2. Physical Examination of the Patient with Pain
DR.BAHMAN ROSHANI

3. Physical Examination of the Patient with Pain
Goals
developing the patient’s trust,
gaining insight into the impact of pain on the patient’s level of functioning,
identifying potential pain generators.

4. Physical Examination of the Patient with Pain
main categories;
1.sensation,
2.motor,
3.reflexes,
4.and coordination

5. Physical Examination of the Patient with Pain
SENSATION AND SENSORY EXAMINATION
peripheral nociceptors
mechanical nociceptors,( pinch, pinprick),
heat nociceptors (temperature greater than 45°C)
, polymodal nociceptors,( mechanical, heat,
(and chemical noxious stimuli.
“fast” or quickly sensed pain, A-ð and C-fibers / Slow pain,

6. Physical Examination of the Patient with Pain
A-d fibers at a rate of( 2 to 30 m/s) sharp,shooting pain
C-fibers less than 2 m/s, dull, poorly localized burning pain. .

7. Sensory alterations should be described in standardized terms in order to create a more universal record of symptoms.
Hyperesthesia Hyperesthesia (hyperalgesia and allodynia). Hyperalgesia is severe pain in response to mild noxious stimuli,. Allodynia is the sensation of pain in response to a non-noxious stimuli (e.g., light touch, fabric on skin). using the contralateral side as a control (when possible). C-fibers painful stimulus warm temperature. A-d pinprick and cold. A-b fibers are examined through light touch, vibration, and joint position

8. Sensory dissociation
loss of fine touch and proprioception pain and temperature sensing are intact.
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.
Posterior column disease (loss of graphesthesia)
The inability to perceive isolated joint position is indicative
of parietal lobe dysfunction or peripheral nerve lesion.1,2
Anatomically, lesions can be divided into central (brain and
spinal cord), spinal nerve root (dermatomal), and peripheral
nerve lesions.(Figs. 4-1 and 4-2)
differentiate between central
and peripheral lesions,(Table 4-1)

10. FIGURE 4-2 A, Cutaneous distribution of the lumbosacral nerves
FIGURE 4-2 A, Cutaneous distribution of the lumbosacral nerves. B, Cutaneous distribution of the peripheral nerves of the lower extremity.
(Redrawn from Wedel DJ: Nerve blocks. In: Miller RD, editor: Anesthesia, ed 4. New York: Churchill Livingstone,1994, p 1547.)

11. TABLE 4–1 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

12. MOTOR EXAMINATION Palpation Tone
inspection (hypertrophy, atrophy and fasciculations, among other pathologies)
Palpation
identify pain generators,
Tone
Hypotonia, polyneuropathy, myopathy, and certain spinal cord lesions
Hypertoni (spasticity and rigidity).
Spasticity is commonly seen after brain and spinal
cord injury and stroke and in multiple sclerosis. Rigidity,
, is characteristic of
extrapyramidal diseases, and is due to lesions in the nigrostriatal
system.

13. isolated voluntary muscle strength
0 to 5 (normal strength)
Greater proximal muscle weakness, indicates myopathy
Greater distal muscle weakness,indicates polyneuropathy.
Single innervation muscle weakness indicates a peripheral nerve lesion
or a radiculopathy

14. TABLE 4–2 Standard Muscle Grading System
Grade Description
No movement
Trace movement, no joint movement
Full range of motion with gravity eliminated
Full range of motion against gravity
Full range of motion against gravity and partial
resistance
5 (normal) Full range of motion against gravity and full

15. REFLEXES AND COORDINATION
valuable guide to the anatomic localization of a lesion (Table 4-3.)
Jendrassik’s maneuver
Clonus may be indicative of an upper motor neuron disease.
Plantar reflex testing.
Babinski’s sign can be seen with many upper motor neuron diseases, and is also normal variant in children up until 12 to 18 months
Hoffman’s sign indicative of an upper motor neuron disease.
Coordination and gait testing
Cerebellar function (finger-nose-finger and heel-knee-shin test.)
Equilibrium
observation of normal gait, heel-and-toe walk, and tandem gait testing (heel-
totoe walking in a straight line).
Romberg’s test (suggestive of mild lesions of the sensory, vestibular, or
proprioceptive systems.)

16. TABLE 4–3 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 reflexve

17. TABLE 4–4 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

18. DIRECTED PAIN EXAMINATION TEMPLATE
The goal is to develop a standardized and consistent examination.
A standard template should include inspection, palpation, percussion,
range of motion, motor examination, sensory examination,
reflexes, and additional regional provocative tests if indicated. (Table 4-5)
Inspection
infection or rash,
surgical or traumatic scars, sudomotor alterations, cutaneous
discoloration, and abnormal hair growth
edema and muscular atrophy or hypertrophy and masses
cutaneous temperature should be measured
sympathetically mediated pain.

19. TABLE 4–5 Directed Pain Examination Template
Examination Observation
Inspection …………… Cutaneous landmarks, symmetry, temperature
Palpation … Gross sensory changes, masses, trigger points, pulses
Percussion …………………. Tinel’s sign, fractures
Range of Motor …………….. Described in degrees, reason for motion limitation
Innervation
Graded 0–5, correlated with 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

20. Palpation percussion Range of motion (ROM) Lymph nodes,
trigger points,
lipomas
Tenderness
contralateral structure palpated
percussion
Pain on percussion of bony
structures can indicate a fracture, abscess, or infection
Pain on percussion over a sensory
nerve, or Tinel’s sign(carpal tunnel syndrome
occipital neuralgia)
Range of motion (ROM)
Joint, connective tissue, or ligamentous laxity can
result in supranormal ROM, whereas pain and structural
abnormalities (strictures, arthritis) can limit ROM.

21. GENERAL OBSERVATIONS
Observations
mannerisms, coordination, interpersonal
interactions, and gait
obtaining vital signs
MENTAL STATUS EXAMINATION (table 4-6)
GAIT
normal, antalgic, or abnormal

22. TABLE 4–6 Brief Mental Examination
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

23. EXAMINATION OF THE DIFFERENT REGIONS OF THE BODY
face,
cervical region,
thoracic region,
lumbosacral region.
FACE
Inspection
infection, herpetic lesions, sudomotor changes, and scarring (both traumatic and postherpetic).
Oral inspection
symmetry of the face;
Facial palpation
masses, sensory changes, and tenderness
over the sinuses.
Percussion (Chvostek’s test) (TMJ)

24. Test Function Cranial Nerve
TABLE 4–7 Cranial Nerve Examination: Summary of Cranial Nerve Functions and Tests
Test
Function
Cranial Nerve
Use coffee, mint, and so on held to each nostril separately; consider basal frontal tumor in unilateral dysfunction
Smell
I. Olfactory
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)
Vision
II. Optic
Pupil size; visually track objects in eight cardinal directions; note Horner’s pupil (miosis, ptosis, anhydrosis)
Extraocular muscles
III, IV, and VI.
(Oculomotor, trochlear, and (abducen
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
Facial sensation, muscles of mastication
V. Trigeminal: motor and
sensory

25. Test Function Cranial Nerve (acoustic)
TABLE 4–7 Cranial Nerve Examination: Summary of Cranial Nerve Functions and Tests
Test
Function
Cranial Nerve
Wrinkle forehead, close eyes tightly, smile, purse lips, puff cheeks; corneal reflex
Muscles of facial expression
VII. Facial
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
Hearing, equilibrium
VIII. Vestibulocochlear
(acoustic)
Palate elevates away from the lesion; check gag reflex
Palate elevation; taste to posterior third of tongue; sensation to posterior tongue,
pharynx, middle ear, and dura
IX. Glossopharyngeal
Check for vocal cord paralysis, hoarse or nasal voice
Muscles of pharynx, larynx
X. Vagus
Shoulder shrug, sternocleidomastoid strength
Muscles of larynx, sternocleidomastoid,trapezius
XI. Accessory
Protrusion of tongue; deviates toward lesion
Intrinsic tongue muscles
XII. Hypoglossal

26. symmetry, muscle condition, and the position of the head, shoulder,
CERVICAL AND THORACIC REGIONS
AND UPPER EXTREMITIES
symmetry, muscle condition, and the position of the head, shoulder,
and upper extremity at rest.
upper extremities
for sudomotor changes
Palpation
can identify muscle spasms, myofascial trigger points,
enlarged lymph nodes, occipital nerve entrapment, and pain
over the bony posterior spine
The normal cervical ROMs are flexion, 0 to 60°;
extension, 0 to 25°; bilateral lateral flexion, 0 to 25°;
and bilateral lateral rotation, 0 to 80°. TABLE 4-8

27. TABLE 4–8 / Cervical Region Nerve Root Testing
Reflex
Sensory
Action
Position
Muscle(s)
Tested
Nerve
Level
Root
None
Shoulders
Shoulder shrug
Sitting
Levator scapulae
Dorsal scapular C4
Biceps
Lateral forearm,
first and second
finger
Patient attempts
further flexion
against resistance
Forearm fully
supinated, elbow
flexed 90°
Musculocutaneous
lateral arm (C5–6) C5
Brachioradialis
Middle finger
Maintain extension
Elbow flexed at
45°, wrist extended
Extensor carpi,
radialis, longus,
and brevis
Radial (C5–6) C6
Triceps
Extend forearm
against gravity
Shoulder slightly
abducted, elbow
slightly flexed
Radial (C6–8) C7
Fourth, fifth finger medial forearm
Finger flexion of
middle finger
Flexor digitorum
profundus
Anterior interosseous
(median) (C7–8) C8
Medial arm
Examiner pushes
patient’s fingers
together, patient
resists
Patient extends and
spreads all fingers
Dorsal interossei
Ulnar, deep branch
(C8–T1) T1

28. Provocative Tests distraction test cervical compression test
Spurling’s (neck compression)
Valsalva maneuver
drop-arm test
shoulder ROM testing
Yergason test (biceps tendon)
tennis elbow test.( lateral epicondylitis)
ulnar Tinel’s sign
median nerve Tinel’s sign
Phalen’s sign

29. THORACIC REGION
Thoracic spine pathology can result in pain in the thorax,
abdomen, and back. Inspection should focus on cutaneous
landmarks and the presence of herpetic lesions, ecchymotic
lesions, or masses. thoracic spine, rib cage, and sternum
kyphosis or scoliosis
Thoracic palpation
abdominal aortic aneurysm
There are no true ROM, motor, or reflex examinations truly specific to the thoracic region

30. LUMBOSACRAL REGION
is the most common location of pain most potential pain-generating structures.
inspection of the patient’s gait and posture
degree of spinal curvature.
postsurgical scars
Lower extremity inspection
Common bony structure pain generators
include the facet joints, sacroiliac joints, and the
coccyx.
The normal lumbar spine ROMs are flexion, 0 to 90°;
extension, 0 to 30°; bilateral lateral flexion, 0 to 25°
; and bilateral lateral rotation, 0 to 60°.
pain on flexion hints at a possible disc
lesion, whereas pain on extension can indicate a facet
arthropathy or myofascial pain generator.
two complementary
tests are heel walk (dorsiflexion), which tests L4–L5 function,
and toe walk (plantar flexion), which tests S1–S2 integrity
The majority of tests
are directed toward pathology in the disc and nerve roots,

31. TABLE 4–9 Lumbar Region Nerve Root Testing
Reflex
Sensory
Action
Position
Muscle(s) Tested
Nerve
BOT LEV
Patellar
Anterior upper
thigh
Hip and knee, upper
thigh flexed at 90°
Hip and knee
flexed at 90°
Psoas, iliacus
Femoral (L2–L4) L2
Anterior lower
Extend knee against
resistance
Supine, hip flexed,
knee flexed at 90°
Quadriceps femoris L3
Knee walk
Maintain extension
against resistance
Ankle dorsiflexed,
peroneal anterior
heel walk
Tibialis
Deep anterior
(L4–L5) L4
Medial
hamstring
Web between big
and second toe
Dorsum of foot
Great toe extended
Foot everted
Extensor hallucis
longus
Deep lateral calf,
peroneal hamstring
Superficial peroneal L5
Achilles
Foot (except
medial aspect)
Maintain flexion
Prone, knee flexed
toe walk
Hamstrings
Sciatic (L5–S2) S1

32. joints, sacroiliac joint, hip, and piriformis muscle.
straight leg raise
slumped-seat test
Patrick Faber test,
Gaenslen’s test, Yeoman’s test, posterior shear test are tests
for sacroiliac joint dysfunction
General tests for intrathecal lesions (Kernig test, the Valsalva, Milgram test)
The Hoover test confirm the presence of malingering paralysis of the legs
Waddell’s signs (non organic)
The five signs or
tests are tenderness, simulation testing, distraction testing,
regional disturbances, and overreaction.

33. CONCLUSION
The physical examination is secondary in importance
only to the pain history.
Costly imaging studies and painful invasive testing can be
avoided by performing a simple yet thorough physical
exam.
Following a brief global assessment of the patient’s health, the
pain examination should be focused toward the affected
region and consistently performed in a structured pattern
using templates and standard “normal” charts and maps.
physical examination that fulfills these criteria is an
invaluable component in establishing the correct diagnosis
in a pain patient.