Let's face it – patient evaluation takes time. Unless you are really into the diagnostic evaluation game, you probably have found the formal exam protocol tedious, if not downright annoying.
With that said, I like freebies. When a patient comes in with a sign that gives me a clue 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 bench / treatment table. In this article, let's talk about some quick observations you can make as soon as the patient walks in the door.
When a patient walks in holding their hand up to their head, that can be a sign as to what the patient's complaint is. The first thing you should look for is if the patient is actively using one or both hands to support their head. In fact, 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 Such a sign indicates the need for immediate stabilization and diagnostic imaging. As Rust's sign implies gross instability, possibly due to fracture, observation of this should never be taken lightly. Only after fracture has been ruled out can you pursue evaluation for other conditions such as severe sprain, subluxation or rheumatoid arthritis.
The patient with a severe soft-tissue injury may also demonstrate this sign when lying down by using their hands to support and lift the head so the cervical tissues are not strained by the action of rising. Further indications of soft-tissue injury are using the hands to hold the head while looking to the side, and twisting 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 lying – on the contrary, patients may tend to exaggerate their symptoms to some degree in order to legitimize their complaints – but you should observe a continuity between the patient's complaints and their physical actions. Whichever your finding, make sure you note it in the file, as it is one more diagnostic piece of information you can use.
A similar observation of value is if a patient tends to support the arm in an elevated position, perhaps even going so far as to rest it on top of the 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.1
Again, 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.2 Again, whichever your finding, note it in your records.
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 also help document the severity of your patients' complaints. This extra documentation can also help make the difference if you must justify your diagnosis and care to an insurer or third party. Take the extra few seconds to add these tests into your exam routine – they will serve you well.
- Evans RC. Illustrated Essentials in Orthopedic Physical Assessment, St. Louis, MO: Mosby, 1994.
- Hoppenfeld S. Physical Examination of the Spine and Extremities. San Mateo, CA: Appleton & Lange, 1976.
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