1 / 42

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

alma-perkins
Télécharger la présentation

CH.4 PHYSICAL EXAMINATION OF THE PAIN PATIENT

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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

More Related