Chapter 03

Pain Types and Viscerogenic Pain

Patterns
 Mechanism of referred visceral pain

• The three main mechanisms of referred

visceral pain are:
• Embryologic development
• Multi segmental innervations
• Direct pressure and shared pathway
 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 the gut ,or
they originate from same tissue.
• This explains symptoms of intrathoracic organ
pathology frequently being referred to the
abdomen as a viscero-viscero reflex.
• For example, pneumonia or pleuritis, to refer
pain that is perceived in the abdomen instead
of the chest.
• the pericardium around the heart is formed
from gut tissue. MI or pericarditis can also
refer pain to the abdomen.
• Organs of same shape e-g ear and kidney.
• Child with missing ear or anomaly medical
staff must look for pathology or missing kidney
of same side.
 Multisegmental Innervation

viscera have multisegmental innervations.

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.
• 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

Diaphragm is the structure close

to the abdominal viscera.
Thats why inflammation of
these viscera impinge
diaphragm.
Gallbladder can produce RT
shoulder pain .
Pancreas can produce LT
shoulder pain.
• 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
 ASSESSMENT OF PAIN AND SYMPTOMS

• Gathering information from client by interviewing.

• A measurement assigns a number or value to give
dimension to pain intensity .
• A comprehensive pain assessment includes
• health history
• physical exam,
• medication history ,
• functional status,
• psychosocial-spiritual factors
 Characteristics of Pain

• Location
• Description of pain
• Intensity
• Duration
• Frequency and duration
• Pattern
 Location of Pain

• Show me exactly where your pain is located?

• If a small, localized area and the pain
does not spread , superficial lesion not
severe.
• If small, localized but spread diffuse,
segmental, referred pain viscera or deep
somatic structure
 Description of Pain

• What does it feel like?

Give some choices
• Knifelike • Dull
• Boring • Burning
• Throbbing • Prickly
• Deep aching • Sharp
FUQ
• Has the pain changed in quality since it frst began?
• Changed in intensity?
• Changed in duration (how long it lasts)?
• pain as knifelike, boring, colicky, coming in waves,
or a deep aching feeling, systemic 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.
 Intensity of Pain

• Visual Analog Scale (VAS)

pain free_____________________________________________ worst pain ever

The Numeric Rating Scale (0 to 10) 0 no pain 10 worstpain

An alternative method a scale of 1 to 5 with word

descriptions for each number
1 = Mild 2 = Discomforting
3 = Distressing 4 = Horrible
5 = Excruciating
 Frequency and Duration of Pain

• How long do the symptoms last?

For example, pain related to systemic disease
a constant. Clients who indicate that the pain
is constant should be asked:
• Do you have this pain right now?
• Did you notice these symptoms this morning
immediately when you woke up?
 Pattern of Pain

• Tell me about the pattern of your pain/symptoms.

• Describe your pain/symptoms from frst waking up
in the morning to going to bed at night.
Follow-up questions may include:
• Have you ever experienced anything like this before?
• If yes, do these episodes occur more or less often than
at frst?
• How does your pain/symptom(s) change with time?
• Are your symptoms worse in the morning or evening?
• systemic disease has
progressive pattern with a cyclical onset (i.e.,
the client describes symptoms as being
alternately worse, better, and worse over a
period of months)
 Aggravating and Relieving Factors

• What brings your pain (symptoms) on?

What makes the pain better?
• How does rest affect the pain/symptoms?
• Are your symptoms aggravated or relieved by any activities?
• If yes, what?
• How has this problem affected your daily life at work or at
home?
• How has this problem affected your ability to care for yourself
without assistance (e.g., dress, bathe, cook, drive)?
 Associated Symptoms

• What other symptoms have you had that you

can associate with this problem?
• Possibilities
• *Burning *Heart palpitations
• * Numbness/Tingling *Diffculty in breathing
• * Hoarseness *Problems with vision *Diffculty in swallowing
• * Nausea *Vomiting *Dizziness
• *Night sweats *Weakness
• If yes for these associated symptoms check for
B/L presence of these symptoms
• bilateral weakness, either proximally or
distally, should serve as a red flag.
• Blurred vision, double vision, scotomas (black
spots before the eyes), or temporary blindness
is early indication of of MS or may possibly be
warning signs CVA.
 SOURCES OF PAIN

• Cutaneous
• Somatic
• Visceral
• Neuropathic
• Referred
 Cutaneous Sources of Pain

• includes superfcial somatic structures located

in the skin and subcutaneous tissue.
• Pain from a cutaneous source can
usually be localized with one fnger. Skin pain
or tenderness can be associated with referred
pain from the viscera or deep somatic
structures.
• Impairment of any organ can result in
sudomotor changes that present as trophic
changes such as itching, dysesthesia,
skin temperature changes, or dry skin.
 Somatic Sources of Pain

• Somatic pain can be superfcial or deep.

Somatic pain is labeled according to its source
as deep somatic, somatovisceral,
somatoemotional , or viscerosomatic.
• Superfcial somatic structures involve the skin,
superfcial fasciae, tendon sheaths, and
periosteum.
Deep somatic pain comes from pathologic
conditions of the periosteum and
cancellous (spongy) bone, nerves, muscles,
tendons, ligaments, and blood vessels, deep
fasciae and joint capsules.
• Deep somatic pain is poorly localized and may
be referred to the body surface, becoming
cutaneous pain.
• associated with an autonomic phenomenon,
such as sweating, pallor, or changes in pulse and
blood pressure, and is commonly accompanied
by a subjective feeling of nausea and
faintness.
• Parietal pain is also considered deep somatic. The
visceral pleura is insensitive to pain,
but the parietal pleura is well supplied with pain
nerve endings.
• it is possible for a client to have extensive visceral
disease (e.g., heart, lungs) without pain
until the disease progresses enough to involve the
parietal pleura.
• there are viscerosomatic sources of pain when
visceral structures affect the somatic musculature, such
as the reflex spasm and rigidity of the abdominal
muscles with inflammation acute appendicitis or the
pectoral trigger point associated with an acute MI.
• These visible and palpable changes in the tension of skin
and subcutaneous and other connective tissues that are
segmentaly related to visceral pathologic processes are
referred to as connective tissue zones or reflex zones .
 Visceral Sources of Pain

• Visceral pain is not well localized for two

reasons:
1. Innervation of the viscera is multisegmental.
2. There are few nerve receptors in these
structures .
• Visceral pain = refered pain
• because visceral fbers synapse at the level of
the spinal cord close to fbers specifc somatic
structures.
• In other words, visceral pain corresponds to
dermatomes from which the organ receives its
innervations, which may be the same
innervations for somatic structures.
• the heart is innervated by the C3-T4 spinal
nerves. Pain of a cardiac source can affect any
part of the soma also innervated by these
levels.
• One with heart attack can experience
jaw, neck, shoulder, mid-back, arm, or chest
pain.
• More specifcally, the pericardium is adjacent
to the diaphragm.
• Pain of cardiac and diaphragmatic origin is
often experienced in the shoulder
because the C5-6 spinal segment (innervation
for the shoulder) also supplies the heart and
the diaphragm.
• Because the somatic and visceral afferent
messages enter at the same level.
• We have reflex responses
• somatic-somatic (a bruise on the leg causes knee pain )
Somato visceral biomechanical dysfunction of the 10th rib can
cause gallbladder changes reflex responses

• viscer o somatic gallbladder impairment 10th rib;heart

attack causes arm or jaw pain .
• A viscero-viscero reflex (cross-organ
sensitization) occurs when pain or dysfunction
in one organ causes symptoms in another
organ.
• E-g pt. with chest pain< cardiac normal
findings.
May be gallbladder as gallbladder heart same
tissue origin.
Gallbladder also shoulder pain, bcz of its contact
with diaphragm.
Gallbladder findings normal.
Why chest pain???
• May be due to arthritic changes of cervical
spine.
• Common sensory pathways from C3 to spinal
cord. Cardiac and brachial plexuses enter the
cord at same level.
 Neuropathic Pain

results from damage to CNS or PNS.

injury or destruction to the peripheral nerves,
pathways in the spinal cord, or neurons
located in the brain.
Can be acute or chronic.
• Disruptions in the transmission of afferent and
efferent impulses in the periphery, spinal cord,
and brain can give rise to alterations in
sensory modalities (e.g., touch, pressure,
temperature), and sometimes motor
dysfunction.
• It can be
*drug induced
*metabolic-based,
*trauma to the sensory neurons or pathways
in either the PNS or CNS.
• Describe as
*burning *sharp *shooting
*tingling *electric shock like
pain is steady or evoked stimulus (e.g., light
touch, cold)
• There is no muscle spasm in neurogenic pain.
Acute nerve root irritation tends to be
severe < burning, shooting, and constant >
Chronic nerve root pain<annoying or nagging>
• Not relieved by opiates and narcotics.
• local anesthesia provide temporary relief.
• Medications used include
*anti-depressants *anticonvulsants
*anticonvulsants *adrenergic
*anesthetics
 Referred Pain

• referred pain is felt in an area far from the site

of the lesion but supplied by the same or
adjacent neural segments. Referred pain can
occur alone or with accompanying deep
somatic or visceral pain.
• Referred pain is usually well localized but it does
not have sharply defined borders.
It can spread or radiate from its point of origin.
• Local tenderness is present in the tissue of the
referred pain area, but there is no objective
sensory deficit.
• Referred pain is often accompanied by muscle
hypertonus over the referred area of pain.
 Differentiating Sources of Pain

Superfcial& deep somatic viscera

• Innervated unilaterally • innervated bilaterally ANS

spinal nerves via visceral afferents.
• Deep somatic increases • Not reproduce on mvts
after mvts. rather remain hurting all the
time.
• Dull aching pain not
relieved on rest
Superficial somatic
• sharp and more localized.
• large myelinated fbers
low threshold for
stimulation.
• fast conduction time
Deep somatic
• dull or deep aching
(responds to rest or a non–
weight-bearing position)
• poorly localized
• small unmyelinated fbers)
• Visceral diseases of the abdomen and pelvis are
more likely to refer pain to the back.
• Intrathoracic refer pain to shoulder.
• Back & shoulder ROM are full and painless.
• Painful stimulus increases pain-modifying
behaviors, such as muscle splinting and guarding,
can result changes in biomechanical patterns and
pain-related disability