Numbness, Tingling, Weakness and Pain

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Numbness, Tingling, Weakness and Pain

• David B. Shuster, M.D.
• Board Certified
• Electrodiagnostic Medicine
• Physical Medicine and Rehabilitation
• Spinal Cord Injury Medicine
• Pain Medicine
• dshust_at_sbcglobal.net

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Function and the neuromusculoskeletal system

• The neuromusculoskeletal system is the final
  common pathway of function, all other systems can
  affect it. Oxygen, for example, must get to
  muscles via adequate cardiovascular and pulmonary
  systems, diabetes destroys nerves, hypothyroidism
  causes muscle weakness. In rehabilitation we are
  concerned with function, with understanding the
  disease processes which impair function, limiting
  their impact and improving a persons function in
  spite of their deficits. Although we teach in
  systems, this is an artificial separation. What
  you are treating is a person with multiple
  overlapping and interdependent systems which
  include the persons psychologic and emotional
  status and the environment in which they
  function.

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• The person will come to you with a
  complaint(usually, sometimes you will elicit it
  by asking the right questions, a thorough
  physical examination may elicit signs without
  symptoms, especially in a stoic individual)
  Perhaps we should organize our teaching by
  symptom. In thinking about the neuromusculoskeleta
  l system we generally think about complaints in
  the limbs, back and neck. Generally, symptoms
  include pain, weakness, numbness and tingling.
  These complaints are often a result of problems
  in the peripheral nervous, thus its inclusion,
  however all systems must be considered in
  deriving a differential diagnosis

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The movement pathway an integration of the motor
and sensory systems and effectors
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Upper motor neuron

• Brain stroke, brain injury, tumor
• Spinal Cord spinal stenosis, central disc
  herniation, tumor, spinal cord injury, ALS

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Lower motor neuron

• Anterior Horn Cell polio, ALS
• Nerve root injury, radiculopathy
• Brachial Plexus trauma, tumor
• Nerve pressure, trauma injuring myelin, axon or
  both
• Neuromuscular junction
• Muscle myopathies, muscle strains or tears

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Effectors

• Tendon tendonitis, tears, ruptures
• Bone osteoporosis, fractures
• Joint arththritis
• Ligament sprains, tears

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Nerve and motor unit normal structure and basic
pathology

• Nerve comprised of many axons, each with a
  myelin sheath
• Damage myelin conduction slows
• Damage myelin enough conduction stops, yet axon
  and muscle are still connected. This is called
  Neuropraxia or in electrodiagnostic language,
  Conduction block

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• Axon damage muscle becomes disconnected from its
  anterior horn cell
• This lesion is called Axonotmesis
• If all axons are damaged and the connective
  tissue sheath is completely disrupted, lesion is
  Neurotmesis

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Normal Median Motor Study
Time Base 1 msec/div
Sensitivity 5 mV/div
Distal Latency (msec) Conduction Velocity
(m/s) Amplitude (mV) Wrist-APB 3.1
15.1 Elbow-Wrist 55
14.7
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Normal Median Sensory Study
Time Base 1 msec/div
Sensitivity 20 uV/div
Distal Latency (msec) Conduction Velocity
(m/s) Amplitude (uV) Wrist to Digit 2 2.3
59 m/s 44.1
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Nerve Conduction Studies

• Motor Latency
• Measure of conduction time from nerve segment
  through neuromuscular junction to muscle fibers
• Sensory Latency
• Measure of conduction time of action potential
  across a nerve segment
• Conduction Velocity
• Measure of the velocity of the fastest conducting
  axons
• Motor Amplitude
• Measure of the number of activated axons and
  muscle fibers
• Sensory Amplitude
• Measure of the number of activated axons

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Nerve Conduction Late Responses H Reflex

• Afferent Path Sensory axons (group Ia fibers)
• Efferent Path Motor Axons (alpha motor neurons)
  
• Follows muscle stretch reflex arc
• Side to side latency comparison most valuable

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H-reflex

• the electrodiagnostic equivalent of the S1 reflex
  which measures the delay in occurance of the
  ankle jerk after stimulation. Generally absent if
  ankle jerk is absent and prolonged if ankle jerk
  is diminished. Useful in diagnosing S1
  radiculopathy

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What happens after axonal damage

• Wallerian degeneration
• Collateral sprouting-polyphasic motor units
  indicate ongoing recovery due to sprouting, as
  strength in a weak muscle increases after nerve
  damage you would expect to find polyphasic motor
  units
• large motor units indicate recovery as sprouting
  is complete

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Needle Electromyography Data

• Insertional Activity
• Spontaneous Activity
• Motor Unit Configuration
• Motor Unit Recruitment

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EMG Spontaneous Activity
Fibrillation Potentials
Positive Sharp Waves
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EMG Neurogenic Motor Unit
10 msec/div
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Electrodiagnostic Medicine Consultation

• A board certified specialty using the tools of
  electromyography and nerve conduction studies as
  an extension of the history and physical
  examination
• A colleague examining your patient

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Electrodiagnostic Medicine Consultation is

• an extension of the clinical history and physical
  examination
• includes needle electromyography and nerve
  conduction studies
• should be correlated with history and physical
  findings
• should include a directed history and physical
  done by the consultant

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Electrodiagnostic Medicine Consultation

• Tell me what you are thinking
• How can I help?
• Interpret the data in terms of the patient

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Electrodiagnostic Medicine Consultation

• What does it tell you?
• What it is
• What it isnt
• How bad
• Acute versus chronic
• Type, site, severity, duration, prognosis
• What is the next step

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Published standards
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American Academy of Orthopaedic Surgeons clinical
guideline on diagnosis of carpal tunnel syndrome
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• The physician may obtain electrodiagnostic tests
  to differentiate among diagnoses.

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• The physician should obtain electrodiagnostic
  tests if clinical and/or provocative tests are
  positive and surgical management is being
  considered

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• If the physician orders electrodiagnostic tests,
  the testing protocol should follow the American
  Academy of Neurology/American Association of
  Neuromuscular and Electrodiagnostic
  Medicine/American Academy of Physical Medicine
  and Rehabilitation (AAN/AANEM/AAPMR) guidelines
  for diagnosis of carpal tunnel syndrome (CTS)

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Electromyography (EMG)

• Uses a recording needle attached to an
  oscilloscope, amplifier and speaker to allow the
  examiner to see and hear the electrical activity
  of muscle fibers and motor units
• Muscle is normally electrically silent with
  normal motor unit size and firing rate
• Denervated muscle fiber spontaneously
  depolarizes. This is manifest by increased
  insertional activity, positive waves and
  fibrillations( positive waves and fibrillations
  acute axon damagelower motor neuron lesion)
• Seen after approximately 2-4 weeks

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Typical electromyographic screening Cervical

• Deltoid Mostly C5 Axillary
• Biceps Mostly C5 Musculocutaneous
• Pronator Teres Mostly C6 Median
• Ext. Carpi Radialis Mostly C6 Radial
• Triceps Mostly C7 Radial
• Flexor Carpi Radialis Mostly C7 Median
• Flexor Carpi Ulnaris Mostly C8 Ulnar
• Flexor digitorum Superficialis Mostly C8 Median
• Thenar C8T1 Median
• Hypothenar C8T1 Ulnar
• Cervical Paraspinals Posterior primary rami

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Lumbosacral

• Vastus Medialis L4 Femoral
• Rectus Femoris L4 Femoral
• Adductor Longus L4 Obturator
• Anterior Tibialis L5 Peroneal
• Tensor Fascia Lata L5 Superior Gluteal
• Extensor Hallucis Longus L5 Peroneal
• Tibialis Posterior L5 Tibial
• Biceps Femoris S1 Sciatic
• Gastrocnemius S1 Tibial
• Lumbosacral Paraspinals Posterior primary rami

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Nerve conduction studies

• Loss of myelin causes nerve slowing, prolonged
  latency is due to demyelination
• To examine a motor nerve stimulate (depolarize)
  the nerve and record over the muscle to which its
  connected
• To examine a sensory nerve stimulate (depolarize)
  the nerve and record over the nerve
• Distal latency Nerve is stimulated distally
  with recording over the muscle innervated by that
  nerve. Latency includes the time it takes for
  chemical transmission across the synapse to occur
• Nerve conduction velocity The same nerve is
  stimulated proximally with recording over the
  same muscle used to record latency. The distance
  from proximal stimulation site to distal
  stimulation site is measured. Latency is
  subtracted from total time from proximal
  stimulation. Distance measured divided by time
  nerve conduction velocity

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Peripheral Nerve Anatomy and Clinical Syndromes

• Begin with complaints and work backwards. This
  is what the patient will complain about. It will
  be your job to think backwards in order to
  determine pathology

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Radiculopathy

• Ventral root from anterior horn cell joins with
  dorsal root distal to dorsal root ganglion to
  form the spinal nerve which divides into anterior
  primary ramus(to limb musculature) and posterior
  primary ramus ( to paraspinal musculature)

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Root avulsion or injury

• Erbs palsy C5 and C6 roots
• Caused by traction on upper plexus generally by
  an injury which increases the angle between head
  and shoulder (ex. Forceps delivery with shoulder
  in fixed position)
• Inability to abduct or supinate with preserved
  intrinsic hand musculature

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Brachial Plexopathy

• Upper trunk injury firearm recoil, heavy
  backpack, stinger
• From pressure on clavicle against scalenes
• Weakness in shoulder abduction, internal and
  external rotation, radial wrist extension

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• Klumpkes palsy C8 and T1 roots
• caused by upward traction on the plexus (ex.
  Grasping an overhead branch while falling out of
  a tree)
• intrinsic hand weakness plus weakness in wrist
  flexors and extensors

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• Middle trunk injury rare
• Weakness in distribution of the radial nerve
  which spares brachioradialis

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• Lower trunk injury similar to Klumpkes.
  Horners syndrome indicates damage to the
  cervical sympathetics. Lower trunk and medial
  cord prone to metastatic compression due to
  proximity of lymph nodes and upper lung

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• Posterior cord injury seen in shoulder
  dislocation
• Weakness in axillary and radial distributions,
  elbow, wrist and finger extension and shoulder
  abduction after the first 30 degrees( the range
  subserved by the supraspinatus)

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Warning signs of nerve root compression due
metastatic disease

• Weight loss
• Increased pain at night
• Fatigue
• Increased pain when lying down

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Median Nerve

• Anterior interosseous syndrome
• Weakness in pronator quadratus, flexor pollicis
  longus and flexor digitorum profundus I II

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Carpal Tunnel Syndrome

• Most common entrapment
• Nocturnal parasthesias and pain which may extend
  proximally
• Can affect autonomic fibers causing Raynauds
  phenomenon
• Hypesthesia in digits 1,2,3 and radial half of
  digit 4
• Weakness in thumb abduction and opposition
• Tinels sign tapping the injured proximal stump
  of a nerve to elicit parasthesia is an indication
  of axonal regeneration rather than entrapment per
  se. This sign may be elicited in any nerve not
  just the median in carpal tunnel syndrome
• Sensation in the thenar eminence is spared
  because the palmar cutaneous branch arises
  proximal to the carpal tunnel

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• A constellation of signs and symptoms in which no
  one test absolutely confirms its diagnosis
• Most frequently encountered compressive
  neuropathy in clinical practice
• Approximately 500,000 surgical decompressions per
  year in the U.S.
• Economic cost exceeding 2 billion

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This patient is pointing to the area of numbness
and tingling? What nerve is affected?
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What nerve is affected?
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Ulnar nerve

• Ulnar Neuropathy at the elbow
• ( Tardy ulnar palsy or cubital tunnel syndrome)
• Injury to the ulnar nerve at the elbow or
  compression under the aponeurosis connecting the
  two heads of the flexor carpi ulnaris
• Hypesthesia over digit 5 and ulnar aspect of
  digit 4
• Weakness in ulnar innervated hand musculature
• Flexor carpi ulnaris usually spared in cubital
  tunnel, first dorsal interosseous most
  consistently affected

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• Ulnar entrapment in Guyons Canal at the wrist
• Spares dorsum of hand supplied by dorsal ulnar
  cutaneous nerve

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Radial nerve

• Radial Neuropathy in Spiral Groove
• Saturday Night Palsy usually spares the triceps.
  Weakness in all other extensors. Sensory loss in
  dorsum of hand and dorsum of digits 1 and 2. If
  neuropraxic injury only(conduction block due to
  myelin loss) should recover in 6-8 weeks

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• Compression due to axillary crutch involves
  triceps as well

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• Superficial radial neuropathy From handcuffs,
  tight watchband, gymnastic hand grips

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Posterior Interossous Syndrome

• Posterior Interossous Syndrome
• Terminal motor branch penetrates the supinator.
  Entrapment at Arcade of Frohse between the two
  heads of the supinator
• Weakness in wrist and finger extension with
  supination spared
• Complaints of pain over the lateral aspect of the
  elbow, no sensory loss
• Radial nerve proper supplies extensor carpi
  radialis longus and brevis. Normal contraction of
  these muscles despite weakness in extensor carpi
  ulnaris causes radial deviation with wrist
  extension

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• Lumbosacral Plexopathies
• Lumbar Plexus
• L1-4 form lumbar plexus within the psoas muscle
• Anterior divisions of L2-4 form the obturator
  nerve, posterior divisions form the femoral
  nerve.
• Sacral Plexus L5-S2
• Lumbosacral plexus damaged by hematoma, pelvic
  fractures, neoplasms from cervix, rectum and
  prostate

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• Obturator nerve
• injured in pregnancy or labor. Causes adductor
  weakness

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• Superior and Inferior gluteal nerves
• Located behind the hip joint
• Superior Gluteal to Tensor Fascia Lata, Gluteus
  Medius(hip abductors). Weakness causes the
  OPPOSITE side of the pelvis to drop as the
  OPPOSITE leg swings forward during gait

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• Sciatic nerve
• may be entrapped by piriformis muscle as it exits
  the greater sciatic notch causing Piriformis
  Syndrome

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• Peroneal neuropathy
• At the fibular head causes foot drop, weakness
  in dorsiflexion of the foot resulting in hip
  hiking(lifting the ipsilateral pelvis) to allow
  the dropped foot to swing through. The toe is
  often stubbed and may result in falls. Sensory
  changes are noted in the web space between toes 1
  and 2(deep peroneal branch injury)
• Injury to the superficial peroneal branch cause
  weakness in foot eversion and sensory deficits
  over most of the dorsum of the foot

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• Please be ready to discuss the following cases
  and questions in class

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• A patient sustained a nerve injury involving
  damage to axons. You see the patient in your
  office a few months later and the patient reports
  increasing strength in a muscle previously
  paralyzed by the nerve injury. What will an EMG
  needle examination most likely show?

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• A patient complains of tingling in the hand.
  Nerve conduction testing shows a prolonged median
  motor latency with a normal median nerve
  conduction velocity. What is this prolongation
  most likely due to?

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• What do Positive waves and fibrillations indicate?

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• Where is the cell body of a peripheral sensory
  nerve is located?

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• A patient complains of the acute onset of low
  back pain with radiation down the posterior
  thigh, leg and lateral aspect of the foot with
  numbness in the lateral aspect of the foot. The
  ankle reflex is 2/2 on the asymptomatic side and
  ½ on the symptomatic side. What are you most
  likely to find on H-reflex testing?

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• A 15-year-old healthy male sustains a shoulder
  dislocation easily reduced in the emergency room.
  Subsequently the patient complains of difficulty
  extending the wrist, elbow and fingers as well as
  difficulty abducting the arm after the first 30
  degrees. What has the patient most likely
  injured?

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• In a patient with complaints of numbness in the
  thumb, what are likely causes to consider?

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• In a patient with complaints of numbness in the
  small finger, what are likely causes to consider?

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• A patient complains that his right foot slaps
  down when he walks and further states that he
  keeps stubbing his toe. He compensates by
  leaning to his left and hiking up the right hip
  to keep from tripping over his foot. What are
  likely causes to consider?

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• A football player dives for a touchdown..He
  scores.and lands striking his right ear and
  superior aspect of his shoulder against the
  ground. You shake his hand and he squeezes
  firmly yet he cannot abduct his right arm to pat
  himself on the back. What is a likely cause?

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• A medical student falls asleep with the upper arm
  draped over a large pathology textbook. The
  student awakens the next morning, having drooled
  all over the textbook, unable to extend the wrist
  or fingers yet able to extend the arm without
  difficulty. The student is certain a stroke has
  been suffered. You reassure the student saying
  that you probably just injured what?

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• A patient complains of numbness and tingling in
  the anterior aspects of digits 1, 2 and 3 as well
  as neck pain with radiation down the arm. The
  numbness and tingling are worse at night.
  Eletrodiagnostic testing shows a prolonged median
  sensory latency as compared to the ulnar and
  increased insertional activity in the cervical
  paraspinal musculature, extensor carpi radialis
  and pronator teres. What are likely causes to
  consider?

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• What are the warning signs of nerve root
  compression due to metastatic disease?

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• A patient presents with acute severe back pain
  beginning that day and accompanied by urinary and
  stool incontinence. What should you do?

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• 78 year old with numbness and weakness in the
  hands

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• 59 year old female with burning dysesthesias in
  the thumb and lateral wrist pain

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• 64 year old main with intermittent numbness and
  hand pain

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• 80 year old female with tingling in the hand and
  pain at the base of the thumb

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• Please be ready to discuss the following case in
  class

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• A 45-year-old male complains of severe shoulder
  and upper arm pain, progressing over
  approximately two weeks. He has worked in heavy
  labor all of his life and reports a long history
  of neck pain, some funny feeling in his hand, and
  some difficulty with grip. He states the funny
  hand feeling and difficulty with grip are getting
  worse, and he cannot work because of the pain.

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Please be prepared to

• Ask additional questions regarding history
• Elicit signs on physical examination
• Decide what diagnostic tests to order to confirm
  your diagnosis and explain your rationale

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Does it hurt?
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Does it hurt?
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We all gain from less pain

• 29 gauge, teflon coated needle
• Large muscle first
• Isometric contraction
• Patient phone call
• Individualize technique Do what is best for the
  patient
• Relax, relax, relax

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Thank you