When I was at Palmer in the mid-1980s, we were given a set of notes in one of our diagnostic courses. The notes covered approximately 70 orthopedic and neurological tests for various regions of the body.
At the time, the information in the two sources seemed substantial; they contained more than 100 tests between them. The information was sufficient for student and outpatient clinics, most state boards, the national boards and for starting a practice. The only exception in my case was having to obtain Joseph Cipriano's text, Photographic Manual of Regional Orthopaedic and Neurological Tests, for the Tennessee board examination. (It was their required text.)
Just after I began practice, I entered the postgraduate program for chiropractic orthopedic certification. It was not long after that I discovered there were more orthopedic and neurological tests – a lot more.
John Mazion was one of my instructors in the orthopedic program. He introduced me to his texts, Illustrated Manual of Neurological Reflexes/Signs/Tests and Orthopedic Signs/Tests/Maneuvers for Office Procedure. Shortly thereafter, Ronald Evans and the team of Janet Gerard and Steven Kleinfield published superb texts on orthopedic testing, Illustrated Orthopedic Physical Assessment and Orthopaedic Testing, respectively. The number of tests I was being exposed to was growing by leaps and bounds. This contributed to the stress of studying for the orthopedic boards. How could I remember them all? Fortunately, I remembered enough to obtain certification.
Since that time, most of the texts mentioned here have been updated at least once. Plus, there are new publications with new tests being published on a regular basis. (I have even added to the volume with texts of my own.)*
The desired effect for the orthopedic and neurological texts and their content is doctor education and patient care. However, a side effect in many cases is confusion. The number of tests is simply overwhelming. I address the volume and confusion when I teach and write about examination skills. It is an uphill battle, to say the least. What should doctors do? We are required to stay abreast of current literature and techniques, but how?
The answer is, "One step at a time." Here are a few tips to help you review, renovate and revive your orthopedic and neurological testing skills and procedures.
Give Your Ortho / Neuro Testing Skills and Procedures a Boost
First, buy an up-to-date text on orthopedic and neurological testing; one that contains evidenced-based information. (See Table.) Look up the tests you currently use to determine if there is literature to support their use. This isn't as hard as it sounds, as the texts have the information listed with the individual tests or in charts within the chapters.
Note that a lack of evidence to support a test could be attributable to the fact the test has not been studied. A lack of evidence for a test should not be equated with evidence against it. Some of the "oldie but goodie" tests have not been studied or were studied ineffectively. Don't "throw the baby out with the bathwater" (an oldie but goody test) if there isn't a tremendous amount of evidence; however, if there are other well-supported tests for the same pathology that can replace a test (an oldie but goodie), consider doing so.
Second, compile a list of tests you feel fits your practice, and the conditions you usually diagnose and treat.
Third, study the tests. You may need to relearn some of the tests you have been using. This sounds odd, but it isn't. Just as we modify our adjusting skills over the years we modify our examination skills, sometimes a little too much. Go back to the basics for your established tests; then start from scratch with the newer tests. There are several key factors that must be learned for almost every test. They are detailed below with brief explanations. Once you have studied and practiced the key factors for each test, developing a new "examination flow" should be easy.
Orthopedic and Neurological Testing: Key Considerations
Test Name: Use the most common name for each test. That name should be listed on forms and other documentation.
Synonyms: It is common for tests to be known by more than one name. You should be familiar with other names for tests in order to communicate with providers using the other names.
Test Objective: You should understand the condition the test is intended to help detect.
Patient and Doctor Positions: Many tests have a single patient position, while others can be performed in more than one position. There are also times when the patient's position must be improvised due to pain or other circumstances. Your position is more flexible. This is important, as there are times when examinations are not performed under ideal circumstances or you may have physical restrictions that prevent a more traditional positioning.
Doctor's Hand Placement: The positioning of your hands is extremely important. Hand positioning must be as specific as possible in order to stress the appropriate tissues.
Stabilization: The patient should always be in a stable position for safety purposes. You also may need to stabilize an area being tested. Stabilization may be intended to prevent further injury or to isolate structures.
Order: Some tests are a single maneuver, while others are a series of steps. Tests that require a series of steps must be performed in the correct order.
Normal Side First: When a test can be performed on either side of the body, it should be performed on the asymptomatic side first to establish a baseline for the patient. The asymptomatic side is assumed to be within normal limits unless there is a reported or detectable problem on the asymptomatic side.
Time: Some tests have a time component – Phalen's test and the elbow flexion test are examples. Their testing positions must be held for a period of time to allow the mechanism of the test to induce symptoms.
Interpretation: Responses or indicators that make a test positive, negative, present, absent, etc., must be known and adhered to for interpretation. Random responses cannot be recorded as positives or pathological findings.
Similar Tests: Many tests share similar mechanisms of performance. This means attention must be paid to detail, and the tests must be performed and interpreted in a precise manner.
Confirmatory Tests: A good rule of thumb is to know two confirmatory tests or procedures for every test you use. This should be considered when compiling the list of new tests to be performed. The key factors for these tests also will have to be studied.
If, after reading this article, you don't want to change how you are examining your patients and don't wish to pursue learning new tests, at least try thinking through the key categories for the orthopedic and neurological tests you use in your practice. Be honest with yourself: Can you describe the necessary details for each test? If not, consider renovating your procedures. Good luck!
Editor's Note: Dr. Miller is the author of Practical Assessment of the Chiropractic Patient, 2nd Edition and Orthopedic and Neurological Examination in a Flash, additional evidence-based resources providing information on neurological / orthopedic testing.
Click here for more information about K. Jeffrey Miller, DC, MBA.