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An Algorithmic Approach to the Physical Exam for the Pain Medicine Practitioner: A Review of the Literature with Multidisciplinary Consensus

Abstract Background Increased utilization of telemedicine has created a need for supplemental pain medicine education, especially for the virtual physical assessment of the pain patient. Traditional clinical training utilizes manual and tactile approaches to the physical examination. Telemedicine limits this approach and thus alternative adaptations are necessary to acquire information needed for sound clinical judgement and development of a treatment plan. Clinical assessment of pain is often challenging given the myriad of underlying etiologies contributing to the sensory experience. The COVID-19 pandemic has led to a dramatic increase in the use of virtual and telemedicine visits, further complicating the ease of assessing patients in pain. The increased reliance on telemedicine visits requires clinicians to develop skills to obtain objective information from afar. While eliciting a comprehensive history and medication assessment are performed in a standard fashion via telemedicine, a virtual targeted physical examination is a new endeavor in our current times. In order to appropriately diagnose and treat patients not directly in front of you, a pivot in education adaptations are necessary. Objective To summarize best care practices in the telemedicine physical exam while presenting an algorithmic approach towards virtual assessment for the pain practitioner. Design Review of the literature and expert multidisciplinary panel opinion. Setting Nationally recognized academic tertiary care centers. Subjects Multidisciplinary academic experts in pain medicine. Methods Expert consensus opinion from the literature review. Results An algorithm for the virtual physical exam for pain physicians was created using literature review and multidisciplinary expert opinion. Conclusions The authors here present simple, comprehensive algorithms for physical exam evaluations for the pain physician stemming from a review of the literature.


Introduction
Clinical assessment of pain is often challenging given the myriad of underlying etiologies contributing to the sensory experience. The COVID-19 pandemic led to an increase in the use of virtual and telemedicine visits [1], complicating the comprehensive pain assessment by limiting physical examination feasibility and reliability. The increased reliance on telemedicine visits requires clinicians to sharpen passive evaluation techniques [2]. While the interview portion of a patient visit conducts in a standard way, (obtaining comprehensive history of present illness, past medical history, past surgical history, review of systems, allergies, current medication list, etc.) a targeted physical examination is an essential component to elucidating the diagnosis, which can be challenging via virtual medicine.
While obtaining a thorough history is unlikely to be limited by the use of a telemedicine platform, the performance of a traditional physical examination may be limited. Traditional clinical training utilizes manual/tactile approaches to the physical examination. Telemedicine limits this approach, and thus alternative adaptations are necessary to acquire information needed for sound clinical judgement and development of a treatment plan.
Our article will provide a review of essential components to conduct a proper telemedicine physical examination for patients suffering from various types of bodily pain.

Pain
Medicine, Rehabilitation, Orthopedic, Rheumatology, and Neurology physicians from across the country performed a comprehensive review of current telemedicine examination literature. They designed an algorithmic approach for the telemedicine examination. (Figures 1-3). A PubMed search was performed using the keywords Telemedicine and Pain which yielded 200 results. Ten manuscripts were selected based on their applicability to the Chronic Pain Medicine Telemedicine examination. The multidisciplinary team of physicians collaboratively crafted an algorithm in real-time based on personal experience and the information reviewed.

General Principles to the Virtual Physical Exam
Patient access to appropriate technology should be assessed prior to initiating a telemedicine video visit. Having a proper electronic device with adequate internet connection and appropriate understanding of software and hardware is paramount before the patient or patientdelegate is able to join the meeting. Specific preparation for the telemedicine visit must be performed in advance in order to minimize superfluously utilized time during the televisit. Instructional information should be prepared and presented to the patient or patient-delegate prior to the visit, by the physician administrators. This is to include, but not limited to, appropriate patient attire, video device placement, ideal lighting and environmental atmosphere. The environment should be one in which is well lit, minimizes outside noise, and spacious enough to move around in all directions. In an effort to visualize as much of the patient from a 2D view as possible, we recommend that patients wear a collarless shirt, shorts, and tie up any hair that may be sitting on the neck. The video device should be placed on a flat and stable surface top. The device should also be positioned in a hands-free way. The patient should be sitting approximately two to six feet from the video device and have six feet of space to move around in all directions. Special patient considerations should be noted and addressed prior to the telemedicine encounter-this includes, but is not limited to, the preparation of any potential props that may be helpful during the examination of a particular body region during the televisit. Personalized instructions should be made in instances where patients are not able to meet the above recommendations. The medical provider may have props, as well, to show to the patient including pictorial diagrams or anatomical models, similar to those used in the office setting. Additionally, the provider should be able to verbally describe the exam, in common language understandable to the general population. To increase the clinical value of the telemedicine visit, the clinician must listen actively and observe intently. As with all new endeavors, flexibility and openness to modify are key [3].

Physical Exam by Chief Complaint
When evaluating patients with a chief complaint of pain in a body region, both history and physical exam are integral parts of diagnosis and further appropriate treatment. Performing a history of present illness and past medical history should conduct as it normally would in an office setting, with special focus on potential for depression, anxiety, and psychosocial hardships. It may be prudent to begin the visit with a determination of the patient's cognitive competence, which includes asking the patient their name, date of birth, reason for visit, and perhaps memory recall. The next step after eliciting cognitive competence and performing a thorough history of present illness and past medical history is a focused physical exam [3].

Headache
Performing a virtual physical examination for headache patients should be conducted via the following basic principles. Advise the patient to sit approximately two feet away from the camera, instruct patients to tie up hair such that it is out of the face and off of the neck, recommend a non-collared shirt, and limit jewelry on the head and neck. The pain physician should begin their telemedicine physical exam with a basic observation of the patients head and neck. Special focus should be on eliciting if any of the following are present-head or neck trauma, signs of toxicity, photophobia, rhinorrhea, rash, erythema, purpura, and so forth. [4]. Pupillary function may also be assessed for opiate or sympathomimetic stimulant usage, but requires the patient to have a light source such as a flashlight or cell phone light, as ambient light variability can complicate the pupillary examination. Constriction suggests opiate usage, whereas dilation may indicate opiate withdrawal or sympathetic stimulant administration [5]. In order to perform a focused optical exam, instruct the patient to look directly at the camera and place the light source in the ipsilateral hand with the arm fully extended away from their head. A full examination of the eye may be performed with the patient holding the light source and covering one eye at a time, including assessment of pupil size, reactivity to light, extraocular muscle function, accommodation, ptosis and more. Additional assessments may include instructing the patient to fixate on your finger in primary gaze and then on horizontal and vertical gaze. Facial sensation can be assessed by having the patient stroke each trigeminal nerve division bilaterally using their index finger. In addition, the patient may be asked to palpate their posterior  Telemedicine Pain Exam: An Algorithmic Approach scalp to assess for occipital neuropathy and migraine. TMJ dysfunction may be elicited by a patient-performed deep palpation of the temporomandibular joint, temporalis, pterygoid, and masseter muscles. The context of the cranio-facial and pupillary exam in a supporting clinical setting may direct the pain physician to a potential list of differential diagnoses [4] (Figure 1, Tables 1 and 7).

Neck and Upper Extremities
Wahezi et al. suggest that the patient with neck and upper extremity pain sit approximately 4 feet from the camera, preferably in a space where there is an abundance of props that the physician may direct the patient to use for examination assistance [3]. Potential props that may assist in examination include a pointing device, such as a 12-inch ruler or a long wooden spoon, a 16 to 28-inch hand towel, an easily graspable cylindrical object such as a 16-ounce soda bottle, 2-liter soda bottle, gallon jug of milk or jar of pasta sauce. The exam may begin by asking the patient to simply point to the area of most tenderness-this may require a finger or an elongated object such as a ruler. The pain physician may direct the patient to palpate the cervical paraspinal muscles including the occipital notch to assess for tenderness to palpation or spasm. Cervical range of motion (ROM) may be performed by instructing the patient to rotate their head laterally to each shoulder, side-bending which includes touching ear to ipsilateral shoulder, then flexion and extension maneuvers. Gross upper extremity ROM maneuvers may then be performed followed by upper extremity strength testing-this may be evaluated by patientperformed shoulder flexion with the arms extended in prone position; subtlety of weakness may be evaluated if the patient performs the task with eyes closed. Also, using a 2-liter soda bottle or a gallon jug of milk, basic strength testing of the shoulder muscles may be performed [3].
Specialty testing, such as the Spurling test for cervical radiculopathy, traditionally requires compression by the examiner [10]. During a telemedicine examination, the patient may be instructed to put a folded towel, lengthwise over their head, holding both ends. Then the patient is instructed to turn their head toward the painful side so that the chin touches the shoulder. The patient is then instructed to tilt their head so that the ear moves closer to the shoulder. If able and without significant discomfort, the towel may be used to further pull the head down toward the ground, simulating further compression. If this self-compression maneuver cannot be performed then non axial loaded rotation and extension may also provoke radicular symptoms in patients with moderate to severe foraminal stenosis. The Jobe Empty Can test can be similarly replicated as in the office by using a full 16-ounce soda bottle or pasta jar where the patient is instructed to hold their arm in 90 degrees of abduction with 30 degrees of forward flexion while the arm is held in internal rotation, so the thumb is pointing to the floor [11]. Hawkins and Neers tests may be performed with the same 16-ounce soda bottle or pasta jar prop. The patient is instructed to have their shoulder held in 90 degrees of forward flexion with the   Ensure the patient has about 3 feet free space in all directions. Video device to be placed 3 feet directly in front of patient and propped on a stable surface.
Mobility and position. Patient may be asked to sit and stand to observe balance and sitstand position transition.

Diagram of shoulder anatomy
Educate patient on shoulder anatomy to describe painful condition once examination is complete.

Patient props
Heavy cylindrical object such as a can of pasta sauce or soda can.

Easy grasp object for muscle testing
Patient Clothing

Tank top
Allows inspection of shoulder

Inspection
Examine the shoulders, arms, front and back looking for asymmetry, swelling, erythema, and wasting.
Any abnormal findings may help to establish a differential diagnosis.

Palpation
Have the patient point to the area of maximum tenderness or pain. Use anatomic photos or models to assist.
Tenderness in the anterior acromial region or greater tuberosity may indicate rotator cuff syndrome. Tenderness in the acromioclavicular joint may be indicative of arthritis or acromioclavicular (AC) separation.
Patient holds glass jar of pasta sauce (or equivalent). The patients arm is held in 90 degrees of abduction with 30 degrees of forward flexion and the arm is held in internal rotation so the thumb is pointing to the floor.
Weakness or pain may demonstrate a supraspinatus tear or rotator cuff impingement. Ability to hold weighted object upside down also tests grip strength (continued) Telemedicine Pain Exam: An Algorithmic Approach The patient abducts arms from his sides, with the thumbs pointing up.
Pain from 60 degrees to 120 degrees of abduction may indicate subacromial impingement. Pain from 150 to 170 degrees of abduction may indicate AC pathology.
Look for irregularity or slowness on one or both sides Normal heel to shin testing should be smooth Abnormalities of any of these exams suggests upper motor neuron pathology elbow in 90 degrees of flexion while the shoulder is internally rotated [12] (Figure 2, Tables 2, 3, and 7).

Lower Extremities, Low Back, Hip and Sacroiliac Joint (SIJ)
Patients with lumbar and lower extremity pain should be dressed in shorts and seated 6-8 feet away from their camera as this generally improves gross visualization of the lower extremity. Begin the exam with a pointed observation for obvious bony or musculature abnormalities in the lower extremities including the joints of the hip, knee, ankle, and foot. The clinician should observe for abnormal seated or standing posture, irregular pain behaviors, guarding, involuntarily rubbing, avoidance in touching the painful area, use of a cane or walker, and imbalance. Ask the patient to point to the site of the most tender pain. As an example, patients with SIJ pain report pain below the belt line and point at the PSIS (positive Fortin finger test). Patients with painful hip joint or SIJ pain also tend to sit or stand leaning off the painful limb [3]. The joints of the pelvis and lower extremity are interlinked in a series in the kinetic chain, such that any dysfunction or pathology at one joint potentially alters the biomechanics at other joints within the kinetic chain [6]. Similarly with the upper extremities, ROM and strength testing may be performed on the lower extremities via instruction through the basic movements that would be performed in office. Instruct the patient to bend forward as far down as possible without bending their knees. Similarly, ask the patient to stand and turn to their side, bend backwards and then sideways to the right and left to evaluate for lumbar range of motion in sagittal and coronal planes and concomitantly facet load test. Common language may help with patient instruction [3].
Observe the quality of movement and whether pain is associated. As an example, limited lumbar extension with pain may be facetogenic [13,15], however the diagnostic accuracy is low [14]. Important questions to ask the patient are: where is the location of the pain, is the pain above or below the belt line, is there associated numbness, tingling, weakness with pain in the lower limb on the painful side. Neurological symptoms with pain suggest radiculopathy or other peripheral neuropathy [3] ( Figure 3). Gait is an important part of the physical exam, as well. Gait abnormalities may be due to pain, muscular weakness, joint instability, or a fused joint. Instruct the patient to walk at normal pace, and then walk on their heels and toes. An antalgic gait occurs with heel spurs, ankle or knee joint injury or osteoarthritis (OA). Quadricep (L3) weakness and knee instability result in back knee gait where the knee hyperextends during stance phase. A drop foot or ankle dorsiflexor (L4) weakness causes foot slap on heel strike and steppage gait, i.e., excessive knee flexion during swing phase. Patients with weak gluteus medius (L5) and hip joint OA, ambulate with lateral trunk lean, referred to as "abductor lurch" or "Trendelenburg gait." A compensatory posterior trunk lean called an "extensor lurch" occurs with gluteus maximus (S1) weakness. Patients with plantar flexor or gastroc-soleus weakness (S1, S2) have difficulty with toe walking and single-leg heel raises and demonstrate easy fatigability on their weak side [7][8][9].
Specialty tests may be performed after ROM and strength testing. The seated straight leg raise test may be performed by asking the patient to sit and lift one leg up with the knee straight in extension in front of them. For the seated slump test, the patient sits with arms behind in forward slump position and lifts the leg up straight. Pain radiation from the lumbar spine to the back of knee or distally indicates sciatic nerve irritability with lumbar herniated nucleus pulposus [16]. Functional tests consisting of sit to stand and single leg heel raise serve as excellent substitutes for manual muscle tests (MMT). Patients with weak knee extensors (L3, L4) cannot stand up from a seated position without support from their arms. Those with ankle dorsiflexion weakness (L4) are unable to perform heel walking, while plantar flexor or gastroc-soleus weakness (S1, S2) causes difficulty with toe walking and single-leg heel raises [13].
The author's test for hip and SIJ pain is conducted by asking the patient to cross his/her symptomatic ankle over the opposite knee while pulling the ipsilateral knee towards chest in the seated position. Groin pain suggests hip joint pain, while back pain suggests SIJ dysfunction. Next, the pain physician may ask the patient to adopt a position like that seen in a figure of 4. The FABER maneuver is conducted by having the patient place one ankle or foot on the opposite knee and then asking the patient to press down on their flexed knee. Back pain with this maneuver suggests SIJ dysfunction [17] (Figure 3, Tables 4, 5, 6 and 7).

Discussion
The clinical challenges associated with a virtual physical exam are ubiquitous. During clinical training, the focus of the physical exam has classically been centered around manual, tactile and resistance evaluations which assist in making the correct diagnosis, in the context of the historical information provided by the patient. While obtaining an accurate patient history is not often negatively impacted by telemedicine, the act of performing a physical exam needs to be revisited and re-learned by most physicians who plan to employ telemedicine during virtual visits. The authors here have created a practical guide for performing the telemedicine virtual physical examination based on multispecialty recommendations (Wahezi et al., "A Practical Guide and Best Practices Approach for the Orthopedic and Neurological Pain Physical Examination").
Although the authors submit that the Telemedicine examination may be improved by following the recommendations in this manuscript we caution the reader to apply these principles carefully with patient physical and cognitive barriers in mind. The telemedicine exam can be used to assert a diagnosis if a history and radiographic evaluation is commensurate with the results of the telemedicine examination; however, if the telemedicine examination cannot be completed, or is deemed unreliable, towards that end then the patient should be invited for a person visit for a more traditional examination. We also recognize that what has been developed is a guide for future exploration and improvement of the field of Telemedicine. The approaches discussed here require validation by future controlled studies to demonstrate equivalence to their practitioner-administered counterparts we recognize that they may play an important role in the current state of medical care.
Telemedicine is a clinical tool that will be utilized for patient care into the foreseeable future. However, there is a lack of instruction on how to improve the efficiency and efficacy of the virtual examination. There is also a knowledge gap in how to create a differential diagnosis based on the findings of inspection and instruction-based physical examination. Furthermore, most clinicians struggle with performing a virtual examination, likely because it was not widely utilized prior to the COVID-19 pandemic and graduate medical education does not require it as part of their curriculum for most programs. This presents a challenge for developing education in this space, as there is a knowledge gap amongst educators which ultimately affects learners. Until telemedicine education is mandated by graduate medical education, the current de facto educational tools include peer-reviewed proactive approaches to instruct our learners. In turn, these manuscripts will be used as the basis for refining and developing educational tools for the next generation of telemedicine.

Conclusion
While pain physicians have embraced telemedicine, the efficiency and value of the examination component seems elusive. Here, authors present a review of clinical pearls for the virtual physical examination for the pain physician and an algorithmic approach that may be helpful for clinicians in all levels of training.