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Approach & evaluation of patients with somatic pain

Dr. Md Rashedul Islam FCPS, MRCP(UK)

Registrar, Neurology, BIRDEM

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•Pain is one of the earliest signs of morbidity, and it stands preeminent among all the sensory experiences by which humans judge the existence of disease within themselves.

•Indeed, pain is the most common symptom of disease.

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INTRODUCTION

• Pain is a sensory experience of special significance to physicians and basic scientists.

• Pain is the commonest symptom which physicians are called upon to treat.

• Apart from its obvious applied value, study of physiology of pain has taught us a lot about neural function in general.

• Pain is an intensely subjective experience, and is therefore difficult to describe.

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RELATED TERMS

• Dysesthesia: Any abnormal sensation described as unpleasant by the patient

• Hyperalgesia: Exaggerated pain response from a normally painful stimulus

• Hyperpathia: Abnormally painful and exaggerated reaction to a painful stimulus

• Hyperesthesia (hypesthesia): Exaggerated perception of touch stimulus 

RELATED TERMS

• Allodynia: Abnormal perception of pain from a normally nonpainful mechanical or thermal stimulus; usually has elements of delay in perception and of aftersensation

• Hypoalgesia (hypalgesia): Decreased sensitivity and raised threshold to painful stimuli

• Anesthesia: Reduced perception of all sensation, mainly touch

RELATED TERMS

• Paresthesia: Mainly spontaneous abnormal sensation that is not unpleasant; usually described as "pins and needles"

• Causalgia: Burning pain in the distribution of one or more peripheral nerves

• Pallanesthesia: Loss of perception of vibration • Analgesia: Reduced perception of pain stimulus

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CLASSIFICATION OF PAIN

PAIN

Somatic(somasthetic)

Visceral (from viscera)e.g. angina pectoris, peptic ulcer, intestinal colic, renal colic, etc.

Superficial (from skin & subcutaneous tissue) e.g. superficial cuts/burns, etc.

Deep (from muscles/bones/fascia/periosteum) e.g. fractures/arthritis/fibrositis, rupture of muscle belly

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PRACTICAL CLINICAL CLASSIFICATION OF PAIN (Cranial )

General Classification

Origin of Pain Quality of Pain

Extra cranial Structure

Craniofacial region Varies

Referred pain from remote pathologic

sites

Distant organs and structures

Aching and pressing

Intracranial pathosis

Brain and related structures

Varies

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Neurovascular Blood Vessels Throbbing, pulsing or pounding

Neuropathic Sensory nervous system

Shooting, sharp, burning pain

Causalgic Sympathetic nervous system

Burning

Muscular Muscles Deep aching, tight

PRACTICAL CLINICAL CLASSIFICATION OF PAIN (Cranial )

•Location •Mode and time of onset •Associated features, e.g., nausea, muscle spasm •Quality and time-intensity attributes •Duration •Severity •Provoking and relieving factors

Whenever pain…

Whenever pain…

Some physicians find it helpful, particularly in gauging the effects of analgesic agents, to use a "pain scale," i.e., to have the patient rate the intensity of his pain on a scale of zero (no pain) to 10 (worst pain) or to mark it on a line (the Visual Analog Pain Scale).

Whenever pain…

chronic pains fall into one of four categories: •pain from an obscure medical disease, the nature of which has not yet been disclosed by diagnostic procedures•pain associated with disease of the central or peripheral nervous system•pain associated with psychiatric disease•pain of unknown cause.

Some pain syndromes

• Pain is not primarily a pathological phenomenon, but serves a protective function.

• Conditions with loss of pain perception exemplify this,resulting in frequent injuries, burns and subsequent mutilations

• Pathological conditions do, however, cause pain – as a symptom of cancer, injury or other disease.

Some examples

CAUSALGIA

• Causalgia is an intense, continuous, burning pain produced by an incomplete peripheral nerve injury. Touching the limb aggravates the pain,and the patient resents any interference or attempt at limb mobilisation.

Some examples

POSTHERPETIC NEURALGIA• Following activation of a latent infection with

varicella zoster virus lying dormant in the dorsal root or gasserian ganglion,

• Patient develops a burning, constant pain with severe, sharp paroxysmal twinges over the area supplied by the affected sensory neurons.

CAUSES OF UPPER LIMB PAIN

CAUSES OF LOWER LIMB PAIN

MUSCLE PAIN (MYALGIA)

• Muscle pain is a common medical complaint.

• Mechanical pain results from excessive muscle tension or contraction and is ‘cramp like’.

• Inflammatory pain results from disruption of muscle fibres, inflammatory exudate and fibre swelling.

MUSCLE PAIN (MYALGIA)

• Ischaemic pain results from metabolic change, usually in response to exercise and is deep and aching.

• Muscle pain may be physiological – as a consequence of extreme exercise or pathological – as a consequence of muscle, soft tissue or systemic illness.

APPROACH TO MUSCLE PAINHistory

Is muscle pain – present at rest?• – Polymyalgia rheumatica• – Fibromyalgia• – Parkinson’s disease• – Collagen vascular diseasepresent with exercise?• – Physiological• – Metabolic myopathies• – Benign myalgic encephalomyelitis (ME)

History

localised?• Muscle haematoma, abscess, tumour or

fibromyalgiageneralised?• – Polymyalgia rheumatica• – Parkinson’s diseasefamily history?• – Metabolic myopathiesexposure to toxins?• – Drug induced myopathies• – Alcoholic myopathy

Examination

Is there• – wasting/weakness? – Inflammatory myopathies• – Metabolic myopathies• – Drug induced myopathies• – Alcoholic myopathySkin rash?• – Inflammatory myopathy (dermatomyositis)• – Collagen vascular disease

Examination

stiffness or spasms?• – Tetanus• – Tetany• – Spasticity• – Neuroleptic malignant syndromemuscle swelling?• – Muscle abscess, tumour• – Metabolic myopathy

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