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CH.4 PHYSICAL EXAMINATION OF THE PAIN PATIENT

CH.4 PHYSICAL EXAMINATION OF THE PAIN PATIENT. R2 이동현. 4 CATEGORIES. Sensation Motor Reflexes Coordination. SENSATION AND SENSORY EXAMINATION. Transmitting fiber . A-delta fiber : myelinated fiber -> sharp shooting pain( “ fast pain ” ) C fiber : unmyelinated fiber

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CH.4 PHYSICAL EXAMINATION OF THE PAIN PATIENT

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  1. CH.4PHYSICAL EXAMINATION OF THE PAIN PATIENT R2 이동현

  2. 4 CATEGORIES • Sensation • Motor • Reflexes • Coordination

  3. SENSATION AND SENSORY EXAMINATION

  4. Transmitting fiber • A-delta fiber : myelinated fiber -> sharp shooting pain(“fast pain”) • C fiber : unmyelinated fiber -> dull, poorly localized burning pain (“slow pain”)

  5. Terminology • Hyperesthesia ; 가해진 자극에 대해 실제 자극보다 더 민감하게 반응 • Hyperalgesia ; pin-prick과 같은 작은 통증자극에도 심한 통증을 호소 • Allodynia ; 비통증자극에 심한 통증반응을 보이는 것 -> neuropatic pain의 중요한 indicatior

  6. Sensory Examination(1) • C fiber ; pain, temperature자극으로 검사 • A-delta fiber ; pinprick, light touch자극으로 검사 • “Sensory dissociation” ; pain, temperature감각이 없는 부위에 pinprick자극시 severe pain response -> spinal cord를 cross하는 fiber의 손상시 나타남

  7. Sensory Examination(2) • A-beta fiber ; light touch, vibration, joint position으로 검사 • “Isolated decreased vibratory sense” ; large fiber neuropathy의 early sign ; position sense deficit 동반시 posterior column disease or peirpheral nerve involvement를 의미

  8. Sensory Examination(3) • “Isolated joint position sense deficit” ; parietal lobe dysfunction or peripheral nerve lesion

  9. Sensory mapping • Dermatome이나 peripheral cutaneous nerve map과 비교하여 병변을 localization하는 것이 중요 • 병변은 central, spinal nerve root (dermatomal), peripheral nerve lesion으로 구분

  10. F4-2

  11. T4-1

  12. MOTOR EXAMINATION

  13. Inspection ; hypertrophy, atrophy, fasciculation • Palpation ; myofascial trigger points와 같은 pain generator를 확인 • Tone ; hypotonia or hypertonia

  14. Spasticity vs Rigidity • Spasticity ; velocity-dependent increase in tone with joint movement -> brain, spinal cord injury, stroke, multiple sclerosis • Rigidity ; generalized increase in muscle tone -> extrapyramidal disease, lesion in nigrostriatal system

  15. Myopathy vs Neuropathy • Distal muscle weakness보다 proximal muscle weakness가 큰 경우 -> myopathy • Distal muscle weakness가 더 큰 경우 -> polyneuropathy • Single innervation muscle weakness -> peripheral neuropathy

  16. T4-2

  17. REFLEXES AND COORDINATION

  18. Reflexes • Deep tendon reflexes (DTR); 병변의 anatomical localization에 유용 • Clonus ; sudden sustained muscle stretch시 rhythmic, uniphasic muscle contraction 발생 -> upper motor neuron disease 의미 • Plantar (Babinski’s) reflexes ; upper motor neuron disease 의미

  19. T4-3

  20. T4-4

  21. Coordination • Coordination and gait test ; cerebral function, equilibrium 평가 • Cerebral function ; finger-nose-finger, heel-knee-shin test • Equilibrium ; heel and toe walk, tandem gait test, Romberg’s test

  22. DIRECTEDPAIN EXAMINATION TEMPLATE

  23. T4-5

  24. General observation • 환자의 mannerism, coordination, interpersonal interaction, gait등을 관찰 • Careful history를 통해 환자의 증상의 본질을 파악하면 더욱 효과적인 physical exam을 시행할 수 있음

  25. Mental examination • T4-6

  26. Gait • Normal/ antalgic/ abnormal • Antalgic gait ; 통증 때문에 병변부의 하지에 weight bearing을 하지 못함 • Abnormal gait ; balance, neurological, musculoskeletal disorder 등이 원인

  27. EXAMINATION OF THE DIFFERENT REGIONS OF THE BODY

  28. Face • Cervical region • Thoracic region • Lumbosacral region

  29. Face • Inspection ; cutaneous landmark for signs of infection, herpetic lesion, sudomotor changes, scarring • Oral inspection ; intraoral lesion이 facial area에 refered pain으로 나타날 수 있음 • Palpation, percussion(Chvostek’s sign), ROM(TM joint)

  30. Cervical and Thoracic areas and upper extremities • Inspection ; symmetry, muscle condition, scarring, position at rest, sudomotor changes, cutaneous temperature • Palpation ; for muscle spasm, myofascial trigger points, tender points, occipital nerve entrapment, pain over bony structures(ex ; facet arthropathy) • Cervical ROM ; flexion(0˚-60˚), extension(0˚-25˚), bilateral lateral flexion(0˚-25˚), bilateral lateral rotation(0˚-80˚)

  31. Provocative test(1) • Distraction test ; cervical traction시켜 cervical spine의 neural foramina를 widening시킴 -> neural foraminal stenosis가 있는 환자에서 compression을 해소시켜 증상호전되는 효과 • Compression test ; 반대로 compression유발하여 증상재현 • Valsalva maneuver ; intrathecal pr. 증가시켜 disc나 tumor에 의한 compression증상이 악화

  32. Provocative test(2) • Drop arm test ; rotator cuff tear 환자에서 팔을 abduction 상태로 유지하지 못함 • Yergason test ; biceps tendon의 inte-grity에 대한 검사 -> 환자의 elbow를 fle-xion한 상태에서 검사자가 환자의 elbow와 wrist를 잡고 ext. rotation시키려 하고 환자는 저항하게 하여 이때 통증 발생시 tendon instability가 있다고 할 수 있음

  33. Provocation test(3) • Tennis elbow test ; wrist extension상태로 환자가 저항하는 상태에서 검사자가 wrist flexion을 시도했을 때 lateral epi-condyilitis가 있는 환자에서 병변부에 tenderness호소 • Tinel’s sign ; nerve percussion시 pain * ulnar n. – olecranon과 medial epicondyle 사이의 groove를 percussion * median n. – wrist부위를 percussion -> carpal tunnel syndrome • Phalen’s sign ; 1분동안 wrist를 dorsiflexion한 상태로 유지했을 때 손가락에 tingling sense -> carpal tunnel syndrome

  34. T4-8

  35. Lumbosacral region • Inspection ; gait, posture at rest, cutaneous landmarks(rash, mass, scar, discoloration 등) • Palpation ; bony pain generator(facet joint, sacroiliac joint, coccyx 등), trigger point, mass • ROM ; flexion(0˚-90˚), extension(0˚-30˚), bilateral lateral flexion(0˚-25˚), bilateral lateral rotation(0˚-60˚) * flexion시 pain -> disc lesion * extension시 pain -> facet arthropathy or muscular pain generator

  36. Provocative test(1) • Nerve root irritation test ; back flexion, straight leg raise, sitting, standing • Test for facet pathology ; extension, lateral flexion, lateral rotation • Test for sacroiliac joint dysfunction ; Faber Patrick test, Gaenslen’s test, Yeoman’s test , posterior shear test • Test for piriformis syndrome ; Pace, Laseque, and Freiberg sign • General test for intrathecal lesion ; Kernig test, Valsalva test, Milgram test

  37. Provocative test(2) • Hoover test ; leg paralysis를 호소하는 환자에서 malingering 유무 확인 –환자는supine position.. 검사자가 한 손으로 환자의 한쪽 다리를 들어올리면서 다른 손은 환자의 반대쪽 다리(supine leg) 밑에 둠 -> supine leg에 힘이 들어가 검사자의 손을 누르는 느낌이 들면 malingering.. 그렇지 않으면 true leg paralysis

  38. Provocative test(3) • Waddell’s sign ; nonorganic pain source가 있는지 확인 -> 다섯가지 signs or test (tenderness, simulation test, distraction test, regional disturbance, overreaction)중 3가지 이상 해당시 positive • Tenderness ; superficial stimuli (light skin roll or pinch)시 deep tenderness or diffuse nondermatomal pain 호소 • Simulation test ; 머리를 누르거나, 어깨나 골반을 rotation시킬 때 lumbar pain호소

  39. Provocative test(4) • Distraction test ; sitting이나 straight leg raise등의 provocative test를 반복하고 결과를 비교 -> 결과들이 일정하지 않으면 positive • Regional disturbance ; motor, sensory deficit이 anatomical distribution과 맞지 않을 때 positive • Overreaction ; verbal expression과 facial expression이 불일치하거나 검사시 부적절하게 반응 것 등

  40. T4-9

  41. Conclusion • Physical exam은 history taking 다음으로 중요한 부분 • 환자의 신뢰를 증진 • 환자가 호소하는 증상을 통해 얻은 impression을 확인하고 정확한 진단을 얻을 수 있는 중요한 수단

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