FIGURE 4-1 A, Cutaneous distribution of the cervical roots. B ...

FIGURE 4-1 A, Cutaneous distribution of the cervical roots. B ...

Physical Examination of the Patient with Pain DR.BAHMAN ROSHANI Physical Examination of the Patient with Pain Goals ,developing the patients trust gaining insight into the impact of pain on the ,patients level of functioning .identifying potential pain generators Physical Examination of the Patient with Pain main categories; ,sensation.1 ,motor.2 ,reflexes.3 and coordination.4

Physical Examination of the Patient with Pain SENSATION AND SENSORY EXAMINATION peripheral nociceptors , mechanical nociceptors,( pinch, pinprick) heat nociceptors (temperature greater than 45C) , polymodal nociceptors,( mechanical, heat, .and chemical noxious stimuli( fast or quickly sensed pain, A- 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 sign of large-fiber (A-b) neuropathy, and early 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 41 Sensory Innervation Landmarks by Dermatome Dermatome C4 C5 C6 C7 C8 T1 T2 T3T11 T4

T10 T12 L1 L2 L3 L4 L5 S1 S2 S3 S4S5 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 42 Standard Muscle Grading System Grade Description No movement 0 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) 1 2 3 4 normal (5 REFLEXES AND COORDINATION valuable guide to the anatomic localization of a lesion (Table 4-3.) Jendrassiks maneuver Clonus may be indicative of an upper motor neuron disease. Plantar reflex testing. Babinskis sign can be seen with many upper motor neuron diseases, and is also normal variant in children up until 12 to 18 months Hoffmans 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). Rombergs test (suggestive of mild lesions of the sensory, vestibular, or proprioceptive systems.) TABLE 43 Root Level Tested for Common Reflexes

Nerve Root Level S1S2 L3L4 C5C6 C7C8 Reflex Achilles reflex Patellar reflex Biceps reflex Triceps reflexve TABLE 44 Deep-Tendon Reflex Grading System Grade Description No response 0 Reduced, less than+ expected Normal+ 2

,Greater than expected+ moderately hyperactive Hyperactive with clonus+ 1 3 4 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 4-5) 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 45 Directed Pain Examination Template Examination Observation Inspection Cutaneous landmarks, symmetry, temperature Palpation .......... Gross sensory changes, masses, trigger points, pulses Percussion . Tinels sign, fractures Range of Motor .. Described in degrees, reason for motion limitation Innervation Graded 05, correlated with examination Sensory Reflexes . Dermatomal distribution of changes, examination description of affected fibers, Graded 04 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 Tinels 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 46 Brief Mental Examination Orientation to person and place, date .repetition Ability to name objects (e.g., pen, watch) Memory immediate at 1 min, and at 5 min; repeat 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 (Chvosteks test) (TMJ) TABLE 47 Cranial Nerve Examination: Summary of Cranial Nerve Functions and Tests Test Function Cranial Nerve Use coffee, mint, and so on held to each nostril separately; consider basal frontal tumor in unilateral dysfunction Smell I. Olfactory 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) Vision II. Optic Pupil size; visually track objects in eight cardinal directions; note Horners pupil (miosis, ptosis, anhydrosis) Extraocular muscles .III, IV, and VI Oculomotor, ( trochlear, and (abducen 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

Facial sensation, muscles of mastication V. Trigeminal: motor and sensory TABLE 47 Cranial Nerve Examination: Summary of Cranial Nerve Functions and Tests Test Function Cranial Nerve Wrinkle forehead, close eyes tightly, smile, purse lips, puff cheeks; corneal reflex Muscles of facial expression VII. Facial

Use timing fork, compare side to side; Rinnes test for air conduction (AC) vs. bone conduction (BC) (BC . AC); Webers test for sensorineural hearing Hearing, equilibrium VIII. Vestibulocochle ar Palate elevates away from the lesion; check gag reflex Palate elevation; taste to posterior third of tongue; sensation to posterior ,tongue pharynx, middle ear, and dura

IX. Glossopharynge al Check for vocal cord paralysis, hoarse or nasal voice Muscles of pharynx, larynx X. Vagus Shoulder shrug, sternocleidomastoid strength Muscles of larynx, sternocleidomas toid,trapezius XI. Accessory Protrusion of tongue; deviates toward

Intrinsic tongue XII. Hypoglossal )acoustic( 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 48 / Cervical Region Nerve Root Testing Sensory

Action Position Muscle( s) Tested Nerve None Shoulders Shoulder shrug Sitting Levator scapulae Dorsal scapular C4

Biceps Lateral ,forearm first and second finger Patient attempts further flexion against resistance Forearm fully supinated, elbow flexed 90 Biceps Musculocutaneo us lateral arm (C5 6)

C5 Brachi oradial is Middle finger Maintain extension against resistance Elbow flexed at wrist, 45 extended Extensor ,carpi radialis, ,longus and brevis

Radial (C56) C6 Triceps Middle finger Extend forearm against gravity Shoulder slightly abducted, elbow slightly flexed Triceps Radial (C68) C7

None Fourth, fifth finger medial forearm Finger flexion of middle finger Flexor digitoru m profundu s Anterior interosseous )C78) (median( C8 None Medial arm

Examiner pushes Dorsal Ulnar, deep T1 Patient Root Level Reflex Provocative Tests distraction test cervical compression test Spurlings (neck compression) Valsalva maneuver drop-arm test shoulder ROM testing Yergason test (biceps tendon) tennis elbow test.( lateral epicondylitis)

ulnar Tinels sign median nerve Tinels sign Phalens 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 patients 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 L4L5 function, and toe walk (plantar flexion), which tests S1S2 integrity The majority of tests are directed toward pathology in the disc and nerve roots, TABLE 49 Lumbar Region Nerve Root Testing Reflex Sensory Action Position Muscle(s ) Tested

Nerve BOT LEV Patella r Anterior upper thigh Hip and knee, upper thigh flexed at 90 Patellar Hip and knee flexed at 90 Psoas,

iliacus Femoral (L2L4) L2 Patella r Anterior lower thigh Extend knee against resistance Supine, hip ,flexed knee flexed at 90 Quadricep s femoris

Femoral (L2L4) L3 Patella r Knee walk Maintain extension against resistance Ankle ,dorsiflexed peroneal anterior heel walk Tibialis Deep anterior )L4L5(

L4 Medial hamstr ing Web between big and second toe Dorsum of foot Maintain extension Great toe extended Foot everted Extensor hallucis longus

,Deep lateral calf peroneal hamstring )L4L5( Superficial peroneal L5 Achille s Foot (except medial )aspect Maintain flexion against Prone, knee flexed Hamstring s

Sciatic (L5S2) S1 toe walk joints, sacroiliac joint, hip, and piriformis muscle. straight leg raise slumped-seat test Patrick Faber test, Gaenslens test, Yeomans 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 Waddells 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 patients 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.

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