Ortho - Lab 1 (Subjective)

Pain Mechanisms (Characteristics)

- Nociceptive

- Peripheral Neuropathic

- Central Mechanisms (Nociplastic)

- Autonomic

Nociceptive

- pain localized to area of injury/dysfunction

- clear, propportionate mechanical or anatomical nature to aggs/eases

- usually intermittent & sharp w/ movement or mechanical provocation

- may be a more constant or dull ache/throb at rest

Mechanical Nociceptive Pain

- localized, intermittent

- predictable consistent response to mechanical stimuli

- no pain on waking, pain on rising

- usually Mild to Moderate severity

- responds to simple painkillers

Inflammatory Nociceptive Pain

- constant, varying pain

- worsened rapidly by movement

- latent pain

- night pain & pain on waking

- high Irritability & Severity

- responds to NSAIDs

- movements limited by pain

Ischemic Nociceptive Pain

- usually intermittent

- predictable pattern

- aggravated by sustained postures and/or repetitive activities

- eased by change of position or cessation of a repetitive activity

Peripheral Neuropathic Pain

- caused by a lesion/disease of the Somatosensory nervous system

- can be lesion of PNS or CNS

- Neuroanatomical distribution (spinal segment or peripheral/cranial nerve pathway)

- descriptions = shock-like, burning, sharp, shooting

- manifest as Allodynia, Paraesthesia, Dysesthesia, Hypoaesthesia

Allodynia

non-painful stimuli perceived as painful

Paraesthesia

an abnormal sensation, often a tingling, prickling, or numbness, that occurs without an outside stimulus

Dysesthesia

a neurological condition characterized by abnormal and often unpleasant sensations in the skin, like burning, tingling, or prickling, which can be triggered by normal stimuli

Hypoaesthesia

a reduced or diminished sense of touch or sensation in a specific area of the body

Central Mechanisms (Nociplastic)

- increase responsiveness of nociceptive neurons in CNS to their normal or sub-threshold afferent input

- can develop as part of any persistent pain condition

- can be a consequence of ongoing nociceptive or neuropathic input

Symptoms of Central Mechanisms (Nociplastic)

- widespread, non-anatomical distribution

- Hyperalgesia, Allodynia

- inconsistent response to stimuli & tests

- patients have difficulty in locating & describing pain

- pain seems to have a "mind of its own"

Autonomic

- sympathetic nervous system = afferent system

- can have indirect impact on pain systems thru release of adrenaline (affecting capillary response & indirectly Cortisol. inhibiting inflammation)

- long term elevations lead to poor tissue quality & reduced immune response

Symptoms of Autonomic Pain

- Local = discoloration, dryness, swelling, sweating

- General = palpitations, BP changes, Hyperhidrosis, changes in breathing, changes in GI, muscle tension, fatigue, poor wound healing

Level 1 Classification for PT Appropriateness

- is the patient appropriate for PT?

- should the patient be seen by the Movement Specialist at this time?

The Flags

- Red

- Orange

- Yellow

- Blue

- Black

Red Flags

- symptom suggestive of serious pathology

- ID thru clinical observation & retrospective analysis

Examples of Red Flags

- severe, unintended weight loss

- progressive neurological symptoms

3 Stages of Red Flags

- Subclinical = absence of signs & symptoms

- Prodromal = vague, non-specific symptoms with few signs

- Clinical = easily ID due to signs & symptoms

Red Flags for LS

- Abdominal Aortic Aneurysm

- Cauda Equina Syndrome

- Cystic Kidney Disease

Abdominal Aortic Aneurysm Interview Data

- back/abdominal/groin pain

- peripheral vascular disease or coronary artery disease & associated risk factors

- symptoms NOT related to movement stresses associated with somatic low back pain

Abdominal Aortic Aneurysm Objective Data

- abnormal width of Aortic or Iliac arterial pulses

- presence of a Bruit in central epigastric area

- absence of palpable pulse

Cauda Equina Syndrome Interview Data

- urine retention or incontinence

- fecal incontinence

- saddle anesthesia

- global or progressive weakness in the lower extremities

Cauda Equina Syndrome Objective Data

- sensory deficits in the feet (L4, L5, S1 areas)

- Ankle DF, Toe Ext., Ankle PF weakness

Cystic Kidney Disease Interview Data

- unilateral flank or low back pain

- difficulty with initiating urination, painful urination, or blood in the urine

- recent history of UTI

- past episodes of kidney stones

Cystic Kidney Disease Objective Data

positive fist percussion test over the kidney

Yellow Flags

- beliefs about pain & harm often generate: abnormally high levels of emotional stress, hyper-vigilance, pain catastrophizing

- patients with chronic LBP develop cerebral signatures in response to pain that greatly influence their pain perception

Yellow Flags Example

- Emotional Distress

- Hypervigilance

- Pain catastrophizing

- elevated fear-avoidance beliefs

- low self-efficacy

- misunderstanding about nature & likely impact of pain

- misunderstanding about best strategies for long-term success

Self-Efficacy

- belief that one can achieve future goals

- strong predictor of successful treatment

Self-Management

- important long-term objective of PT for patients with LBP care

- most beneficial for patients with high efficacy

Yellow Flag Monitoring

- may develop over a time & can be difficult to accurately determine during initial visit

- determining factors that predict delayed recovery & development of chronic symptoms may require several measurements over time

Blue Flags

- related primarily to injured workers

- describe a patient's perception of work & work conditions that may impair return to work

Black Flags

- wider context of factors such as social & financial issues

- reimbursement incentives to remain disabled

Subjective Examination Order

1. Kind of Disorder (description of symptoms)

2. Site of Sx (body chart)

3. Behavior of Sx (aggs/eases, 24-hour)

4. Special Questions

5. History

SINSS

- Severity

- Irritability

- Nature

- Stage

- Stability

Severity

- intensity of patient's current symptoms

- based on degree that symptoms limit the patient's activity & normal sleep

Irritability

- amount of activity required to produce & increase symptoms

- magnitude of symptoms

- amount of time for symptoms to return to a baseline

Nature

suspected pathology or involved tissue

Stage

phase of the condition & length of time since injury

Stability

appropriateness of the patient for PT

10 OBJ Measures PT are responsible for

1. Posture

2. Gait

3. Functional Assessment

4. ROM

5. Joint Mobility

6. Palpation

7. Joint Integrity & Ligament Testing

8. Flexibility

9. MMT, Motor Coordination & Power

10. Neurodynamic Testing