REIDER PART 272

332 Chapter 8 Cervical and Thoracic Spine

Figurę 8-50. Nonanatomic tenderness.

the axial compression test or a painful response to the rotation simulation maneuver. In the case of the axial compression test, organie pain should be experienced only in the neck, the shoulders, or the upper extremities. Patients who report pain in the Iow back or radiating down the entire spine in response to the axial compression test are judged as having a positive simulation sign.

The alternative way to test for simulation is by the rotation simulation maneuver. In this maneuver, the shoulders are rotated in a manner coplanar with the pelvis while the patient is standing (Fig. 8-51). This is essentially

Figurę 8-51. Rotation simulation maneuver.

a log roli and puts no torsional force on the thoracic or lumbar spines. It should, therefore, not provoke pain from those regions. A report of pain in response to the rotation simulation maneuver is, therefore, considered a positive simulation sign and suggests nonorganic pathology.

Distraction Sign

The third sign of Waddell is called the distraction sign. When a positive distraction sign is present, the response of the patient to the straight-leg raising test varies depending on whether it is performed with the patient in the supine or the seated position. In the presence of true nerve root tension, the patient should experience radiating pain in whichever position the straight-leg raising test is performed. Patients with nonorganic pain often know by experience that straight-leg raising in the supine position should be painful but may not realize that passivc extension of their knee while seated produces the same position of tension on the sciatic nerve roots (Fig. 8-52). They may, thus, inconsistently fail to report pain in response to the seated-leg raising maneuver. Such an inconsistent response is said to represent a positive distraction sign because the patient is distracted from the naturę of the test by the unfamiliar position.

Regional Sensory or Motor Disturbance The fourth nonorganic sign of Waddell is called regional sensory or motor disturbance. A regional sensory disturbance is considered present when abnormal sensation is noted in a nonanatomic distribution such as a stocking or glove distribution in the leg or the arm, respectively. A regional motor disturbance is suspected if the examiner discovers diffuse motor weakness of multiple muscle groups, such as weakness of every muscle group tested in the upper extremity, or if the cxaminer senses, during

Figurę 8-52. Distraction sign. Supine straight-leg raising reproduces symptoms, but seated-leg raising does not.