Chiropractor oral assessment prep

Knowledge: Bilateral sciatica with altered urinary function and saddle or perineal sensory change is cauda equina syndrome until proven otherwise. The main cause is a large central disc herniation, and outcomes for bladder, bowel and sexual function depend on early decompression, so delay causes permanent harm. Bladder dysfunction, especially retention with overflow, is a late sign, which makes the earlier warning signs of bilateral radicular pain and perineal numbness important to ask about directly.

Management: I would not manipulate. I would ask directly about perianal and genital numbness, bowel control, sexual function and leg weakness, and perform a brief neurological examination including lower limb power, reflexes, sensation and perianal sensation if appropriate and chaperoned. If there is any positive finding I would arrange immediate transfer to an emergency department with a spinal surgical service, by ambulance if he cannot be safely transported, with a written summary of my findings, and I would tell him clearly why he must not fly tonight.

Ethics and communication: He has consented to a manipulation but that consent is invalid where the treatment is contraindicated, and I would explain this respectfully. My duty is to his safety above his schedule or my wish to keep him as a patient. I would document his symptoms, my examination, my advice, his response and the referral, and if he refused to go I would document that with the risks explained and still ring the emergency department ahead.

Reference: NICE Guideline NG59, Low Back Pain and Sciatica in Over 16s: Assessment and Management (2016, updated 2020) and Finucane et al., International Framework for Red Flags for Potential Serious Spinal Pathologies (Journal of Orthopaedic and Sports Physical Therapy, 2020)

Knowledge: Recent unusual neck pain and headache, minor trauma or exertion, transient dizziness and a new Horner-type ptosis (miosis and ptosis with sparing of sweating) suggest internal carotid artery dissection, which can cause stroke within days. Risk factors include recent minor trauma, hypertension, connective tissue disorders and migraine. The IFOMPT framework stresses that no single clinical test, including positional provocation tests, reliably predicts risk, so the history and neurological examination are central, and that neck pain with headache can itself be the early presentation of dissection rather than a consequence of manipulation.

Management: I would not manipulate or perform provocative positional testing. I would take her blood pressure, perform a cranial nerve and basic neurological examination, and if there is Horner features, new neurological signs or a thunderclap or worst-ever headache I would call 998 and send her to an emergency department, not drive her myself, for urgent CT or MR angiography. Even if her examination were normal, her pattern of pain makes me want same-day medical assessment, so I would arrange this with a call and a written summary.

Ethics and communication: The consent process for any cervical technique must include the rare risk of vascular injury, but here consent is not the issue, because the treatment is contraindicated. I would be candid that I do not know the diagnosis but that I am worried it could be a vessel injury, and that I would rather be cautious. I would document the findings and the referral, and I would not make the diagnosis sound more certain than it is.

Reference: Rushton et al., International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention (IFOMPT, 2020; Journal of Orthopaedic and Sports Physical Therapy, 2023) and Biller et al., Scientific Statement on Cervical Arterial Dissections (Stroke, 2014)

Knowledge: Green (bilious) vomiting in an infant is a surgical emergency until proven otherwise because of the risk of malrotation with volvulus. Other red flags include fever, a bulging fontanelle, poor feeding, lethargy, blood in the stool, abdominal distension and failure to thrive. The Cochrane review of manipulative therapies for infantile colic found low-quality evidence with high risk of bias, and the apparent benefit is not distinguishable from parental reporting bias, so I would not claim that I can treat colic.

Management: I would stop and tell the parents that green vomiting is a warning sign that needs an emergency assessment now, and send the baby to the nearest paediatric emergency department by ambulance or car depending on her condition, with a note of what I have seen. I would not perform any spinal technique at this visit. If she were later found to have only colic and the parents still wanted my help, I would offer only advice and gentle soft-tissue care, with a clear explanation of the weak evidence.

Ethics and communication: For a treatment of an infant I need the informed consent of a parent with authority, and where the mother appears uneasy I would speak to her directly and make sure both parents have understood the information, since a consent that is not shared is not a safe consent. I would not use fear or promises, and I would document the discussion. I would explain with cultural sensitivity and, if needed, through a qualified interpreter, avoiding the use of a family member as interpreter for clinical information.

Reference: Dobson et al., Manipulative Therapies for Infantile Colic (Cochrane Database of Systematic Reviews, 2012) and WHO Guidelines on Basic Training and Safety in Chiropractic (2005)

Knowledge: A past history of malignancy, unexplained weight loss, night pain unrelieved by rest, age over 50 and long-term corticosteroid use together raise strong suspicion of vertebral metastasis or osteoporotic compression fracture, and each is an absolute or strong contraindication to high-velocity manipulation. Prostate cancer commonly metastasises to bone, and a pathological fracture or cord compression could follow. Plain films have limited sensitivity for early metastasis, so a normal film does not rule it out.

Management: I would not manipulate. I would perform a neurological examination for early cord signs and arrange same-week medical review with blood tests (including PSA, calcium, alkaline phosphatase, full blood count) and MRI of the spine, and I would telephone his general practitioner or an oncologist or send a letter, and escalate same-day if there are any neurological signs. I would give him analgesia advice only within my scope and ask for the medical team's plan before any manual treatment.

Ethics and communication: I would explain honestly why I am concerned and what I do not yet know, and avoid raising unnecessary alarm, but I would not soften the message so much that he thinks he can delay. If he refuses medical review, I will respect his right to refuse, document what I advised and why, and offer to contact his physician with his permission. I would not continue treatment that I judge unsafe to retain him as a patient. Imaging that I request must be justified, and I must follow the radiation protection rules that apply to my facility.

Reference: Finucane et al., International Framework for Red Flags for Potential Serious Spinal Pathologies (Journal of Orthopaedic and Sports Physical Therapy, 2020) and Bergmann and Peterson, Chiropractic Technique: Principles and Procedures (Elsevier)