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.
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.
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.
Aggravating factors
• 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.
• 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.
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