This thesis in the context of the proton structure

Introduction

The physical examination wil l relate closely to the findings from the initial interview. The history given by the patient should already have provided the clinician with sufficient information to be making tentative conclusions about certain aspects of the case. Very often it is clear from the history to which mechanical syndrome the patient belongs, whether the patient has simple neck pain or with nerve root involvement, and whether there exists a mechanically determined directional preference. Details gathered may suggest serious spinal pathology that needs further investigation.

The clinical examination is designed to confirm the initial findings and fully expose the mechanical nature and extent of the problem.

The two parts of the first day's assessment should thus produce a good general picture of the patients symptomatic and mechanical presentations. From these findings come the optimal management of the condition. The whole assessment provides baseline measures of pain, movement and function against which to judge the value of any subsequent intervention. The information also gives prognostic indicators, derived from such items as the duration of the problem, the previous history, the age of the patient or the constancy of the pain.

The physical examination involves various observations and move­

ments about which the clinician must make judgements. Such perceptual tests, in which a human being is the measuring device, are bedevilled by subjectivity with consequent variability of results.

Intraobserver and interobserver variability is seen as the inevitable consequence of such perceptual tests (Gray 1997). Although we cannot totally prevent this phenomenon, we can limit its impact by conducting the examination in the same way each time it is done.

Clinicians need to perform tests consistently on each occasion, and patients must always start from the same position - in this way we can be more certain that different test results reflect changes in the mechanical presentation rather than being the fault of inconsistent examination technique.

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Given the problem of reliability, it is probably best to limit the infor­

mation sought during the assessment. It is especially important not to overburden the physical examination with an excessive number of tests and movements. Multiple tests have a greater chance of generating unreliable information and may only serve to confuse rather than enlighten the examining clinician.

Sections in this chapter are as follows:

• aims of physical examination

sitting posture and its effects on pain

• neurological examination examination of movement

• protrusion flexion

• retraction extension

• rotation (right and left)

• lateral flexion (right and left)

• repeated movements

• repeated movements in derangement syndrome

• repeated movements in dysfunction syndrome

• repeated movements in postural syndrome

• selecting repeated movements repeated test movements

• protrusion (sitting)

• retraction (sitting)

• retraction and extension (sitting) retraction and extension (lying)

• exploring frontal plane movements lateral flexion (sitting)

• rotation (sitting) flexion (sitting)

PHYS ICAL EXAM I NATI O N

• static mechanical evaluation

• testing inconclusive

other examination procedures

• mechanical syndromes derangement dysfunction postural inconclusive.

Aims of physical examination

During the physical examination the following points should be exposed:

• usual posture

symptomatic response to posture correction

• any obvious deformities or asymmetries that are related to this episode

neurological examination

baseline measures of mechanical presentation

symptomatic and mechanical response to repeated move­

ments.

The following conclusions should be made:

• syndrome classification

• appropriate therapeutic loading strategy, or

• appropriate testing loading strategy.

Sitting posture and its effects on pain

If during the history-taking the patient is seated unsupported on a treatment table or examination couch, we are able to observe their natural unsupported seating posture. Posture is best observed without the patient being aware that you are doing so, such as during the history­

taking. Often patients sit slouched, in a posture of lumbar and thoracic flexion, which produces a protruded head posture of lower cervical

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flexion and upper cervical extension. Some patients are more aware of the relationship between their posture and pain and make an attempt to sit upright as experience has told them this is more comfortable, but such patients are unusual. Regarding recognition of a protruded head posture, it may be helpful to imagine dropping a plumb line from the patient's chin. If this would fall in space some way in front of their trunk, then head posture is protruded; would this fall onto their chest, then head posture is reasonably upright. This model can also be helpful to explain to patients a better sitting posture.

Other points to be aware of are an exaggerated cervico-thoracic kyphoSiS and a lateral deviation of the head. When there is a fixed increased cervico-thoracic kyphoSiS, attaining full range cervical extension or retraction can be very difficult. If a lateral or rotational deviation is present, you need to know if it is fixed or if the patient can correct it. Sometimes patients assume this position out of habit or as a voluntary way of achieving a less painful posture; however, they are quite capable of correcting this and rotating or lateral rtexing in the opposite direction. In a small number of patients, usually acute with severe onset, the neck is stuck in this laterally deviated position and any attempt to correct it is extremely painful and impossible.

This deformity of wry neck is the cervical equivalent of the lateral shift in the lumbar spine.

The patient will have been in sustained sitting for fifteen to twenty minutes while the history was taken - this is a good moment to investigate the effect of posture correction on neck and associated symptoms. Just as with any evaluation of symptom response, we must first determine the baseline symptoms. 'As you are sitting there now, do you have any of the symptoms that you have told me about?' It is, as always, especially important to determine the most distal symptoms, and may be useful to know if symptoms have worsened or come on whilst they have been sitting. Then the procedure of posture correction is performed, as detailed in Chapter 14, Procedure 3. The lumbar lordosis is restored, and then the head is retracted to a neu­

tral position. Once in this position for a minute or two, the patient is again questioned about symptoms and symptom location. 'In that position, do symptoms feel better, worse or the same?'