Concussion Care Pathway

7. Physical Examination

 

A comprehensive physical examination should consider the biopsychosocial aspects of the patient’s condition, cultural considerations, and the necessity of obtaining informed consent. This approach is crucial for both new and existing patients, especially when they present with new complaints. Obtaining informed consent involves explicitly addressing the purpose and process of the examination, ensuring the patient understands and agrees to the procedures. Special care should be taken when contact is made in sensitive areas, prioritizing the patient’s comfort and understanding throughout the examination. Additionally, cultural awareness is essential in healthcare, as a patient's cultural background can significantly influence their perception and response to treatment. Practitioners should adapt their examination techniques and interactions to be respectful and sensitive to cultural differences, tailoring their approach to meet the specific needs and considerations of each patient.

 

Observation:

Assess for abnormalities, asymmetries, posture, gait, coordination movements, facial expression, signs of distress.

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Range of Motion:

Cervical spine's active, passive, and resisted ROM in all planes (flexion, extension, lateral flexion, and rotation). Consider regional and segmental hypomobility, hypermobility and aberrant movement patterns.

 

Palpation:

Identify areas of tenderness in the cervical spine and surrounding musculature

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Neurological and Functional Examination:

Cranial Nerve Tests:

• CN I (Olfactory): Sense of smell.

  • Record Findings: E.g., "Patient correctly identifies coffee and peppermint scents with both nostrils."

• CN II (Optic): Visual acuity and visual fields.

  • Record Findings: E.g., "Visual acuity 20/20 bilaterally, visual fields full to confrontation."

• CN III, IV, VI (Oculomotor, Trochlear, Abducens): Eye movements, pupil response.

  • Record Findings: E.g., "Extraocular movements intact, pupils equal, round, reactive to light and accommodation (PERRLA)."

• CN V (Trigeminal): Facial sensation, mastication muscles.

  • Record Findings: E.g., "Facial sensation intact in all three branches, masseter and temporalis muscles strong bilaterally."

• CN VII (Facial): Facial expressions (smile, frown), taste (anterior 2/3 of the tongue).

  • Record Findings: E.g., "Symmetrical facial movements, patient can smile, frown, and raise eyebrows; taste test not performed."

• CN VIII (Vestibulocochlear): Hearing and balance.

  • Record Findings: E.g., "Whisper test positive bilaterally, Romberg test negative."

• CN IX, X (Glossopharyngeal, Vagus): Gag reflex, palate elevation, swallowing.

  • Record Findings: E.g., "Gag reflex intact, palate elevates symmetrically, no difficulty swallowing."

• CN XI (Accessory): Shoulder shrug, head rotation.

  • Record Findings: E.g., "Shoulder shrug strong and symmetrical, head rotation against resistance normal."

• CN XII (Hypoglossal): Tongue movements (deviation).

  • Record Findings: E.g., "Tongue midline without deviation, moves normally in all directions."

 

Motor Strength: 

• Key Observations: Asymmetry or weakness in upper and lower extremities indicating nerve root involvement:

  • C5: Shoulder abduction

  • C6: Wrist extension

  • C7: Wrist flexion and finger extension

  • C8: Finger flexion

  • T1: Finger abduction/adduction

  • L2: Hip flexion

  • L3: Knee extension

  • L4: Foot dorsiflexion and some contribution to foot inversion

  • L5: Foot dorsiflexion, big toe extension, and foot inversion

  • L5/S1: Knee flexion

  • S1: Plantarflexion and foot eversion

  • S2: Big Toe flexion

• Record the clinical findings for each. e.g., C5: Shoulder abduction:  L 3/5, R 5/5

 

Sensory Examination: 

• Key Observations: Check for sensory deficits in upper and lower extremities, corresponding to specific dermatomal distributions:

  • C5: Lateral arm (over the deltoid)

  • C6: Lateral forearm, thumb, index finger

  • C7: Middle finger

  • C8: Ring finger, small finger, medial forearm

  • T1: Medial arm (just above the elbow)

  • T2: Axilla and upper medial arm

  • L3: Medial thigh at the knee

  • L4: Medial side of the calf

  • L5: Top of the foot and toes

  • S1: Lateral side of the foot and little toe

• Record the clinical findings for each. e.g., "Patient reports that they perceive the same for sharp, light, and vibration for C5, C6, C7, C8 and T1." "Patient reports a loss of perception of sharp and light for C7 on the right with all other sensations intact."

 

Reflexes:

• Key Observations: Asymmetry or absence of reflexes in upper and lower extremities can indicate nerve root compression or other neurological conditions:

  • C5: Biceps reflex

  • C6: Brachioradialis reflex

  • C7: Triceps reflex

  • L4: Patellar reflex

  • L5: Medial hamstring reflex

  • S1: Achilles reflex

• Record Findings: e.g., C5: R 2/4, L 3/4

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Tests of Cerebellar, Vestibular, and Proprioceptive Function:

1. Coordination and Cerebellar Function:

• Finger-to-Nose Test: Assesses coordination and smoothness of movement; difficulty may indicate cerebellar dysfunction.

• Heel-to-Shin Test: Evaluates lower limb coordination; difficulty may indicate cerebellar dysfunction.

• Rapid Alternating Movements: Tests for dysdiadochokinesia, which is indicative of cerebellar dysfunction.

• Rebound Test: Assesses the ability to stop movement smoothly; a positive test may indicate cerebellar pathology.

 

2. Balance, Vestibular, and Proprioceptive Function:

• Romberg Test: Primarily evaluates vestibular function by testing balance with eyes closed. A positive result may indicate vestibular or proprioceptive deficits.

• Stance (tandem stance, single-leg stance): Assesses balance and coordination; difficulties suggest possible vestibular ataxia or proprioceptive dysfunction.

• Tandem Walking (heel-to-toe walk, complex tandem gait, dual task gait): Assesses balance and coordination; difficulties suggest possible vestibular ataxia or proprioceptive dysfunction.

• Vestibular Ocular Motor Screening (VOMS): Includes tests such as gaze stabilization and saccades, assessing vestibular and oculomotor function.

• Gait Assessment: Observes gait patterns to evaluate integration of proprioceptive input and overall coordination. Abnormal gait can indicate proprioceptive deficits, cerebellar dysfunction, or vestibular issues.

• Balance Error Scoring System (BESS):

  • Stances: Patient performs three different stances on two surfaces: firm (floor) and foam (unstable surface).

    • Double-leg stance: Feet together, hands on hips, eyes closed.

    • Single-leg stance: Stand on the non-dominant leg, hands on hips, eyes closed.

    • Tandem stance: Heel-to-toe stance with the non-dominant foot at the back, hands on hips, eyes closed.

  • Scoring: Each stance is held for 20 seconds while the number of errors per stance is recorded (errors include opening eyes, stepping or stumbling, lifting hands off hips, or moving the feet out of the test position). Maximum of 10 errors per stance.

  • Interpretation: A higher score (more errors) indicates greater balance impairment.

 

Memory and Cognitive Testing:

1. Immediate Recall: Present the patient with a list of 5 words (SCAT6/SCOAT6 typically uses a standardized word list). The patient is asked to repeat the words immediately after hearing them. Repeat the list up to three times to reinforce the memory trace. Interpretation: Difficulties with immediate recall suggest problems with encoding new information.

2. Delayed Recall: After a 5-10 minute delay, during which the patient is engaged in other tasks or tests, ask them to recall the same list of words. Interpretation: Poor delayed recall indicates issues with memory retention.

3. Orientation: Ask the patient standard orientation questions:

   • Time: What is today’s date? (Day, month, year)

   • Place: Where are you right now? (Location, city, or venue)

   • Situation: What happened? (Awareness of the current situation or event leading to the injury)

4. Concentration Tasks: Interpretation: Difficulty with these tasks suggests problems with working memory and concentration:

   • Digit Span: Present the patient with a sequence of digits and ask them to repeat the sequence in the same order (forward span) and in reverse order (backward span). Start with 3 digits and increase the length until the patient can no longer accurately recall the sequence.

   • Months in Reverse Order: Ask the patient to recite the months of the year in reverse order, starting from December to January.

 

Lower Motor Neuron Signs:

• Key Observations: Muscle atrophy, fasciculations, reduced muscle tone, symmetrical loss of function. May indicate a systemic neurological condition (e.g., radiculopathy, peripheral neuropathy, ALS, spinal muscular atrophy).

• Record as: E.g., "LMN signs: Atrophy (yes/no), Fasciculations (yes/no), Muscle tone (reduced/normal), Function loss (symmetrical/asymmetrical)."

 

Upper Motor Neuron Signs:

• Key Observations: Increased muscle tone, hyperreflexia, pathological reflexes (e.g., Babinski sign, Clonus). May indicate conditions affecting the central nervous system (e.g., cervical spondylotic myelopathy, multiple sclerosis, stroke, spinal cord injuries).

• Record as: E.g., "UMN signs: Muscle tone (increased/normal), Hyperreflexia (yes/no), Babinski sign (positive/negative), Clonus (yes/no)."

Note: See other care pathways depending on patient’s signs/symptoms, e.g., Neck Pain Care Pathway, Cervicogenic and Tension-type Headache Care Pathway, Soft-tissue Shoulder Disorders Care Pathway, Low Back Pain Care Pathway