What a chiropractor assesses on a first clinic visit

Medical history and health factors that a chiropractor usually reviews on the first visit

During the first visit, a reason for consultation The history of the main symptom: onset, location and irradiation of pain, intensity, time pattern, aggravating or relieving factors, functional limitation and previous episodes. It also reviews the medical and surgical history (osteoporosis, inflammatory arthritis, vascular disorders, fractures or surgeries, pregnancy, recent oncological or infectious history), together with current medication, allergies and treatments already tried.

Habits and health context that may influence the picture are assessed: occupation and ergonomics, physical activity and sport, repetitive loads, sleep quality, stress or mood, tobacco and alcohol consumption, and weight changes. In addition, the following are systematically sought RED FLAGS and possible contraindications for manual techniques, such as:

• Unexplained weight loss, fever, history of cancer or recent infection.
• Significant trauma or suspected fracture.
• Progressive neurological deficits, saddle anaesthesia or sphincter disturbances.
• Severe osteoporosis or prolonged use of corticosteroids.
• Bleeding disorders, anticoagulation or signs of cervical vascular pathology.

The assessment includes inspection, palpation and mobility testing, as well as a neurological examination (strength, reflexes, sensitivity, coordination and gait) and orthopaedic tests for differential diagnosis. Depending on the findings, the following can be considered complementary tests -(e.g. X-rays or MRI) when there is suspicion of specific pathology, presence of red flags or atypical evolution, and, if appropriate, referral to another health professional.

Physical examination by the chiropractor: posture, mobility and initial orthopaedic tests

Posture assessment

The inspection assesses the global alignment head, shoulder girdle, spine and pelvis in anterior, lateral and posterior view. The physiological curvatures, Anatomical references, shoulder and scapula symmetries, pelvic tilt/rotation and plantar support, as well as compensations during standing and gait. Anatomical references and standardised clinical photography can be used to document asymmetries, but are not a substitute for diagnostic tests when necessary.

Mobility assessment

It explores the range of movement active and passive cervical, thoracic and lumbar spine and related joints (e.g. hip and shoulder), recording amplitude, quality of movement, end-feel, reproducible pain and compensation patterns. The palpation identifies changes in tone, sensation and soft tissue. When symptoms suggest it, basic neurological screening (strength, reflexes, sensation) is added to detect possible signs of radicular or spinal cord involvement requiring further assessment.

Initial orthopaedic tests

These manoeuvres aim to target the potentially involved structure by controlled provocation of the symptom, are interrupted in the event of severe pain and are interpreted in conjunction with the clinical history:

• Lasègue (SLR)Tightens the lumbosacral neural component; reproducible irradiation may suggest radicular irritation.
• Slump testassesses mechanical sensitivity of the neural tissue in the posterior chain.
• Spurlingcompresses the cervical spine foramominally to assess radicular pain.
• FABER/Patrickhelps to differentiate between hip or sacroiliac joint involvement according to the location of the pain.
• Kempmay point to lumbar or thoracic facet involvement when it reproduces local pain.
• Adamsdetects asymmetries of the trunk in flexion to screen for scoliosis.

No single test, in isolation, establishes a definitive diagnosis; further consideration is given to the “RED FLAGS”(progressive neurological deficit, non-mechanical nocturnal pain, systemic symptoms, among others) to decide whether referral or further investigations are necessary.

Basic neurological assessment of the chiropractor in the first consultation: sensibility, reflexes and muscle strength.

Sensitivity scanning

In the first consultation, different types of skin sensitivity are explored to detect neurological alterations. The following are assessed dermatomas bilaterally with stimuli such as light touch, pressure, gentle prodding, temperature and vibration; also, the proprioception on fingers. Patterns of hypoaesthesia, hyperesthesia, The clinical context (pain, time course, daily variability) is taken into account to interpret the findings with caution. The clinical context (pain, time of evolution, daily variability) is taken into account to interpret findings with caution.

Osteotendinous reflexes

The assessment of deep reflexes looks for changes in the motor pathway and spinal segments. Bicipital (C5-C6), brachioradialis (C6), tricipital (C7), patellar (L3-L4) and Achilles (S1) reflexes are usually explored, according to their symmetry and to a clinical grading (e.g. 0 to 4+). The presence of sustained clonus or signs such as Babinski or Hoffmann is considered to be indicative of possible upper motor neuron signs. Factors such as patient stress, temperature or certain drugs can modify the response, so several repetitions are performed and the information is integrated with the rest of the test.

Muscle strength and myotomes

Strength is examined by comparative manual testing by muscle groups, relating to myotomes segmental (e.g. C5 shoulder abduction, C6 elbow flexion, C7 elbow extension, C8-T1 digital clamp, L2-L3 hip flexion, L3-L4 knee extension, L4-L5 ankle dorsiflexion, L5 hallux extension, S1 plantar flexion). It is possible to use the MRC scale 0-5 and observed for pain inhibition on exertion, as well as atrophy or fasciculations. Marked deficits, significant asymmetries or progressive worsening are considered relevant findings requiring careful clinical assessment.

When a chiropractor may order x-rays or other complementary tests in the initial assessment

In the initial evaluation, a chiropractor may consider ordering X-rays or other complementary tests when the anamnesis and physical examination suggest specific pathology or risk of complications, but not routinely for non-specific musculoskeletal pain without warning signs. The indication should seek to confirm or rule out potentially serious conditions and guide safe decisions, optimising the balance between diagnostic benefit and radiation exposure.

These are common indications when there are RED FLAGS as:

• Progressive neurological deficits, saddle anaesthesia, urinary retention or incontinence: suspicion of cauda equina syndrome or spinal cord compression.
• High-energy trauma, significant fall, acute pain in people with osteoporosis or prolonged use of corticosteroids: possible fracture or instability.
• Fever, chills, disproportionate nocturnal pain, immunosuppression or IV drug use: suspicion of infection (e.g. spondylodiscitis).
• Unintentional weight loss, history of cancer, persistent pain at rest or at night: suspicion of neoplasia.
• Obvious or progressive structural deformity, or findings suggestive of significant congenital/degenerative anomalies.
• Radiculopathy with marked weakness or severe signs of nerve irritation.

The choice of test is tailored to the clinical objective: plain radiographs to assess fractures, alignment and instability; MRI for soft tissue, discs, spinal cord and roots in the presence of neurological deficits or suspected infection/neoplasia; CT scan when more bone detail is required or if radiography is inconclusive; CBC (e.g., CBC, ESR/CRP) if an infectious or inflammatory process is suspected; and, in selected cases, densitometry in the presence of neurological deficits or suspected infection/neoplasia; CBC (e.g., blood count, ESR/CRP) if an infectious or inflammatory process is suspected, blood count, ESR/CRP) if an infectious or inflammatory process is suspected; and, in selected cases, densitometry for possible bone fragility or electrodiagnostic studies when radicular involvement is not clinically delimited. These decisions must respect the ALARA principle for radiation, the competence and powers granted by local regulations, and be supported by documented clinical justification and, where appropriate, coordination with other professionals.

Red flags and referral reasons a chiropractor looks for before proposing care

Signs and symptoms requiring urgent medical evaluation

• Progressive neurological deficitsIncreasing motor weakness, marked hypo/arreflexia, ataxia or “saddle” anaesthesia.
• Sphincter disturbances (urinary/fecal retention or incontinence) and perineal anaesthesiasuspicion of cauda equina syndrome.
• Sudden onset of severe pain after significant trauma or in the presence of osteoporosis o prolonged corticotherapy: possible vertebral fracture.
• Fever, chills, non-mechanical nocturnal pain, IV drug use or immunosuppression: possible spinal infection (osteomyelitis/dyscitis).
• Unexplained weight loss, The background to cancer, persistent pain not relieved by rest: consider neoplasm.

Vascular or neurological findings contraindicating manipulation and requiring referral

• Cervical pain with signs of vertebrobasilar ischaemia (diplopia, dysarthria, severe vertigo, nystagmus, ataxia, drop attacks, bilateral paraesthesias): suspicion of arterial dissection or vertebrobasilar insufficiency.
• Pulsating low back/abdominal pain with cardiovascular risk factors or hypotension: possible abdominal aortic aneurysm.
• New and severe headache with nuchal rigidity, fever, focal neurological deficit or altered mental status: intracranial pathology or meningitis to be ruled out.

Contexts advising medical co-management prior to chiropractic care

• Pregnancy with atypical low back pain associated with bleeding, marked hypertension, sudden oedema or severe headache.
• Anticoagulation o coagulation disorders: assess risk of bruising with manual techniques.
• Active systemic inflammatory diseases (e.g. rheumatoid arthritis with possible cervical instability, flare-up spondyloarthritis).
• Severe osteoporosis o bone metastases known.
• New pain at extreme ages (<20 o>55) with atypical or systemic features.
• Recent spinal surgery o recent epidural injectionrisk of complications requiring prior medical assessment.