Transcript 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.