Oxford Handbook of Rheumatology (Oxford Medical Handbooks) 3rd Edition

Book Preface

Adults and children can present with musculoskeletal (MSK), inflammatory, and autoimmune diseases in varied ways. Symptoms can be simple and focal, such as regional pain, or general and non-specific, often in the context of a generalized process such as fever or fatigue. The following are important points in assessing the time, type, and nature of presentation:

•Why someone has presented at a particular time.

•What is the impact of symptoms, emotionally and functionally.

•The individual’s perceptions, fears, or cultural references that might modify (amplify or suppress) expression of the symptoms.

•What fears, beliefs, and factors might present a barrier to effective medical engagement.

•The same pathological processes might present variably at different ages: broadly speaking, the young, adults, and the elderly.

In this chapter, the assessment of symptoms has been separated into two parts. First, the assessment of symptoms in adults and second, the patterns of disease presentation in children and adolescents.

Musculoskeletal pain in adults
Introduction
The most common presenting symptom to the rheumatologist is unexplained or ineffectively treated MSK pain.

•Pain is defined by its subjective description, which may vary depending on its physical (or biological) cause, the patient’s understanding of it, its impact on function, and the emotional and behavioural response it invokes.

•Pain is particularly prone to be ‘coloured’ by cultural, linguistic, and religious differences. Therefore, pain is not merely an unpleasant sensation to many; it is, in effect, an ‘emotional change’.

•Pain experience is different for every individual.

Localization of pain
Adults usually localize pain accurately, although there are some situations worth noting in rheumatic disease where pain can be poorly localized (Table 1.1):

•Adults may not clearly differentiate between periarticular and articular pain, referring to bursitis, tendonitis, and other forms of soft tissue injury as ‘joint pain’. Therefore, it is important to confirm the precise location of the pain on physical examination.

•Pain may be well localized but caused by a distant lesion, e.g. interscapular pain caused by mechanical problems in the cervical spine, or right shoulder pain caused by acute cholecystitis.

•Pain caused by neurological abnormalities, ischaemic pain, and pain referred from viscera is harder for the patient to visualize or express, and the history may be given with varied interpretations.

•Bone pain is generally constant despite movement or change in posture—unlike muscular, synovial, ligament, or tendon pain—and often disturbs sleep. Fracture, tumour, and metabolic bone disease are all possible causes. Such constant, local, sleep-disturbing pain should always be investigated.

•Patterns of pain distribution are associated with certain MSK conditions. For example, polymyalgia rheumatica (PMR) typically affects the shoulder girdle and hips, whereas rheumatoid arthritis (RA) affects the joints symmetrically, with a predilection for the hands and feet.

•Patterns of pain distribution may overlap, especially in the elderly, who may have several conditions simultaneously, e.g. hip and/or knee osteoarthritis (OA), peripheral vascular disease, and degenerative lumbar spine all may cause lower extremity discomfort.