The patient came into my office with obvious back problems. He was leaning to the side with his hand on his hip; the classic antalgic posture. My staff quickly helped him check in so we could get him in the back and evaluate his condition.
As we talked, he explained how he had twisted his back working in the yard over the weekend and couldn't take the spasms anymore. He also commented that he had experienced similar problems before and that chiropractic had always helped - that's how he ended up in my office. During the course of my examination, I performed some basic orthopedic checks on his neck. He stopped me and noted an additional history of neck pain. Then he stated that he didn't want his neck adjusted, because he had heard how dangerous that could be.
Let that sink in a minute - a previous chiropractic patient who was afraid of having his neck worked on, not because of a bad experience, but because of what he had heard somewhere else along the way.
The dangers of cervical manipulation have certainly helped in the campaign against chiropractic. The negative propaganda put out by various groups plays on patients' fears and is very difficult to overcome. Most patients equate neck manipulation with karate moves they saw in a Chuck Norris movie on TV. Many medical doctors have not been educated enough to know that good chiropractic care involves more than a violent twisting of the head just to make the neck crack. Clearly the neck is the most exposed and susceptible part of the spine, even when it is not injured. It takes a tremendous amount of trust on behalf of the patient to lay his or her neck in your hands so you can "spin their head around." When dealing with any patient, proper evaluation of the neck is critical. Most chiropractors I know are great adjusters and their patients have great respect for their skill. However, skill alone is not adequate. You must be able to objectively show there is a problem that needs to be corrected, and be able to define that problem in terminology another doctor, insurance company or attorney can understand.
Standard of care dictates that a patient's complaints must be evaluated locally (the area of complaint) and globally (any related or affected structures). In today's medical-legal climate, you must be aware of how one area of the body can affect another. In previous articles, I discussed how irritation in the neck can cause hand and wrist problems1 and how the neck and lower back will compensate for each other.2 Therefore, when a patient presents with any spinal complaint, it is reasonable to perform a full-spine exam.
My basic evaluation of the neck is not complicated; I can run through it in a matter of seconds. However, the tests I use give me great insight into what is going on.
- DeJerine's. This is more of a question than a formal test, and should be done during every new-patient exam. Just ask if the patient has increased pain or radicular symptoms with coughing, sneezing or bearing down. An increase in pain is positive and indicates an obstruction of the flow of spinal fluid, usually due to discal injury. The location of the pain with this irritation can help identify the involved nerve root and the site of the problem.
- George's. This is the classic test for cerebrovascular insufficiency. You have every reason to make sure you perform this test on each of your patients, even if you are not treating the neck. The first part of the test is simple auscultation for bruits over the supraclavicular fossa. Then have the patient rotate their head to the side and look up behind them. Watch for any ischemic reactions (i.e, eyes twitching, dizziness). If any of these findings are positive, the patient is at risk for a stroke. It doesn't mean you can't treat them, but you need to be very aware of their condition and treat conservatively.3
- Cervical Foraminal Compression. With the patient seated, gently push down on the top of the head. Pain is a positive finding, but must be further investigated. If pain is produced, have the patient rotate toward the side of pain and again gently push down. Localized pain suggests foraminal encroachment, while radicular pain indicates pressure on the nerve root.4 Sharp local pain suggests facet irritation. Variations of this maneuver include Jackson's and Spurling's.
- Cervical Distraction. This is a great follow-up test to help differentiate your findings from the compression test. Gently lift the patient's head using your palms or forearms on the occiput and hold traction for 30-60 seconds. A positive finding can be increased or decreased pain. Increased pain suggests myospasm. Decreased pain, either localized or radicular, indicates IVF compromise or facet irritation. Your diagnosis may be further confirmed if the patient's symptoms return when the weight of the head is returned to the neck.
- Shoulder Depressor. While supporting the patient's head erect with one hand, apply downward pressure to the same shoulder. Increased or reproduced pain indicates that adhesions have formed around the dural sleeve, nerve root or joint capsule.
- Soto-Hall. With the patient lying supine, flex the head and neck. As you bring traction into the spine, pain will be produced at the level of injury. This is a great screening maneuver for subluxation, sprain/strain and meningeal irritation, but if you have positive findings (pain anywhere along the spine) you must follow up with additional testing at the level of pain. Also, watch for the knees to buckle, as in Kernig's, as this is a red flag for meningitis.
- Rust's Sign. This is not so much a test as an observation. If the patient is using one or both hands to support the head, this is a sign of severe instability. This is often seen with acute muscle spasm or subluxation, but also may indicate fracture.
- Bakody. This is another observation. If a patient notes that raising his or her arm decreases the pain in the neck on that side, this suggests traction or compression on the lower trunks of the brachial plexus. In more severe cases, the patient actually may find it more comfortable to keep their hand on their head, as dropping the arm is too painful. Evan's text also notes that the more difficult it is for the patient to lower the arm, the more difficult the condition will be to treat conservatively.5
These are a few quick basic tests that can give you a quick understanding of what structures in the neck are irritated, and where the irritation lies. Certainly there is a lot more you can add in. Palpation is critical; there is no good orthopedic test just for trigger points. Basic neurologic testing is also necessary (if there is paresthesia in the C5 dermatome, you know what nerve root is irritated). Finally, it must be noted that neck pain and headache - particularly migraine - can be an indicator of a vertebral artery dissection. Symptoms related to CVA frequently include unilateral, unprompted posterior cervical pain of acute onset. These symptoms may precede stroke by several days and must be considered important warning signs.6 The absence of orthopedic findings in a patient with recent, insidious onset headache also should be considered a red flag.
So, what have I learned? Even when there is no neck pain, make it a habit to check the neck; you may pick up on an associated or referred problem. This will make your documentation easier; it will give you good information to explain your findings to the patient, and it helps you justify your treatment. Sure, it takes a few extra moments, but the extra information is well worth the effort.
- Briggs DR. Things I have learned: beyond the carpal tunnel. Dynamic Chiropractic, Feb. 13, 2006. www.chiroweb.com/archives/24/04/17.html.
- Briggs DR. Things I have learned: the short leg dilemma. Dynamic Chiropractic, Feb. 26, 2005. www.chiroweb.com/archives/23/05/16.html.
- Bovee ML. The Essentials of the Orthopedic & Neurological Examination. Davenport, IA: Palmer College, 1977.
- Evans RC. Illustrated Essentials in Orthopedic Physical Assessment. St. Louis, MO: Mosby, 1994.
- Kier AL, McCarthy PW. Cerebrovascular accident without chiropractic manipulation: a case report. Journal of Manipulative and Physiological Therapeutics, May 2006;29:4.
- Hoppenfeld S. Physical Examination of the Spine and Extremities. San Mateo, CA: Appleton & Lange, 1976.
- Vizniak NA, Carnes MA. Quick Reference Clinical Chiropractic Conditions Manual. Canada: DC Publishing International, 2004.
Click here for more information about Douglas R. Briggs, DC, Dipl. Ac. (IAMA), DAAPM, EMT.