The speed with which I say that is noteworthy considering years ago that question wasn’t high on my list. When you effectively probe patients about their symptoms (most notably via a good verbal history), you’ll notice it’s actually not that common for people to have a symptom in only one isolated spot. A man might come see you because the front of his right knee hurts, but with questioning you find it’s also sometimes on the left knee and his back gets tight sometimes. Or a woman has left neck pain but when you do movement testing she notices right neck pain too. Or a kid says the outside of his elbow hurts but, yes, the inside of his elbow is tingly.
Where the symptom is is extremely important - regarding someone’s history, during the physical exam, and during repeated movements. The pain someone is describing could be in a completely different area (for example, wrists hurting with prone lumbar extension) or it could be relevant. Where the pain is matters in terms of both diagnosis and treatment; if I didn’t have that information I’d be lost. Most importantly, it tells me information about which structure is misbehaving (significantly, joint vs musculotendinous tissue), which movements are likely to be beneficial, and how to interpret the effect of movements. -- Laura
If it's accepted that arm and leg pain can originate from the spine, it should be understood that joint pain can as well. I screen the spine with extremity limb and joint complaints. Forearms, thighs, arms, legs, hands, and feet are not entirely different from wrists, hips, elbows, shoulders, knees, and ankles. Limb (between joints) pain is more often coming from the spine than isolated joint pain, but it still happens frequently. Clinicians need to look for this referred and radicular pain. I use repeated movements of the spine to investigate if extremity joint pain is indeed spinal in origin, which could take anywhere from a few minutes to a few visits. -- Laura
Certain diagnoses create constant symptoms. Certain diagnoses create consistent symptoms. Constant numbness, tingling, pain, etc. means it’s there every waking moment. It may vary in intensity, but it’s there regardless of your activity or position. Consistent is similar to predictable. Each and every time I jump my knee hurts. Each and every time I bend to put on my shoes my calf feels like it’s on fire. Each and every time I play golf three days in a row my shoulder acts up. As a clinician, I need to know which questions to ask and then how to interpret the patient’s answers to accurately diagnose.
We accept the fact that realigning a fractured bone creates a brief increase in pain for the greater good, correct? Nobody wants pain, but sometimes pain is a necessary part of getting better. It’s my job to educate patients regarding the multifaceted and subjective experience of pain. If I provide patients with intelligent explanations, any fear or anxiety is usually diminished.
When does getting better with physical therapy permit or even necessitate pain? One example is centralization in a deranged (stuck) joint. If mild pain in the arm moves to the neck as a result of neck exercises, this is a positive outcome, even if the neck pain is temporarily more burdensome. Secondly, pain with specific exercises addressing a dysfunctional knee tendon is necessary, but it should not last long after the exercise is finished. Finally, stretching a frozen shoulder as far as it can go should also hurt, but, again, that pain should not last.
With surgical care for orthopedic problems, anesthesia is used to mitigate pain. With conservative care like physical therapy, patients can use rest, ice, heat, etc. to address any temporary increase in pain.
“Deranged” is not a scary word. It’s simply the term I use when a joint isn’t working perfectly. Moving any deranged joint (like the neck joint example above) can hurt to perform. There are specific rules, however. If we have the correct exercise for that joint, pain should improve with repetitions of the prescribed exercise. It should become less frequent, less intense, or less widespread. Pain after the exercise should not last.
Again, it’s my job to know this stuff and to teach it to patients. There are MANY variables when it comes to pain with rehab which vary according to diagnosis, prognosis, individual, and so on. More pain as a result of physical therapy that actually disrupts a patient’s life is very rare. Through education and following the rules, we can accomplish the long-term goal of eliminating pain with little to no increase in short-term pain. --Laura
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