A functional examination is by definition an examination that examines the function of the involved area. A functional examination of the musculoskeletal system should not be just a series of orthopedic tests eliciting a diagnosis but, also, a differential testing of the passive tissue (ligaments, bursa, joint capsule) versus the contractile tissue (muscle, musculotendinous portion, adjoining tendon, and tenoperiosteal insertion). Only by such a comparison can you truly determine the source of the pain.
Let us, for example, functionally examine a 70-year-old with a recent cervical strain/sprain. An x-ray might show severe spondylosis and foraminal encroachment. Motion views might show decreased range of motion. Obviously, the spinal degeneration was present the day before the trauma. As to the range of motion on x-ray, we cannot be certain of the pre-existing range. Functional testing of the cervical muscles might be carried out by asking the patient to isometrically resist against our pressure while we test for any pain (muscle involvement) while the patient pushes in all six directions. Possibly there is no pain on resisted testing. We then passively rotate the spine in all directions feeling for the end-feel, range of motion, and most importantly, whether pain is elicited. If resisted testing was painless and passive testing was painful, then it would be apparent that the passive structures (joint, capsule, and ligaments) are probably the primary source of the pain. Motion palpation of the spine might elicit painful segmental loss of motion at one or several spinal segments. I emphasize painful loss of motion because this patient may have had asymptomatic intersegmental loss of motion for the past 20 years.
Based on the above functional examination, my report of findings would be that this patient could consider himself well when the positive functional findings were no longer present. In other words, before this patient is dismissed, he has to pass the final examination. Just because he feels well is not enough. This patient would be given a passive cervical examination every visit. The patient would learn to feel what is normal for him by comparison with the normal side. This patient would be treated until all the tests that elicited the pain, that was probably not there before the trauma, was gone. Healing might be slow on an elderly individual, and I would initially give him a range of time that might be required until dismissal. Explaining to the patients their problem and what they should expect based on the functional examination allows the patient to understand why they should not miss visits or dismiss themselves when they determine that they are well. The day they come into the office and pass all tests, before treatment, is the day they are dismissed. You can't pass the course until you pass the final examination.
Theoretically, the last visit of patients should not require an adjustment since they are well. If you adjust them then there was something wrong which should be examined again until all is well.
While I used the spine as an example, a functional examination associated with a report of findings is especially applicable for the extremities.
As I traveled around the country the past four years for MPI, I am amazed that at least 80 percent of each class does not examine the musculoskeletal system with the underlying concept of comparing the passive and contractile tissue. Happily, more of our colleges are teaching this crucial concept.
Warren I. Hammer, M.S., D.C., D.A.B.C.O.
Norwalk, Connecticut
Editor's Note:
Dr. Hammer will conduct his next soft tissue seminar on March 14-15, 1992 in Las Vegas, Nevada. You may call 1-800-327-2289 to register.
Dr. Hammer's new book, Functional Soft Tissue Examination and Treatment by Manual Methods: The Extremities, is now available. Please see the Preferred Reading and Viewing list on page xx, Part #T126 to order your copy.
Click here for previous articles by Warren Hammer, MS, DC, DABCO.