treatment/rehabilitation programme was a good idea. The most obvious symptom is

understands the rules of referred pain, then it can be seen that a client indicating medial knee pain with a vague wave of the hand around the area, is suffering from a different complaint to another client who indicates their medial knee pain with the pointing of one finger. In the latter case it is likely that local pathology is allowing the client to localise the sensation somewhat more accurately than in the former case, where pain may be referred to the knee from some pathology of the hip joint. Linked to site of pain or symptoms, is that of spread. Ask the client whether their pain stays localised to the same area, or does it move in anyway. Again knowledge of referred pain may further add to the evidence that the symptoms being experienced are from a referred source more proximal to the site of perceived pain.

Onset and duration It is always useful to attempt to find out what factors may have lead to the onset of the client’s problem. Generally there are three forms of onset; gradual, sudden, and insidious. The latter is a term that refers to an onset of unknown origin, and can apply itself across both of the former two onsets (i.e. insidious gradual, or insidious sudden). Sudden onsets are usually associated with trauma, and as such a ‘mechanism of injury’ may be established. Using sound anatomical and biomechanical knowledge, it may help to identify the tissues likely to be causing the symptoms. Gradual onsets may be the result of overuse, or repeated trauma (e.g. tendonitis). Examples of insidious onsets may be pathologically more severe or even sinister; insidious gradual may be onset of a tumour, insidious sudden may reflect a systemic problem

such as gout. Duration is an interesting one as it

can provide an idea of how likely you are to be able to change the client’s symptoms. Generally speaking the longer someone has a condition, the less likely you are to be able to change or cure it. That does not mean to say that one should not attempt to change it; you may be the first therapist to be approached about the condition, or the first to actually accurately diagnose the problem.

Behaviour and symptoms What you are looking for under the heading of behaviour is how do the symptoms change during the day, are they constant, and what aggravates or what eases them? Is there any diurnal variation? That is, what are the symptoms like first thing in the morning, later in the day, at night? Conditions affecting the capsule and ligaments tend not to like extensive static periods and feel ‘stiff’ when first moving, and better once moved. Tendonitis tends to be worse either during or after activity, whereas muscle lesions hurt on movements that recruit that particular muscle. It is rare for symptoms such as pain from musculoskeletal origin to be constantly present (this is the often the manifestation of internal organ problems or systemic disease). Musculoskeletal pain often is intermittent and movement dependant, and identifying what movements cause the onset of symptoms, and what positions cause relief, can help identify the tissue at fault. It may also help with provision of treatment if someone identifies that movement and application of warmth helps their knee. This would indicate that incorporating some kind of heat treatment and mobilisation or exercise into their

MAY ALSO GIVE AN IDEA OF WHETHER THEY HAVE HAD DISTURBED SLEEP!

14

THE FACE CAN GIVE CLEAR INDICATIONS OF PAIN, WHETHER SEVERE, OR PROLONGED, AND

pain however some clients complain of other sensations such as locking, giving way, pins and needles (paraesthesia) and even numbness (anaesthesia). They may also complain of stiffness (as a symptom, as opposed to lack of range of motion – which you would measure as objective sign). There are many authors who have written about pain and the types of pain that people experience and relate this to the various types of tissue (1,4,5,). The fact that the pathophysiological mechanisms behind pain and its perception is so complex is further complicated when psychological influences are included (6). This makes clinical reasoning of pain become more subjective which may lead to many opportunities for misunderstanding. For example, clients have described the pain of sciatica as ‘feeling like a red-hot poker down the back of my leg’, or sharp knee pain as ‘feeling like I have been stabbed’. As both the client and the therapist need to fully understand what is meant by such descriptions, and either or both may misinterpret what is really being experienced, diagnosis based on such reasoning may be flawed.

Previous medical history (PMH) and medication Many therapists like to ask questions around this subject early on in the interview, however this may result in digging up matter that is quite personal. Leaving it to the end on the other hand, allows you to establish rapport with your client. Again, there are many things to consider here, ideally keep it reasonably simple. Several forms of treatment are contraindicated by the presence of certain conditions and there are too many to consider at this stage of assessment (as you have no idea what treatments you wish to perform at this point). Therefore, ask the client whether they have had any previous major operations, accidents or illnesses. The common response to this is a glib ‘no’, so it is useful to double check and ask them again whether they are sure. This has the purpose of ensuring the client realises that this is an important question requiring careful consideration. You may well get the same original response, however you are more likely to be able to trust this

sportEX dynamics 2010;24(Apr):13-15