Table 1: Systemic vs Musculoskeletal Pain Characteristics Systemic Pain
Musculoskeletal Pain
Onset
• Recent, sudden. • Is not present for years without progression of symptoms.
• May be sudden if associated with acute injury or repetitive motion. • May be gradual if secondary to chronic overload of the affected part. • Usually unilateral. • May be stiff after prolonged rest, but pain level decreases. • Achy, cramping pain. • Local tenderness to pressure.
Description • Knife like quality of stabbing from the inside out, boring, deep aching. • Cutting, gnawing.
• Throbbing. • Bone pain. • Unilateral or bilateral.
Intensity
• Related to degree of noxious stimuli,usually unrelated to presence of anxiety.
• Mild to severe. • May depend on anxiety level.
• Mild to severe. • Dull to severe.
Duration
• Constant; awakens person at night.
• Duration modified by rest or change in position. • May be constant but is more likely intermittent, depending on activity or position. • Restriction of active, passive, and/or accessory movement. • One or more movements specifically aggravate the pain.
Pattern
• Although constant, may come in waves. • Gradually progressive, cyclical. • Night pain. • Unrelieved by rest or change in position. • Cannot alter, provoke, alleviate, or aggravate symptoms. • Pain is organ dependent, for example esophagus - eating; heart - exertion; gastrointestinal – peristalsis (eating). • Organ dependent for example,gallbladder – leaning forward, kidney – leaning to the affected side.
Aggravating factors
• Altered by movement.
Relieving factors
• Rest or change in position. • Muscle pain may be relieved by rest. • Stretching. • Heat or cold.
In addition, patients with systemic pain might have the following associated signs and symptoms: Fever and/or chills, sweats, unusual vital signs, gastrointestinal symptoms (such as nausea, vomiting, anorexia, unexplained weight loss, diarrhea, and/ or constipation), early satiety, bilateral symptoms, painless weakness of muscles, diaphoresis, dizziness, visual disturbances, skin lesions, and bowel/bladder symptoms. Healthcare consideration: When evaluating a client presenting to physical therapy complaining of musculoskeletal symptoms, it is easy to become focused on identifying musculoskeletal factors that confirm this suspicion or presentation. Effective differential diagnosis involves adopting a stance of openness to all the possible explanations for a client’s condition. Observation of and questioning about all the factors possibly related to the origin of symptoms includes exploration of such things as the presence of fever, abnormal vital signs, gastrointestinal symptoms, painless muscles weakness, diaphoresis, visual disturbances, skin lesions, and bowel/bladder symptoms, among many others. Immediate medical attention Cavallaro Goodman et al. (2018) have constructed a list of symptoms that require immediate medical attention. When these symptoms are present, immediate medical attention is advised: ● Angina symptoms: Angina symptoms that do not resolve after 20 minutes of rest; angina symptoms that do not resolve after administration of nitroglycerin. ● Angina symptoms accompanied by nausea, vomiting, and/or profuse sweating. ● Bowel and/or bladder incontinence with or without saddle numbness.
These three important considerations—past medical history, clinical presentation, and pain pattern—demonstrate how important it is to get a thorough medical history and to spend time during the interview to dig deep into the onset and nature of the client’s symptoms and pain. Anecdotally, the author remembers an instructor of an advanced manual therapy class stating that the more knowledgeable and skilled a therapist is, the more time they will spend on the subjective part of the initial examination as a means of understanding the etiology of the client’s symptoms. A tool that clinicians can use to help identify yellow flags is the Optimal Screening for Prediction of Referral and Outcome Review of Systems (OSPRO-ROS). This tool includes standard symptom descriptors used to aid in screening for potential systemic involvement. It includes questions related to the cardiovascular, gastrointestinal, endocrine, nervous, integumentary, pulmonary, and musculoskeletal systems (George et al., 2018). ● Symptoms of inadequate ventilation or C02 retention (shallow breathing with dizziness, drowsiness, fatigue, headache). ● Anaphylactic shock (feeling light-headed, breathing difficulties, wheezing, fast heart rate, clammy skin, confusion) ● Diabetes and client is confused or lethargic, or demonstrates a change in mental status. ● Positive McBurney’s sign (pain with pressure over McBurney point, or two-thirds the distance between the umbilicus and the anterior superior iliac spine one the right side of the
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