All Things Considered

Many patients seeking chiropractic care report seeing one or more medical doctors prior to initiating treatment. A common criticism expressed by the physicians' patients is, "All he did was ask me a few questions and write a prescription; he never touched me." This is not surprising, as many medical texts state that a good history provides 80 to 90 percent of the information necessary to form an accurate diagnosis. This broad statement is true for most infectious and systemic diseases; however, it is inaccurate for most neuromusculoskeletal (NMS) conditions. Assessment of function is the major component of NMS diagnosis.

The medical profession's overreliance on patient history in NMS cases is a direct benefit to chiropractic practitioners, because medical patients disheartened by a lack of medical results often seek chiropractic care. Doctors of chiropractic must be conscious of this situation, and the possibility of its reversal. Reversal occurs when the doctor of chiropractic begins relying too heavily on functional testing and downplays or ignores patient history of NMS complaints.

Some bits of information reported during history can be red flags that may indicate the need for additional testing, contraindicate chiropractic adjustment, or indicate the need for referral to another provider. Examples of such information are provided below. The examples relate to cardiovascular signs and symptoms that are important in ruling out possible cardiovascular compromise prior to cervical adjustment.

Transient Ischemic Attack (TIA)

Also called ministrokes, these episodes are warning signs of stroke and a definite indication of vascular compromise. TIA occurs prior to 10 percent of all strokes. Patients experiencing TIA from carotid thrombosis have a poor prognosis; 25 percent die within four years of the first episode, 40 percent from stroke.¹ TIA is associated with headache and mild neurological dysfunctions that last from several minutes to several hours before resolution.

Amaurosis Fugax

Also known as "fleeting blindness," amaurosis fugax results in a unilateral loss of vision when an emboli originating from the ipsilateral internal carotid artery ascends to the retina through the ophthalmic artery. The blindness is often described by the patient as a shade being drawn over a portion of the eye. Symptoms typically resolve in a few minutes. Sixteen percent of patients experience subsequent stroke or loss of vision.² Diabetes, hypertension and smoking are common findings for patients experiencing amaurosis fugax.

Drop Attacks

Defined as collapsing without losing consciousness, drop attacks occur when a patient rotates the head and neck, causing decreased blood flow in the vertebral arteries. If either the vertebral arteries themselves or collateral circulation in the carotid arteries is compromised, the resulting ischemia causes the patient to collapse. Head position changes rapidly with collapse, resulting in restoration of blood flow. Thus, ischemia is sufficient enough to result in collapse, but not sustained enough to result in a loss of consciousness or permanent injury. Vertebrobasilar screening procedures are likely positive when performed on these patients. However, these maneuvers may be contraindicated for these individuals, for obvious reasons.

The signs and conditions listed above are examples of red flags typically identified only by taking a good patient history. Asking the right questions3 before moving on to functional tests is important for the chiropractic physician to avoid becoming overly dependent on a single aspect of patient evaluation. History, functional tests and imaging are all parts of the diagnostic puzzle. It is rare that one of these procedures can stand alone in the diagnostic process.

References

1. Diamond, Seymour and Jose L. Medina. Clinical Symposia: Headaches. Vol. 41, No. 1. Summit, New Jersey: Ciba-Geigy; 1989.
2. Souza, Thomas A. Differential Diagnosis and Management for the Chiropractor, 2nd ed. Gaithersburg, MD: Aspen; 2001.
3. Miller, K. Jeffrey. Patient health survey. In: Practical Assessment of the Chiropractic Patient. Huntington Beach, CA: MPAmedia, 2002.