MDT Bulletin of The McKenzie Institute Americas Region

Clinical Tips
Driving it Home: Applying the History to the Examination
Kim Greene, PT, Dip. MDT

You have just finished taking the credentialing exam and all that hard work is finally starting to pay off. Over the last three months, you have reduced a lateral shift deformity, remodeled an ANR, and referred a patient back to the physician for confirmation that she has MS. You feel like you have superhuman powers. You have dreams of opening your own clinic with your name in lights:

Load Master, Inc., PT

But there is one remaining obstacle: EFFICIENCY IN THE EXAMINATION. You are as efficient as an old Ford Pinto, assessing only eight patients a day. How can you be successful at this rate? What information from the history will help guide your examination? Where do you start on the examination form? These are all questions that are addressed during the Diploma Program. Knowing how to make the examination flow efficiently requires that you take a first-class history and then apply it to the examination, a skill that takes practice. The following suggestions will help fine tune your examination, so that you perform like a Lexus instead of a Pinto.

First and often forgotten, the postural assessment allows you to jump-start the examination by assessing the effect of alternate postural positions. As those of you who have seen Robin McKenzie in action know, he frequently spends 10 minutes assessing the effects of posture correction. This often requires adjusting the size of the roll, as well as changing the location of the roll or the position of the patient to get a positive response. You should also note that not everyone will benefit from a lumbar roll. If you suspect a derangement, some patients will need time to reduce before they can tolerate any extension. This is often the case if the patient refuses to sit or presents with a deformity. Some common mistakes in this portion of the examination include:

Overlooking the neurological examination will result in the loss of valuable baselines, causing the examiner to hydroplane. Significantly, you must perform a neurological examination before the repeated movement testing, if the patient describes symptoms into the extremities. Students often neglect this portion of the exam, especially if the patient denies spinal pain or describes only weakness. Even if the most distal symptom does not appear relevant however, you must complete a neurological exam in order to notify the physician of a worsening scenario. Our ability to quickly identify these patients is an immense selling point of the MDT method and must always be on the forefront of the assessment process. A few reminders when assessing neurological status:

In the movement loss portion of the exam, therapists frequently cruise right through, forgetting to slow down to assess important aspects. Documenting PDM, deviations, ERP and quality of movement in the pain column supports classification. With functional activities such as bending, reaching, and turning, it is always pertinent to ask the patient if this is their "normal motion". Often, this is not obvious to the patient until the movement is performed. And if, for example, the patient admits that she has not been able to touch her toes "in years", then these notations should be documented accordingly.

At last, you are in the final stretch and can start the repeated movement portion of the examination. This can feel as if you are on a roundabout with no easy exit, as you perform the test movements like a robot, testing each movement in the order it appears on the form. To avoid this detour, it is crucial to refer back to the history. The history must guide the exam in determining starting positions for direction or load. For example, if the provisional classification is an acute derangement and you initiate repeated movements in a loaded position, the patient will deflate like a flat tire. You'll be stuck on the side of the road for several days until the patient recovers, morphing Load Master into Load Disaster.

By contrast, if a patient is describing a chronic, unchanging presentation, you will most likely need to explore multiple repetitions followed by overpressure and mobilization to determine classification. Many students stop testing after 10-20 repetitions and change the loading strategy or direction, assuming they have come to a dead end, when in fact, they could learn much more information by performing more repetitions with more force.

And remember that many patients need time to reduce. Starting the exam with static testing often provides the most guidance to direction, but students starting the Diploma program often have never utilized this valuable tool. Simply listening to the patient and applying the information from the history will save you time. Before long, you'll be able to fly through your evaluations and Load Master, Inc. will be the talk of the town.