Pain Types and Viscerogenic Pain Patterns

Chapter 3


Pain Types and Viscerogenic Pain Patterns


Pain is often the primary symptom in many physical therapy practices. Pain assessment is a key feature in the physical therapy interview. Pain is now recognized as the “fifth vital sign,”1 along with blood pressure, temperature, pulse, and respiration.


Recognizing pain patterns that are characteristic of systemic disease is a necessary step in the screening process. Understanding how and when diseased organs can refer pain to the neuromusculoskeletal (NMS) system helps the therapist identify suspicious pain patterns.


This chapter includes a detailed overview of pain patterns that can be used as a foundation for all the organ systems presented. Information will include a discussion of pain types in general and viscerogenic pain patterns specifically. Additional resources for understanding the mechanisms of pain are available.2


Each section discusses specific pain patterns characteristic of disease entities that can mimic pain from musculoskeletal or neuromuscular disorders. In the clinical decision-making process the therapist will evaluate information regarding the location, referral pattern, description, frequency, intensity, and duration of systemic pain in combination with knowledge of associated symptoms and relieving and aggravating factors.


This information is then compared with presenting features of primary musculoskeletal disorders that have similar patterns of presentation. Pain patterns of the chest, back, shoulder, scapula, pelvis, hip, groin, and sacroiliac (SI) joint are the most common sites of referred pain from a systemic disease process. These patterns are discussed in greater detail later in this text (see Chapters 14 to 18).


A large component in the screening process is being able to recognize the client demonstrating a significant emotional overlay. Pain patterns from cancer can be very similar to what we have traditionally identified as psychogenic or emotional sources of pain. It is important to know how to differentiate between these two sources of painful symptoms. To help identify psychogenic sources of pain, discussions of conversion symptoms, symptom magnification, and illness behavior are also included in this chapter.



Mechanisms of Referred Visceral Pain


The neurology of visceral pain is not well understood at this time. Proposed models are based on what is known about the somatic (nonvisceral) sensory system. Scientists have not found actual nerve fibers and specific nociceptors in organs. Peripheral mechanisms are suspected.3 We do know the afferent supply to internal organs is in close proximity to blood vessels along a path similar to the sympathetic nervous system.4,5


Research is ongoing to identify the sites and mechanisms of visceral nociception. During inflammation, increased nociceptive input from an inflamed organ can sensitize neurons that receive convergent input from an unaffected organ, but the site of visceral cross-sensitivity is unknown.6


Viscerosensory fibers ascend the anterolateral system to the thalamus with fibers projecting to several regions of the brain. These regions encode the site of origin of visceral pain, although they do it poorly because of low receptor density, large overlapping receptive fields, and extensive convergence in the ascending pathway. Thus the cortex cannot distinguish where the pain messages originate from.7,8


Studies show there may be multiple mechanisms operating at different sites to produce the sensation we refer to as “pain.” The same symptom can be produced by different mechanisms and a single mechanism may cause different symptoms.9


In the case of referred pain patterns of viscera, there are three separate phenomena to consider from a traditional Western medicine approach. These are:




Embryologic Development


Each system has a bit of its own uniqueness in how pain is referred. For example, the viscera in the abdomen comprise a large percentage of all the organs we have to consider. When a person gives a history of abdominal pain, the location of the pain may not be directly over the involved organ (Fig. 3-1).



Functional magnetic resonance imaging (fMRI) and other neuroimaging methods have shown activation of the inferolateral postcentral gyrus by visceral pain so the brain has a role in visceral pain patterns.10,11 However, it is likely that embryologic development has the primary role in referred pain patterns for the viscera.


Pain is referred to a site where the organ was located in fetal development. Although the organ migrates during fetal development, its nerves persist in referring sensations from the former location.


Organs, such as the kidneys, liver, and intestines, begin forming by 3 weeks when the fetus is still less than the size of a raisin. By day 19, the notochord forming the spinal column has closed and by day 21, the heart begins to beat.


Embryologically, the chest is part of the gut. In other words, they are formed from the same tissue in utero. This explains symptoms of intrathoracic organ pathology frequently being referred to the abdomen as a viscero-viscero reflex. For example, it is not unusual for disorders of thoracic viscera, such as pneumonia or pleuritis, to refer pain that is perceived in the abdomen instead of the chest.4


Although the heart muscle starts out embryologically as a cranial structure, the pericardium around the heart is formed from gut tissue. This explains why myocardial infarction or pericarditis can also refer pain to the abdomen.4


Another example of how embryologic development impacts the viscera and the soma, consider the ear and the kidney. These two structures have the same shape since they come from the same embryologic tissue (otorenal axis of the mesenchyme) and are formed at the same time (Fig. 3-2).



When a child is born with any anomaly of the ear(s) or even a missing ear, the medical staff knows to look for possible similar changes or absence of the kidney on the same side.


A thorough understanding of fetal embryology is not really necessary in order to recognize red flag signs and symptoms of visceral origin. Knowing that it is one of several mechanisms by which the visceral referred pain patterns occur is a helpful start.


However, the more you know about embryologic development of the viscera, the faster you will recognize somatic pain patterns caused by visceral dysfunction. Likewise, the more you know about anatomy, the origins of anatomy, its innervations, and the underlying neurophysiology, the better able you will be to identify the potential structures involved.


This will lead you more quickly to specific screening questions to ask. The manual therapist will especially benefit from a keen understanding of embryologic tissue derivations. An appreciation of embryology will help the therapist localize the problem vertically.



Multisegmental Innervation


Multisegmental innervation is the second mechanism used to explain pain patterns of a viscerogenic source (Fig. 3-3). The autonomic nervous system (ANS) is part of the peripheral nervous system. As shown in this diagram, the viscera have multisegmental innervations. The multiple levels of innervation of the heart, bronchi, stomach, kidneys, intestines, and bladder are demonstrated clearly.



There is new evidence to support referred visceral pain to somatic tissues based on overlapping or same segmental projections of spinal afferent neurons to the spinal dorsal horn. This concept is referred to as visceral-organ cross-sensitization. The mechanism is likely to be sensitization of viscera-somatic convergent neurons.12


For the first time ever, scientists showed that individuals diagnosed with multiple visceral problems obtained relief from pain in all organ systems with overlapping segmental projections when only one visceral area was treated. In other words, nontreated visceral disease significantly decreased when one viscera of the overlapping segments was addressed. For groups of people with no overlapping segments, spontaneous relief of referred pain was not obtained until and unless all involved visceral systems were treated.12


Pain of a visceral origin can be referred to the corresponding somatic areas. The example of cardiac pain is a good one. Cardiac pain is not felt in the heart, but is referred to areas supplied by the corresponding spinal nerves.


Instead of actual physical heart pain, cardiac pain can occur in any structure innervated by C3 to T4 such as the jaw, neck, upper trapezius, shoulder, and arm. Pain of cardiac and diaphragmatic origin is often experienced in the shoulder, in particular, because the C5 spinal segment supplies the heart, respiratory diaphragm, and shoulder.



Direct Pressure and Shared Pathways


A third and final mechanism by which the viscera refer pain to the soma is the concept of direct pressure and shared pathways (Fig. 3-4). As shown in this illustration, many of the viscera are near the respiratory diaphragm. Any pathologic process that can inflame, infect, or obstruct the organs can bring them in contact with the respiratory diaphragm.



Anything that impinges the central diaphragm can refer pain to the shoulder and anything that impinges the peripheral diaphragm can refer pain to the ipsilateral costal margins and/or lumbar region (Fig. 3-5).



This mechanism of referred pain through shared pathways occurs as a result of ganglions from each neural system gathering and sharing information through the cord to the plexuses. The visceral organs are innervated through the ANS. The ganglions bring in information from around the body. The nerve plexuses decide how to respond to this information (what to do) and give the body finely-tuned, local control over responses.


Plexuses originate in the neck, thorax, diaphragm, and abdomen, terminating in the pelvis. The brachial plexus supplies the upper neck and shoulder while the phrenic nerve innervates the respiratory diaphragm. More distally, the celiac plexus supplies the stomach and intestines. The neurologic supply of the plexuses is from parasympathetic fibers from the vagus and pelvic splanchnic nerves.4


The plexuses work independently of each other but not independently of the ganglia. The ganglia collect information derived from both the parasympathetic and the sympathetic fibers. The ganglia deliver this information to the plexuses; it is the plexuses that provide fine, local control in each of the organ systems.4


For example, the lower portion of the heart is in contact with the center of the diaphragm. The spleen on the left side of the body is tucked up under the dome of the diaphragm. The kidneys (on either side) and the pancreas in the center are in easy reach of some portion of the diaphragm.


The body of the pancreas is in the center of the human body. The tail rests on the left side of the body. If an infection, inflammation, or tumor or other obstruction distends the pancreas, it can put pressure on the central part of the diaphragm.


Since the phrenic nerve (C3-5) innervates the central zone of the diaphragm, as well as part of the pericardium, the gallbladder, and the pancreas, the client with impairment of these viscera can present with signs and symptoms in any of the somatic areas supplied by C3-5 (e.g., shoulder).


In other words, the person can experience symptoms in the areas innervated by the same nerve pathways. So a problem affecting the pancreas can look like a heart problem, a gallbladder problem, or a mid-back/scapular or shoulder problem.


Most often, clients with pancreatic disease present with the primary pain pattern associated with the pancreas (i.e., left epigastric pain or pain just below the xiphoid process). The somatic presentation of referred pancreatic pain to the shoulder or back is uncommon, but it is the unexpected, referred pain patterns that we see in a physical or occupational therapy practice.


Another example of this same phenomenon occurs with peritonitis or gallbladder inflammation. These conditions can irritate the phrenic endings in the central part of the diaphragmatic peritoneum. The client can experience referred shoulder pain due to the root origin shared in common by the phrenic and supraclavicular nerves.


Not only is it true that any structure that touches the diaphragm can refer pain to the shoulder, but even structures adjacent to or in contact with the diaphragm in utero can do the same. Keep in mind there has to be some impairment of that structure (e.g., obstruction, distention, inflammation) for this to occur (Case Example 3-1).



Case Example 3-1   Mechanism of Referred Pain


A 72-year-old woman has come to physical therapy for rehabilitation after cutting her hand and having a flexor tendon repair. She uses a walker to ambulate, reports being short of breath “her whole life,” and takes the following prescription and over-the-counter (OTC) medications:



During the course of evaluating and treating her hand, she reports constant, aching pain in her right shoulder and a sharp, tingling, burning sensation behind her armpit (also on the right side). She does not have any associated bowel or bladder signs and symptoms, but reports excessive fatigue “since the day I was born.”


You suspect the combination of Feldene and Ibuprofen along with long-term use of Vioxx may be a problem.



What Is the Most Likely Mechanism of Pain: Embryologic Development, Multisegmental Innervation of the Stomach and Duodenum, or Direct Pressure on the Diaphragm?


Even though Vioxx is a cyclooxygenase-2 (COX-2) inhibitor and less likely to cause problems, gastritis and gastrointestinal (GI) bleeding are still possible, especially with chronic long-term use of multiple nonsteroidal antiinflammatory drugs (NSAIDs).


Retroperitoneal bleeding from peptic ulcer can cause referred pain to the back at the level of the lesion (T6-10) or right shoulder and/or upper trapezius pain. Shoulder pain may be accompanied by sudomotor changes such as burning, gnawing, or cramping pain along the lateral border of the scapula. The scapular pain can occur alone as the only symptom.


Side effects of NSAIDs can also include fatigue, anxiety, depression, paresthesia, fluid retention, tinnitus, nausea, vomiting, dry mouth, and bleeding from the nose, mouth, or under the skin. If peritoneal bleeding is the cause of her symptoms, the mechanism of pain is blood in the posterior abdominal cavity irritating the diaphragm through direct pressure.


Be sure to take the client’s vital signs and observe for significant changes in blood pressure and pulse. Poor wound healing and edema (sacral, pedal, hands) may be present. Ask if the same doctor prescribed each medication and if her physician (or physicians) knows which medications she is taking. It is possible that her medications have not been checked or coordinated from before her hospitalization to the present time.



*Removed from the market in 2004 by Merck & Co., Inc., due to reports of increased risk of cardiovascular events.



Assessment of Pain and Symptoms


The interviewing techniques and specific questions for pain assessment are outlined in this section. The information gathered during the interview and examination provides a description of the client that is clear, accurate, and comprehensive. The therapist should keep in mind cultural rules and differences in pain perception, intensity, and responses to pain found among various ethnic groups.13


Measuring pain and assessing pain are two separate issues. A measurement assigns a number or value to give dimension to pain intensity.14 A comprehensive pain assessment includes a detailed health history, physical exam, medication history (including nonprescription drug use and complementary and alternative therapies), assessment of functional status, and consideration of psychosocial-spiritual factors.15


The portion of the core interview regarding a client’s perception of pain is a critical factor in the evaluation of signs and symptoms. Questions about pain must be understood by the client and should be presented in a nonjudgmental manner. A record form may be helpful to standardize pain assessment with each client (Fig. 3-6).



To elicit a complete description of symptoms from the client, the physical therapist may wish to use a term other than pain. For example, referring to the client’s symptoms or using descriptors such as hurt or sore may be more helpful with some individuals. Burning, tightness, heaviness, discomfort, and aching are just a few examples of other possible word choices. The use of alternative words to describe a client’s symptoms may also aid in refocusing attention away from pain and toward improvement of functional abilities.


If the client has completed the McGill Pain Questionnaire (see discussion of McGill Pain Questionnaire in this chapter),16 the physical therapist may choose the most appropriate alternative word selected by the client from the list to refer to the symptoms (Table 3-1).




Pain Assessment in the Older Adult


Pain is an accepted part of the aging process, but we must be careful to take the reports of pain from older persons as serious and very real and not discount the symptoms as part of aging. Well over half of the older adults in the United States report chronic joint symptoms.17 We are likely to see pain more often as a key feature among older adults as our population continues to age.


The American Geriatrics Society (AGS) reports the use of over-the-counter (OTC) analgesic medications for pain, aching, and discomfort is common in older adults along with routine use of prescription drugs. Many older adults have taken these medications for 6 months or more.18


Older adults may avoid giving an accurate assessment of their pain. Some may expect pain with aging or fear that talking about pain will lead to expensive tests or medications with unwanted side effects. Fear of losing one’s independence may lead others to underreport pain symptoms.19


Sensory and cognitive impairment in older, frail adults makes communication and pain assessment more difficult.18 The client may still be able to report pain levels reliably using the visual analogue scales in the early stages of dementia. Improving an older adult’s ability to report pain may be as simple as making sure the client has his or her glasses and hearing aid.


The Verbal Descriptor Scale (VDS) (Box 3-1) may be the most sensitive and reliable among older adults, including those with mild-to-moderate cognitive impairment.20 But these and other pain scales rely on the client’s ability to understand the scale and communicate a response. As dementia progresses, these abilities are lost as well.



A client with Alzheimer’s-type dementia loses short-term memory and cannot always identify the source of recent painful stimuli.21,22 The Alzheimer’s Discomfort Rating Scale may be more helpful for older adults who are unable to communicate their pain.23 The therapist records the frequency, intensity, and duration of the client’s discomfort based on the presence of noisy breathing, facial expressions, and overall body language.


Another tool under investigation is the Pain Assessment in Advanced Dementia (PAINAD) scale. The PAINAD scale is a simple, valid, and reliable instrument for measurement of pain in noncommunicative clients developed by the same author as the Alzheimer’s Discomfort Rating Scale.24 A disadvantage of this pain scale is that the pain is inferred by the examiner or caregiver rather than self-reported directly by the individual experiencing the pain.25


Facial grimacing; nonverbal vocalization such as moans, sighs, or gasps; and verbal comments (e.g., ouch, stop) are the most frequent behaviors among cognitively impaired older adults during painful movement (Box 3-2). Bracing, holding onto furniture, or clutching the painful area are other behavioral indicators of pain. Alternately, the client may resist care by others or stay very still to guard against pain caused by movement.26



Untreated pain in an older adult with advanced dementia can lead to secondary problems such as sleep disturbances, weight loss, dehydration, and depression. Pain may be manifested as agitation and increased confusion.21


Older adults are more likely than younger adults to have what is referred to as atypical acute pain. For example, silent acute myocardial infarction (MI) occurs more often in the older adult than in the middle-aged to early senior adult. Likewise, the older adult is more likely to experience appendicitis without any abdominal or pelvic pain.27



Pain Assessment in the Young Child


Many infants and children are unable to report pain. Even so the therapist should not underestimate or prematurely conclude that a young client is unable to answer any questions about pain. Even some clients (both children and adults) with substantial cognitive impairment may be able to use pain-rating scales when explained carefully.28


The Faces Pain Scale (FACES or FPS) for children (see Fig. 3-6) was first presented in the 1980s.29 It has since been revised (FPS-R)30 and presented concurrently by other researchers with similar assessment measures.31


Most of the pilot work for the FPS was done informally with children from preschool through young school age. Researchers have used the FPS scale with adults, especially the elderly, and have had successful results. Advantages of the cartoon-type FPS scale are that it avoids gender, age, and racial biases.32


Research shows that use of the word “hurt” rather than pain is understood by children as young as 3 years old.33,34 Use of a word such as “owie” or “ouchie” by a child to describe pain is an acceptable substitute.32 Assessing pain intensity with the FPS scale is fast and easy. The child looks at the faces, the therapist or parent uses the simple words to describe the expression, and the corresponding number is used to record the score.


A review of multiple other measures of self-report is also available,14 as well as a review of pain measures used in children by age, including neonates.35


When using a rating scale is not possible, the therapist may have to rely on the parent or caregiver’s report and/or other measures of pain in children with cognitive or communication impairments and physical disabilities. Look for telltale behavior such as lack of cooperation, withdrawal, acting out, distractibility, or seeking comfort. Altered sleep patterns, vocalizations, and eating patterns provide additional clues.


In very young children and infants, the Child Facial Coding System (CFCS) and the Neonatal Facial Coding System (NFCS) can be used as behavioral measures of pain intensity.36,37


Facial actions and movements, such as brow bulge, eye squeeze, mouth position, and chin quiver, are coded and scored as pain responses. This tool has been revised and tested as valid and reliable for use postoperatively in children ages 0 to 18 months following major abdominal or thoracic surgery.38


Vital signs should be documented but not relied upon as the sole determinant of pain (or absence of pain) in infants or young children. The pediatric therapist may want to investigate other pain measures available for neonates and infants.39,40



Characteristics of Pain


It is very important to identify how the client’s description of pain as a symptom relates to sources and types of pain discussed in this chapter. Many characteristics of pain can be elicited from the client during the Core Interview to help define the source or type of pain in question. These characteristics include:



Other additional components are related to factors that aggravate the pain, factors that relieve the pain, and other symptoms that may occur in association with the pain. Specific questions are included in this section for each descriptive component. Keep in mind that an increase in frequency, intensity, or duration of symptoms over time can indicate systemic disease.



Location of Pain


Questions related to the location of pain focus the client’s description as precisely as possible. An opening statement might be as follows:



If the client points to a small, localized area and the pain does not spread, the cause is likely to be a superficial lesion and is probably not severe. If the client points to a small, localized area but the pain does spread, this is more likely to be a diffuse, segmental, referred pain that may originate in the viscera or deep somatic structure.


The character and location of pain can change and the client may have several pains at once, so repeated pain assessment may be needed.



Description of Pain


To assist the physical therapist in obtaining a clear description of pain sensation, pose the question:



When a client describes the pain as knifelike, boring, colicky, coming in waves, or a deep aching feeling, this description should be a signal to the physical therapist to consider the possibility of a systemic origin of symptoms. Dull, somatic pain of an aching nature can be differentiated from the aching pain of a muscular lesion by squeezing or by pressing the muscle overlying the area of pain. Resisting motion of the limb may also reproduce aching of muscular origin that has no connection to deep somatic aching.



Intensity of Pain


The level or intensity of the pain is an extremely important but difficult component to assess in the overall pain profile. Psychologic factors may play a role in the different ratings of pain intensity measured between African Americans and Caucasians. African Americans tend to rate pain as more unpleasant and more intense than whites, possibly indicating a stronger link between emotions and pain behavior for African Americans compared with Caucasians.41


The same difference is observed between women and men.42,43 Likewise, pain intensity is reported as less when the affected individual has some means of social or emotional support.44


Assist the client with this evaluation by providing a rating scale. You may use one or more of these scales, depending on the clinical presentation of each client (see Fig. 3-6). Show the pain scale to your client. Ask the client to choose a number and/or a face that best describes his or her current pain level. You can use this scale to quantify symptoms other than pain such as stiffness, pressure, soreness, discomfort, cramping, aching, numbness, tingling, and so on. Always use the same scale for each follow-up assessment.


The Visual Analog Scale (VAS)45,46 allows the client to choose a point along a 10-cm (100 mm) horizontal line (see Fig. 3-6). The left end represents “No pain” and the right end represents “Pain as bad as it could possibly be” or “Worst Possible Pain.” This same scale can be presented in a vertical orientation for the client who must remain supine and cannot sit up for the assessment. “No pain” is placed at the bottom, and “Worst pain” is put at the top.


The VAS scale is easily combined with the numeric rating scale with possible values ranging from 0 (no pain) to 10 (worst imaginable pain). It can be used to assess current pain, worst pain in the preceding 24 hours, least pain in the past 24 hours, or any combination the clinician finds useful.


The Numeric Rating Scale (NRS; see Fig. 3-6) allows the client to rate the pain intensity on a scale from 0 (no pain) to 10 (the worst pain imaginable). This is probably the most commonly used pain rating scale in both the inpatient and outpatient settings. It is a simple and valid method of measuring pain.


Although the scale was tested and standardized using 0 to 10, the plus is used for clients who indicate the pain is “off the scale” or “higher than a 10.” Some health care professionals prefer to describe 10 as “worst pain experienced with this condition” to avoid needing a higher number than 10.


This scale is especially helpful for children or cognitively impaired clients. In general, even adults without cognitive impairments may prefer to use this scale.


An alternative method provides a scale of 1 to 5 with word descriptions for each number16 and asks:



This scale for measuring the intensity of pain can be used to establish a baseline measure of pain for future reference. A client who describes the pain as “excruciating” (or a 5 on the scale) during the initial interview may question the value of therapy when several weeks later there is no subjective report of improvement.


A quick check of intensity by using this scale often reveals a decrease in the number assigned to pain levels. This can be compared with the initial rating, thus providing the client with assurance and encouragement in the rehabilitation process. A quick assessment using this method can be made by asking:



The description of intensity is highly subjective. What might be described as “mild” for one person could be “horrible” for another person. Careful assessment of the person’s nonverbal behavior (e.g., ease of movement, facial grimacing, guarding movements) and correlation of the person’s personality with his or her perception of the pain may help to clarify the description of the intensity of the pain. Pain of an intense, unrelenting (constant) nature is often associated with systemic disease.


The 36-Item Short-Form Health Survey discussed in Chapter 2 includes an assessment of bodily pain along with a general measure of health-related quality of life. Nurses often use the PQRST mnemonic to help identify underlying pathology or pain (Box 3-3).




Frequency and Duration of Pain


The frequency of occurrence is related closely to the pattern of the pain, and the client should be asked how often the symptoms occur and whether the pain is constant or intermittent. Duration of pain is a part of this description.



Further responses may reveal that the pain is perceived as being constant but in fact is not actually present consistently and/or can be reduced with rest or change in position, which are characteristics more common with pain of musculoskeletal origin. Symptoms that truly do not change throughout the course of the day warrant further attention.



Pattern of Pain


After listening to the client describe all the characteristics of his or her pain or symptoms, the therapist may recognize a vascular, neurogenic, musculoskeletal (including spondylogenic), emotional, or visceral pattern (see Table 3-1).


The following sequence of questions may be helpful in further assessing the pattern of pain, especially how the symptoms may change with time.



The pattern of pain associated with systemic disease is often a progressive pattern with a cyclical onset (i.e., the client describes symptoms as being alternately worse, better, and worse over a period of months). When there is back pain, this pattern differs from the sudden sequestration of a discogenic lesion that appears with a pattern of increasingly worse symptoms followed by a sudden cessation of all symptoms. Such involvement of the disk occurs without the cyclical return of symptoms weeks or months later, which is more typical of a systemic disorder.


If the client appears to be unsure of the pattern of symptoms or has “avoided paying any attention” to this component of pain description, it may be useful to keep a record at home assisting the client to take note of the symptoms for 24 hours. A chart such as the McGill Home Recording Card16 (Fig. 3-7) may help the client outline the existing pattern of the pain and can be used later in the episode of care to assist the therapist in detecting any change in symptoms or function.



There is also a Short-Form McGill Pain Questionnaire that has been validated for use to assess treatment response. It is designed to measure all kinds of pain—both neuropathic and nonneuropathic—using a numeric rating scale to assess 22 pain descriptors from zero (none) to 10 (worst possible).47


Medications can alter the pain pattern or characteristics of painful symptoms. Find out how well the client’s current medications reduce, control, or relieve pain. Ask how often medications are needed for breakthrough pain.


When using any of the pain rating scales, record the use of any medications that can alter or reduce pain or symptoms such as antiinflammatories or analgesics. At the same time remember to look for side effects or adverse reactions to any drugs or drug combinations.


Watch for clients taking nonsteroidal antiinflammatory drugs (NSAIDs) who experience an increase in shoulder, neck, or back pain several hours after taking the medication. Normally, one would expect symptom relief from NSAIDs so any increase in symptoms is a red flag for possible peptic ulcer.


A client frequently will comment that the pain or symptoms have not changed despite 2 or 3 weeks of physical therapy intervention. This information can be discouraging to both client and therapist; however, when the symptoms are reviewed, a decrease in pain, increase in function, reduced need for medications, or other significant improvement in the pattern of symptoms may be seen.


The improvement is usually gradual and is best documented through the use of a baseline of pain activity established at an early stage in the episode of care by using a record such as the Home Recording Card (or other pain rating scale).


However, if no improvement in symptoms or function can be demonstrated, the therapist must again consider a systemic origin of symptoms. Repeating screening questions for medical disease is encouraged throughout the episode of care even if such questions were included in the intake interview.


Because of the progressive nature of systemic involvement, the client may not have noticed any constitutional symptoms at the start of the physical therapy intervention that may now be present. Constitutional symptoms (see Box 1-3) affect the whole body and are characteristic of systemic disease or illness.



Aggravating and Relieving Factors


A series of questions addressing aggravating and relieving factors must be included such as:



The McGill Pain Questionnaire also provides a chart (Fig. 3-8) that may be useful in determining the presence of relieving or aggravating factors.



Systemic pain tends to be relieved minimally, relieved only temporarily, or unrelieved by change in position or by rest. However, musculoskeletal pain is often relieved both by a change of position and by rest.



Associated Symptoms


These symptoms may occur alone or in conjunction with the pain of systemic disease. The client may or may not associate these additional symptoms with the chief complaint. The physical therapist may ask:


Mar 20, 2017 | Posted by in MANUAL THERAPIST | Comments Off on Pain Types and Viscerogenic Pain Patterns
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