"Objective" physical signs

[NJPAIN]

Are there any truly objective physical signs, other than perhaps a deformity, that can be documented on the physical examination of someone with low back pain?

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[Promethean]

What constitutes truly objective? As in, cannot be manufactured?

If we weren't talking chronic pain, I'd look to vital signs.

Maybe grimacing? At least, when the patient is distracted / isn't aware of being observed.

 

[lobelsteve]

Weakness. Sensory loss to needle stick, altered reflex. Los of passive rom despite pain. Clonus. Hoffmans.
None of these are pain related. Weakness can be limited from effort, pain inhibition, or neurological. If weakness is detected it should be descibed in a named muscle tested and a likely reason given. 4/5 left leg means the doc doesnt care.

 

[101N]

What prompts the question?

 

[NJPAIN]

Mainly my obsession (OCD) with consistency in my practice. I do some IME work for MVA. While I know that most of the physicians in my area who do IME work spend 5 minutes on an exam and 15 minutes on a report, I struggle with trying to apply the same standard to those patients cared for by other MDs as I would want applied to patients that I care for. I probably just shouldn't give a crap like everyone else. A question that is now frequently specifically posed by the insurer is "are there any objective findings on physical exam that support the diagnosis". As pointed out by Steve there are only a few that are truly objective. As we all know, many patients with low back and or radicular pain in our own practices don't have a dropped reflex or similar objective finding. I want to be certain that I am not over- interpreting the term "objective" in this setting.

 

[freddydpt]

Weakness - painless vs. painful vs. don't give a crap
Sensory loss to needle stick (testing with eyes closed)
Altered reflexes. Clonus. Hoffmans.
Loss of PROM despite pain.

I would add:
Functional mobility - slow sit to stand, antalgic gait or other gait abnormalities
Joint mobility - altered arthrokinematic glides of the joints (SI joint, vertebral segments)
Crepitus or clunks with a particular ROM
Palpable muscle spasms/knots/trigger points (whatever term you'd like to use) and response to any manual intervention
Myofascial mobility and erythematous reaction to any soft tissue mobility - I'll find some patients will have a pseudomotor reaction on the side they have pain (if it's unilateral)
Deformity in terms of lateral shift, scoliosis, leg length discrepancy, flat feet, postural deformity (correctable vs. uncorrectable)

I also think exaggerated responses to light touch is an objective component of exam and will document for next poor soul who examines that patient.

 

[Jitter Bug]

There isn't much objective for axial back pain, you could argue it's hard to make yourself spasm, so some docs will document palpable spasms.

Most of the objective stuff is in the neuro exam in the extremities, so you can document the presence or absence of that stuff in your reports. It's good to have a thorough list of objective testing when you are trying to sort out folks with strong secondary gain.

Reflexes are under partial voluntary control so I don't consider them objective. All my MVC and W/C stare intently at their patellas and hold their breath and tighten up their quads to block the patellar tendon reflex. Then comment in an offhand way "Yeah no-one has been able to get any reflexes off that leg since my accident."

The best way to separate real from fake is watch them walk out and climb into their vehicle after the IME is over. If you are lucky they will have a truck with a lift kit and you can watch them swing on up.

 

[Ducttape]

none of the above signs that are mentioned will consistently correlate with pain. lobel is 100% right that "None of these are pain related." it is easier to document specific Waddells and let the readers of your IME determine for themselves if a particular patient has aberrant pain behaviors. the presence of these adverse subjective findings is probably more objective than any positive findings, and the lack thereof of any Waddells and documentation thus seems much more informative to me when i am reviewing a patient's IME.

at my fellowship, the main office had a good view of the parking lot. initially, i was disheartened by the multitude of chronic pain patients whose limps and antalgic shuffling gaits, really unable to stand without their canes, seemed to be miraculously cured while jogging to their sparkling new caddies and Ford F150 super crew cabs. one of them actually dropped his cane, and bent forward with ease to pick it up.

after that first week, i got used to seeing this sight...

 

[lobelsteve]

none of the above signs that are mentioned will consistently correlate with pain. lobel is 100% right that "None of these are pain related." it is easier to document specific Waddells and let the readers of your IME determine for themselves if a particular patient has aberrant pain behaviors. the presence of these adverse subjective findings is probably more objective than any positive findings, and the lack thereof of any Waddells and documentation thus seems much more informative to me when i am reviewing a patient's IME.

at my fellowship, the main office had a good view of the parking lot. initially, i was disheartened by the multitude of chronic pain patients whose limps and antalgic shuffling gaits, really unable to stand without their canes, seemed to be miraculously cured while jogging to their sparkling new caddies and Ford F150 super crew cabs. one of them actually dropped his cane, and bent forward with ease to pick it up.

after that first week, i got used to seeing this sight...

Fixed it. Internet going down now.