Download TABLE 4

Physical Examination of the
Patient with
Pain
DR.BAHMAN ROSHANI
Physical Examination of the Patient
with Pain
• Goals
developing the patient’s trust,
gaining insight into the impact of pain on the
patient’s level of functioning,
identifying potential pain generators.
Physical Examination of the Patient
with Pain
 main categories;
1.sensation,
2.motor,
3.reflexes,
4.and coordination
Physical Examination of the Patient
with Pain
SENSATION AND SENSORY EXAMINATION
peripheral nociceptors
mechanical nociceptors,( pinch, pinprick),
heat nociceptors (temperature greater than 45°C)
, polymodal nociceptors,( mechanical, heat,
and chemical noxious stimuli.(
“fast” or quickly sensed pain, A-ð and C-fibers / Slow pain,
Physical Examination of the Patient
with Pain
• A-d fibers at a rate of( 2 to 30 m/s)
sharp,shooting pain
• C-fibers less than 2 m/s, dull, poorly localized
burning pain.
.
Sensory alterations should be described in standardized
terms in order to create a more universal record of
symptoms.
Hyperesthesia
Hyperesthesia (hyperalgesia and allodynia).
Hyperalgesia is severe
pain in response to mild noxious stimuli,.
Allodynia is the sensation of pain in response to
a non-noxious stimuli (e.g., light touch, fabric on skin).
using the contralateral side as
a control (when possible).
C-fibers painful stimulus warm temperature.
A-d pinprick and cold.
A-b fibers are examined through light touch, vibration,
and joint position
Sensory dissociation
loss of fine touch and proprioception pain and temperature sensing are intact.
Isolated decreased vibratory sense is an early
sign of large-fiber (A-b) neuropathy, and if combined with
position sense deficit indicates posterior column disease or
peripheral nerve involvement.
Posterior column disease (loss of graphesthesia)
The inability to perceive isolated joint position is indicative
of parietal lobe dysfunction or peripheral nerve lesion.1,2
Anatomically, lesions can be divided into central (brain and
spinal cord), spinal nerve root (dermatomal), and peripheral
nerve lesions.(Figs. 4-1 and 4-2)
differentiate between central
and peripheral lesions,(Table 4-1)
FIGURE 4-2 A, Cutaneous distribution of the lumbosacral nerves. B, Cutaneous
distribution of the peripheral nerves of the lower extremity.
(Redrawn from Wedel DJ: Nerve blocks. In: Miller RD, editor: Anesthesia, ed 4. New
York: Churchill Livingstone,1994, p 1547.)
TABLE 4–1
Sensory Innervation Landmarks by Dermatome
Dermatome
C4
C5
C6
C7
C8
T1
T2
T3–T11
T4
T10
T12
L1
L2
L3
L4
L5
S1
S2
S3
S4–S5
Landmark
Shoulder
Lateral aspect of the elbow
Thumb
Middle finger
Little finger
Medial aspect of the elbow
Axilla
Corresponding intercostal space
Nipple line
Umbilicus
Inguinal ligament at midline
Halfway between T12 and L2
Mid-anterior thigh
Medial femoral condyle
Medial malleolus
Dorsum of foot
Lateral heel
Popliteal fossa at midline
Ischial tuberosity
Perianal area
MOTOR EXAMINATION
inspection (hypertrophy, atrophy and fasciculations, among other pathologies)
Palpation
identify pain generators,
Tone
Hypotonia, polyneuropathy, myopathy, and certain spinal cord lesions
Hypertoni (spasticity and rigidity).
Spasticity is commonly seen after brain and spinal
cord injury and stroke and in multiple sclerosis. Rigidity,
, is characteristic of
extrapyramidal diseases, and is due to lesions in the nigrostriatal
system.
isolated voluntary muscle strength
0 to 5 (normal strength)
Greater proximal muscle weakness, indicates myopathy
Greater distal muscle weakness,indicates
polyneuropathy.
Single innervation muscle weakness indicates a
peripheral nerve lesion
or a radiculopathy
TABLE 4–2
Standard Muscle Grading System
Grade
0
1
2
3
4
5 (normal)
Description
No movement
Trace movement, no joint movement
Full range of motion with gravity eliminated
Full range of motion against gravity
Full range of motion against gravity and partial
resistance
Full range of motion against gravity and full
REFLEXES AND COORDINATION
valuable guide to the anatomic localization of a lesion (Table 4-3.)
Jendrassik’s maneuver
Clonus may be indicative of an upper motor neuron disease.
Plantar reflex testing.
Babinski’s sign can be seen with many upper motor neuron diseases, and is also normal variant
in children up until 12 to 18 months
Hoffman’s sign indicative of an upper motor neuron disease.
Coordination and gait testing
Cerebellar function (finger-nose-finger and heel-knee-shin test.)
Equilibrium
observation of normal gait, heel-and-toe walk, and tandem gait testing (heeltotoe walking in a straight line).
Romberg’s test (suggestive of mild lesions of the sensory, vestibular, or
proprioceptive systems.)
TABLE 4–3
Root Level Tested for Common Reflexes
Nerve Root Level
S1–S2
L3–L4
C5–C6
C7–C8
Reflex
Achilles reflex
Patellar reflex
Biceps reflex
Triceps reflexve
TABLE 4–4
Deep-Tendon Reflex Grading System
Grade
0
1+
2+
3+
4+
Description
No response
Reduced, less than expected
Normal
Greater than expected,
moderately hyperactive
Hyperactive with clonus
DIRECTED PAIN EXAMINATION
TEMPLATE
The goal is to develop a standardized and consistent examination.
A standard template should include inspection, palpation, percussion,
range of motion, motor examination, sensory examination,
reflexes, and additional regional provocative tests if indicated. (Table 45)
Inspection
infection or rash,
surgical or traumatic scars, sudomotor alterations, cutaneous
discoloration, and abnormal hair growth
edema and muscular atrophy or hypertrophy and masses
cutaneous temperature should be measured
sympathetically mediated pain.
TABLE 4–5
Directed Pain Examination Template
Examination
Observation
Inspection …………… Cutaneous landmarks, symmetry, temperature
Palpation
….......... Gross sensory changes, masses, trigger points, pulses
Percussion …………………. Tinel’s sign, fractures
Range of Motor …………….. Described in degrees, reason for motion limitation
Innervation
Graded 0–5, correlated with examination
Sensory Reflexes ……………. Dermatomal distribution of changes,
examination description of affected fibers, Graded 0–4
Provocative ………………….
Description of concordant vs. tests
disconcordant pain, appropriate for region
Palpation
Lymph nodes,
trigger points,
lipomas
Tenderness
contralateral structure palpated
percussion
Pain on percussion of bony
structures can indicate a fracture, abscess, or infection
Pain on percussion over a sensory
nerve, or Tinel’s sign(carpal tunnel syndrome
occipital neuralgia)
Range of motion (ROM)
Joint, connective tissue, or ligamentous laxity can
result in supranormal ROM, whereas pain and structural
abnormalities (strictures, arthritis) can limit ROM.
GENERAL OBSERVATIONS
Observations
mannerisms, coordination, interpersonal
interactions, and gait
obtaining vital signs
MENTAL STATUS EXAMINATION
GAIT
normal, antalgic, or abnormal
(table 4-6)
TABLE 4–6
Brief Mental Examination
repetition.Orientation to person and place, date
Ability to name objects (e.g., pen, watch)
repeat
Memory immediate at 1 min, and at 5 min;
the names of
three objects
Ability to calculate serial 7s, or if patient refuses have
them spell
“world” backward
Signs of cognitive deficits, aphasia
EXAMINATION OF THE DIFFERENT
REGIONS OF THE BODY
face,
cervical region,
thoracic region,
lumbosacral region.
FACE
Inspection
infection, herpetic lesions, sudomotor changes, and scarring (both traumatic and postherpetic).
Oral inspection
symmetry of the face;
Facial palpation
masses, sensory changes, and tenderness
over the sinuses.
Percussion (Chvostek’s test) (TMJ)
TABLE 4–7
Cranial Nerve Examination: Summary of Cranial Nerve Functions and Tests
Cranial Nerve
Function
Test
I. Olfactory
Smell
Use coffee, mint, and so on held to each nostril
separately; consider basal frontal tumor in
unilateral dysfunction
II. Optic
Vision
Assess optic disc, visual acuity; name number of
fingers in central and peripheral quadrants; direct
and consensual pupil reflex; note Marcus-Gunn
pupil (paradoxically dilating pupil)
III, IV, and VI.
(Oculomotor,
trochlear, and
abducen(
Extraocular
muscles
Pupil size; visually track objects in eight cardinal
directions; note Horner’s pupil (miosis, ptosis,
anhydrosis)
V. Trigeminal:
motor and
sensory
Facial
sensation,
muscles of
mastication
Cotton-tipped swab/pinprick to all three
branches; recall bilateral forehead innervation
(peripheral lesion spares forehead, central
lesion affects forehead); note atrophy, jaw
deviation to side of lesion
TABLE 4–7
Cranial Nerve Examination: Summary of Cranial Nerve Functions and Tests
Cranial Nerve
Function
Test
VII. Facial
Muscles of facial
expression
Wrinkle forehead, close eyes tightly, smile, purse
lips, puff cheeks; corneal reflex
VIII.
Vestibulocochlear
Hearing, equilibrium Use timing fork, compare side to side; Rinne’s
test for air conduction (AC) vs. bone conduction
(BC) (BC . AC); Weber’s test for sensorineural
hearing
(acoustic)
IX.
Glossopharyngeal
Palate elevation;
Palate elevates away from the lesion; check gag
taste to posterior
reflex
third of tongue;
sensation to
posterior tongue,
pharynx, middle ear,
and dura
X. Vagus
Muscles of pharynx,
larynx
Check for vocal cord paralysis, hoarse or nasal
voice
XI. Accessory
Muscles of larynx,
sternocleidomastoi
d,trapezius
Shoulder shrug, sternocleidomastoid strength
XII. Hypoglossal
Intrinsic tongue
muscles
Protrusion of tongue; deviates toward lesion
CERVICAL AND THORACIC REGIONS
AND UPPER EXTREMITIES
symmetry, muscle condition, and the position of the head, shoulder,
and upper extremity at rest.
upper extremities
for sudomotor changes
Palpation
can identify muscle spasms, myofascial trigger points,
enlarged lymph nodes, occipital nerve entrapment, and pain
over the bony posterior spine
The normal cervical ROMs are flexion, 0 to 60°;
extension, 0 to 25°; bilateral lateral flexion, 0 to 25°;
and bilateral lateral rotation, 0 to 80°. TABLE 4-8
TABLE 4–8 / Cervical Region Nerve Root Testing
Root
Level
Nerve
Muscle(s)
Tested
Position
Action
Sensory
Reflex
Dorsal scapular
Levator
scapulae
Sitting
Shoulder shrug
Shoulders
None
Biceps
Forearm fully
supinated,
elbow
flexed 90°
Patient attempts
further flexion
against resistance
Lateral
forearm,
first and
second
finger
Biceps
C6 Radial (C5–6)
Extensor
carpi,
radialis,
longus,
and brevis
Elbow flexed at
45°, wrist
extended
Maintain extension
against resistance
Middle finger
Brachio
radialis
C7 Radial (C6–8)
Triceps
Shoulder slightly
abducted, elbow
slightly flexed
Extend forearm
against gravity
Middle finger
Triceps
C8 Anterior
Flexor
digitorum
profundus
Finger flexion of
middle finger
Fourth, fifth
finger medial
forearm
None
Examiner pushes
patient’s fingers
together, patient
resists
Medial arm
None
C4
C5 Musculocutaneous
lateral arm (C5–6)
interosseous
(median) (C7–8)
T1 Ulnar, deep branch
(C8–T1)
Dorsal
interossei
Patient extends
and
spreads all
fingers
• Provocative Tests
 distraction test
 cervical compression test
 Spurling’s (neck compression)
 Valsalva maneuver
 drop-arm test
 shoulder ROM testing
 Yergason test (biceps tendon)
 tennis elbow test.( lateral epicondylitis)
 ulnar Tinel’s sign
 median nerve Tinel’s sign
 Phalen’s sign
THORACIC REGION
Thoracic spine pathology can result in pain in the thorax,
abdomen, and back. Inspection should focus on cutaneous
landmarks and the presence of herpetic lesions, ecchymotic
lesions, or masses. thoracic spine, rib cage, and sternum
kyphosis or scoliosis
Thoracic palpation
abdominal aortic aneurysm
There are no true ROM, motor, or reflex examinations truly
specific to the thoracic region
• LUMBOSACRAL REGION
is the most common location of pain most potential pain-generating structures.
inspection of the patient’s gait and posture
degree of spinal curvature.
postsurgical scars
Lower extremity inspection
Common bony structure pain generators
include the facet joints, sacroiliac joints, and the
coccyx.
The normal lumbar spine ROMs are flexion, 0 to 90°;
extension, 0 to 30°; bilateral lateral flexion, 0 to 25°
; and bilateral lateral rotation, 0 to 60°.
pain on flexion hints at a possible disc
lesion, whereas pain on extension can indicate a facet
arthropathy or myofascial pain generator.
two complementary
tests are heel walk (dorsiflexion), which tests L4–L5 function,
and toe walk (plantar flexion), which tests S1–S2 integrity
The majority of tests
are directed toward pathology in the disc and nerve roots,
TABLE 4–9 Lumbar Region Nerve Root Testing
BOT
LEV
Nerve
Muscle(s)
Tested
Position
Action
Sensory
Reflex
L2
Femoral (L2–L4)
Psoas,
iliacus
Patellar
Hip and knee
flexed at 90°
Hip and
knee, upper
thigh flexed
at 90°
Anterior upper
thigh
Patellar
L3
Femoral (L2–L4)
Quadriceps
femoris
Supine, hip
flexed,
knee flexed
at 90°
Extend knee
against
resistance
Anterior lower
thigh
Patellar
L4
Deep anterior
(L4–L5)
Tibialis
Ankle
dorsiflexed,
peroneal
anterior
heel walk
Maintain
extension
against
resistance
Knee walk
Patellar
L5
Deep lateral calf,
peroneal hamstring
(L4–L5)
Superficial peroneal
Extensor
hallucis
longus
Great toe
extended
Foot everted
Maintain
extension
Web between
big
and second toe
Dorsum of foot
Medial
hamstri
ng
S1
Sciatic (L5–S2)
Hamstrings
Prone, knee
flexed
Maintain
flexion
against
resistance
Foot (except
medial aspect)
Achilles
toe walk
joints, sacroiliac joint, hip, and piriformis muscle.
straight leg raise
slumped-seat test
Patrick Faber test,
Gaenslen’s test, Yeoman’s test, posterior shear test are tests
for sacroiliac joint dysfunction
General tests for intrathecal lesions (Kernig test, the Valsalva, Milgram test)
The Hoover test confirm the presence of malingering paralysis of the legs
Waddell’s signs (non organic)
The five signs or
tests are tenderness, simulation testing, distraction testing,
regional disturbances, and overreaction.
• CONCLUSION
 The physical examination is secondary in importance
only to the pain history.
 Costly imaging studies and painful invasive testing can be
avoided by performing a simple yet thorough physical
exam.
 Following a brief global assessment of the patient’s health, the
pain examination should be focused toward the affected
region and consistently performed in a structured pattern
using templates and standard “normal” charts and maps.
 physical examination that fulfills these criteria is an
invaluable component in establishing the correct diagnosis
in a pain patient.