clinical reasoning of the MSK spinal patient Flashcards
(33 cards)
what is clinical reasoning?
thought process used in patient diagnosis and management
what is the musculoskeletal clinical translation framework?
this is a structured model designed to guide the translation of MSK research into clinical practice
- it provides an approach to ensure that research findings lead to effective and evidence based care
explain the individual perspective in the framework?
- eg what is the main problems or concerns for the patient? (may be pain, function or quality of life etc)
-how do the problems affect your daily activities/ quality of life etc?
-what do you expect from this session?
what are key early clinical reasoning categories?
-diagnosis
-pain mechanisms
what are different pain mechanisms?
- nociceptive
-neuropathic
-nociplastic
descrive nociceptive pain
pain that arises from actual damage to non neural tissue and is due to the activation of nociceptors
- deep, dull aching pain
describe neuropathic pain
pain caused by a lesion or disease of the somatosensory nervous system
eg superficial burning, shooting with or without paraesthesia
describe nociplastic pain and give EG?
-pain arising from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors
eg fibromyalgia
what kind of areas are important for a subjective exam for spinal patient?
- HPC- what brings you here today?
-MOI - pain - location (body chart), type, aggs, eases, severity
-24 hour pattern
-any other symptoms eg P+N’s, stiffness, weakness, pain radiating to other locations?
-red flag questions - CES, Ca, fever etc
-past medical history - any medical conditions, previous back problems, medications
-social Hx - occupation, family, hobbies - physical activity profile - are you active? if so how - be specific
-sleep
-goals and expectations for physio
what kind of questions need to be asked on body chart?
- type and area
-severity
-quality of pain
-abnormal sensation - P and Ns, numbness - labelling pain - worst is P1
what is referred pain?
a painful sensation at a site other than the source of nociception
what are common hypotheses to do with referred pain?
- common dermatome hypothesis- when pain is referred, it is usually to a structure that developed from the same embryonic segment or dermatome as the structure in which the pain originates eg shoulder and diaphragm
- convergence - inputs from visceral and skin receptors coverage on the same spinal cord neuron
- facilitation or irritable focus - pain impulse from the viscera alone are unable to pass directly from spinal cord neurons to the brain
what structures are capable of pain referral, especially into the limbs?
-nerves
-bones
-muscle
-vascular structures
-viscera - only some eg cardiac - eg heart attack causing pain in the left arm
what are examples of “pain description” with different somatic structures?
what kind of topics should be discussed in relation to the behaviour of symptoms?
-aggravating factors eg mechanical - what activities or positions eg standing, sitting, walking, bending bring it on?
-is it severe enough to stop activity?
-24 hour pattern - am, night, weekday vs weekend?
-easing factors - mechanical - any positions that ease the pain? any drugs/ heat or cold?
what are examples of screening questions for inflammatory arthritis?
SCREEN’EM
-skin eg rash
-colitis or crohn’s
-relatives - any family Hx
-eyes, uveitis, dry eyes
-early morning stiffness
-nocturnal pattern, nails etc
-exercise response/ effect
-medication effect
what are other symptoms to look out for other than pain?
-stiffness
-giving way/ instability of spine - why?
-locking
-clicks - painful or not ?
-weakness
-pins and needles
-numbness - sensory loss
what are examples of topics that need to be addressed with special questions?
-general health
-unexplained weight loss
-severe, unremitting pain
-night pain
-Hx of cancer
what are examples of questions that need to be asked for lumbar regions?
-saddle anaesthesia (lack of feeling in genital/ pelvic area)
-bowel and bladder changes?
what are examples of patients goals/ expectations?
symptoms - painfree or less pain?
-function - return to all activities or delay return until all symptoms gone?
-social - return to work/ sport or take time off work
describe the kind of things done in a physical exam?
-observation - movement
-range of motion - active or passive
-muscle tests- strength, flexibility, motor control
-neurological tests - function etc
-neurodynamic tests
-palpation
-accessory movements
-special tests
screen adjacent regions eg hip - but how?
why do we need to clear the spine for all peripheral pain?
if the spine is involved directly - eg referral
-indirect involvement
eg hip pain - clear lumbar spine or pelvis
eg knee pain - clear hip, pelvis and lumbar spine
-shoulder pain - clear cervical spine and thoracic spine
what kind of things would you observe in a physical exam?
-willingness to move
-gait - can the tissue take the load or are they antalgic (eg limp)
-posture - anterior, lateral, posterior
-bony structure and alignment
-muscle bulk
-skin etc
what kind of things would you look for ROM in a physical exam?
-active ROM - are they normal, hypermobile, or hypo mobile?
passive ROM - passive physiological movements or intervertebral movements
