The significance of testing functional movements early in the examination process

Dr. Jordan Berry // #TechniqueThursday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Jordan Berry discusses reimaging the objective examination for patients presenting with low irritability, especially only in specific positions or under specific loads. 

Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

JORDAN BERRYWhat is up? PT on ICE Daily Show. This is Dr. Jordan Berry, Lead Faculty for Cervical Spine and Lumbar Spine Management. Today we're chatting about a topic called Low Irritability Equals Function First. Okay, so I hope you're having an awesome Thursday. We're about to break down just a concept that I think matters when you're thinking about the novice versus the expert clinician and how they're efficient during their initial evaluation. This key concept of when you're thinking about going into the objective exam and you know the irritability is low or at least moderately low, we're always gonna test the functional movements first. Okay, so a few concepts that we talk about during our live cervical and lumbar spine management courses, when we're thinking about the objective exam and what the expert clinician does different as opposed to the novice, one of those things is that they have a very long, detailed, subjective exam, and they have a short, clear, and crisp objective exam. and how as you gain more experience and more pattern recognition, typically that will sway even more lopsided towards being a longer subjective while having a shorter and more dialed objective exam. And then another concept we talk about is that when the patient irritability is low, you have to be really aggressive during the physical exam testing in order to recreate the symptoms, right? Because if you under test, then you might not actually recreate those familiar symptoms to know that the treatment that you're about to apply is going to work and that you're moving in the right direction. And so, one way that you can accomplish both of those things, right, with keeping a short, clear and crisp objective exam, and then making sure that you're going to be aggressive during the physical exam testing when the irritability is low, is always thinking about testing the functional movements first. Okay, so let me give you a clinical example with this, and then we'll break it down and talk about why it matters and why it's important. So, Imagine that you're in an initial evaluation and you've done your body chart and you know that the symptoms are somewhere around the area of the lumbar spine, like we'll say low lumbar into the right glute wrapping around towards the right hip, maybe even like anterior lateral right hip as well. But you know there's some vague diffuse symptoms that are somewhere in the lumbar spine and somewhere in the hip as well. And during this objective, you also gather that an aggravating factor is squatting anything over 95 pounds. And so day one, during the initial eval, you know you're gonna be trying to differentially diagnose if the symptoms are coming from the lumbar spine, or if they're coming from the hip, or maybe both. But primarily, again, the initial evaluation, day one, during the objective exam, we're trying to tease out What is the primary symptom generator? We have to nail that down day one. What a novice would do is as they're going into the objective exam, they would likely just hammer through a battery of tests for the lumbar spine and the hip. So they'd probably have that person hop up and you're going through all the basic stuff, right? You're going through active range of motion, your joint exam, your segmental exam, potentially neurodynamics, your test and hit PROM and strength testing and palpation. You're essentially just working down this battery of tests to try to see if anything recreates the familiar symptoms. And so let's say that you go through that 12, 15 minutes of objective exam testing and you figure out that hip passive range of motion, like internal rotation or fader recreates that familiar hip pain. And so now we have an asterisk sign, right? We've got our, um, let's, let's call it internal rotation is what we're going to retest and we've recreated the familiar symptoms. So you've done a good job, right? You haven't done anything wrong, but I would argue that that is not expert level because number one, it took us a fairly long time to get to that answer of what is recreating the symptoms. And honestly, the patient doesn't really care about any of the stuff that you just tested. So, an expert here is going to look at function first. So, we might do some of the same objective testing that we did just a minute ago with the novice, but the first thing that we're going to do if the irritability is low to moderate is look at function. So, if the subjective exam we found out that anything over a 95-pound squat recreates the familiar symptoms, well, I'm going to look at a 95-pound squat. So I get that person out in the gym, maybe we do a warm-up set, and then we load up to 95, and right when they drop down, right when the patient drops down into the bottom of the squat, they get that familiar hip pain. Now, right then, you have one of your asterisk signs, but we could also modify that movement or try to tease out in real time if we can change the symptoms or affect them in any way. So let's say that person drops down into the squat, bottom of the squat, they get their symptoms, and you grab a big mobility band. wrap it around the hip, and give a big lateral distraction, a lateral pull, while they go down into a second rep of the squat, and the symptoms are completely gone. So think about what you've now done. Number one, you have a better asterisk sign, I would argue, because it's something that the patient actually cares about. It's functional, it's very easy to retest, but you've also clued yourself in on your differential diagnosis. Because if I can do something to the hip, right, do a self-mob to the hip or do a lateral distraction for the hip and immediately change the symptoms that we got with squatting, then I know when I go back to the table and I do my more traditional objective exam testing, I'm going straight to the hip. So maybe on day one now, I can leave all of the lumbar spine testing and maybe hold it off until day two. because now I know that I can affect the hip. Now we go back to the table. We do some of the objective testing and I go right towards PROM and I jam that hip up into IR and fader and recreate those familiar symptoms. Boom. Now we've got our two objective asterisk signs. We've got one passive range of motion. We've got one that's functional, the squat. So now when I apply it to some sort of treatment, I've got two ways that I can retest. SUMMARY So number one, why this matters so much of testing function first when irritability is low is differential diagnosis. It's just a fast way to identify oftentimes where the symptoms are coming from or at least cluing you in as to what direction you need to go in instead of just testing all the lumbar spine stuff and all the hip stuff. Now I've clued myself in that I'm probably going to focus on hip day one. So the second thing why it's important is efficiency. We always say during objective exam testing, as little as possible, as much as necessary. So I only want to test the stuff that's absolutely necessary so I'm efficient, but also I don't risk flaring up the patient with doing a bunch of tests and measures that aren't necessary to begin with. And if I can eliminate a few things right off the bat from that functional testing, why not start there? And then lastly, it's way better buy-in. It's way better buy-in. So day one, you're always trying to have the patient walk out thinking, man, I'm finally in the right spot. This person totally gets my issue. And they're definitely going to be walking out saying that if you're first off testing the functional stuff, the stuff that they actually care about that you pick up in the subjective. No patient cares about hip IR, cares about lumbar AROM, cares about palpation. They don't care about that. They care about the thing that they want to get back to that they love. And if you're including that in the physical exam, the buy-in is going to skyrocket. So think about that over the next week or so. About maybe changing the order of your physical exam if this is not typically how you order things. When the irritability is low to moderate and you pick that up during the subjective exam, then when you go into the objective exam, you make sure that you're testing function first. It's gonna help with differential diagnosis, it's gonna help you be efficient, and you're gonna get way better buy-in. All right, so think about that this week. Next week in the clinic, I'd love to hear feedback on that as well. Just to leave you with a few upcoming courses that we have with cervical and lumbar, this coming weekend, we've got cervical management in Oviedo, Florida, few seats left for that. And then also this weekend, we've got lumbar spine management in San Luis Obispo in California. And then coming up August 3rd and 4th, we've got cervical in Cincinnati, Ohio. And then also August 3 through 4, we've got lumbar spine management in Aspinwall, Pennsylvania. All right. Thanks so much for listening. Have an awesome Thursday in the clinic. And if you're going to be a cervical or lumbar spine management course coming up soon, hopefully I will see you there. All right. Have a great day. Thank you.

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