Pain

Question 1

Define pain

Answer 1

• an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage

Question 2

Functions of pain

Answer 2

• Sensory discriminative function: self preservation (hand on hot stove) = actual tissue damage
• Affective function: emotional unpleasantness = avoid additional pain
• Cognitive evaluative function: learning & behavioral adaptation = learn to avoid experience again

Question 3

Describe the pain KISS principle

Answer 3

• KISS = keep it stupid simple
• Nociceptive: proportionate pain, ages and eases, intermittent
• Peripheral neurogenic: dermatomal or cutaneous distribution, + neurodynamic tests & palpation, hx of nerve pathology
• Central: disproportionate pain, disproportionate aggs & eases, diffuse palpation tenderness, psychosocial issues

Question 4

Types of pain

Answer 4

• Cutaneous: skin, specific
• Somatic: bone/muscle/tendon/lig., poorly localized
• Visceral: organs/heart, poorly localized
• Neuropathic: peripheral nerve/spinal cord pathways, follows nerve path or is diffuse
• Referred: cutaneous/somatic/visceral sources, well localized

Question 5

Mechanisms of referred visceral pain

Answer 5

• embryologic development
• multisegmental innervation
• direct pressure & shared pathways

Question 6

Describe visceral referred pain due to embryologic development

Answer 6

• referred to the site the organ was located during fetal development
• kidneys, liver, heart, & intestines form around 3wks & are all located in the gut

Question 7

Describe visceral referred pain due to multisegmental innervation

Answer 7

• visceral pain referred to the corresponding somatic area as the autonomic nervous system is part of the peripheral nervous system (PNS = sympathetic & parasympathetic)
• example: cardiac pain. felt along C3-T4 distribution (jaw, neck, upper traps, shoulder, & arm)
• termed visceral organ cross sensitization

Question 8

Describe visceral referred pain due to direct pressure & shared pathways

Answer 8

• example: pain of cardiac & diaphragmatic origin is often felt in the shoulder bc both supplied by C5-C6
• shared pathways: ganglion gathers & shares info with the spinal cord, nerve plexuses, & peripheral nerves

Question 9

Common patterns of visceral pain referral

Answer 9

• Lesion at diaphragmatic irritation refers to shoulder & low back
• Lesion at heart refers to shoulder, neck, upper back, TMJ
• Lesion at urogenital tract refers to back, inguinal region, & genitalia
• Lesion at pancreas, liver, spleen, or gallbladder refers to shoulder, midthoracic, or low back

Question 10

Common patterns of somatic pain referral

Answer 10

• Lesion at C7, T1-T5 refers to interscapular & posterior shoulder
• Lesion at shoulder refers to neck, upper back
• Lesion at L1-L2 refers to SI joint & hip
• Lesion at hip joint refers SI joint & knee
• Lesion at pharynx refers to ipsilateral ear
• Lesion at TMJ refers to head, neck, heart

Question 11

Pain assessment/quality of pain

Answer 11

• Muscular: soreness, ashiness, cramping, dull, deep
• Joint: occasional catch that is sharp, deep in the joint (localized)
• Nerve: sharp, stinging, stabbing, electric, numbness
• Viscera (organ) or chronic widespread pain: deep diffuse pain that is all over (regional)

Question 12

Common referral patterns

Answer 12

• Anterior Right Shoulder: liver and gallbladder
• Posterior Right Shoulder: liver and gallbladder
• Posterior Left Scapular Area: heart
• Anterior Left Shoulder: heart
• Posterior Left Shoulder: pancreatitis
• Anterior Left Neck: lungs and diaphragm
• Posterior Left Neck: lungs and diaphragm
• Medial Left Arm: heart and GERD
• Middle Scapula Inferior Boarder: penetrating duodenal ulcer
• Right Axilla: penetrating duodenal ulcer

Question 13

Pain timelines

Answer 13

• Acute time: 24-48hrs
• Subacute time: 3-14 days
• Chronic time: >3-6mo
• Short term pain is more often the result of an active pathology
• Long term pain is more likely to be the result of neuroplastic changes within the central nervous system

Question 14

What does SINSS stand for

Answer 14

• Severity = intensity
• Irritability = tissue & functional reactivity
• Nature = symptoms
• Stage = acute, sub acute, chronic, acute on chronic
• Stability = progression of the condition

Question 15

Pain pattern for systemic disease

Answer 15

• cyclical onset, progressive
• “worse” then “better” then “worse”

Question 16

Associated factors that can often occur along with the pain

Answer 16

• constitutional, dermatological, mental, neurological signs & symptoms

Question 17

Describe how pain location can have diagnostic importance

Answer 17

• Remote pain: cause of pain is located away from the site of symptoms
• Local pain: cause of pain is located at the site of symptoms
• Remote & local causes are often confused by the patient & clincian

Question 18

Systemic versus MSK (musculoskeletal) pain

Answer 18

• Systemic: sudden onset, pain described as throbbing, cutting, stabbing, or bone pain, mild to severe intensity, constant/no change in symptoms & wakes pt up at night, cyclical pattern, pain can’t be altered
• MSK: sudden or gradual onset, unilateral pain like achey, stiff, or cramping, mild to severe intensity, symptoms can be changed with rest, certain movement aggravate symptoms, pain is altered by movement, pain can be relieved by rest or modalities

Question 19

How to screen emotional overlay pain

Answer 19

• McGill Pain Questionnaire
• Pain Catastrophizing Scale
• Symptom magnification (out of the ordinary, longer time to heal, nothing works)
• Waddell’s nonorganic signs

Question 20

Define symptom magnification

Answer 20

• a self-destructive socially reinforced behavioral response pattern consisting of reports or displays of symptoms which control the life of the suffer (Matheson)
• the symptoms rather than the physiologic phenomenon of the injury determine the outcome/function

Question 21

Define malingering

Answer 21

• falsification or profound exaggeration of illness to gain external benefits
• we need to stick to what we can objectively measure

Question 22

Describe Waddell’s signs

Answer 22

• used to detect psychogenic or inappropriately labeled nonorganic (inaccurate/not physical pain) manifestations of back pain

Question 23

Nonorganic test sequence (Waddell’s signs)

Answer 23

• Tenderness: non anatomic over large area, unable to localize or pinpoint
• Simulation tests: axial loading, trunk rotation
• Distraction: observation, hand client shirt/coat, SLR: flip test (distract patient during test)
• Regional disturbances: entire leg is numb or painful, pain not localized in single moo/dermatome, leg gives way/large muscle group
• Overreaction: client applies minimal effort on maximum performance task, client overreacts to. loading during objective examination
• if more than 3/5 present then there is high probability that patient has non-organic pain

Question 24

Non-anatomic or behavioral description of symptoms

Answer 24

• pain at tip of tailbone
• whole leg pain from groin to below knee in stocking pattern
• whole leg numbness/’going dead’
• whole leg giving way or collapsing
• constant pain for yrs on end w/o relief
• unable to tolerate any treatment, reaction or side effects to every intervention
• emergency admission to hospital for back pain without precipitating traumatic event

Question 25

Associated signs & symptoms of systemic pain

Answer 25

• constitutional symptoms
• warning signs of cancer
• painless weakness of muscles
• GI symptoms: Nausea, vomiting, anorexia, unexplained weight loss, diarrhea, constipation
• bilateral symptoms
• bowel/bladder symptoms
• early satiety (feeling full after eating)