Physical Examination in Pain Medicine

[drusso]

I see this all time. Patients diagnosed with various chronic pain disorders who have never had hands laid on them for a thorough MSK exam. The fact the more patients are seen by mid-level practitioners, ED physicians, and occupational medicine docs who lack basic competency in MSK and Spine physical examinations compounds the problem. How many RX's for opioids could be spared if a patient in pain received a comprehensive MSK examination and then reassurance that "nothing's broken, nothing's snapped, nothing's damaged" and that time and rehabilitation favor resolution?

http://www.kaiserhealthnews.org/Sto...-do-not-perform-physical-exams-correctly.aspx

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[emd123]

I see this all time. Patients diagnosed with various chronic pain disorders who have never had hands laid on them for a thorough MSK exam. The fact the more patients are seen by mid-level practitioners, ED physicians, and occupational medicine docs who lack basic competency in MSK and Spine physical examinations compounds the problem. How many RX's for opioids could be spared if a patient in pain received a comprehensive MSK examination and then reassurance that "nothing's broken, nothing's snapped, nothing's damaged" and that time and rehabilitation favor resolution?

http://www.kaiserhealthnews.org/Sto...-do-not-perform-physical-exams-correctly.aspx

Pure blasphemy!

 

[powermd]

I can't tell you how many times patients have said to me "you're the first doctor who actually took the time to do an examination like this. None of the other doctors I've seen even touched me."

Kind of sickening, really. OTOH, I'm glad my competitors suck.

 

[Dr. Ice]

I agree wholeheartedly, with the exception of those patients I see with either 3 days or 20 years of low back pain. I find that while I go through all the motions, the PE tends to be very low yield. Unfortunately, these people wind up fairly often on my schedule.

 

[lonelobo]

I can't tell you how many times patients have said to me "you're the first doctor who actually took the time to do an examination like this. None of the other doctors I've seen even touched me."

Kind of sickening, really. OTOH, I'm glad my competitors suck.

Of course sometimes I will see a patient who I do a thorough Exam on and then tell them I will not prescribe there Oxy/Soma/Xanax cocktail. They then go back to their PCP's and say I never touched or spent time with them

 

[Ducttape]

I see this all time. Patients diagnosed with various chronic pain disorders who have never had hands laid on them for a thorough MSK exam. The fact the more patients are seen by mid-level practitioners, ED physicians, and occupational medicine docs who lack basic competency in MSK and Spine physical examinations compounds the problem. How many RX's for opioids could be spared if a patient in pain received a comprehensive MSK examination and then reassurance that "nothing's broken, nothing's snapped, nothing's damaged" and that time and rehabilitation favor resolution?

http://www.kaiserhealthnews.org/Sto...-do-not-perform-physical-exams-correctly.aspx

EMD didnt expound more on this, but an ER physical examination is not geared towards chronic pain.

anyone ER doc that is doing an appropriate thorough MSK exam is ignoring the nearby acute subdural/MI/sepsis patient.

 

[lobelsteve]

HEENT, Heart, lungs, Abd: 99% useless for 99% of what we do.
Neuro, Ortho exams are almost all of it (except in Ramsay-Hunt, TN, etc.)

Anes, ER, IM, FP : Not adequately taught or trained.
Ortho: Half way
Neuro: Half way
PMR: 100%
Psych: 0%

It makes the catching up in fellowship all the more important.

Funny, just reviewed prominent pain doc in WV. SCS for Axial T-spine pain ordered at first visit and performed. Not working at 6 months and asks for revision, patient refuses. Narcs up entire time, not employed, mid 30's. 3 years of care. Never documented any exam but: HEENT, Heart, lungs, Abd

 

[emd123]

It's not that hard guys. Let's not pretend that the Pain Msk exam can only be done by Einstein or Steven Hawking's first born. Doctors that don't exam their patients= big problem. Stating you can only be from one specialty and do an excellent exam = absurd.

Seriously guys, the best people at physical exam are 2nd yr medical students that just aced physical diagnosis. Let's not kid ourselves here.

Yes, exam is important, but if you're not 90% sure of your diagnosis after finishing the history, and you're having to spend an hour an an exam to get your diagnosis, I'm worried.

Is this just another "Nana nana boo boo, my specialty's better than yours" thread?

 

[lobelsteve]

It's not that hard guys. Let's not pretend that the Pain Msk exam can only be done by Einstein or Steven Hawking's first born.

Seriously, the best people at physical exam are 2nd yr medical students that just aced physical diagnosis. Let's not kid ourselves here.

Yes, exam is important, but if you're not 90% sure of your diagnosis after finishing the history, and you're having to spend an hour an an exam to get your diagnosis, I'm worried.

Is this just another "Nana nana boo boo, my specialty's better than yours" thread?

Nope and nope.
The concordance with properly done provocative testing, history, and imaging should be what determines treatment and how the patient will respond. Many folks do not know Sens/Spec of the exam tests, don't do them properly, and do not know how to interpret the exam. Want to talk about SLR, Gaenslen's, FABER? Never met a fellow who got those right without some assistance and corrective action early on. I really like Magee's Orthopedic Physical Assessment for all of this.

Learning murmur's is tough. Exam is easy.

 

[SSdoc33]

Is this just another "Nana nana boo boo, my specialty's better than yours" thread?

it wasnt until you turned it into one

 

[UMichGas]

What are some other good books/resources for the MSK/Pain exam? Thanks.

 

[lobelsteve]

What are some other good books/resources for the MSK/Pain exam? Thanks.

Hoppenfeld.
Snider. Essentrials of MSK Care

 

[pjuer]

HEENT, Heart, lungs, Abd: 99% useless for 99% of what we do.
Neuro, Ortho exams are almost all of it (except in Ramsay-Hunt, TN, etc.)

Local hospital and surgery center require heart, lungs etc , documented for procedures. Hospital even wants Mallampati score and ASA classification on exam if you give 1-2 mg Versed. More useless paperwork every year. Most of exam is neuro and ortho

 

[lobelsteve]

Local hospital and surgery center require heart, lungs etc , documented for procedures. Hospital even wants Mallampati score and ASA classification on exam if you give 1-2 mg Versed. More useless paperwork every year. Most of exam is neuro and ortho

I'll make that the Anes 's job and I'll focus on the problem at hand. But I'm in office so less nonsense to deal with.

 

[ampaphb]

Nope and nope.
The concordance with properly done provocative testing, history, and imaging should be what determines treatment and how the patient will respond. Many folks do not know Sens/Spec of the exam tests, don't do them properly, and do not know how to interpret the exam. Want to talk about SLR, Gaenslen's, FABER? Never met a fellow who got those right without some assistance and corrective action early on. I really like Magee's Orthopedic Physical Assessment for all of this.

Learning murmur's is tough. Exam is easy.

Bull$hyte. I learned them from Charlie in residency. So when I got to Atlanta, I taught YOU what a slump test was.

 

[lobelsteve]

Bull$hyte. I learned them from Charlie in residency. So when I got to Atlanta, I taught YOU what a slump test was.

What's a slump test?

 

[ampaphb]

http://www.ncbi.nlm.nih.gov/m/pubmed/18391677/

 

[hyperalgesia]

I'd like to do a study on how many exam findings, normal and abnormal, were actually discovered by the examiner and how many were just documented to meet the requirements (JC, etc). I bet more than 50% are falsified.

 

[VA Hopeful Dr]

Of course sometimes I will see a patient who I do a thorough Exam on and then tell them I will not prescribe there Oxy/Soma/Xanax cocktail. They then go back to their PCP's and say I never touched or spent time with them

Bingo. I learned long ago that if a patient says something bad about another doctor, its BS 95% of the time. For pain patients, I bet its even higher.

 

[lobelsteve]

http://www.ncbi.nlm.nih.gov/pubmed/20166095

 

[nvrsumr]

Doing a full MSK exam on every patient means you didn't take an adequate history.

 

[Ducttape]

Not to be too cynical...

But for those guys touting 20-30 min NP appointments, how DO you fit in a thorough MSK exam?

It takes my patients 10 minutes alone to get hx, describe their pain and mitigating factors (and 0.05 sec to tell me how well Vicodin works)...

 

[jesspt]

Nope and nope.
The concordance with properly done provocative testing, history, and imaging should be what determines treatment and how the patient will respond. Many folks do not know Sens/Spec of the exam tests, don't do them properly, and do not know how to interpret the exam. Want to talk about SLR, Gaenslen's, FABER? Never met a fellow who got those right without some assistance and corrective action early on. I really like Magee's Orthopedic Physical Assessment for all of this.

Learning murmur's is tough. Exam is easy.

Fantastic text. But the primary author is aPT - I may be biased.

 

[drusso]

EMD didnt expound more on this, but an ER physical examination is not geared towards chronic pain.

anyone ER doc that is doing an appropriate thorough MSK exam is ignoring the nearby acute subdural/MI/sepsis patient.

Well, now that EM residencies are a bonafide path to ACGME sports medicine fellowships, maybe the EM RRC's will consider adding basic MSK exam skills to their core competencies.

 

[101N]

Not to be too cynical...

But for those guys touting 20-30 min NP appointments, how DO you fit in a thorough MSK exam?

It takes my patients 10 minutes alone to get hx, describe their pain and mitigating factors (and 0.05 sec to tell me how well Vicodin works)...

How comprehensive is your intake questionnaire?

 

[Ducttape]

8-10 pages.

10 pages for the Spanish-English one.

Imbedded with SOAPP-R, oswestry, BPI, "answers"to ORT. Updated bout once every year, when I have a slow day....


The base questionnaire was the one I used in fellowship that they kindly allowed me to use. It's roughly a third larger than that one.

 

[101N]

Hmm, mine is 4 pages.

My questionnaire and the PDMP save me a ton of time. I've used the SOAPP-R, COMM, & ORT but abandoned them for a modified DIRE. Unless you are doing a study, I don't think the ODI/NDI are worth the effort.

 

[lobelsteve]

2 pages of questions. 1 page pain diagram. Soappr. ICAT. 5pages total from me. Another 5-10 of general paperwork from hospital/practice.

 

[SSdoc33]

Reading McGee is like reading Harrison's. Good reference, I guess, but it's a
little dense.

No intake form. I just talk to my patients. God forbid.

 

[Aether2000]

I agree with Steve that most anesthesiologists have inadequate MSK physical exam skills. When performing such exams one has to first ask: what is the false positive and false negative rates of such exams, how likely is the exam going to lead on an expensive wild goose chase, and what is the relevance to the clinical situation. Is a comprehensive physical exam necessary on every patient on every office visit? Of course not. Is a physical exam of any kind always necessary on every patient every visit? Depends... is there anything new in the history or any significant change in musculoskeletal or neuro history? Then of course. What about no change in pain symptoms for the past 2 years with no neurological changes by history? Hmmmm. And if a person has focal pain in the left elbow due to tendinosis, is a lower extremity neuro exam really necessary?
Surely there is massive overuse of documented-templated physical exams that either never get done or only are done with such a cursory nature that the validity is questionable. And what are the most statistically valid physical exam maneuver test for each pain source? Not well defined in many cases.
So, it all depends.....
With injections it is definitely important to perform a reasonably thorough MSK and neuroexam since it is important for the approach and the mechanics of the injection.

 

[clubdeac]

If this is the one I'm thinking of it has along with a detailed explanation of each exam, the specificities and sensitivities of each exam. It was a good one

http://www.amazon.com/Musculoskeletal-Physical-Examination-Evidence-Based-Approach/dp/1560535911

 

[deleted682700]

What's the point of spending time in taking history and physical exam in back pain when there is no co relation between pain and pathology? Any way they are going to get imaging done. In fact the problem is that imaging findings don't correlate with pts pain.
Of course I am not minimizing the value of history and physical exam. There must be some algorithm in this madness.

 

[Taus]

What's the point of spending time in taking history and physical exam in back pain when there is no co relation between pain and pathology? Any way they are going to get imaging done. In fact the problem is that imaging findings don't correlate with pts pain.
Of course I am not minimizing the value of history and physical exam. There must be some algorithm in this madness.

Bc non-specific diagnosis leads to non specific treatment and non-specific (aka poor) outcomes. You will not be very successful treating back pain without taking an appropriately focused H&P. When that correlates to what you see on imaging you have a chance to be successful. Without that you're just doing bs series of 3 interlaminars....

 

[Taus]

Bc non-specific diagnosis leads to non specific treatment and non-specific (aka poor) outcomes. You will not be very successful treating back pain without taking an appropriately focused H&P. When that correlates to what you see on imaging you have a chance to be successful. Without that you're just doing bs series of 3 interlaminars....

Adding to that- there is literature on the sensitivity and specificity of components of history and physical items for back pain. You need to be familiar with that. That's in addition to knowing how to do a legit neuro exam.

 

[BobBarker]

So what do you guys do routinely for LBP? I am doing kemps, Patrick's, slr, strength, sensation, general palpation for myofascial screening, occasionally a SCOUR if I think the hip is involved. Somewhat self-taught so give me your critiques, please.

 

[Papa Lou]

Nope and nope.
The concordance with properly done provocative testing, history, and imaging should be what determines treatment and how the patient will respond. Many folks do not know Sens/Spec of the exam tests, don't do them properly, and do not know how to interpret the exam. Want to talk about SLR, Gaenslen's, FABER? Never met a fellow who got those right without some assistance and corrective action early on. I really like Magee's Orthopedic Physical Assessment for all of this.

Learning murmur's is tough. Exam is easy.

You frequently perseverate on this topic. "My specialty is better than yours" is what you're saying as you run around the schoolyard with your lollipop like a child. Who's mind do you think you're changing? Give it a rest.

Two facts: Anesthesiology residency entrance requirements are more competitive than PMR. PMR pain doctors are just as notorious for mostly med management and lack of interventional practice, as Anesthesia doctors are for mostly interventional practice and minimal med management.

Being completely impartial I'd prefer to be managed with injections over medication-dumping into my bloodstream.

One last fact: whoever said the best physical exams are given by second year medical students whose passing grade depends on it is right. It takes a few hours (maybe a couple days) to learn a complete musculoskeletal exam for pain management. Are we supposed to be impressed? You're saying your residency prepared for you to be better at this task? Get off my lawn.

Both specialties have their strengths and weaknesses and it is great to have a compliment of them in the field of pain medicine. Drop it.

 

[lobelsteve]

You frequently perseverate on this topic. "My specialty is better than yours" is what you're saying as you run around the schoolyard with your lollipop like a child. Who's mind do you think you're changing? Give it a rest.

Two facts: Anesthesiology residency entrance requirements are more competitive than PMR. PMR pain doctors are just as notorious for mostly med management and lack of interventional practice, as Anesthesia doctors are for mostly interventional practice and minimal med management.

Being completely impartial I'd prefer to be managed with injections over medication-dumping into my bloodstream.

One last fact: whoever said the best physical exams are given by second year medical students whose passing grade depends on it is right. It takes a few hours (maybe a couple days) to learn a complete musculoskeletal exam for pain management. Are we supposed to be impressed? You're saying your residency prepared for you to be better at this task? Get off my lawn.

Both specialties have their strengths and weaknesses and it is great to have a compliment of them in the field of pain medicine. Drop it.

So you are saying you drive up cost of care with excessive injections and have exam skills equal to an MS2. Exam skills takes months to years to see pathology and not just do maneuvers on normals. Its a free internet and i believe PMR is much better suited for Pain in the outpatient setting. Unsure how that is childish.

 

[Ducttape]

actually, having a psychiatric background is probably best suited for chronic pain.

i hate to say this, but i see no EBM to suggest that provider residency training makes an impact on efficacy of therapy for chronic pain. please post of you do, otherwise this is hypothetical tooting of ones horn, so to speak.

i had a hard time determining what is sensitivity and specificity of PE for low back pain. Cochrane did put this out:
http://www.cochrane.org/CD007431/BA...ow-back-pain-and-sciatica-a-systematic-review.

Authors' conclusions:
When used in isolation, current evidence indicates poor diagnostic performance of most physical tests used to identify lumbar disc herniation. However, most findings arise from surgical populations and may not apply to primary care or non-selected populations. Better performance may be obtained when tests are combined.

also, please post evidence that shows that PE actually alters prognosis in obtaining improvement from functional or pain relief standpoint.


finally, we all bring different perspectives, based on our training, to the table when it comes to chronic pain. fellowship training should be used to equal out some of the differences in our baseline training. the only caveat i can say is that the best pain doctor is one that is multidisciplinary and has been in practice for years...

 

[SSdoc33]

You frequently perseverate on this topic. "My specialty is better than yours" is what you're saying as you run around the schoolyard with your lollipop like a child. Who's mind do you think you're changing? Give it a rest.

Two facts: Anesthesiology residency entrance requirements are more competitive than PMR. PMR pain doctors are just as notorious for mostly med management and lack of interventional practice, as Anesthesia doctors are for mostly interventional practice and minimal med management.

Being completely impartial I'd prefer to be managed with injections over medication-dumping into my bloodstream.

One last fact: whoever said the best physical exams are given by second year medical students whose passing grade depends on it is right. It takes a few hours (maybe a couple days) to learn a complete musculoskeletal exam for pain management. Are we supposed to be impressed? You're saying your residency prepared for you to be better at this task? Get off my lawn.

Both specialties have their strengths and weaknesses and it is great to have a compliment of them in the field of pain medicine. Drop it.

if you are looking to start a fight, steve has 10 years of posts you can look up and pick apart. im certain you'll find things to rant about. this last topic was from a year ago. get with it, papa

 

[ampaphb]

So if I'm understanding the argument being made, it seems to boil down to "we do our physical exam as well as you do, but in case we don't, it doesn't matter anyway."

 

[ampaphb]

actually, having a psychiatric background is probably best suited for chronic pain.

i hate to say this, but i see no EBM to suggest that provider residency training makes an impact on efficacy of therapy for chronic pain. please post of you do, otherwise this is hypothetical tooting of ones horn, so to speak.

i had a hard time determining what is sensitivity and specificity of PE for low back pain. Cochrane did put this out:
http://www.cochrane.org/CD007431/BA...ow-back-pain-and-sciatica-a-systematic-review.


also, please post evidence that shows that PE actually alters prognosis in obtaining improvement from functional or pain relief standpoint.


finally, we all bring different perspectives, based on our training, to the table when it comes to chronic pain. fellowship training should be used to equal out some of the differences in our baseline training. the only caveat i can say is that the best pain doctor is one that is multidisciplinary and has been in practice for years...

physical exam does not have impact on efficacy or prognosis. It improves diagnostic accuracy and is part of the patient selection criteria for virtually all pain studies.

 

[Ducttape]

no, i am making the argument is that a board certified pain doc being "better" at doing PE does not mean that one is a "better" pain doctor, just as being "better" at doing epidurals or "better" at understanding pharmacokinetics makes one "better"...

 

[ampaphb]

So a patient presents with unilateral back and buttock pain, which extends into their posterior thigh when severe. Since according to you PE doesn't provide useful info, do you do an interlam? A tf-esi? MBB? SI jt? Piriformis?

Without a good physical exam, your patient will undergo a bunch of unnecessary procedures. You might get to the right answer eventually, but I wouldn't let you turn any of my friends or family members into your personal pin cushion.

 

[Ducttape]

i never said it didnt provide useful information.

i imsinuated that physical examination is only part of the evaluation process, and that the interpersonal variabilities between providers based solely on their residency training (with different PE skills/ procedural skills/ knowledge base) likely has little impact in the overall odds in improvement in functionality, quality of life, or pain scales.

 

[Hoya11]

So a patient presents with unilateral back and buttock pain, which extends into their posterior thigh when severe. Since according to you PE doesn't provide useful info, do you do an interlam? A tf-esi? MBB? SI jt? Piriformis?

Without a good physical exam, your patient will undergo a bunch of unnecessary procedures. You might get to the right answer eventually, but I wouldn't let you turn any of my friends or family members into your personal pin cushion.

Is there any data to support this statement? Any data that an extensive/expert physical exam can reduce number of injections needed to produce meaningful relief in patients with one-sided axial LBP? The answer is no, and the reason for that is because its not true. "Where is the pain generator" is a skill that comes with experience, instinct, analysis and reasoning. You put all the piece together to see what is the best way to proceed, and with imaging results, prior procedure results, and history, physical exam is just a small piece.

Does this person really have pain?
Is it blockable?
Are they addicted to opiates and just seeking opiates?
What has worked for them for injections in the past?
What does imaging show?
How did pain begin, how is it now, and what makes it worse?

you have to keep these big picture questions ahead of the text book distinctions between piriformis and SIJ tenderness. Would you do an SI on someone with SIJ tenderness, where SIJ injections have failed in the past, but they have never had a piriformis injection, becuase they have a negative physical exam for piriformis synd? hell no, you try stuff that hasnt been tried before, you cant rely on these patients/subjective physical exams for much. Im sure this view is not held by people who spent the last 3 years talking about how awesome their specialty is at PE, but its the truth and thats a weak weak thing to hang your hat on

 

[ampaphb]

You brushed over "is it blockable". Assume the patient is an injection virgin (or, in the alternative, has undergone SI inj by the ***** down the street from you whose images show his "SI jt injections" never produce an arthrogram).

Also, posterior thigh pain might represent radicular pain, and might represent facet jt referral pattern, so to immediately jump to only axial pain generators would potentially lead to unnecessary procedures.

 

[lonelobo]

Outpatient Pain Practice
Physiatrists > anesthesiologist

 

[Extralong]

HEENT, Heart, lungs, Abd: 99% useless for 99% of what we do.
Neuro, Ortho exams are almost all of it (except in Ramsay-Hunt, TN, etc.)

Anes, ER, IM, FP : Not adequately taught or trained.
Ortho: Half way
Neuro: Half way
PMR: 100%
Psych: 0%

It makes the catching up in fellowship all the more important.

Funny, just reviewed prominent pain doc in WV. SCS for Axial T-spine pain ordered at first visit and performed. Not working at 6 months and asks for revision, patient refuses. Narcs up entire time, not employed, mid 30's. 3 years of care. Never documented any exam but: HEENT, Heart, lungs, Abd

Totally agree with above, but in fellowship, you better damn well learn and do appropriate focused physical exams. Thats a given.

actually, having a psychiatric background is probably best suited for chronic pain.

i hate to say this, but i see no EBM to suggest that provider residency training makes an impact on efficacy of therapy for chronic pain. please post of you do, otherwise this is hypothetical tooting of ones horn, so to speak.

i had a hard time determining what is sensitivity and specificity of PE for low back pain. Cochrane did put this out:
http://www.cochrane.org/CD007431/BA...ow-back-pain-and-sciatica-a-systematic-review.


also, please post evidence that shows that PE actually alters prognosis in obtaining improvement from functional or pain relief standpoint.


finally, we all bring different perspectives, based on our training, to the table when it comes to chronic pain. fellowship training should be used to equal out some of the differences in our baseline training. the only caveat i can say is that the best pain doctor is one that is multidisciplinary and has been in practice for years...

Yea, I agree. Imagine you send a chronic pain patient with mood issues to a local therapist. The patient comes back to you and tells you what they have been working on. How the heck would you know if its the right stuff, if the therapist knows what the heck they are doing, if they are making progress, or if you need to add medication aboard, unless you come from psych. Its like when a family doc refers a patient with shoulder/back pain to physical therapy without writing what to work on; they may know the patient needs physical therapy but not know if the patient is making progress or if further treatment is warranted or what is the expected outcome of the physical therapy(which may not be full recovery).

 

[emd123]

A good history is 90% of Medicine, practiced properly. The exam, though important, acts only to confirm your history. Likewise, imaging and diagnostics only act to confirm your history and exam. Proper treatment can only flow from there, when filtered through wise clinical judgement.

 

[Papa Lou]

Psychiatrists play an invaluable role in pain medicine. As a pain doctor they can often have the biggest impact in the most number of patients. What's going to impact a chronic pain sufferer's life the most is.......tailored physical exercise and tailored mental work. Many things we do work quite well, but for the most bang for your buck, those two things help most with increased functionality (in most instances, what we might call quality of life). So psychiatrists can do a hell of a job, just as much as some PMRs and some anesthesiologists can do a hell of a job.

As an aside this forum, like most online forums, is frequented by certain types of personality "quirks," if not full on disorders. Is it coincidence the majority of you are PMRs? I refuse to jump to conclusions.

Improve accuracy of diagnosis and accuracy of therapy, all building from a passion for your practice, and then maybe individuals can stand out in the community despite the obvious limitations of their primary background.