In orthopaedic and neurological testing, some tests can be performed using more than one patient position. In some situations this is by design, as discussed in part 1 of this article (August issue). In other situations, it is a result of adapted use.
1. Position May Vary Based on How the Testing Procedure Was Learned
It isn't unusual for two doctors to discuss a testing procedure and discover they are performing the same test in different manners. The origin of the difference can often be traced to the doctors' training. Both had the experience of a "Good Old Doc So-and-So" at their chiropractic college who taught examination techniques. Odds are the Good Old Docs were different ages, used different textbooks, and had different levels of academic and practice experience.
For example, I learned to slowly dorsiflex the foot and hold that position during Braggard's test. A colleague uses a different method, quickly snapping the foot into dorsiflexion and releasing it immediately. We traced the difference back to our initial training.
2. Position May Vary Based on Experience and Preference
Once doctors leave chiropractic college, there is a tendency to modify skills. This happens with technique and examination skills. Some things don't operate in the real world like they are portrayed in textbooks. The caution here is to avoid too much modification and lower your standards of care.
3. Position May Vary to Accommodate a Physical Limitation (Patient or DC)
Patients often experience pain that prevents them from achieving or sustaining an examination position. For example, some morbidly obese patients are unable to make it onto examination tables and doctors of smaller stature may have trouble moving obese patients. For a doctor, personal obesity can also be a problem. This situation can force the doctor to modify patient testing positions to assist in the performance of an examination.
Other physical limitations of the doctor can also force adaptation. Injured or arthritic hands, elbows, shoulders, hips and knees are common chiropractic occupational maladies.
4. Position May Vary to Accommodate the Availability of Equipment
Some chiropractic tables are contoured instead of flat. Tables can also have different degrees of padding. These differences can influences starting and ending postures associated with some tests.
As you know, some orthopaedic tests require the use of a table; for example, supine straight leg raising. But there are times when a table is not available. In this situation, a chair will do, allowing you to perform a seated SLR test.
Similar circumstances can occur when adjusting. A diversified procedure such as a rotary break can be delivered with the patient on a table or in a chair.
5. Position May Vary in Order to Increase Efficiency / Safety
Toe walking is a test of S1 motor strength. The patient is instructed to walk across the room or down the hall on their toes. Unfortunately, the patient is usually walking away from the examiner. This decreases the examiner's ability to spot or stabilize the patient. The test also requires enough space for the patient to walk.
To assist in protecting the patient and operate in an area in which space is limited, heel raises can be substituted for toe walking.
6. Position May Vary to Help Confirm Results, for Differential Diagnosis or to Detect Malingering
The supine and seated versions of the SLR test help confirm each other. The results should be essentially the same. If they are not, it can raise suspicion, especially if results vary greatly. It can be a good idea to perform the test in both positions.
7. Position May Change Simply Because the Doctor Forgot How to Perform a Test Correctly
Patient position may vary based on a doctor's skill. Although rare, a doctor may simply be performing a test incorrectly, having forgotten how the patient should be positioned. The doctor may also interchange the names of specific tests, resulting in incorrect performance, incorrect diagnosis and incorrect treatment. This is often the result of apathy and failure to maintain skills. As you might expect, it is not a useful adaptation.
It is a good idea to periodically review the tests listed on forms and in EMR systems used in the office.
Clinical Takeaway
The topic of patient positioning during examinations isn't widely covered in literature, but it is important. Doctors can usually employ different patient positions when utilizing adjusting techniques. The same abilities should apply for examination techniques.
Resources
- Centeno CJ. The Spine Dictionary: A Comprehensive Guide to Spine Terminology. Philadelphia: Hanley & Belfus, 1999.
- Dutton M. Orthopaedic Examination, Evaluation and Intervention, 2nd Edition. New York: McGraw-Hill, 2008.
- Evans R. Illustrated Orthopedic Physical Assessment, 3rd Edition. St. Louis: Mosby, 2009.
- Magee DJ. Orthopedic Physical Assessment, 5th Edition. St. Louis: Saunders/Elsevier, 2008.
- Simel DL, Rennie D. The Rational Clinical Examination: Evidence Based Clinical Diagnosis. New York: McGraw-Hill, 2009.
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