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. It takes time to perform a consultation, evaluation, and meridian assessment - and then assimilate all that data into a report. As practitioners, we like to be "hands on" - most folks I know hate having to spend time doing the requisite exams and paperwork that always comes with patient care.
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, I want to talk about some quick observation 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 - 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. Evan's text considers this one of the most telling and important observations. 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 that the cervical tissues are not strained by the action of rising. Further observations of soft tissue injury would be using the hands to hold the head while looking to the side, and twisting of 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 patients 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.
Another similar observation would be 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.
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. Whichever your finding – note it in your records.
As a healthcare professional, you are responsible for the care you provide your patient. That care may well need to be validated by proper documentation at some point in time. 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 are in your diagnosis and treatment protocol. These extra notes help document the severity the 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.
References
Chronic pain afflicts over 20% of the adult population. Sadly, most MDs have essentially no education in treating pain, beyond offering a few toxic medications. Then they tend to steer people with pain away from those health practitioners who are trained. This puts the acupuncture community on the front lines for addressing this epidemic.
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