20-45° Brachial Plexus

– Rotation is considered a primary component of thoracic range of motion under the AMA Guidelines for Permanent Impairment

• The Seminar Exam

• The Relative Exam

• The “It’s the same old thing exam” Drift and Maximum Foraminal Compression

• Drift is a test for upper motor neuron lesions • Maximal Foraminal Compression Test is for radicular problems emanating from the cervical spine

• Brachial Plexus/Nerve Root Test • Upper Extremity Equivalent of SLR • Built in Confirmatory Test • Nerve vs. Muscle

• Facet Syndrome/Lumbar Disc Pathology

• Seated Over Standing?

• Medial vs. Lateral Disc

• SLR • Braggard's • Lindner’s • Dejerine’s Cough • Bonnet’s • Piriformis

Practical Assessment of the Chiropractic Patient K. Jeffrey Miller, DC, FIANM(us), MBA K. Jeffrey Miller, DC, FIANM(us), MBA Chiropractic Orthopaedist

• Shoulder Range of Motion Test • Symmetry is the key here • Identification of a lateral scapula

Miller 2002 Mazion’s Test

• Glenohumeral Joint pathology or dysfunction • This isolates the glenohumeral joint • A chiropractic test, John Mazion was one of the first chiropractic orthopedists, he taught many of my ortho classes

Miller 2002 Dugas’ Test

• Shoulder Dislocation • Unlikely to see • Why? • Replicated during Mazion’s Test

• Just listed here as a secondary test because of replication

Miller 2002 Impingement Test

• Impingement Pathology • The shoulder motion is the same as Mazion’s and Duga’s • Impingement can be from soft tissues and/or bony structures

Miller 2002 Apley’s Supraspinatus Test

• Rotator Cuff • Can be adapted for biceps tendon • Bursitis is a DDx Supraspinatus Test

• Supraspinatus Rotator Cuff Test • Tendonitis or Tear • Note the position of the thumbs and the abducted arms • Nice for quick bilateral comparison

Miller 2002 Speed’s Test

• Biceps Test for Tendonitis or Tear • Hand position-supination • Arms less abducted than supraspinatus test

Miller 2002 Acromioclavicular Stress

• AC Joint Test • Most Common area for Shoulder Degenerative Arthritis • Shearing motion • This Maneuver can also be Therapeutic Cozen’s Test

• Lateral Epicondylitis Test

• Same Mechanism as C6 Motor Test

Miller 2002 Reverse Cozen’s Test

• Medial Epicondylitis Test

• Same Mechanism as C7 Motor Test

Miller 2002 Valgus Stress

• Medial Collateral Ligament Test • This test should be performed with the arm straight and a second time with the elbow flexed by 30 degrees • Why? Varus Stress

• Lateral Collateral Ligament test • This test should be performed with the arm straight and a second time with the elbow flexed by 30 degrees • Why? Finkelstein’s Test

• Test for Stenosing Tenosynovitis • Should Always be Performed when Symptoms of CTS are Present • An example of when not to rely solely on history

Miller 2002 Ellis Test

• Test for Wrist Flexor Tendonitis • Great test for early detection of pathology that can lead to CTS • This is hard to find a reference for. • Art Croft was mine.

Miller 2002 Phalen’s Test

• Carpal Tunnel Syndrome • The testing positioning is held for 1-2 minutes • Some sources say 30 sec to 1 minute Reverse Phalen’s Test

• Carpal Tunnel Syndrome • The testing positioning is held for 1-2 minutes • Some sources say 30 sec to 1 minute • I feel like Phalen’s and reverse Phalen's tests would be positive more frequently if doctors had the patience to wait for symptoms to develop Anthropometry

• Measure circumference 4 inches above and below the elbow • Swelling - edema • Musculature / atrophy Hibb’s Test

• Tests for Hip Joint Pathology • Early motion tests the hip • Late motion tests SI joint • Better than Patrick’s Test • Why? (2 reasons) • Obturator Sign

Miller 2002 Obturator Sign Comparison: Hibb’s-Obturator What is wrong with the previous slide? Tests Replicated or Observed During Hibb’s Test

• Obturator Sign

Miller 2002 Patrick’s Test

• Hip Joint • Tests External Rotation • Less Accurate than Hibb’s • Because internal rotation is usually lost before external rotation • Obturator Sign Suprapatellar Compression

• Superficial Patellar Edema • Clark’s/Patellar Grind • Squat • Pressure • Quick Test Valgus Stress Test

• Tests the Medial Collateral Ligament of the Knee • Better at 30º of Flexion • Hand placement on lower leg determines the leverage on the joint

Miller 2002 Varus Stress Test

• Tests the lateral Collateral Ligament of the Knee • Better at 30º of Flexion • Hand placement on lower leg determines the leverage on the joint

Miller 2002 Lachman’s Test

• Testing anterior cruciate ligament • More accurate than the anterior drawer test • The lower leg should not touch the table • Lately I have changed my hand placement. I grasp the tibia with both hands and allow the patient’s body weight to be the stabilizing factor to the femur. Anterior Draw Test

• Tests the Anterior Cruciate Ligament

Miller 2002 Posterior Draw Test

• Tests the Posterior Cruciate Ligament

Miller 2002 Slocum’s Test External Tibial Rotation

• Tests anteromedial rotational instability • Same position as Hughston’s Posterolateral Drawer, different direction of rotation/pull • It is all about the foot placement Hughston’s Posterior Lateral Drawer

• Tests posterolateral rotational instability • Same position as Slocum’s Test External Tibial Rotation, different direction of rotation/pull • It is all about the foot placement Slocum’s Test Internal Tibial Rotation

• Tests anterolateral rotational instability • Same position as Hughston’s Posteromedial Drawer, different direction of rotation /pull • It is all about the foot placement Hughston’s Posteromedial Drawer

• Tests posteromedial rotational instability • Same position as Slocum’s Test Internal Tibial Rotation, different direction of rotation/pull • It is all about the foot placement McMurray’s Test

• Tests for Torn Meniscus in the Knee • Palpate the joint margin while flexing and extending the knee • Feeling a click may indicate a tear • The Patient may be More Exact in Reporting a Positive Finding, the doctor may not feel the click

Miller 2002 Thessaly’s test

• Meniscal tear • Better that most meniscal tests • Weight bearing • Easier than Duck walking for most patients Hughston’s Plica Test

• Tests for the Presence of a Plica in the Knee • Very similar to McMurray’s Test • Palpate the medial edge of the patella • The foot is key here as well

Miller 2002 Bounce Home Test

• Tests for Torn Meniscus in the Knee and Joint Locking

Miller 2002 Allis

• For determining structural deficiencies • The Femoral and Tibial differences can be assessed • Picture 1 femoral defect • Picture 2 tibial defect Ankle Anterior Drawer

• Same Principles as any Drawer test • Anterior Instability Ankle Posterior Drawer

• Same Principles as any Drawer Test • Posterior Instability Ankle Valgus Stress

• Same Principle as any Valgus Stress • Medial Instability • Less likely to see due to • Malleolus and strength of the deltoid ligament Ankle Varus Stress

• Same Principle as any Varus Stress • Lateral Instability • Medically - a lateral ankle sprain is considered the most common musculoskeletal injury. One in every ten thousand people per day Anthropometry Anthropometry

• Six inches above and below the knee for circumference – • Musculature - atrophy • Swelling - edema

• Leg length • ASIS to either malleolus • Either works just be consistent • This test is far from accurate • Imaging - Extremity alignment study Practical Assessment in Orthopedic Care

Orthopaedic Test and Treatment Clusters Evidence Based Assessment of Grouped Tests K. Jeffrey Miller, DC, FIANM (us), MBA Texts that Contain Cluster Information

• Malanga & Mautner – Musculoskeletal physical examination, 2nd ed., Elsevier, 2017 • Cook & Hegedus – Orthopaedic physical examination tests, 2nd ed., Pearson, 2013 • Cleland & Koppenhaver – Netter’s Orthopaedic clinical examination, 2nd ed., Saunders, 2011 • Clinically Relevant Technologies – Core iPhone/iPad App, version 6 • Miller – Practical assessment of the chiropractic patient, 2nd ed., ABEL Media 2014 Clusters • In recent years, evaluating the accuracy of physical tests has evolved into testing of clusters or groupings of the tests. The clusters have been evaluated against a gold standard if one exists.

• Sensitivity, specificity, positive and negative likelihood ratios, Kappa Values and other statistical information have been identified for each cluster. Clusters

• This information is then used to recommend for or against each cluster.

• Use of the cluster is often referred to in terms of Post Test Probability (PTP). Clusters

• For example: – The cluster for cervical radiculopathy • Upper limb tension test A • Cervical rotation to the involved side <60 degrees • Distraction Test • Spurling’s Test – Post Test Probability is based on the number of tests found to be positive. The greater the number the greater the chance of the condition being present. • 2 positive tests = 21% • 3 positive tests = 65% • 4 positive tests = 90% Clusters

• For this cluster:

– A positive test was for cervical radiculopathy or carpal tunnel syndrome

– The gold standard was electrophysiological examination Clusters • It must be noted: – The diagnosis from the cluster is variable. – Even when all 4 tests are positive the results do not reach 100% probability. – Clusters are not a new concept. It has always been acknowledged that a diagnosis should be based on multiple numbers of positive tests. Single tests are rarely, independently reliable in Dx. Orthopedic Test Clusters

• Gillard’s TOS Cluster

• Cervical Traction Cluster • Cook’s Clinical Prediction Rule • Cervical Myelopathy Cluster for Lumbar Stenosis Cluster

• Cervical Radiculopathy Cluster • Roman’s Clinical Prediction Rule for Compression Fracture Cluster Orthopedic Test Clusters

• SI Provocation Cluster

• Specific Exercise (lumbo-pelvic) • Lumbar Instability Cluster Cluster • Lumbar Manipulation Cluster • Laslett’s Sacrum Cluster #1 • Lumbar Traction Cluster • Laslett’s Sacrum Cluster #2

• Van der Wurff’s SI Cluster Orthopedic Test Clusters

• Ozgocmen’s SI Cluster • Cook’s Cluster #1 (SI) • Cibulka & Koldehoff’s SI Cluster • Cook’s Cluster #2 (SI) • Riddle & Freburger’s SI Cluster • Cook’s Cluster #3 (SI) • Kokmeyer SI Cluster • Cook’s Cluster#4 (SI) • Arab’s palpation Cluster (SI) • Cook’s Cluster #5 (SI) • Arab’s Pain Provocation Cluster (SI) Orthopedic Test Clusters

• Shoulder Instability Cluster • Shoulder Rotator Cuff Cluster • Shoulder Impingement Cluster • Knee Effusion Cluster • Shoulder Labral Tares Cluster • Patellofemoral Dysfunction Cluster • Shoulder AC Joint Path Cluster • Shoulder Biceps Tendinopathy Cluster Cervical

• Myelopathy Test Cluster 1. Hoffman’s Sign Test 2. Cervical Deep Tendon Reflex Test 3. Inverted Supinator Test 4. Suprapatellar Quadriceps Test 5. Hand Withdrawal Reflex Test 6. Babinski Sign Test 7. Clonus of the Ankle Test Myelopathy Test Cluster Continued

Study # of positives Tests include Reliability Sensitivity Specificity LR+ LR- QUADAS Score (0-14) Cook, 2009 1 of 2 • Inverted Supinator 0.67 0.33 1.0 1.0 (IVS) • Suprapatellar Reflex Cook, 2009 2 of 2 • IVS 0.50 0.75 2.0 0.7 • Babinski sign Cook, 2009 2 of 3 • Hoffmann’s Reflex 0.50 0.83 3.0 0.6 • Babinski sign • IVS Cook, 2009 3 of 4 • Hoffmann’s Reflex 0.44 0.82 2.7 0.7 • Suprapatellar Reflex • Babinski sign • IVS Cervical

• Cervical Radiculopathy Test Cluster 1. Upper Limb Tension Test A 2. Involved cervical rotation < 60 degrees 3. Distraction Test 4. Spurling’s Test Study Reliability Sensitivity Specificity LR+ LR- QUADAS Score (0-14) Wainner et al. (2 out 39 56 0.88 1.08 10 of 4 positive tests) Wainner et al. (3 out 39 94 6.1 0.64 10 of 4 positive tests) Wainner et al. (4 out 24 99 0.76 0.76 10 of 4 positive tests) Thoracic • Gillard’s Cluster for Thoracic Outlet Syndrome 1. Wright’s Test 2. Adson’s Test 3. Hyper-abduction Test 4. Roo’s Test 5. Tinel’s Test • QUADAS = Quality Assessment of Diagnostic Accuracy Studies; helps evidence bases researcher detect error and/or bias, scores ≤ 7 bad and ≥ 8 good (you want 10 or above)

Study # of positive Reliability Sensitivity Specificity LR+ LR- QUADAS Score (0-14) Gillard et al. 2 of 5 90 6 0.95 1.7 8

Gillard et al. 3 of 5 90 29 1.3 0.34 8 Gillard et al. 4 of 5 87 38 1.4 0.34 8 Gillard et al. 5 of 5 84 84 5.3 0.19 8 Lumbo-Pelvic

• Cook’s Clinical Prediction Rule for Lumbar Stenosis 1. Bilateral symptoms 2. Leg pain more than back pain 3. Pain during walking/standing 4. Pain relief upon sitting 5. Age > 48 years

Study # of positive Reliability Sensitivity Specificity LR+ LR- QUADAS Score (0- 14) Cook et al. < 1 of 5 96 20 1.2 0.19 7 Cook et al. 4 out of 5 6 98 4.6 0.95 7 Lumbo-Pelvic • Lumbar Manipulation Test Cluster 1. Duration of current episode of low back pain < 16 days 2. Extent of distal symptoms: No symptoms distal to the knee 3. FABQ work subscale score < 19 points 4. Segmental mobility testing with at least 1 hypo-mobile segment in the lumbar spine 5. Hip internal rotation ROM with at least 1 hip with >35 degrees of internal rotation ROM

Study # of positives Reliability Sensitivity Specificity LR+ LR- QUADAS Score (0-14) Flynn, 2002 1+ variables 1.00 0.03 1.03 Flynn, 2002 2+ variables 1.00 0.15 1.18 Flynn, 2002 3+ variables 0.94 0.64 2.61 Flynn, 2002 4+ variables 0.63 0.97 24.38 Lumbo-Pelvic

• Sacroiliac Provocation Test Cluster 1. Sacroiliac Distraction Test 2. Sacroiliac Compression Test 3. Thigh Thrust Test 4. Gaenslen’s Test for Right Leg 5. Gaenslen’s Test for Left Leg 6. Sacral Thrust Test

Study # of positives Reliability Sensitivity Specificity LR+ LR- QUADAS Score (0-14) Laslett, 2005 1 of 6 1.00 0.44 1.78 0.00 Laslett, 2005 2 of 6 0.93 0.66 2.73 0.10 Laslett, 2005 3 of 6 0.94 0.78 4.29 0.80 Laslett, 2005 4 of 6 0.60 0.81 3.20 0.49 Laslett, 2005 5 of 6 0.27 0.88 2.13 0.84 Sacroiliac

• Van der Wurff’s Cluster 1. Distraction Test 2. Compression Test 3. Thigh Trust 4. Patrick Sign 5. Gaenslen's Test

Study # of positives Reliability Sensitivity Specificity LR+ LR- QUADAS Score (0-14) Van der Wurff et al. 3 of 5 85 79 4.02 0.19 12 Sacroiliac

• Arab’s Pain Provocation Cluster 1. Thigh Thrust 2. Hip Abduction 3. FABER

Study # of positives Reliability Sensitivity Specificity LR+ LR- QUADAS Score (0-14) Arab et al. 3 of 3 0.88 right 1.0 left Shoulder

• Instability Test Cluster

1. Anterior Apprehension Test

2. Relocation Test

3. Surprise Test

Study # of positives Reliability Sensitivity Specificity LR+ LR- QUADAS Score (0-14) Lo, 2004 3 of 3 0.40 1.00 0.60 Lo, 2004 2 of 3 0.98 0.96 24.05 0.02 Shoulder • Diagnostic Clusters – Rotator Cuff

Study Cluster Reliability Sensitivity Specificity LR+ LR- QUADAS Score (0-14)

Malhi & Khan Supraspinatus weakness or 100 99 5 impairment of abduction

Litaker et al. Age ≥ 65 and weakness in 49 95 9.84 0.54 10 external rotation and night pain MacDonald et Hawkins and Neer 88 38 1.42 0.32 7 al. Hawkins or Neer 83 56 1.89 0.31

Ardic et al. Hawkins or Neer 78 50 1.56 0.44 12 Bak et al. Active abduction < 90 degrees + 54 65 1.20 0.71 13 empty can + ERLS test Bak et al. Active abduction < 90 degrees + 72 39 1.18 0.72 13 empty can + Hawkins Shoulder

• Diagnostic Clusters – Impingement

Study Cluster Reliability Sensitivity Specificity LR+ LR- QUADAS Score (0-14)

Malhi & Khan Hawkins or Neer or 84 76 3.5 0.21 5 Painful Arc or Subacromial Crepitus Calis et al. At least 3 of 6: Hawkins, Neer, 84 44 1.5 0.36 8 Horizontal Adduction, Speed, Yergason, Painful Arc Drop, Drop Arm Michener at 3 or more positive of: 75 74 2.93 0.34 11 al. Hawkins, Neer, Painful Arc, Empty Can, External Rotation Weakness Shoulder

• Diagnostic Clusters – AC Joint Pathology

Study Cluster Reliability Sensitivity Specificity LR+ LR- QUADAS Score (0-14) Chronopoulos 2 or more of: 81 89 7.36 0.21 10 et al. Cross-body Adduction, AC Resisted Extension, and Active Compression Shoulder

• Diagnostic Clusters – Biceps Tendinopathy

Study Cluster Reliability Sensitivity Specificity LR+ LR- QUADAS Score (0-14) Kibler et al. Upper Cut and 9 Speed’s Gill et al. Speed’s and 68 49 1.31 0.65 12 Biceps Palpation Knee

• Clusters for Patellofemoral Dysfunction

Study Reliability Sensitivity Specificity LR+ LR- QUADAS Score (0-14) Cook et al. 1. Pain with resisted knee extension and 35 89 3.3 0.79 10 squatting 2. 2 of 3 (pain with resisted knee extension, 60 85 4.0 0.50 squatting, peripatellar palpation 3. 3 of 3 (pain with resisted knee extension, squatting, kneeling) 33 89 3.1 0.70 Pihlajamaki et al.

Anterior knee pain + crepitus or pain with 72 42 1.24 0.67 8 manual examination of the patella In Conclusion

• A lack of evidence for something does not equate with evidence against something • Not everything has been studied (by Medicine or Chiropractic) • Some things that have been studied were the subject of poorly designed/executed studies • Some studies have high degrees of bias • Some things have been studied a limited number of times • The study of the studies is as important as the studies • Practitioners/organizations that claim to be solely evidence based are not – Read this article

– Title: Major risks and complications of cervical epidural steroid injections: An updated review by Nancy Epstein (Google the title) file:///D:/Major%20risks%20and%20complications%20of%20cervical%20epidural%20steroid%20injections_%20An%20updated%20review.pdf Texts that Contain Cluster Information

K. Jeffrey Miller, DC, FIANM(us), MBA

International Academy of Neuromusculoskeletal Medicine Diplomate Program K. Jeffrey Miller, DC, FIANM(us), MBA Chiropractic Orthopaedist

• As a Doctor of Chiropractic you are already an experienced practitioner. You are skilled in history, examination and other diagnostic techniques. – This program expands your skill set . You will learn additional diagnostic techniques and also development a greater understanding of the circumstances and application of your current diagnostic skills – You will use your skills in a variety of circumstances… 1. Height Clinical Examination Categories 2. Weight Vital Signs 3. Blood pressure seated, There are five to seven vital 4. Blood pressure supine and signs listed as routine depending upon what you standing read. Performing three can 5. Temperature count as having recorded 6. Heart rate vitals 7. Respiration rate Clinical Examination Categories 1. Heart rate Vital Signs 2. Blood pressure There are five to seven vital signs listed as routine 3. Temperature depending upon what you read. Performing three can 4. Respiration rate count as having recorded 5. Pain vitals Clinical Examination Categories

• Pain is being considered the new vital sign, labeled “The Fifth Vital Sign”

– Numeric Pain Rating Scale (NPRS) - the 0 through 10 scale

– What resulted in the focus on pain and pain scales? What resulted in the focus on pain and pain scales?

• The Opioid Crisis

– American Pain Society coin the slogan, “Pain: the Fifth Vital Sign”

– 1998, Veterans Health Admin also began using pain as the fifth vital sign

– Joint Commission for Accreditation of Healthcare Organizations did the same

• The result: NPRS, Visual Analog, Wong-Baker etc. The “Five Vital Signs”

• Pulse

• Blood Pressure

• Body Temperature

• Respiration

• Pain Clinical Examination Categories

• Vital Signs

– Constitutional Vital Signs

• Updated Blood Pressure Standards BP Category Systolic in mmHg Diastolic in mmHg Normal Less Than 120 Less Than 80 Elevated 120 – 129 Less Than 80 HBP – Stage 1 130 – 139 80 – 90 HBP – Stage 2 140 or Higher 90 or Higher HBP – Hypertensive Higher Than 180 Higher Than 120 Crisis! Immediate Care Required! Clinical Examination Categories

• Vital Signs

– Constitutional Vital Signs

• Staff Assistance

– Exams involving measurements vs those requiring immediate interpretation

• But ultimately, whose Responsibility ??? Responsibility

• Some specialties now avoid recording vital signs. The thought process concerns responsibility. Abnormal findings can require further testing, treatment, referral, follow up etc. • Example – Medical orthopaedist do not routinely prescribe blood pressure medications. It is considered a peripheral part their practice. They do not want to take responsibility for something they don’t typically treat. So, they often avoid routinely recording vital signs. • An exception here: BP during surgery • What do you think? Clinical Examination Categories

• Chiropractic Vital Signs - Posture Analysis

– Chiropractic “Bread and Butter”

• Used in multiple situations, in and out of the office: new and established patient examinations, scoliosis screening, pre-participation exams etc. Clinical Examination Categories

• Screening Examinations – In and out of the office – Baselines - foundations – My 4 and 5 procedure screening examination • The seminar examination – A big no, no these days • The relative examination • The “same old thing” examination Clinical Examination Categories

• Consultations – In chiropractic, consultations have long been considered to be talking with a patient or taking a patient’s history – The true definition in healthcare is from the CPT coding system • Consultation – An examination performed by one doctor at the request of another doctor » This is the first of the three “R’s” • Referral/Request • Rendering of the service • Report back Clinical Examination Categories

• General Physical Examination – Review and examination of Systems – # Examination areas – In addition to the musculoskeletal and neurological systems I review the following: cardiovascular, respiratory, GU, GI, EENT, Clinical Examination Categories

• Pre-participation Examinations – Sports • AAFP/AAP • NCAA • State – Exercise programing strongly related here • Baseline and progress – Camps (church, scouts etc.) – Band, cheerleading, dance teams etc. Clinical Examination Categories

• Pre-participation Examinations

– National, state, local and other organizations have specific forms, most are available online

– I recently had a student collect the NCAA, Boy Scout and Girl Scout forms, as well as the required forms from every state Clinical Examination Categories Clinical Examination Categories Clinical Examination Categories

• Emergency Examinations – BLS • The ABCs • In or out of office emergencies • Licensing • Credentialing • Carrier requirements – On-field emergencies • It used to be the ABCs now it is… • ABCDs (airway, breathing, circulation and defibrillation) – Newer version, DRS-ABCD: danger, response, shout, airway, breathing, circulation and defibrillation • Spine protocols Clinical Examination Categories

• Post Offer Employment Examinations – Pre and Post ADA law practices – For me…No Pass or Fail • Mild, moderate, significant risk – DOT (this is its own category) – Use exercise programing standards as guidelines • Occupational Athletes • Percentage of body weight examples Clinical Examination Categories

• Impairment Rating Examinations – Current guides – Your states preferences • The current guides, the state’s own guides, no official standards – The difference between impairment and disability • Other names for these – The exam form and content from the 5th edition of the Guides

Clinical Examination Categories

• Chiropractic Technique Examinations – Examdoc.com - PART chart – Motion and static palpation – Reflex based technique analysis – Indicator based adjusting – Pattern adjusting…areas of anatomical transition… – ”The Flying Seven” pelvis/SI left and right sides, lumbar, thoracic, lower cervical, upper cervical left and right – Area of complaint vs full spine – E & M built is into the manipulation code for us but not for Osteopaths, they can use a separate code and charge an E & M procedure with every manipulation • Under what circumstances can we do this? Clinical Examination Categories

• Extremity Examination

– Extremity care has always been a part of chiropractic

– Extremity care is often associated with sports but it is really a part of every general practice and is definitely a part of an occupational practice

• Occupational athletes Clinical Examination Categories

• Department of Transportation Physicals

– This is a good program

– The examination procedures are standard

– The government’s rules and guidelines are the key to certification in… my opinion Clinical Examination Categories

• Observable Examination Findings – 75-100 observations could be made weekly in most practices. There is probably at least one thing you can notice about every patient that could be recorded as an objective finding. – Probable cause – Do some “people watching” • Airports • Ringing the Salvation Army Bell • Crowds in general Observed Objective Findings

Left Posterior Right Posterior Observed Objective Findings

Left Posterior Right Posterior

Short Left Leg The jeans drag the ground and/or are stepped on repeatedly