MSK Upper Quadrant

• Clinical Reasoning Framework:

  • consider the person:
  • find out more about pats
  • hobbies, social context, family, lifestyle, medical background, job, their thoughts on physio
  • all of these help form a good development plan
  • triage for red flags e.g. special questions
  • stage and SIN helps decide how to manage pts and prognosis
  • dominant pain mechanism helps decide what the cause of the pain may be
  • is diagnosis specific or non-specific (no particular structure at fault for the pathology)
  • what is pts main problem e.g. pain, capacity, function
  • hypotheses & prognosis

  
• Red flags:

  • signs and symptoms that indicate possible presence of serious medical conditions that can cause irreversible disability or death unless managed properly
  • every pts presenting with neck pain should have the 5 D's (dizziness, dysafnia (articulation problems), dysphasia (swallow problems), diplopia (double vision), drop attacks) and 3 N's (nausea, nystagmus, numbness) excluded
  • these are asked in the subjective history and should be cleared before assessment
  • if someones has any of the 5 D's, 3 N's or other special questions, need to ask more to make sure its due to the injury
• Radiculopathy:

  • where there is impingement of nerve roots by a disc or any osteophytes, there can be mechanical compression of the nerve root, leading to ischemia and nerve damage
  • local inflammatory mediators will add to pain
• Somatic referred pain:

  • Manifestation:
  • dull, aching, gnawing and difficult to localise pain
  • inconsistent and non-dermatomal pattern
  • Mechanism:
  • the convergence of nociceptive afferents on second order neurons in the spinal cord that also happen to supply regions of the lower limbs
• Radicular pain:

  • Manifestation:
  • Lancinating, shocking, electric feeling in a thin band
  • Mechanism:
  • compression and/or inflammation leads to abnormal discharges spreading from the dorsal root or its ganglion
• Management framework

  A) context

  B) advice and education

  C) symptom control

  D) build capacity

  E) return to function

  
• Red flags - 5 D's and 3 N's:

  • D:
  • Dizziness
  • Diplopia, blurred vision or transient hemianopia
  • Drop attacks (loss of power or consciousness)
  • Dysphagia (problems swallowing)
  • Dysarthria (problems speaking)
  • N:
  • Nystagmus (bouncing pupils)
  • Nausea or vomiting
  • Numbness
  • (Other neurological symptoms)
  • 5 others:
  • Light headiness or fainting
  • Disorientation or anxiety
  • Disturbances in the ears - tinnitus
  • Pallor, tremors, sweating
  • Facial paraesthesia or anaesthesia