Referred Pain and Pain patterns

Question 1

What is referred pain

Answer 1

dysfunction in one area that leads to pain somewhere else

Question 2

What are mechanisms of referred pain

Answer 2

• related to development
• multisegmental innervation
• direct pressure/shared pathway

Question 3

How is development related to referred pain?

Answer 3

• CT and organs come from the same cell resulting in shared characteristics
• for example the kidney and ear came from the same area in embryo
• and referred pain tends to stay on the same side that they organ is on

Question 4

Mulisegmental innervation

Answer 4

• organs are innervated via the autonomic nervous system
• input is sent back to the rest of the system over several spinal segments
• result is diffuse pain, or pain in a location distant from the source
• the innervation spans many levels of the spinal cord and can be innervated by a similar part as another area

Question 5

Direct pressure as a mechanism of referred pain

Answer 5

• pressure on the respiratory diaphragm by an organ can refer pain
• pressure/impingement on the central portion of diaphragm: shoulder pain (closer to the top of abdomen)
• pressure on the peripheral portion of diaphragm: lumbar or rib pain

Question 6

Shared pathways as a mechanism

Answer 6

• spinal nerves innervate across many levels and can also innervate many things
• C3-C5 innervate phrenic nerve/diaphragm but also pericardium, pancrease, gallbladder
• can cause pain in shoulder/thoracic spine

Question 7

How do you figure out if they are symptoms of MSK pain vs other pain

Answer 7

• history: if they dont remember a mechanism of injury
• location: typically referred pain pattern
• fluctuation: MSK pain tends to hurt when you use it vs a constant pain that does get better/worse with movement
• type of pain: acute vs chronic; stapping, throbbing sharp etc
• night pain for months at a time

Question 8

Night pain

Answer 8

• may be a red flag
• cancer
• ischemic heart disease due to the pressure on the chest from laying down
• peptic ulcer disease
• or DJD of spine, pelvis, or hips
• always ask more questions

Question 9

• back pain and what to look for

Answer 9

• deep or constant: refer back + pair with history
• bowel or bladder changes
• pain with weight-bearing could be a fracture may need to refer back
• pain with activity but not MSK

Question 10

Thoracic pain

Answer 10

• patient may or may not say back pain
• could be cardiac, pulmonary, GI, or gallbladder

Question 11

Shoulder or neck pain

Answer 11

• deep or constant pain
• cardiac: pain will increase with activity ie: shoulder pain from walking down the stairs
• cervical injuries
• neuropathies/nerve compression
• tumor; pancoast tumor (lung cancer)

Question 12

Jaw pain causes

Answer 12

• TMJ
• cardiac: cardiac ischemia can cause jaw pain that is not pain with activity

Question 13

Headaches severe cases

Answer 13

• infection
• tumor
• bleed
• refer back if treatments are not working or if they say its the worst headache they have ever had

Question 14

Elbow, wrist, hand pain

Answer 14

• fracture
• ligament
• infection
• raynaud syndrome can go up
• complex regional pain syndrome:

Question 15

Knee pain

Answer 15

• can be referred from the hip or groin
• assess the knee

Question 16

What is typical presentation of MSK pain

Answer 16

• unilateral
• relieved with rest
• tenderness to pressure
• restricted movement
• aggravating factors: usually movement/positions
• alleviating factors: rest, change position, stretching, heat/cold
• associated symptoms: usually none

Question 17

What is typical presentation of systemic pain

Answer 17

• knifelike, boring, deep ache
• unilateral or bilateral
• constant or comes in waves
• unrelieved by rest
• aggravating factors: may be difficult to alter, provoke, alleviate, aggravate
• alleviating factors: sometimes position may alleviate (organ dependent)
• associated symptoms: fever, chills, sweats, night pain, GI distress, skin lesions, rashes, weightloss/gain, SOB

Question 18

What associated symptoms may require consultation or referral

Answer 18

• burning
• dyspnea
• difficulty swallowing/hoarseness
• dizziness
• fever, chills, sweat
• heart palpitations’
• nausea/vomiting
• night sweats/pain
• numbness/tingling
• SOB
• vision problems
• weakness
• weight loss/gain

Question 19

Pain patterns: vascular pain

Answer 19

• throbbing
• pounding
• pulsing
• beating

Question 20

Pain patterns: Neurogenic pain

Answer 20

• sharp
• crushing
• pinchin
• buring
• hot
• searing
• itchy
• stinging
• pulling
• jumping
• shooting
• electrical
• gnawing
• pricking

Question 21

Pain patterns: muscloskeletal

Answer 21

• aching
• sore
• heavy
• hurting
• deep
• cramping
• dull

Question 22

Pain patterns: emotional

Answer 22

• tiring
• miserable
• vicious
• agonizing
• frightful
• piercing
• dreadful
• killing
• exhausting
• unbearable
• cruel
• annoying

Question 23

What are some ways to assess how intense the pain is

Answer 23

• visual analog scale
• numeric rating scale
• box scale
• verbal rating scale
• behavioral rating scale
• FACES scale
• FLACC scale: for babies, rate based on what is observed
• short-form McGill pain questionnaire

Question 24

complex regional pain syndrome:

Answer 24

pain that is in one area and becomes chronic to the point where it affects the whole extremity