PHYSICAL EXAMINATION

PHYSICAL EXAMINATION

The patient should be undressed and posture should be eval uated in both frontal and sagittal planes. Shoulder or waist asymmetry suggests the presence of scoliosis. The Adams forward bend test will accentuate trunk asymmetry and allow appr eciation of rib or loin prominence on the convex side of each curve. The skin should be examined for cutaneous neuro fibromata, café-au-lait patches or axillary freckling commonly present in neurofibromatosis. Neurological examination should include abdominal reflexes. Leg lengths should be measured. In the case of kyphosis , the sagittal alignment and forward gaze should be assessed. Palpation is useful to locate specific areas of tenderness. The normal range of motion in the cervical spine is 45° of flex ion, 55° of extension, 70° of rotation and 40° of lateral bend. The normal range of motion in the lumbar spine is 40–60° of fle xion, 20–35° of extension, 15–20° of lateral bending and 3–18° of rotation. Schober’s test is a simple clinical test William Adams , 1820–1900, described the forward bending test for scoliosis in 1865. His understanding of the nature of the rotational element of scoliosis was given by a postmortem examination he performed on an eminent surgeon and geologist, Gideon Mantell. Paul Schober , 1865–1943, German physician. Johann Ho ff mann , 1857 ‒ 1919, Professor of Neurology , Heidelberg, Germany . Joseph Francis Felix Babinski , 1857–1932, neurologist, Hôpital de la Pitié, Paris, France. skin midway between the posterior superior iliac spines and at points 10 /uni00A0 cm proximal and 5 /uni00A0 cm distal to this mark while the pa tient is standing. The patient is then asked to bend forwards - as far as possible and the distance between the two points is measured with the patient in the flexed position. Normally one would expect to see an increase of at least 5 /uni00A0 cm between the two points in the erect and flexed positions. A distance of less than 5 /uni00A0 cm between these points may indicate ankylosing - spondylitis. - Neurological examination of the upper and lower limbs will focus on tone, power, coordination, reflexes, sensation and gait ( Tables 37.2 and 37.3 ) . A rectal examination and y assessment of perineal sensation should be performed if there is any concern about cauda equina integrity . The superficial abdominal reflex is an upper motor neurone (UMN) reflex. - It is performed by stroking one of four abdominal quadrants in succession. The umbilicus should move towards the quad - rant that was stroked. The reflex should be symmetrical from - side to side. Absent or asymmetrical abdominal reflexes may - indicate intraspinal pathology such as syringomyelia or spinal cord injury . - Myelopathy or UMN lesions are reported by spasticity , motor weakness, hyper-reflexia, positive Ho ff mann’s sign (forced flexion of the distal phalanx of the middle finger results in flexion of the thumb and index finger), upgoing Babinski response and patellar and ankle clonus. Summary box 37.2 UMN lesions are characterised by: /uni25CF /uni25CF /uni25CF /uni25CF - /uni25CF /uni25CF /uni25CF /uni25CF - Typical signs of radiculopathy (lower motor neurone [LMN] lesion) include sensory loss, motor weakness, flaccid paralysis, muscle atrophy , loss of reflexes and muscle fascicu - lation. The straight leg raise (SLR) test is performed with the patient in the supine position. The leg is elevated with the knee - straight to increase tension along the L5 and S1 nerve roots. The test is positive if the leg elevation prov okes radicular pain. The crossed SLR test is carried out by elevating the asymp - tomatic leg; if positive, this produces sciatic symptoms in the opposite leg. A positive test is associated with a herniated disc

Increased tone – spastic Hyper-re /f_l exia Muscle spasms Motor weakness Disuse atrophy Positive Hoffmann’s sign Ankle and patellar clonus Upgoing plantar response

in /uni00A0 97% /uni00A0 of patients. Lasègue’s sign denotes radicular pain aggravated by ankle dorsiflexion. The femoral nerve stretch test is performed with the patient in the prone position by extending the hip and flexing the knee. This creates tension on the L2, L3 and L4 nerve roots. The femoral nerve stretch test is considered positive if radicular pain occurs in the anterior thigh region during the test. The examination should include, where appropriate, exam ination of the shoulder, hip, knee, sacroiliac joint and vascular system, as dual pathology is common in the ageing community . In 1979, Waddell and colleagues (see Further reading developed and validated a series of signs and tests that have proved helpful in identifying individuals who are magnify ing or exaggerating symptoms, possib ly for secondary gain ( Table 37.4 ) /uni25CF /uni25CF : /uni25CF : /uni25CF : /uni25CF : Summary box 37.3 LMN lesions are characterised by: /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Charles Ernest Lasègue , 1816–1863, Professor of Medicine, University of Paris, and physician, La Salpêtrière, Paris, France

Neurological level Motor C5 Deltoid C6 Wrist extensors C7 Triceps C8 Long /f_i nger /f_l exors T1 Interosseus muscles TABLE 37.3 Neurological evaluation of the lower limb. Neurological level Motor L2 Hip /f_l exion L3 Knee extension L4 Ankle dorsi /f_l exion L5 Extensor hallucis longus S1 Ankle plantar /f_l exion TABLE 37.4 Non-organic physical signs in low back pain. Tenderness : super /f_i cial or non-anatomical Simulation tests axial loading or rotation Distraction tests variable straight leg raises Regional disturbances non-anatomical sensory or motor loss Over-reaction grimacing, muscle tremor, etc. Decreased tone – /f_l accid Hypore /f_l exia Denervation fasciculations Motor weakness Sensory loss Severe atrophy Downgoing plantar response Sensation Re /f_l exes Lateral arm Biceps (C5/6) Lateral forearm Brachioradialis (C5/6) Middle /f_i nger Triceps (C7/8) Medial forearm No re /f_l ex Medial arm No re /f_l ex Sensation Re /f_l exes Anterior thigh, groin No re /f_l ex Anterior and lateral thigh Patellar (L3/4) Medial leg and foot Patellar (L3/4) Lateral leg and foot No re /f_l ex Lateral foot and little toe Achilles (S1/2)

PHYSICAL EXAMINATION

The patient should be undressed and posture should be eval uated in both frontal and sagittal planes. Shoulder or waist asymmetry suggests the presence of scoliosis. The Adams forward bend test will accentuate trunk asymmetry and allow appr eciation of rib or loin prominence on the convex side of each curve. The skin should be examined for cutaneous neuro fibromata, café-au-lait patches or axillary freckling commonly present in neurofibromatosis. Neurological examination should include abdominal reflexes. Leg lengths should be measured. In the case of kyphosis , the sagittal alignment and forward gaze should be assessed. Palpation is useful to locate specific areas of tenderness. The normal range of motion in the cervical spine is 45° of flex ion, 55° of extension, 70° of rotation and 40° of lateral bend. The normal range of motion in the lumbar spine is 40–60° of fle xion, 20–35° of extension, 15–20° of lateral bending and 3–18° of rotation. Schober’s test is a simple clinical test William Adams , 1820–1900, described the forward bending test for scoliosis in 1865. His understanding of the nature of the rotational element of scoliosis was given by a postmortem examination he performed on an eminent surgeon and geologist, Gideon Mantell. Paul Schober , 1865–1943, German physician. Johann Ho ff mann , 1857 ‒ 1919, Professor of Neurology , Heidelberg, Germany . Joseph Francis Felix Babinski , 1857–1932, neurologist, Hôpital de la Pitié, Paris, France. skin midway between the posterior superior iliac spines and at points 10 /uni00A0 cm proximal and 5 /uni00A0 cm distal to this mark while the pa tient is standing. The patient is then asked to bend forwards - as far as possible and the distance between the two points is measured with the patient in the flexed position. Normally one would expect to see an increase of at least 5 /uni00A0 cm between the two points in the erect and flexed positions. A distance of less than 5 /uni00A0 cm between these points may indicate ankylosing - spondylitis. - Neurological examination of the upper and lower limbs will focus on tone, power, coordination, reflexes, sensation and gait ( Tables 37.2 and 37.3 ) . A rectal examination and y assessment of perineal sensation should be performed if there is any concern about cauda equina integrity . The superficial abdominal reflex is an upper motor neurone (UMN) reflex. - It is performed by stroking one of four abdominal quadrants in succession. The umbilicus should move towards the quad - rant that was stroked. The reflex should be symmetrical from - side to side. Absent or asymmetrical abdominal reflexes may - indicate intraspinal pathology such as syringomyelia or spinal cord injury . - Myelopathy or UMN lesions are reported by spasticity , motor weakness, hyper-reflexia, positive Ho ff mann’s sign (forced flexion of the distal phalanx of the middle finger results in flexion of the thumb and index finger), upgoing Babinski response and patellar and ankle clonus. Summary box 37.2 UMN lesions are characterised by: /uni25CF /uni25CF /uni25CF /uni25CF - /uni25CF /uni25CF /uni25CF /uni25CF - Typical signs of radiculopathy (lower motor neurone [LMN] lesion) include sensory loss, motor weakness, flaccid paralysis, muscle atrophy , loss of reflexes and muscle fascicu - lation. The straight leg raise (SLR) test is performed with the patient in the supine position. The leg is elevated with the knee - straight to increase tension along the L5 and S1 nerve roots. The test is positive if the leg elevation prov okes radicular pain. The crossed SLR test is carried out by elevating the asymp - tomatic leg; if positive, this produces sciatic symptoms in the opposite leg. A positive test is associated with a herniated disc

Increased tone – spastic Hyper-re /f_l exia Muscle spasms Motor weakness Disuse atrophy Positive Hoffmann’s sign Ankle and patellar clonus Upgoing plantar response

in /uni00A0 97% /uni00A0 of patients. Lasègue’s sign denotes radicular pain aggravated by ankle dorsiflexion. The femoral nerve stretch test is performed with the patient in the prone position by extending the hip and flexing the knee. This creates tension on the L2, L3 and L4 nerve roots. The femoral nerve stretch test is considered positive if radicular pain occurs in the anterior thigh region during the test. The examination should include, where appropriate, exam ination of the shoulder, hip, knee, sacroiliac joint and vascular system, as dual pathology is common in the ageing community . In 1979, Waddell and colleagues (see Further reading developed and validated a series of signs and tests that have proved helpful in identifying individuals who are magnify ing or exaggerating symptoms, possib ly for secondary gain ( Table 37.4 ) /uni25CF /uni25CF : /uni25CF : /uni25CF : /uni25CF : Summary box 37.3 LMN lesions are characterised by: /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Charles Ernest Lasègue , 1816–1863, Professor of Medicine, University of Paris, and physician, La Salpêtrière, Paris, France

Neurological level Motor C5 Deltoid C6 Wrist extensors C7 Triceps C8 Long /f_i nger /f_l exors T1 Interosseus muscles TABLE 37.3 Neurological evaluation of the lower limb. Neurological level Motor L2 Hip /f_l exion L3 Knee extension L4 Ankle dorsi /f_l exion L5 Extensor hallucis longus S1 Ankle plantar /f_l exion TABLE 37.4 Non-organic physical signs in low back pain. Tenderness : super /f_i cial or non-anatomical Simulation tests axial loading or rotation Distraction tests variable straight leg raises Regional disturbances non-anatomical sensory or motor loss Over-reaction grimacing, muscle tremor, etc. Decreased tone – /f_l accid Hypore /f_l exia Denervation fasciculations Motor weakness Sensory loss Severe atrophy Downgoing plantar response Sensation Re /f_l exes Lateral arm Biceps (C5/6) Lateral forearm Brachioradialis (C5/6) Middle /f_i nger Triceps (C7/8) Medial forearm No re /f_l ex Medial arm No re /f_l ex Sensation Re /f_l exes Anterior thigh, groin No re /f_l ex Anterior and lateral thigh Patellar (L3/4) Medial leg and foot Patellar (L3/4) Lateral leg and foot No re /f_l ex Lateral foot and little toe Achilles (S1/2)

PHYSICAL EXAMINATION

The patient should be undressed and posture should be eval uated in both frontal and sagittal planes. Shoulder or waist asymmetry suggests the presence of scoliosis. The Adams forward bend test will accentuate trunk asymmetry and allow appr eciation of rib or loin prominence on the convex side of each curve. The skin should be examined for cutaneous neuro fibromata, café-au-lait patches or axillary freckling commonly present in neurofibromatosis. Neurological examination should include abdominal reflexes. Leg lengths should be measured. In the case of kyphosis , the sagittal alignment and forward gaze should be assessed. Palpation is useful to locate specific areas of tenderness. The normal range of motion in the cervical spine is 45° of flex ion, 55° of extension, 70° of rotation and 40° of lateral bend. The normal range of motion in the lumbar spine is 40–60° of fle xion, 20–35° of extension, 15–20° of lateral bending and 3–18° of rotation. Schober’s test is a simple clinical test William Adams , 1820–1900, described the forward bending test for scoliosis in 1865. His understanding of the nature of the rotational element of scoliosis was given by a postmortem examination he performed on an eminent surgeon and geologist, Gideon Mantell. Paul Schober , 1865–1943, German physician. Johann Ho ff mann , 1857 ‒ 1919, Professor of Neurology , Heidelberg, Germany . Joseph Francis Felix Babinski , 1857–1932, neurologist, Hôpital de la Pitié, Paris, France. skin midway between the posterior superior iliac spines and at points 10 /uni00A0 cm proximal and 5 /uni00A0 cm distal to this mark while the pa tient is standing. The patient is then asked to bend forwards - as far as possible and the distance between the two points is measured with the patient in the flexed position. Normally one would expect to see an increase of at least 5 /uni00A0 cm between the two points in the erect and flexed positions. A distance of less than 5 /uni00A0 cm between these points may indicate ankylosing - spondylitis. - Neurological examination of the upper and lower limbs will focus on tone, power, coordination, reflexes, sensation and gait ( Tables 37.2 and 37.3 ) . A rectal examination and y assessment of perineal sensation should be performed if there is any concern about cauda equina integrity . The superficial abdominal reflex is an upper motor neurone (UMN) reflex. - It is performed by stroking one of four abdominal quadrants in succession. The umbilicus should move towards the quad - rant that was stroked. The reflex should be symmetrical from - side to side. Absent or asymmetrical abdominal reflexes may - indicate intraspinal pathology such as syringomyelia or spinal cord injury . - Myelopathy or UMN lesions are reported by spasticity , motor weakness, hyper-reflexia, positive Ho ff mann’s sign (forced flexion of the distal phalanx of the middle finger results in flexion of the thumb and index finger), upgoing Babinski response and patellar and ankle clonus. Summary box 37.2 UMN lesions are characterised by: /uni25CF /uni25CF /uni25CF /uni25CF - /uni25CF /uni25CF /uni25CF /uni25CF - Typical signs of radiculopathy (lower motor neurone [LMN] lesion) include sensory loss, motor weakness, flaccid paralysis, muscle atrophy , loss of reflexes and muscle fascicu - lation. The straight leg raise (SLR) test is performed with the patient in the supine position. The leg is elevated with the knee - straight to increase tension along the L5 and S1 nerve roots. The test is positive if the leg elevation prov okes radicular pain. The crossed SLR test is carried out by elevating the asymp - tomatic leg; if positive, this produces sciatic symptoms in the opposite leg. A positive test is associated with a herniated disc

Increased tone – spastic Hyper-re /f_l exia Muscle spasms Motor weakness Disuse atrophy Positive Hoffmann’s sign Ankle and patellar clonus Upgoing plantar response

in /uni00A0 97% /uni00A0 of patients. Lasègue’s sign denotes radicular pain aggravated by ankle dorsiflexion. The femoral nerve stretch test is performed with the patient in the prone position by extending the hip and flexing the knee. This creates tension on the L2, L3 and L4 nerve roots. The femoral nerve stretch test is considered positive if radicular pain occurs in the anterior thigh region during the test. The examination should include, where appropriate, exam ination of the shoulder, hip, knee, sacroiliac joint and vascular system, as dual pathology is common in the ageing community . In 1979, Waddell and colleagues (see Further reading developed and validated a series of signs and tests that have proved helpful in identifying individuals who are magnify ing or exaggerating symptoms, possib ly for secondary gain ( Table 37.4 ) /uni25CF /uni25CF : /uni25CF : /uni25CF : /uni25CF : Summary box 37.3 LMN lesions are characterised by: /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Charles Ernest Lasègue , 1816–1863, Professor of Medicine, University of Paris, and physician, La Salpêtrière, Paris, France

Neurological level Motor C5 Deltoid C6 Wrist extensors C7 Triceps C8 Long /f_i nger /f_l exors T1 Interosseus muscles TABLE 37.3 Neurological evaluation of the lower limb. Neurological level Motor L2 Hip /f_l exion L3 Knee extension L4 Ankle dorsi /f_l exion L5 Extensor hallucis longus S1 Ankle plantar /f_l exion TABLE 37.4 Non-organic physical signs in low back pain. Tenderness : super /f_i cial or non-anatomical Simulation tests axial loading or rotation Distraction tests variable straight leg raises Regional disturbances non-anatomical sensory or motor loss Over-reaction grimacing, muscle tremor, etc. Decreased tone – /f_l accid Hypore /f_l exia Denervation fasciculations Motor weakness Sensory loss Severe atrophy Downgoing plantar response Sensation Re /f_l exes Lateral arm Biceps (C5/6) Lateral forearm Brachioradialis (C5/6) Middle /f_i nger Triceps (C7/8) Medial forearm No re /f_l ex Medial arm No re /f_l ex Sensation Re /f_l exes Anterior thigh, groin No re /f_l ex Anterior and lateral thigh Patellar (L3/4) Medial leg and foot Patellar (L3/4) Lateral leg and foot No re /f_l ex Lateral foot and little toe Achilles (S1/2)