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Examination And Tests

Remarks | History | Examinations | Test No. 1 | Test No. 2 | Test No. 3 | Test No. 4 | Test No. 5 | Test No. 6

Remarks

The preceding chapters have dealt with background materials and generalizations. From this point, the text will give step by step procedures in testing for offending musculo-fascial groups and application of corrective elongation measures. The scope of this instruction is not in the echelon of the physiatrist, orthopedist or even the practitioner of general medicine. It is offered as a program which may be administered by the registered nurse, physical therapist and trained medical aids. Especially important is its adaptability to pre-ventative aspects which may be applied in early stages of pain and spasm by shrewd foremen or athletic coaches and trainers. But above all, it may be applied by the individual concerned at any time and anywhere he feels its need.

Thus as an adjuvant to other accepted methods of treatment, the program is simple and should remain so. Needless to say, if the patient does not respond to these simple procedures, he should be referred to a Medical Doctor. Most physicians will find, however, that this program will relieve him of many so-called minor cases which clutter up his busy practice.

The History

As yet, there is no accurate testing device which measures pain. At times, cases seem to reek with malingering, but proof of gold-bricking lies in the realm of the medico-industrial team rather than the patient. A diagnosis of malingering is hesitantly applied only after all other possibilities have been ruled out; this includes thorough history, physical examination, x-rays (a study in itself) and adequate trial of therapeutic measures.

The history frequently reveals the diagnosis even before examination. Two maxims attributed to Sir William Osier are apropos: "Let the patient talk long enough and he'll give you the diagnosis." Another which should apply to any field of healing arts, "If you can't help the patient, for gosh sake don't hurt him." The history should incorporate:

1. Is this the first attack? If so, what was the activity at the time of the onset? If previous attacks have been experienced, what were the symptoms of such and compare them to the present; also, check for mild complaints in the interim.
   
   
2. Was the onset sudden or gradual? A vast majority will be gradual. If sudden, what activity and what position was being maintained at the stroke of pain? If gradual, what stance and movements are utilized in work and avocational pursuits?
   
   
3. Is there an infection anywhere? Colds, skin sores, urinary dyscrasias, abdominal or pelvic soreness or general infections should be screened.
   
   
4. Does the pain lie in the middle or to one side or the other?
   
   
5. Does the pain radiate around to the abdomen or down either leg? This helps establish the spinal segment involved; however, pain radiation down Sciatic Nerve distribution is not pathognomonic (indicative) of herniated disc alone.
   
   
6. Is there numbness or tingling in extremities or back? Is there any area which seems over-sensitive?
   
   
7. Do certain angles of trunk flexion and bending give pain? Does the pain increase as bending progresses? Does hyper extension or trunk rotation increase the pain? Is sitting difficult?
   
   
8. What position is found in standing, sitting or lying which affords relief?

In industrial practice, it is wise to write down the patient's statements verbatum and have him sign them on his initial visit. Include date of call, date of injury, activity at the time of injury, placement of pain; ascertain whether or not stooping, lifting, twisting (most common cause of back injury), foot slipping or being struck or bumped on the back were involved. The signed statement makes the patient realize there is interest in his case; it records facts at a time when the patient will tell the truth because he knows this will give clues to diagnosing his case; it is registered at a time when facts and details are fresh in his memory; it pares to minimum the amount of time he has to consciously or unconsciously fabricate the details to lead to unwarranted compensation.

Obviously, if systemic disease or more severe pathology which requires medical attention is the etiology, the history must be directed in those channels; however, that is the range restricted to the medical profession only.

Physical Examinations

The plural is used in this paragraph heading for a definite reason. One phase of the examination is for diagnostic purposes and should be carried out by the nurse or physician; the other is part and parcel of the elongation program (Section D).

1. Visual examination—look for deformities; check for increase or decrease from normal curves; note any list, forward tilt or backward tilt of pelvis; note spasm of any muscle, particularly the large erector spinii muscles; note any skin blemishes; check protruding abdomen.
   
   
2. Motion tests—have patient bend with arms toward the floor. In destructive lesions, motion in any direction causes pain. In muscle spasm or contracted fascio-ligamentous cases, pain is increased as flexion progresses; sudden relief of pain at a certain angle hints of disc syndrome. In mechanical lesions, extension causes pain. Rotation and lateral flexion should be enacted. The Trendelenberg test of standing on one leg and flexing the other is another disc test; these people favor the affected side when walking.
   
   
3. Palpation—deep pressure over the spinous processes will cause pain in mechanical types. Sacral pressure elicits pain in lum-bosacral (frequently the offender) joint trouble. Percussion of a spinous process may cause pain in destructive lesions. Sensitive fingertips of the examiner will easily recognize the harp-string feel of muscle spasm.
   
   
4. Neurological—This is in the physician's field; the examination will be negative unless nerve-root pressure is present.
   
   
5. X-ray—Again, this is the physician's realm. It is not valuable in mechanical, infectious or referred lesions. It may be of value in arthritic, congenital and destructive lesions, and at times in ruptured disc cases. 6. Tests specific for herniated disc—

(a) Patient flattens lordosis to plane of table.

(b) Pull knee to chest and hold for count of two; alternate to other leg use both legs simultaneously.

(c) Rotate pelvis with both legs flexed up, forming right angle at knees, lower leg parallel to table.

(d) Patient prone, tighten buttocks and alternate leg raising; then simultaneously.

(e) Patient lies prone and crawls to knee-chest position with out raising elbows, palms and forehead from table.
 
Fig. 14. Schematic of test No. 1 (scout test).

Steps In Examining For Offending Muscle Or Fascial Groups For Elongation Program

Test No. 1

Purpose—This is a general or scout test which will help to identify the area or areas involved; thus one or two of the following specific area tests are needed. It reveals, also, any tenderness along the longitudinal ligaments and Ligamentum Flavim which traverses the entire length of the vertebral column.

Procedure—
 
Fig. 15. Positioning for scout test (test No. 1).

1. Seat patient on edge of treatment table.
2. Patient's arms, head and trunk hang loosely in a forward bent position.
3. Raise patient's leg to point of pain at knee joint.
4. Repeat with other leg.

Fig. 16. Schematic of test No. 2 (upper cervicals).

Physiology of test—By releasing tension of the forward bent position and leg extension, the irritation of the posterior ligamentous attachments and its resulting pain are relieved. Illustration No. 14 Illustration No. 15
 
Test No. 2

Purpose—To test the upper cervical and occipital musculofascial
groups. Procedure—

1. Patient is seated on a straight-backed chair, hips pressed against base of chair back, feet locked behind front legs of chair.

Fig. 17. Positioning for upper cervicals (test No. 2).

2. Grasp chair seat with left hand, place chin in palm or right hand with fingers pointing toward right ear. Head should be tilted slightly forward. From this position the patient should be able to turn his head to a ninety degree angle over the right shoulder without pain. Reverse procedure for test for left side.
 
Physiology of test—A ninety degree rotation of the chin to each side should be possible without pain in the upper cervical and occipital groups. The chair is grasped as an anchor to the shoulder; feet are locked to stabilize the trunk and pelvic musculature; the head is tilted forward so as to shorten the fascia and afford greater traction for elongation of that tissue. This allows the stretched tissues to relax and avoid impinging on adjacent nerves; certain headaches are relieved in this manner. Illustration No. 16          Illustration No. 17

Fig. 18. Schematic of test No. 3 (lower cervicals).
Test No. 3

Purpose—To test the lower cervical muscles and fascio-ligamentous
tissues.

Procedures—
 
1. Patient is seated on straight-backed chair, hips pressed against base of chair back, feet locked behind front legs of chair.

2. Grasp chair seat with left hand; turn head to forty-five degree angle toward right shoulder tip; keep chin down; place right hand on left temple with fingers pointed toward left ear.

3. Drop head over the right shoulder and using the right hand as an aid apply slight pressure in direction of movement.

4. Reverse position and motion.

Fig. 19. Positioning for lower cervicals test (test No. 3).

Physiology of test—The head should reach a thirty to forty degree angle over the respective shoulder without stimulating pain in the lower cervical muscles. The chin must be kept down or the upper cervical muscles and fascia will come into play. A warning: this test can do harm if an overzealous therapist or patient carries the rotation too far. Illustration No. 18 Illustration No. 19
 
(The physician's assistant is guiding the patient in the test.)

Fig. 20. Schematic of test No. 4 (thoracic area).

Test No. 4

Purpose—To locate muscular tightness in the thoracic (chest) region.

Procedure—

1. Patient is seated on straight-backed chair, hips pressed against base of chair back, feet locked behind front legs of chair.
2. Keep hips tight against back of chair and body in erect position.
3. Twist upper trunk at waist to a ninety degree position.
4. Reverse procedure and motion.

Fig. 21. Positioning for thoracic area (test No. 4).

Physiology of test—A ninety degree turn should be achieved without pain occurring in the chest area or shoulders. Illustration No. 20 Illustration No. 21 (Physician's assistant is guiding patient in test.)

Fig. 22. Schematic for testing lumbar musculature (step 2 of test No. 5).

Test No. 5

Purpose—A test of the lower back (lumbar) region.

Procedure

1. Patient stands erect; heels and toes together; knees stiff, arms at sides.
2. Bend head and shoulders laterally to right without bending forward, move right fingertips toward the floor.
3. Reverse motion.
4. Resume erect position.
5. Turn right shoulder backward to position over right heel.
6. Reach with right fingertips toward right heel.
7. Reverse motion to left.
8. Hyperextend backward.

Fig. 23. Positioning for lateral arc of spine lumbar musculature (step 2 of test No. 5).

Fig. 24. Schematic of step 5, test No. 5 (lumbar area and anterior and pelvic musculature).

Physiology of test—In steps 2 and 3 the lateral arc of normal spine will be clearly defined (Illustration 22 and 23). In steps 5 and 6 any abnormality will be noted by pain in the anterior pelvic area and/or back of knee (Illustration 24 and 25). In step 8 the hyperextension syndrome becomes apparent. Don't forget that Test No. 1, the scout test, can be reutilized when needed to corroborate findings. Illustration No. 26 Illustration No. 27
Fig. 25. Positioning for step 5, test No. 5 (anterior abdominal and pelvic musculature test). Pictured right to left are Charles L. Redd, Therapist,
Dr. Harvey E. Billig, Jr., a patient and Dr. George H. Hassard.

Fig. 26. Schematic of step 8, test No. 5 (hyperextension test).

Test No. 6

Purpose—To ascertain extent of contraction or constriction in the hips, thighs and legs. (Particularly the iliotibial attachments.)

Procedure

1. Patient stands erect; heels and toes together; knees stiff, arms at sides.
2. Bend forward at hips, to full flexion; arms hang loosely toward floor; head down.

Fig. 27. Positioning for hyperextension test (step 8 of test No. 5).

Physiology of test—Extreme tension and discomfort will be noted at the lateral knee attachment and behind knees as well as some restriction of spinal curvature. The knees must be straight or tension will be relaxed in the test area. Illustration No. 2P. Illustration No. 29
 

Fig. 28. Schematic of test No. 6 (hips, thighs and legs) Note: Knees are not bent.

Fig. 29. Positioning for leg extensors (test No. 6).

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