Telemedicine for Pain & Headache

As physicians in all specialties increasingly incorporate telemedicine into our practices, evaluation of headache, pain, and other neurologic conditions associated with pain (eg, peripheral neuropathy, movement disorders, or demyelinating diseases) indirectly via telemedicine is needed. This article highlights key aspects of this examination in a multidisciplinary fashion.

Struggles of the clinical neurologic examination with telemedicine are ubiquitous. During clinical training, the focus of the examinations is centered on manual, tactile, and resistance evaluations that assist diagnosis in the context of the medical history. Although history taking is not often negatively affected by telemedicine, unless there is a connection problem with the telemedicine platform, physical examination skills need to be revisited and relearned by many who perform telemedicine visits. The authors have created a practical guide for the telemedicine virtual physical examination based on multispecialty recommendations, summarized here.¹

Telemedicine Exam for Headache

Prior to a telemedicine appointment for headache, the patient’s access to appropriate technology should be assessed. Goals and preparation specific for the telemedicine visit need to be discussed well in advance. Instructional information needs to be prepared and presented prior to the visit.

When evaluating a patient with a chief complaint of headache on telemedicine (Table), history taking remains essential. A telemedicine examination requires the patient sit 2 feet away from the computer screen. Observe for depression, anxiety, agitation, sedation, photophobia, rhinorrhea, head or neck trauma, or evidence of toxicity. To determine cognitive competence, ask the patient their name, date of birth, reason for visit, memory recall, language, and concentration.

To evaluate pupillary function, have the patient use a flashlight or cell phone light and instruct them to look directly at their screen while holding the light away from the head with their arm fully extended. Observe for ptosis. Ask the patient to cover each eye and report what they see in the other eye. Instruct the patient to fixate on your finger in primary, horizontal, and vertical gaze. Have them stroke each trigeminal nerve division bilaterally with their index finger. A limitation of telemedicine is inability to do a fundoscopic examination.

There are limitations in conducting a sensory as well as reflex examination during a telemedicine visit unless there is a provider with the patient being examined. Patients can be asked to put cold or warm items on their extremities comparing locations and sides. They can be asked if these are perceived, and the presence of warm or cold allodynia can be assessed.

Direct the patient to palpate the cervical paraspinal muscles including the occipital notch to assess for tenderness/spasm. In addition, have them gently touch their scalp to assess for scalp allodynia. Have them use their thumb to palpate the temporal mandibular joint (TMJ) to evaluate for dysfunction. To assess for pronator drift, ask the person to move 4 feet from computer screen and raise their arms bilaterally with palms facing upwards and eyes closed while monitoring for subtle weakness. Instruct them to rotate their head laterally to each shoulder, followed by flexion and extension for the cervical musculoskeletal examination.

A Romberg exam can be completed if there is another person with the patient. Neuromuscular assessments may be limited as well. In suspected myotonia, test the ability to quickly open the eyes and fist or after forced closure, check for a releasing grip. In myotonia, there is impaired muscle relaxation that is often painful and worsens with exposure to cold

Telemedicine Exam for Neck & Shoulder Pain

Considerations before a telemedicine encounter for the patient include patient attire, video device placement, appropriate lighting and environmental noise, adequate space, and useful props. Specifically, the patients should wear a collarless tank top shirt, and those with longer hair should have it tied up to make visual inspection easier during the visit. The video device needs to be propped on a stable surface and set up so that the patient will be hands free, in a space that allows them to be 3 to 6 feet away from the camera. They should also have 6 feet of free space to move in all directions. For neck and shoulder exams, props include a pointing device (eg, a 12-inch ruler or a long wooden spoon, a 16- to 28-inch hand towel, and cylindrical objects that can be easily grasped (eg, a 16-ounce soda bottle or a pasta jar), and a 2-liter plastic soda bottle. Conversely, the medical provider should consider props such as diagrams of the cervical spine and shoulder or anatomical models, just as those used on the office, in addition to appropriate lighting and noise, video device placement, and space.

Although most of the exam can be performed via telemedicine as in the office (Figure 1), some specific tests require some creativity and planning. Simple tasks like point to the area of most tenderness or pain may require a prop such as a ruler or wooden stick to confirm the patient’s description of pain area. The Spurling test for cervical radiculopathy requires compression by the examiner.² During a telemedicine examination, the patient can be instructed to fold a towel lengthwise and place it over their head, holding on to both ends. In this position, they turn their head toward the painful side so the chin goes to the shoulder and then tilt their head so that the ear moves closer to the shoulder. If able, the towel can be used to pull the head down toward the ground, simulating compression. 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.³ With the same object, the Hawkins and Neers test can be performed by instructing the patient to hold their shoulder in 90 degrees of forward flexion with the elbow in 90 degrees of flexion while the shoulder is internally rotated.⁴ Finally, using a full 2-liter soda bottle (or a gallon milk jug), basic strength testing of the shoulder muscles can be performed.

Telemedicine Exam for Back & Lower Extremity Pain

As in all new endeavors, flexibility and openness to modify as we learn are key. The provider should be able to verbally describe examination maneuvers and also perform them so that the patient can mirror as needed. Proper patient preparation is important. We suggest the minimum requirements for an in-home telehealth visit are a clutter free, well-lit room with at least 6 feet of walking space; a smart phone, tablet or computer with a functioning camera, microphone, and speakers; ability to position the camera to visualize a patient’s full profile during standing and walking; and attire consisting of shorts and a tee-shirt.

Observe for abnormality in the hip, knee, ankle, and foot. These joints are interlinked in a series in the kinetic chain, such that any dysfunction or pathology at joint alters the biomechanics at others up and down the kinetic chain (Figure 2).⁵ Treatment includes correcting abnormalities at adjacent joints. Also, the lumbar spine refers pain to these joints and vice versa.

Ask whether the pain is above or below the belt line. Ask the patient to point to the site of pain. Patients with sacroiliac joint (SIJ) pain report pain below the belt line and point at the posterior superior iliac spine (Fortin finger test). Ask if there is numbness, tingling, or weakness with pain in the lower limb on the painful side? Neurologic symptoms with pain suggest the possibility of radiculopathy or other peripheral neuropathies.

Observe the patient sitting, standing, and walking with attention to abnormal posture, pain behaviors, guarding, involuntary rubbing or avoiding touching a painful area, use of cane or walker, and imbalance. People with hip joint or SIJ pain tend to sit or stand leaning off the painful limb

Gait abnormalities may be due to pain, muscle weakness, joint instability or fused joint. Instruct the patient to walk at normal pace, and then on their heels and toes.^6-8 An antalgic gait occurs with heel spurs, ankle or knee joint injury or osteoarthritis (OA). Quadriceps weakness (L3) and knee instability result in back knee gait, and the knee hyperextends during stance phase. A drop foot or ankle dorsiflexor (L4) weakness causes foot slap on heel strike and or steppage gait (ie, excessive knee flexion during swing phase). Patients with a weak gluteus medius (L5) and hip joint OA ambulate with lateral trunk lean, referred to as an abductor lurch or Trendelenburg gait. A compensatory posterior trunk lean called an extensor lurch occurs with gluteus maximus (S1) weakness. Individuals with planter flexor or gastrocsoleus weakness (S1, S2) have difficulty with toe walking and single leg 10-heel raises and demonstrate easy fatigability on weak side.

Instruct the patient to bend as far down as they can without bending their knees. Similarly, ask them to bend backwards and sideways to the right and left to evaluate for lumbar range of motion in the sagittal and coronal planes. Observe the quantity and quality of movement and if there is any pain with movement. Limited lumbar extension with pain may be facetogenic.⁵

Ask the patient to sit and lift 1 leg up with knee straight in front. 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 back of knee or distally indicates sciatic nerve irritability with lumbar herniation of the nucleus pulposus.

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 dorsiflexor weakness (L4) are unable to perform heel walking, and plantar flexor or gastrocsoleus weakness (S1, S2) causes difficulty with toe walking and single leg 10 heel raises.

To test for hip and SIJ pain, ask the patient to cross their symptomatic leg and knee over the opposite knee while in a sitting position. Groin pain suggest hip joint pain, whereas back pain suggests SIJ dysfunction. Ask the patient to adopt a figure 4 position (flexion abduction external rotation [FABER] exam) by placing the ankle and foot on the opposite knee and press down on flexed knee. Back pain with this maneuver suggests SIJ dysfunction.

Summary

With all telehealth visits, preparation is key and includes checking technology capabilities and also arranging for appropriate lighting, space, and props for use in the examination. To get the most out of the telehealth visit, listen actively and observe intently. Give clear instructions, and if needed, demonstrate on yourself to explain the test. Many in-office maneuvers used to diagnose causes of pain can be done with patience and practice.