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May, 2010

Build Patient Confidence With Clinical Testing

By K. Jeffrey Miller, DC, DABCO

It's human nature to not like to be surprised. In very basic psychological terms, it will evoke a "fight or flight" response, such as if in battle. Granted, presenting a new chiropractic patient with a treatment plan is hopefully not as stressful as being in an active war zone, but chiropractors should work as hard as possible to avoid drawn-out treatments or excessive costs that may make a patient wary of agreeing to the treatment plan. One of the best ways to accomplish this is by doing certain clinical tests at each initial evaluation.

Once a chiropractor starts in practice, they settle into their own routine for examining a new patient. The initial routine for a new patient examination is a result of their training and choice of adjusting technique(s). I have provided some suggestions here for tests that should be performed during any new patient examination, regardless of the doctor's choice of adjusting technique(s). These clinical tests will speed up the process of an initial examination routine. This will save time and money in the long run.

Vital Signs

The buzz word in chiropractic today is "wellness." We stress the importance of treating the patient as a whole. An initial examination of this purpose should always contain assessment of the patient's vital signs. How can you treat the patient as a whole without making this assessment?

Current Procedural Terminology (CPT) coding describes several constitutional signs. Three of these signs must be recorded in order to qualify as having documented vital signs. Doctors must select from height, weight, pulse rate, respiration rate, temperature, and blood pressure in the supine, seated and standing postures. Height, weight, seated blood pressure and temperature are recommended tests that should always be done. Vital signs are often thought of as medical, rather than chiropractic, procedures. However, regardless of their origin, vital signs are very important in getting the picture of the patient as a whole.

Postural Evaluation

The chiropractic equivalents of medical vital signs are postural tests. Assessing the patient's posture to determine the status of the kinetic chain from the feet up should always occur in a standard chiropractic examination. The doctor should assess the patient's posture from the anterior, posterior and lateral views.

Observing and recording information on the angulations of the lower extremities, spinal curves and compensations to any abnormal postural findings provides the foundation for establishing the need for chiropractic care.

Four Tests

Hautant's Test: A positive finding for this test would be if the patient's hand pronates or if there is arm drift, dizziness, visual disturbances, tinnitus or light-headedness. These may indicate a vertebral artery compromise, cervical nerve-root compromise or a brain lesion/UMN.

Brachial Plexus Tension Test: A positive finding would be shoulder and/or arm pain. This may indicate cervical nerve-root irritation, brachial plexus pathology or cervicobrachial muscle problems.

Slump Test: The slump test appeared in the literature in 1985 in a paper written by the Australian physical therapist, GD Maitland.1 Since then, it has gained prominence as a key neurological test and has been written about extensively. In his book Orthopedic Physical Assessment, David Magee expresses his opinion that the slump test should be a part of every scoliosis screening.2 I personally consider the slump test to be vital in all spinal and postural evaluations. The slump test places tension on the neuromengial tract to help identify disc pathology, sciatica, radicular pathology, meningitis and other significant neurological conditions.

Kemp's Test: In this test, a positive finding would be if the patient experiences back and/or leg pain. This may be an indication of  facet syndromes, disc pathologies, nerve-root irritation or sciatica.

Be Thorough

Everyone can encounter a situation where tests beyond their routine examination content are required. These situations are unavoidable. However, they should not occur because of a lack of planning. Being thorough in an examination process provides better diagnostic information and better documentation, and helps provide patient confidence and satisfaction.

Do not intentionally spread an examination over the course of a few visits. If your postural examination reveals excessive pronation of the foot, which may require foot scanning, do the scan on that same visit. Do not delay it until a later visit. If you do the scan right away on the initial visit, you will be able to formulate the most accurate diagnosis and plan of care.

Summary

Avoid providing a treatment plan until every diagnostic procedure necessary has been done. Adding tests after a treatment plan has been recommended is inappropriate unless the patient fails to improve. If a patient gets a cost estimate from an auto mechanic, they do not like finding out that the car repair will be extended or more expensive than they initially thought. The same is true for any sort of treatment plan. Patients don't like surprises when it comes to their health care any more than they do with their car repair bills. If you can do these clinical tests on the first visit and not delay further assessment any more than is necessary, patients won't end up with "sticker shock" and you will find they are much more amenable to your treatment plan.

References

  1. Maitland GD. The slump test: examination and treatment. Austr J Physiother 1985;31(6).
  2. Magee DJ. Orthopedic Physical Assessment. Philadelphia: WB Saunders, 2002.

Click here for more information about K. Jeffrey Miller, DC, DABCO.

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