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Most patient assessment is the taking of the history itself: Listen to the patients; they will tell you what is wrong with them. Physical examination then serves as a confirmation of your suspicions. Spine, neuromuscular, and musculoskeletal disorders comprise the bulk of conditions seen in the pain clinic, so basic physical exam is reviewed here. The reader is urged to refer to classic texts for more detail regarding this expansive topic: The single vade mecum is Hoppenfeld's Physical Examination of the Spine and Extremities.1 Comprehensive instruction in all musculoskeletal examination maneuvers is found in Magee's Orthopedic Physical Assessment.2 Musculoskeletal examination as well as anatomy, imaging, and management are covered in detail in the “Essentials.”3 A complete text for neurological exam is DeJong's The Neurologic Examination.4 Beyond reading, practice over years is encouraged to attain mastery. We cite utility of common tests in terms of sensitivity and specificity when available. Beyond the science, the art and the truth are that the physical examination is a bonding ritual with patients.

The physical exam begins as soon as you see the patient walking into the room, with the assessment of gait. For the most careful assessment, it is best to have the patient disrobe. Common themes of physical examination include inspection, palpation, motion testing, and provocation or special tests, which are often eponymous. Spine and musculoskeletal range of motion values are not universally agreed upon, and values here are for reference. Many special physical exam protocols exist, and a few with practical application in pain are included at the close of this chapter.


Inspection: Visually inspect spine alignment, including normal curvatures, sagittal and coronal balance, or any scoliosis or excess kyphosis. The four normal curves exist only in the sagittal plane and include cervical lordosis, thoracic kyphosis, lumbar lordosis, and sacral kyphosis. Normal sagittal balance is the arrangement of these curves so that an imagined plumb line from C7 would pass through S1.

Scoliosis is a three-dimensional curvature of the spine as the spine deviates from midline in the coronal plane with maximal rotation occurring at the apex of the curve—the majority of which are idiopathic and seen in the thoracic and lumbar spine. The curve is named for the side of the apex. To evaluate for spinal curves, the patient slowly bends forward at the waist with knees straight. Paraspinal or rib humping correlates with the apex of the curve (hump on the left is levoscoliosis, on the right is dextroscoliosis).

Palpation: Palpate bony landmarks and paraspinal regions. Cervical and thoracic bony landmarks include spinous process, mastoid process, inion, and paraspinal regions corresponding to facet joints. Lumbosacral bony landmarks include spinous process, coccyx, iliac bone including posterior superior iliac spine, and paraspinal regions corresponding to sacroiliac and facet joints.

Provocation: Provocation includes range of motion testing ...

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