Understanding Musculoskeletal Pain Flashcards
Pain from OR can come from:
Trauma
Surgical Trauma
Repeated/long intubation
Assessment of pain focus on what 5 things?
Sensory
Cognitive
Emotional
Behavior
Spiritual influences
The goal of the pain interview is to:
- Build trust
- Gather information
- Facilitate change
What is one chronic medication that can affect our anesthesia plan?
Pain meds
Rule out red flags:
Bowel/bladder dyfunction
Saddle anesthesia
Bilateral leg swelling
Severe, sudden onset headache
Fever, weight loss, night sweats
Recent injury
Hx of cancer
What is saddle anesthesia?
a loss of sensation in the area of the body that would come into contact with a saddle when sitting, including the buttocks, perineum (area between the anus and genitals), and inner thighs, typically indicating a problem with the lower spinal nerves, often associated with a condition called cauda equina syndrom
What is the OPQRSTU mnemonic?
Used to assess pain:
Onset
Provocative/palliative
Quality/Character
Region/Radiation
Severity
Timing/treatment
You/Impact
What type of comorbidity do we commonly see with greater pain intensity?
Psych
When you get exposed to cold, you get an _______ release
Endorphin
Which nerve causes foot drop if disrupted?
Peroneal nerve
Why are pain interviews often confrontational?
Doubt
Frustration
______ and _______ can facilitate focus on the function of the pt’s words rather than the content of the pt’s words; can also help the clinician stay in the therapeutic mindset despite intense emotional content
Mindfulness
Self-awareness
Data has shown pts with ______ conditions have past issues (mental health, childhood issues)
Chronic pain
We have to consider _________ on pain
Psychosocial influences
What should you do if confrontation with a patient is unavoidable?
Suggest a break and seek assistance from a team member
What 4 things are associated with higher pain intensity?
Psychiatric conditions
Poor sleep
Sleep disordered breathing
History of substance use disorder, including tobacco
The components of the clinical exam include:
Inspection and general appearance
Mental status
Vital signs
Posture and gait
Palpation
Range of motion (active/passive)
Neurological exam
Special tests
It’s important to think about _____ when assessing vital signs
Pathology
The goal of the physical exam is to exclude:
Red flags
Complement the psychosocial assessment
Quantify impairment
Describe the motor grading:
Grading: 5 = normal
4 = Full ROM against resistance
3 = Full ROM against only gravity
2 = Full ROM with gravity eliminated
1 = Palpable/ observable contraction
0 = No palpable contraction
Describe the muscle stretch reflex grading:
0 = absent
1 = diminished
2 = normal
3 = hyperactive
4 = hyperactive with clonus
What are the pathologic reflexes?
Babinksi, Hoffman, clonus
What is myotome?
Muscle groups innervated by a specific spinal nerve
What disease process commonly follows dermatome distribution?
Shingles
In the absence of red flags and normal physical exam, ________ reinforces sick behavior and worsens long-term outcome
Routine imaging
CT’s are used for:
Soft tissue
MRIs are used for?
Detailed look/nerves
What is the most practical type of imaging?
Xray
Do not image an uncomplicated headache unless:
- Neurologic exam is abnormal
- Unable to diagnose by history and exam
- Headache is sudden or explosive,
- Different from prior ones, especially over 50 y/o
- Progressively worsening
- Brought on by exertion
- Accompanied by fever, seizure, vomiting, a loss of coordination, vision/speech/alertness changes
- The patient is immunocompromised or with a known malignancy
Diagnostic imaging studies should only be performed when?
In patients who have severe or progressive neurologic deficits or with features suggesting a serious or specific underlying condition
When trying to establish a specific pain path-anatomic diagnosis, what is included?
- Determine is acute/chronic
- Location
- Mechanism
- Etiology
What is the differentiation cut off between acute and chronic pain?
3 months
What is the pain scale that uses terms like “mild to moderate to severe” called?
VRS (verbal rating scale)
What is the pain scale that uses “0-10” called?
NRS (numeric rating scale)
What does “PEG” in the PEG assessment scale mean?
Pain, enjoyment, general activity
Critiques of the PEG scale include:
No assessment of sleep or stress
What questions are asked in the PEG scale?
- What number best describes your pain on average in the past week?
- What number best describes how, during the past week, pain has interfered with your enjoyment of life?
- What number best describes how, during the past week, pain has interfered with your general activity?
T/F
PTSD feeds into chronic pain
True
What is the STOP-BANG screen tool used to assess?
Presence and need to treat obstructive sleep apnea
What is the STOP-BANG score that indicates a high probability of moderate/severe OSA?
Score of 5-8
What does STOP-BANG stand for?
S = snoring?
T = tired?
O = observed apnea?
P= high blood pressure?
B = BMI > 35?
A = Age >50?
N = Neck circumference > 40 cm (16 inch)
G = Gender is male?
Diagnose and assess the severity of fibromyalgia using what?
Widespread pain index (WPI)
Symptom Severity score (SS)
What symptoms are common in fibromyalgia?
Fatigue
Cognitive effects
Somatic symptoms
Brain fog
ORT is a simple ______ tool that can be used in primary care
Opiod screening
Describe ORT scale with numbers:
0-3 : low risk
4-7 : moderate risk
>8 : high risk
What are the 5 domains that are risk factors for opioid misuse?
- family history of substance abuse
- personal history of substance abuse
- age
- history of preadolescent sexual abuse
- psychological disorders
What are the other two screening tools for opioid risks, and what do they stand for?
SOAPP (Screener and Opioid Assessment for Patients with Pain)
COMM (Current Opioid Misuse Measure)
When assessing the effectiveness of treatment, what do we use?
4 (+2) A’s
Check:
- activity
- analgesia
- aberrant drug related behavior
- adverse effects
Consider:
- affect
- adjuncts
Quality of life scale:
Neck pain is anywhere between the _____ and the ____
Base of the skull
First thoracic spinous process
What can also cause arm pain or headaches?
Neck pain
Recall the bony structures when assessing neck pain
Spine
Scapula
Gleno-humeral jt.
Recall the muscles when assessing neck pain
Upper Trapezius
Rhomboids
Scalene
Levator Scapulae
Sternocleidomastoid
Splenius and longus capitis
Pectoralis major
What is an uncommon headache anesthetic that can be given?
4% lido on cotton swab and place up the nose
What are key behaviors to look for when assessing physical pain?
Grimace
Groan
Guarding
Over reaction
Inconsistencies
Give-way weakness
Shaking
Assess myofascial pain for:
Local Tenderness
Single or multiple muscles
Trigger points active
Firm or Taut Bands
Local twitch response (LTR)
Muscle weakness
Muscle shortening
What can fever, night sweats, hx of cancer, weight loss be indicative of?
Tumors/cancer
What can fever, recent surgery, illicit drug use, immunosupression, catheterization, travel be indicative of?
Infection?
What can trauma, recent surgery, manipulation, corticosteroids be indicative of?
Fracture
What can cardiovascular, cerebrovascular risk factors be indicative of?
Aneurysm
Nmeonic for reg flag conditions, and what it stands for?
N SWIFT PICS
N = Neuro: progressive neuro deficit
S = Steroids: prolonged use
W = Weight loss: unexplained
I = Immunosuppression
F = Fever: unexplained
T = Trauma: even mild if over 50
P = Porosis: osteoporosis/osteopenia
I = IVDU: IV drug abuse
C = Cancer: history of cancer
S = Severity: of pain
Following whiplash, what percentage of people can expect their neck pain to recover rapidly?
80%
Risk factors for chronic neck and low back pain:
Stress at work
Previous injuries
Litigation
Other known sources for chronic neck with trauma (Whiplash) that merit further investigation are:
zygapophyseal joints (facets)
internal disc disruption
How do distinguish between facet pain and disc pain?
Arch neck back and pain – facet
Arch neck forward – disc
What can be used to help detect arthritis?
Xrays
For referring pain, pain follows what type of distribution?
Myotomal
Follows muscular distribution
For radiating pain, pain follows what type of distribution?
Dermatome
nerve itself is being self affect→ follows nerve distribution
Radiating pain is usually accompanied with neurological signs such as:
paresis, hyperreflexia or hypoesthesia
What type of block is used to treat radiating pain?
Medial branch block
What is a kyphoplasty?
Injecting cement into the vertebrae to strengthen it
Low back pain is anywhere between what?
the tip of the last thoracic spinous process to the tip of the sacro -coccygeal joints
The further down the back we get, the more _____ the pain is
Complex
Bony structures when assessing back pain:
Spine
Iliac crests
Hip jt
Muscles when assessing back pain:
Quadratum lomborun
Multifidus
Psoas
Gluteaus max, med, minimus
Piriformis
Nerves when assessing back pain:
Lumbo-sacral plexus
Sciatic Nerve
Dermatomes
Motor innervation and reflexes
Describe cauda equina syndrome:
some sort of injury higher in the sacrum resulting in damage to lumbosacral nerve; can progress to paralysis
Causes of cauda equina syndrome:
cancer, trauma, epidural placement causing hematoma
Following acute low back pain episode, what percent of people can expect to recover rapidly?
80%
Preferred test for when a red flag is present:
CRP (C-reactive protein)
ESR (erythrocyte sedimentation rate)
FBC (full blood count)
IEPG (immuno-electrophoretogram)
MRI (magnetic resonance imaging)
PSA (prostate specific antigen)
What musculoskeletal disease process should be suspected in all pts over 50
Osteopenia
Symptom management can include:
- Bed rest should not be prescribed
- Encourage activity
- Acupuncture, stretch and spray, and heat packs are low risk and may offer some symptom relief
- NSAIDS and muscle relaxants are not particularly effective
- Opioids are not indicated
How does acupuncture work?
Lateral inhibition
Bony structures to assess with shoulder pain:
Spine
Scapula
Gleno-humeral jt.
The shoulder and pectoral girdle are compromised of:
Scapula
Clavicle
Humerus
The shoulder and pectoral girdle are stabilized by:
Rotator cuff
*Most common complaint with shoulders
Muscles associated with the shoulder:
Upper Trapezius
Rhomboids
Scalene
Levator Scapulae
Sternocleidomastoid
Splenius and longus capitis
Pectoralis major
Nerves associated with shoulder pain:
Occipital Nerve
Dermatomes
Motor innervation and reflexes
What type of surgical procedure can caused referred shoulder pain?
Laparoscopic
Describe Apley Scratch test:
pain when reaching to opposite scapula
Describe Neers test:
pain with shoulder flexion
Describe Hawkin’s test:
pain with shoulder internal rotation
Describe Drop arm test:
pain with shoulder abduction
Describe Lift off test:
pain with internal rotation and push
Describe O’Brian’s test:
pain with rotation and abduction
Describe Speed’s and Ferguson test:
tests with elbow flexion
Describe Apprehension test:
pain on pushing the humeral head
Which of the shoulder exams test rotator cuff injury?
Apley, Neer, Hawkin’s, Drop arm, Lift off and O’Brian
Which of the shoulder exams detect biceps tendonitis?
Speed’s and Yerguson
Which of the shoulder exams detect labral tears?
Apprehension
Most common shoulder pain conditions:
Rotator cuff impingement or tear
Gleno-humeral / sub-acromial bursitis
Gleno-humeral instability
Bicep tendonitis
Common shoulder pain conditions in the elderly:
- Mostly Osteoarthritis
- Less frequently due to Adhesive capsulitis
- Always review Red Flags: metastases, infection, and systemic disease
- Tend to respond less to intra-articular injections and rehabilitation
- If there’s limited functionality, discuss surgery or palliation
What is a simple thing we can inject into the joint to relieve shoulder pain?
PRP: platelet-rich plasma
Basically taking platelet plug and injecting it into joint - causes great tissue growth
What type of treatment is usually required to correct should instability (rotator cuff tear)?
Arthroscopic surgery
What type of pain is common and increases with age, especially in individuals over 60?
Hip and knee
Hip pain usually occurs due to:
Mechanical wear and tear or trauma
Hip pain can be generated from _____ or referred to/from ______
The hip
The low back, thigh, buttocks, groin
What is snapping hip syndrome?
a ligament passing tightly over a bony prominence,
The hamstrings ____ the hip and _____ the knee
Extend
Flex
What are the 4 quadriceps?
the vastus lateralis, medialis, intermedialis and rectus femoris
It’s hard to identify hip pain because it’s a ___________ area
Muscular dense
Where is blood supply most vulnerable?
Femoral neck
What are the 3 planes of direction (each has 2 motions) in the hip?
Flexion and extension
External rotation and internal rotation
Abduction and adduction
Describe sacroiliac joint pain:
pain in the lower back and pelvis that can radiate into the buttocks, thighs, and sometimes the legs.
How do you differentiate between true hip pain and SI joint pain?
FABER test – cross leg over, and put pressure on SI joint; take it and force it apart– extends SI joint open and if this is painful it is SI joint pain
Range of motion will hurt if its in true hip pain
Describe McCarthy test:
bilateral hip flexion may suggest labral tear
Describe Fitzgerald test:
very similar to FABER without pressing the hip
Describe Ober test:
hip extension may detect iliotibial band (ITB) problem
What is seen in the picture on the right?
Arthritic hip joint
Different hip disease that can appear at different ages:
Hip Osteoarthritis is most common in the elderly.
Congenital Hip Disorders appear in the very young.
- Slipped Capital Femoral Epiphysis (SCFE), Legg-Clave-Perthes Disease (LCP)
Trochanteric Bursitis can appear at all ages.
Avascular Necrosis of the hip can be idiopathic but more frequently is associated with a corticosteroids, alcoholism and systemic disease (Lupus and Rheumatoid Arthritis).
What is the most common predisposing factor for hip oestoarthritis?
Age
Hip MRIs are beneficial in early diagnosis of:
Inflammatory
Infectious
AVN
Describe SCFE:
Slipped Capital Femoral Epiphysis
a fracture of the growth plate and is a pathology of adolescence, usually causes hip and groin pain, often can cause thigh and knee pain
Describe LCP
Legg-Clave-Perthes Disease
a childhood hip disorder initiated by a disruption of blood flow to the femoral head causing avascular necrosis. Over time, healing occurs by new blood vessels infiltrating the dead bone and removing the necrotic bone which leads to a loss of bone mass leading to some degree of collapse and deformity of the femoral head and sometimes secondary changes to the shape of the hip socket.
Knee pain can refer to what area?
Thigh
Lower back
Leg
Three compartments of the knee:
Tibiofemoral
Patellofemoral
Proximal tubiofibular
What 3 bones make up the knee?
Tibia
Patella
Femur
What is the one quad which both crosses the knee and hip, and acts to extend the knee and flex the hip?
Rectus femoris
When assessing the knee, look at:
Gait
ROM
Reflexes
Pulses
Patellofemoral pain appears twice as often in ____ and is aggravated by what?
Women
Squatting, climbing stairs, prolonged sitting, running, lifting
_______ of the knee presents with morning stiffness, knee crepitus, bony tenderness, bony enlargement, & no palpable warmth of the knee
Osteoarthritis
What does a + moviegoer’s sign mean?
patient experiences their main complaint with sitting for a long time with their knees flexed at 90 deg.
What kind of tear is common in OA after twisting the knee with a fixed foot?
Meniscal
What is most commonly at the pre-patellar once it becomes infected and may require aspiration?
Bursitis
What type of knee injuries are common with trauma?
Ligamentous
Most knee injuries are what type of injury?
Soft tissue
Explain the Ottawa rules for imaging:
- Age > 55
- Tenderness at the head of the fibula
- Isolated tenderness of the patella
- Inability to flex knee to 90 degrees
- Inability to walk 4 weight bearing steps
- Plain radiography is an appropriate first line
- If unrevealing MRI is useful for the detection of ongoing knee instability
