CHAPTER 5 PHYSICAL EXAMINATION OF THE PATIENT WITH PAIN Howard S. Smith, MD,FACP, Andrew Dubin, MD 1. Which physical examination findings are the most reliable when evaluating the peripheral nervous system in a patient with chronic pain issues? When evaluating the peripheral nervous system in a patient with chronic pain, sensory and motor findings are helpful but are of less utility than reflex testing because they can be affected by the patient. Alterations in reflexes are more reliable findings. Areflexia, hyperreflexia, or hyporeflexia usually are indicative of pathology. 2. What is the medial hamstring reflex, and what are its implications? When testing the medial hamstring reflex, the examiner has the patient sit on the examination table with knee flexed to 90 degrees. Then using outstretched fingers, the examiner compresses and stretches the medial hamstring tendons. Percussion over the fingers with the reflex hammer elicits the normal response of knee flexion. This is useful in determining whether the patient has an L5 radiculopathy (in this condition the patient has normal patellar tendon and Achilles tendon reflexes but an absent medial hamstring reflex). 3. What is the axial compression test, and what are the implications of a positive test? Axial compression involves compression of the cervical spine, directly caudad. A positive test occurs when pain is experienced, localized in the cervical region, or radiates distally. A positive test may indicate degenerative joint disease of the spine or nerve root impingement in the upper cervical spine. 4. What is Spurling’s test, and what are the implications of a positive test? Spurling’s test involves compression of the cervical spine while it is slightly extended, rotated, and tilted toward one side. In a positive test, pain radiates distally, usually in a radicular distribution, indicating nerve root compression in the mid to lower cervical region. The nerve compression is ipsilateral to the side that the neck is tilted. 5. Under what circumstances is the chest expansion test used? The chest expansion test may be used if ankylosing spondylitis is suspected. In normal subjects, the difference between the totally deflated and totally inflated chest is usually more than 4 cm. In ankylosing spondylitis, it is almost invariably less than 4 cm. The patient is asked to exhale fully, and the chest is measured. The patient is then asked to inhale fully, and the chest is measured again. The difference between the two measurements is the chest expansion and if less than 4 cm may indicate ankylosing spondylitis. 6. What is the straight leg raising test and what are its implications? Straight leg raising (SLR) is used to check for lower lumbar root irritation (radiculitis) or radiculopathy. In a supine position, the patient’s leg is passively elevated from the ankle. The knee is kept straight. Normal patients can reach nearly 90 degrees without pain. In patients with lower lumbar nerve root irritation, SLR is relatively sensitive and produces pain radiating distally in a radicular distribution. Somewhat less sensitive but more specific is contralateral SLR. In this case, the pain-free leg is elevated; in a positive test, pain is felt on the affected side (e.g., the side of the nerve roots involvement). The straight leg raise is usually positive for sciatic pain going below the knee at 30 to 45 degrees, except in flexible dancers and athletes. Pain from tight hamstrings is localized to the muscle and tendons and may limit range of motion. If “true” sciatic pain radiating down the leg in a radicular distribution is experienced by the patient, then the examiner should bring down the leg 10 degrees until the pain subsides and plantarflex the foot, asking “does this make the pain worse?”. If it does, this may indicate enhanced pain behavior. Then dorsiflex the foot. This tugs on the sciatic nerve and may worsen the pain of root irritation or impingement. If the examiner brings the leg down to where the pain gets better and then externally rotates the leg (hip), this should make the pain better, and internal rotation of the leg may make it worse. A more central herniation may yield pain in the affected leg on raising of the well leg. 7. What is a sitting root test? A sitting root test (SRT) is essentially the same as the SLR test, but the patient is sitting rather than supine. The implications are the same. Findings on straight leg raise and SRT should correlate. A positive SLR but negative SRT may indicate enhanced pain behaviors. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: Neuroimaging in the Patient with Pain Pharmacologic Management Tension-Type Headache Sympathetic Neural Blockade Cancer Pain Syndromes Temporary Neural Blockade Stay updated, free articles. Join our Telegram channel Join Tags: Pain Management Secrets Jun 14, 2016 | Posted by admin in PAIN MEDICINE | Comments Off on Physical Examination of the Patient with Pain Full access? Get Clinical Tree
CHAPTER 5 PHYSICAL EXAMINATION OF THE PATIENT WITH PAIN Howard S. Smith, MD,FACP, Andrew Dubin, MD 1. Which physical examination findings are the most reliable when evaluating the peripheral nervous system in a patient with chronic pain issues? When evaluating the peripheral nervous system in a patient with chronic pain, sensory and motor findings are helpful but are of less utility than reflex testing because they can be affected by the patient. Alterations in reflexes are more reliable findings. Areflexia, hyperreflexia, or hyporeflexia usually are indicative of pathology. 2. What is the medial hamstring reflex, and what are its implications? When testing the medial hamstring reflex, the examiner has the patient sit on the examination table with knee flexed to 90 degrees. Then using outstretched fingers, the examiner compresses and stretches the medial hamstring tendons. Percussion over the fingers with the reflex hammer elicits the normal response of knee flexion. This is useful in determining whether the patient has an L5 radiculopathy (in this condition the patient has normal patellar tendon and Achilles tendon reflexes but an absent medial hamstring reflex). 3. What is the axial compression test, and what are the implications of a positive test? Axial compression involves compression of the cervical spine, directly caudad. A positive test occurs when pain is experienced, localized in the cervical region, or radiates distally. A positive test may indicate degenerative joint disease of the spine or nerve root impingement in the upper cervical spine. 4. What is Spurling’s test, and what are the implications of a positive test? Spurling’s test involves compression of the cervical spine while it is slightly extended, rotated, and tilted toward one side. In a positive test, pain radiates distally, usually in a radicular distribution, indicating nerve root compression in the mid to lower cervical region. The nerve compression is ipsilateral to the side that the neck is tilted. 5. Under what circumstances is the chest expansion test used? The chest expansion test may be used if ankylosing spondylitis is suspected. In normal subjects, the difference between the totally deflated and totally inflated chest is usually more than 4 cm. In ankylosing spondylitis, it is almost invariably less than 4 cm. The patient is asked to exhale fully, and the chest is measured. The patient is then asked to inhale fully, and the chest is measured again. The difference between the two measurements is the chest expansion and if less than 4 cm may indicate ankylosing spondylitis. 6. What is the straight leg raising test and what are its implications? Straight leg raising (SLR) is used to check for lower lumbar root irritation (radiculitis) or radiculopathy. In a supine position, the patient’s leg is passively elevated from the ankle. The knee is kept straight. Normal patients can reach nearly 90 degrees without pain. In patients with lower lumbar nerve root irritation, SLR is relatively sensitive and produces pain radiating distally in a radicular distribution. Somewhat less sensitive but more specific is contralateral SLR. In this case, the pain-free leg is elevated; in a positive test, pain is felt on the affected side (e.g., the side of the nerve roots involvement). The straight leg raise is usually positive for sciatic pain going below the knee at 30 to 45 degrees, except in flexible dancers and athletes. Pain from tight hamstrings is localized to the muscle and tendons and may limit range of motion. If “true” sciatic pain radiating down the leg in a radicular distribution is experienced by the patient, then the examiner should bring down the leg 10 degrees until the pain subsides and plantarflex the foot, asking “does this make the pain worse?”. If it does, this may indicate enhanced pain behavior. Then dorsiflex the foot. This tugs on the sciatic nerve and may worsen the pain of root irritation or impingement. If the examiner brings the leg down to where the pain gets better and then externally rotates the leg (hip), this should make the pain better, and internal rotation of the leg may make it worse. A more central herniation may yield pain in the affected leg on raising of the well leg. 7. What is a sitting root test? A sitting root test (SRT) is essentially the same as the SLR test, but the patient is sitting rather than supine. The implications are the same. Findings on straight leg raise and SRT should correlate. A positive SLR but negative SRT may indicate enhanced pain behaviors. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: Neuroimaging in the Patient with Pain Pharmacologic Management Tension-Type Headache Sympathetic Neural Blockade Cancer Pain Syndromes Temporary Neural Blockade Stay updated, free articles. Join our Telegram channel Join Tags: Pain Management Secrets Jun 14, 2016 | Posted by admin in PAIN MEDICINE | Comments Off on Physical Examination of the Patient with Pain Full access? Get Clinical Tree
