Foundations of MSK - Lecture 1

history

subjective

tests and measures

objective

diagnosis, prognosis, goals

assessment

intervention

plan

biopsychosocial approach to evidence informed PT includes

• pt values and expectations

• best available evidence

• knowledge/clinical expertise

3 components of pt history

1) patient interview

2) 1st order decision

3) differential diagnosis —> includes planning tests and measures

1st order decision

decides if pt. is appropriate for PT eval

differential diagnosis

working diagnoses or pretest probability of disorder

differential diagnosis includes

• pain dx

• stage of injury (tissue healing timeframe dx)

• region

• med dx

• movement dx

parts of pt interview (9)

• description/location of symptoms

• hx of current and precious episodes

• pt expectations

• self-report outcome measures

• medical screening questionnaire

• pt profile

• C/C

• symptom behavior

• systems review

ROS includes

1. Past medical hx

2. Past surgical hx

3. Medications 

• 4. Radiographic tests

when is a pt not appropriate for PT eval (1st order decision)

• Not an NMSK condition

• Emergent NMSK condition

medical hx screening questionnaire includes

• systemic disease that may mimic NMS disease or be source of problem

• changes in overall health that may require referral to MD/consultation

• personal/family hx that may be relevant to current problem or alter PX

• other (CV, resp, endocrine, pregnancy, depression, communication)

a self-report outcome measure that is specific to a region provides

baseline quantitative measures of pt.s perceived activity and participation limitations

generic self-report outcome measure

• Patient Specific Functional Scale (PSFS)

• not region specific

• pt. identifies 3 activities they have difficulty with

red flag

serious pathology

yellow flag

adverse prognostic indicators (e.g beliefs, emotional responses, pain behavior)

in the short term (acute), adaptive behaviors _______. in the long term (after healing), malidaptive behavior may_______

allow the injury to heal; impair daily functioning, result in greater physical disability and chronic pain conditions, and increase risk for poor outcome

in order to determine the c/c, ask the pt.

open ended questions

what is included in the pt. profile

• age/race

• gender

• occupation and work status

• lifestyle - activity level

• referring provider/diagnosis

• other (litigation, primary language)

definition of pain

an unpleasant sensory and emotional experience associated with actual or potential tissue damage; or described in terms of such damage

neuromatrix theory of pain

(cognition, experience, emotion, coping strategies, social interaction) + (cortisol, immune system, endocrine system, ANS) = altered neuromatrix output, altered movement patterns, chronic pain

3 types of pain

• nociceptive

• peripheral neuropathic

• central sensitization

Nopeptive pain

pain right now, localized, can be chronic

Central sensitization

aka nociplastic pain; anxieties/yellow flags start to make CNS ramp up, release cortisol, increase/spread pain, global

Peripheral neuropathic pain

nerve pain

pain quality/type: deep, diffusive/vague ache

somatic or visceral

pain quality/type: hot, burning, electric pattern

nerve root (radicular)

pain quality/type: numbness/tingling

**if not reported, ask!

seek exact location

pain quality/type: deep/superficial

can you touch it? yes: superficial no: deep

constant pain

varies

intermittent pain

on/off

constant pain, does not vary

red flag

local pain

pain source located at/under area of sx

referred pain

location of pain coming from another site (visceral or somatic)

somatic referred pain

•Sx originate at a site other than where the patient feels the pain

•Described as deep, aching, & poorly localized

•Joints, Muscles, Nerves

somatic referred radicular pain

•Due to ischemic & inflammatory processes involved in nerve root compression, not compression alone

•Results in a sharp, lancinating pain, generally along dermatome

visceral referred pain

• anterior chest wall or abdominal region

• kidney, pancreas, abdominal aorta

• can manifest as back pain

history of present episode includes

• insidious onset or MOI

• when?

• sx?

• how progressed?

• tx so far?

symptom behavior includes

1) aggravating factors (concordant sign/sx)

2) easing factors

3) 24 hour-behavior

severity

intensity and impact on function

irritability

amount/type of activity to produce sx & time to ease, ability of tissue to tolerate physical stress/load

easing factors: nothing

• non-mechanical condition (red flag)

• active inflammatory condition

easing factors: rest eases

• most NMS problems improve with rest

easing factors: movements/activities/positions

what and how long? may assist with treatment

easing factors: medications

what, how often, does it help?

24 hour pain behavior

• seeks to identify 1st order decision]

• if acute ankle injury, not necessary

PMH questions

•Do you or have you had a history of diabetes, cardiac problems, a history of cancer or any other illnesses I should know about?

•Have you had any recent illnesses?

•Any surgeries in the past?

red flags indicating underlying pathology (8)

•History of cancer (CA)

•Pulsatile abdominal mass

•Unexplained weight loss

•Unremitting night pain

•Fever or chills

•Prolonged corticosteroid use

•Progressive neurological deficit

•Pathological change in bowel and bladder function

past surgical history questions

•Have you had any surgeries?

•What?

•When?

•Any sequelae?

medication questions

•“Please tell me about all the medications you take.”

•Meds may hide or create symptoms

medications and common side effects/sequelae

Antibiotics (skin reactions, non-inflammatory joint pain)

Diuretics (muscle weakness, cramping)

Non-steroidal anti-inflammatory drugs (back and/or shoulder pain due to retroperitoneal bleeding, gastrointestinal symptoms)

Corticosteroids (avascular necrosis femoral head, osteoporosis, immunosuppression, steroid–induced myopathy, connective tissue weakness)

Thorazine/tranquilizers (gait disturbances)

Antipsychotics or antidepressants (movement disorders)

Contraceptives (elevated blood pressure)

Opioids (nausea, constipation, dry mouth, dizziness)

Anticoagulants (bleed or bruise easily)

Statins (muscle aches and pains, weakness, myositis)

radiologic test questions

Imaging, EMG, lab tests:

•What, when, results?

pt. expectations and goals for PT

what do you want to be able to do at the end of PT?

• higher expectations associated with quicker and greater functional recovery

analyze data using the:

SINSS

severity

intensity of sx & impact on function and pt’s life

severity scale

0-3 - mild

4-6 - moderate

7-10 - severe

nuisance - disability

irritability

a measure of how easily the pt’s condition gets irritated and how long the irritation takes to calm down

irritability scale

mile - moderate - highly irritable

irritability scale tells you

• gentle or vigorous exam

• ability of tissue to handle the load

nature

• = 1st order decision

• is the pt. appropriate for PT

referral is recommended when

• Non- NSM

• emergent NSM

PT and/or referral is recommended when

mixed

PT eval is recommended when

MSK condition

stage

the timeframe of the pt’s episode and the pain mechanisms

stages of injury

• acute: onset - 14 days

• subacute: 2 weeks - 3 months

• chronic: >3 months

stage of injury can help diagnose:

the pain mechanism ( nociceptive, peripheral neuropathic, central sensitization)

stability

is the problem getting better, worse or staying the same(ISQ)

1st order/triage decision question set:

• what are the SINSS?

• are there any red flags?

• are there any yellow flags?

• are there any precautions or contraindications?

if the pt. belongs in PT; move on to differential dx

• what is the medical differential diagnosis? (List all the possibilities by priority)

• what is the PT/movement differential dx? (List all the possibilities by priority)

• what is the main region of interest to examine in detail and what related regions need to be ruled out?

• how vigorous can the exam be?

plan T & M