Do you know the difference between “hard” and “soft” exam findings?
Posted on June 21, 2016 by Dr. G
“Functional” exams compared to “medical” exams.
As a chiropractor with specialties in functional neurology and functional medicine, I often explain to my patients that the way doctors like myself read blood work is different from conventional medical doctors. Our job is to read blood work as a measure of how healthy our patients are and whether or not they are trending in a direction that may lead to medical conditions or a possible crisis in the future. We also read blood work to understand your physiology in a way that can look at multiple systems at the same time and see how they can be supported naturally.
We recognize the reference range used on blood work is based on the people in our population who are the sickest among us. The reference range is determined by a community rating and varies from laboratory to laboratory. A laboratory in the Bronx will have different reference range values than a laboratory in New Jersey, which will be different than a laboratory in San Diego. A relative of mine used to work for a lab company when she was 17 years old. They used to ask her for a sample of blood periodically, just so they had some “healthy” samples for the computer to reference when calculating the normative data. People who are sick are more likely to get their blood checked than people who are healthy. The laboratory reference range is often comparing you to your sicker neighbors.
For the benefit of our patients’ health and well being, our recommendations are not based solely on laboratory reference ranges but rather “functional” ranges that are based on the healthiest among us.
Physical exam findings are similar. When a doctor conducts a physical, they are checking blood pressure, reflexes, sensation, balance, nerve functions, muscle strength, etc. They are looking for what we call “hard signs” that give doctors information to diagnose a particular disorder. If there is loss of sensation, loss of reflex, or diminished muscle strength, it is up to the doctor to develop a differential diagnosis of several possibilities. The possibilities in this situation can include:
- Nerve pinch or compression away from the spinal cord
- Nerve pinch or compression close to the spinal cord
- Compression on the spinal cord or brain from a:
- Tumor
- Aneurysm
- Disc herniation
- Bone spur
- Other…
Diagnostic tests like MRI, X-ray, CT scans, etc. can confirm the doctor’s suspicions. Hard signs and additional tests can lead the doctor to make the diagnosis. The above possibilities may require medical intervention in the form of surgery, medication, or other type of medical procedure.
Often times, there is a combination of physical exam findings that do not fit a diagnosis of a “hard lesion” like the ones mentioned above. The diagnostic tests that are designed to confirm a structural problem or diseased state of organs may be negative. This usually results in a prescription to treat symptoms for as long as the symptoms persist and a failure to discover the cause of the symptoms. Medical education provides the doctor with the skills to investigate causes that can be affected by medical procedures. Medical procedures are very limited to drugs and surgery. If the intervention is not drugs or surgery, then it is not in the realm of medical treatment. Treatments that are not drugs and surgery are either considered therapy and performed by a medical therapist (psychologist, physical therapist, etc.), or it is considered “alternative” and not likely to be in the mainstream of medical intervention.
The problem with this type of thinking is that it leaves no room for the possibility of a “soft” lesion or diagnosis. A “soft” finding in a physical exam includes a series of more subtle exam findings that do not lead the doctor to a hard lesion, like a tumor, disc, stroke, or diseased organ. Rather, it leads the doctor, in this case a well trained holistic healthcare practitioner, to diagnose a system or systems in the body that are not diseased but not working as they should.
In the case of the nervous system, if the cells in a region of the brain are not diseased by a tumor, MS lesion, or stroke but rather are not working to the level they could, we may consider that a “soft” lesion or “soft” finding. Cells that are diseased and cells that are not activated can look similar on a physical exam. A soft lesion can result in muscle weakness, abnormal sensations, or loss of various reflexes as well. The difference is, the cells that are diseased are likely to be “broken” structurally, and therefore will not return unless the cause is corrected (e.g., the tumor is removed).
A “soft” lesion however requires the doctor to discover why the cells are not activated in the absence of a hard lesion. This is difficult and requires a special type of investigation. Sometimes there is a deficiency problem requiring nutritional intervention. Sometimes there is a biochemical problem that may be due to inflammation or chronic immune activation requiring in many cases a natural approach to normalizing immune health and function. Sometimes there is a lifestyle issue that creates chronic degeneration and muscular imbalances that reduce normal reflexes we depend on which ultimately results in symptoms of disease without the disease itself being present. Lifestyle interventions, breaking metabolic vicious cycles, and activating the nervous system through environmental stimulus can be very powerful in restoring us back to normal function and reducing suffering in the absence of drugs and surgery.
Drugs and surgery are the only interventions conventional medical doctors have at their disposal. Holistic doctors have a much larger arsenal of interventions and are often more limited by their imagination than anything else.
Too often, we seek a pharmaceutical solution for the symptoms caused by the “soft” lesion which never solves the cause. Masking symptoms with drugs allows the problem to grow from a “soft” lesion that has a natural and complete solution to a hard lesion that includes possible permanent loss of function or requires medical intervention that is dangerous like surgery.
Thanks for reading!
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