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30.7.

2016

Amechanismbasedapproachtoclinicalreasoningofpain.

Amechanismbasedapproachtoclinicalreasoningofpain.
PainisoneofthemostcommoncomplaintsofthepatientsIseeasamusculoskeletalphysiotherapist
workinginaprivatepracticesetting.Morerecentlyinmyclinicalpracticetherehasbeenalargeamountof
complexpatientspresentingwithchronicbackpainwithorwithoutlegpain,chronicneckandarmpain,and
headaches.Eachofthesehavingcomponentsofnociceptivepain,neuropathicpainandcentral
sensitisation.Thishaschallengedmyunderstandingofeachpainmechanismandmyabilitytoexplainto
patientswhattheirproblemisandeducatethemaboutpainmanagement.
InspiredtotryunderstandpainalittlebitdeeperIamgoingtowriteaseriesofblogpostsregardingpain.It
willstartwiththemechanismsofpainandclustersofsymptomspredictiveofeachtype,delvefurtherinto
themechanismofcentralsensitisationandhowtoexplainthistoothers,andfinallyoutlinewhatpain
educationmightinvolveina1:1privatepracticesetting(whenwedon'thaveaccesstopainmanagement
clinics).
Sothisisthefirstblogandwillcovermostlypainmechanisms,theunderlyingneurophysiology,and
whatrecentresearchtellsusabouttherelationshipbetweencategoriesandtheclinical
presentation.
Thepicturebelowrepresentsthemostcommonlyacceptedcategoriesofpain.

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(Smart&Doody,2006,p.172)
Smart&Doody(2006)conductedaqualitativestudytoexploretheclinicalreasoningprocessofpain
implementedbyexperiencedmusculoskeletalphysiotherapists.Thisresearchfrom2006to2012hasleadto
agreaterunderstandingofourunderstandingofpain.
Theirresultsindicatedthatphysiosuseadiverserangeofreasoningmodelswhichinclude:
Biomedicalreasoningincludedreasoningofpainrelatedtostructural/anatomicalsource,
biomechanicalprinciples,aetiology,pathologicalprocessesanddiagnosticlabeling(K.Smart&Doody,
2007,p.43).
Psycholsocialreasoningincludedreasoningrelatedtopatientscognitions,emotions,behaviours,
attitudesandcopingstylesandsociologicalfactors(Smart&Doody,2007,p.44).
PainMechanismsreasoningisassociatedwiththeneurophysiologicalbasisofpain,specifically
nociceptive,peripheralneurogenic,centralandautonomic/sympatheticmechanismsofpain(Smart&
Doody,2007,p.4445).
Chronicity
Irritability/severity
K.Smart,Blake,Staines,andDoody(2010,p.81)conductedaDelphistudywiththeaimtoidentifythose
potentialclinicalcriteriauponwhichcliniciansmaybasesuchmechanismsbasedclassifications.
Theygeneratedanexpertconsensusderivedlistofclinicalcriteriaassociatedwithadominanceof
nociceptive,peripheralneuropathicandcentralmechanismsofpain.Theresultswerepresentedina
threepartarticlewhichhighlightedthefollowingresults.

Nociceptivepain.
Nociceptivepainisthoughttobeaprocesswheretheperipheralprimaryafferentneuronesareactivatedby
anoxiousstimuluswhichiseitherchemical,mechanicalorthermalinnature.
Smartetal(2012b)compiledalistof11symptomsandfourclinicalsigns(seeimagebelow)thoughttobe
predictiveofnociceptivepain.FollowingfurtheranalysisfromtheDelphistudy,sixsymptomsand1sign
wereretained.
1.Thestrongestpredictorofnociceptivepainwaspainlocalisedtotheareaofinjury/dysfunction
(with/withoutsomesomaticreferral).
2.Clear,proportionatemechanical/anatomicalnaturetoaggravatingandeasingfactors.
3.Painisusuallyintermittentandsharpwithmovement/mechanicalprovocationandmaybeamore
constantdullacheorthrobatrest.
4.Theabsenceof
1.Painassociatedwithdysesthesia.
2.Nightpainorsleepdisturbances.
3.Paindescribedasburning,shooting,sharporelectricshocklike.
4.Antalgicpostures/movementpatterns.
Theabovesignsandsymptomshadasensitivityof90.9%,specificity91%,positivepredictivevalueof
92.7%andnegativepredictivevalueof88.9%.Overallthepositivelikelihoodrationof10.10suggeststhat
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patientspresentingwiththisclusterofsymptomsare10timesmorelikelytohavenociceptivepain
thanperipheralneuropathicorcentralsensitisationpain.

(Woolf,2011,p.S3)

PeripheralNeurogenicPain
Estimatessuggestthatbetween20and35%ofpatientswithlowbackpain(LBP)mayhaveanunderlying
neuropathiccomponentandthatthecostsassociatedwithmanagingsuchpatientsarearound70%
highercomparedtothosewithnociceptiveLBP(FreynhagenandBaron,2009).Importantly,patientswitha
dominanceofneuropathicpainareknowntoreportmoreseverepain,greaterfunctionalimpairments
andpoorerhealthrelatedqualityoflifecomparedtothosewithnociceptive/nonneuropathicpain(Smith
etal.,2007Bouhassiraetal.,2008Smartetal.,2012a).(K.M.Smart,Blake,Staines,Thacker,&Doody,
2012a,p.345)
Sotheyarehardertomanageandimproveandthemechanismunderlyingneuropathicpainismuchmore
complextoo....
Theunderlyingprocessofperipheralneuropathicpainisthoughttoinvolve:sensitisationofneural
connectivetissues,ectopicexcitabilityresultinginspontaneousfiringofimpulsesindependentofa
peripheralstimulus,crossexcitationresultinginsignalamplification,structuralchangesconsistingof
axonalsproutingofnonnociceptivefibresresultinginenhancementofnociceptivesignallingwithnon
noxiousinputs,andneuroimmuneinteractionsleadingtochemicalmodulationofpain.Forfurther
explanationofthesemechanismsofperipheralneuropathicpainrefertoSmartetal(2012a,p.346).
K.M.Smart,Blake,etal.(2012a)identifiedaclusteroftwosymptomsandonesignpredictiveof
peripheralneuropathicpain:
Thestrongestpredictorofperipheralneuropathicpainwasapainreferredinadermatomalor
cutaneousdistribution.Patientswiththissymptomwhere24timesmorelikelytobeclassifiedwith
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thispaintype.
Patientswithahistoryofnerveinjury,pathologyormechanicalcompromise,were12timesmorelikely
tobeclassifiedwithperipheralneuropathicpain,and
Pain/symptomprovocationwithmechanical/movementtests(e.g.Active/Passive,Neurodynamic)that
move/load/compressneuraltissuemeantthatpatientswere14timesmorelikelytobeclassifiedwith
peripheralneuropathicpain.
Thisclusterwasfoundtohavehighlevelsofclassificationaccuracywithasensitivityof86.3%,specificityof
96%,whichindicatesthatapatientwiththeclusterofsymptomsandsignsoutlinedbythemodel
waslikelytohavebeenclassifiedwithperipheralneuropathicpainwithan86.3%levelof
probability(K.M.Smart,Blake,etal.,2012a,p.348).

Neuropathicpain(imagefromgoogleimages).

Centralsensitisationpain
K.M.Smart,Blake,Staines,andDoody(2012)conductedastudytoidentifytheclusterofsubjective
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symptomsandphysicalsignsthatwouldleadtothemechanismclassificationofcentralsensitisationpain.
TherewerethreesymptomsandonesignfoundtobestronglyassociatedwithCSP.
Thestrongestpredictorwasdisproportionate,nonmechanical,unpredictablepatternofpain
provocationinresponsetomultiple/nonspecificaggravating/easingfactors.
Paindisproportionatetothenatureandextentoftheinjuryorpathology.
Strongassociationwithmaladaptivepsychosocialfactors(e.g.negativeemotions,poorselfefficacy,
maladaptivebeliefsandpainbehaviours).
Diffuse/nonanatomicareasofpain/tendernessonpalpation.(K.M.Smart,Blake,Staines,&Doody,
2012,p.342)
Thisclusterofsymptomswasfoundtohavesensitivityof91.8%,specificityof97.7%.Thiscanbe
interpretedasapositivepredicativevalueof91.8%andnegativepredictivevalueof97.7%.Positive
likelihoodrationof40.64i.epatientswiththesesymptomsare40timesmorelikelytohaveCSP.
Overallthepredictiveaccuracyofthisclusterofsymptomsisveryhighandthereforecanbeusedclinically
toidentifypatientswithCSP.
Interestingly,anumberofsymptomsandsignsoftenassociatedwithCSP,suchaspainpersistingbeyond
expectedtissuehealingtimesandhyperalgesia,didnotemergeaspredictorsofCSP(Smart,etal.,2012,
p.342).

(Woolf,2011,p.S4)
Conclusion
TheoutcomeofthesedelphistudiesandtheworkbySmartandcolleagueshasprovidedtherapistswith
clustersofsymptomsandclinicalsignstoassistwiththedifferentiationbetween,anddiagnosisof,different
painmechanisms.Thisisknowntobeoneofthefivemodelsusedbytherapistsduringtheclinicalreasoning
process.
Sian

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Afulllistoftheoriginsignsandsymptomsareoutlinedbelow.Rememberthatnotallofthesesymptoms
havethesamepredictiveaccuracyandclinicalutility.
SymptomsandclinicalfeaturesofCENTRALSENSITISATIONPAIN(Smart,Blake,Staines,Thacker,&
Doody,2012,p.338)

SymptomsandclinicalfeaturesofNEUROPATHICPAIN(Smartetal.,2012a,p.347)

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SymptomsandclinicalfeaturesofNOCICEPTIVEPAIN(Smartetal.,2012b,p353).

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References
Smart,K.,Blake,C.,Staines,A.,&Doody,C.(2010).Clinicalindicatorsofnociceptive,peripheral
neuropathicandcentralmechanismsofmusculoskeletalpain.ADelphisurveyofexpertclinicians.Manual
therapy,15(1),8087.
Smart,K.,&Doody,C.(2006).Mechanismsbasedclinicalreasoningofpainbyexperiencedmusculoskeletal
physiotherapists.Physiotherapy,92(3),171178.
Smart,K.,&Doody,C.(2007).Theclinicalreasoningofpainbyexperiencedmusculoskeletal
physiotherapists.Manualtherapy,12(1),4049.
Smart,K.M.,Blake,C.,Staines,A.,&Doody,C.(2012).Mechanismsbasedclassificationsof
musculoskeletalpain:part1of3:symptomsandsignsofcentralsensitisationinpatientswithlowback(leg)
pain.Manualtherapy,17(4),336344.
Smart,K.M.,Blake,C.,Staines,A.,Thacker,M.,&Doody,C.(2012a).Mechanismsbasedclassificationsof
musculoskeletalpain:part2of3:symptomsandsignsofperipheralneuropathicpaininpatientswithlow
back(leg)pain.Manualtherapy,17(4),345351.
Smart,K.M.,Blake,C.,Staines,A.,Thacker,M.,&Doody,C.(2012b).Mechanismsbasedclassificationsof
musculoskeletalpain:Part3of3:Symptomsandsignsofnociceptivepaininpatientswithlowback(leg)
http://www.raynersmale.com/blog/2014/3/28/explainingcentralsensitisationtopatientswithchronicpain

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pain.Manualtherapy,17(4),352 357.
Woolf,C.J.(2011).Centralsensitization:implicationsforthediagnosisandtreatmentofpain.Pain,152(3),
S2S15.

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