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Paul ThawleyMScCLINICAL REASONING
Referred Symptoms
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All pain has a source
All treatment must reach the source
All treatment must benefit the lesion
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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)
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Ombregt et l 2003Adapted from Ombregt et al 2003
Frontal lobe
Sensory cortex
Temporal lobe
Thalamic relay
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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
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Referral -possible mechanisms
Convergence-projection Theory
Strong et al (2002); Ombregt et al (2003)
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Referral -possible mechanisms
Heart C3 - T5
Gall bladder T9
Testicle T11 - L1
Diaphragm C3 - 5
Latissimus dorsi C6 - 8
Gluteal muscles L5 - S2
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Referral -possible mechanisms
Error in perception (Cyriax, 1984; Kesson and Atkins 2005)
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Referred symptoms may be
Somaticvisceral: deep, not well localisedmusculoskeletal: deep, not well localised
Neuropathic: continuous, burning, lancinating
Psychological (biopsychosocial model): not well localised
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Central somatic and neurological structures
Central, central unilateral or bilateral symptoms
Referred over many segments (multisegmental)
Proximal and/or distal referral
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Multisegmental Reference
Ombregt et al 2003
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Unilateral somatic and neurological structures
Unilateral, segmental (dermatomal) referral
Generally refers distally
Occupies all or part of a dermatome
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Netter 1997
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Conesa & Argote 1976
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Factors Influencing Referral of Symptoms
Strength of stimulus
Position in the dermatome
Depth
Nature of the structure
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Nature of the Structure
Central somatic e.g. dura mater, PLL, disc
referral of multisegmental painreferred tenderness
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Nature of the Structure
Central neurological structures e.g. spinal cordno painmultisegmental reference of
paraesthesiaupper motor neurone lesion
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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
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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
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Nature of the Structure
Unilateral neurological structures e.g. nerve rootcompression phenomenonsegmental reference of paraesthesiano edge or aspectlower motor neurone lesionmay become pain sensitive
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Nature of the Structure
Unilateral neurological structures e.g. nerve trunk
release phenomenononset related to time of compressiondeep, painful paraesthesiasome aspect, no edge
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Nature of the Structure
Unilateral neurological structures e.g. peripheral nerve
numbness in cutaneous distribution of nerve
edge and aspect
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General rules of referred psychological symptoms
Generally associated with chronic pain states
Not well localised
Inconsistent signs and symptoms
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Medical Model
Pathology Symptoms
Treatment
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Biopsychosocial Model
Biology
Psychosocial Factors
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Biopsychosocial Model
Biology
Psychosocial Factors
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Psychosocial Factors(yellow flags)
No recognisable pattern
Poor co-operation
Seeks answer expected
Contradictory signs
‘Juddering’Beware the bizarre, but consistent patient