Chapter 4 Physical Examination of the Patient with Pain

Question 1

What are the four main categories of pain physical exam?

Answer 1

The pain physical exam is a comprehensive neurologic assessment that can be divided into four main categories: sensation, motor, reflexes, and coordination

Question 2

What is the major goals of sensory examination?

Answer 2

One of the major goals of sensory examination is determining which fibers, neuronal types, or neural tracts are involved in the transmission of each patient’s specific pain.

Question 3

What are the three classifications of nociceptors?

Answer 3

There are three broad classes of nociceptors differentiated based on the type of noxious
stimuli they detect:
mechanical nociceptors respond to pinch and pinprick,
heat nociceptors respond to a temperature greater than 45°C, and
polymodal nociceptors respond equally to mechanical, heat, and chemical noxious stimuli

Question 4

How is information transmitted from nociceptor to CNS?

Answer 4

Once the nociceptor is activated, the generated impulse is then transmitted to the central nervous system (CNS) via A-d and C-fibers.

Question 5

What is the difference between A-d and C-fibers?

Answer 5

A-d fibers are responsible for “fast” or quickly sensed pain, while C-fibers are responsible for “slow” pain.

Fast pain is transmitted by small myelinated A-d fibers at a rate of 2 to 30 m/s and is typically characterized as a sharp, shooting pain.

Slow pain is transmitted by even smaller unmyelinated C-fibers at a rate of less than 2 m/s, and is characterized as a dull, poorly localized burning pain.

Question 6

How are A-d and C-fibers tested?

Answer 6

C-fibers are tested using both painful stimulus (pinprick) and warm temperature.
A-d fibers are tested with a pinprick and cold

Question 7

What is Sensory dissociation?

Answer 7

Sensory dissociation is a state in which patients
present with loss of fine touch and proprioception in the same region in which pain and temperature sensing are intact.
Patients report a sharp sensation to a pinprick in an area without fine touch or proprioception.
This constellation of symptoms (or the converse—intact proprioception and fine touch without temperature and pain intact) can occur with lesions that interrupt fibers at the spinal cord level. The symptoms can be explained by the geography of
the respective neural tracts in the spinal cord.

Question 8

What areas of the spinal cord is responsible for (proprioception and light touch) and (pain, temperature)?

Answer 8

The posterior columns house the tracts that transmit proprioception and light touch, whereas the anterolateral cord carries the spinothalamic tract (pain, temperature) and motor tract

Question 9

What is a Syrinx?

Answer 9

A syrinx can cause a progressive myelopathy
that presents as a central high cervical cord syndrome with a sensory deficit in a cape or shawl distribution, and neck, shoulder, and arm muscle wasting

Question 10

How are the A-b fibers tested?

Answer 10

A-b fibers are examined through light touch, vibration, and joint position.
Vibration is tested with a 128-Hz tuning fork and has increased value when combined with joint position testing.
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

Question 11

What is the symptoms of posterior column disease ?

Answer 11

indicated by the loss of graphesthesia or the ability to interpret a number outlined on the patient’s palm or calf

Question 12

What is the symptoms of parietal lobe dysfunction?

Answer 12

The inability to perceive isolated joint position is indicative of parietal lobe dysfunction or peripheral nerve lesion

Question 13

Anatomically how are lesions divided?

Answer 13

Anatomically, lesions can be divided into central (brain and spinal cord), spinal nerve root (dermatomal), and peripheral nerve lesions.

Question 14

Indications of lower motor neuron disorders?

Answer 14

atrophy and fasciculations occur with lower motor neuron disorders

Question 15

Hypotonia

Answer 15

a decrease in the normal expected muscular resistance to passive manipulation, is due to a depression of alpha or gamma motor unit activity either centrally or peripherally. Hypotonia can
be seen in polyneuropathy, myopathy, and certain spinal cord lesions

Question 16

Hypertonia

Answer 16

a greater-than-expected normal resistance to passive joint manipulation, is divided into spasticity and rigidity

Question 17

Spasticity

Answer 17

a velocity dependent increase in tone with joint movement. it is seen with excitation of spinal reflex arcs or with loss of descending inhibitory control in the reticulospinal or rubrospinal tracts. Spasticity is commonly seen after brain and spinal cord injury and stroke and in multiple sclerosis.

Question 18

Rigidity

Answer 18

a generalized increase in muscle tone, is characteristic of extrapyramidal diseases, and is due to lesions in the nigrostriatal system

Question 19

How is muscle strength tested and graded?

Answer 19

isolated voluntary muscle strength is

tested and graded from 0 to 5 (normal strength)

Question 20

Greater proximal muscle weakness, in contrast to distal muscle weakness

Answer 20

indicates myopathy

Question 21

Greater distal muscle weakness, compared to proximal muscle weakness

Answer 21

indicates polyneuropathy

Question 22

Single innervation muscle weakness indicates

Answer 22

a peripheral nerve lesion or a radiculopathy (if one nerve root provides all motor innervation for the given muscle)

Question 23

Jendrassik’s maneuver

Answer 23

In cases of hypoactive reflexes, distraction techniques such as Jendrassik’s maneuver
(hooking the digits of both hands together and attempting to forcibly separate both hands) can be employed to better elucidate between true loss of reflex and examination artifact

Question 24

Clonus

Answer 24

a grade-four reflex, is characterized by rhythmic, uniphasic muscle contractions in response to sudden sustained muscle stretch.
Clonus is not always an abnormal finding but may be indicative of an upper motor neuron disease

Question 25

Plantar reflex testing

Answer 25

Plantar reflex testing (elicited with sharp stimulus on the lateral aspect of the sole of the foot) should be documented in terms of an up-going (Babinski’s sign) or down-going great toe

Question 26

Babinski’s sign

Answer 26

Babinski first noted the great toe moving upward and the toes fanning outward in response to a key scratch along the lateral plantar surface of the foot in patients with pyramidal lesions. Babinski’s sign can be seen with many upper motor neuron diseases, and is also a normal variant in children up until 12 to 18 months of age.

Question 27

Hoffman’s sign

Answer 27

In the hand, one can elicit a Hoffman’s sign, which is thumb and index finger flexion with tapping of the distal third or fourth digit. This is indicative of an upper motor neuron disease

Question 28

Cerebellar function and Equilibrium

Answer 28

Coordination and gait testing is a sensitive indicator of cerebellar function and equilibrium. Cerebellar function is tested by traditional finger-nose-finger and heel-knee-shin tests. Equilibrium is assessed by observation of normal gait, heel-and-toe walk, and tandem gait testing (heel-totoe walking in a straight line

Question 29

Romberg’s test

Answer 29

Equilibrium is also tested by Romberg’s test (having a patient stand with feet together and eyes closed). Romberg’s test is positive when the patient sways and loses balance with eyes closed and is suggestive of mild lesions of the sensory, vestibular, or proprioceptive systems

Question 30

A standard template (directed pain examination template) should include

Answer 30

Examination: Observation Inspection: Cutaneous landmarks, symmetry, temperature Palpation: Gross sensory changes, masses, trigger points, pulses.Tenderness to palpation over specific structures suggests that these entities are pain generators. Percussion: Tinel’s sign, fractures Range of Motion: Described in degrees, reason for motion Innervation: Limitation Graded 0–5, correlated with examination Motor Examination, Sensory 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 When using region-specific templates, it should be noted whether pain is concordant (in the usual location, nature, and intensity) or discordant (different from the patient’s usual complaint)

Question 31

Nerve Root Level Tested for Common Reflexes

Answer 31

``` Nerve Root Level Reflex S1–S2 Achilles reflex L3–L4 Patellar reflex C5–C6 Biceps reflex C7–C8 Triceps reflex ```

Question 32

Deep-Tendon Reflex Grading System

Answer 32

``` Grade Description 0 No response 1+ Reduced, less than expected 2+ Normal 3+ Greater than expected, moderately hyperactive 4+ Hyperactive with clonus ```

Question 33

Sensory Innervation Landmarks by Dermatome

Answer 33

Dermatome Landmark C4 Shoulder C5 Lateral aspect of the elbow C6 Thumb C7 Middle finger C8 Little finger T1 Medial aspect of the elbow T2 Axilla T3–T11 Corresponding intercostal space T4 Nipple line T10 Umbilicus T12 Inguinal ligament at midline L1 Halfway between T12 and L2 L2 Mid-anterior thigh L3 Medial femoral condyle L4 Medial malleolus L5 Dorsum of foot S1 Lateral heel S2 Popliteal fossa at midline S3 Ischial tuberosity S4–S5 Perianal area

Question 34

Standard Muscle Grading System

Answer 34

Grade Description 0 No movement 1 Trace movement, no joint movement 2 Full range of motion with gravity eliminated 3 Full range of motion against gravity 4 Full range of motion against gravity and partial resistance 5 (normal) Full range of motion against gravity and full resistance

Question 35

Objectives of palpation

Answer 35

to identify and delineate subcutaneous masses, edema, and muscle contractures; assess pulses; and to localize tender trigger points.

Question 36

What does pain on percussion of bony structures indicate?

Answer 36

a fracture, abscess, or infection

Question 37

Pain on percussion over a sensory nerve, or Tinel’s sign, can indicate

Answer 37

nerve entrapment or the presence of a neuroma

Question 38

Range of motion (ROM)

Answer 38

an active test limited by the patient’s effort and report of limitation. The possibilities of range of motion depend on the body location or joint. Joint, connective tissue, or ligamentous laxity can result in supranormal ROM, whereas pain and structural abnormalities (strictures, arthritis) can limit ROM

Question 39

Brief Mental Examination

Answer 39

Patient’s level of consciousness; alertness 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

Question 40

Two main phases of Gait

Answer 40

gait is divided into two main phases,swing and stance, which are further subdivided into several components

Question 41

How is Gait described?

Answer 41

describe the gait as normal, antalgic, or abnormal. An antalgic gait is characterized by the avoidance of bearing weight on an affected limb or joint secondary to pain. An abnormal non-antalgic gait is a broad category that includes balance, neurologic, and musculoskeletal disorders.

Question 42

What should be included in gait analysis ?

Answer 42

Included in gait analysis should be the observation of tilts, pelvic motion and tilt, and drifting.

Question 43

How is the pain physical examination divided?

Answer 43

the pain physical examination can be broadly divided into face, cervical region, thoracic region, and lumbosacral region.

Question 44

Inspection of the face

Answer 44

Begins by observing the cutaneous landmarks for signs of infection, herpetic lesions, sudomotor changes, and scarring (both traumatic and postherpetic). Oral inspection is indicated since intraoral lesions frequently refer pain to distant facial regions. It is also crucial to observe the symmetry of the face; signs of asymmetry should be investigated. Facial palpation is important to identify masses, sensory changes, and tenderness over the sinuses. Percussion can confirm sinus tenderness and distal neurologic derangements

Question 45

Chvostek’s test

Answer 45

The most common facial percussive test is Chvostek’s test (masseter spasm with tapping of the angle of the mandible, which suggests hypocalcemia)

Question 46

When is a facial examination is indicated?

Answer 46

A facial examination is indicated in headache patients secondary to referred pain patterns (supraorbital neuralgia, sinus headache, or headache secondary to TMJ syndrome)

Question 47

A directed cervical examination includes

Answer 47

A directed cervical examination includes the upper thorax, head, shoulders, and upper extremities, as pain can be referred to these areas. Inspection should focus on symmetry, muscle condition, and the position of the head, shoulder, and upper extremity at rest.

Question 48

What does palpation in the cervical and trunk | region identify?

Answer 48

Palpation in the cervical and trunk region can identify muscle spasms, myofascial trigger points, enlarged lymph nodes, occipital nerve entrapment, and pain over the bony posterior spine elements that suggests facet arthropathy

Question 49

Pain in a dermatomal pattern often indicates

Answer 49

a spinal cord or nerve root lesion

Question 50

I. Olfactory - Smell

Answer 50

Use coffee, mint, and so on held to each nostril separately; consider basal frontal tumor in unilateral dysfunction

Question 51

II. Optic- Vision

Answer 51

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)

Question 52

III, IV, and VI. Oculomotor, trochlear, and abducens Extraocular muscles-

Answer 52

Pupil size; visually track objects in eight cardinal directions; note diplopia (greatest on side of lesion); accommodation; note Horner’s pupil (miosis, ptosis, anhydrosis)

Question 53

V. Trigeminal | motor and sensory- Facial sensation, muscles of mastication-

Answer 53

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

Question 54

VII. Facial | Muscles of facial expression

Answer 54

Wrinkle forehead, close eyes tightly, smile, purse lips, puff cheeks; corneal reflex

Question 55

VIII. Vestibulocochlear (acoustic) | Hearing, equilibrium

Answer 55

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

Question 56

IX. Glossopharyngeal

Answer 56

Palate elevation; taste to posterior third of tongue; sensation to posterior tongue, pharynx, middle ear, and dura - Palate elevates away from the lesion; check gag reflex

Question 57

X. Vagus | Muscles of pharynx, larynx

Answer 57

Check for vocal cord paralysis, hoarse or nasal voice

Question 58

XI. Accessory | Muscles of larynx, sternocleidomastoid, trapezius

Answer 58

Shoulder shrug, sternocleidomastoid strength

Question 59

XII. Hypoglossal | Intrinsic tongue muscles

Answer 59

Protrusion of tongue; deviates toward lesion

Question 60

Distraction Test

Answer 60

a maneuver that evaluates the effect of cervical traction on a patient’s pain perception. The patient’s head is slightly elevated superiorly, off-loading the cervical spine. This motion allows widening of the neural foramina, relieving compression caused by neural foraminal stenosis

Question 61

Cervical Compression | Test

Answer 61

involves downward pressure on the head, causing compression of the cervical spine and narrowing of the foramina.

Question 62

A Spurling’s (neck compression) test

Answer 62

performed by gently axially loading the cervical spine while extending the neck and rotating the head, is considered positive if it elicits radicular symptoms ipsilaterally. The exacerbation of symptoms indicates foraminal stenosis. A Valsalva maneuver may also be helpful in delineating pathology in the cervical spine. An increase in intrathecal pressure develops with this maneuver, and increased pain may be secondary to compression of the disc material or tumor

Question 63

Drop-Arm Test

Answer 63

help identify the presence of a tear in the rotator cuff. In this test, the patient with rotator cuff dysfunction will not be able to retain the arm in an abducted position

Question 64

A full-thickness rotator cuff tear can be most accurately diagnosed with a combination of what three positive finding

Answer 64

painful arc, the drop-arm sign, and weakness in external rotation.

Question 65

Yergason test

Answer 65

examines the integrity of the biceps tendon in its bony groove in the humerus. In this maneuver the patient flexes the elbow. The examiner grasps the elbow and wrist of the patient and attempts to rotate the arm externally while the patient resists the maneuver. Instability of the tendon is manifested by the presence of pain in the area of the tendon

Question 66

Tennis Elbow Test

Answer 66

lateral epicondylitis pain can have their symptoms reproduced by the tennis elbow test. The test involves wrist extension by the patient as the lateral forearm is stabilized by the examiner. An attempt to flex the wrist is made while the patient resists. In the presence of lateral epicondylitis, the patient will notice tenderness in the area

Question 67

Ulnar Nerve Tinel’s Sign

Answer 67

A positive ulnar Tinel’s sign is elicited at the elbow by tapping over the groove between the olecranon and the medial epicondyle and causing pain or numbness in ulnar distribution.

Question 68

Median Nerve Tinel’s Sign

Answer 68

A positive median nerve Tinel’s sign is elicited by tapping on the carpal tunnel, and is suggestive of carpal tunnel syndrome

Question 69

Phalen’s sign

Answer 69

paresthesias, or pain in the fingers when flexing the patient’s wrists and placing the dorsal hand surfaces together for a minute, may also indicate median nerve dysfunction at the level of the carpal tunnel

Question 70

Lower extremity inspection includes

Answer 70

vigilance for sudomotor and temperature changes.

Question 71

Palpation in the lumbar spine begins with

Answer 71

identification of the bony landmarks, specifically the iliac crests. The horizontal line connecting the iliac crests roughly estimates the L4–L5 leveL

Question 72

Common bony structure pain generators in the lumbar | region include

Answer 72

the facet joints, sacroiliac joints, and the coccyx.

Question 73

Pain on palpation | over the iliac crest can indicate

Answer 73

Cluneal Nerve Entrapment.

Question 74

Normal lumbar spine ROMs are

Answer 74

Flexion, 0° to 90°; extension, 0° to 30°; bilateral lateral flexion, 0° to 25°; bilateral lateral rotation, 0° to 60°

Question 75

Pain on flexion and extension can indicate

Answer 75

pain on flexion hints at a possible disc lesion, whereas pain on extension can indicate a facet arthropathy or myofascial pain generator

Question 76

Heel walk and Toe walk tests

Answer 76

``` heel walk (dorsiflexion), which tests L4–L5 function, and toe walk (plantar flexion), which tests S1–S2 integrity ```

Question 77

Straight Leg Raise Test

Answer 77

The most frequently performed test for nerve root irritation is the straight leg raise, which is specific for a radicular pathology when pain radiates distal to the knee. This test provokes lumbar radicular symptoms by applying a stretch force to these nerves, which is accentuated by ankle dorsiflexion

Question 78

Facet arthropathy can be diagnosed by

Answer 78

eliciting pain with facet loading maneuvers (lateral flexion, lateral rotation, and extension)

Question 79

Tests for sacroiliac joint dysfunction

Answer 79

Patrick Faber test, Gaenslen’s test, Yeoman’s test, posterior shear test

Question 80

Tests for piriformis syndrome

Answer 80

the Pace, Laseque, and Freiberg signs

Question 81

General tests for intrathecal lesions include

Answer 81

Kernig test for meningeal irritation, the Valsalva, and the Milgram test for intrathecal pathology. Kernig test, a supine patient flexes the chin onto the chest. A positive sign is when the patient complains of pain in the spine. Milgram test involves a supine patient raising the leg a few inches off the examination table. The inability of the patient to hold this position for 30 seconds may indicate an intrathecal lesion

Question 82

Signs to determine confounding patient

Answer 82

The Hoover test and Waddell’s signs

Question 83

Hoover Test

Answer 83

The Hoover test may be used to confirm the presence of malingering with regards to paralysis of the legs. In this test, the patient is supine and the examiner raises one leg of the patient while the other hand of the examiner is underneath the patient’s other (supine) leg. The tendency is for the patient to press down on the supine leg (the downward movement of the heel of the foot is felt by the examiner’s hands), the absence of movement of the supine leg indicates true leg paralysis

Question 84

Waddell’s signs

Answer 84

Waddell’s signs are a measurement of patient pain behaviors and provide indications of a nonorganic source for the patient’s pain. There are five potential Waddell’s signs; the presence of three or more positive signs is a strong indication of a nonorganic source for the patient’s pain

Question 85

Five Waddell’s signs

Answer 85

Tenderness, simulation testing, distraction testing, regional disturbances, and overreaction.

Question 86

Tenderness

Answer 86

Tenderness is a deep or diffuse nondermatomal report of pain to a superficial stimulus most often a light skin roll or pinch.

Question 87

Simulation testing

Answer 87

Simulation testing is a report of pain in the lumbar region to axial loading of the head or to body rotation with the shoulders and pelvis in line.

Question 88

Distraction testing

Answer 88

Distraction testing is repetition and comparison of the results of a provocative test in an obvious and less obvious nonstandard fashion; the most common is sitting versus supine straight leg raise tests. If the results are contrary, this is considered positive

Question 89

Regional disturbances

Answer 89

Regional disturbances are primarily motor, and include sensory deficits that do not follow an anatomic distribution. They can be a nondermatomal distribution of sensory change, such as a glove and stocking distribution or complete limb weakness.

Question 90

Overreaction

Answer 90

Overreaction in the context of cultural variation includes disproportionate verbal and facial expressions, unconventional anatomic movements and postures, and inappropriate responses to the examination