● During examination, the assessor is unable to reproduce or reduce the client’s symptoms (Heick & Lazaro, 2022). ● Symptoms that are not relieved with a change in position or with rest. ● Over time, the patient’s ability to relieve their symptoms by a change in position, by resting, or by applying heat diminishes or no longer works. ● A growing mass, either painful or painless, is a tumor until it is shown not to be. If a hematoma is present, it should decrease (not increase) in size over time (Heick & Lazaro, 2022).
● Weight gain or loss of more than 10% over the course of 10 to 21 days without trying. Unintentional weight loss may be an indicator of existing illness (Mariam et al., 2021). According to Perera et al. (2020), 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. ● Symptoms that are cyclical (better, worse, then better again) or progressive (continue to get worse).
PAIN PATTERN AND DIFFERENTIAL DIAGNOSIS
● Certain pain descriptors are not typically associated with musculoskeletal issues, for example, throbbing (vascular), knifelike, boring, or a deep aching (Goodman et al., 2017). ● Shoulder or upper extremity pain that occurs along with signs and symptoms related to specific viscera or system (Goodman et al., 2017). Healthcare Consideration: As stated above, nighttime pain can be a warning for the presence of a tumor or infection and is considered a red flag for shoulder pain. However, Mengi & Akif Guler, (2022) state that pain at night is also a common symptom with rotator cuff–related shoulder pain. Differential diagnosis would include further assessment for subjective and objective findings that would confirm the rotator cuff is involved.
The pattern of pain described by a patient can give therapists important clues regarding the origin of their symptoms. Following are some examples of pain patterns that might be problematic: ● Pain is present in the shoulder or upper extremity, but the range of motion in accompanying joints is full. Range of motion loss is common with musculoskeletal positions. Motion may be limited by joint dysfunction, periarticular or intraarticular swelling, muscle flexibility limitations, or pain (Ristori et al., 2018). Pain that is present with full range of motion may arise from a systemic or viscerogenic origin. ● Night pain. Pain at night is a red flag for the possible presence of tumor or infection. ● Pain that is constant and intense. This type of pain may signal the onset of an acute medical condition, as this is not a typical presentation for pain of a musculoskeletal or neuromuscular origin (Arendt-Nielsen et al., 2011).
VISCEROGENIC/SYSTEMIC CAUSES OF SHOULDER PAIN
Screening for pulmonary causes of shoulder pain The lungs may have extensive disease without causing pain. Pain starts when the disease process extends to the parietal pleura. This pain is sharp and localized, increasing with respiratory movement. This pain may be alleviated by lying on the affected side, as this position decreases chest movement. By contrast, shoulder pain that is caused by musculoskeletal issues is typically aggravated when lying on the involved shoulder. Pulmonary involvement should be suspected when shoulder pain is made worse with lying down. Recumbency causes an increase in venous return from the lower extremities. This increase in fluid volume can stress a compromised cardiopulmonary system, with resultant referred shoulder pain. In addition, lying down shifts the contents of the abdomen toward the head, putting pressure on the diaphragm, which then presses up on the lungs. In older adults, pneumonia can cause shoulder pain when the affected lung presses on the diaphragm. With pneumonia, there are often accompanying symptoms. With older adults, the only accompanying symptom may be Screening for cardiovascular causes of shoulder pain The heart is innervated by the C5–C6 spinal segments. These segments also innervate the shoulder. Consequently, the heart can be the root cause of shoulder pain. Shoulder symptoms that increase when the patient increases their activity level may indicate a cardiac cause. In these cases, the examiner should inquire about associated cardiac symptoms, including presence of nausea, unexplained sweating, jaw pain, back pain, and chest discomfort or pressure. Vital signs should also be regularly taken.
new-onset cognitive deficits or confusion. Clinicians should determine baseline cognitive function and/or perform cognitive screens on older patients to rule out confusion. To assess clients’ cognitive status, clinicians can assess how they initiate a daily task, prevent and/or fix errors, demonstrate interactive skills, and appropriately manage time (AOTA, 2021). The Mini-Cog is a short cognitive screen that many healthcare professionals use (Limpawattana & Manjavong, 2021). Screening for pulmonary disease should include awareness of pleuritic symptoms such as persistent cough, tachypnea, dyspnea, wheezing, and hyperventilation. Healthcare Consideration: Irritation of the diaphragm can elicit referred pain in the shoulder. This is because the phrenic nerve of the diaphragm has cervical nerve origins that are the same as the supraclavicular nerve, C3 and C4 (Ott et al., 2022). This explains why conditions such as pneumonia can cause shoulder pain. ● Angina or myocardial infarction - Angina or a myocardial infarction can cause arm and shoulder pain. This pain typically starts three to five minutes after activity is initiated. It will be unaffected by positioning, breathing, or movement. Women are more likely to report that their pain radiates to their left arm and are more likely to report associated nausea compared to men (Lowry et al., 2022).
EliteLearning.com/Physical-Therapy
Page 17
Powered by FlippingBook