paul thawleymsc clinical reasoning referred symptoms
Post on 28-Dec-2015
217 Views
Preview:
TRANSCRIPT
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
top related