851 pain.2

What are the 3 primary pain phenotypes?

Nociceptive, peripheral neuropathic, and nociplastic pain. Patients may have overlapping phenotypes; identify the predominant mechanism to guide treatment. Pain Phenotypes.pptx

What is nociceptive pain?

Pain from activation of nociceptors in non-neural tissue due to actual/threatened tissue injury, without a lesion/disease of the somatosensory nervous system.

What is the hallmark pattern of nociceptive pain?

Localized pain with a clear, consistent, reproducible relationship to mechanical/anatomical aggravating and easing factors.

How is nociceptive pain commonly described?

Sharp with movement/loading; dull ache or throb at rest.

What findings support nociceptive pain?

Localized symptoms + reproducible mechanical provocation + absence of neurologic signs.

What treatments generally fit a predominantly nociceptive presentation?

Exercise, manual therapy, and postural/mechanical correction. Pain Phenotypes.pptx

What is peripheral neuropathic pain?

Pain caused by a lesion/disease of the somatosensory nervous system that follows a neuroanatomically plausible distribution.

What does “neuroanatomically plausible” mean?

Symptoms correspond to a dermatome or specific peripheral nerve territory.

How is neuropathic pain commonly described?

Burning, shooting, electric-shock-like pain with possible numbness, tingling, or pins-and-needles.

What examination findings support neuropathic pain?

Neuroanatomic sensory/reflex changes and/or positive neurodynamic testing such as SLR or ULTT.

What questionnaires help identify a neuropathic component?

painDETECT and DN4. Pain Phenotypes.pptx

Why should imaging not determine neuropathic pain by itself?

Imaging correlates imperfectly with clinical neuropathic findings; the clinical exam is still necessary. Pain Phenotypes.pptx

What treatments generally fit a predominantly neuropathic presentation?

Neurodynamic techniques ± pharmacologic treatment targeting nerve sensitization. Pain Phenotypes.pptx

What is nociplastic pain?

Pain arising from altered nociception without sufficient evidence of tissue damage or a somatosensory nervous system lesion/disease to explain the symptoms.

What is the hallmark symptom distribution of nociplastic pain?

Widespread, diffuse, or non-anatomic symptoms that do not follow a clear dermatome or tissue pattern.

What symptom behavior suggests nociplastic pain?

Pain disproportionate to pathology with diffuse, inconsistent, or unpredictable aggravating/easing factors.

What are hyperalgesia and allodynia?

Hyperalgesia = exaggerated pain response to a painful stimulus; allodynia = pain from a normally nonpainful stimulus.

What associated symptoms commonly occur with nociplastic pain?

Poor sleep, fatigue, cognitive/emotional disturbance, generalized hypersensitivity, and psychosocial factors.

What treatments generally fit a predominantly nociplastic presentation?

Multimodal care including pain neuroscience education, graded exposure, and cognitive-behavioral strategies. Pain Phenotypes.pptx

Which phenotype is most associated with localized, predictable mechanical pain?

Nociceptive.

Which phenotype is most associated with burning/electric pain following a dermatome?

Peripheral neuropathic.

Which phenotype is most associated with widespread, disproportionate, non-anatomic pain?

Nociplastic.

Can a patient have more than one pain phenotype?

Yes. Pain phenotypes frequently overlap; determine which mechanism appears predominant and use it to guide management. Pain Phenotypes.pptx

What is a PROM?

Patient-Reported Outcome Measure; quantifies the patient’s symptoms, function, disability, health, or beliefs.

What PROMs in this lecture screen neuropathic pain?

DN4 and painDETECT. Pain Phenotypes.pptx

What PROMs can assess fear/kinesiophobia?

FABQ and TSK-11. Pain Phenotypes.pptx

What are examples of general/functional PROMs?

Patient-Specific Functional Scale (PSFS) and Global Rating of Change (GROC). Pain Phenotypes.pptx

What is MCID?

Minimum Clinically Important Difference = smallest score change considered clinically meaningful.

What is MDC?

Minimum Detectable Change = smallest score change that exceeds expected measurement error.

What is the difference between MCID and MDC?

MCID asks whether the change is meaningful; MDC asks whether the change is larger than measurement error. Pain Phenotypes.pptx

How should MCID/MDC values be interpreted?

As reference ranges rather than absolute cutoffs; also consider direction of change and its functional meaning. Pain Phenotypes.pptx

What does SMART stand for?

Specific, Measurable, Achievable, Relevant, Time-bound.

What makes a PT goal clinically strong?

It connects an objective measure to a meaningful patient-specific functional activity.

How can PROMs strengthen SMART goals?

They provide measurable, patient-centered targets for symptoms, function, or disability.

When using a PROM in a goal, what change should ideally be targeted?

A change that meets/exceeds the MDC so improvement is more likely to represent true change rather than measurement error. Pain Phenotypes.pptx

What is wrong with “Patient will improve strength by discharge”?

It lacks a specific measurement, functional relevance, and defined timeframe.

Which is stronger: “Improve shoulder strength to 5/5” or “Improve shoulder strength to 5/5 within 6 weeks to lift groceries independently”?

The second because the objective impairment is connected to function and a timeframe.

What does SINSS stand for?

Severity, Irritability, Nature, Stage, Stability.

What is the primary purpose of SINSS?

To prioritize information and determine what/how aggressively to examine and treat the patient. Pain Phenotypes.pptx

What does severity describe?

Intensity and impact of the patient’s symptoms.

What does irritability describe?

How easily symptoms are provoked, how intense they become, and how long they take to settle.

How does high irritability change the examination?

Use fewer provocative tests and a gentler/conservative examination dosage.

How does low irritability change the examination?

Allows a more thorough objective examination. Pain Phenotypes.pptx

What does “nature” identify?

Likely source/mechanism: MSK, nerve, non-MSK/systemic, psychosocial, etc.

What are the lecture’s general stages?

Acute =

What does stability describe?

Whether symptoms are improving, worsening, unchanged, or fluctuating.

What should unchanged symptoms despite treatment make you consider?

Reconsider the working hypothesis or treatment approach. Pain Phenotypes.pptx

What is the overall examination sequence?

History → PROMs → Differential list → Plan exam → Perform exam → Synthesize → Finalize PT diagnosis → Educate patient. Pain Phenotypes.pptx

Why is the patient history so important?

It begins connecting symptoms into a clinical pattern and develops the hypotheses that guide the objective exam.

What is the purpose of the differential diagnosis list?

Identify potential pain generators/problems that objective testing will rule in or rule out.

How should differentials be organized?

Most likely, less likely, and remotely likely diagnoses.

What should determine which objective tests are selected?

Differential diagnoses, test sensitivity/specificity, tissue irritability, safety, and patient positioning.

What should the clinician ask before performing a test?

“Will this test help rule in/out one of my hypotheses or change my clinical reasoning?”

What spinal region should be considered with an upper-quarter complaint?

Cervical spine.

What spinal region should be considered with a lower-quarter complaint?

Lumbar spine. Pain Phenotypes.pptx

Why should the spine be cleared before assuming a regional joint is responsible?

The spine may refer symptoms into the extremity and mimic a regional musculoskeletal disorder.

How should objective testing be organized for efficiency?

Group tests by patient position: standing, sitting, supine, side-lying, prone. Pain Phenotypes.pptx

When should highly provocative tests generally be performed?

Later in the examination.

Why save highly provocative tests until later?

An early symptom flare may alter later test findings and reduce their diagnostic value.

Can low-yield tests be eliminated as the differential narrows?

Yes, but never omit a necessary red-flag screen simply to save time. Pain Phenotypes.pptx

What does “synthesize the findings” mean?

Integrate the history and objective findings to determine the most likely pain generator/PT diagnosis and whether the patient is appropriate for PT.

What is the major clinical reasoning sequence from this lecture?

History creates hypotheses → SINSS determines testing dosage → objective exam rules diagnoses in/out → predominant pain phenotype helps guide treatment.

A patient sprains their ankle yesterday. Pain is localized over the lateral ankle, sharp with weight bearing, relieved by rest, and consistently reproduced with inversion. Most likely pain phenotype?

Nociceptive. Symptoms are localized, mechanically reproducible, and proportional to the injured tissue.

A patient has low-back pain with burning pain traveling down the posterior leg into the lateral foot, paresthesia, and a positive SLR. Most likely phenotype?

Peripheral neuropathic. Burning pain + neuroanatomically plausible distribution + positive neurodynamic test.

A patient reports bilateral widespread neck, shoulder, and low-back pain with fatigue, poor sleep, diffuse tenderness, and pain that varies unpredictably despite minimal identifiable tissue pathology. Most likely phenotype?

Nociplastic. Widespread/non-anatomic pain + disproportionate symptoms + hypersensitivity/systemic associated features.

A patient’s MRI demonstrates a lumbar disc protrusion, but symptoms do not follow a dermatome, neurologic testing is normal, and SLR is negative. Can you diagnose neuropathic pain based on the MRI alone?

No. Imaging correlates imperfectly with clinical neuropathic findings; clinical signs must support the diagnosis.

A patient has localized knee OA pain but also burning paresthesia extending into the foot in a peripheral nerve distribution. What should you suspect?

A mixed pain presentation, likely with nociceptive + neuropathic components. Determine the predominant mechanism while addressing both.

A patient has severe shoulder pain that is provoked by minimal movement and remains elevated for hours afterward. How should irritability affect your exam?

High irritability → perform a more conservative exam with fewer provocative tests and gentler dosage.

A patient reports 2/10 knee pain only after running 5 miles, and symptoms resolve within several minutes. How does this affect your exam?

Low severity/irritability → a more thorough mechanical examination is likely tolerated.

You strongly suspect a rotator cuff disorder before testing. What should determine the tests you perform?

Select tests that help rule in/out your differential, considering diagnostic utility, irritability, safety, and efficient positioning.

A patient presents for shoulder pain. Before performing an extensive shoulder examination, what referred source should be considered?

Cervical spine.

A patient presents with lateral hip pain. What spinal source should be considered before assuming symptoms originate from the hip?

Lumbar spine.

You perform a very provocative special test first and cause a major symptom flare. Why is this a problem?

Subsequent examination findings may be altered, decreasing their diagnostic usefulness.

During the exam, your differential has narrowed to two likely diagnoses. Should you continue performing every test on your original list?

No. Eliminate/defer low-yield procedures once the differential narrows, while still completing necessary safety/red-flag screening.

A patient improves their disability questionnaire score by 2 points, but the instrument’s MDC is 7 points. What can you conclude?

The improvement may be within measurement error; you cannot confidently conclude that true change occurred.

A patient’s PROM score improves beyond its MDC, but they report no improvement in meaningful activities. What should you do?

Consider the PROM and functional meaning together; exceeding the MDC alone does not replace patient-centered clinical interpretation.

A goal states: “Patient will decrease pain.” Why is this weak?

It is not adequately specific, measurable, functionally relevant, or time-bound.

Rewrite “Patient will walk better.”

Example: “Within 6 weeks, patient will walk ½ mile independently without stopping to allow return to community walking.”

A chronic low-back-pain patient suddenly develops a new flare that began 4 days ago. Is the condition simply “chronic”?

The underlying condition may be chronic with an acute exacerbation.

A patient has completed several weeks of appropriate treatment but symptoms and function are completely unchanged. What does SINSS stability tell you?

“Not changing” should prompt reassessment of your working hypothesis and/or treatment approach.

A patient reports severe diffuse pain, unpredictable aggravating factors, poor sleep, and marked fear of movement. Would repeated aggressive tissue-provocation testing likely be appropriate?

Probably not. The pattern suggests significant nociplastic features and high irritability; examination/treatment should be appropriately dosed and multimodal.

A patient with widespread pain asks why strengthening alone has not eliminated their symptoms. What pain phenotype should make you consider broader treatment strategies?

Nociplastic pain, because management may require pain education, graded exposure, and cognitive-behavioral strategies in addition to physical exercise.

Why create the differential before the objective exam?

So the examination is intentionally designed to rule potential diagnoses in/out rather than becoming a collection of unrelated tests.

Why does identifying the predominant mechanism matter?

Because treatment aimed exclusively at local Achilles tissue may be insufficient if altered pain processing has become a major contributor. Pain Phenotypes.pptx