CH.4 PHYSICAL EXAMINATION OF THE PAIN PATIENT

1
CH.4PHYSICAL EXAMINATION OF THE PAIN PATIENT

• R2 ???

2
4 CATEGORIES

• Sensation
• Motor
• Reflexes
• Coordination

3
SENSATION AND SENSORY EXAMINATION
4
Transmitting fiber

• A-delta fiber myelinated fiber
• -gt sharp shooting pain(fast pain)
• C fiber unmyelinated fiber
• -gt dull, poorly localized burning pain
  (slow pain)

5
Terminology

• Hyperesthesia ??? ??? ?? ?? ???? ? ???? ??
• Hyperalgesia pin-prick? ?? ?? ?????? ?? ??? ??
• Allodynia ?????? ?? ????? ??? ? -gt neuropatic
  pain? ??? indicatior

6
Sensory Examination(1)

• C fiber pain, temperature???? ??
• A-delta fiber pinprick, light touch???? ??
• Sensory dissociation
• pain, temperature??? ?? ??? pinprick???
  severe pain response
• -gt spinal cord? cross?? fiber? ??? ???

7
Sensory Examination(2)

• A-beta fiber light touch, vibration, joint
  position?? ??
• Isolated decreased vibratory sense
• large fiber neuropathy? early sign
• position sense deficit ???
• posterior column disease or peirpheral
  nerve involvement? ??

8
Sensory Examination(3)

• Isolated joint position sense deficit
• parietal lobe dysfunction
• or peripheral nerve lesion

9
Sensory mapping

• Dermatome?? peripheral cutaneous nerve map? ????
  ??? localization?? ?? ??
• ??? central, spinal nerve root (dermatomal),
  peripheral nerve lesion?? ??

10
(No Transcript)
11

• F4-2

12

• T4-1

13
MOTOR EXAMINATION
14

• Inspection hypertrophy, atrophy, fasciculation
• Palpation myofascial trigger points? ?? pain
  generator? ??
• Tone hypotonia or hypertonia

15
Spasticity vs Rigidity

• Spasticity velocity-dependent increase in tone
  with joint movement
• -gt brain, spinal cord injury, stroke, multiple
  sclerosis
• Rigidity generalized increase in muscle tone
• -gt extrapyramidal disease, lesion in
  nigrostriatal system

16
Myopathy vs Neuropathy

• Distal muscle weakness?? proximal muscle
  weakness? ? ??
• -gt myopathy
• Distal muscle weakness? ? ? ??
• -gt polyneuropathy
• Single innervation muscle weakness
• -gt peripheral neuropathy

17

• T4-2

18
REFLEXES AND COORDINATION
19
Reflexes

• Deep tendon reflexes (DTR) ??? anatomical
  localization? ??
• Clonus sudden sustained muscle stretch?
  rhythmic, uniphasic muscle contraction ?? -gt
  upper motor neuron disease ??
• Plantar (Babinskis) reflexes upper motor
  neuron disease ??

20

• T4-3

21

• T4-4

22
Coordination

• Coordination and gait test cerebral function,
  equilibrium ??
• Cerebral function finger-nose-finger,
  heel-knee-shin test
• Equilibrium heel and toe walk, tandem gait
  test, Rombergs test

23
DIRECTEDPAIN EXAMINATION TEMPLATE
24

• T4-5

25
General observation

• ??? mannerism, coordination, interpersonal
  interaction, gait?? ??
• Careful history? ?? ??? ??? ??? ???? ?? ????
  physical exam? ??? ? ??

26
Mental examination

• T4-6

27
Gait

• Normal/ antalgic/ abnormal
• Antalgic gait ?? ??? ???? ??? weight bearing?
  ?? ??
• Abnormal gait balance, neurological,
  musculoskeletal disorder ?? ??

28
EXAMINATION OF THE DIFFERENT REGIONS OF THE BODY
29

• Face
• Cervical region
• Thoracic region
• Lumbosacral region

30
Face

• Inspection cutaneous landmark for signs of
  infection, herpetic lesion, sudomotor changes,
  scarring
• Oral inspection intraoral lesion? facial area?
  refered pain?? ??? ? ??
• Palpation, percussion(Chvosteks sign), ROM(TM
  joint)

31
Cervical and Thoracic areas and upper extremities

• Inspection symmetry, muscle condition,
  scarring, position at rest, sudomotor changes,
  cutaneous temperature
• Palpation for muscle spasm, myofascial trigger
  points, tender points, occipital nerve
  entrapment, pain over bony structures(ex facet
  arthropathy)
• Cervical ROM flexion(0-60),
  extension(0-25), bilateral lateral
  flexion(0-25), bilateral lateral
  rotation(0-80)

32
Provocative test(1)

• Distraction test cervical traction?? cervical
  spine? neural foramina? widening?? -gt neural
  foraminal stenosis? ?? ???? compression? ????
  ?????? ??
• Compression test ??? compression???? ????
• Valsalva maneuver intrathecal pr. ???? disc?
  tumor? ?? compression??? ??

33
Provocative test(2)

• Drop arm test rotator cuff tear ???? ??
  abduction ??? ???? ??
• Yergason test biceps tendon? inte-grity? ?? ??
  -gt ??? elbow? fle-xion? ???? ???? ??? elbow?
  wrist? ?? ext. rotation??? ?? ??? ???? ?? ?? ??
  ??? tendon instability? ??? ? ? ??

34
Provocation test(3)

• Tennis elbow test wrist extension??? ??? ????
  ???? ???? wrist flexion? ???? ? lateral
  epi-condyilitis? ?? ???? ???? tenderness??
• Tinels sign nerve percussion? pain
  ulnar n. olecranon? medial epicondyle ???
  groove? percussion
  median n. wrist???
  percussion -gt
  carpal tunnel syndrome
• Phalens sign 1??? wrist? dorsiflexion? ???
  ???? ? ???? tingling sense -gt carpal
  tunnel syndrome

35

• T4-8

36
Lumbosacral region

• Inspection gait, posture at rest, cutaneous
  landmarks(rash, mass, scar, discoloration ?)
• Palpation bony pain generator(facet joint,
  sacroiliac joint, coccyx ?), trigger point, mass
• ROM flexion(0-90), extension(0-30),
  bilateral lateral flexion(0-25), bilateral
  lateral rotation(0-60)
• flexion? pain -gt disc lesion
• extension? pain -gt facet arthropathy or
  muscular pain generator

37
Provocative test(1)

• Nerve root irritation test back flexion,
  straight leg raise, sitting, standing
• Test for facet pathology extension, lateral
  flexion, lateral rotation
• Test for sacroiliac joint dysfunction Faber
  Patrick test, Gaenslens test, Yeomans test ,
  posterior shear test
• Test for piriformis syndrome Pace, Laseque, and
  Freiberg sign
• General test for intrathecal lesion Kernig
  test, Valsalva test, Milgram test

38
Provocative test(2)

• Hoover test leg paralysis? ???? ????
  malingering ?? ?? ???supine position.. ???? ?
  ??? ??? ?? ??? ?????? ?? ?? ??? ??? ??(supine
  leg) ?? ? -gt supine leg? ?? ??? ???? ?? ??? ???
  ?? malingering.. ??? ??? true leg paralysis

39
Provocative test(3)

• Waddells sign nonorganic pain source? ??? ??
  -gt ???? signs or test (tenderness, simulation
  test, distraction test, regional disturbance,
  overreaction)? 3?? ?? ??? positive
• Tenderness superficial stimuli (light skin roll
  or pinch)? deep tenderness or diffuse
  nondermatomal pain ??
• Simulation test ??? ????, ??? ??? rotation?? ?
  lumbar pain??

40
Provocative test(4)

• Distraction test sitting?? straight leg raise??
  provocative test? ???? ??? ?? -gt ???? ???? ???
  positive
• Regional disturbance motor, sensory deficit?
  anatomical distribution? ?? ?? ? positive
• Overreaction verbal expression? facial
  expression? ?????? ??? ????? ?? ? ?

41

• T4-9

42
Conclusion

• Physical exam? history taking ???? ??? ??
• ??? ??? ??
• ??? ???? ??? ?? ?? impression? ???? ??? ??? ?? ?
  ?? ??? ??