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Long Case Summary Examination notes - Up to date - Mid 2022

Updated: May 15, 2022



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.



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