How to differentiatepain? - Stamina Helse AS · How to differentiatepain? TordMoen...

24.08.2015

1

How to differentiate pain?

Tord Moen

Spes. IdrettsfysioterapiMNFF

Spes. Manuellterapeut MNFF

Klinikk 24 Tromsø

NSF Alpint herrer

Underholdning for verdens beste fysioterapeuter

Plan

• What is vertebral and visceral pain?

• How does visceral pain present?

• Visceral refered pain theories

• Visceral pain: From stimuli to response

• Age and sex differences

• When do we need to refer on?

• Case examples

• Take home message

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Vertebral pain

• Deep somatic pain

• Activity dependent

• Spesific aggs.

• Can refer dermatomical

• Poorly localized

askdrkit.com

(Ness ,1995)

Visceral pain

• Most frequent reason for

medical attention

• Counts for less than 10% of

afferent segmental input

• Visceral pain is not evoked

from all viscera

• It can be a referred pain

• Exaggerated motor and

automnomic reflexes are

often present

• Diffuse and poorly localized

• Often long lasting pain

• No change with rest

• Progressive and cyclic

(Donatelli, 2004)

(Giamberardino et al., 2004)

(Goodman and Snyder, 2007)

(Ness, 1995)

Features of visceral pain

• 1. pain is true visceral

– Vague, deep,dull, achy

– Poorly localized

– Accompanied by

sympathetic signs

• 2. pain is referred

– More defined

– Superficial

(Donatelli, 2004)


(Procacci and Maresca, 1999)

medexsystems.com.au

Referred visceral pain

• Little investigation

• Different theories

(Giamberardino, 2006)

Referred pain theories

• Convergence-projection theory (Head 1893)

– Psychical error of judgement

• Convergence facilitation theory (Mackenzie 1893)

– Irritable focus by constant bombardment

– Producing sympathetic output



• Multisegmental

innervation

– Pain in corresponding

somatic areas


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Multisegmental innervation

• Diaphragm C3-5

• Heart C3-T5

• Esophagus T4-T6

• Lungs T5-T6

• Pancrea T6-T10

• Stomach T6-T10

• Liver, gallbladder T7-T9

• Kidney T9-L1

• Colon/large intestine T11-L1

(Donatelli, 2004)



• Embryologic development

– Develops and then migrates




From stimuli to response

1. Nociceptive stimulation of small unmyelinated C-fibres within sympathetic and parasympathetic nerves

2. Dorsal horn

3. Second order neurons in dorsal horn projects to anterolateral system. Ascend through spinothalamic, spinoreticular and spinomesencephalic tracts

4. Brain target are the thalamus reticular formation and mid brain respectively

(Donatelli, 2004)

(Stochenda,l 2010)

gut.bmj.com

From stimuli to response

1. Stimulation of nociceptors

2. Central sensitization

3. Lowering of treshold in dorsal horn

4. Referred hyperalgesia

5. Reflex muscle guarding of surounding tonic muscles

6. Altered mechanical respons from muscles

7. Lead to musculoskeletal impairment(Donatelli, 2004)

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Age differences

• Elderly have more atypically presentations

– Impaired A delta fiber function

– Reduced turnover of neurotransmitter system

– Hypertension or diabetes

• Less pain

• Less intence

• Less referal


Sex differences

• Viscero-visceral pain

– Uterus pain, depending on dysmenorrheic

• Genital infections (more women)

• Coronnary disease (men 4:1)


When do we referre?

History and

physical

examination

Referre

red flag

Treatment

musculo-

skeletal

Screening

for red flag

(Goodman and

Snyder, 2007)

Guidelines for immediate medical

attention

• Anginal pain

• Cauda equina lesions

• Inadequate ventilation

• Appendicitis signs

• Aneurism signs


Guidelines for referral

• Unknown cause

• Lack of neuromusculoskeletal signs

• Lack of progress

• Development of new symptoms

• History of cancer


Systemic changes accompanied with

musculoskeletal symptoms:

• Nausea

• Vomiting

• Sweating

• Weight loss (>10%)

• Dizziness

• Fatigue

• Fever

• Infections


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Pulmonary• Shoulder pain aggravated by

respiratory movements auto

splinting or supine position

Gastrointestinal• Back and abdominal pain at same

level

• Pain or relieve of pain with meals

• Use of NSAIDS

Cardiac• Changes in angina pattern

• Severe chest pain

• Radiating angina pain

• Sympathetic changes

• Family history

Genitourinary• Blood, colour changes in urine or

stool

• Cervical spine pain with urinary

incontinence(Goodman and Snyder, 2007)

Liver disease• Right shoulder pain and or

scapular/midback pain of unknown

cause

• Bilateral carpal/tarsal tunnel

syndrome of unknown cause

• Changes in skin or eye colour


Why do we need to know this?

• Life and death

• First contact practioners

• More elderly people

• Early detection and referral

• Some estimates 1% is a masqurader

• 79% of elderly have 1/7 disabling conditions

– Arthritis, hypertension, heart disease, diabetes,

respiratory disease, stroke and cancer.


Case

Case 1

• 45 year old man

• Thoracic/mid

scapular vague pain

– Local sweating

• Low sternal and

epigastric vague pain

Case 2

• 39 year old man

• Severe left shoulder

and chest pain after

lifting heavy item

• Think he has torn a

muscle

Myocardial ischemia

True

visceral

pain

Somatic

referred

Myocaridal

infarction

Minutes

-hours



Case 3

• Woman 32 years old

• Dancer

• Headache, left sided

• Some vague mid thoracic pain

• Aggravates with moderate activity

• Not reproducable in AROM, PROM, PAIVMs

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Myocardial ischemia & headache

HeartVagal

nerve

Trigemino

cervical

nucleus

Head

ache/

Migrane

(Han and Lee, 2009)

Myocardial ischemia & headache

• Cardiac implications

– 6% had craniofacial pain

as only complaint from

coronary ischemia

– 32% had craniofacial

together with other pain

(Myers, 2008)

mdconsult.com

Lung tumour & headache

• Lung cancer

implications

– Ipsilateral

• Jaw

• Ear

• TMJ

(Bindhoff and Heseltine, 1988)

health.nytimes.com

Case

Case 4

• 23 year old male

• Soccer player

• Poorly localized back pain

• Groin pain

• Overactive bladder

Case 5

• 67 year old male

• Retired

• Back pain

• Rectal pain

• Does not function sexually

Male reproductive causes

Type

• Prostate cancer

• Testicle cancer

Symptoms

• Back pain

• Groin pain

• Rectal pain

• Bladder problems

• Sexual dysfunction


flickr.com

Case 6

Subjective

• 38-year-old male

• Weightlifter

• Referred for chronic LBP

• Current episode of 2 months duration

• Rx NSAID, heel lift

• Worsened last 2 week

• Sleeping problem, cant find comfortable position

• 10 year history of LBP

Physical

• Aggrevated by ext.

• PIVMS PAIVMS +ve L5

• Neurological negative

• Palpable puls abdominal

(Mechelli, 2008)

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Case 6

• Referred to GP

• Ultrasound reveled 10

cm AAA

• Successful surgery 2

days later

(Mecheli, 2008)

Puls palpation for AAA

Abdominal aortic aneurism

• Severe back pain

• Deep boring pain in mid

lumbar

• Sharp intense severe

knife like pain in the

abdomen, chest, back

(determined by location

of AAA)


(Mechelli, 2008)

Case

• Arnold Chiari

• Hjerne tumorer

• Eggstokk cyster

• Kne canser

Symptomer

• Hodepine

• Svimmelhet

• Synsforstyrrelser

• Motoriske

forstyrrelser

• Nakkesmerter

• Pareser,

parestesier

• Tremor

• Blære-

/tarmfunksjon

• Mentaletester

/ observasjoner• Motoriske

tester

• Hjernenerver

• Reflekser

• Sensibilitet• Koordinasjon

Oppfølgning/beha

ndling på Klinikk24

Muskel-/skjelett-

/nervesystemet

Vestibulærsystemet

Nevrologiske lidelser

Fastlege

Akutte alvorlige symptomer: 113

Henvise spesialisthelsetjenesten

UNN: 07766

Retningslinjer ved mistanke om alvorlig sykdom/skade

Sentrale

Hjerte/kar

Perifere

Patellofemorale smerter

• “Lochness monster of the knee” (Grelsamer et at 2009)

– Multifaktorelt problem

– Lokale, distale og proksimale fallgruver

• Infrapatellar fatpad revolution (McConnel, Kolding 2013)

Manuellterapeut Tord Moen - K24

Infrapatellar fettpute (IFP)

• Stikkende smerter medialt i kneet

• Hevelse bilateralt

• Vansker med bøye og strekke kneet


• Hoffa, 1904

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IFP

Fysiologisk og anatomisk• Vaskularisert

• Rikelig innervert– En av de mest smertesensitive

strukturer i kneet (Kennedy et al 1982 med fler)

• Anatomiske forbindelser– Patella

– Lig mucosum som er forbundetmed ACL

– Femur

– Proksimale patella sene

– Mediale og laterale menisk

– Periost på tibia

– retinakelet


IFP- funksjon

Biomekanisk

• Stabiliserer (Bohnsack 2005)

– <20 gr og >100 gr

• Øker patellafemorale

kontaktpunkt


Saddik et al 2004

Bohnsack, 2005

Kennedy et al 2002

Dragoo et al 2012

IFP- artroskopi

• Artroskopi i kne

– Fibrøst arrvev

• På det verste etter 6 mnd

• Forsvinner etter 12 mnd i

50 % av tilfellene


Tang et al 2000

IFP- et diagnostisk problem

• Ofte underdiagnostisert

• Ofte feildiagnostisert som patellatendinopati,

menisk-skade og runners knee

• Kan forverres ved operasjon


Dragoo et al 2012

IFP- symptomer

Anamnese:

• Typisk akutt hendelse er

spark på ball eller fraspark i

svømming

• Smerter ved å stå lenge

• Smerter ved å gå opp eller

ned trapper

Undersøkelse

• Står med hyperekstendert kne

• Om aktiv inflammasjon, står

pasienten ofte med lett

flektert kne

• Fettputen ser større ut på

affisert side enn frisk side

• Palpasjonssmerter ved

ekstensjon

• Smerter ved

kneekstensjonsøvelser


Dragoo et al 2012

IFP- forskning

Injeksjon av saltvann i IFP

• Injeksjon av saltvann i

fettputen(Bennel et al. 2004; Hodges et al. 2009)

Resultat

• Betydelig infrapatellar

smerte

• Retroptellar smerte

• Medial femur smerte

• Lyske-smerte

• Redusert aktivitet i vastus

medialis og vastus lateralis


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Take home messages

• Hard to distinquish from vertebral pain

• Time dependent diagnosis

• Continous process detecting visceral

impairment

• Combine referred pain theories

– Same theories for somatic referred pain

• Treatment to friends and family

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