• Identify Musculoskeletal Cause for Pathokinesiologic Disorder

• Identify Signs and/or Symptoms that Require Evaluation by a More Appropriate Health Care Provider (Especially important if patient is direct access to PT services)

• Systemic Disease
• Psycho-emotional Disease
• Disease that Mimics Musculoskeletal Problem

• Pain of musculoskeletal origin can be reproduced by tensing the tissue at fault

• If the pain can't be reproduced by tensing the tissues, suspect non-musculoskeletal origin (this is a biggie!)

• PT Contraindicated

• Treatment is outside the scope of PT (see "Red Flags")

• Medical diagnosis not established

• Funnel Technique

• Open-ended questions
• "How does bedrest affect your back pain?"
• Closed-ended questions
• "Do you have any pain after lying in bed all night?"
• Follow-up Questions

• Paraphrasing

• Family illnesses

• Social, occupational, living envoirnment

• Medications

• Systems screen -
• endocrine/metabolic
• cardiopulmonary
• gastrointestinal
• genitourinary
• integumentary
• musculoskeletal
• neuromuscular
• pregnancy, delivery, postpartum

• Hospitalizations, surgeries, other prexisting medical or health-related conditions

• Vital Signs

• Normal resting pulse = 60 - 100 bpm
• greater than 20 bpm elevation more than 3 minutes after exertion or change in position is abnormal
• Normal BP = 90/70 to 140/90 (young adults), 160/100 elderly males, 170/90 elderly females
•   Normal temperature = 97 to 100.2 degrees F

Medical Referral is required if undiagnosed systemic signs and symptoms are present

Here are some "Red Flags" (undiagnosed and unexplainable signs and symptoms that require medical referral):

Gastrointestinal abdominal pain anorexia dysphagia early satiety heartburn indigestion nausea vomiting (hematemesis) weight loss (10 - 15 lbs in 10 - 15 days) weight gain (unexplained, significant, recent) bowel and baldder changes: constipation diarrhea blood in stool	Neurologic dizziness dysesthesia bilateral symptoms headaches paresthesia vision changes
Cardio-pulmonary hemoptysis dyspnea palpitations chest pains persistent cough	Other chills, fever diaphoresis fatigue, weakness hoarseness jaundice night pain night sweats skin rash sores lumps or thickenings
Genito-urinary, reproductive hematuria difficulty/pain with urination hematospermia abnormal menstration breast abnormalities

• Conversion Reaction

• emotional response leads to a physical manifestation (a sign or symptom)
• bizarre gait or movement pattern
• jerky muscle test
• inconsistency
• non-anatomic sensory changes

(also see Nonorganic Physical Signs in Low Back Pain)

Reference: Goodman, CC: Red Flags: Recognizing signs and symptoms, PT Magazine, Sept 1993, pp 55-62.