Musculoskeletal System and Pain. A thorough assessment of the musculoskeletal system provides vital information on the health status of the client such as exercise and metabolism. Bone density and curvatures of the musculoskeletal systems vary widely in different cultural groups. A change in bone density and injury to the skeletal system from working environments create risks for trauma and long-term disability.
Clients seeking care for musculoskeletal issues often complain of joint pain or muscular injury. We want to gain as much information as possible about the current condition or injury that has motivated them to seek care. Don’t forget, when delving into the history of musculoskeletal injuries, to ask about any medications they are taking because many medications can affect the musculoskeletal system. Also inquire into their lifestyle habits. What kind of job do they have? What are their hobbies? Many of these activities have repetitive motions, which can lead to stress injuries. Previously you were taught this mnemonic device to inquire about chest pain. It is also a good tool to utilize any time you wish to obtain more information about other types of pain.
Precipitating or Palliative: What precipitates the symptom? Does stress, anger, or certain physical positions or factors trigger the symptom or make it worse? What makes the symptom lessen or subside?
Quality or Quantity: What does the symptom feel like, look like, or sound like? Are you having the symptom right now? If so, is it more or less severe than usual? To what degree does the symptom affect your normal activities?
Region or Radiation: Where in the body does the symptom occur? Does the symptom appear in other regions, and if so, where?
Severity: How severe is the symptom? How would you rate it on a scale of 1 to 10, with 10 being the most severe? Does the symptom seem to be diminishing, intensifying, or staying the same?
Timing or Temporal: When did the symptom begin? Was the onset sudden or gradual? How often does the symptom occur? How long does the symptom last?
The Physical Examination
The musculoskeletal examination begins when you first meet the patient. Notice how the patient walks, moves, and stands. These observations can provide cues for detecting musculoskeletal problems; they help make up your general physical assessment of the patient.
Follow this general assessment with an examination of specific muscles and joints using the techniques listed below. These techniques are performed simultaneously rather than sequentially, as is done in other physical assessments.
- Range of motion (ROM)
- Tests for muscle strength
Attention to health history taking is very important because patients will occasionally make general comments that suggest problems.
During your assessment for range of motion, be alert to age limitations because muscles tend to become weaker as clients age and adopt sedentary lifestyles. Older adults are more prone to falls due to loss of balance because of postural changes over their lifespan.
Identifying Muscle Strength
Drag the terms at the bottom to their matching definitions below.
Full range of motion against gravity with moderate resistance
Full range of motion with gravity
No muscle contraction
Full range of motion without gravity (passive range of motion)
Full range of motion against gravity with full resistance
Strength Rating 4
Strength Rating 5
Strength Rating 3
Strength Rating 2
Strength Rating 0
When there has been a musculoskeletal injury, it is essential that you astutely and skillfully assess the injury. This more detailed assessment determines the severity of the injury and whether the injury is improving or worsening. This graphic illustrates the five Ps of musculoskeletal injury, or the five Ps of neurovascular assessment.
Psychosocial, Cultural, and Environmental Considerations
Musculoskeletal degeneration that occurs with disease, inactivity, and aging can affect the psychosocial status of the client including altered body image. Any disturbance in self-esteem may produce symptoms of anxiety or depression. Impaired physical ability and the ability to do all the things the client has always done, such as activities of daily living, can lead to stress, hopelessness, and other psychosocial problems. Clients of all ages that have a history of frequent fractures, sprains, or any trauma to the musculoskeletal system should be assessed for physical abuse. State laws for reporting vary from state to state.
Focus Areas for Musculoskeletal Health
- Physical activity
- Increase the number of adults and children who participate in moderate and vigorous physical activity.
- Increase the number of those who perform activities to improve and maintain strength, flexibility, and endurance.
- Reduce the number of adults who have activity limitations as a result of arthritis.
- Increase the number of individuals with arthritis who maintain independence.
- Increase the number of people who seek healthcare for chronic joint pain.
- Reduce disparities in joint replacement.
- Reduce proportion of adults with osteoporosis.
- Reduce activity limitations from chronic back conditions.
Introduction to the Concept of Pain
Nociceptive pain develops when functioning and intact nerve fibers in the peripheral and the central nervous systems are stimulated. This can be triggered by events outside the nervous system from actual or potential tissue damage. Nociception can be divided into four phases: (1) transduction, (2) transmission, (3) perception, and (4) modulation.
- Transduction pain = injured tissue; pain receptors move along the spinal cord
- Next is transmission = moves from spinal cord to brain
- Then you have perception = knowing you have pain
- Finally, Modulation = Neurons release neurotransmitters to block the pain impulses.
Neuropathic pain is pain that does not adhere to the typical and rather predictable phases in nociceptive pain. It is “pain caused by a lesion or disease of the somatosensory nervous system” (Jarvis, 2016).
Neuropathic pain implies an abnormal processing of the pain message from an injury to the nerve fibers. This type of pain is the most difficult to assess and treat. Pain is often perceived long after the site of injury heals, and it evolves into a chronic condition
Acute pain is usually a short-term pain lasting weeks to 6 months and usually follows a predictable trajectory resolving as an injury heals. Examples of acute pain include surgery, trauma, and kidney stones. Acute pain has a self-protective purpose; it warns the individual of actual or threatened tissue damage.
Chronic or persistent pain is diagnosed when the pain continues for 6 months or longer. Chronic pain can be divided into malignant (cancer-related) and nonmalignant. Malignant pain often follows the pathology created by the tumor cells. The pain is caused by tissue necrosis or stretching of an organ by the growing tumor. Chronic nonmalignant pain is often associated with musculoskeletal conditions, that is, arthritis, low back pain, or fibromyalgia, just to name a few.