Subjective Assessment

Pain associated with the MSK system can be described in many ways such as aching, sharp, cramping, stiffness, or burning sensation. Myalgia is a term that refers to muscle aches and pains.

Clients may tell you about pain in their muscles, joints and bone. Sometimes they might not be able to specify, but instead just show the location. Thus, your assessment is important to figuring out the issue.

You might start by asking: Do you currently or have you recently had any pain or other sensations in your joints, muscles, or bones?

If the client’s response is affirmative, ask: Do you have the pain now?

Additional probes may include:

Region: Where do you feel the pain/sensation?

Radiation: Does the pain radiate to another part of your body

Quality/quantity: Tell me about it. What does it feel like? How bad is it?

Severity: Can you rate your pain on a scale of 0 to 10 with 0 being no pain and 10 being the most pain you have ever had?

Timing: When did it begin? What were you doing when it began? Is it constant or intermittent? Do you wake up with the pain and if so, how long does it last?

Provocative/palliative: Is there anything that makes it worse? (If you suspect a fracture, it may be appropriate to ask if movement increases the pain because fractures can cause sharp, intense pain with movement). Is there anything that makes it better?

Treatment: Have you treated it with anything? Do you take any medications for it? Does it work? Have you sought treatment regarding this pain? If the pain is in the lower extremities, does walking relieve or aggravate it?

Understanding: Do you know what is causing it or what it is related to? Did you have a recent injury?

Other questions: How does the pain affect your life? Does it affect your activities of daily living? What type of work do you do? Does it involve physical activity or heavy lifting? Does it involve sitting/standing for long periods of time?

If the client has had an injury or a fall, you may suspect a fracture if they describe a sharp and intense pain on movement or when they attempt to bear weight. If you suspect a fracture, assess for potential deformities, swelling, and decreased circulation distal to the location. Immediate help may be required to decrease the risk of further injury to the MSK, peripheral vascular, and nervous systems, as well as respiratory system (e.g., a fractured rib).

When caring for clients with impaired cognition or with clients who are preverbal or non-verbal, refer to the pain assessment chapter, particularly pain tools related to children, cognitive impairment, and critical care.

When possible, clients should monitor their pain level and treatment strategies with chronic pain. You might ask them to document their pain in a journal and discuss further strategies for pain management.

Types of pain management strategies for some MSK conditions may include non-opioid medications, e.g., acetaminophen or ibuprofen. Non-medicinal pain strategies could include deep breathing exercises, massage, physiotherapy, stretching, ice and heat, and some rest (but you should tell the client it is important to maintain light activity).

Headache is a specific type of pain that can be felt in one certain location or all over the head. It can be described in many ways including sharp, achy, throbbing, full, or squeezing with a viselike quality.

You should inquire about the presence of severe and frequent headaches.

Headaches can be related to the MSK (e.g., tension or cervicogenic headaches) or neurological system (e.g., migraine). Assessment will help you start thinking about which system could be causing the headache. A headache can be the primary cause (e.g., migraine, tension headache) or secondary cause (e.g., cervicogenic or sinus headaches). For example, migraines are primarily related to the neurological system, but head/neck pain and stiffness can occur due to tension that can affect the MSK system; this would be considered a secondary cause.

Do you currently have a headache? Have you recently experienced any headaches that you are concerned about? Do you have frequent, severe, and/or reoccurring headaches that disrupt your day-to-day functioning?

Remember to incorporate the language that the client uses into your probing questions.’

Additional probes if the client’s responses are affirmative may include:

Quality/quantity: What does your headache feel like? How bad is your headache?

Severity: Can you rate your headache on a scale of 0 to 10 with 0 being no pain and 10 being the most pain you have ever had?

Region/radiation: Where do you feel your headache? Does it radiate anywhere?

Provocative/palliative: Is there anything that makes your headache worse? Is there anything that makes your headache better?

Timing/treatment: When did the headache begin? Was it sudden or gradual? What were you doing when it began? Is it constant or intermittent? Have you taken anything to treat your headache? Have you taken any medications

Understanding: Do you know what is causing the headache? Do other members in your family experience similar headaches?

Other: How does it affect your daily life?

Almost everyone has had a headache. Common causes include stress, dehydration, changes in sleep, poor posture/body alignment, and certain foods (e.g., nitrates).

Frequent and severe headaches are more concerning.

It is important to determine if the headache is primary (e.g., migraine, tension) or secondary and related to another medical condition (e.g., head injury, trauma, tumor, stroke). A sudden onset of a severe headache may require immediate intervention. You should call for emergency help if it is accompanied by confusion, trouble seeing, speaking, or walking, fainting, or numbness/weakness. This kind of headache could be related to a stroke, brain aneurysm, or other serious medical condition.

Joint stiffness refers to when joint movement is limited or difficult (medical term is ankylosis). The joint may feel achy or sore.

Joint stiffness can be caused by degeneration of cartilage and/or decreased synovial fluid being produced with age. It can also be caused by other MSK conditions such as arthritis, gout, or bursitis.

Do you currently have any stiffness in your joints? Have you had any recent stiffness in your joints?

Additional probes if the client’s responses are affirmative may include:

Quality/quantity: What does it feel like? How bad is it?

Region: Which joints feel stiff?

Timing: When did it begin? Is there a time of day when the stiffness is worst? Is it constant or intermittent? If intermittent, how long does it last for?

Provocative/palliative: Is there anything that makes it better (e.g., position)? Is there anything that makes it worse (e.g., exercise or sitting for long periods of time)? Is it aggravated or associated with any specific movements?

Treatment: Have you treated it with anything (e.g., ice, heat, exercise)? Do you take any medications or supplements for it? Do you use any mobility aids?

Understanding: Do you know what causes your joint stiffness? Do you have any related symptoms (e.g., pain, swollen glands or lymph nodes, increased saliva production)?

Other: How does it affect your ability to move around? How does it affect your sleep?

Joint stiffness is a common MSK concern. Understanding the pathophysiology of the cause of the stiffness will help you determine effective interventions.

You should assess the location of the joint stiffness to help determine the cause and whether and how it is affecting the client’s activities of daily living.

Preventive strategies that can ease joint stiffness include gentle range of motion movements, exercise (e.g., walking), hot and cold compresses, good body alignment/posture, managing weight, and balancing rest and activity.

Muscle spasms are involuntary muscle contractions.

The cause of muscle spasms is often unknown, but they can be related to inactivity, fatigue, stress, lack of stretching, dehydration, overuse of the muscle, or pain. Muscle spasms can feel like a twitch or cramping and can create pain.

Do you experience muscle spasms?

If the client’s response is affirmative, additional probes might include:

Quality/quantity: Tell me about the muscle spasm. What does it feel like? How bad is it?

Region: Which muscle(s) has the spasm?

Timing: How often do you have them? When did it begin? When do you feel the muscle spasm (e.g., at night, after exercise)? Is it constant or intermittent?

Provocative/palliative: Is there anything that makes it better? Is there anything that makes it worse? Is it aggravated or associated with any other symptoms?

Treatment: Have you treated it with anything (e.g., stretching, hot or cold compresses)? Do you take any medications or supplements for it?

Understanding: Do you know what caused the muscle spasm or what it is related to?

Assess the cause of the muscle spasm and associated signs and symptoms. If it is related to a neurological system concern, symptoms will vary (e.g., numbness, paralysis, tremor) and other interventions will be required.

Adequate water intake, especially during exercise or warm weather, will assist with dehydration-related muscle spasms.

Some clients will describe intense muscle spasms in the night, particularly in the calf muscle. Stretching and massaging the spasm can relieve the symptoms.

Stretching before and after activities, as well as after being stationary for long periods, will help decrease the risk of muscle spasms.

Mobility, lack of balance, and weakness.

A person’s mobility can be affected and limited by their joints, muscles, or bones, as can lack of balance and weakness.

Tell me about your mobility? Tell me about your daily activities and exercise?

Do you have any limitations when walking, standing, sitting, or any other body movements?

Do you have mobility limitations? For example, do you have any concerns with your balance or any weakness while moving?

Do you use any mobility aids (e.g., walker, cane, crutch, bar handles, wheelchair, prosthetics)?

If the client’s response is affirmative, additional probes might include:

Quality/quantity: Tell me about your mobility concerns. What does it feel like? How bad is it?

Region/radiation: Which part of your body experiences limitations or weakness related to your mobility/movement? Does the limitation/weakness remain in the one location or does it move to another location (e.g., hip to knee)? Does this happen when you walk for longer periods of time?

Timing: When do you feel a lack of balance or weakness when you are mobile? When did the mobility concerns begin? How long have you been experiencing the limitation or weakness? Is it constant or intermittent?

Provocative/palliative: Is there anything that makes it better? Is there anything that makes it worse? Does a certain movement or activity aggravate it or make it feel better? Is it associated with any other symptoms (e.g., pain or numbness)?

Treatment: Have you treated it with anything (e.g., stretching, hot or cold compresses, mobility aids)? Do you take any medications or supplements for it (e.g., ibuprofen, fish oil)? Do you regularly use any mobility aids?

Understanding: Do you know what caused the mobility issue or what it is related to? How does it affect your daily life?

Mobility will depend on the client’s developmental age, current health, and morbidity status. It can also be affected by certain medications that can affect balance or cause fatigue.

Help the client take precautions against falling. Think about the SAFE mnemonic:

• Safe environment (e.g., well-lit environment, tripping hazards removed).
• Assist with mobility (e.g., if relevant, ensure mobility aids and glasses are in reach, document and assist with mobility).
• Fall risk reduction (e.g., non-slip footwear, bed in lowered position, call bell in reach).
• Engage the client and family (e.g., having conversations about risk factors and prevention).

(Canadian Institute of Patient Safety, 2015).

You should identify any risk for falls: fall-related injuries are the number one cause of death in seniors (Canadian Fall Prevention Curriculum, 2017).

A careful assessment is needed for any client at risk of falling. Various assessment tools are available to systematically assess risk factors related to falls, which include history of falls/near falls, acute condition, ability to move around, mobility aids, or hearing, vision, or cognitive impairment.

If the client has already been assessed, you should follow recommendations, as well as all institutional policies to prevent falls.

If the client has mobility limitations, assess how this affects their overall daily life (e.g., physically, psychosocially, financially).

Redness, swelling, temperature changes, and deformities may be related to the joints, muscles, or bones.

Always ask one question at a time. Questions might include:

Have you experienced any redness (or swelling or temperature changes or deformities) in any joints (or muscles or bones)?

Use variations of the PQRSTU mnemonic to assess these symptoms further if the client’s response is affirmative.

These symptoms can be related to the MSK system or another body system. You should assess each symptom individually to determine the systematic cause.

Injury and trauma can cause a range of musculoskeletal symptoms and/or exacerbate existing issues. It is important to explore the mechanism of injury.

Have you had any recent injuries/trauma?

If the client’s response is affirmative, additional probes might include:

Quality/quantity: Tell me about the injury/trauma? What does it feel like? How bad is it?

Region/radiation: Which part of your body experienced the injury/trauma? Have the effects of the injury/trauma remained in one location or is another location affected?

Timing: When did the injury/trauma occur? How long have you been experiencing it?

Provocative/palliative: Is there anything that makes it better? Is there anything that makes it worse?

Treatment: Have you treated it with anything?

Understanding the mechanism of injury and how the injury occurred will inform your objective assessment and interventions.

Other MSK symptoms can include fatigue, numbness, dizziness, or flu-like symptoms.

Always ask one question at a time. Questions might include:

Have you experienced any body fatigue? (or numbness or dizziness or flu-like symptoms?)

Use variations of the PQRSTU mnemonic to assess these symptoms further if the client’s response is affirmative.

These symptoms can be related to other body systems and non-MSK issues. To determine whether they are MSK related, you will need to explore these symptoms along with any other associated symptoms.

Personal and family history of MSK conditions and diseases.

Some of the common issues associated with the MSK system, including back pain, repetitive strain injury (RSI) such as carpal tunnel syndrome or tendinitis, osteoarthritis (OA), rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), gout, and fibromyalgia, can have a familial connection.

Do you have any chronic conditions or diseases that affect your muscles, bones, and joints? Do you have a familial history of conditions or diseases that affect the muscles, bones, and joints (e.g., arthritis, lupus, gout, and fibromyalgia)?

If the client’s response is affirmative, begin with an open-ended probe: Tell me about the condition/disorder/disease?

If the client has a personal history, probing questions might include:

Timing: When did you begin experiencing symptoms related to this condition? When were you diagnosed? Are the symptoms constant or intermittent?

Quality/quantity: How does it affect you? What symptoms do you have? How bad are the symptoms?

Treatment: How is it treated? Have you had any surgeries? Do you take medication?

Provocative/palliative: Is there anything that makes it worse? Is there anything that makes it better?

The biological and non-biological nature of family may be important to consider when asking questions: risk factors may be influenced by genetics and/or culture and/or environmental factors.

Some musculoskeletal disorders are related to genetics (e.g.,  (e.g., achondroplasia, Duchenne muscular dystrophy, osteogenesis imperfecta), but it is more common that a combination of environment and cultural factors play a larger role (e.g., osteoarthritis, degenerative disc disease).