Event 3: Mrs. Johnson's Chiropractic Visit

Mrs. Johnson has been referred for chiropractic treatment. This sequence of initial evaluation, referral for consultation and repeated assessment of treatment efficacy is a typical clinical care pathway.

Clinical Care Pathway

Flowchart of the clinical care pathway for chiropractic care
Clinical care pathway


Adapted From: A hospital-based standardized spine care pathway: report of a multidisciplinary, evidence-based process.  J Manipulative Physiol Ther. 2011 Feb;34(2):98-106

Initial Visit with the Chiropractor

Gait and Range of Motion

Physical Examination: Some Important Concepts

  • Assess balance status
  • Gait (wide based/ataxic/shuffling)
  • Observation of spine 
    • (curvature/antalgia)
  • Range of motion
  • Spinal 
  • Extremity
Illustration shows a kyphotic spine as more rounded at the top than a normal spine
Kyphotic spine vs normal spine

Neurologic Examination in the Older Adult

  • Special considerations:
    • Myotomes
      • Myotome- muscles innervated by a single nerve root
    • Reflexes
      • Dynamic Testing
    • Sensory evaluation
      • Dermatome- sensory region of skin innervated by a nerve root
      • Pinprick
      • Vibration
      • Proprioception

Orthopedic Exam

  • Standing, seated, supine, prone
    • Always perform what is most comfortable for the patient and gains the most information
    • Named tests often do not provide the entire picture 
    • Anatomy
      • Stretch, Compress, Distract, Translate the spine.
      • Assessment of the spine in each of these directions assists in determining treatment plan.
  • Directional preference
    • Provides information for both treatment and home exercise


  • Fall prevention
  • Nutritional Recommendations 
    • Osteoporosis: Calcium/Magnesium/Vit D
    • Confirm with pharm D and primary care provider
  • Encourage activity and exercise
    • Activity is often better than specific exercises
    • Referral to Physical Therapy for continuation of exercise program

Spinal Manipulation

Next: Event 4: Follow Up

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