SCREENING

MUHAMMAD JAWAID KHANZADA

Pain

• The fifth vital sign

• recognizing pain patterns that are characteristic of
systemic disease and is a necessary step in
screening process.
Mechanisms of Referred Visceral Pain

• In case of referred pain patterns of viscera, there are three

separate phenomena

• 1- Embryologic development
• 2- Multisegmental innervation
• 3- Direct pressure and shared pathways
Case

• A 35 years old male having pain in abdomen for the last few
days. After undergoing diagnostic ultrasound of gut the
markers are negative. The patient is referred to
physiotherapy for abdomen trigger point evaluation which
also results in negation.
• On inquiry patient stated to have respiratory problem.
Embryologic development
• 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.
• Embryologically, the chest is part of gut. Intrathoracic organ
pathology frequently being referred to the abdomen as viscero-
viscero reflex for e.g disorders of thoracic viscera, such as
pneumonia or pleuritis refers pain to abdomen.
• Myocardial infarction and pericarditis can also refer pain to
abdomen.
• Embryological development impacts the viscera and the soma.
• When a child is born with any anomaly of ear the kidney is
always looked for similar changes.
Case

• 55yrs old female coming for physiotherapy for last 3

weeks, with the complaint of pain in left shoulder
which often radiates in C5 dermatomal region. She
also tells that the pain often increases during
walking and climbing stairs. The capsular pattern is
also positive.
Multisegmental innervations

• Pain of visceral origin can be referred to the corresponding

somatic areas.
• Cardiac pain is not felt in the heart but is referred to the area
supplied by corresponding spinal nerve.
• Cardiac pain can occur in any structure innervated by C3 to
T4.
• Pain of cardiac and diaphragmatic origin is often experienced
in shoulder, in particularly, bcoz C5 supplies the heart and
respiratory diaphragm and shoulder.
Case

• A 32 years old computer worker came to you with

the complaint of low back pain and ribs pain which
is slightly lateral to chest bone ( sternum) of left
side.
• O/E all tests for musculoskeletal are negative. On
inquiry patient often feels slight heaviness in
breathing.
Direct pressure and shared pathways

• Anything that impinges the central diaphragm can

refer pain to the shoulder and anything that
impinges the peripheral diaphragm can refer pain to
ipsilateral costal margins and/or lumber region.
Case

• A consultant sent 43 years old lady to you with the diagnosis

of frozen shoulder and has prescribed NSAIDS. Upon
entering physio opd you assesed her and confirm the
diagnosis. For treatment you applied TENS with hot packs
and taught her pendulum exercises . At the end of session
she was happy and described her pain 6/10 on VAS which
previously was 9/10. She left OPD at 1:00 pm. The next
morning she came and compliant that pain was increased at
night that she could not sleep. Analyze…..
Somatic sources of pain

• Most of PT treat somatic system whether it is

neuromuscular, musculoskeletal or neuromusculoskeletal.
• Can be superficial (skin, superficial fascia,tendon
sheath,periosteum) or deep (n/v, m/s, tendon, lig., blood
vessel, jt. Capsule, deep fascia)
• Somatic pain is labelled according to its source..deep
somatic, somatovisceral, somatoemotional.psychosomatic
VISCERAL SOURCES OF PAIN

• Includes pain from internal organs and heart

• C3-T4—heart
• C3-C5– peritoneal covering of gall bladder and central zone of
diaphragm and portion of pericardium
• C5-C6– pericardium and diaphragm
• T1-T4--- sensory fibers to heart and lung
• T7-T8– sensory fibers to gallblader, bile duct and stomach
• T9-T10– sensory fiber to duodenum
• T10– sensory fiber to appendix
• L1-L2– sensory fibers to ureter/renal system