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
