Things I Have Learned: Another Freebee

By Douglas R. Briggs, DC, Dipl. Ac. (IAMA), DAAPM

Let's face it - patient evaluations take time. Unless you are really into the diagnostic evaluation game, you probably have found the formal exam protocol tedious, if not downright annoying.

It takes time to goad the tissues and joints, do the neurological evaluation, and then run through a battery of orthopedic tests. Then you have to assimilate all that data into a report. As chiropractors, we like to be "hands on" - most docs I know hate having to spend time doing the requisite exams and paperwork that always come with patient care.

I like freebies. When a patient comes in with a sign that gives me a clue as to what is going on, it helps me be more focused in my exam, so I don't waste time trying to figure out what test to do next. I have previously shared information about observing how a patient gets up from the exam table. In this article, I want to talk about some quick observations you can make as soon as the patient walks in the door.

If a patient walks in holding their hand(s) to their head, the first thing you should look for is if the patient is actively using one or both hands to support their head. The patient may not even be willing to remove their hands from supporting the head. This is called Rust's sign. This active splinting of the head and neck for support is a reflex guarding mechanism, and indicates instability - usually in the upper cervical spine. Evans' text considers this one of the most telling and important observations.¹ This sign indicates the need for immediate stabilization and diagnostic imaging, as it implies gross instability, possibly due to fracture. Observation of this should never be taken lightly. When you have ruled out fracture, appropriate evaluation may then be pursued for other conditions, such as severe sprain, subluxation or rheumatoid arthritis.

The patient with a severe soft-tissue injury also may demonstrate this sign when lying down, by using their hands to support and lift the head so that the cervical tissues are not strained by the action of rising. Further observations of soft-tissue injury would be using the hands to hold the head while looking to the side, and twisting of the trunk to avoid rotation of the neck.

The opposite of this test is also valuable in assessing a patient. When a patient presents with complaints of severe neck pain, but does not consistently demonstrate the need to support the head (especially upon distraction), you may suspect the validity of their complaints. That is not to say that the patient is being deceptive - on the contrary, patients may tend to exaggerate their symptoms to some degree in order to legitimize their complaints to the doctor. In any case, you should observe continuity between the patient's complaints and their physical actions. Whatever your finding may be, make sure you note it in the file, as it is one more diagnostic piece of information you can use.

Another similar observation would be if a patient tends to support their arm in an elevated position, perhaps even going so far as to rest it on top of their head. This is referred to as Bakody's sign, and could be considered antalgic posturing of the neck. In a patient with neck pain, abduction and external rotation of the ipsilateral shoulder by moving the hand toward the head decreases stretching of the compressed nerve roots. Evans notes that it is not uncommon for patients to voluntarily assume this pose while waiting in the examination room, as it is the position of minimal discomfort.²

Also watch for the opposite of this sign. The "reverse Bakody" can be noted when the patient resists raising the arm and hand toward the head. This finding should be correlated with other orthopedic testing, as it could indicate facet irritation, glenohumeral dysfunction, rotator-cuff trauma or myofascial spasm.³ Whatever your findings are, note them in your records.

As a health care professional, you are responsible for the care you provide your patient. That care may well need to be validated by proper documentation at some point in time. As all you have to do is watch the patient, it should be easy to add these tests into your exam protocol. Certainly there are other tests, signs, and observations to be made in the individual case-but the more information you have to confirm your findings, the more secure you will be in your diagnosis and treatment protocol. These extra notes help document the severity of the patient's complaints. This extra documentation also can help make the difference if you must justify your diagnosis to an insurer or third party. Take the extra few seconds to add these tests into your exam routine - they will serve you well.

References

1. Evans RC. Illustrated Essentials in Orthopedic Physical Assessment. St. Louis: Mosby, 1994.
2. Ibid.
3. Hoppenfeld S. Physical Examination of the Spine and Extremities. San Mateo, Calif: Appleton & Lange, 1976.

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