History and Physical Examination of the Patient With Pain

This chapter provides an overview of appropriate history taking and a structured approach to the physical examination of a pain patient, along with the anatomic and physiologic basis of the physical findings. Physical examination serves to further explore and confirm the findings from the clinical history. Data obtained from the history are essential to pair with the physical exam to create a thoughtful differential diagnosis of the etiology of the pain so that the need for further diagnostic testing can be determined and further assist in treatment planning.

The history is one of the most important pillars of proper pain assessment. The importance of this aspect of clinical evaluation cannot be overemphasized. Many practitioners adopt the “PQRST” approach to historical evaluation. Using such, a patient is asked what provokes or palliates their symptoms (P), the nature of its quality (Q), whether/where it radiates (R), the severity of their pain (S), and temporal components (T). Assessing the person in pain also requires additional careful consideration of pain physiology, anatomy, functional limitations, and the patient’s ability to convey the information. The practitioner needs to understand the onset of symptoms (insidious or traumatic), types of daily activities limited by pain, psychological effects of pain, and the presence of neuroanatomic vs. referral or co-incidental pain radiation. This information is required to discern whether the patient’s pain is nociceptive, neuropathic, nociplastic, or other types of pain. It is important to understand that many people experiencing chronic pain are not exclusively experiencing one type or the other, but rather may have varying degrees of each, thus mixed pain types. Complete and personalized history taking is essential to understanding a patient’s pain and properly devise a treatment strategy to improve life quality. The time and effort spent completing this are likely to be of value when treating a person in pain.

The key components of the physical examination include a general physical examination, a detailed neurologic examination, a detailed musculoskeletal examination, and an examination for cutaneous or trophic findings. The musculoskeletal examination includes inspection, palpation, percussion, auscultation, and provocative maneuvers.

General Physical Examination

Vital signs, including temperature, heart rate, respiratory rate, blood pressure, and weight, should be noted at each visit. This information is useful in forming an impression of the overall health and comorbid conditions of the patient.

A few moments should be spent observing and documenting the general appearance and gait of the patient. Whenever possible, the examining physician should make every effort to bring the patient back to the examining room from the waiting room. This allows the physician the opportunity for examination as the patient transitions from sitting to standing and ambulates to the examining room. This observation time allows an “unofficial” examination that may reveal inconsistencies not noted on the “official formal” examination.

Observations include how the patient dresses and personal hygiene. Pain behavior, posture, and anatomic abnormalities such as contractures, amputation, and asymmetries should also be noted. Maladaptive postural dynamics play an important role in generating myofascial pain. Excessive lumbar lordosis places strain on the lumbar extensor muscles and results in low back pain. Similarly, forward flexion of the cervical spine with drooping of the shoulders strains the cervical paraspinous and scapular muscles and thereby causes neck and upper back pain.

Evaluation of gait includes assessment of stride length, base, arm swing, and stability. An unsteady, wide-based ataxic gait can be seen in patients with cerebellar and proprioceptive disorders. In patients with hip and lower extremity pain, the stance phase is reduced in the affected limb, along with a shortened swing phase on the uninvolved side, which results in an antalgic gait pattern. A waddling gait can occur in patients with weakness of the hip girdle muscles or bilateral degenerative hip joint disease. Many gait deviations can occur in patients with foot drop, including vaulting, steppage gate, circumduction, and persistent abduction of the affected limb.

Neurologic Examination

Components of the neurologic examination include:

mental status examination
cranial nerve testing
motor strength examination
deep tendon reflexes
sensation
coordination
special tests

Mental Status Examination

A reasonable assessment of mental status can often be made as part of history taking and inquiry into activities of daily living and function. A basic mental status examination includes assessment of the level of consciousness; orientation to person, place, time, and situation; registration and short-term memory; attention and concentration; and assessment of language for aphasia. The Folstein Mini-Mental Status Examination is a useful screening tool for detecting cognitive deficits and dementia.

Assessment of mood, affect, suicidal and homicidal ideation, and neurovegetative symptoms such as sleep, appetite, and energy level should be assessed routinely. This helps uncover comorbid psychiatric conditions (e.g. depression, anxiety, and psychosis), which can have a profound impact on the treatment of pain patients.

Cranial Nerve Testing

The cranial nerve examination localizes pathology primarily at the level of the brainstem. Central pain conditions associated with brainstem pathology (e.g. strokes, tumors, demyelinating disease, and vascular malformations) can be associated with cranial nerve deficits.

Cranial Nerve I

Olfactory Nerve

Test one nostril at a time. Odors such as coffee, mint, or cloves can be used. Noxious odors such as ammonia are avoided because they activate trigeminal nerve receptors in the nasal passages.

The most common cause of smell dysfunction is nasal and sinus pathology. Dementia, neurodegenerative conditions, and basal frontal tumors can also result in smell dysfunction.

Cranial Nerve II

Optic Nerve

Visual acuity is determined with a Snellen chart. Visual fields are tested by the confrontation method at the bedside. More formal visual field testing with perimetry can be requested if indicated. Pupillary reaction to light and accommodation tests the optic and ophthalmic nerves. Funduscopic examination is done to evaluate the optic disc and retina. Papilledema and enlargement of the blind spot can occur in conditions associated with elevated intracranial pressure, including idiopathic intracranial hypertension, which is a relatively common cause of intractable headache.

Cranial Nerves III, IV, and VI

Ophthalmic, Trochlear, and Abducens Nerves

These nerves control eye movement and can be tested by asking the patient to track a moving object in the eight positions of cardinal gaze. Eyelid elevation and pupillary constriction are controlled by the third cranial nerve and are evaluated by assessing the direct, consensual, and accommodation reflexes. Sympathetic fibers innervate the pupillary dilator muscles. Horner’s syndrome exists in several clinical conditions, including after stellate ganglion blockade. This syndrome includes ipsilateral ptosis, miosis, and anhidrosis. However, the mechanism of these changes involves sympatholysis and is independent of cranial nerve function.

Cranial Nerve V

Trigeminal Nerve

This nerve supplies sensory input to the face, mouth, tongue, and scalp up to the vertex. The mandibular division of the trigeminal nerve also supplies the muscles of mastication (i.e. temporalis, masseter, medial, and lateral pterygoid muscles).

Sensation along the ophthalmic, maxillary, and mandibular divisions of the trigeminal nerve are tested with temperature, pinprick, and light touch. The trigeminal nerve also provides the afferent limb of the corneal blink reflex.

Peripheral lesions of the trigeminal nerve result in ipsilateral loss of facial sensation with weakness and atrophy of the ipsilateral jaw muscles.

Cranial Nerve VII

Facial Nerve

The facial nerve innervates the muscles of facial expression, the submandibular and lacrimal glands, and taste in the anterior two-thirds of the tongue. Testing is usually limited to checking facial motor function (e.g. forehead wrinkling, eye closure, smile, pursing lips, and corneal blink). Supranuclear lesions of the seventh nerve typically spare the forehead, whereas nuclear and infranuclear lesions do not.

Sensory testing of the facial nerve is not routinely performed but can be accomplished by applying sweet, sour, and salt stimuli to the ipsilateral half of the anterior two-thirds of the tongue.

Cranial Nerve VIII

Vestibulocochlear Nerve

The vestibulocochlear nerve mediates hearing and balance. Hearing can be assessed with a 512 Hz tuning fork. The Rinne and Weber tests are commonly used to assess for sensorineural and conductive deafness.

In the Weber test, the base of a gently vibrating tuning fork is placed on the midforehead or the vertex. The patient is asked which ear hears the sound better. Normally, the sound is heard equally in both ears. With unilateral sensorineural hearing loss, the sound is better in the unaffected ear. With unilateral conductive hearing loss, sound is perceived better in the affected ear.

The Rinne test is conducted by placing the base of a gently vibrating tuning fork on the mastoid bone behind the ear. When the patient can no longer hear the sound, the fork is quickly moved next to the patient’s ear. In patients with sensorineural deafness and normal hearing, air conduction is better than bone conduction. With conductive deafness, bone conduction is better than air conduction.

Nystagmus noted on eye movement testing may be a sign of vestibular dysfunction. In patients with complaints of episodic vertigo, the Dix-Hallpike maneuver is useful for making the diagnosis of benign paroxysmal positional vertigo. The test is performed by rapidly moving the patient from a sitting to a supine position while the patient’s head is turned 45° to the right. The patient should remain supine with head turned for 20-30 s and then returned to the sitting position. The observation of rotatory nystagmus with limited duration is what is considered clearly positive. The response is noted, and then the test is repeated as described above with the head now turned to the left.

Examination of the vestibulocochlear nerve can be informally done by observing the patient when conversing to determine grossly if they are having difficulty hearing speech. To formally test the vestibulocochlear nerve, the examiner should create a soft sound, usually through a whisper or finger rubbing, next to each ear. This should be done with each ear individually and the opposite ear covered. The patient should be asked if the sound was equal on both sides, and a normal finding would be that there was no difficulty hearing the noise in either ear or that it was equal in both ears. If the patient notices decreased sound on either ear, the ear canals should be inspected with an otoscope to ensure that the tympanic membrane is intact and that there is no material such as wax or exudate physically blocking the canal that would interfere with the patient’s hearing.

Cranial Nerve IX

Glossopharyngeal Nerve

The glossopharyngeal nerve subserves taste in the posterior third of the tongue and sensation in the pharynx. It provides the afferent limb of the gag reflex.

Cranial Nerve X

Vagus Nerve

The vagus nerve innervates the pharyngeal and laryngeal muscles and forms the efferent limb of the gag reflex. Symptoms of vagus nerve lesions include dysarthria and dysphagia.

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