3: Clinical Examination
- Page ID
- 59123
\( \newcommand{\vecs}[1]{\overset { \scriptstyle \rightharpoonup} {\mathbf{#1}} } \)
\( \newcommand{\vecd}[1]{\overset{-\!-\!\rightharpoonup}{\vphantom{a}\smash {#1}}} \)
\( \newcommand{\id}{\mathrm{id}}\) \( \newcommand{\Span}{\mathrm{span}}\)
( \newcommand{\kernel}{\mathrm{null}\,}\) \( \newcommand{\range}{\mathrm{range}\,}\)
\( \newcommand{\RealPart}{\mathrm{Re}}\) \( \newcommand{\ImaginaryPart}{\mathrm{Im}}\)
\( \newcommand{\Argument}{\mathrm{Arg}}\) \( \newcommand{\norm}[1]{\| #1 \|}\)
\( \newcommand{\inner}[2]{\langle #1, #2 \rangle}\)
\( \newcommand{\Span}{\mathrm{span}}\)
\( \newcommand{\id}{\mathrm{id}}\)
\( \newcommand{\Span}{\mathrm{span}}\)
\( \newcommand{\kernel}{\mathrm{null}\,}\)
\( \newcommand{\range}{\mathrm{range}\,}\)
\( \newcommand{\RealPart}{\mathrm{Re}}\)
\( \newcommand{\ImaginaryPart}{\mathrm{Im}}\)
\( \newcommand{\Argument}{\mathrm{Arg}}\)
\( \newcommand{\norm}[1]{\| #1 \|}\)
\( \newcommand{\inner}[2]{\langle #1, #2 \rangle}\)
\( \newcommand{\Span}{\mathrm{span}}\) \( \newcommand{\AA}{\unicode[.8,0]{x212B}}\)
\( \newcommand{\vectorA}[1]{\vec{#1}} % arrow\)
\( \newcommand{\vectorAt}[1]{\vec{\text{#1}}} % arrow\)
\( \newcommand{\vectorB}[1]{\overset { \scriptstyle \rightharpoonup} {\mathbf{#1}} } \)
\( \newcommand{\vectorC}[1]{\textbf{#1}} \)
\( \newcommand{\vectorD}[1]{\overrightarrow{#1}} \)
\( \newcommand{\vectorDt}[1]{\overrightarrow{\text{#1}}} \)
\( \newcommand{\vectE}[1]{\overset{-\!-\!\rightharpoonup}{\vphantom{a}\smash{\mathbf {#1}}}} \)
\( \newcommand{\vecs}[1]{\overset { \scriptstyle \rightharpoonup} {\mathbf{#1}} } \)
\( \newcommand{\vecd}[1]{\overset{-\!-\!\rightharpoonup}{\vphantom{a}\smash {#1}}} \)
\(\newcommand{\avec}{\mathbf a}\) \(\newcommand{\bvec}{\mathbf b}\) \(\newcommand{\cvec}{\mathbf c}\) \(\newcommand{\dvec}{\mathbf d}\) \(\newcommand{\dtil}{\widetilde{\mathbf d}}\) \(\newcommand{\evec}{\mathbf e}\) \(\newcommand{\fvec}{\mathbf f}\) \(\newcommand{\nvec}{\mathbf n}\) \(\newcommand{\pvec}{\mathbf p}\) \(\newcommand{\qvec}{\mathbf q}\) \(\newcommand{\svec}{\mathbf s}\) \(\newcommand{\tvec}{\mathbf t}\) \(\newcommand{\uvec}{\mathbf u}\) \(\newcommand{\vvec}{\mathbf v}\) \(\newcommand{\wvec}{\mathbf w}\) \(\newcommand{\xvec}{\mathbf x}\) \(\newcommand{\yvec}{\mathbf y}\) \(\newcommand{\zvec}{\mathbf z}\) \(\newcommand{\rvec}{\mathbf r}\) \(\newcommand{\mvec}{\mathbf m}\) \(\newcommand{\zerovec}{\mathbf 0}\) \(\newcommand{\onevec}{\mathbf 1}\) \(\newcommand{\real}{\mathbb R}\) \(\newcommand{\twovec}[2]{\left[\begin{array}{r}#1 \\ #2 \end{array}\right]}\) \(\newcommand{\ctwovec}[2]{\left[\begin{array}{c}#1 \\ #2 \end{array}\right]}\) \(\newcommand{\threevec}[3]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \end{array}\right]}\) \(\newcommand{\cthreevec}[3]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \end{array}\right]}\) \(\newcommand{\fourvec}[4]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \\ #4 \end{array}\right]}\) \(\newcommand{\cfourvec}[4]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \\ #4 \end{array}\right]}\) \(\newcommand{\fivevec}[5]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \\ #4 \\ #5 \\ \end{array}\right]}\) \(\newcommand{\cfivevec}[5]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \\ #4 \\ #5 \\ \end{array}\right]}\) \(\newcommand{\mattwo}[4]{\left[\begin{array}{rr}#1 \amp #2 \\ #3 \amp #4 \\ \end{array}\right]}\) \(\newcommand{\laspan}[1]{\text{Span}\{#1\}}\) \(\newcommand{\bcal}{\cal B}\) \(\newcommand{\ccal}{\cal C}\) \(\newcommand{\scal}{\cal S}\) \(\newcommand{\wcal}{\cal W}\) \(\newcommand{\ecal}{\cal E}\) \(\newcommand{\coords}[2]{\left\{#1\right\}_{#2}}\) \(\newcommand{\gray}[1]{\color{gray}{#1}}\) \(\newcommand{\lgray}[1]{\color{lightgray}{#1}}\) \(\newcommand{\rank}{\operatorname{rank}}\) \(\newcommand{\row}{\text{Row}}\) \(\newcommand{\col}{\text{Col}}\) \(\renewcommand{\row}{\text{Row}}\) \(\newcommand{\nul}{\text{Nul}}\) \(\newcommand{\var}{\text{Var}}\) \(\newcommand{\corr}{\text{corr}}\) \(\newcommand{\len}[1]{\left|#1\right|}\) \(\newcommand{\bbar}{\overline{\bvec}}\) \(\newcommand{\bhat}{\widehat{\bvec}}\) \(\newcommand{\bperp}{\bvec^\perp}\) \(\newcommand{\xhat}{\widehat{\xvec}}\) \(\newcommand{\vhat}{\widehat{\vvec}}\) \(\newcommand{\uhat}{\widehat{\uvec}}\) \(\newcommand{\what}{\widehat{\wvec}}\) \(\newcommand{\Sighat}{\widehat{\Sigma}}\) \(\newcommand{\lt}{<}\) \(\newcommand{\gt}{>}\) \(\newcommand{\amp}{&}\) \(\definecolor{fillinmathshade}{gray}{0.9}\)A Person-Centered Approach to Clinical Examination
Increasingly, research has shown that attributing the experience pain solely to poor posture, minor leg length discrepancies, vertebral misalignment and other structural abnormalities is an oversimplification of a complex process (Green et al., 2018; Lewis et al., 2020; Swain et al., 2020). Even in the case of osteoarthritis wear and tear on the joints may not be the primary cause of pain (Culvenor et al., 2019; Girish et al., 2011; Sihvonen et al., 2018). This may sound counter-intuitive, but it is part of our ever-changing understanding of the experience of pain and disability.
Contemporary pain management is shifting away from a pathoanatomical model to a person-centered model of care that is responsive to the individual context of each patient. Clinical examination and decision-making ought to reflect this change by understanding that structural abnormalities alone do not explain or necessarily predict pain.
Postural Assessment: Poor Posture May Not Be the Primary Cause of Spinal Pain
The presumption that poor posture is a primary contributor to spinal pain is not supported by compelling evidence (Swain et al., 2020). When performing a postural analysis, static posture may vary based on a number of factors and has limited validity in predicting the cause of a person’s pain. Long-term research trials have demonstrated that posture during sitting, standing, and lifting does not predict low back pain or its persistence (O’Sullivan et al., 2020).
Structural abnormalities alone do not explain or necessarily predict pain, this is why attributing the experience of chronic pain to poor posture, minor leg length discrepancies, vertebral misalignment is an oversimplification of a complex process (Lewis & O’Sullivan, 2018; Maher et al., 2019). Minor anatomical variation is considered normal and is not considered a pathological abnormality. People experience pain differently due to differences in genetics, emotional stress, and history of physical trauma and sensitization of the nervous system (Rethorn et al., 2019; Swain et al., 2020).
Orthopedic Special Testing Provides Limited Information about The Cause of Chronic Pain
Orthopedic special testing is based on a biomechanical process which can overlook important underlying processes such as sensitization of the nervous system or underlying psychosocial factors. People with chronic pain often may have multiple comorbidities which may lead to inconclusive testing (Wideman et al., 2019). The role of orthopedic testing is to define a treatable pathology, which is reasonable, in the management of acute injuries. In the chronic pain population, orthopedic special tests involve a degree of subjectivity and few are sensitive or specific enough to have clinical value on their own (Cook, 2010; Hegedus et al., 2017; Salamh & Lewis, 2020). Even when orthopedic special tests are clustered there are issues with testing validity. As demonstrated by a large body of research orthopedic special testing can not reliably confirm the presence or absence of a pathology when patients are experiencing chronic pain (Salamh & Lewis, 2020).
- Sensitivity refers to the percentage of people who test positive for a specific disease among a group of people who have the disease.
- Specificity refers to the percentage of people who test negative for a specific disease among a group of people who do not have the disease.
Musculoskeletal Imaging Does Not Reliably Identify The Source of Chronic Pain
The use of musculoskeletal imaging is focused on determining a pathoanatomical diagnosis. This is unreliable at determining the source of chronic pain (Cuff et al., 2020; Maher et al., 2019). In cases of osteoarthritis, the diminishing joint cartilage may not be the primary contributor to pain (Hunter & Bierma-Zeinstra, 2019). Imaging studies have demonstrated that when a non-symptomatic-population is scanned they will often have degenerative changes in the knee, hip, shoulder, and spine (Brinjikji et al., 2015; Culvenor et al., 2019; Girish et al., 2011; Horga et al., 2020; Kim et al., 2015). These are now considered to be common age-related changes that are part of normal aging and often unassociated with the experience of pain (Hunter & Bierma-Zeinstra, 2019; Lewis et al., 2020; Maher et al., 2019).
Incidental findings that would carry a diagnosis of degenerative disc disease are common in both symptomatic and asymptomatic persons, and cannot be directly correlated to the person’s pain. So even after diagnostic imaging we may still have limited information as to how we should proceed and formulate a meaningful treatment plan. Most clinical practice guidelines recommend against widespread imaging, which is supported by the research that shows a sizable portion of people with no pain show abnormalities or degenerative tissue (e.g., degenerative disk disease, rotator cuff tear, degenerative torn meniscus, femoroacetabular impingement, etc.) (Foster et al., 2018; Kamper et al., 2020; Lin et al., 2020). In a pathoanatomical approach the inability to directly connect structural abnormalities and clinical presentation can create confusion for both patients and clinicians.
A Person-Centered Approach to Pain & Disability
This disconnect between structural abnormalities and clinical presentation can create confusion for both patients and clinicians. This does not mean we should give up performing a thorough health history and physical examination of our patients. What it does mean is that we ought to adopt a person-centered model of care and interpret these findings in the context of individual patient presentation. A person-centered model of care is a multidimensional approach that gives therapists a better understanding of an individual’s symptoms.
A skilled clinical examination helps to orientate, and aid clinical decision-making based on patients’ limitations, goals, and course of pain. By capturing the patient’s narrative, it can also help to identify meaningful goals and direct the most appropriate intervention based on pain presentation, functional limitations, and psychosocial factors.
The added value of a person-centered assessment is that even when underlying mechanisms are unclear, by understanding the patient’s functional limitations and how pain is affecting their activities of daily life we can still formulate a meaningful treatment plan. A skilled clinical examination and a comprehensive health history taking has even been shown to have a therapeutic effect related to pain, fear-avoidance, pain catastrophizing, and functional measures of mobility and sensitivity (Louw et al., 2020).
Table \(3.0.1\) Foundations of a Person-Centered Approach
| Evidence-Based Healthcare | Evidence-based healthcare is a clinically-oriented approach based on the three principles of evidence-based practice (best available evidence, clinical expertise and patient values) |
| Biopsychosocial Framework of Health & Disease | Biopsychosocial framework of health and disease is a whole-person approach that incorporates biomedical, psychological, and social influences in the patient's experience. |
| Shared-Decision Making | Shared-decision making is an approach in which patients and clinicians work together to develop a shared appreciation of the patient's situation and decide how to best manage it. |
The Multidimensional Clinical Examination
Massage therapists often are already taking a person-centered approach to the assessment of pain. An example of this would be the use of SOAP notes to combine quantitative measurements (questionnaires, scales and tests), with qualitative reporting (patient’s narratives).
In practice a thorough health history is done to gather information about patients’ limitations, course of pain, and prognostic factors (e.g., coping style) and answers to health-related questions. This information is then blended with the patient narrative and information gathered from a traditional physical examination including orthopedic special testing, neurological screening tests, mobility and/or muscle strength assessment. For assessing and monitoring patient progress validated outcome measurements (e.g., patient-specific functional scale, brief pain inventory, visual analog scale, McGill pain questionnaire, global impression of change, patient-centered outcomes questionnaire) can be used to capture quantitative measurements.
A person-centered clinical examination is one that seeks to better understand the complex web of interactions in the patient’s history, physiology and lifestyle. This information is then used to formulate a clinical hypothesis that does not seek a single source of pain. If adopted widely a person-centered model of care helps to reframe pain leading to improved patient-clinician relationships, improved self-efficacy, and better health outcomes for patients with pain.
Summary
Contemporary best-practices for pain supports a multidimensional approach that addresses biopsychosocial influences and empowers people with shared decision-making. Adopting a person-centered model of care does not discount the use of a traditional orthopedic assessments, it helps to put into context the interconnected and multi-directional interaction between physiology, thoughts, emotions, behaviors, culture, and beliefs.
If adopted a person-centered model of care could help reduce suffering and costs associated with musculoskeletal pain in our society. By helping patients avoid unnecessary procedures, minimize unnecessary harms and decrease economic burden associated with low-value care.
Contemporary pain management is shifting away from a pathoanatomical model to a person-centered model of care that is responsive to the individual context of each patient. Clinical examination and decision-making ought to reflect this change by understanding that structural abnormalities alone do not explain or necessarily predict pain. This section of the textbook will explore treatment options and best-practice recommendations for evidence-based assessment strategies.
References and Sources
Ballantyne, J. C., & Sullivan, M. D. (2015). Intensity of Chronic Pain–The Wrong Metric?. The New England journal of medicine, 373(22), 2098–2099. https://doi.org/10.1056/NEJMp1507136
Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., … Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR. American journal of neuroradiology, 36(4), 811–816. doi:10.3174/ajnr.A4173
Caneiro, J. P., Roos, E. M., Barton, C. J., O’Sullivan, K., Kent, P., Lin, I., … O’Sullivan, P. (2020). It is time to move beyond ‘body region silos’ to manage musculoskeletal pain: five actions to change clinical practice. British journal of sports medicine, 54(8), 438–439. https://doi.org/10.1136/bjsports-2018-100488
Cook, C. (2010). The lost art of the clinical examination: an overemphasis on clinical special tests. The Journal of manual & manipulative therapy, 18(1), 3–4.
Cook, C. & Hegedus, E. (2013). Orthopedic Physical Examination Tests (2nd ed.). Pearson.
Cook, C. E., & Décary, S. (2020). Higher order thinking about differential diagnosis. Brazilian journal of physical therapy, 24(1), 1–7. https://doi.org/10.1016/j.bjpt.2019.01.010
Cuff, A., Parton, S., Tyer, R., Dikomitis, L., Foster, N., & Littlewood, C. (2020). Guidelines for the use of diagnostic imaging in musculoskeletal pain conditions affecting the lower back, knee and shoulder: A scoping review. Musculoskeletal care, 18(4), 546–554. https://doi.org/10.1002/msc.1497
Culvenor, A. G., Øiestad, B. E., Hart, H. F., Stefanik, J. J., Guermazi, A., & Crossley, K. M. (2019). Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis. British journal of sports medicine, 53(20), 1268–1278. doi:10.1136/bjsports-2018-099257
Décary, S., Longtin, C., Naye, F., & Tousignant-Laflamme, Y. (2020). Driving the Musculoskeletal Diagnosis Train on the High-Value Track. The Journal of orthopaedic and sports physical therapy, 50(3), 118–120. https://doi.org/10.2519/jospt.2020.0603
Engel, G. L. (1980). The clinical application of the biopsychosocial model. The American journal of psychiatry, 137(5), 535–544. https://doi.org/10.1176/ajp.137.5.535
Foster, N. E., Anema, J. R., Cherkin, D., Chou, R., Cohen, S. P., Gross, D. P., … Lancet Low Back Pain Series Working Group (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet (London, England), 391(10137), 2368–2383. doi:10.1016/S0140-6736(18)30489-6
Girish, G., Lobo, L. G., Jacobson, J. A., Morag, Y., Miller, B., & Jamadar, D. A. (2011). Ultrasound of the shoulder: asymptomatic findings in men. AJR. American journal of roentgenology, 197(4), W713–W719. doi:10.2214/AJR.11.6971
Green, B. N., Johnson, C. D., Haldeman, S., Griffith, E., Clay, M. B., Kane, E. J., … Nordin, M. (2018). A scoping review of biopsychosocial risk factors and co-morbidities for common spinal disorders. PloS one, 13(6), e0197987. doi:10.1371/journal.pone.0197987
Hegedus, E. J., Wright, A. A., & Cook, C. (2017). Orthopaedic special tests and diagnostic accuracy studies: house wine served in very cheap containers. British journal of sports medicine, 51(22), 1578–1579. doi:10.1136/bjsports-2017-097633
Horga, L. M., Hirschmann, A. C., Henckel, J., Fotiadou, A., Di Laura, A., Torlasco, C., D’Silva, A., Sharma, S., Moon, J. C., & Hart, A. J. (2020). Prevalence of abnormal findings in 230 knees of asymptomatic adults using 3.0 T MRI. Skeletal radiology, 49(7), 1099–1107. https://doi.org/10.1007/s00256-020-03394-z
Hunter, D. J., & Bierma-Zeinstra, S. (2019). Osteoarthritis. Lancet (London, England), 393(10182), 1745–1759. doi:10.1016/S0140-6736(19)30417-9
Kamper, S. J., Logan, G., Copsey, B., Thompson, J., Machado, G. C., Abdel-Shaheed, C., … Hall, A. M. (2020). What is usual care for low back pain? A systematic review of health care provided to patients with low back pain in family practice and emergency departments. Pain, 161(4), 694–702. https://doi.org/10.1097/j.pain.0000000000001751
Kim, C., Nevitt, M. C., Niu, J., Clancy, M. M., Lane, N. E., Link, T. M., Vlad, S., Tolstykh, I., Jungmann, P. M., Felson, D. T., & Guermazi, A. (2015). Association of hip pain with radiographic evidence of hip osteoarthritis: diagnostic test study. BMJ (Clinical research ed.), 351, h5983. https://doi.org/10.1136/bmj.h5983
Lewis, J., & O’Sullivan, P. (2018). Is it time to reframe how we care for people with non-traumatic musculoskeletal pain?. British journal of sports medicine, 52(24), 1543–1544. doi:10.1136/bjsports-2018-099198
Lewis, J. S., Cook, C. E., Hoffmann, T. C., & O’Sullivan, P. (2020). The Elephant in the Room: Too Much Medicine in Musculoskeletal Practice. The Journal of orthopaedic and sports physical therapy, 50(1), 1–4.
Lin, I., Wiles, L., Waller, R., Goucke, R., Nagree, Y., Gibberd, M., … O’Sullivan, P. (2020). What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. British journal of sports medicine, 54(2), 79–86. doi:10.1136/bjsports-2018-099878
Louw, A., Goldrick, S., Bernstetter, A., Van Gelder, L. H., Parr, A., Zimney, K., & Cox, T. (2020). Evaluation is treatment for low back pain. The Journal of manual & manipulative therapy, 1–10. Advance online publication. https://doi.org/10.1080/10669817.2020.1730056
Maher, C. G., O’Keeffe, M., Buchbinder, R., & Harris, I. A. (2019). Musculoskeletal healthcare: Have we over-egged the pudding?. International journal of rheumatic diseases, 22(11), 1957–1960. doi:10.1111/1756-185X.13710
O’Sullivan, P. B., Caneiro, J. P., O’Sullivan, K., Lin, I., Bunzli, S., Wernli, K., & O’Keeffe, M. (2020). Back to basics: 10 facts every person should know about back pain. British journal of sports medicine, 54(12), 698–699. https://doi.org/10.1136/bjsports-2019-101611
Rethorn, Z. D., Cook, C., & Reneker, J. C. (2019). Social Determinants of Health: If You Aren’t Measuring Them, You Aren’t Seeing the Big Picture. The Journal of orthopaedic and sports physical therapy, 49(12), 872–874. doi:10.2519/jospt.2019.0613
Salamh, P., & Lewis, J. (2020). It Is Time to Put Special Tests for Rotator Cuff-Related Shoulder Pain out to Pasture. The Journal of orthopaedic and sports physical therapy, 50(5), 222–225. https://doi.org/10.2519/jospt.2020.0606
Slater, D., Korakakis, V., O’Sullivan, P., Nolan, D., & O’Sullivan, K. (2019). “Sit Up Straight”: Time to Re-evaluate. The Journal of orthopaedic and sports physical therapy, 49(8), 562–564. doi:10.2519/jospt.2019.0610
Swain, C., Pan, F., Owen, P. J., Schmidt, H., & Belavy, D. L. (2020). No consensus on causality of spine postures or physical exposure and low back pain: A systematic review of systematic reviews. Journal of biomechanics, 102, 109312. https://doi.org/10.1016/j.jbiomech.2019.08.006
Walton, D. M., & Elliott, J. M. (2018). A new clinical model for facilitating the development of pattern recognition skills in clinical pain assessment. Musculoskeletal science & practice, 36, 17–24. doi:10.1016/j.msksp.2018.03.006
Wideman, T. H., Edwards, R. R., Walton, D. M., Martel, M. O., Hudon, A., & Seminowicz, D. A. (2019). The Multimodal Assessment Model of Pain: A Novel Framework for Further Integrating the Subjective Pain Experience Within Research and Practice. The Clinical journal of pain, 35(3), 212–221. doi:10.1097/AJP.0000000000000670
Zadro, J. R., Décary, S., O’Keeffe, M., Michaleff, Z. A., & Traeger, A. C. (2020). Overcoming Overuse: Improving Musculoskeletal Health Care. The Journal of orthopaedic and sports physical therapy, 50(3), 113–115. https://doi.org/10.2519/jospt.2020.0102
Zulman, D. M., Haverfield, M. C., Shaw, J. G., Brown-Johnson, C. G., Schwartz, R., Tierney, A. A., … Verghese, A. (2020). Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter. JAMA, 323(1), 70–81. doi:10.1001/jama.2019.19003