History and Physical Examination of the Pain Patient
Pain Management, Chapter 5, 36-49
Chapter outline
- The Targeted Pain History 36
- The Pain Litany 37
- Mode of Onset and Location 37
- Chronicity 37
- Tempo (Duration and Frequency) 38
- Character and Severity 38
- Associated Factors 38
- General Aspects of the Targeted Pain History 38
- Medication History 39
- General Aspects of the Patient Interview 40
- Summary of the Targeted History 42
- The Targeted Physical Examination 42
- General Aspects 43
- Assessment of Mental Status 43
- Cranial Nerves 43
- Motor Examination 46
- Sensory Examination 47
- Deep Tendon Reflexes 48
- Examination of Gait 49
- Conclusion 49
The cornerstone of clinical success in the practice of pain management is a correct diagnosis. Unfortunately, in this era of increasing reliance on technology and constant pressure on the physician to become more efficient, the core elements in achieving the correct diagnosis—namely, a targeted history and physical examination—are sadly regarded as less critical in the care of the patient. Proceeding without a concise history often leads to clinical errors that not only squander our limited health care resources but also compromise the patient's opportunity to obtain pain relief.
Indeed, shortcuts taken in obtaining old records, personally reviewing imaging studies, contacting prior treating physicians, calling family members of a confused patient, and most importantly just sitting and listening to what the patient believes to be important frequently lead to misdiagnosis and an unsatisfactory outcome for the patient and pain specialist alike. Frequently, the most cost-effective use of technology is a telephone call to a family member or prior treating physician. Often the discipline to engage in several minutes of conversation with a knowledgeable party can yield countless benefits both in cost saving and in added medical and psychological insight into the patient's predicament.
The bond of trust that is so integral to the relationship between patient and pain specialist is often determined by the care and thoroughness with which the initial historical material is obtained. Experience has shown that when physicians are rushed for time, the intake interview becomes abbreviated, thereby setting the stage for medical errors and interpersonal dissatisfaction.
Many of the chapters that follow highlight the utility of highly sophisticated technology, invasive testing modalities, and diagnostic and therapeutic nerve blocks. Although these clinical interventions may be extremely important in the evaluation of a given patient, they do not replace the preeminent role of the history and physical examination in the diagnosis of the patient in pain. Most, if not all, of what a pain specialist needs to know can be gleaned from simply taking the time to take a concise history and perform a targeted physical examination. By far, the most cost-effective endeavor in the evaluation of the patient in pain is to be thorough in the initial targeted history taking and physical examination. If this initial consultation ends without a clear direction regarding the underlying pathologic process, the likelihood that technology will “save the day” is very remote. It has been said, with varying degrees of conviction, that “one magnetic resonance scanner (MRI) scanner is worth 100 neurologists (or pain specialists).” In this 21st century with an MRI on every other street, this adage can be restated as follows: “One physician (of any specialty) willing to sit and actually listen to patients can be of more practical benefit than 100 magnets (of any Tesla strength).”
The Targeted Pain History
Obtaining a history is a skill. Practice and repetition improve our skills, reduce the tendency to omit important material, and ultimately enable us to focus our questions to conserve time without sacrificing accuracy. As a starting point, the search should be directed to answer two questions : “Where is the disease causing the pain—in the brain, spinal cord, plexus, muscle, tendon, or bone?” and “What is the nature of the disease?” It is the trademark of an experienced clinician to formulate an efficient line of questioning that deals with both these issues simultaneously. Highlights of the critical elements in that process follow. The goal is to keep the process brief, simple, and workable.
The secret of becoming skilled at taking a history is being a good listener. The physician should put the patient at ease. The patient should never be given the impression that the physician is rushed or overworked and that only limited time is available to get the story across. The physician must remember that the patient in pain is usually anxious, if not overtly frightened, and may be inadequate in presenting the situation and having his or her plight properly perceived. Experience teaches us that the physician cannot force the pace of the interview without losing vital information and valuable mutual trust and insight. The following discussion describes the elements of the targeted history that not only define pain in a context useful for proper identification, localization, and source but also enable the physician to determine priorities about the urgency of care.
The Pain Litany
The pain litany —a formulaic exploration of the patient's pain history—enables the physician to identify the signature of the specific pain syndrome from its usual manifesting characteristics. ,
The pain litany takes the following form :
- 1. Mode of onset
- 2. Location
- 3. Chronicity
- 4. Tempo (duration and frequency)
- 5. Character and severity
- 6. Associated factors:
- ▪ Premonitory symptoms and aura
- ▪ Precipitating factors
- ▪ Environmental factors (occupation)
- ▪ Family history
- ▪ Age at onset
- ▪ Pregnancy and menstruation
- ▪ Gender
- ▪ Past medical and surgical history
- ▪ Socioeconomic considerations
- ▪ Psychiatric history
- ▪ Medications and drug and alcohol use
- ▪
The targeted history also allows physicians to distinguish sick patients from well ones. If it is determined that in all probability the patient is well (i.e., has no life-threatening illness), the workup and treatment plan may proceed at a more conservative pace. From the outset, the interviewer proceeds in an orderly fashion but remains vigilant for signals of an urgent situation. Pain of uncertain origin should always be regarded as a potential emergency.
Mode of Onset and Location
The mode of onset of the pain sets the direction of the initial history and carries much weight in distinguishing sick from well patients. For example, the sudden, explosive presentation of a subarachnoid hemorrhage secondary to a ruptured intracranial aneurysm, manifested by severe headache, neck pain, and a sense of impending doom, contrasts sharply with the chronic diffuse headache and vague neck tightness of tension-type cephalalgia.
The location of pain provides additional diagnostic information. The pain in trigeminal neuralgia, for instance, is usually limited to one or more branches of cranial nerve (CN) V and does not spread beyond the distribution of the nerve. The V2 and V3 divisions of this nerve are much more frequently involved than is V1 ( Fig. 5.1 ). The pain is rarely bilateral except in certain cases of multiple sclerosis, brainstem neoplasms and skull base tumors, and infections.
Sensory distribution of the trigeminal nerve.
(From Waldman SD: Atlas of interventional pain management , ed 2, Philadelphia, 2004, Saunders, 34.)
Another example of the importance of pain location is the burning, prickling dysesthesias of meralgia paresthetica. The unilateral involvement of the lateral femoral cutaneous nerve produces painful dysesthesias in the anterior thigh, more commonly in men, who notice the disturbance when they put a hand in a trouser pocket.
The physician must find out how and where the pain started. The patient should be asked to identify the site of maximum pain.
Chronicity
The duration of awareness of a painful illness targets the initial history and heavily influences the sick from well distinction. For this reason, it often serves as a starting point. “How long have you had this pain?” is an essential question. The patient should be asked to try to date the pain in relation to other medical events, such as trauma, surgery, and other illnesses.
In general, back pain that has been present for 30 years and is not associated with any progression is strong evidence of a self-limited pain syndrome, hence the “well” determination. Conversely, a patient with severe low back pain of sudden onset or pain that suddenly changes in character must be assigned to the category of “sick until proved otherwise.” This type of accentuated pain presentation has often been called the first or worst syndrome. It applies to both spinal pain and headache. Patients in this category deserve serious concern, and their pain should be viewed with medical urgency. Equating the concept of chronicity with benign disease has its pitfalls; the physician must beware of failing to
- ▪ Identify ominous changes in a long-standing, stable pain syndrome (e.g., when a patient with chronic low back pain suddenly becomes incontinent).
- ▪ Attribute the onset of symptoms to a benign cause without adequate evaluation (e.g., dismissing a sudden increase in low back pain in the postoperative patient as muscle spasm without considering diskitis and bacterial epidural abscess).
- ▪ Recognize new symptoms superimposed on chronic complaints (e.g., attributing an increase in headache with cough to chronic cervical spondylitis disease rather than considering that because the patient has a known breast malignancy, silent metastasis may be causing increased intracranial pressure).
Indeed, the characteristics of thoroughness, experience, insight into the patient's personality, and constant resistance to being lulled into false security prevent such diagnostic disasters. As Mark Twain observed, “Good decisions come from experience and experience comes from making bad decisions.”
Tempo (Duration and Frequency)
The tempo of a disorder may provide one of the best clues to the diagnosis of the pain. In facial pain, trigeminal neuralgia (tic douloureux) is described as brief electric shocks or stabbing pain. Onset and termination of attacks are abrupt, and affected patients are usually pain free between episodes. Attacks last only a few seconds. It is not unusual for a series of attacks to occur in rapid succession over several hours. In contrast, the pain of temporal (giant cell) arteritis is usually described as a dull, persistent, gnawing pain that is exacerbated by chewing.
In migraine, the pain is frequently throbbing and may last for hours to days. Cluster headaches, by contrast, are named for their periodicity: they occur once or more often each day, last about 30 minutes, and often appear shortly after the onset of sleep. They may occur in clusters for weeks to months with headache-free intervals. In short, the concept of pain tempo is another feature of the targeted history that is helpful in differentiating pain syndromes.
Character and Severity
Although considerable overlap exists between character and severity of pain, some generalization can be made when taking a targeted history. Vascular headaches tend to be throbbing and pulsatile, and the pain intensity is often described as severe. Cluster headaches may have a deeper, boring, burning, wrenching quality. This pain is reputed to be among the worst known to humans.
Trigeminal neuralgia is typically described as paroxysmal, jabbing, or shocklike, in contrast to non-neuralgic pain such as experienced in temporomandibular joint (TMJ) dysfunction, which is often described as a unilateral, dull, aching pain in the periauricular region. TMJ pain is exacerbated by bruxism, eating, and yawning but may be patternless. The characteristic pain of postherpetic neuralgia usually includes both burning and aching superimposed on paroxysms of shocks and jabs. It usually occurs in association with dysesthesias, resulting in an unpleasant sensation even with the slightest touch over the skin (allodynia).
Many of the more common pain syndromes have a distinctive character and level of severity that is helpful in properly identifying them. Clinical insight into these characteristics comes with time and through listening to many patients describe their pain. Certain patients with cluster headaches or trigeminal neuralgia have a frantic, almost desperate demeanor that is proportionate to the severity of their pain. The patient with acute lumbar disk herniation often writhes before the physician and is essentially unable to sit in a chair. The body language and facial expressions associated with true excruciating pain are difficult to feign, and exaggerated behaviors often immediately become suspect almost on a visceral level.
Associated Factors
Multiple associated factors round out the targeted pain history. The subtle differences among painful conditions allow clinicians to use these factors to complete the various parts of the puzzle. For example, intermittent throbbing pain behind the eye is consistent with cluster headache. If the patient is a young woman, however, the diagnosis of cluster headache is improbable because of the known male preponderance of this condition. Accordingly, the combination of associated factors such as age and sex aid in the diagnosis. A dull, persistent pain over one temple in a young African American male patient probably is not giant cell or temporal arteritis, a disease most often seen in white women older than 50 years.
Table 5.1 describes various pain syndromes according to patient age, sex, family history, precipitating factors, and occupational issues. As Osler said, “Medicine is a science of uncertainty and an art of probability.” Matching our knowledge about the natural history and characteristics of the various diseases that cause pain with information derived from the patient's history is the physician's most powerful diagnostic tool. It is through this process that the physician develops confidence in the diagnosis that often exceeds that based on information from ancillary tests. An autoworker who uses an impact wrench 10 hours a day, complains of numbness in the first three digits of his right hand, and wakes up four times a night “shaking his hand out” has carpal tunnel syndrome, regardless of the results of nerve conduction studies and electromyography.
Table 5.1
Demographics of Some Common Pain Syndromes
| Pain Syndrome | Sex Preponderance (Ratio) | Family History | Age of Onset (yr) | Associated Features and Comments |
|---|---|---|---|---|
| MigraineChildhood (<10 dult="" yr=""> 10 yr) | M (1.5:1)F (3:1) | PositivePositive | 315–20 | Abdominal pain, episodic vertigo, mood changesDecrease by third month of pregnancy, increase with menstruation and oral contraceptives |
| Cluster headache | M (8:1) | Not positive | 25–40 | Common at night, precipitated by alcohol and nitrates |
| Multiple sclerosis | F (2:1) | Positive | 20–40 | Trigeminal neuralgia, tonic spasms, dysesthesia, extremity pain |
| Temporal arteritis | F (3:1) | Not positive | >60 | Increased erythrocyte sedimentation rate, anemia, low-grade fever, jaw claudication |
| Trigeminal neuralgia | F (2:1) | Not positive | >55 | V2 (45%) > V3 (35%) > V1 (20%); triggered by jaw movement, heat, and cold |
| Ankylosing spondylitis | M (5:1) | Positive | 20–30 | Pain forces patient out of bed at night, is not relieved by lying flat |
| Rheumatoid arthritis | F (3:1) | Positive | 35–50 | Higher rate in nulliparous women not exposed to oral contraceptives |
| Thromboangiitis obliterans | M (8:1) | Not positive | 20–40 | Smoking |
| Carpal tunnel syndrome | F (2:1) | Not positive | 30–60 | Certain occupations, pregnancy, diabetes, hypothyroidism |
Data from references , , , , and .
General Aspects of the Targeted Pain History
An old clinical maxim states, “Healing begins with the history!” The clinician should be able to put the patient at ease and should then ask open-ended questions that will give the patient an opportunity to describe the pain in his or her own words. “Now, tell me about your pain” is an excellent prompt. This approach allows the patient to describe what he or she believes is most important. It is therapeutic in itself. Physicians are often wary of the open-ended question, because they are afraid that the patient will ramble. Although this can occur, a far more common problem is that the physician narrows the line of questioning after jumping to a premature conclusion.
The patient's past medical history and family history are often as important as the current complaints. Medications, surgical procedures, and prior imaging studies are not explored in adequate detail. Many patients have been subjected to thousands of dollars of imaging, blood work and neurodiagnostic studies but often remain in the dark not only about their test results but also about the modality or even the actual body part interrogated.
When a patient without records who complains of chronic headaches states that all the “scans” were normal, the physician must be careful. These “scans” may be an MRI image of the brain but could also refer to a computed tomography (CT) scan of the paranasal sinuses or even plain radiographs of the skull. The best policy is to review all pertinent imaging studies and not just the reports. Radiologists truly do a remarkable job of interpreting studies, often with very limited clinical information. In difficult cases, however, review of prior imaging studies in light of a newly derived specific historical or physical finding can be particularly helpful and may even “save the day.”
When the pain is chronic, other doctors may already have been consulted. They probably have ordered diagnostic tests and tried therapies; indeed, it is always wise to obtain previous records or, preferably, to contact the other physicians directly. If a diagnosis seems obvious but previous doctors missed it, the physician should be cautious. When nothing has worked before, there is usually a good reason for the treatment failures. Under these circumstances, it is prudent and wise to assume that the other physicians were competent. Physicians are frequent violators of the maxim, “Do unto others as you would have them do unto you.” Frank or subtle criticism of a colleague's efforts is pointless, upsets the patient, and may even initiate litigation.
One other impulse that should be resisted is the tendency to ascribe pain to psychogenic causes. Learning to believe patients who have pain averts many awkward and potentially costly errors. Once the physician projects the belief that a patient's pain is based mainly on psychogenic mechanisms, it is an extremely difficult position to recant. At all costs, the pain specialist should remain nonjudgmental, should believe in the patient's pain, and should gain the patient's confidence. The only proven “cure” for having dismissed a patients' pain as psychogenic is to learn that serious organic disease was uncovered by another physician who saw the patient later in the course of the disease. Like everyone in medicine, pain specialists should be humble and careful with their words.
Medication History
The importance of a thorough drug history cannot be overstated, particularly in the setting of chronic benign pain. It is not unusual for a patient to relate a very involved history of pain and multiple operations, diagnostic studies, and consultations. At the end of the interview, not uncommonly as the patient is preparing to leave, he or she will casually mention needing to have a prescription renewed and will add that it is “just a pain pill.” It is at this very point that an otherwise pleasant consultation can become confrontational.
Confusion among physicians about the differences among narcotics and opioids is widespread. Many physicians also fail to recognize that the relative analgesic, euphoric, and anxiolytic properties of a given compound are not equivalent. For example, the analgesic strength of propoxyphene (Darvon) may be equivalent to one or two aspirins, but the magnitude of its anxiolytic effects in a given patient can be considerable. Not only opioids pose a problem. Carisoprodol (Soma, Rela) is a noncontrolled skeletal muscle relaxant that is also available through veterinary supply catalogs. Its active metabolite is meprobamate (Equanil, Miltown), an anxiolytic-sedative agent popular in the late 1950s. Patients using carisoprodol may be at risk (frequently unrecognized) for meprobamate dependency.
Triptans, ergots, aspirin, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), minor tranquilizers, and barbiturate-containing compounds (Fiorinal, Esgic, and Phrenilin) taken in varying doses can contribute to rebound-type headache. In this setting, the daily use of headache-abortive drugs enhances and increases the frequency of daily headaches. The scope of this problem is difficult to assess, but in certain headache clinics, the use of such drugs is the single most common reason for chronic refractory daily headaches. Although every pharmacologic agent has some inherent risk, two practical considerations may be crucial in the targeted pain history. The first involves many individuals, particularly older persons, who are taking anticoagulants (warfarin, heparin) or antiplatelet agents (aspirin, clopidogrel [Plavix], and ticlopidine [Ticlid]) for any of a variety of reasons. Many disasters can occur in this setting. Inadvertent overdosing of an older, confused patient can cause intracerebral bleeding (headache) or back and radicular pain (secondary to retroperitoneal hemorrhage). Second, the physician evaluating headache symptoms should keep in mind that estrogen, progesterone, and nitrates can play major roles as headache-provocative agents and that simply discontinuing these drugs can provide almost immediate improvement.
Both the scope and the frequency of problems related to chemical dependency have been underrecognized in many clinical settings. Some patients are willing to subject themselves to expensive diagnostic studies, multiple nerve blocks, and even surgery to ensure an uninterrupted supply of specific medications (frequently opioids). The specialist in pain management is uniquely positioned to recognize these problems and to offer suggestions in a compassionate, nonjudgmental fashion that may ultimately extricate patients from both their chemical dependency and their convoluted relationship with the medical system. Until drug dependency issues are addressed, effective inroads into the management of chronic pain will be thwarted.
Certain clinicians have described a satisfactory experience administering opioids for chronic benign pain. Their positive experience (along with aggressive pharmaceutical company marketing) has promoted liberal prescribing policies among primary care physicians and specialists treating common conditions such as back pain, arthritis, and fibromyalgia. The long-term use of opioids in these diseases is not supported by strong scientific evidence and remains controversial. Such an ambiguous situation only accentuates the importance of obtaining a thorough drug history and assessing the true impact of drug use on the individual patient's pain problems. Table 5.2 lists the “red flag” agents that, when used by a patient in pain, should alert the physician to consider possible drug abuse or exacerbation of pain by medication. Information on dosage and duration of use is important.
Table 5.2
“Red Flag” Drugs in the Targeted Pain History
| Drug Class | Drug |
|---|---|
| CONTROLLED ABUSED SUBSTANCES * | |
| Schedule II narcotics | Morphine (Roxanol, MS Contin) Codeine, fentanyl (Sublimaze) Sufentanil (Sufenta) Hydromorphone (Dilaudid) Meperidine (Demerol) Methadone (Dolophine) Oxycodone (Percodan, Tylox, OxyContin, Roxicodone) Opium Cocaine |
| Non-narcotic agents | Dextroamphetamine (Dexedrine, Adderall) Methamphetamine (Desoxyn) Methylphenidate (Ritalin) Phenmetrazine (Preludin) Amobarbital (Amytal) Pentobarbital (Nembutal) Secobarbital (Seconal) Glutethimide (Doriden) Secobarbital-amobarbital (Tuinal) |
| Schedule III narcotics | Codeine (Tylenol with codeine, Fiorinal with codeine) Dihydrocodeine (Synalgos-DC) Hydrocodone (Tussionex, Hycodan, Vicodin, Lortab, Lorcet) Butalbital (Fiorinal, Esgic, Phrenilin, Medigesic) |
| Schedule IV narcotics | Propoxyphene (Darvon, Darvocet, Wygesic) Butorphanol (Stadol) Pentazocine (Talwin) Alprazolam (Xanax) Chlordiazepoxide (Librium) Clonazepam (Klonopin) Clorazepate (Tranxene) Diazepam (Valium) Eszopiclone (Lunesta) Flurazepam (Dalmane) Lorazepam (Ativan) Midazolam (Versed) Oxazepam (Serax) Quazepam (Doral) Temazepam (Restoril) Triazolam (Halcion) Zaleplon (Sonata) Zolpidem (Ambien) |
| Non-narcotic agents | Phenobarbital Mephobarbital (Mebaral) Chloral hydrate Ethchlorvynol (Placidyl) Meprobamate (Equanil, Equagesic)Carisoprodol (Soma, Rela) |
| Schedule V | Buprenorphine (Buprenex) Diphenoxylate (Lomotil) Pregabalin (Lyrica) |
| NONCONTROLLED ABUSED SUBSTANCES | Triptans (Imitrex, Zomig, Relpax, Amerge, Frova, Treximet, Maxalt, Axert)Ergotamine (Cafergot, Wigraine, Ergostat) Dihydoergotamine (Migranal nasal spray, D.H.E.45)Chlordiazepoxide (Librax) Tramadol (Ultram, Ultracet) (nonscheduled opioid) Nalbuphine (Nubain) (nonscheduled opioid) Caffeine (Excedrin, Anacin) |
| NONABUSED DRUGS IMPORTANT IN A TARGETED PAIN HISTORY | Oral contraceptives Anticoagulants (heparin, warfarin, clopidogrel [Plavix]) Antiplatelet agents (aspirin, ticlopidine) Antianginals (nitrates) |
Data from Brust JC: Neurological aspects of substance abuse, Boston, 1993, Butterworth-Heinemann, and Missouri Taskforce on the Misuse, Abuse, and Diversion of Prescription Drugs, 1994.
Pain specialists should make it policy to insist that patients bring all their medications at the time of the consultation. If you as a physician believe that a patient has a drug dependency problem, face the problem openly and with kindness. Resist the all too common practice of writing a prescription for that magical minimal amount of the drug being abused, an amount that can end the consultation without a dreaded angry confrontation. For those of us in clinical practice, this is an all too familiar “end of consult” strategy of providing what we know to be part of the problem. Prepare to assume your share of the guilt, Dr. Feelgood, in this major public health disaster.
General Aspects of the Patient Interview
The following general but significant points enhance the patient interview process:
- ▪ The surroundings are professional, comfortable, and private.
- ▪ The patient is appropriately gowned, is chaperoned if appropriate, and is sitting upright and at eye level with the interviewer, if possible.
- ▪ Old records, scans, radiographs, and consultations have been obtained and reviewed before the consultation.
- ▪ The physician listens to and does not interrupt the patient or allow outside interruptions.
- ▪ The physician remains nonjudgmental; moral, religious, and political beliefs of the physician are irrelevant to this process.
- ▪ The physician is honest and open with the patient; keeping information from the patient at the family's request is usually a bad decision.
- ▪ Both the patient and the physician can trust in the confidentiality of both the consultation and the medical records.
The specialty of pain management is practiced by physicians from numerous disciplines. In particular, physicians trained in operating room anesthesia may not be as sensitive to some certain issues. From the standpoint of neurologists, for whom interviewing patients is a major component of practice, these basic rules of common etiquette are frequently ignored. First, the office should be both professional and comfortable. For reasons of economy, pain clinics are frequently placed in noisy and crowded additions to either the operating room suite or the emergency department. This atmosphere may not be conducive to dealing with patients with acute and chronic pain, who are often extremely apprehensive and easily frustrated.
It is important that patients have a private place where they undress and are examined. Although this may appear to be a small point, a chaotic examining site can inspire a patient's resentment, even if the medical care is of high quality. One other point that needs reinforcing is that physician and patient should always be properly chaperoned. It is not unusual, because of the hectic schedules of both physicians and ancillary personnel, for a patient and physician to be left alone in situations in which this arrangement is at best uncomfortable and at worst compromising and dangerous. Strict adherence to standardized protocol for chaperoning is really the best way of averting serious problems in this area. The keys to obtaining a complete and effective targeted pain history are listed here The examiner should use the following protocol:
- 1. Build rapport with the patient by introducing self properly, taking an initial social history, and simultaneously assessing the patient's mood, anxiety level, and capability of giving a history on his or her own.
- 2. Most importantly: Establish the chief complaint at the outset of the history. Why is the patient here? Open-ended questions allow the patient to tell his or her own story.
- 3. Use the framework of the pain litany (discussed earlier) to investigate the pain further. Where is the pain? What is its nature?
- 4. Do not jump to conclusions. This is the most common cause of error because the interview too soon becomes narrowly focused, and important associations are not pursued or are ignored. The examiner should ask about other doctors whom the patient has seen and their treatments.
- 5. Determine the impact of the pain on the patient's life—psychological fears, family issues (marriage), compensation, and work record.
- 6. Explore past medical and family history. Using a timeline approach to establish continuity, the current pain should be placed in context with other major medical events: previous surgery, hospitalizations, cancer, and medical and paramedical relationships.
- 7. Obtain a thorough drug history (see Table 5.2 ). Information on duration, frequency, amount, and source of medication should be sought. The importance of this information cannot be overemphasized.
The examination should begin with the physician's introducing himself or herself to the patient and putting the patient at ease. A routine social history, such as occupation, place of employment, marital status, and number of children, should be obtained. During this interchange, the physician should be assessing the verbal and nonverbal cues that ultimately determine the caliber of the historical information. This social introduction affords the physician insight into what type of person the patient is. Over time and with the refinements of experience, this portion of the interview assumes diagnostic importance equal to that of the data-gathering portion of the consultation.
It seems obvious that the patient's chief complaint would be the logical starting point of any history. Unfortunately, too much time can be spent taking a history without ever addressing the chief complaint. Coming to grips with the patient's primary reason for seeking medical attention is really the crucial piece of data. Is it the pain? Is it questions about disability or worker's compensation? Is it a morbid fear of cancer? Is it that the physician who prescribed the patient's pain medications has retired and the patient is concerned about prescription renewal? Until the physician has a strong sense of the principal reason for the consultation, the history is often both misguided and aimless. Sitting in front of the patient, the physician should always ask himself or herself, “Why has this patient come to see me?” Sometimes, the patient's motives are not what they first appear to be.
Summary of the Targeted History
The value of the targeted history cannot be overstated. It affords the physician the greatest chance of understanding the nature of the pain and, more important, its effects on the patient. Diagnostic tests, laboratory reports, and other consultants' opinions often introduce error when they are interpreted from a perspective detached from the patient. The physician should remember that, no matter how many physicians have seen the patient earlier, historical facts critical to the diagnosis may have been overlooked or not properly sought.
Taking the targeted history is a social interaction. Courtesy, professionalism, and kindness consistently result in patient satisfaction. Issues related to compensation, returning to work, and concurrent drug use should be dealt with openly and directly, without imposing the physician's personal, political, or religious value judgments.
The Targeted Physical Examination
If, after obtaining the targeted historical information, the pain specialist is lost, the chance that the situation may be suddenly illuminated by the physical examination findings is extremely remote. As a basic point, the physical examination should follow the history and, indeed, be specifically directed by clues obtained during the patient interview. For example, it makes little sense to concentrate on a detailed examination of sensory function and individual muscle testing in the lower extremities of a patient who has diplopia, facial pain, and a family history of multiple sclerosis. The physical examination is an extension of the history. The examination provides objective support and is performed efficiently and systematically so that important findings are not overlooked. The problem with the neurologic examination has been selecting those elements that are truly critical. In 2009, Canadian neurologists and medical students reached a helpful consensus ( Table 5.3 ). It is compact, yet an excellent screening tool.
Table 5.3
Neurologic Examination
| Key Elements of the Neurologic Examination | Time to Complete |
|---|---|
| 1. Mental status | 90 seconds |
| 2. Cranial nerves/funduscopic examination | 90 seconds |
| 3. Power arms/legs | 60 seconds |
| 4. Pinprick, vibratory sensation | 60 seconds |
| 5. Reflexes, gait, Romberg's sign, tandem walking | 90 seconds |
| Total time: 6–7 minutes |
Data from Heyman CH, Rossman HS: A multimodal approach to managing the symptoms of multiple sclerosis, Neurology14:63:S12, 2004.
The examination should not consume a great deal of time. Basic aspects, such as taking blood pressure, performing a screening mental status examination, and checking visual acuity, strength, and deep tendon reflexes, however, pay multiple dividends. On occasion, certain important diseases, such as unrecognized hypertension, diabetic retinopathy, and skin cancer, can be uncovered.
The very physical aspect of examining the patient imparts a reassuring sense of personal caring to the entire consultation. The benefits of this experience are considerable. Pain patients want to be examined, expect to be examined, and ultimately derive benefit from the process. As Goethe said, “We see only what we know.” The facility with which we examine patients is ultimately a function of our knowledge, experience, and willingness to learn. The neurologic examination is not difficult and should not intimidate physicians in training or non-neurologists. It can be performed effectively in most cases in less than 10 minutes. The physician should develop a routine and keep it simple.
General Aspects
The patient's temperature, pulse, and blood pressure should always be recorded, as should height and weight. The patient should be undressed and properly gowned. It is a constant source of amazement how frequently examinations are performed to evaluate painful conditions, even disorders involving the neck and low back, while patients are fully clothed. The pain specialist should do the following: examine the patient's entire body for skin lesions such as hemangiomas, areas of hyperpigmentation, and café au lait spots (neurofibromatosis); document scars from previous operations; and inquire into other scars not mentioned in the initial history. Needle marks, skin ulcerations, and tattoos (which sometimes betray drug culture orientation) may be surprising findings.
The spine should be examined for kyphosis, lordosis, scoliosis, and focal areas of tenderness. Dimpling of the skin or excessive hair growth may suggest spina bifida or meningocele. The motility of the spine should also be evaluated in flexion, extension, and lateral rotation. During this period of the examination, an overall assessment of multiple joints can be done for deformities, arthritic change, trauma, and prior surgical procedures. Clearly, much can be learned just by having the patient stand before the physician and asking the patient about abnormalities that become noticeable. No matter how inconvenient or uncomfortable it is, the physician should try not to omit this portion of the examination. Particularly in patients with chronic pain, this part of the examination may yield crucial and unexpected revelations.
Assessment of Mental Status
Most major intellectual and psychiatric problems become apparent during the history taking. The frequency with which serious intellectual deficits are missed is surprising, however. For example, subtle aspects of memory, comprehension, and language may not be caught unless they are specifically sought. In my experience, aphasia (a general term for all disturbances of language not the result of faulty articulation) is frequently mistaken for an organic mental syndrome or dementia. Recognition of this point not only is critical in diagnostic evaluation but also has important implications for obtaining informed consent for testing, nerve blocks, and surgical procedures.
Table 5.4 summarizes an approach to rapid assessment of the patient's mental status. Each practitioner should develop a personal set of standard questions to gain a sense of the normal versus the abnormal. Attention to these details in assessing mental status helps to avoid the embarrassment of overlooking receptive aphasia, Alzheimer's disease, or Korsakoff's syndrome. Table 5.5 is the classic Folstein Mini-Mental State Examination with age-adjusted normative data. A score of 24 or higher is considered normal. Although this examination is effective in detecting clinically significant defects in speech and cognitive function, the average practitioner will find it overly tedious for use in routine pain management evaluation. In many of these situations, patients exhibit an unusual capacity to disguise underlying deficits by reverting to evasions or generalities or by filling in gaps with stereotypical responses that they have used before to escape the embarrassment of the discovery of major problems in language, memory, and other spheres of cognitive function.
Table 5.4
The “Quick and Dirty” Mental Status Examination *
| Orientation | Ask the following questions: What is your full name? What is today's date? What is the year? Who is the president? Who is the vice president? |
| Calculations | Ask the following questions: How many nickels are in a dollar? How many dollars do 60 nickels make? |
| Memory | Ask the following questions: What was your mother's maiden name? Who was President before George W. Bush? Give the patient three items to remember (examples: a red ball, a blue telephone, and address 66 Hill Street). After several minutes of conversation, ask the patient to repeat the list. |
| Speech | Have the patient repeat two simple sentences, such as the following: Today is a lovely day. The weather this weekend is expected to be excellent. Have the patient name several objects in the room. Ask the patient to rhyme simple words, such as ball, pat, and can. |
| Comprehension | Ask the patient to do the following: Put the right hand on the left hand. Point to the ceiling with the left index finger. |
Table 5.5
Folstein Mini-Mental State Examination
| Task | Instructions | Scoring | |
|---|---|---|---|
| Date orientation | “Tell me the date.” Ask for omitted items. | One point each for year, season, date, day of week, and month | 5 |
| Place orientation | “Where are you?” Ask for omitted items. | One point each for state, county, town, building, and floor or room | 5 |
| Register three objects | Name three objects slowly and clearly. Ask the patient to repeat them. | One point for each item correctly repeated | 3 |
| Serial 7s | Ask the patient to count backward from 100 by 7. Stop after 5 answers. (Or ask the patient to spell “world” backward.) | One point for each correct answer (or letter) | 5 |
| Recall three objects | Ask the patient to recall the objects mentioned earlier. | One point for each item correctly remembered | 3 |
| Naming | Point to your watch and ask the patient, “What is this?” Repeat with a pencil. | One point for each correct answer | 2 |
| Repeating a phrase | Ask the patient to say, “No ifs, ands, or buts.” | One point if successful on first try | 1 |
| Verbal commands | Give the patient a plain piece of paper and say, “Take this paper in your right hand, fold it in half, and put it on the floor.” | One point for each correct action | 3 |
| Written commands | Show the patient a piece of paper with “CLOSE YOUR EYES” printed on it. | One point if the patient's eyes close | 1 |
| Writing | Ask the patient to write a sentence. | One point if sentence has a subject, a verb, and makes sense | 1 |
| Drawing |  Ask the patient to copy a pair of intersecting pentagons onto a piece of paper. | One point if the figure has 10 corners and 2 intersecting lines | 1 |
| Scoring | A score of 24 or above is considered normal. | 30 |
Adapted from Folstein et al: Mini Mental State, J Psych Res 12:196–198, 1975.
One final point relates to the patient's emotional state. The examiner must remain vigilant about the patient's mood and displays of emotion. An unusually silly, euphoric, or grandiose presentation may be seen in manic states. Similarly, a discouraged, hopeless, or self-deprecating presentation may signal serious depression. As highlighted in the discussion on the targeted history, the physician must remain alert for clinical manifestations of drug use, such as slurred speech, motor hyperactivity, sweating, flushing, and distractibility. In short, the physician should get to know the patient but, in the end, should vigorously resist any early impulse to suggest that stress or anxiety alone is the principal cause of the patient's pain.
Cranial Nerves
To return to the theme of keeping the targeted physical examination simple so that important points are not missed, the evaluation of CN function often overwhelms practitioners not trained in clinical neurology. It remains an important area, particularly in the evaluation of headache and facial pain. Rapid recognition of CN dysfunction may have profound significance for localizing a cerebral lesion or identifying increased intracranial pressure. In combination with the history, CN dysfunction may also be a strong indicator of a specific disease (e.g., the combined presence of explosive headache and CN III palsy implies a ruptured aneurysm until that diagnosis is excluded).
Table 5.6 highlights an efficient approach to the clinical evaluation of the CNs. Certainly, when headache and facial pain are the basic issues, particular attention should be given to this portion of the examination. The key, once again, is developing a routine that, with practice, becomes thorough. It is far beyond the scope of this chapter to describe all the nuances of CN function. Anyone evaluating patients for headache or facial pain must be able to recognize papilledema and abnormalities of ocular motor nerve function, must be familiar with the sensory division of the trigeminal nerve, and must be able to recognize isolated CN palsies. More complex problems, such as diplopia, cavernous sinus disease, and complex brainstem lesions, are best left to specialists in neuro-ophthalmology and neurology.
Table 5.6
Clinical Evaluations of Cranial Nerve Function
| Cranial Nerves | ||
|---|---|---|
| Number | Name | Evaluation Procedures |
| I | Olfactory | Test ability to identify familiar aromatic odors, one naris at a time with eyes closed (not routinely tested) |
| II | Optic | Test vision with Snellen chart or Rosenbaum near-vision chart Perform ophthalmoscopic examination of fundi Be able to recognize papilledema Test fields of vision using confrontation and double simultaneous stimulation |
| III, IV, VI | Oculomotor, trochlear, abducens | Inspect eyelids for drooping (ptosis) Inspect pupil size for equality (direct and consensual response) Check for nystagmus Assess basic fields of gaze Note asymmetrical extraocular movements |
| V | Trigeminal | Palpate jaw muscles for tone and strength while patient clenches teeth Test superficial pain and touch sensation in each branch: V1, V2, V3 |
| VII | Facial | Test corneal reflex Inspect symmetry of facial features Have patient smile, frown, puff cheeks, wrinkle forehead Watch for spasmodic, jerking movements of face |
| VIII | Acoustic | Test sense of hearing with watch or tuning fork Compare bone and air conduction of sound |
| IX | Glossopharyngeal | Test gag reflex and ability to swallow |
| X | Vagus | Inspect palate and uvula for symmetry with gag reflex Observe for swallowing difficulty Have patient take small sip of water Watch for nasal or hoarse quality of speech |
| XI | Spinal accessory | Test trapezius strength (have patient shrug shoulders against resistance) Test sternocleidomastoid muscle strength (have patient turn head to each side against resistance) |
| XII | Hypoglossal | Inspect tongue in mouth and while protruded for symmetry, fasciculations, and atrophy Test tongue strength with index fingers when tongue is pressed against cheek |
The importance of developing the ability to recognize papilledema cannot be overstated. Physicians who evaluate patients with headache who do not examine the patients' fundi are doing substandard work. Using an ophthalmoscope, the physician should turn down the lights and, if the fundus is still not visualized clearly, not hesitate to dilate the patient's eyes. The use of 0.5% tropicamide (Mydriacyl) is helpful for this purpose. Plate 1 demonstrates a few commonly encountered funduscopic findings. It is but a start as the physician begins to gain confidence in this aspect of physical diagnosis. The normal optic disc ( Fig. 5.2 ) can be compared with discs seen in early ( Fig. 5.3 ) and advanced papilledema ( Fig. 5.4 ). Pseudopapilledema can be encountered both with optic nerve drusen ( Fig. 5.5 ), which are globules of calcified mucoproteins that accumulate at the optic disc, and with myopic degeneration of the disc ( Fig. 5.6 ). Central retinal vein occlusion ( Fig. 5.7 ) frequently manifests with loss of central visual acuity with retinal hemorrhages, disc edema, and tortuous dilated veins. Finally, the color of the disc and the configuration and size of the optic cup should be assessed. Figure 5.8 demonstrates the pallor of optic atrophy as a result of inadequately treated papilledema. Figure 5.9 is an example of an enlarged deep optic cup seen in glaucoma. Getting started is always the hard part, but learning to examine an optic fundus is well worth the effort.
Normal optic disc.
Early papilledema.
Advanced papilledema.
Central retinal vein occlusion.
Optic nerve drusen.
These globules of calcified mucoproteins accumulate at the optic disc.
Myopic degeneration of the disc.
The pallor of optic atrophy as a result of inadequately treated papilledema.
An enlarged deep optic cup seen in glaucoma.
This point is emphasized because Donohoe has four young women in his practice who are blind because their papilledema and increased intracranial pressure resulting from pseudotumor cerebri (idiopathic intracranial hypertension) were discovered far too late. Their stories were basically the same. They were all overweight, all had headaches, all were seen by multiple physicians, all had normal MRI brain imaging, and all had lost most of their vision before the correct diagnosis was made and proper therapy was instituted. This diagnosis rests on the ability to maintain a high index of suspicion and properly perform a funduscopic examination.
In general, the pain specialist, even one whose basic training has been in anesthesia or psychiatry, can, with proper effort, become familiar with the basics of common disorders. Ultimately, the physician who does make the effort to learn this material and incorporate it into clinical pain management practice will not have to deal constantly with feeling uneasy about a weakness in clinical aptitude. Such a physician will also avoid losing precious time in developing experience with these key physical findings associated with a variety of headache and facial pain problems.
Motor Examination
Motor examination should begin with inspection of muscle volume and contour. The physician should pay particular attention to atrophy and hypertrophy. The patient should be properly gowned so that these observations can be made without invading the patient's privacy. During this examination, fasciculations, contractures, alterations in posture, and adventitious movements may be identified. Strength is measured both proximally and distally in the upper and lower extremities and is graded according to the scale shown in Table 5.7. Detailed individual muscle testing is not carried out unless a specific nerve root or plexopathy is under investigation.
Table 5.7
Grading of Muscle Strength
| Clinical Finding | Grade | Percentage of Normal Response |
|---|---|---|
| No evidence of contractility | 0 | 0 |
| Slight contractility, no movement | 1 | 10 |
| Full range of motion, gravity eliminated | 2 | 25 |
| Full range of motion with gravity | 3 | 50 |
| Full range of motion against gravity, some resistance | 4 | 75 |
| Full range of motion against gravity, full resistance | 5 | 100 |
From Chipps EM, Clanin NJ, Campbell VG: Neurologic disorder, St Louis, 1992, Mosby-Year Book.
Tone is best tested by passive manipulation, with note made of the resistance of muscle when voluntary control is absent. Changes in tone are more readily detected in muscles of the arms and legs than in muscles of the trunk. Relaxation is critical to proper evaluation. Hypertonicity is usually seen with lesions rostral to the anterior horn cells, including brain, brainstem, and spinal cord. Hypotonicity is associated with diseases affecting the neuraxis below this level, involving nerve root, peripheral nerve, neuromuscular junction, and muscle. Study of the motor system should be integrated with evaluation of the sensory examination and deep tendon reflexes, to provide cumulative information critical to identifying the site of the lesion—brain, brainstem, spinal cord, root, plexus, nerve, or muscle.
Sensory Examination
The sensory examination should be kept simple and should be targeted by clues obtained through the history. Certainly, time spent in defining sensory loss in the lower extremities would be justified in a patient who complains of pain, weakness, and numbness in the foot but not in a patient who has double vision and facial pain. Note in Figure 5.10 the difference between the skin areas innervated by dermatomes—specific segments of the cord, roots, or dorsal root ganglia—and the corresponding peripheral nerve cutaneous sensory distribution. These specific differences and changes in motor function and reflexes clinically define a nerve root from a peripheral nerve abnormality. Tables 5.8 and 5.9 highlight comparisons between specific spinal root and peripheral nerve lesions of the upper and lower extremities. With time, experience, and persistence, the pain specialist can become confident in the evaluation of peripheral nerve root lesions. So many of the common pain syndromes (cervical radiculopathies, lumbar radiculopathies, carpal tunnel syndrome, femoral neuropathy, peroneal neuropathy) may be rapidly and accurately diagnosed without expensive and uncomfortable neurodiagnostic testing. Being persistent and resisting the fear that the task is overwhelming result in the ability to evaluate patients in pain efficiently.
Comparison of spinal segmental (dermatomal) and peripheral nerve cutaneous sensory supply.
(Adapted from Haerer AF, editor: DeJong's the neurologic examination , ed 5, Philadelphia, 1992, Lippincott.)
Table 5.8
Clinical Manifestations of Root Versus Nerve Lesions in the Arm
| Roots | C5 | C6 | C7 | C8 | T1 |
|---|---|---|---|---|---|
| Sensory supply | Lateral border upper arm | Lateral forearm, including finger I | Over triceps, midforearm, and finger III | Medial forearm to finger V | Axilla to elbow |
| Reflex affected | Biceps reflex | None | Triceps reflex | None | None |
| Motor loss | Deltoid Infraspinatus Rhomboids Supraspinatus | Biceps Brachialis Brachioradialis | Latissimus dorsi Pectoralis major Triceps Wrist extensors Wrist flexors | Finger extensors Finger flexors Flexor carpi ulnaris | Intrinsic hand muscles (in some thenar muscles through C8) |
| Nerves | Axillary (C5, C6) | Musculotaneous (C5, C6) | Radial (C5–C8) | Median (C6–C8, T1) | Ulnar (C8, T1) |
|---|---|---|---|---|---|
| Sensory supply | Over deltoid | Lateral forearm to wrist | Lateral dorsal forearm and back of thumb and finger II | Lateral palm and lateral finger I, II, III, and half of IV | Medial palm and finger V and medial half of finger IV |
| Reflex affected | None | Biceps reflex | Triceps reflex | None | None |
| Motor loss | Deltoid | Biceps Brachialis | Brachioradialis Finger extensors Forearm supinator Triceps wrist extensors | Abductor pollicis brevis Long flexors of fingers I, II, III Pronators of forearm Wrist flexors | Intrinsic hand muscles Flexor carpi ulnaris Flexors of fingers IV, V |
From Patten J: Neurological differential diagnosis, New York, 1977, Springer-Verlag.
Table 5.9
Clinical Manifestations of Root Versus Nerve Lesions in the Leg
| Roots | L2 | L3 | L4 | L5 | S1 |
|---|---|---|---|---|---|
| Sensory supply | Across upper thigh | Across lower thigh | Across knee to medial malleolus | Side of leg to dorsum and sole of foot | Behind lateral malleolus to lateral foot |
| Reflex affected | None | None | Patellar reflex | None | Achilles reflex |
| Motor loss | Hip flexion | Knee extension | Inversion of foot | Dorsiflexion of toes and foot | Plantar flexion and eversion of foot |
| Nerves | Obturator (L2–L4) | Femoral (L2–L4) | Peroneal Division of Sciatic (L4, L5, S1–S3) | Tibial Division of Sciatic (L4, L5, S1–S3) |
|---|---|---|---|---|
| Sensory supply | Medial thigh | Anterior thigh to medial malleolus | Anterior leg to dorsum of foot | Posterior leg to sole and lateral aspect of foot |
| Reflex affected | None | Patellar reflex | None | Achilles reflex |
| Motor loss | Adduction of thigh | Extension of knee | Dorsiflexion, inversion, and eversion of foot | Plantar flexion and inversion of foot |
From Patten J: Neurological differential diagnosis, New York, 1977, Springer-Verlag.
For pain syndromes of the upper extremity, the examiner should be able to differentiate sensory involvement of the radial, median, and ulnar nerves from that of specific roots (C5-T1) (see Table 5.8 ). For pain syndromes of the lower extremities, the examiner should be able to differentiate the peroneal and tibial nerve sensory distribution from that of the L4, L5, and S1 roots (see Table 5.9 ). Such distinctions elucidate most of the common problems. Over time, the pain specialist can increase confidence in the examination and may develop a stronger foundation in peripheral neurology than many neurologists, neurosurgeons, and orthopedists possess.
Deep Tendon Reflexes
Deep tendon reflexes are actually muscle stretch reflexes mediated through neuromuscular spindles. This are the one facet of the clinical examination that is objective ( Table 5.10 ). Responses to mental status testing and motor examination, performance on sensory testing, and even gait can be consciously altered by the patient for any of a variety of reasons. Guillain-Barré syndrome (acute inflammatory polyneuropathy), however, a condition that in its initial stages may be misdiagnosed as anxiety related, characteristically shows absence of all the deep tendon reflexes, an important early clue to the organic nature of the disorder.
Table 5.10
Deep Tendon Reflex Scale
| Grade | Deep Tendon Reflex Response |
|---|---|
| 0+ | No response |
| 1+ | Sluggish |
| 2+ | Active or normal |
| 3+ | More brisk than expected, slightly hyperactive |
| 4+ | Abnormally hyperactive, with intermittent clonus |
From Seidel HM, Ball J, Daines J, et al: Mosby's guide to physical examination, ed 7. St Louis, 2010, Mosby.
A deep tendon reflex examination can be graded using the numerals 1 through 4 ( Fig. 5.11 ). Testing of the superficial reflexes, such as the abdominal or cremasteric reflexes, is not particularly valuable in clinical assessment. The only superficial reflex worth evaluating is the plantar reflex (a superficial reflex innervated by the tibial nerve, L4-S2). The response to stroking the plantar surface of the foot is usually flexion of both the foot and the toes. In diseases of the cortical spinal system, dorsiflexion of the toes occurs, especially the great toe, with separation or fanning of the others; this finding, Babinski's sign of upper motoneuron involvement (brain, brainstem, and spinal cord), is often paired with increased deep tendon reflexes and clonus (i.e., sustained muscular contractions following a stretch stimulus noted frequently in the ankle).
Diagram of a deep tendon reflex examination.
(From Waldman SD, editor: Interventional pain management , ed 2, Philadelphia, 2001, Saunders, 95.)
Unilateral absence of a deep tendon reflex implies disease at the peripheral nerve or root level. Diffuse reduction or absence of deep tendon reflexes suggests a more generalized process affecting the peripheral nerve, seen frequently in peripheral neuropathies secondary to diabetes, alcohol abuse, or inflammation. The objective data obtained quite rapidly from testing deep tendon reflexes are correlated with motor and sensory findings to determine whether a problem lies in a specific peripheral nerve, a specific nerve root, a diffuse peripheral nerve, or the spinal cord. It should take less than 30 seconds to complete this part of the examination.
Examination of Gait
Walking is an intricate process influenced by mechanical factors such as muscles, bones, tendons, and joints and, more importantly, dependent on nervous system integration. Just watching the patient walk during the examination is an extremely valuable exercise. The patient should be asked to walk with eyes open and closed and to stand with eyes open and closed (Romberg's sign). Gaits associated with parkinsonism (small, short steps with a stooped posture), normal-pressure hydrocephalus (magnetic gait, as if the patient were walking in magnetic shoes across a metal floor), muscular dystrophy, stroke, peripheral nerve injury, cerebellar ataxia, Huntington's chorea, and hysteria (astasia-abasia) are but a few characteristic patterns of disturbed locomotion. In short, a strong measure of neuro-orthopedic well-being is implied by the patient who walks well with eyes open and closed.
Conclusion
The basic point of this chapter is simple. A targeted and well-organized pain history is the foundation of proper diagnosis. Advances in diagnostic technology, no matter how sophisticated, cannot replace listening to the patient's own story of the illness. It is through this process that physicians most effectively gain insight, not only into the nature of the illness but also, and more importantly, into the personality of the patient who is in pain. The professionalism and sensitivity with which physicians obtain this information do much to establish the relationship with the patient and the ultimate success of therapies. If any room exists for shortcuts, it is not in this portion of the evaluation.
The targeted physical examination should be viewed as an extension of the insights derived from the history. It should be performed in a professional, thorough, but not laborious fashion. As the calling of pain management becomes more popular, physicians of various disciplines should avoid faddish technologic advances and opportunism made possible by inequities in reimbursement and should commit themselves to the very basics: obtaining historical data and eliciting physical findings. Energy expended to this end will reduce costs, enhance patient satisfaction, and foster lasting credibility in the evolving field of pain management.
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