Physical Examination
The physical assessment of the patient can be complicated if the
patient is in severe pain, manifests drug-seeking behavior, or has an agenda that
is not consistent with the doctor's. Because the findings on physical examinations
can be subjective (meaning that they are influenced by the patient's cooperation
and motivation), as is the historical information, it is important to compare the
findings of the physical examination with those in the patient's records.[31]
This provides some insight into the progression or regression of the primary disease
process with the passage of time or the application of treatment. Certainly, before
interventional therapy a neurologic examination should be documented in the record.
Observation of the patient's gait, posture, and pain behaviors (grimacing, moaning,
limping), and the use of appliances for ambulation should precede assessment of joint
range of motion, musculoskeletal function, the presence of trigger points or muscle
spasms, changes in muscle tone/bulk, sensory/motor/reflex changes, temperature differences,
and other tailored, focal examinations, as for abdominal pain or headaches.
Sensory abnormalities are common in neuropathic pain but are present
to variable degrees. Otto and co-workers reviewed the pain descriptions in patients
with painful polyneuropathy.[35]
Of 81 patients,
88% reported deep aching pain, 69% had pain with pressure, 59% had paroxysms of pain,
and 31% had pain with light touch. These authors associated the paroxysms of pain
with small fiber dysfunction, and the pain evoked by touch with abnormal summation
of sensory input.
As emphasized previously, the nervous system in a patient with
neuropathic pain has undergone some degree of structural and functional reorganization
as manifested by this variety of sensory reports. It is of practical importance
to avoid performing tests early in the examination that are likely to cause the patient
discomfort, because the subsequent pain, muscle spasm, guarding, and anxiety will
markedly decrease the patient's fullest cooperation. The documentation of the patient's
physical status is crucial for the patient who is involved in litigation, disability,
and workman's compensation matters. It is hoped that through the physical examination
sequence, one can correlate the patient's complaints of pain with relevant anatomic
possibilities.
Fishbain and colleagues have recently clarified the significance
of the much-quoted Waddell signs.[36]
Using an
extensive, evidence-based review analysis, these authors determined that Waddell
signs do not discriminate organic from non-organic pain, do not correlate with psychological
distress or secondary pain, but are associated with greater pain levels in patients
and poorer treatment outcome. Thus, being as thorough as possible is helpful medically
and in documentation for billing purposes. Rewards for fiscal conservatism in contemporary
managed care clearly elevate the significance of history-taking and physical examination
skills in the present day. That a neurological examination is recorded prior to
providing an interventional pain therapy is not only sound medical practice but may
be a tremendous benefit in the medico-legal realm if the patient develops a real
or a perceived complication of such therapy.
