Differential Diagnosis > Pain Types and Patterns > Flashcards

Pain Types and Patterns Flashcards

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1
Q

T/F: organs are richly innervated with nerve fibers and specific nociceptors

A

FALSE

actual nerve fibers and specific nociceptors have not been found in organs

suspected pain transmission from organs is a result of peripheral mechanisms

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2
Q

Why can the cortex not distinguish where pain messages originate from?

A
  1. low receptor density
  2. large overlapping receptive fields
  3. extensive convergence in the ascending pathway
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3
Q

What are the 3 proposed mechanisms of referred visceral pain?

A
  1. Embryologic development
  2. Multisegmental innervation
  3. Direct pressure and shared pathways
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4
Q

describe the embryologic development theory of reffered pain

A
  • Thought that embryologic development has primary role in visceral referred pain patterns
    • pain is referred to a site where the organ was located in fetal development
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5
Q

Provide 3 examples of the embryologic development theory of reffered pain

A
  1. Thoracic disorders referring to abdomen
    • Chest was part of the gut in embryologic development
    • pneumonia or pleuritis may be percieved in abdomen instead of chest
  2. Heart disorders referring to abdomen
    • pericardium is formed from gut tissue
    • MI and pericarditis can refer pain to abdomen
  3. Kidney and ear
    • come from the same embryologic tissue
    • anomaly of ear at birth assocaited with similar anomalies of kidney on same side
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6
Q

Describe the multisegmental innervation theory of reffered pain

A
  • Organs have multiple levels of innervation
  • Referred visceral pain to somatic tissue may be due to overlapping of same segmental projections of spinal afferent neurons to the spinal dorsal horn
    • visceral-organ cross-sensitization
    • pain of visceral origin → corresponding somatic area
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7
Q

Provides some examples of multisegmental innervation

A
  1. Cardiac pain
    • not felt in heart, but referred to areas of corresponding spinal nerve (C3-T4)
      • Jaw
      • Neck
      • Upper Trap
      • Shoulder
      • Arm
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8
Q

Describe the direct pressure and shared pathways theory of reffered pain

A
  1. Viscera near diaphragm become inflammed/irritated and swell/enlarge and then press onto and irritate the diaphragm
  2. pain pattern is ipsilateral to area of irritation
    • spleen → L shoulder
    • Tail of pancreas → L shoulder
    • Head of pancreas → R shoulder
    • Gallbladder → R shoulder
    • Liver → R shoulder
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9
Q

how do impingments upon different portions of the diaphragm manifest differently?

A
  1. impingement on central diaphragm → refers to shoulder
  2. impingement on peripheral diaphragm → refers to ipsilateral costal margin and/or lumbar region
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10
Q

List several possible sources of pain

A
  1. Cutaneous
  2. Somatic
  3. Visceral
  4. Neuropathic
  5. Referred
  6. Central Sensitization (CS)
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11
Q

Describe cutaneous sources of pain

A
  1. includes superficial somatic structures in skin and subcutaneous tissue
  2. pain is well localized​
    • can point to are that “hurts”
    • usually locatable with one finger
  3. can be associated with referred pain from viscera or deep somatic structures
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12
Q

how can organ pain result in cutaneous pain?

A

organ impariment can result in sudomotor changes resulting trophic changes such as:

  1. itching
  2. dysesthesia
  3. skin temp changes
  4. dry skin
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13
Q

T/F: cutaneous pain is a reliable indicator of various pathologies etiologies

A

FALSE

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14
Q

how is somatic pain labeled?

A

according to the source → 5 subtypes

  1. superficial somatic
  2. deep somatic
  3. somatovisceral
  4. viscerosomatic
  5. somatoemotional (psycho
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15
Q

how is somatic referred pain described?

A
  1. dull
  2. aching
  3. gnawing
  4. expanding pressure to diffuse to localize
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16
Q

superficial somatic pain is a result of pathologic condition of what structures?

A

superficial somatic structures:

  1. skin
  2. superficial fascia
  3. tendon sheaths
  4. periosteum
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17
Q

deep somatic pain is a result of patholoic condition of what structures?

A
  1. periosteum or cancellous bone
  2. nerves
  3. muscles
  4. tendons
  5. ligaments
  6. blood vessels
  7. deep fascia
  8. joint capsules
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18
Q

how might deep somatic pain be described?

A
  1. poor localized and may refer to body surface (cutaneous pain)
  2. can also be assocaited with:
    • sweating
    • pallor
    • changes in BP
    • feeling of nausea and faintness
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19
Q

what is somatovisceral pain?

A

pain that occurs when myalgic conditions cause disturbance of underlying viscera

(somatic source with visceral symptoms)

  • trigger point in abdominal muscles causing diarrhea, vomiting, or excessive burping
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20
Q

describe viscerosomatic pain

A

occur when visceral structures affect the somatic musclature

(viscera hurt and somatic symptoms)

  • reflex spasm/rigidity of abdominal muscles secondary to acute appendicitis
  • pectoral trigger point associated with acute MI
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21
Q

describe somatoemotional pain

A

aka psychosomatic pain

occurs when emotional or psychologic distress produces physical symptoms

  • can be for a brief period
  • recurrent/multiple manifestations over months and years
    • somatization disorder
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22
Q

Describe visceral sources of pain

A
  1. includes internal organs and heart muscles
  2. not well localized and reported as diffuse
    • multisegmental innervation
    • few nerve receptors in the organs
  3. often accompanied by ANS response
  4. has ability to result in referred pain
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23
Q

what type of ANS responses may occur due to visceral sources of pain?

A
  1. change in vitals
  2. diaphoresis
  3. skin pallor
  4. S/S associated with the involved organ system
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24
Q

List the characteristics of viscerogenic pain

A
  1. gradual, progressive and cyclical pain patterns
    • condition gradually gets worse
    • not the same as “cooperate-get better-then overdo”
  2. Constant pain
  3. PT intervention fails
  4. pain does not fit expected pattern
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25
List red flags assocaited with characteristics of viscerogenic pain
1. constant and intense pain * especially in presence of hx of cancer * ask "do you have that pain right now?" * pt will often report a position or 2 that makes pain better or worse 2. lack of progress in PT 3. early improvement in PT followed by a turn for the worse
26
how is bone pain and aspirin an odd clincal situation?
* Red flag if there is disproportionate relief of bone pain with simple aspirin * suggests bone pain secondary to cancer * this is b/c aspirin inhibits pain-inducing prostaglandins produced by tumors
27
describe neuropathic sources of pain
1. results from damage to/pathophysiologic changes to peripheral or central nervous system * possible due to damage to peripheral nerve, a pathway in the spinal cord or neurons in the brain 2. may cause sensory and/or motor dysfunction
28
T/F: individuals with the same lesion may not have the same pain/symptoms
TRUE
29
how is neuropathic pain typically described?
1. sharp 2. shooting 3. burning 4. tingling 5. producing electric shock sensation 6. pain is steady or can be caused by non-noxious stimulus (light touch, cold)
30
T/F: it is uncommon to have a combo of neuropathic and somatic pain
FALSE
31
what is referred pain?
pain felt in area far from the site of the lesion but supplied by the same or adjacent neural segments occurs secondary to shared central pathways
32
how is referred pain typically described?
1. usually well localized but lacks sharply defined borders 2. can radiate from point of origin 3. often accompanied by muscle hypertonus over referred area
33
what are the criteria for central sensitization pain?
1. percieved pain/disability disproportionate to nature of injury/pathology AND 2. diffuse/neuro-anatomically illogical distribution OR hypersensitivity present Central Sensitization Inventory (CSI) * cutoff score of 40 indicates possibility of predominant CS pain. (40 or above)
34
how can you differentiate between superficial and deep somatic pain?
* Quality of superficial somatic pain tends to be sharp and more localized * quality of deep somatic pain likley to be dull or deep ache that responds to rest and non-WBing position * poorly localized and can be referred from another site * pain increases with movement but is able to find a comfortable spot
35
List types of pain
1. Tension 2. Inflammatory 3. Ischemic 4. Myofascial 5. Joint 6. Radicular 7. Arterial, Pleural and Tracheal 8. GI 9. Pain at rest 10. Night pain 11. Pain with activity 12. chronic pain
36
Describe Tension Pain
1. organ distension can cause tension pain * ie bowel obstruction, constipation or passing a kidney stone 2. may be caused by blood pooling secondary to trauma or pus accumulation 3. if in bowel can be described as "colicky" with waves of pain and tension 4. difficult to find a comfortable position
37
Describe Inflammatory Pain
1. Visceral or parietal peritoneum inflammation described as deep or boring * visceral peritoneum → poorly localized * parietal peritoneum → more localized 2. pain secondary to inflammation results in pts attempting to seek positions of stillness with little movement
38
Describe Ischemic Pain
1. indicated decreased or loss of blood supply 2. if in viscera pain is reported as: * sudden, intense, constant and progressive in severity/intensity 3. not typically relieved with analgesics 4. pt unable to find position of comfort and will avoid movement or changing positions
39
Describe myofascial pain
1. myalgia can be symptom of underlying systemic disorder * a few possible systemic sources of muscle involvment include: * cancer * renal failure * hepatic disease * endocrine disorders
40
Give some examples of myofascial pain
1. anxiety/depression disorders may result in myalgias 2. prolonged corticosteroid use may result in degenerative myopathy with muscle wasting and tendon rupture 3. endocarditis may present with myalgias and no other manifestations 4. polymyalgia rheumatica marked by diffuse pain and stiffness in many muscles, especially shoulder and pelvic girdles
41
List categories of myofasical pain
1. Muscle tension 2. Muscle spasm 3. Muscle trauma 4. Muscle deficiency 5. Trigger points
42
what is muscle tension?
1. occurs when prolonged muscle contraction results in local ischemia, increased cellular metabolites and subsequent pain 2. can also occur with physical stress/fatigue 3. visceral-somatic response can cause muscle tension and could progress to spasm. * all these cause increased tension in abdominal muscles * appendicitis * diverticulitis * pelvic inflammatory
43
what are muscle spasms?
1. sudden involuntary contraction of muscle or group of muscles secondary to overuse or injury 2. painful visceral disease can cause muscle spasm of the overlying musculature (visceral-somatic response)
44
what type of muscle contraction most often results in muscle trauma?
Eccentric contractions
45
List S/S of rhabdomyolsis
1. profound muscle weakness 2. pain 3. swelling 4. stiffness and cramping 5. associated s/s * reddish brown urine (cola-colored ) * decreased urine output * malaise * fever * sinus tachycardia * N/V * agitation, confusion
46
describe muscle deficiency
1. weakness or stiffness 2. bilateral symptoms should raise a red flag 3. proximal muscle weakness with change in one or more DTRs is red flag * especially in the presence of PMH of cancer
47
what are trigger points?
1. hyperirritable spots within taut band of skeletal muscle or in the fascia * visceral disease can produce trigger points
48
T/F: trigger points can produce visceral symptoms
TRUE even w/o actual impairment or disease of organ (ie abdominal trigger point causing upset stomach)
49
Joint pain with fatigue is considerd \_\_\_\_\_\_\_\_\_\_
a red flag for anxiety, depression or cancer
50
what is difference between joint pain of systemic cause vs MSK cause?
the presence of associated S/S with systemic causes
51
joint pain of systemic nature is usually reported as \_\_\_\_\_\_\_
constant and present with all movement
52
what does joint pain in the presence of a rash indicate?
increases suspicion of systemic cause
53
List the different types of joint pain
1. Drug-induced 2. Inflammatory Bowel Disease * ulcerative colitis * Crohn's disease 3. Arthritis * infectious arthritis * reactive arthritis
54
describe drug-induced joint pain
1. can occur as an allergic response to meds 2. can occur even up to 6 weeks after taking meds (especially antibiotics) 3. joint pain can also be a side effect of statins 4. non-inflammatory joint pain is common presentation of delayed allergic reaction
55
described IBD joint pain
1. Ulcerative colitis and Crohn's disease can be accompanied by arthritic component * skin rash affects 25% of pts with IBD 2. joint problems usually are responsive to treatment of IBD but do on occasion require separate managment
56
describe infectious arthritis
1. suspect with persistent joint pain and inflammation with illness of unclear origin or in presence of documented infection 2. increased suspicion with presence of skin rash, low-grade fever and lymphadenopathy in presence of joint pain 3. usually bilateral involvement of fingers, knees, shoulders or ankles
57
describe reactive arthritis
1. Reiter's syndrome * urethritis * conjunctivitis * multiple joint involvement 2. referral required with pt presenting with skin rash, lesions on genitals or recent history of infection in presence of joint pain
58
differentiate between radicular, radiating, and referred pain
1. Radicular pain * caused by nerve root compression * does not skip myotomes or dermatomes associated with peripheral nerve involved 2. Radiating pain * pain spreads from originating point of pain 3. Referred pain * occurs often far away from site of pathologic origin
59
Does systemic disease present in a dermatomal or myotomal pattern?
It can but it is more common that pain does not match a dermatomal or myotomal radicular pattern
60
describe arterial pain
1. listen for description of throbbing or sharp 2. any process associated with increased systolic pressure may intensify throbbing pain * examples include * exercise * fever * alcohol consumption * bending over
61
describe pleural and tracheal pain
1. pain will correlate with respiratory movements * ie breathing, laughing or coughing
62
how can arterial, pleural and tracheal pain be reproduced or worsened?
1. not reproduce with palpation or resisted movement 2. may worsen with recumbency
63
what to look for to ID GI pain
1. look for change in symptoms associated with eating or not eating 2. always ask: * "does the pain increase, decrease, or stay the same immediately after eating and 1-3 hours later?"
64
describe pain at rest secondary to ischemia
1. acute onset of severe unilateral extremity involvment in the presence of the 5 Ps is indicative of acute arterial occclusion * pain, pallor, pulselessness, paresthesia, paralysis 2. pain is reported to be burning or shooting and paresthesia may also be present
65
T/F: in NMS pathologies pain with activity is common
TRUE
66
what is a delay or lag time between the start of activity and onset of symptoms indicative of?
vascular-induced pain
67
differentiate between chronic pain from systemic disease
in the case of acute on chronic, ask questions to determine if the current episode is similar to past episodes and also look for the presence of assocaited S/S or ogran system involvment or constitutional symptoms
68
what do we want to know about patient's pain?
1. location 2. description 3. intensity 4. frequency and duration 5. pattern 6. aggravating and relieving factors
69
screening considerations for pain location
small localized area of pain is less of a concern than small localized area that spreads of refers
70
screening considerations of pain description
knifelike, boring, coming in waves or deep aching pain should get our attention and call for the need to consider the possibility of systemic origin
71
screening considerations for intensity of pain
systemic disease often associated with pain of an intense, unrelenting nature
72
screening considerations for frequency and duration of pain
* systemic disease is most often associated with constant rather than intermittent pain * symptoms that truly do not change over the course of the day require further investigation
73
screening considerations for pattern of pain
1. do the pts symptoms fall into vascular, neurogenic, MSK or emotional pattern 2. pattern associated with systemic disease is progressive pattern with cyclical onset
74
screening considerations for aggravating and relieving factors
systemic pain is typically relieved minimally, relieved only temporarily or unrelieved by change in position and/or rest
75
screening for emotional overlay can be accomplished using what scales?
1. pain catastrophizing scale 2. McGill Pain questionnaire
76
systemic vs MSK pain patterns
1. unlikely that pt presenting with back, hip, SI or shoulder pain present for last 5-10 years is systemic in nature 2. note pain descriptors commonly assocaited with pain of systemic nature 3. observe pts response after initial eval 4. aggravating/relieving factors often have to do with change in position or change in activity level in symptoms secondary to NMS dysfunction
77
Red Flag Pain Patterns
1. pain of unknown cause 2. pain accompanied by full and painless ROM 3. night pain (constant and intense) 4. symptoms that are constant and intense 5. pain described as throbbing, knifelike, boring, or deep aching 6. pain that cannot be altered, aggravated, provoked, reduced, eliminated or alleviated 7. does not improve with PT intervention
78
Red Flag Pain Patterns cont.
1. pain that is poorly localized 2. pattern of coming and going like spasms, colicky 3. pain accompanied by S/S assocaited with specific viscera or system 4. changes in MSK symptoms with food intake or increased pain with meds use 5. pain out of proportion to injury or that persists beyond the expected time frame for physiologic healing
Differential Diagnosis
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