Archives for November 2013

Etch-a-Sketch Exam

When a patient arrives with a chief complaint, be it back pain, limited hip ROM, headache, sore neck, or tingling/numbness down one leg.  What do you choose to do for an evaluation? 

While there are certain standards of care clinicians must follow, various schools of thought place emphasis on different parts of the examination process.  (side note: non-clinicians should recognize these symptoms and make appropriate referral)

I was once taught that the patient history will reveal 85% of the diagnosis.

I have also heard that history is unnecessary, movement/functional assessment alone will show us where the truly problem lies.

Let’s compare:

Take a complete, thorough, and detailed history.

History taking = ???% of your diagnosis

  • When did it start?
  • How did it start (mechanism of injury)?
  • What makes it worse?  Better?
  • Have you had it before?
  • What does it feel like?
  • How is it impacting your work, sport/recreation, and daily life?
  • Constant or intermittent?
  • Other treatment?  Pictures/imaging?
  • Past medical history? Medications? Surgeries?  Family history?
  • What are your concerns about your condition?
  • & more based on the answers provided.

View a complete movement assessment.

Observing movement, posture, and exercise gives us all the information that the patient is unable to provide.

Respecting regional interdependence, understanding that patients lie or at least fail to tell us the whole truth (intentionally or unintentionally), and that movement is a window into the nervous system often revealing the true cause of the condition we could look at:

  • Breathing
  • Upright posture
  • Active ROM (passive ROM if appropriate)
  • Basic functional movements: Squat, lunge, gait or single leg stance
  • View sports positions or activities of daily living
  • Or follow a commercial assessment model (insert a high quality acronym here… SFMA, DNS…..)
  • Perform condition specific tests or follow up tests based on the results of the initial assessment….

I have seen both of these work.  At times  a high quality history reveals a very clear picture of what is wrong and what the likely treatment solution should be.  Other times, it doesn’t.  Often, a movement based assessment the dysfunction reveals itself clearly and the path to progress is ready to be followed, but not always.  However, both have challenges:

Histories are subjective.  They are subject to bias based on the patients ideas, beliefs, fears, internet-reading habits, recollection, and motivations.  Movement assessment is more revealing but also only gives a present snapshot, it does not tell you what else lurks in the past that need to be aware of.  Red flags, yellow flags, recent surgeries, and the possibility of gross instability are all very difficult to detect based on movement assessment, until it’s too late.

I’ve heard many answers and there are several competing thoughts.  Here’s my take.

Take a history.  Draw the clearest clinical picture you can.  Also take a moment and think about what you expect to see in the future (exam, treatment, exercise, prognosis).  The ability to identify red flags and determine if this is in your box, or should be referred out of your office is invaluable.  These issues are rare, but do happen.  Early identification of yellow flags, complicating factors and psychosocial overlays is also necessary to effective treatment strategy and determination of prognosis.  Further, in a wonderful TED talk Abraham Verghese describes that the art and ritual of the physical exam earns the doctor the right to advise the patient.  I believe that history taking does as well.  Once the patient feels they have been heard and are understood, the likelihood of engagement and compliance increases.

Then, wipe the slate clean.

Begin assessing the patient’s movements and function with a fresh eye.  Forget what you know you’ll find.  Forget what you expect to see.  See the patient as if it’s the first time you’ve met.  Paraphrased from a conversation with the manual medicine pioneer Dr. Karel Lewit, “You need to see what your eye sees and then work on explaining it.”  A radiology instructor of mine (the great chiropractic radiologist Dr. John Taylor), warned of ‘satisfaction of search’, once you find what you’re looking for, most people stop looking.  That’s when you miss something important.  An open mind and blank slate prevent  cognitive bias.

This fresh view approach takes time to master.  It is learning the short memory of great athletes. The tennis player who can forget losing the last point and refocus.  The golfer who shanked the last drive and needs to hit a narrow fairway.  A quarterback who has thrown a few picks and now needs to aim for a tight window.  Your clinical mind needs to master this same skill.

In clinical practice you will need both high quality history taking, and skilled interpretation of movement and functional assessment.  By doing both well and resetting your mind in between, you can compare the results.  I’ve found this to be very prognostic.  When my understanding of the history matches my fresh look at the movement assessment, it tends to be a straight forward case with a good prognosis.  When they fail to match cleanly, it tells me there are more layers to this case and the patient and I should be prepared for that.

  • See what your eye sees, then explain it.
  • Understand your patient (from their viewpoint and then from yours).
  • Compare the results; what does that tell you.
  • Then, decide on a plan of action.

With the holidays coming, it’s a great time to ask for an Etch-a-Sketch (or to watch Elf)