Pain and source of symptoms

True or false: a patient can have pain and not be aware of it

false

Pain

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

Pain is always a _________ that is influenced by ________ factors

personal experience; biological, psychological, and social

Through __________ individuals learn the concept of pain

life experiences

_____ and _____ are different phenomena. Pain is not described solely based on activity in sensory neurons

pain and nociception

A person’s reports of an experience as pain should be ______

respected

Pain usually serves _______ role, it may have adverse effects on ______________

an adaptive role; function and social and psychological well-being

Inability to _______ does not negate the possibility that a human or a nonhuman animal experiences pain

communicate

Differential diagnosis

understanding type of pain and presentation will assist and/or guide assessment and intervention

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Categorizing pain - timing

• acute - days-weeks

• subacute - weeks-months

• chronic - months-years

Categorizing pain - mechanisms of pain

• nociceptive

• nociplastic

• neuropathic

• autonomic

• visceral

Categorizing pain - common pain patterns

• tension

• inflammatory

• ischemic

• myofascial

Acute pain

• clear onset

• inflammatory physiology dominates

• predictable aggravating factors

• pain decreases with rest and protection

• mechanical in nature

acute pain - goal of PT

• protect healing tissue

• control inflammation

• maintain mobility

• prevent maladaptive movement patterns

subacute pain

• decreasing inflammation

• stiffness & weakness

• pain is provoked by load

• symptoms become more movement specific

• fear-avoidance may emerge

• takes more time for pain to emerge

subacute pain - goals of PT

• graded loading

• restore ROM

• re-establish neuromuscular control

• prevent transition to chronic pain

chronic pain

• tissue healing is complete

• central sensitization may be present

• mechanical patterns become less predictable

• fear-avoidance, catastrophizing, and deconditioning

chronic pain - goal of PT

• graded exposure

• functional restoration

• pain neuroscience education

• addressing psychosocial factors

acute on chronic pain

• new acute flare of a pre-existing chronic condition

• baseline chronic symptoms

• sudden increase in pain intensity or functional loss

• often triggered by overload, new movement, deconditioning, stress, poor sleep, illness

• behaves mechanically and predictable and may include sensitization or fear-avoidance

• occurs over a span of years

acute on chronic pain- goals of PT

• graded exposure

• functional restoration

• pain neuroscience education

• addressing psychosocial factors

nociceptive (somatic)

tissue damage

neuropathic

damage to somatosensory system

nociplastic

disturbance in central pain processing

autonomic

sympathetic & parasympathetic dysfunction

visceral

serious pathology

Nociceptive pain

• pain that arises from actual or threatened damage to non-neural tissue

• originates from peripheral nociceptive sensory fibers

• activates peripheral nociceptors

• responds well to PT interventions

nociceptive pain is triggered by:

• injury

• inflammation

• mechanical irritant

• ischemia

peripheral nociceptors

• skin

• fascia

• tendons

• bone

• ligament

• joint capsule

PT interventions for nociceptive pain

• postural re-educating

• muscle stretching

• joint mobilization

• muscle strengthening

• motor control exercises

Nociception characteristics*

slide 15

Nociceptive qualities

slide 16

Neuropathic pain

• history of mechanical compromise, nerve injury, or pathology

• intermittent or constant pain

• central (dermatomal) or peripheral (cutaneous) distribution

what is an example of an injury that could cause neuropathic pain?

• diabetes

• GBS

• sciatica

Nociplastic pain

• no clear evidence of actual or threatened tissue damage

• no evidence for disease or lesion of the somatosensory system causing the pain

  • inability to regulate nociceptive input properly

• pain provocation that is disproportional, non-mechanical, and unpredictable

• unpredictable response to pain provocation - alodynia / hyperalgesia

• increased excitability, decreased inhibition

• diffuse, non-anatomic area of pain and/or tenderness on palpation

• central sensitization - patterns

• brain believes there is noxious stimuli, but there is not

Autonomic Pain

• dysfunction of the autonomic nervous system - abnormal responses

• not under volitional control

• sympathetic and parasympathetic nervous systems

  • have antagonist effects on end organs

autonomic pain - peripheral nervous system division is responsible for innervation of:

• smooth muscle

• cardiac muscle

• glands

Complex Regional Pain Syndrome (CRPS) - autonomic pain

• continuing pain

• sensory

• vasomotor

• sudomotor/edema

• motor/trophic

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Visceral - referred pain

• internal organs

  • no nerve fibers/nociceptors

• not well localized

  • multi segmental innervation

  • direct pressure

  • shared pathways

• location depends on organs

• gradual

• progressive

• cyclical

• constant

  • pain at rest

• night pain

• unaffected by exam or treatment

• referral pattern

Referred pain - characteristics

• can be acute or chronic

• generally localized with poorly defined borders

  • local tenderness

  • radiates from point of origin

• felt in an area away from the site of innervation

  • central neural pathway innervation

  • visceral organs

Associated signs/symptoms of visceral pain

• severe, unrelenting pain

• + fever

• unexplained weight loss

• atypical reproduction of symptoms

Tension pain

“colicky” or cramping pain, intermittent waves (peristaltic force)

tension pain - causes

organ distention (bowel obstruction, kidney stones), fluid/pus accumulation, or trauma

tension pain - pt behavior

constant movement, unable to find comfortable position

Inflammatory pain

• deep/boring

• typical of visceral or parietal peritoneum involvement

inflammatory pain - localization

• visceral: poorly localized

• parietal: sharp, localized (one-finger point)

inflammatory pain - patient behavior

seeks “quiet” and stillness, movement exacerbates pain

Ischemic pain

loss of blood supply/perfusion to tissues

ischemic pain is a _____

clinical red flag

ischemic pain presentation

• sudden, intense onset

• constant and progressive

• analgesic resistance: not relieved by standard pain meds

• no position of comfort: similar to tension pain, but often more severe

Myofascial pain - muscle tension

• a muscle that has forgotten how to relax

• caused by lifestyle - bad posture or repetitive motions

  • muscle is constantly “on”, blood can’t flow through it, creating ischemia

• muscle gets irritated because of a chemical called substance P

  • pain and irritation → more tension → more pain

Myofascial pain - muscle spasm

• “the bodyguard” a sudden, involuntary clench - usually a defensive reflex

• the muscle clenches to protect a nearby joint, bone, or muscle that is hurt

  • ex: back muscles locking up after you “throw your back out”

• important screening tool - if an internal organ is in trouble, the muscles on top of it will often spasm to protect the organ

Myofascial pain - muscle trauma

• muscle damage: acute trauma, burns, crush injuries, or with unaccustomed intensity or duration of muscle contraction, especially eccentric contractions

  • tissue structure and biology changes completely

• muscle fibers break

• potassium inside cells leak out into the surrounding fluid - sets off an “alarm” in your nervous system, causing sharp pain and swelling

How to determine a region of pain - subjective

• symptom behavior

  • worse/better?

How to determine a region of pain - examination

• screens

  • spine

  • peripheral joints

  • movement screens

• Tests

  • challenge hypothesis

Tissue types

• musculoteninous

• capsuloligamentous

• intra-articular

• extra-articular

Musculotendinous (& Bursa)

• pain: dull, achey, sore, heaviness

A patient presents with bicep pain. Which 3 motions would most likely elicit pain?

• resisted elbow flexion

• resisted elbow extension

• AROM elbow flexion

• AROM elbow extension

• PROM end range elbow flexion

• PROM end range elbow extension

• resisted elbow flexion

• AROM elbow flexion - shows irritability

• PROM end range elbow extension - puts muscle on stretch

Capsuloligamentous

• limits joint motion

• joint capsule

• synovium

• capsular ligaments

• accessory motion testing - joint mobs

Intra-articular

• meniscus / labrum

• cartilage

• loose bodies

Extra-articular

• fascia / connective tissue

• peripheral nerve

Which of the following symptoms is most likely associated with a systemic cause of pain? (non-musculoskeletal pain)

• intermittent pain that comes and goes with activity

• moderate pain that does not change with activity

• severe pain that decreases after a short period of rest

• morning stiffness that improves with movement

moderate pain that does not change with activity

systemic pain onset

• recent, sudden

• does not present as observed for years without progression of symptoms

musculoskeletal pain onset

• may be sudden or gradual

• sudden: usually associated with acute overload stress, traumatic event, repetitive motion; can occur as a side effect of some medications

• gradual: secondary to chronic overload of the affected part, may be present off and on for years

Determining location

• “show me exactly where your symptoms are located”

• “do you have any other related symptoms? of yes, where and what causes it?”

Systemic pain description

• knife-like quality of stabbing from the inside out, boring pain

• cutting, gnawing

• throbbing

• bone pain

• unilateral or bilateral

Musculoskeletal pain description

• usually unilateral

• may be stiff after prolonged rest, but pain level decreases

• achy, cramping pain

• local tenderness to pressure is present

Systemic pain intensity

• usually unrelated to presence of anxiety

  • emotional state doesn’t matter

• mild to severe

• dull to severe

Musculoskeletal pain intensity

• may be mild severe

• may depend on the person’s anxiety level or emotional state

• level of pain may increase in a client fearful of a “serious” condition

Systemic pain duration

• constant, no change, awakens person at night

musculoskeletal pain duration

• more likely to be intermittent

• may be constant but will fluctuate depending on the activity or the position

• duration can be modified by rest or change in position

Systemic pain pattern

• although constant, may come in waves - insidious or non musculoskeletal exacerbation

• gradually progressive, cyclical

• night pain

• location: chest/shoulder

  • accompanied by SOB, wheezing

  • eating alters symptoms

  • sitting up relieves symptoms (decreases venous return to hear - possible pulmonary or cardiovascular etiology)

• symptom unrelieved by rest or change in position

musculoskeletal pain pattern

• restriction of active/passive/accessory movements observed

• one or more movements “catch” the client and aggravate the pain

A patient presents with “proximal anterior shoulder pain” which of the following MOST accurately labels a postural exam finding of a thoracic kyphosis?

• comparable sign

• contributing factor

• incidental finding

contributing factor

A patient presents with “proximal anterior shoulder pain” which of the following most accurately labels the finding right posterior elbow pain with resisted elbow flexion?

• contributing factor

• comparable sign

• not a significant finding

• need more information

• not a significant finding

• need more information