Examinations and general start for all examinations:
Wash hands and introduce
Weigh patient
Gait
Heel/toe walking (L4/5 heels, S1 Toes)
Balance on one leg and other
Squat (L3/L4)
General Examination - Chronic pain (FPM Video)
Inspection of spine and posture (Frontal and lateral plane)
Forward flexion (hands on legs as far as possible)
Extension
Lateral flexion
Provocation facet joint check
Palpation of the spinous processes
Palpation of paraspinal muscles
Palpation of SIJ if required
Seated:
Thoracic rotation and flexion
Neck - Flexion, Extension, Lateral flexion, extension, Lateral rotation
Hands
Movements for hands and elbows and shoulders through active ROM
(Can add neurological if required)
Lying down:
Observation and muscle bulk
Hip examination
FABERs test
Distraction test
Compression test
Knee examination (general)
Lower limb neurological examination
Add cardiovascular or abdominal examination if required
Lying prone:
Palpation of spine if required
CRPS (Motor/Trophic, Sensory, Sudomotor/oedema, Vasomotor)
Inspection (Trophic changes, nails, skin, colour, temperature) (Look)
Sensory (light touch and pinprick), sudomotor (sweating/hair) (pulses) (Feel)
Motor (weakness, contractures, ROM) (Move)
Functional (What can you not do with it?)
Headache
Inspect neck and posture (Look)
Palpate cervical spine: (Feel)
Spinous processes
Paraspinal muscles
Occipital nerves
Movements of the neck: (Move)
Flexion/Extension
Rotation
Lateral flexion
Facial examination: (Function and other)
Front of face sinuses
TMJ examination
Neurological examination CNS 2-12
CN2 - Vision and pupils and accommodation and swinging eye test and visual fields
CN 3 - Extraocular movements (corneal motor and ptosis)
CN 4 - Superior oblique
CN 6 - Lateral rectus
CN 5 - Facial sensation (corneal sensation) and muscles of mastication (and jaw jerk reflex
CN 7 - Facial muscles (movements of the face)
CN 8 - Hearing (Rinne / Weber)
CN 9 & 10 - Uvula and rise of palate and gag
CN 11 - Shrug shoulders
CN 12 - Tongue
Neck pain / upper limb radicular
Inspect neck and posture (Look)
Palpate cervical spine: (Feel)
Spinous processes
Paraspinal muscles
Occipital nerves
Movements of the neck: (Move)
Flexion/Extension
Rotation
Lateral flexion
Sensory:
Back of neck - (C2)
Supraclavicular fossae (C3)
Shoulder tip (C4)
Lateral elbow (C5)
Thumb (C6)
Middle finger (C7)
Little finger (C8)
Medial elbow (T1)
Axilla (T2)
Motor:
Shoulder abduction (C4) - Axillary nerve
Elbow flexors - Biceps (C5) - Musculocutaneous nerve
Wrist extensors - Brachioradialis (C6) - Radial nerve
Elbow extensors - Triceps (C7) - Radial nerve
Finger flexion (C8) - Anterior interosseous nerve (Ulnar nerve)
Finger abduction (T1) - Ulnar (First dorsal interosseous) Median (Abductor pollicis brevis)
Reflexes:
C5 - Biceps
C6 - Brachioradialis
C7 - Triceps
C8 - Finger jerks
Hoffman's - UMNL
Lower back pain / Lower limb radicular
Observation:
C7 - Most prominent spinous process at neck
T7 - Lower body of scapulae
L4 - Iliac crests
S2 - Sacral dimples at PSIS
Kyphosis, scoliosis (functional disappears with forward flexion)
Motor Assessment:
L2 - Hip flexion - Psoas muscle - Nerve to psoas major
L3 - Knee extensors - Quads - Femoral nerve
L4 - Ankle dorsiflexion - Tibialis anterior - Anterior tibial nerve
L5 - Big toe extension - Extensor Hallucis Longus
S1 - Plantar flexion - Gastrocnemius - Posterior Tibial
Reflexes: (and clonus!)
L3/4 - Knee jerk
S1/2 - Ankle reflex
Plantar - UMNL lower limb
Sensory:
Large Abeta fibres - Touch and vibration - Test with cotton wool (Static mechanical allodynia) or brush (Dynamic mechanical allodynia)
Small Adelta and C fibres - Pain - Test with pinprick
Dorsal columns - Proprioception
Muscular trigger points and palpation:
All facet joints
SIJ palpation
Erector spinae
Quadratus lumborum
Gluteals
Piriformis muscle
ROM - Schober's test (for LS spinal movement) (Mark at PSIS - then 5 cm above and below and bend forwards. Less than 5cm is abnormal
Kemp's test - Facet loading test
Abdominal pain examination (from video on FPM)
Start with hands (anaemia)
Face (GI findings)
Abdomen examination
Exposure
Inspection
Gentle palpation
Liver/Spleen/Kidneys
Bruits
Hernias and lifting head up
Can consider - Ilioinguinal, hypogastric, genitofemoral nerve, inguinal ligament, pudendal nerve
Specific focal examinations and rectal examination
Straight leg raise and clam shell test
- Ortho (Wrist, Elbow, Shoulder, Hip, Knee, Ankle)
Chronic widespread pain
Sensory examination: (Dr Paul Wrigley - study quantitative sensory testing)
He argues that loss of sensation is more specific than increased sensitivity
Positive pain features can be nociceptive/neuropathic
Assess Balance - Romberg, Heel/Toe walking can be considered as well
General sensory
Balance
Pain oriented:
Hypersensitivity/Sensitisation (Periph/central, spinal cord, brain, descending)
Focal neurological problems, other conditions (e.g. CRPS, Fibromyalgia)
Neuropathic pain (fibre size, specific diagnoses ...)
MSK & Visceral pain
Function
Questions to ask when examining:
- Light touch - what is normal? Is there normative data?
- Is something affecting your testing? (e.g. lots of noise, worse pain)
- Careful application of the stimulus done in the same way
"Does that feel what you think a toothpick should feel like?"
"Does this feel the same on both sides?"
"In what way does it feel different?"
A couple of times tapping is ok
Go from an area you can't feel to an area that you can
You may need to outline the affected area - or it may be a screening test and not require exact painting of areas
Low back examination (Milton/Martine)
Gait
Toe and heel walking
Squat
Trendelenberg
Static cutaneous mechanical Allodynia - Local Allodynia or diffuse allodynia
Straighten leg, then resist flexion of the knee.
Examination videos:
Overall general examination:
Dr Nick Christelis - Examination Back and lower spine
Summary of Evidence - Statements
CRPS evidence: Cochrane review 2016
Treatment guidelines recommend a multidisciplinary approach
PT and OT goal is to increase movement of the limb
Low level evidence for PT and OT - however best evidence is for GMI and mirror imagery in CRPS 1
GMI is: Laterality, imagination of movement with image, view unaffected limb with mirror
Psychological therapies for coping, relaxation, thermal biofeedback, and graded exposure therapy - Trials are small
Amitriptyline, Gabapentin and Carbamazepine have most evidence of some benefit in small trials
NSAID trial results have been mixed
Steroids have some evidence of benefit where there is a strong inflammatory component
Cochrane 2013 suggests bisphosphonates may be beneficial but low quality studies
Sympathetic nerve blocks have unclear results however they are commonly performed
Reasonably strong evidence of benefit for SCS in CRPS and suggestion that it should be considered earlier in disease course to prevent secondary complications
DRG may be superior over epidural from the ACCURATE study but remains unrepeated
Vitamin C may be preventative particularly in those who have previously had CRPS elsewhere who are undergoing surgery
Reference:
Shim, H., Rose, J., Halle, S., & Shekane, P. (2019). Complex regional pain syndrome: a narrative review for the practising clinician. British journal of anaesthesia, 123(2), e424–e433. https://doi.org/10.1016/j.bja.2019.03.030
Neuropathic pain evidence:
Amitriptyline NNT = 3.6
Duloxetine NNT = 6
Gabapentinoids NNT = 7
Cannabinoids NNT = 24 (NNH = 6)
Brachial plexus injury and management
Post stroke management
Headache management / migraine particularly
Multiple sclerosis
Functional neurological disorder / CWP management
Pelvic/abdominal pain
Non-specific low back pain
Cochrane 2021 - Moderate level evidence that exercise is probably effective compared to no treatment, usual care or placebo
Acupuncture increasingly shows less benefit versus sham acupuncture in latest Cochrane 2020 (2)
References:
1. Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews 2021, Issue 9. Art. No.: CD009790. DOI: 10.1002/14651858.CD009790.pub2. Accessed 25 April 2022.
2. Mu J, Furlan AD, Lam WY, Hsu MY, Ning Z, Lao L. Acupuncture for chronic nonspecific low back pain. Cochrane Database of Systematic Reviews 2020, Issue 12. Art. No.: CD013814. DOI: 10.1002/14651858.CD013814. Accessed 25 April 2022.
Post amputation pain - Summary
- Type of neuropathic pain
- Antidepressants
(Amitriptyline most studied but side effects often make intolerable. Small studies on duloxetine and mirtazepine)
- Gabapentin (mixed evidence of benefits and high side effects in this population)
- NMDA receptor antagonists (ketamine and memantine) - IV and oral some small benefit
- Serum calcitonin Mixed results
- Calcium channel blockers, beta blockers, alpha-2 adrenergic agonists etc - minimal evidence
CBT, hyponosis, biofeedback and guided imagery have been trialled
EMDR and mirror visual feedback and virtual reality have also been trialled. Case series studies only and longer term larger studies have not yet occurred. Possible benefit of MVR in reversing cortical reorganisation but has not been confirmed.
Massage, acupuncture, ultrasound have all some modest short term benefit
Surgical/Interventional
- Neuromodulatory - implants and transcutaneous stims - unclear
- Deep brain, motor cortex or other stimulators - unclear possible short term benefit
Neuromas and heterotopic ossification can be treated as found - mixed outcomes
Reference:
Modest, J. M., Raducha, J. E., Testa, E. J., & Eberson, C. P. (2020). Management of post-amputation pain. Rhode Island medical journal, 103(4), 19-22.
Trigeminal neuralgia
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