New York Physical Therapy Ebook Continuing Education

● History of immunosuppression, including use of steroids, organ transplant, or diagnosis of infection with human immunodeficiency virus (HIV) ● Evidence shows that HIV-infected individuals are at risk for developing inflammatory rheumatic diseases as well as avascular necrosis and osteoporosis (Walker-Bone et al., 2017). ● History of injection drug use, which is associated with a wide range of medical complications that are predominantly musculoskeletal and vascular. 1. Clinical presentation. The signs and symptoms present during initial physical examination (and differential diagnosis) can serve as a warning that a systemic cause of the problem is possible. A. No known cause of symptoms, unknown etiology, or insidious onset of symptoms. Knowing the mechanism of injury can help a clinician diagnose the patient’s injury. For example, a patient who has a swollen ankle and describes landing on a teammate’s ankle when coming down from a rebound alerts the clinician to the strong possibility of an inversion ankle sprain. When there is not a clear mechanism of injury, it is more challenging to diagnose the origin of the patient’s symptoms. B. Once treatment is started, if symptoms do not improve or are not relieved by physical therapy intervention, this warrants referral to a medical specialist. When expected progress is not made, the question “What am I missing?” becomes relevant. As physical therapists, we often assess a lack of improvement as the provision of ineffective treatment or a lack of knowledge on our parts. We must always keep in mind the possibility that the client’s issue might be systemic and be ready to refer the client to their physician as appropriate. C. Significant weight loss or gain without effort (more than 10% over 10 to 21 days). Unintentional weight loss may be an indicator of existing illness (Mariam et al., 2021). According to Perera et al. (2021), community-dwelling adults with unintentional weight loss are often diagnosed with malignancy, gastrointestinal disorders, or psychiatric disorders, while institutionalized older adults are most often diagnosed with a psychiatric disorder. Evidence-based practice: Unintentional weight loss may be an indicator of existing illness. According to Perera et al. (2020), community-dwelling adults with unintentional weight loss are often diagnosed with malignancy, gastrointestinal disorders, or psychiatric disorders. Institutionalized older adults who experience unintentional weight loss are most often diagnosed with a psychiatric disorder (Perera et al., 2020). D. Gradual, progressive, or cyclical nature of symptoms (better, worse, better, and so on). E. Unable to provoke, reproduce, alleviate, eliminate, or aggravate symptoms during examination (Heick et al., 2023). F. Symptoms unrelieved by rest or a change in position; no position is comfortable. G. If relieved by rest, positional change, or application of heat, over time these relieving factors no longer reduce symptoms. H. A growing mass, either painful or painless, is a tumor until it is shown not to be. A hematoma should decrease in size over time—not increase (Heick et al., 2023).

Healthcare consideration: Musculoskeletal injuries are often relieved by a change in position. When musculoskeletal tissue is injured, both pressure and strain on the tissue can be painful. For example, if a patient has a fracture of the calcaneus and puts pressure on the heel, it will hurt. If a patient has lumbar spinal stenosis and stands with the lumbar spine in extension for a prolonged period so that pressure or strain is placed on the nerve roots, it will hurt. Therefore, pain that is unrelieved by positional change is a red flag. 2. Pain pattern. The pattern of pain described by the patient can provide important clues regarding the origin of their symptoms. Here are some examples of pain patterns that might be problematic. A. Pain accompanied by full range of motion. Loss of range of motion is common with musculoskeletal positions. Motion may be limited by joint dysfunction, periarticular or intra-articular swelling, muscle flexibility limitations, or pain (Range of Motion, n.d.-b). Healthcare consideration: When a joint is taken through its full range of motion, different structures are stressed. At different points in the motion muscles, ligaments, and tendons are stretched or shortened while joint surfaces are opened up or compressed. Pain accompanied by full range of motion can thus distinguish musculoskeletal from nonmusculoskeletal sources of pain. B. Night pain. Pain at night is cited as a red flag by the Agency for Healthcare Policy and Research guidelines to alert the clinician to the possible presence of tumor or infection. C. Pain that is constant and intense. This type of pain may signal onset of an acute medical condition because this not a typical presentation for pain of a musculoskeletal or neuromuscular origin (Arendt-Nielsen et al., 2011). D. Pain that is described as throbbing (vascular), knifelike, boring, or a deep aching (Carvallaro Goodman et al., 2018). E. Pain accompanied by signs and symptoms associated with a specific viscera or system (Carvallaro Goodman et al., 2018). F. Pain that cannot be provoked, reproduced, alleviated, or eliminated during examination (Carvallaro Goodman et al., 2018). Case Study: Helen Hayes This 62-year-old female was referred to physical therapy by her primary care physician to address right-sided low back pain. Pain is localized to the lower thoracic and lumbar areas. The client is unable to remember any precipitating incident, although she does state that her back “goes out” every few years. Client demonstrated full and pain-free trunk range of motion. Overpressure at end range of motion was also pain free. Spinal accessory motion testing was only mildly limited from T8 to T12. No palpable tenderness was noted in the lower thoracic to lumbar musculature. Neurological exam normal. Question What red flags have been elicited in this examination? Discussion The client is unable to report an incident that correlates with the onset of her symptoms. This is considered a red flag. Another red flag is that the clinician is unable to reproduce the client’s symptoms. This client was referred back to her physician and was diagnosed with a kidney infection. Cavallaro Goodman et al. (2018) present a comparison of typical pain patterns for systemic versus musculoskeletal dysfunction (see Table 1). This list can be useful in differentiating the source of a patient’s pain.

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Book Code: PTNY1024

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