Chapter 4 Physical Examination of the Patient with Pain Flashcards
What are the four main categories of pain physical exam?
The pain physical exam is a comprehensive neurologic assessment that can be divided into four main categories: sensation, motor, reflexes, and coordination
What is the major goals of sensory examination?
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.
What are the three classifications of nociceptors?
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
How is information transmitted from nociceptor to CNS?
Once the nociceptor is activated, the generated impulse is then transmitted to the central nervous system (CNS) via A-d and C-fibers.
What is the difference between A-d and C-fibers?
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.
How are A-d and C-fibers tested?
C-fibers are tested using both painful stimulus (pinprick) and warm temperature.
A-d fibers are tested with a pinprick and cold
What is Sensory dissociation?
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.
What areas of the spinal cord is responsible for (proprioception and light touch) and (pain, temperature)?
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
What is a Syrinx?
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
How are the A-b fibers tested?
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
What is the symptoms of posterior column disease ?
indicated by the loss of graphesthesia or the ability to interpret a number outlined on the patient’s palm or calf
What is the symptoms of parietal lobe dysfunction?
The inability to perceive isolated joint position is indicative of parietal lobe dysfunction or peripheral nerve lesion
Anatomically how are lesions divided?
Anatomically, lesions can be divided into central (brain and spinal cord), spinal nerve root (dermatomal), and peripheral nerve lesions.
Indications of lower motor neuron disorders?
atrophy and fasciculations occur with lower motor neuron disorders
Hypotonia
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
Hypertonia
a greater-than-expected normal resistance to passive joint manipulation, is divided into spasticity and rigidity
Spasticity
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.
Rigidity
a generalized increase in muscle tone, is characteristic of extrapyramidal diseases, and is due to lesions in the nigrostriatal system
How is muscle strength tested and graded?
isolated voluntary muscle strength is
tested and graded from 0 to 5 (normal strength)
Greater proximal muscle weakness, in contrast to distal muscle weakness
indicates myopathy
Greater distal muscle weakness, compared to proximal muscle weakness
indicates polyneuropathy
Single innervation muscle weakness indicates
a peripheral nerve lesion or a radiculopathy (if one nerve root provides all motor innervation for the given muscle)
Jendrassik’s maneuver
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
Clonus
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
Plantar reflex testing
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
Babinski’s sign
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.
Hoffman’s sign
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
Cerebellar function and Equilibrium
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
Romberg’s test
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
A standard template (directed pain examination template) should include
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)
Nerve Root Level Tested for Common Reflexes
Nerve Root Level Reflex S1–S2 Achilles reflex L3–L4 Patellar reflex C5–C6 Biceps reflex C7–C8 Triceps reflex
Deep-Tendon Reflex Grading System
Grade Description 0 No response 1+ Reduced, less than expected 2+ Normal 3+ Greater than expected, moderately hyperactive 4+ Hyperactive with clonus
Sensory Innervation Landmarks by Dermatome
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
Standard Muscle Grading System
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
Objectives of palpation
to identify and delineate subcutaneous masses, edema, and muscle contractures; assess pulses; and to localize tender trigger points.
What does pain on percussion of bony structures indicate?
a fracture, abscess, or infection
Pain on percussion over a sensory nerve, or Tinel’s sign, can indicate
nerve entrapment or the presence of a neuroma
Range of motion (ROM)
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
Brief Mental Examination
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
Two main phases of Gait
gait is divided into two main phases,swing and stance, which are further subdivided into several
components
How is Gait described?
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.
What should be included in gait analysis ?
Included in gait analysis should be the observation of tilts, pelvic motion and tilt, and drifting.
How is the pain physical examination divided?
the pain physical examination can be broadly divided into face, cervical region, thoracic region, and lumbosacral region.
Inspection of the face
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
Chvostek’s test
The most common facial percussive test is Chvostek’s test (masseter spasm with tapping of the angle of the mandible, which suggests hypocalcemia)
When is a facial examination is indicated?
A facial examination is indicated in headache
patients secondary to referred pain patterns (supraorbital neuralgia, sinus headache, or headache secondary to TMJ syndrome)
A directed cervical examination includes
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.
What does palpation in the cervical and trunk
region identify?
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
Pain in a dermatomal pattern often indicates
a spinal cord or nerve root lesion
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 abducens Extraocular muscles-
Pupil size; visually track objects in eight cardinal directions; note diplopia (greatest on side of lesion); accommodation; 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
VII. Facial
Muscles of facial expression
Wrinkle forehead, close eyes tightly, smile, purse lips, puff cheeks; corneal reflex
VIII. Vestibulocochlear (acoustic)
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
IX. Glossopharyngeal
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
X. Vagus
Muscles of pharynx, larynx
Check for vocal cord paralysis, hoarse or nasal voice
XI. Accessory
Muscles of larynx, sternocleidomastoid, trapezius
Shoulder shrug, sternocleidomastoid strength
XII. Hypoglossal
Intrinsic tongue muscles
Protrusion of tongue; deviates toward lesion
Distraction Test
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
Cervical Compression
Test
involves downward pressure on the head, causing
compression of the cervical spine and narrowing of the
foramina.
A Spurling’s (neck compression) test
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
Drop-Arm Test
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
A full-thickness rotator cuff tear can be most accurately diagnosed with a combination of what three positive finding
painful arc, the drop-arm sign, and weakness in external rotation.
Yergason test
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
Tennis Elbow Test
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
Ulnar Nerve Tinel’s Sign
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.
Median Nerve Tinel’s Sign
A positive median nerve Tinel’s sign is elicited by tapping
on the carpal tunnel, and is suggestive of carpal tunnel
syndrome
Phalen’s sign
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
Lower extremity inspection includes
vigilance for sudomotor and temperature changes.
Palpation in the lumbar spine begins with
identification of the bony landmarks, specifically the iliac crests. The horizontal line connecting the iliac crests roughly estimates the L4–L5 leveL
Common bony structure pain generators in the lumbar
region include
the facet joints, sacroiliac joints, and the coccyx.
Pain on palpation
over the iliac crest can indicate
Cluneal Nerve Entrapment.
Normal lumbar spine ROMs are
Flexion, 0° to 90°;
extension, 0° to 30°;
bilateral lateral flexion, 0° to 25°;
bilateral lateral rotation, 0° to 60°
Pain on flexion and extension can indicate
pain on flexion hints at a possible disc lesion, whereas pain on extension can indicate a facet arthropathy or myofascial pain generator
Heel walk and Toe walk tests
heel walk (dorsiflexion), which tests L4–L5 function, and toe walk (plantar flexion), which tests S1–S2 integrity
Straight Leg Raise Test
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
Facet arthropathy can be diagnosed by
eliciting pain with facet loading maneuvers (lateral flexion, lateral rotation, and extension)
Tests for sacroiliac joint dysfunction
Patrick Faber test, Gaenslen’s test, Yeoman’s test, posterior shear test
Tests for piriformis syndrome
the Pace, Laseque, and Freiberg signs
General tests for intrathecal lesions include
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
Signs to determine confounding patient
The Hoover test and Waddell’s signs
Hoover Test
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
Waddell’s signs
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
Five Waddell’s signs
Tenderness, simulation testing, distraction testing, regional disturbances, and overreaction.
Tenderness
Tenderness is a
deep or diffuse nondermatomal report of pain to a superficial
stimulus most often a light skin roll or pinch.
Simulation testing
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.
Distraction testing
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
Regional disturbances
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.
Overreaction
Overreaction in the context of cultural variation includes disproportionate verbal and facial expressions, unconventional anatomic
movements and postures, and inappropriate responses to
the examination
