Lecture 1-28 Flashcards
Pain
What type of model do we use to assess pain?
Biopsychosocial model
T/F: Pain is only physical
F
Pain has cognitive, sensory, and emotional influences, and behavioral manifestations
Back pain that is worsened by walking and improved by sitting, maybe suggestive of what?
Lumbar spinal stenosis
What does OPQRSTU stand for? What do we use this for?
Onset
Provocative/palliative
Quality
Region/radiation
Severity
Timing/treatment
U you/impact
To identify pain characteristics
What is catastrophizing?
A coping mechanism that is a negative cascade of distressing thoughts and emotions about actual or anticipated pain
What is kinesiophobia?
Fear of movement
What is catastrophizing associated with?
-Increase pain intensity
-Increase risk of chronic pain
What are your red flags of pain?
-bowel/bladder dysfunction
-saddle anesthesia
-bilateral leg weakness
-severe, sudden onset headache
-fever, weight loss, night sweats
-recent injury
-history of cancer
What scale is able to categorize Catastrophizing? What are the important ratings?
Mark Sullivan Scale
- I worry all the time about whether the pain will end.
- It’s terrible and I think it’s never going to get any better.
- It’s awful, and I feel that it overwhelms me.
- I become afraid that the pain will get worse.
- There’s nothing I can do to reduce the intensity of the pain.
Higher # is less intense
Pyschiartic conditions are associated with ________
Higher pain intensity & pain-related disabiity
Poor sleep is associated with ______
onset and worsening of chronic pain
Sleep disordered breathing may be caused by ______ and may increase your risk of ______________
opioid medication
respiratory depression or death
History of substance use disorder including tabacco is associated with increased likelihood of __________
prescription opioid misuses and abuse
What are the components of a pain exam?
- general appearance
- mental status
- vital signs
- posture & gait
- palpation
- ROM
- neuro
- special tests
What is Trendelenburg?
Drop of pelvis when lifting leg opposite to weak G. medius
What is another name for foot drop? What is this? What pathologies do you see this in?
“Steppage” or “slap-foot”
Unilateral - muscles that lift the front part of the foot become weak/paralyzed
common peroneal nerve palsy
L5 radiculopathy
How do you grade motor movement?
0 - 5
0- no movement
What is a myotome?
muscle group innervated by a specific spinal nerve
What is a normal reflex value?
2
0 - none
4 - hyper
During a physcial pain assessment, what do we exclude?
Red flags
What are CTs good at looking at vs MRIs?
CT: soft tissue & bony structures
MRI: soft tissue integrity, muscles, tendons, nerves
T/F: We use diagnostic imaging without red flags or red flag signs. Why?
F
Reinforces sick behaviors & worsen long term outcomes
How can you figure out if an abnormal finding on an MRI is age appropriate or a source of pain?
Dx block:
-selective nerve root block
-medial branch block
When can you do imaging on the lower back?
-red flags present or
-after 6 weeks
If there’s a HA thats brought on by excertion, what should you expect?
Increased ICP
Get imaging
If patient is immunocompromised or has a malignacy and is complaining of a HA, what do we do? Why?
Imaging
Possible mets to brain
I should always try to establish a specific pain _________ Dx. Which includes these 4 things:________
Patho-anatomic
- Acute/chronic
- Location.
- Mechanism
- Etiology
What is a BPI? When is this beneficial to use?
Brief pain inventory
It is short form used to answer questions about pain and previous treatment responses. Very useful in primary care.
What is a PEG? What is its benefits?
Pain, enjoyment, general activity
Assesses more function and quality of life
3 questions measurement derived from the BPI
What does a positive answer on the PC-PTSD screen indicate?
pt may have PTSD or trauma related problem & needs further support
A score of ____ or higher on the GAD-7 means what?
10
pt may have panic disorder, social anxiety disorder, PTSD
What is the relevance of STOP-BANG? What does it mean?
Tool used to Dx/Tx sleep apnea
If more than 3 yes, Tx for OSA
5-8 = mod/severe OSA
Snoring
Tired
Observed apnea
High BP
BMI > 35
Age > 50
Neck > 40 cm (16 in)
Gender is male
What is fibromyalgia?
Chronic pain condition that includes:
-fatigue
-cognitive effect
-brain fog
How do you Dx fibromyalgia?
- WPI ≥ 7 and SS ≥ 5
or
WPI 3 - 6 and SS ≥ 9 - Symptoms have been present for 3 months
- Pt doesnt have a disorder that would otherwise explain the pain
What is ORT? What are the risk ranges?
Opioid risk tool
low: 0-3
moderate: 4-7
high: ≥ 8
T/F: Scored for ORT are weighted equally for male & female
F
they are weighted differently
What screening tool do we use for people currently taking opioids?
COMM: Current opioid misuse measure
≥ 13 (idk what this is for but im including it)
What screening tool should we use in patients with a higher risk of misuse?
SOAPP-R: Screener & opioid assessment for patients with pain - revised)
What is the QoL scale? How are the numbers rated?
Quality of life scale
The higher the number = better
What point differentiates between upper & lower neck pain?
C4
What is the perimeter for neck pain?
Base of skull –> 1st thoracic spinous process (T1)
Headaches caused by neck pain are ________ headaches
cervicogenic
Most neck pain will be _______ pain
myofascial
What is N SWIFT PICS?
Another way to remember red flags
Neuro
Steriods
Weight loss
Immunospressed
Fever
Trauma
Porosis
IVDU (IV drug use)
Cancer
Severity of pain
What is the time for acute vs chronic neck pain?
acute: < 3 months
chronic: > 3 months
What type of imaging do we use to detect osteoarthrosis?
None
It cant be detected on imaging
What are chronic neck pain conditions with trauma that merit further investigation?
Zygapophyseal joints
internal disc disruption
In neck pain with no known origin and no red flags, what should we do?
No imaging
-explain & reassure
Consider median branch block for facet pain
- provactive discography for disc disruption
What is the difference between radiating and referring pain?
Referring: Muscle pain
-follows myotomes
-normal neuro exam
radiating: nerve pain
-follows dermatomes
-abnormal neuro exam
On the neck, I’d want to get an _____ done for imaging
MRI
If Dx block provides pain relief, what should we consider?
percutaneous radiofrequency neurotomy
-Sx
What is considered low back pain?
Tip of last thoracic spinous process (T12/rib12) –> tip of sacro-coccygeal joints
Everything under _____ is considered back pain
T1
What else can be refered to as back pain?
Lower extremity pain above and/or below the knee
Where is the vertebrae injury in Cauda Equina vs Conus Medularis?
Cauda Equina: L2 - sacrum
Conus Medularis: L1 - L2
Where is the spinal level injury in Cauda Equina vs Conus Medularis?
Cauda Equina: Injury –> lumbosacral nerve roots
Conus Medularis: Injury –> Sacral cord segment & roots
What are some of the main presentation difference between Cauda Equina vs Conus Medularis?
Both cause pain & sensory disturbances in SADDLE ANESTHESIA area
Cauda Equina: Asymmetric
Conus Medularis: symmetric
Cauda Equina: Symptoms usually severe
Conus Medularis: usually not severe
Cauda Equina: weakness to paralysis
Conus Medularis: normal to mild/mod weakness
Cauda Equina: late/less severe
Conus Medularis: Early/severe sphincter & sexual dysfunction –> impaired erections
Cauda Equina: more favorable outcomes
Conus Medularis: less favorable
T/F: The prognosis for acute low back pain is favorable
T
What is my 1st line test for suspected AAA?
Ultrasound
What are my 1st line tests for suspected tumor?
- ESR (Erythrocyte sedimentation rate)
- CRP (C-reactive protein)
- MRI
- PSA (Prostate specific antigen)
- IEPG (Immuno-electrophoretogram)
- serum protein
- Electrophoresis
What are my 1st line tests for a pathologic fx?
X ray
What does CRP (C-reactive protein) tell me?
a marker of inflammation in the body
It is produced by the liver in response to infection, injury, or chronic disease.
What does ESR (Erythrocyte sedimentation rate) tell me?
measures how fast red blood cells settle in a tube over one hour.
Higher ESR: inflammation, infection, autoimmune disease, or cancer
Lower ESR: sickle cell disease, polycythemia, or heart failure
T/F: Osetopenia should be expected in all pts over 50
T
What bones are the shoulder comprised of?
Scapula
Clavicle
Humerus
What are the bony structures in the shoulder area?
Spine
Scapula
Gleno-humeral joint
What should you expect if you cant lift your shoulder? What stabilizes the rotator cuff?
Compromised rotator cuff
Rotator cuffs are stabilized by: Pectoral girdle
-shoulder
Where can shoulder pain be referred from/to? Why is this important?
Neck
Heart
Gallbladder
I need to be able to rule out other pathologies that could be causing shoulder pain like cervicogenic HA, MI, cholecystitits)
Which tests will identify a rotator cuff injury? How do you perform them?
Apley scratch: pain when reaching to opposite scapula
Neer: pain w/ shoulder flexion
Hawkin’s: pain w/ shoulder internal rotation
Drop arm: pain w/ shoulder abduction
O’Brian: pain w/ rotation & abduction
Which test will identify bicep tendonitis? How do you perform it?
Speed’s & Yerguson: elbow flexion
Which test will identify labral tear? How do you perform it?
Apprehension: pushing on humeral head
Most shoulder conditions are _________. They need to be seen by who?
Musculoskeletal
physiatrist or ortho
If rehabilitation fails, then what type of imaging should we get?
MRI
What are the most common shoulder pain conditions?
Rotator cuff tear
-gleno-humoral/sub-acromial bursitis
-gleno-humoral instability (pendinitis)
-bicep tendinitis
T/F: elderly patient tend to respond less to intra-articular injections, and rehab rehabilitation
T
In elderly patients with limited functionality, what should we disuss with them?
Sx or
-palliative
__________ is required to correct any shoulder instability
Arthroscopic Sx
Hip pain is common & increases in people in ages over ____
60
What does “hip joint” pain refer to?
Ball & socket: Femoral head & acetabulum
What is mechanical hip pain?
Musculoskeletal
Normally localized and increased with loading (standing)
What is referred hip pain?
poorly localized and may/may not be increased with loading (standing)
What should I expect with hip pain at rest?
Rheumatologic
-infection
-cancer
Where can hip pain be referred to/from?
low back
-thigh
-butt
-groin
Where does extra-articular hip pain come from?
lumbar spine
-knee
-greater trochanter
-piriformis muscle
Dislocation of the hip can NOT happen without ______
trauma
What is “snapping hip syndrome”? What anatomy is involved?
ligament passing tightly over bony prominence
Ligament: iliofemerol ligament & pubofemoral ligament
bony prominences: greater trochanter & anterior iliac spine
Hamstrings ______ the hip & ______ the knee
Extend
Flex
Which quadricept muscle can cause both hip & knee pain? Why?
Rectus femoris
Crosses the knee & hip at the anterior inferior iliac spine
What are the 4 quadriceps muscles?
- Vastus lateralis
- medialis
- intermedialis
- rectus femoris
In the hip, where is blood supply most vulnerable?
femoral neck
When history & exam suggest avascular necrosis, what should we do? Why?
Perform imaging
blood supply to the fermoal neck is vulnerable and can lead to bone weakness, limited movement, arthritis.
How do we test ROM in the hip?
3 planes w/ 2 directions each
Flex/extend in supine
internal/external rotation in seated position
abduction/adduction in supine
What is the test that detects hip flexion contraction?
Thomas test
What the test that detects hip labral injury or sacroiliac joint problem?
FABER
-Patrick’s test
McCarthy: bilateral hip flexion = labral tear
-Fitzgerald: similar to FABER w/o pressing on hip
What test suggests an iliotibial band problem?
Ober: hip extension
What is normally affected in arthritis?
Worn out cartilage in a joint
Bone rubbing against bone
What is a common his disorder in the elder?
hip osteoarthritis
_________ hip disorders appear in the very young
congenital
What is a hip disorder common for pediatric patients? What are they?
Slipped Capital femoral epiphysis (SCFE): femoral head slips off the femoral neck at the growth plate (physis)
Legg-Clave-Perthes Disease (LCP): caused by avascular necrosis of the femoral head, leading to bone death and eventual regeneration; usually unilateral
What is a hallmark symptom of Trochanteric bursitis?
Pain upon palpation of middle of lateral greater trochanter
What are the gender, race & genetic effects on Osteoarthritis?
gender: more common in women
race: none
genetics: clear components exist
Hip replacement may be indicated in mostly _______
trauma
Transient trochanteric bursitis relief can be given by ________
intra-articular steroid injections
T/F: I can do intra-articular steroid injections with avascular necrosis
F
Where can knee pain refer to?
Thigh
lower back
leg
T/F: referred pain into the knee region is typically poorly localized, and will often not increase with mechanical loading
T
If there’s referred pain suspected into the knee, what areas should I investigate?
Hip
-lumbar spine
-leg
What are the 3 joints in the knee? Which is the main one? What is its relevance?
Tibiofemoral: fibrocartilagenous meniscus deepens socket for femoral condyles to roll into; provides cushion & stability
Patellofemoral
Proximal tibiofibular
Where does the patella sit?
in the quadricep tendon & attaches to the tibial tuberosity
The hamstrings cross the hip as the ________ attachment is on the ___________ and ________ cross the knees
Proximal
ischial tuberosity
distally
What muscle cross the knee proximally & crosses the ankle at the achilles tendon?
gastrocnemius
The gastrocnemius muscle is a strong _______ of the ankle and helps ________ the knee
plantarflexor
flex
What test should be used for meniscus lesions?
Thessaly test: Stand on 1 leg, hold arms of pt, and rotate over knee joint.
-complains of pain = positive
Patellofemoral pain is more common in people under the age of _______.
45 years old
What is Patellofemoral pain characterized by?
Positive Moviegoer sign: pain when sitting for long periods w/ knee @ 90 degree
T/F: There is Sx for Patellofemoral pain
F
Do not consult nobody. They wont help you.
What is common w/ osteoarthritis after twisting the knee w/ a fixed foot? What can this lead to?
Meniscal tear
knee locking
-effusion
-pain with loading
Where is bursitis of the knee common at? What may it require?
pre-patellar
aspiration
Knee ligament injuries are common with _______ and should warrant what?
trauma
Early bracing & rehab –> possible Sx after these 2
Most acute knee injuries are __________
soft tissue injuries
What type of imgaing is appropriate for 1st line for the knee? What should we move to after this?
plain radiography such as Xray
MRI
