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Exam Is Key

Dec 31, 2019

Many in the modern manual therapy world emphasize the need for a patient examination that pinpoints the best treatment approach.  Craig Liebenson, D.C., for example, in his Spinal Rehabilitation, 2nd edition, textbook places importance on patient categorization for condition specific treatment, hence better clinical outcomes. A study titled "Sub-grouping Patients with Low Back Pain:  A Treatment Based Approach to Classification," August 23, 2011, in the online version of Sports Health: A Multidisciplinary Approach was discussed in The Chiropractic Report, from November 2011.

This study was about categorizing low back patients, although we suggest this concept can apply to other areas as well.  In your exam of a patient with low back pain, would they respond best to adjustments, spinal stabilization, an anti-inflammatory diet, soft tissue, end range loading, or traction?  The percentage of low back pain patients who improve with conservative care improves from 50% with only manipulation to 95% when properly categorized and subsequently specifically treated.

There are lots of classes, books, articles and colleagues to help teach this information if this is a new concept.  Dynamic spinal evaluation for joint dysfunction/fixation is foundational for D.C.'s. The need for spinal stabilization is nicely screened with gait evaluation and functional screens, e.g. active straight leg raise test or hip extension test.  End range loading, i.e. McKenzie screens, can help you discover if end range loading is going to be your most clinically effective and time efficient approach. Traction is a treatment tool that can help certain patients, especially when other conservative treatment fails.  Examination findings are less clear for traction, but some of you reading this routinely use decompression traction and like its clinical effectiveness.

It is very important to do a thorough patient history including prior treatments.  Have they been to another D.C., adjustments performed and no improvement noted? Has your patient been to a therapist who did stabilization exercises, but only aggravated the patient’s condition, or a McKenzie practitioner who could not help the patient either? If previous treatment has failed, look more closely at a different approach. The Abraham Maslow quote, "If your only tool is a hammer, then everything looks like a nail" is a great line to keep in mind.

After your thorough history and examination, treat the big findings, the obvious things first.  For example, if someone with a lumbar radiculopathy centralizes with end range extension and has stiff iliofemoral joints and T/L junction, start with working on those things.  

One area not part of this study that we feel is a key clinical issue is poor nutrition and chronic inflammation.  A patient who is in a pro-inflammatory state simply does not heal as well as a nutritionally healthy person. Give your patient the best chance to recover by helping them understand the importance of what they eat and drink for healing.

It is a new ballgame out there in the health care world.  We need to strive for clinical effectiveness in a time efficient manner.  The majority of your patients are paying for care with their own hard earned cash, so they want and need results. Clinical mediocrity is a recipe for failure.  As we go forward, the cream will rise to the top and the scams to increase collections will be harder to come by.

Len Faye, D.C. often asks the question, "Who went to chiropractic school to be mediocre?"  Hopefully, not you. Learn to perform an excellent exam, learn to perform the best, most appropriate treatment; and learn to do this in an efficient manner.  Remember to give your best to your patients and build the practice of your dreams.

Mark King, D.C.
[email protected]

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