Physical examination protocol in the study of VPT and nerve conduction in working women with and without chronic pain ID number ……………………… General health Height Weight Heart Lungs Blood pressure Urinary sample OK Affected cm kg OK OK OK Arrhythmia Rales mmHg Glucose Murmurs Wheeze NECK Neck without pain Palpation cervical spine M. Masseter M. Temporalis Protuberance occipitalis ext. M. Trapezius pars descendens M. Sternocleidomastoideus Processus spinosus Intraspinal Paravertebral Left OK OK OK OK OK OK OK OK Pain Pain Pain Pain Pain Right OK OK OK OK OK Pain Pain Pain Pain Pain If positive findings, register level Pain Pain Pain left right Range of motion (ROM) Range of motion in degrees if not OK can be approximated in 5-degree segments (normal according to Joint Motion). Passive ROM is not examined if active ROM is OK. Definitions and normal values are given in Greene W.B., Heckman J.D., eds. The Clinical Measurement of Joint Motion. 1994, American Academy of Orthopaedic Surgeons. 1-154. Cervical spine Rotation, left Rotation, right Lateral flexion, left Lateral flexion, right Flexion Extension Active OK OK OK OK OK OK Degrees (5-90) Passive OK OK OK OK OK OK Degrees (5-90) Pain at resisted motion Cervical spine Rotation to the … Lateral flexion to the … Flexion Extension Left No No Yes Yes No No Yes Yes 1 Right No No Yes Yes Diagnostic tests Left Right Foramen compression test Negative Positive Negative Positive Cervical spine Lasègue Negative Positive Negative Positive 1. Performed with the patient sitting with his/her head rotated to the right and left with simultaneous lateral flexion to the right and left with a light axial compression. Likelihood ratio of 7 for ruling in nerve or cord compression. The test is positive when radiating pain or tingling in the lower arm and hand are reported by the patient. Red flag rheumatoid arthritis. 2. Performed with the patient sitting, push down the shoulder by axial compression of the acromion with simultaneous lateral flexion of the patient’s cervical spine towards the contralateral side. This procedure will extend the plexus and instead of the axial compression of the acromion you can pull down the shoulder with a firm grip at the patient’s wrist. The test is positive only if radiating pain or tingling is felt in the forearm, hand and fingers. It is important to perform these two tests at all types of pain, ache or disturbed sensations in the arm, hand and fingers. Traction cervical spine Negative Positive The test is positive if pain arises in the cervical spine. AER (Roos’ test) Left Negative sek Right Negative sek The abduction external rotation test should be performed for 60 seconds at least (it is also common to perform a 3-minute test). NB. The test is positive when tingling or pain is felt in the forearm, in most cases on the ulnar side. If pain or ache in the neckshoulder angle is perceived by the patient, you can register this but it is does not mean that the test is positive. If there is a colour change in the forearm this should be registered since it could be an indication of possible vascular thoracic outlet syndrome (uncommon). If so, you should place a stethoscope in the supraclavicular fossa during the test to register possible murmurs which could indicate vascular TOS. SHOULDER Shoulder without pain Inspection Muscle atrophy AC/SC joint Elevated shoulders No OK No Yes, what muscles Abnormal Yes, left Palpation Acromioclavicular OK Pain Processus coracoideus OK Pain The insertion of the short head of the biceps and the minor pectoral muscles Tuberculus majus OK Pain The insertion of the teres minor, the supraspinatus and infraspinatus muscles Tuberculum minus OK Pain The insertion of the teres major and the subscapular muscles Sulcus intertubercularis OK Pain The tendon to the long head of the biceps muscles moves in the sulcus Trapezius pars descendens OK Pain Infraspinatus OK Pain OK Pain OK Pain OK Pain On the scapula Rhomboides Between the scapular blades Levator scapulae The upper medial corner of the scapula Fossa supraclavicularis 2 Yes right Left shoulder Flexion Abduction Extension Outward rotation Inward rotation Painful arc1 OK OK OK OK OK OK Impaired Impaired Impaired Impaired Impaired Impaired 1. For the painful arc, register the range of abduction that promotes most symptoms. Right shoulder Flexion Abduction Extension Outward rotation Inward rotation Painful arc1 OK OK OK OK OK OK Impaired Impaired Impaired Impaired Impaired Impaired 1. For the painful arc, register the range of abduction that promotes most symptoms. Pain at resisted movement Elevation of shoulder girdle Abduction (30o) Flexion Extension Inward rotation Outward rotation Bursa – test1 AC compression2 1. 2. Left shoulder No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes Right shoulder No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes One hand pushes under the elbow while the other hand pushes the acromion. Acromioclavicular compression. Horizontal flexion of the arm in the glenohumeral joint. A positive test gives pain in the acromioclavicular area. ELBOW Elbow joint without pain Range of motion (ROM) ROM = If not OK, register impaired range of motion in degrees. Elbow Flexion, left Flexion, right Extension, left Extension, right Supination, left Supination, right Pronation, left Pronation, right Carrying angle Active Degrees (5-180) OK OK OK OK OK OK OK OK Left degrees Pain at resisted movement Force grip Extension, wrist Left No No Yes Yes 3 Passive Degrees (5-180) OK OK OK OK OK OK OK OK Right degrees Right No No Yes Yes Palpation Lateral epicondyle Lateral epicondyle, muscle belly Medial epicondyle Medial epicondyle, muscle belly Frohse’s arcade1 1. Left OK OK OK OK OK Pain Pain Pain Pain Pain Right OK OK OK OK OK Pain Pain Pain Pain Pain An opening in M. Supinator where N. Interosseus posterior (N. Radialis) passes with risk of entrapment 2-3 cm from the lateral epicondyle. Normally, you feel tenderness at this point but with an entrapment the patient reports tingling in the forearm down to the dorsum of the hand. Diagnostic tests Pronator Teres test Middle finger extension (Maudsley’s test) Left OK OK Pain Pain Right OK OK Pain Pain Right OK OK OK OK Impaired Impaired Impaired Impaired Right OK OK OK OK OK OK OK Pain Pain Pain Pain Pain Pain Pain Right OK OK OK Atrophy/HyperAtrophy/HyperAtrophy/Hyper- Right OK OK OK OK No Impaired Impaired Impaired Impaired Yes HAND/WRIST Hand/wrist without pain Inspection (e.g. ganglions) OK Abnormality Range of motion (ROM) ROM = If not OK, register impaired range of motion in degrees. Flexion, wrist Extension, wrist Radial deviation Ulnar deviation Left OK OK OK OK Palpation CMC 1 CMC 2 CMC 3 MCP IP Carpal bones Prox of extensor retinaculum Forearm muscles Flexor carpi radialis Flexor carpi ulnaris Flexor digitorum Left OK OK OK Impaired Impaired Impaired Impaired Left OK OK OK OK OK OK OK Pain Pain Pain Pain Pain Pain Pain Atrophy/HyperAtrophy/HyperAtrophy/Hyper- Range of motion (ROM) ROM = If not OK, register impaired range of motion in degrees. Flexion fingers Extension fingers Finger-spread Thumb movement1 Tendonitis stenosans2 1. 2. Left OK OK OK OK No Impaired Impaired Impaired Impaired Yes Opposition. Put your index finger in the patient’s palm below MCP and then above MCP and ask the patient to flex and extend his/her fingers repeatedly. If positive, you may feel a bump in the tendons. 4 Superficial sensitivity (cotton wool) Left Index finger OK Middle finger OK Little finger OK Reflexes Brachioradialis Biceps Triceps Left OK Decreased OK Decreased OK Decreased Diagnostic tests Finkelstein’s test1 Phalen’s test Tinel’s test 2-point discrimination Temperature perception² Left Negative Negative Negative OK OK Impaired Impaired Impaired Right OK OK OK Exaggerated Exaggerated Exaggerated Right Decreased Decreased Decreased Impaired Impaired Impaired Right Negative Negative Negative OK OK Positive Positive Positive mm Impaired Exaggerated Exaggerated Exaggerated Positive Positive Positive mm Impaired 1. The thumb is kept along the index finger (the fingers should not grip on the thumb) and then the patient is asked to perform ulnar deviation of his/her hand with a straight arm. 2. A tuning fork at room temperature should be perceived as cold on the index and little finger´s digital pulp Muscular strength – grip force (Vigorimeter) Dominant hand Left-handed Right-handed Left maximum value of 3 attempts Right maximum value of 3 attempts Ambidextrous kPa kPa LOW BACK Low back without pain Movement Free Scoliosis Pelvic tilting, difference in level Muscle atrophy Stiff No No No Movements in the thoracic and low back OK Impaired Hypermobility Forward flexion Backward flexion Lateral flexion left Lateral flexion right Rotation left Rotation right Functional muscle strength OK Standing on toe Standing on heels Squatting Left impaired 5 With difficulty Yes Yes Yes, what muscles Painful Right Right Right Right Right Right Right Right impaired Left Left Left Left Left Left Left Painful Movement in hip joint Flexion Inward rotation Outward rotation Abduction Adduction OK Left impaired Palpation – if positive findings, register level Processus spinosus OK Pain Ligamentum intraspinali OK Pain Paraspinal OK Pain left Sacroiliaca joints OK Pain left Neurology Lasègue SLR Dorsiflexion of the foot Extensor hallucis MM Extensor digitorum1 Patellar reflex OK OK OK OK OK Achilles reflex OK Right impaired L1-L5 L1-L5 L1-L5 L1-L5 Positive left Positive left Weak left Weak left Decreased left Exaggerated left Decreased left Exaggerated left Pain right Pain right Positive right Positive right Weak right Weak right Decreased right Exaggerated right Decreased right Exaggerated right 1. A bump of muscles can be seen on the lateral side of the dorsum of the foot. Atrophy could indicate nerve damage. Sensitivity L4 (medium malleolus) L5 (dorsum of the foot) S1 (lateral malleolus) OK OK OK Impaired Impaired Impaired Estimated pain during examination 0 10 Constant pain/ache during the last 3 months Yes No 6 L1-L5 L1-L5 (degrees) (degrees)
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