Pain Mechanisms in Practice

Question 1

Signs + Symptoms of Nociceptive Pain

Answer 1

• intermittent
• sharp with movement/mechanical
• dull ache/throb @ rest
• localised to area of injury + w/ or w/o somatic referral
• clear, proportionate mechanical/anatomical nature to aggravating and easing factors

Question 2

What signs and symptoms would be absent in nociceptive pain?

Answer 2

• pain is not burning, shooting, sharp or electric (dysesthesia)
• lack of night pain/disturbed sleep
• lack of antalgic (pain relieving) postures/movements

Question 3

What are the symptoms of neuropathic pain?

Answer 3

• history of nerve injury, pathology or mechanical compromise
• pain referred in a dermatomal or cutaneous distribution
• pain/symptom provocation with mechanical/movement tests => move/load/compress neural tissue
• pain significantly higher with reduced QoL, different meds, prolonged diagnosis

Question 4

What are the symptoms of central sensitisation?

Answer 4

• pain disproportionate to nature of injury or pathology
• non-mechanical, unpredictable pattern of pain provocation
• no specific aggravating/easing factors
• diffuse/non-anatomical areas of pain/tenderness on palpation
• strong association with maladaptive psychosocial factors e.g. negative emotions
• occurs quickly in tissue injury but adaptive in short term => only chronic when maladaptive

Question 5

How is central sensitisation assessed?

Answer 5

• central sensitivity inventory

Question 6

How can patients fear affect pain modulation?

Answer 6

• fear about future of condition
• inherited beliefs about hurt = harm
• issues around controllability of pain
• management reflects compliance to ex + PHx
• therapists can reinforce by taking control
• ask patient to identify specific activities or goals => recovery related to high degree of flexibility in goal adjustment

Question 7

How can patients anxiety affect pain modulation?

Answer 7

• anxiety about their condition
• no clear explanation and prognosis
• heightened somatic awareness e.g. catastrophic thinking

Question 8

How can patients anger affect pain modulation?

Answer 8

• previously failed management => affect patients compliance with treatment
• attitudes of other about their condition
• socio-economic consequences of their pain

Question 9

How can patients depression affect pain modulation?

Answer 9

• associated limitation
• learned helplessness

Question 10

Where should patients go based on their type of pain?

Answer 10

• nociceptive = A&E/osteo/pain clinic e.g. nerve root irritation
• neuropathic pain = A&E/osteo/pain clinic e.g. nerve root irritation
• central sensitisation = A&E/osteo/pain clinic e.g. diabetic peripheral neuropathy

Question 11

Case Study:

• a 45 yo w/ 5 year history of LBP
• presents with antalgic posture, leg pain and ‘numbness’ in calf
• leg feels weak
• increasing frequency + intensity of episodes but lasting for less time
• has given up golf and sailing as a result
• Comes to you to put it back in

Answer 11

• neuropathic pain
• interferes with QoL
• neurological symptoms => increasing pain, frequency, intensity, leg weakness, antalgic posture
• adaptation of posture

Question 12

Case study:

• neuro testing reveals reduced reflex on right (at first but returns with treatment)
• SLR test negative
• mild reduction in pin-prick in lateral calf

Answer 12

• more peripheral sensitisation
• responds to treatment, only mild reduction in pin-prick sensitivity
• would ask about responding to heat/cold

Question 13

Give an example of nociceptive pain

Answer 13

• acute segmental strain, first ever episode

Question 14

Give an example of neuropathic pain

Answer 14

• nerve root irritation

Question 15

Give an example of central sensitisation

Answer 15

• 6 month history of intermittent LBP