Week 4 Guiding Q's (Exam 1)

Question 1

What are the 3 mechanisms for referred visceral pain?

Answer 1

1. Embryologic Development
2. Multisegmental innervation
3. Direct pressure and share pathways

Question 2

What is embryologic development? Give examples.

Answer 2

• 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

Examples
•The chest is part of the gut in embryologic development
•Thoracic disorders can sometimes refer to the abdomen (ie pneumonia or pleuritis may be perceived in abdomen instead of chest)
•The heart does start out embryologically as a cranial structure but pericardium is formed from gut tissue
•MI or pericarditis can also refer pain to abdomen
•Kidney and ear come from the same embryologic tissue
•Anomaly of the ear at birth leads medical staff to look for similar changes of the kidney

Question 3

What is multisegmental innervation? Give examples

Answer 3

• Organs have multiple levels of innervation
• New evidence supports referred visceral pain to somatic tissues based on *overlapping or same segmental projections of spinal afferent neurons to the spinal dorsal horn
• Visceral-organ cross-sensitization
• Pain of visceral origin → corresponding somatic area

Example:
•Cardiac pain
•Not felt in heart but *referred to areas of corresponding spinal nerve
•Can occur in any structure innervated by *C3-T4 (what innervates the heart)
oJaw
oNeck
oUpper trap
oShoulder
oArm

Question 4

What is direct pressure and shared pathways?
What side will the pain usually be on?
Where would the spleen, tail of the pancreas, head of the pancreas, gallbladder, and liver refer to?
What does the brachial plexus innervate? What about the celiac plexus?
Where would the central diaphragm refer to? Peripheral diaphragm?

Answer 4

-Viscera near diaphragm
•Inflammation, infection or obstruction of these organs can result in contact with the diaphragm

-Pain pattern is ipsilateral to area of irritation (bc the organ is the actual problem)

• Spleen → L shoulder
• Tail of pancreas → L shoulder
• Head of pancreas → R shoulder
• Gallbladder → R shoulder pain
• Liver → R shoulder pain

-This referral pattern occurs secondary to shared neural pathways

•Ganglions gather info and pass it along to the nerve plexuses which then decide how to respond to the info

•Plexuses originate in the neck, thorax, diaphragm & abdomen
oBrachial plexus-upper neck and shoulder
oCeliac plexus-stomach and intestines

Symptoms may be experienced in the areas innervated by the same nerve pathway
Impingement on central diaphragm
oCan refer to shoulder
Impingement on peripheral diaphragm
•Can refer to ipsilateral costal margins and/or lumbar region

Question 5

What structures are included in cutaneous sources of pain? How is cutaneous pain typically described?
What can organ impairment result in?
T/F: Cutaneous pain is a reliable indicator of pathologic etiology

Answer 5

o Includes superficial somatic structures in skin and subcutaneous tissue
o Pain is well localized (can point to area that “hurts”)
o Usually locatable with one finger
o Can be associated with referred pain from viscera or deep somatic structures

o Organ impairment can result in sudomotor changes resulting in trophic changes

• Itching
• Dysesthesia
• Skin temperature changes
• Dry skin

Cutaneous pain is not a reliable indicator of pathologic etiology

Question 6

What are the types of somatic sources of pain and what structures contribute to each? (5)

Answer 6

o Can be superficial or deep, labeled according to source

1. Superficial somatic
2. Deep somatic
3. Somatovisceral
4. Viscerosomatic
5. Somatoemotional (psychosomatic)

Question 7

What are the superficial somatic structures? (3)

Answer 7

1. Skin
2. Superficial fascia
3. Tendon sheaths and periosteum

Question 8

Deep somatic pain

What structures?
Is it localized or not?
What type of SxS are associated?

Answer 8

result of pathologic conditions of

1. Periosteum or cancellous bone, nerves, muscles, tendons, ligaments, blood vessels deep fasciae and joint capsules
2. Deep somatic pain is poorly localized and may refer to body surface (cutaneous pain)
3. Can also be associated with sweating, pallor, changes in BP, feeling of nausea and faintness

Question 9

How is somatic referred pain usually reported? (4)

Answer 9

reported as dull, aching, gnawing or expanding pressure too diffuse to localize

Question 10

What is somatovisceral pain?

Answer 10

Pain occurs when myalgic conditions cause disturbance of underlying viscera

Example: trigger point in abdominal muscles causing diarrhea, vomiting or excessive burping

Question 11

Viscerosomatic Pain

Answer 11

Sources of pain occur when visceral structures affect the somatic musculature

Example: reflex spasm/rigidity of abdominal muscles secondary to acute appendicitis or pectoral trigger point associated with acute MI

Question 12

Somatoemotional (psychosomatic pain)

Answer 12

occurs when emotional or psychologic distress produces physical symptoms

• Can be for a brief period
• Recurrent/multiple manifestations over months and years (Somatization disorder)

Question 13

What structures are included in visceral sources of pain? How is visceral pain typically described and what are the characteristics of viscerogenic pain?

is it localized or not?
What is it often accompanied by?

Answer 13

o Includes *internal organs and heart muscle
o Not well localized
 Multisegmental innervation
 Few nerve receptors in the organs
o Pain reported as poorly localized and diffuse
o Often *accompanied by an autonomic nervous system response
 Change in vitals, diaphoresis, skin pallor or signs & symptoms associated with the involved organ system
o Has the ability to result in *referred pain
 Visceral fibers synapse at level of spinal cord close to fibers supplying somatic structures
 Ie Heart innervated by C3-T4 and can produce pain in any part of the body innervated by these levels

Question 14

*Gradual, Progressive and Cyclical Pain Patterns

Answer 14

 Condition gradually gets worse

 Not to be confused with “cooperate-get better-then overdo” cycle that can be associated with NMS problem

Question 15

*Constant Pain

Answer 15

 Constant and intense pain is red flag (especially in presence of history of cancer)
 Can ask “Do you have that pain right now?”
 Often pt will report a position or 2 that make pain better (or worse)

Question 16

What type of responses to PT intervention would be red flags? (2) regarding pain

Answer 16

• Lack of progress can be a red flag symptom

- Early improvement followed by taking a turn for the worse is also a red flag

Question 17

What is meant by

Pain Does Not Fit Expected Pattern (2)

Answer 17

• Full and painfree ROM

- Unable to reproduce pain in examination

Question 18

*Bone Pain and Aspirin

Answer 18

Odd clinical situation

Disproportionate relief of bone pain with simple aspirin is a red flag (suggests bone pain is secondary to cancer)

Aspirin inhibits pain-inducing prostaglandins produced by tumor

Question 19

what are the different categories of visceral pain?

Answer 19

• gradual, progressive and cyclical pain patterns
• constant pain
• PT interventions fails
• Pain does not fit expected pattern
• bone pain and aspirin

Question 20

•What structures are included in neuropathic sources of pain? How is neuropathic pain typically described?

Answer 20

o 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
o May cause *sensory and/or motor dysfunction
 Could be drug-induced, metabolic-based or secondary to trauma
o Individuals with *same lesion may not have the same pain/symptoms
o Described as sharp, shooting, burning, tingling or producing electric shock sensation
 Pain is steady or can be caused by non-noxious stimulus (ie light touch, cold)
o Not uncommon for patients to have combination of neuropathic and somatic pain

Question 21

What is referred pain?

What does it occur secondary to?

Localized or no?

What is it often accompanied by?

Answer 21

o Pain felt in area *far from the site of the lesion but supplied by the same or adjacent neural segments
o Occurs secondary to shared central pathways
o Usually well localized but lacks sharply defined borders
 Can radiate from point of origin
 Often accompanied by muscle hypertonus over referred area
o Referred pain
 Visceral disorders can refer to somatic tissue
 Somatic impairments can refer to visceral location or mimic visceral pain patterns

Question 22

•What is central sensitization (CS)? What are the criteria for identifying CS pain?

Answer 22

Criteria for CS pain
-Perceived pain/disability disproportionate to nature of injury/pathology
AND
-Diffuse/neuro-anatomically illogical distribution OR hypersensitivity present

Central Sensitization Inventory (CSI)
Cutoff score of 40 indicates possibility of predominant CS pain

Question 23

List the types of pain (12)

Answer 23

1. Tension
2. Inflammatory
3. Ischemic
4. Myofascial
5. Joint
6. Radicular
7. Arterial, Pleural and Tracheal
8. Gastrointestinal
9. Pain at Rest
10. Night Pain
11. Pain with Activity
12. Chronic Pain

Question 24

Tension pain

What causes it (2 things), how is it described, what positions are comfortable

Answer 24

-Organ distention can cause tension pain
Ex: bowel obstruction, constipation or passing a kidney stone

• Also may be caused by *blood pooling secondary to trauma or pus/fluid accumulation secondary to infection
• Tension pain in the bowel may be described as “colicky” with *waves of pain and tension
• With tension pain, it is difficult to find a comfortable position

Question 25

Inflammatory Pain (what causes it, how is it described, localized or not, and what positions provide comfort)

Answer 25

• Visceral or parietal peritoneum inflammation may cause pain described as *deep or boring
• Poorly localized with visceral peritoneum involvement
• More localized with with parietal peritoneum involvement (ie can point to it with one or two fingers)
• Pain secondary to inflammation results in patients attempting to *seek positions of stillness with little movement

Question 26

Myofascial Pain (what can it be a symptom of, what type of drugs can cause it, what type of things can cause it)

Answer 26

• *Myalgia can be symptom of underlying systemic disorder
• A few possible systemic sources of muscle involvement include cancer, renal failure, hepatic disease or endocrine disorders
• Examples
o Anxiety/depressive disorders may result in myalgias
o Prolonged corticosteroid use may result in degenerative myopathy with muscle wasting and tendon rupture
o Endocarditis may present with myalgias and no other manifestations
o Polymyalgia rheumatica marked by diffuse pain and stiffness in many muscles, especially shoulder and pelvic girdles

Question 27

Muscle tension (what causes it)

Answer 27

• Occurs when prolonged muscle contraction results in local ischemia, increased cellular metabolites and subsequent pain
• Can also occur with physical stress/fatigue
• Visceral-somatic response can cause muscle tension and could progress to spasm (ie appendicitis, diverticulitis or pelvic inflammatory disease can cause increased tension in abdominal muscles)

Question 28

Muscle spasm

Answer 28

 Sudden involuntary contraction of muscle or group of muscles secondary to overuse or injury
 Painful visceral disease can cause muscle spasm of the overlying musculature (visceral-somatic response)

Question 29

Muscle trauma

Answer 29

Can occur with acute trauma, burns, crush injuries or unaccustomed intensity or duration of muscle contraction (especially eccentric contractions)

example: rhabdomyolysis

Question 30

What is rhabdomyolysis?

Answer 30

occurs when disintegration of muscle tissue occurs with release of their contents into the bloodstream producing a potentially fatal muscle toxicity

-Can occur secondary to trauma, extreme muscular activity, toxic effects, metabolic abnormalities or could be medication-induced

Question 31

Signs and symptoms of rhabdo (11)

Answer 31

Profound muscle weakness
Pain
Swelling
Stiffness and cramping

 	Associated signs and symptoms
 	*Reddish-brown urine
 	Decreased urine output
 	Malaise
 	Fever
 	Sinus tachycardia
 	Nausea, vomiting
 	Agitation, confusion

Question 32

*Muscle Deficiency

What type of symptoms should raise a red flag?

Answer 32

Weakness or stiffness
Bilateral symptoms should raise a red flag
Proximal muscle weakness with change in one or more DTRs is a red flag for cancer especially in the presence of PMH of cancer

Question 33

*Trigger Points

Answer 33

Hyperirritable spots within taut band of skeletal muscle or in the fascia
Visceral disease can produce trigger points
Trigger points can also produce visceral symptoms without actual impairment or disease of organ (ie abdominal trigger point causing upset stomach)

Question 34

Joint pain (when would it be a red flag, what are the major difference between systemic and MSK joint pain)

Answer 34

Joint pain with *fatigue may be a red flag for anxiety, depression or cancer
Major difference when comparing joint pain of systemic cause as opposed to musculoskeletal cause is the *presence of associated signs and symptoms
Joint pain of systemic nature usually reported as constant and *present with all movements
*Joint pain in the presence of a rash or following a recent rash increases suspicion of systemic cause

Question 35

Drug induced joint pain

Answer 35

Can occur as an *allergic response to medication
Can occur even up to 6 weeks after taking medication (especially antibiotics)
Joint pain can also be a *side effect of statins
Non-inflammatory joint pain is common presentation of delayed allergic reaction

Question 36

IBD joint pain

Answer 36

Skin rash affects 25% of pts with IBD

Joint problems usually are responsive to treatment of IBD but do on occasion require separate management

Question 37

Infectious arthritis joint pain

Answer 37

Microorganisms cause inflammation of synovial membrane and release cytokines with end result being cartilage destruction
Suspect with persistent joint pain and inflammation with illness of unclear origin or in presence of documented infection
Increased suspicion with presence of skin rash, low-grade fever and lymphadenopathy in presence of joint pain
Usually *bilateral involvement of fingers, knees, shoulders or ankles

Question 38

Reactive arthritis joint pain

Answer 38

aka Reiter’s syndrome
*Reiter’s syndrome: urethritis, conjunctivitis and multiple joint involvement
Referral required with pt presenting with skin rash, lesions on genitals or recent history of infection (esp GI or GU infection in last 1-4 weeks) in presence of joint pain

Question 39

radicular pain

Answer 39

Caused by nerve root compression

Does not skip myotomes or dermatomes associated with peripheral nerve involved

Question 40

Radiating pain

Answer 40

Pain spreads from originating point of pain

Question 41

Referred pain

Answer 41

Occurs often far away from site of pathologic origin

Question 42

Systemic disease (does it follow a dermatomal or myotomal pattern?)

Answer 42

can present in dermatomal or myotomal pattern however it is more common that pain does not match a dermatomal or myotomal radicular pattern

Question 43

Arterial pain

What types of activities would increase the pain?

Answer 43

◦ Listen for description of *“throbbing” or sharp
◦ Any process associated with *increased systolic pressure may intensify throbbing pain
Examples include exercise, fever, alcohol consumption or bending over

Question 44

Pleural and tracheal pain

Answer 44

◦ Pain will correlate with *respiratory movements (ie breathing, laughing or coughing)

Not reproduce with palpation or resisted movement
May worsen with recumbency

Question 45

GI pain

Answer 45

Look for *change in symptoms associated with eating or not eating
Pain can increase with ingestion and decrease with emptying of stomach or bowels
Pain can also be relieved by presence of food in the event of pain being generated by effects of gastric acid on esophagus, stomach or duodenum and pain would increase with an empty stomach
*“Does the pain increase, decrease or stay the same immediately after eating and 1-3 hours later?”
In the case of distension of liver, kidney, spleen and pancreas, pain may increase with body positions/movement that increase intraabdominal pressure and vice versa

Question 46

Pain at rest- what would describe this for ischemia vs. cancer?

Answer 46

Secondary to Ischemia 
◦	*Acute onset of severe unilateral extremity involvement in the presence of the “five Ps” is indicative of acute arterial occlusion
◦	Pain
◦	Pallor
◦	Pulselessness
◦	Paresthesia
◦	Paralysis 
◦	Pain is reported to be *burning or shooting and paresthesia may also be present		

Secondary to Neoplasm
Usually occurs at night

Question 47

Night Pain
what is this a classic red flag for?
How would we determine if night pain is acute, subacute or chronic for NMS pain?

Answer 47

Classic *red flag of cancer
Bone pain at night in presence of previous history of cancer is a *highly suspicious symptom
Pt reporting being awake for hours at night or being awakened repeatedly *is significant
◦ Not as concerned if pt describes night pain as feeling discomfort/pain after they lie down before they fall asleep
In regards to pain of NMS origin, we may be able to determine acuteness vs chronicity by further questioning about night pain
◦ Cannot lie on involved side=actue
◦ Can stay on involved side for 30 mins to an hour before symptoms present=subacute
◦ Can lie on involved side for up to 2 hours before symptoms present=chronic

Question 48

Pain with Activity:

Answer 48

In *NMS pathologies, pain with activity is common
In regards to systemic disorders, pain with activity is most often caused by vascular compromise
◦ Ie pain with activity of upper quadrant and angina or intermittent vascular claudication with lower quadrant
Usually *delay or lag time between beginning of activity and onset of symptoms with vascular-induced pain
◦ Usually 5-10 minutes after onset of activity
◦ How can we differentiate between pain with activity of NMS origin or secondary to vascular compromise?

Question 49

Chronic pain

Answer 49

Differentiating 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 associated signs and symptoms of organ system involvement or constitutional symptoms
◦ *Symptoms out of proportion to injury and/or those that are not consistent with the *objective findings may be red flag for systemic disease
Do keep in mind that chronic pain does change how the body processes pain

Question 50

• Summarize the red flags associated with location, description, intensity, frequency & duration, pattern and aggregating & relieving factors.

LOCATION

Answer 50

Screening Considerations
o *Small localized area of pain is less of a concern than small localized area that spreads or refers
o Show me where your pain is located.”

Follow-up Questions

• Do you have any other pain or symptoms anywhere else?
• If yes, what causes the pain or symptoms to occur in this other area?

Question 51

• Summarize the red flags associated with location, description, intensity, frequency & duration, pattern and aggregating & relieving factors.

DESCRIPTION

Answer 51

•	Screening Considerations
•	*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
•	“What does it feel like?”
o	May want to offer potential descriptors
•	Is your pain/Are your symptoms
o	Knifelike
o	Boring
o	Throbbing
o	Deep aching 
o	Dull
o	Burning
o	Prickly
o	Sharp

Question 52

• Summarize the red flags associated with location, description, intensity, frequency & duration, pattern and aggregating & relieving factors.

INTENSITY

Answer 52

• Screening Considerations
o Systemic disease often associated with pain of an *intense, unrelenting nature
• Utilize the Numeric Rating Scale or VAS
• Also assess the pt’s behavior to look for behaviors consistent with description of intensity

Question 53

• Summarize the red flags associated with location, description, intensity, frequency & duration, pattern and aggregating & relieving factors.

FREQUENCY & DURATION

Answer 53

• Screening Considerations
• 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
 “How long do the symptoms last?”
 Follow-up Questions
• Do you have this pain right now?
• Did you notice these symptoms this morning immediately when you woke up?

Question 54

• Summarize the red flags associated with location, description, intensity, frequency & duration, pattern and aggregating & relieving factors.

PATTERN

Answer 54

• Screening Considerations
• Do the patients symptoms fall into a vascular, neurogenic, musculoskeletal or emotional pattern
• Pattern associated with systemic disease is *progressive pattern with cyclical onset
• “Describe your pain/symptoms from first waking up in the morning to going to bed at night?”
o Follow-up Questions
 Have you ever experienced anything like this before?
 If yes, do these episodes occur more or less often than at first?
 How has your pain changed over time?

Question 55

• Summarize the red flags associated with location, description, intensity, frequency & duration, pattern and aggregating & relieving factors.

AGGRAVATING AND RELIEVING FACTORS

Answer 55

• Screening Considerations
o *Systemic pain is typically relieved minimally, relieved only temporarily or unrelieved by change in position and/or rest
• “What makes your symptoms better? Worse?”
• Follow-up Question
o How does rest affect your symptoms?

Question 56

• Describe how you could differentiate symptoms of a systemic condition with that of a psychogenic presentation.

Answer 56

o Watch for following red flags
 Symptoms are out of proportion to injury
 Symptoms persist beyond expected time for physiologic healing
 No position is comfortable
o Above could reflect possibility of *emotional/psychologic overlay or more serious underlying systemic disorder
o Screening for emotional overlay can be accomplished using
 Pain Catastrophizing Scale
 McGill Pain Questionnaire

Question 57

Systemic vs. Musculoskeletal Pain Patterns:

Answer 57

Unlikely that pt presenting with back, hip, SI or shoulder pain present for last 5-10 years is systemic in nature
◦ Unless sudden/recent change in clinical presentation with development of constitutional symptoms or system related S & S
2. Note pain descriptors commonly associated with pain of systemic nature
◦ Knifelike, boring, deep, throbbing
3. Observe pts response after initial eval
◦ May see reduction in symptoms after eval and pt education secondary to reduction in pt anxiety in pain of NMS origin
4. Aggravating/relieving factors often have to do with change in position or change in activity level in symptoms secondary to NMS dysfunction
Able to alter, provoke, alleviate, eliminate or aggravate symptoms in examination

Question 58

• Review table 3-2 comparing systemic vs MSK pain.

Answer 58

See ppt