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1

Ruling out _ _ as the source of symptoms must be on the of primary objectives of the therapist's evaluation. This responsibility is increased as the number of states _ _ _ _ increases.

Ruling out PATHOLOGICAL CONDITIONS . . .

This responsibility is increased as the number of states PASSING DIRECT ACCESS LEGISLATION increases

2

Mechanical dsyfunction is defined as _ or _ function of _, _ and _ structure resulting from either _ or _ _.

Defined as IMPAIRE OR ALTERED function of SKELETAL, ARTHROIDAL, AND MYOFASCIAL structures resulting from either TRAUMA OR ABNORMAL POSTURES

3

Pathological conditions may be manifested as solely _ _ _ (eg. Joint _, abnormal _ _) with the most overt sypmotoms possibly being _ or _ _.

May be manifested as solely MECHANICAL DSYFUNCTIONS (eg. Joint HYPOMOBILITY, abnormal MUSCLE TONE) with the most overt symptoms possibly being NECK OR BACK PAIN

4

The purposes of this article are to 1) present an overview of _ _ _ and _ _ from _. 2) review general evaluation principles that may aid in the _ of _ _ _ from _ _. 3) present common symptoms and signs of _ _ _ of the _ and _ _.

1) present an overview of TRUE VISCERAL PAIN and REFERRED PAIN from VISCUS

2) Review general evaluation principles that may aid in the DIFFERENTIATION OF MECHANICAL DSYFUNCTION from PATHOLOGICAL LESIONS

3) Present common symptoms and signs of SPECIFIC VISCERAL DISORDERS of the GASTROINTESTINAL and UROGENITAL SYSTEMS

5

Because _ _ are innervated by _ they have the potential to cause a patients pain. These _ _ _ are found in the _ _ _ _ of the viscus, including their _ and _ _.

Because VISCERAL ORGANS are innervated by NOCICEPTORS they have the potential to cause a patient's pain.

These FREE NERVE ENDINGS are found in the LOOSE CONNECTIVE TISSUE WALLS of the viscus, including their EPITHELIAL AND SEROUS LININGS.

6

Once receptors are activated the neural information is transmitted along _, _ _ _ _ housed with in the _ and _ nerves of the _ _ _.

Neural information is transmitted along SMALL, UNMYELINATED TYPE C NERVE FIBERS housed with in the SYMPATHETIC and PARASYMPATHETIC nerves of the AUTONOMIC NERVOUS SYSTEM.

7

Transmission of neural information along type C nerve fibers may result in the perception of _ _ and _ to _ _.

Perception of DEEP ACHING and HARD TO LOCALIZE PAIN

8

Chemical stimulation of nociceptors may result from a build up of _ _ _ such as _ or _ _, secondary to an _ _ of the viscus. _ _ of the smooth muscle wall of a visceral structure or _ _ of viscus may also cause _ _ to develop due to the collapse of the structure's _ _.

May result from a build up of METABOLIC END PRODUCTS such as BRADYKININS OR PROTEOLYTIC ENZYMES, secondary to an ISCHEMIC STATE of the viscus.

PROLONGED SPASM of the smooth muscle wall of a visceral structure or PROLONGED DISTENTION of viscus may also cause ISCHEMIC STATE to develop due to the collapse of the structure's MICROVASCULAR NETWORK.

9

Other potentially _ _ may come in contact with _ _ resulting in stimulation of local nociceptors. An example would be _ _ _ leaking through a _ or _ _ into the _ cavity.

Other potentially HARMFUL SUBSTANCES may come in contact with UNPROTECTED TISSUE resulting in the stimulation of local nociceptors.

An example would be ACIDIC GASTRIC JUICES leaking through a GASTRIC or DUODENAL ULCER into the peritoneal cavity.

10

There is more _ than _ when considering the _ clinical phenomenon of _ _.

There is more MYSTERY than FACT when considering the CONFUSING clinical phenomenon of REFERRED PAIN.

11

Referred pain is defined as pain experienced in tissues that are _ _ _ of _ _ and whose _ or _ _ are _ _ in the physiological process of _ _.

Experienced in tissues that are NOT THE SITE of TISSUE DAMAGE and whose AFFERENT OR EFFERENT NEURONS are NOT INVOLVED in the physiological process of PAIN PERCEPTION

12

With referred pain _ _ of _ _ results in perception of pain at a distance from the _ of the _. Referred pain may lie within the _ of those _ _ the receive sensory information from the _ _.

With referred pain CORTICAL MISINTERPRETATION of SENSORY INFORMATION results in perception of pain at a distance from the SITE OF THE LESION.

Referred pain may lie with the DERMATOME of those SPINAL SEGMENTS that receive sensory information from the VISCERAL ORGAN.

13

Therapists should be aware of the _ _ _ of the various _ _.

Should be aware of the COMMON REFERRAL PATTERNS of the various VISCERAL STRUCTURES.

14

Few principles exist that _ _ _ the presence of either _ _ _ or _ _. Specific findings or patterns of findings revealed during the exam should _ the _ that _ _ may be _ or _ _ for the patients trunk or neck symptoms.

Few principles exists that DEFINITIVELY RULE OUT the presence of either MECHANICAL MUSCULOSKELETAL DYSFUNCTION or PATHOLOGICAL CONDITIONS.

Specific findings or patterns of finding revealed during the exam should RAISE the SUSPICION that PATHOLOGICAL LESION may be PARTIALLY OR COMPLETELY RESPONSIBLE for the patients trunk or neck symptoms

15

A _ _ will aid the clinical in detecting potential pathological conditions. Accurate descriptions of the _ of _ experienced and the _ of _ are helpful in making a differential diagnosis.

A GOOD HISTORY will aid the clinician in detecting potential pathological conditions.

Accurate descriptions of the TYPE OF PAIN experienced and the BEHAVIOR OF SYMPTOMS are helpful . . .

16

Visceral pain has been described as being _ _, _, _ and _ in character. Pain can be _, but may _ _ to a _ and then _.

Has been described as POORLY LOCALIZED, DIFFUSE, DULL and VAGUE in character. Pain can be CONSTANT, but may RHYTHMICALLY BUILD to a PEAK and then RECEDE.

17

Sensations of _ _ have been attributed to spasm of the muscle wall of hollow viscus. The _ of the _ sensation _ as the smooth muscle wall _ and _. Cycle may last up to a _ _.

Sensations of CRAMPING PAIN have been attributed to the spasm of the muscle wall of hollow viscus.

The INTENSITY of the CRAMPING sensation VARIES as the smooth muscle wall CONTRACTS AND RELAXES.

Cycle may last up to a FEW MINUTES

18

Gastroenteritis, constipation, menstruation, gall bladder disease, and urethral obstruction all have been attributed to causing a _ _ of _, which may be experienced in the _ or referred to the _.

All been attributed to causing a CRAMPING TYPE OF PAIN which may be experienced in the ABDOMEN or referred to the BACK.

19

_ _ cramping pain, _ of the _, _, and _ and _ sensation associated with activity and relieved promptly with rest may suggest a _ _ _. The complaint of _ _ at rest can also indicate the presence of a _ _.

LOWER LEG cramping pain, HEAVINESS of the LEGS, and PINS AND NEEDLES sensation associated with activity and relieved promptly with rest may suggest a PERIPHERAL VASCULAR DISORDER.

The complaint of RESTLESS LEGS at rest can also indicate the presence of a VASCULAR DISORDER.

20

Classically aggravation or alleviation of symptoms from a mechanical musculoskeletal dsyfunction can be related to a _ in _ or _ _ or to _ _.

Can be related to a CHANGE IN BODY OR LIMB POSITION or to SPECIFIC MOVEMENTS

21

If sypmtoms do not vary, regardless of body position and movement, or are present at rest, the therapist should suspect a _ _. This is especially important if the patient complains of their _ _ _, _ them _ _ _.

Therapist should suspect PATHOLOGICAL DISORDER

This is especially important if the patient complains of their MOST SEVERE PAIN, WAKING them UP AT NIGHT.

22

If the patient reports and incident, accident, or trauma that precipitated the onset of sypmtoms, a _ _ _ is probably the source of the complaint.

A MECHANICAL MUSCULOSKELETAL DSYFUNCTION is probably the source of the complaint.

23

If the onset of the original symptoms is _ _ or if unexplained symptoms develop _ during the _ of _, the therapist should be wary of a pathological lesion.

If the onset of the original symptoms is TRULY INSIDIOUS, or if unexplained symptoms develop INSIDIOUSLY during the COURSE OF TREATMENT the therapist . . .

24

If the patient complains of insidious onset of symptoms in multiple joints the therapist should be wary of? (Ex. -2)

Should be wary of the PRESENCE OF INFLAMMATORY DISORDERS

Examples: RA, Lupus

25

Presence of symptoms such as _, _, _, etc for more than _-_ _ duration suggest the possible presence of an occult infection or a neoplasm.

Presence of symptoms such as FEVER, CHILLS, NAUSEA, etc. for more than 1-2 WEEK duration suggest . . .

26

Unexplained weight loss, anorexia, malaise, change in bowel habits, or rectal or vaginal bleeding are also early signs of the presence of?

Early signs of the presence of NEOPLASTIC DISORDER

27

If the patient has a history of _, especially in organs which commonly _ to the _, and the patient has not seen a physician prior, the therapist should make the appropriate referral _.

If the patient has a history of CANCER, especially in organs which commonly METASTASIZE TO THE SPINE, and the patient has not seen a physician prior the therapist should make the appropriate referral IMMEDIATELY.

28

Investigating which _ the patient _ _ _ along with corresponding _ _ may provide explanations for the presence of certain complaints such as dizziness, fatigue, light headedness, constipation, etc.

Investigating which MEDICATION the patient MAY BE TAKING along with corresponding SIDE EFFECTS may provide explanation . . .

29

The therapist should also inquire about significant _ _, because certain _ have _ tendencies.

Inquire about significant FAMILY HISTORY because certain DISEASES have FAMILIAL tendencies.

30

Therapist should not assume the patient will _ _ regarding the presence of abdominal pain or their symptoms being related to visceral function. what should be routine? (2)

Should not assume patient will VOLUNTEER INFORMATION . . .

Questions FOCUSING ON CERTAIN VISCERAL STUCTURES/ FUNCTION and questions ON GENERAL HEALTH