Pain Phenotyping - Done Flashcards
What is pain phenotyping?
Set of observable pain characteristics of an individual resulting from the interaction between the body and the environment
What is nociceptive pain?
Non-nervous tissue compromise
What two categories is nociceptive pain broken into?
- MSK: including spondylogenic
- Viscerogenic
What is neuropathic pain?
Nervous tissue compromise
What three categories is neuropathic pain broken into?
- Radicular
- Radiculopathy
- Terminal Nerve Branch Neuropathy
What is nociplastic pain?
Altered pain perception without complete evidence of actual or threatened tissue compromise
What kind of pain produces local as well as referred symptoms from the involved spinal structure?
Spondylogenic
What is spondylogenic pain?
- Pain from the spine
- It is common
- Local and/or referred spinal pain from noxious stimulation of spinal structures
Can spondylogenic pain cause visceral dysfunction?
CANNOT cause visceral dysfunction as some providers claim
Is spondylogenic pain segmental or nonsegmental?
Nonsegmental
What is a segment?
Two vertebrae and its spinal nerve… ex: L4-L5 and nerve between
How would someone describe spondylogenic pain?
Deep, achy, boring, and vague
With spondylogenic pain will you have neuro findings?
No, they are WNL
Is spondylogenic pain entirely reproducible?
Not entirely
With spondylogenic pain you have somatic convergence or referred pain. Because of this, you have sensory afferent nerves that _____ on a _____ same innervation.
converge, shared
With spondylogenic pain which do you have a greater referral of pain from? Proximal and deep structures or distal and superficial structures?
Proximal and deep
Why would you get more pain referrals from proximal and deep structures with spondylogenic pain?
The spinal facets are able to refer more than say a knee joint or a hip joint
What are symptoms of spondylogenic pain?
- Non-segmental pain
- Rarely if any paresthesias
- Vague, deep, achy, and boring pain
- Referred into a vague area due to somatic convergence that settles into a consistent location
What are signs of spondylogenic pain?
- Neuro scan WNL
- Can’t reproduce entire symptom pattern with motion
Where will you find spondylogenic pain in the thoracic spine?
Wraps around the respective vertebral levels with overlap in the trunk
Where will you find spondylogenic pain in the lumbar spine?
- MOST often in the gluteal region and proximal thigh
- May go as far as the foot
- Inconsistent pattern between individuals
Are spondylogenic pain symptoms from a compromised spinal nerve?
No, and your neuro test will show you that since they are WNL
What is viscerogenic pain?
Referred pain from an organ
What is viscerosomatic convergence?
Viscera and somatic (body) sensory afferents converge on and share the same innervation
How might someone describe a viscerogenic pain?
Vague, deep, achy, and boring pain
What is an example of referred viscerogenic pain?
Kidneys can refer into the T10-L1 dermatomes
What are the signs and symptoms of viscerogenic pain?
- Not typically able to be mechanically reproduced
- Neuro scan WNL
What is radicular pain?
Ectopic or abnormal discharge from highly inflamed dorsal root of spinal nerve
What are symptoms of radicular pain?
Lancing, electrical shock-like pain along an extremity in a narrow 2-3” band
What are signs of radicular pain?
- Dermatoms, DTRs, and Myotomes likely WNL: may be difficult to localize segment if acute/mild; it takes time for hypo-activity to show
- (+) Neurodynamic mobility tests due to HIGH inflammation
- NOT common
- Imaging helpful for involved spinal nerve
What is radiculopathy?
Blocked conduction of spinal nerve due to compression and/or inflammation
What are symptoms of a radiculopathy?
- Segmental paresthesias that are often constant and long-duration
- Segmental paresthesias that have a slow progression to a vague area due to dermatomal overlap
What are signs of radiculopathy?
- Neuro scan (+) for spinal nerve hypoactivity
- Imaging helpful for involved spinal nerve
What is terminal nerve branch pain?
Decreased conduction of the terminal nerve branch
What are symptoms of terminal nerve branch pain?
- Non-segmental paresthesias that are often intermittent and short-duration
- Non-segmental paresthesias that have a fast progression to a well-defined area of numbness because of minimal sensory overlap of terminal nerve branch (unlike spinal nerve)
- Possible weakness
What are signs of terminal nerve branch pain?
- Dermatomes, DTRs, and myotomes WNL
- Non-segmental terminal nerve branch hypoactivity that leads to decreased sensation along terminal nerve branch distribution and possible weakness of muscle innervated by terminal nerve branches
- (+) neurodynamic mobility tests
What is nociplastic pain?
- Defined as altered pain perception without complete evidence of actual or threatened tissue compromise
- initial term of sensitization pain in 2010
- Current term originated in 2017
- Signs and symptoms of sensitization are present within nociplastic pain
- Sensitization is an underlying mechanism
- Patients with sensitization are labeled as having nociplastic pain
What is the pathogenesis of nociplastic pain?
- Thinning of myelin sheath
- Increased sensitivity and
misinterpretation by peripheral nociceptors - Persistent excitation of A-delta
and C fibers
What sensation do A-delta and C fibers carry?
Persistent excitation of A-delta and C fibers inhibit what?
Inhibits larger myelinated A-beta fibers pre-synaptically making it harder to override P! with motion
When there is an increased sensitivity and misinterpretation by CENTRAL structures what happens?
- Increased excitability of segmental dorsal horn neurons
- Lower synaptic resistance so P! sensations occur easier
A loss of descending anti-nociceptive mechanisms causes what?
- Less endogenous opiates released
- Less P! control
Why can symptoms “spread”
with nociplastic pain?
Somatic Convergence: Shared areas of innervation share symptoms; think of spondylogenic and referred pain
What is somatic convergence?
- C-fibers that transmit pain, split, and travel at least 2 spinal segments superiorly and inferiorly
- Ex: persistent symptoms with L4, 5
hypermobility/instability can eventually spread and create symptoms through the entire LQ (L2-
S2)… Like a domino effect
With somatic convergence, the brain perceives the pain as coming from where?
- Even more areas with persistent symptoms… its a downward spiral
- Brain homunculus “smudged”
What functional questionnaires can you use for nociplastic pain?
- Central Sensitization Inventory
- Neurophysiology of Pain Test: to assess fear avoidance, catastrophizing, understanding
- Regional specific
What is the prevalence of nociplastic pain?
A growing number of conditions such as:
- Migraine
- Neck pain: traumatic and non-traumatic
- Shoulder pain
- Lateral elbow pain
- LBP
- Age-related Joint Changes
- Persistent fatigue syndrome
- Fibromyalgia
What is the criteria for possible nociplastic pain?
- ≥ 3 months of pain
- Regional or spreading symptoms
- Pain that cannot be entirely explained by nociceptive or neuropathic pathways
- Pain hypersensitivity or allodynia (non-painful stimuli causing pain)
What is the criteria for probable nociplastic pain?
- The addition of any of the
following comorbidities to “possible”
criteria - Sensitivity to sound, light, and/or odor
- Sleep disturbances
- Fatigue
- Cognitive problems
What kind of benefit do JM have on nociplastic pain?
- Theoretical benefits on symptoms
- MOST accepted- stimulates descending inhibitory pain mechanisms i.e., MORE endorphins
Do JM induce or reduce presynaptic inhibition in nociplastic pain?
- Induces presynaptic inhibition
- Limit pain transmission by A-delta and C fibers
- Better overriding of pain by A-beta stimulation
What can JM reduce in nociplastic pain?
- Reduces dorsal horn excitability
- Decreases inflammatory mediators
What should METs look like for nociplastic pain?
- Low to moderate global aerobic and resistance activities
- 2-3x/wk.
- 30-90 minutes per session
- At least 7 weeks duration
- Endogenous/opiate analgesia
- Helps pt. to interpret pain and motion as non-threatening
- Reorganizes Homunculus
Why is neuroscience education/behavioral therapy important for pts with nociplastic pain?
- Not just mind over matter
- Explain increased sensitivity and misinterpretation to reduce stress/anxiety of misperceived tissue
injury - Challenge the patient’s reasoning of fears
- Ensure the safety of exercise
- Transition to adaptive pain coping
What is the prognosis for someone with nociplastic pain?
- Varying degrees of improvement
- Longer recovery
- Likely not a full resolution of symptoms
