Page 96 Guide to Pain Management in Low-Resource Settings

84 Paul Kioy and Andreas Kopf

fi ve point system from 0 to 4: 0 = absent, 1 = decreased, Pearls of wisdom
2 = normal, 3 = increased, and 4 = increased with clonus.
Of particular interest is the symmetry of responses and Suggested neurological examination tests for the pain
the least force necessary to elicit the responses which patient by the non-neurologist:
may be a more sensitive measure than the grading sys- Trendelenburg-test: descending of the hip to
tem above. Comparison between the upper limbs and the unaff ected site with pain when walking for longer
the lower limbs may yield some information regarding distances (insuffi cience of the gluteal muscles)
spinal cord lesions. Before recording a refl ex as absent, “Nerve stretching” tests: the Lasègue test is
a re-enforcing technique (like contracting muscles in performed in the sitting and the supine position, and
other limbs or clenching the jaws) should be tried. Th e is positive if pain is felt in the back radiating to the leg
hall mark of upper motor neuron defi cit remains the in- with <70° of straight leg raise, especially if fl exing the
creased deep tendon refl exes, disappearance of superfi - foot on the ipsilateral site increases the pain (Bragard
cial refl exes and appearance of pathological refl exes. test), which would be highly positive if pain starts at
Th e pathological refl exes include Hoff man’s re- <35° and/or if pain is provoked with contralateral test-
fl ex, the Trömner refl ex, the abdominal refl exes, and the ing (malingering should be suspected if the test has
plantar responses, which are useful in identifying upper diff erent results in the sitting and supine position, or if
motor neuron defi cits. Th e so-called primitive or frontal fl exion of the head does not increase the pain).
lobe release refl exes (grasp, pouting, rooting, etc.) are • Allocation of nerve roots:
hardly ever part of a routine clinical examination (with Hip fl exion (when sitting) and patellar refl ex is
the possible exception of neonates) but can be carried negative (L2)
out if the clinical situation demands it. Knee extension (when sitting) and patellar refl ex
Th e cerebellum coordinates muscle contrac- is negative (L3)
tions and movements in all voluntary muscles, and cer- Supination in ankle joint (when supine) and heel
ebellar dysfunction results in symptoms of ataxia that standing negative (L4)
is truncal if the fl occulonodular lobe is aff ected or limb Extension of big toe (when supine) and heel
ataxia if the hemispheres are at fault. Truncal ataxia is standing negative (L5)
associated with disturbed gait that is typically broad Atrophy of gluteal muscles and standing on one
based and reeling and does not get worse when eyes leg negative (L5/S1/S2)
are closed. Th is can be observed when the patient walks • Valleix pressure point test: provoking radiating
into the examination room or when he/she is request- pain in the leg when palpating along the pathway
ed to walk naturally in the room. Tandem walking (10 of the sciatic nerve on the dorsal site of the thighs
steps), heel walking, and one leg stances (holding form • Leg-holding test: lifting of the straight leg by 20°
more than 10 seconds) can also be tested. Th e Rom- in the supine position for >30 seconds (if <30 sec-
berg’s test is usually included among the tests of coordi- onds, suspicious for myelopathy, especially when
nation, although it largely assesses the posterior column the Babinski test is positive)
functions and joint position sense rather than strict cer- • Tuning fork test: vibration sensitivity (negative
ebellar function. result indicates polyneuropathy)
Th e neurophysiological process of movement • Babinski test: forced brushing of the sole of the foot,
coordination is a complex one requiring an intact as- positive when slow extension of the big toe is ob-
cending sensory system, basal ganglia, the pyramidal served (indicates myelopathy with pyramidal lesion)
system and the vestibular apparatus. Lesions in one of • Brudzinski test: refl exive fl exion in the hip and
these structures may impair one or other aspect of co- knee joints when bending the head
ordination. Fortunately such lesions will usually be ac- • Jackknife test: no spasticity at rest, but after pas-
companied by other neurological manifestations that sive movement of the joints, increasing spasticity
help discriminate lesions. Limb coordination to assess followed by a sudden muscle relaxation
cerebellar function may be tested using a variety of • Paresis grading test: the severity of paresis is
tests: the fi nger-nose test, rapid fi nger tapping, and rap- graded according to Janda at six levels (0= no
id alternating hand movements in the upper limbs, and muscle contraction, 1 = <10%, 2 = <25%, 3 =
the heel to shin test and foot tapping in the lower limbs. <50%, 4 = <75%, 5 = normal strength)