paul thawleymsc clinical reasoning referred symptoms

Paul ThawleyMScCLINICAL REASONING

Referred Symptoms

All pain has a source

All treatment must reach the source

All treatment must benefit the lesion

Definition of pain

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”

International Association for the Study of Pain (1980)

Ombregt et l 2003Adapted from Ombregt et al 2003

Frontal lobe

Sensory cortex

Temporal lobe

Thalamic relay

Multidimensional aspects of painSensory: physical qualities, intensity, location

Emotional: fear, anxiety, anger, worryCognitive: thoughts about pain - how bad is it,

what to do about it Social factors: family, work, cultural, past

experience

Referral -possible mechanisms

Convergence-projection Theory

Strong et al (2002); Ombregt et al (2003)

Referral -possible mechanisms

Heart C3 - T5

Gall bladder T9

Testicle T11 - L1

Diaphragm C3 - 5

Latissimus dorsi C6 - 8

Gluteal muscles L5 - S2

Referral -possible mechanisms

Error in perception (Cyriax, 1984; Kesson and Atkins 2005)

Referred symptoms may be

Somaticvisceral: deep, not well localisedmusculoskeletal: deep, not well localised

Neuropathic: continuous, burning, lancinating

Psychological (biopsychosocial model): not well localised

Central somatic and neurological structures

Central, central unilateral or bilateral symptoms

Referred over many segments (multisegmental)

Proximal and/or distal referral

Multisegmental Reference

Ombregt et al 2003

Unilateral somatic and neurological structures

Unilateral, segmental (dermatomal) referral

Generally refers distally

Occupies all or part of a dermatome

Netter 1997

Conesa & Argote 1976

Factors Influencing Referral of Symptoms

Strength of stimulus

Position in the dermatome

Depth

Nature of the structure

Nature of the Structure

Central somatic e.g. dura mater, PLL, disc

referral of multisegmental painreferred tenderness

Nature of the Structure

Central neurological structures e.g. spinal cordno painmultisegmental reference of

paraesthesiaupper motor neurone lesion

Nature of the StructureUnilateral somatic structures e.g. bone

and periosteum, ligament, tendon, muscle, joint capsule, bursa

segmental reference of paindepends on strength of stimulus,

position in dermatome, depth

Nature of the StructureUnilateral somatic structures

e.g. dural nerve root sleeve

segmental reference of pain in all or part of the dermatome

greater the compression, the more distal the pain

no edge or aspect

Nature of the Structure

Unilateral neurological structures e.g. nerve rootcompression phenomenonsegmental reference of paraesthesiano edge or aspectlower motor neurone lesionmay become pain sensitive

Nature of the Structure

Unilateral neurological structures e.g. nerve trunk

release phenomenononset related to time of compressiondeep, painful paraesthesiasome aspect, no edge

Nature of the Structure

Unilateral neurological structures e.g. peripheral nerve

numbness in cutaneous distribution of nerve

edge and aspect

General rules of referred psychological symptoms

Generally associated with chronic pain states

Not well localised

Inconsistent signs and symptoms

Medical Model

Pathology Symptoms

Treatment

Biopsychosocial Model

Biology

Psychosocial Factors

Biopsychosocial Model

Biology

Psychosocial Factors

Psychosocial Factors(yellow flags)

No recognisable pattern

Poor co-operation

Seeks answer expected

Contradictory signs

‘Juddering’Beware the bizarre, but consistent patient