Ep. 24 Body Part Pain Algorithm
In this episode of 'It's Not In Your Head' podcast, hosts Dr. Dan Bates and Justine Feitelson discuss nociceptive pain, also known as body part pain. The episode delves into their Nociceptive Pain Algorithm, breaking down the different types of somatic pain, including mechanical, inflammatory, myofascial, bony, and vascular pain. It includes discussions on different pain management strategies from first-line to specialist referrals, the interplay of different pain types and overlapping issues when it comes to instability, and emphasizes the importance of proper diagnosis and treatment so you can make effective decisions as a clinician even while you are still working through a patients full presentation.
Nociceptive Pain Algorithm: Understanding Body Part Pain
In this episode of "It's Not In Your Head," Dr. Dan Bates and Justine Feitelson discuss the nociceptive pain algorithm, focusing on understanding and managing body part pain, particularly musculoskeletal pain. This comprehensive overview provides insights into the different types of nociceptive pain, their characteristics, and approaches to diagnosis and treatment.
Types of Pain
Dan begins by reviewing three main types of pain:
1. Neuropathic pain
2. Nociceptive (body part) pain
3. Nociplastic pain – (Central sensitization)
He emphasizes that nociceptive pain, also referred to as body part pain, is the most common type of chronic pain.
Nociceptive Pain Categories
Nociceptive pain is further divided into two main categories:
1. Somatic pain (musculoskeletal pain)
2. Visceral pain (pain arising from organs)
Dan explains that somatic pain is typically more localized and easier to pinpoint, while visceral pain tends to be more diffuse and harder to localize.
Subtypes of Nociceptive Pain
The discussion then delves into the subtypes of nociceptive pain:
1. Mechanical pain
2. Inflammatory pain
3. Myofascial pain
4. Bony pain
5. Vascular pain
Types of Nociceptive Pain
Nociceptive pain, also referred to as body part pain, is the most common type of chronic pain. It can be further categorized into several subtypes, each with distinct characteristics:
Mechanical Pain
Mechanical pain is characterized by:
- Painful clicking, clunking, or instability in joints
- Instability arises from potential ligament insufficiency or neuromuscular dysfunction
- Pain that is typically aggravated by specific movements or positions
Clinical Presentation of Mechanical Pain
Nature of Pain
Mechanical pain is often characterized by pain that worsens with specific movements or activities and improves with rest (O'Driscoll, 2000; Moliterno et al., 2014).
It is typically associated with structural abnormalities or instability in the affected joint or spine (O'Driscoll, 2000; Moliterno et al., 2014).
Painful Clicking or Clunking
Patients may report recurrent painful clicking, snapping, clunking, or locking of the joint, particularly during specific movements (O'Driscoll, 2000).
This is commonly observed in conditions like posterolateral rotatory instability of the elbow, where these symptoms occur during the extension portion of the arc of motion with the forearm in supination (O'Driscoll, 2000).
Temporomandibular joint (TMJ) disorders also present with painful clicking, especially when associated with other factors like bruxism and poor sleep quality (Poluha et al., 2020).
Instability
Joint instability is a key feature, often leading to recurrent subluxation or dislocation (O'Driscoll, 2000).
In the case of spinal metastases, mechanical radiculopathy due to spinal instability is a significant concern, often necessitating surgical intervention for stabilization (Moliterno et al., 2014).
Pain on Loading
Mechanical pain is typically exacerbated by axial loading or weight-bearing activities (Moliterno et al., 2014).
For instance, lumbar radiculopathy in cancer patients is characterized by radicular pain produced by axial loading, indicating neoplastic instability (Moliterno et al., 2014).
Other Key Features
Gender and Psychosocial Factors: Female gender, pain catastrophizing, and poor sleep quality are associated with increased pain in conditions like TMJ disorders (Poluha et al., 2020).
Physical Examination Tests: Specific tests such as the lateral pivot-shift apprehension test and the stand-up test are used to diagnose joint instability (O'Driscoll, 2000).
Radiographic Features: Imaging, such as lateral stress radiographs, can reveal subluxation and other structural abnormalities (O'Driscoll, 2000).
Summary
Mechanical pain is characterized by pain that worsens with specific movements or activities and improves with rest. Key features include painful clicking or clunking, joint instability, and pain on loading. Conditions like posterolateral rotatory instability of the elbow and TMJ disorders often present with these symptoms. Gender, psychosocial factors, and specific physical examination tests are also important in the clinical presentation and diagnosis of mechanical pain.
References
O'Driscoll, S. (2000). Classification and evaluation of recurrent instability of the elbow.. Clinical orthopaedics and related research, 370, 34-43. https://doi.org/10.1097/00003086-200001000-00005
Poluha, R., De La Torre Canales, G., Bonjardim, L., & Conti, P. (2020). Clinical variables associated with the presence of articular pain in patients with temporomandibular joint clicking. Clinical Oral Investigations, 25, 3633 - 3640. https://doi.org/10.1007/s00784-020-03685-8
Moliterno, J., Veselis, C., Hershey, M., Lis, E., Laufer, I., & Bilsky, M. (2014). Improvement in pain after lumbar surgery in cancer patients with mechanical radiculopathy.. The spine journal : official journal of the North American Spine Society, 14 10, 2434-9. https://doi.org/10.1016/j.spinee.2014.03.006
Inflammatory Pain
Inflammatory pain presents with the following features:
- Worse in the morning or after periods of inactivity
- Improves with warm-up and movement
- Worsens with cooling down
- Associated with stiffness
- May respond to anti-inflammatory medications
Clinical Presentation of Inflammatory Pain
Nature of Pain:
Pain is one of the four cardinal signs of inflammation, along with redness, heat, and swelling (Sluka et al., 2014; Diamond & Tracey, 2011; Serhan, 2017).
Inflammatory pain is often associated with conditions like rheumatoid arthritis, inflammatory bowel disease, and other autoimmune diseases (Diamond & Tracey, 2011; Pujalte & Albano-Aluquin, 2015).
Association with Redness, Heat, and Swelling:
Inflammatory pain is typically accompanied by redness, heat, and swelling due to the release of cytokines and other inflammatory mediators (Sluka et al., 2014; Diamond & Tracey, 2011; Serhan, 2017).
These symptoms are part of the body's immune response to infection or trauma (Diamond & Tracey, 2011; Serhan, 2017).
Worsening in the Morning, Rest, and Cooling Down:
Patients often experience worsening pain in the morning and after periods of rest, which is characteristic of inflammatory conditions like spondylarthropathies (Cantini et al., 1998; Pujalte & Albano-Aluquin, 2015).
Cooling down can exacerbate symptoms, particularly in conditions like Warm CRPS, where inflammation is more pronounced (Bruehl et al., 2016).
Improvement with Warming Up:
Symptoms of inflammatory pain often improve with warming up and physical activity, as movement can help reduce stiffness and promote circulation (Cantini et al., 1998; Pujalte & Albano-Aluquin, 2015).
Exercise is recommended as part of the management for conditions like inflammatory spinal pain (Cantini et al., 1998).
Use of Anti-Inflammatories:
Nonsteroidal anti-inflammatory drugs (NSAIDs) and COX-2 inhibitors are commonly used to manage inflammatory pain by targeting proinflammatory mediators (Sluka et al., 2014; Serhan, 2017).
These medications help reduce pain, redness, heat, and swelling by inhibiting the production of inflammatory cytokines (Sluka et al., 2014; Serhan, 2017).
Summary
Inflammatory pain is characterized by its association with redness, heat, and swelling, and it typically worsens in the morning, with rest, and cooling down. Improvement is often seen with warming up and physical activity. Anti-inflammatory medications like NSAIDs and COX-2 inhibitors are effective in managing the symptoms by targeting the underlying inflammatory processes.
References
Sluka, K., Walder, R., Burnes, L., Kolker, S., & Ikeuchi, M. (2014). Inflammation and Pain. Inflammation Research, 57, S82-S83. https://doi.org/10.1007/BF03353871
Bruehl, S., Maihöfner, C., Stanton‐Hicks, M., Perez, R., Vatine, J., Brunner, F., Birklein, F., Schlereth, T., Mackey, S., Mailis-Gagnon, A., Livshitz, A., & Harden, R. (2016). Complex regional pain syndrome: evidence for warm and cold subtypes in a large prospective clinical sample. PAIN, 157, 1674–1681. https://doi.org/10.1097/j.pain.0000000000000569
Cantini, F., Salvarani, C., Olivieri, I., Niccoli, L., Padula, A., Bellandi, F., & Palchetti, R. (1998). Tuberculous spondylitis as a cause of inflammatory spinal pain: a report of 4 cases.. Clinical and experimental rheumatology, 16 3, 305-8.
Diamond, B., & Tracey, K. (2011). Mapping the immunological homunculus. Proceedings of the National Academy of Sciences, 108, 3461 - 3462. https://doi.org/10.1073/pnas.1100329108
Pujalte, G., & Albano-Aluquin, S. (2015). Differential Diagnosis of Polyarticular Arthritis.. American family physician, 92 1, 35-41.
Serhan, C. (2017). Treating inflammation and infection in the 21st century: new hints from decoding resolution mediators and mechanisms. The FASEB Journal, 31, 1273 - 1288. https://doi.org/10.1096/fj.201601222R
Myofascial Pain
Myofascial pain is characterized by:
- Muscle tightness and stiffness
- Presence of trigger points (focal areas of sensitivity within muscles)
- Potential referred pain patterns
Clinical Presentation of Myofascial Pain
Nature of Pain
Myofascial pain syndrome (MPS) is characterized by chronic musculoskeletal pain, often presenting as deep, aching pain in affected muscles (Zhuang et al., 2014; Barbero et al., 2019; Jaeger, 2013).
Pain is typically referred from specific, hyperirritable spots known as myofascial trigger points (MTrPs) (Barbero et al., 2019; Bennett, 2007; Lavelle et al., 2007).
Muscle Tightness
Affected muscles often exhibit taut bands, which are palpable tight strands within the muscle (Zhuang et al., 2014; Bennett, 2007; Lavelle et al., 2007).
These taut bands can restrict the full range of motion and contribute to muscle stiffness (Bennett, 2007; Jaeger, 2013).
Trigger Points
Myofascial trigger points are hyperirritable spots within a taut band of skeletal muscle, painful upon compression (Barbero et al., 2019; Gerwin, 2016; Lavelle et al., 2007).
Trigger points can cause referred pain, motor dysfunction, and autonomic phenomena (Lavelle et al., 2007; Jaeger, 2013).
They are often identified through manual palpation, which has good reliability despite some diagnostic limitations (Barbero et al., 2019; Grabois, 2015).
Other Key Features
Referred Pain: Pain can be referred to other areas, following characteristic myotomal patterns (Bennett, 2007; Jaeger, 2013).
Local Twitch Response: Palpation of trigger points may elicit a local twitch response, a brief contraction of the taut band (Zhuang et al., 2014).
Comorbidities: MPS can coexist with other conditions like fibromyalgia, bursitis, and tendonitis, complicating diagnosis and treatment (Bennett, 2007).
Diagnosis: Diagnosis is primarily clinical, based on the presence of trigger points and associated symptoms, though some ancillary tests may support the diagnosis (Grabois, 2015; Fischer, 1988).
Treatment: Management includes both invasive (e.g., dry needling, injections) and non-invasive (e.g., physical therapy, massage) approaches (Barbero et al., 2019; Lavelle et al., 2007).
Summary
Myofascial pain syndrome is a prevalent chronic pain condition characterized by the presence of myofascial trigger points, which are hyperirritable spots within taut bands of muscle. These trigger points cause deep, aching pain, muscle tightness, and referred pain. Diagnosis relies on clinical examination, particularly manual palpation, and treatment involves a combination of invasive and non-invasive methods.
References
Zhuang, X., Tan, S., & Huang, Q. (2014). Understanding of myofascial trigger points. Chinese Medical Journal, 127, 4271–4277. https://doi.org/10.3760/cma.j.issn.0366-6999.20141999
Barbero, M., Schneebeli, A., Koetsier, E., & Maino, P. (2019). Myofascial pain syndrome and trigger points: evaluation and treatment in patients with musculoskeletal pain.. Current Opinion in Supportive & Palliative Care. https://doi.org/10.1097/SPC.0000000000000445
Grabois, M. (2015). Muscle pain syndrome: Evaluation and treatment. Journal of Pain and Relief. https://doi.org/10.4172/2167-0846.S1.002
Bennett, R. (2007). Myofascial pain syndromes and their evaluation.. Best practice & research. Clinical rheumatology, 21 3, 427-45. https://doi.org/10.1016/J.BERH.2007.02.014
Gerwin, R. (2016). Myofascial Trigger Point Pain Syndromes. Seminars in Neurology, 36, 469 - 473. https://doi.org/10.1055/s-0036-1586262
Lavelle, E., Lavelle, W., & Smith, H. (2007). Myofascial trigger points.. The Medical clinics of North America, 91 2, 229-39. https://doi.org/10.1016/j.mcna.2006.12.004
Fischer, A. (1988). Documentation of myofascial trigger points.. Archives of physical medicine and rehabilitation, 69 4, 286-91.
Jaeger, B. (2013). Myofascial trigger point pain.. The Alpha omegan, 106 1-2, 14-22. https://doi.org/10.1016/b978-0-443-07003-7.50009-8
Bony Pain
Bony pain has the following characteristics:
- Pain on impact or weight-bearing
- May wake patients in the middle of the night
- Can be associated with stress fractures or, in some cases, cancer metastasis
Clinical Presentation of Bone Pain
Nature of Bone Pain:
Bone pain is a common symptom in various bone-related diseases and conditions, including Paget’s disease, bone sarcomas, multiple myeloma, osteoid osteoma, and bone metastases (Tan & Ralston, 2014; Kha et al., 2023; Seesaghur et al., 2020; Carneiro et al., 2021; Kane et al., 2015).
It can be persistent and severe, often described as deep, aching, or throbbing (Tan & Ralston, 2014; Seesaghur et al., 2020; Mantyh, 2018).
Pain on Loading:
Bone pain often worsens with weight-bearing activities or movement, which is particularly noted in conditions like cancer-induced bone pain and bone metastases (Kane et al., 2015; Wu et al., 2010).
This type of pain can significantly impact daily functioning and mobility (Kane et al., 2015; Wu et al., 2010).
Night Pain:
Pain that wakes patients in the middle of the night is a notable feature in several bone conditions, including osteoid osteoma and bone sarcomas (Kha et al., 2023; Carneiro et al., 2021).
Night pain is often severe and can disrupt sleep, contributing to overall poor quality of life (Kha et al., 2023; Carneiro et al., 2021).
Other Key Features:
Bone Deformity: Common in Paget’s disease and can be associated with pain (Tan & Ralston, 2014).
Pathological Fractures: Occur in conditions like Paget’s disease and multiple myeloma, often presenting with acute pain (Tan & Ralston, 2014; Seesaghur et al., 2020).
Palpable Mass: Noted in bone sarcomas, which can be associated with localized pain (Kha et al., 2023).
Systemic Symptoms: Conditions like multiple myeloma may present with systemic symptoms such as fatigue, anemia, and hypercalcemia, alongside bone pain (Seesaghur et al., 2020).
Radiographic Findings: Imaging often reveals lytic lesions, sclerosis, or other abnormalities in the affected bones, aiding in diagnosis (Carneiro et al., 2021; Bastard et al., 2022).
Conclusion
Bone pain is a multifaceted symptom that can present in various ways depending on the underlying condition. It is often exacerbated by movement or weight-bearing, can disrupt sleep, and may be accompanied by other clinical features such as bone deformity, fractures, and systemic symptoms. Understanding these presentations is crucial for timely diagnosis and effective management.
References
Tan, A., & Ralston, S. (2014). Clinical Presentation of Paget’s Disease: Evaluation of a Contemporary Cohort and Systematic Review. Calcified Tissue International, 95, 385-392. https://doi.org/10.1007/s00223-014-9904-1
Kha, S., Sharma, J., Kenney, D., Daldrup-Link, H., & Steffner, R. (2023). Assessment of the Interval to Diagnosis in Pediatric Bone Sarcoma. Pediatric Emergency Care, 39, 963 - 967. https://doi.org/10.1097/PEC.0000000000003031
Seesaghur, A., Petruski-Ivleva, N., Banks, V., Wang, J., Mattox, P., Abbasi, A., Maskell, J., Neasham, D., & Ramasamy, K. (2020). Bone Pain As a Presenting Symptom in Patients with Newly Diagnosed Multiple Myeloma in the Primary Care Setting: A Population-Based Cohort Study. Blood, 136, 18-18. https://doi.org/10.1182/blood-2020-138819
Carneiro, B., Da Cruz, I., Filho, A., Silva, I., Guimarães, J., Silva, F., Nico, M., & Stump, X. (2021). Osteoid osteoma: the great mimicker. Insights into Imaging, 12. https://doi.org/10.1186/s13244-021-00978-8
Mantyh, P. (2018). Mechanisms that drive bone pain across the lifespan.. British journal of clinical pharmacology, 85 6, 1103-1113. https://doi.org/10.1111/bcp.13801
Kane, C., Hoskin, P., & Bennett, M. (2015). Cancer induced bone pain. BMJ : British Medical Journal, 350. https://doi.org/10.1136/bmj.h315
Bastard, L., Hagège, B., Breban, M., & Gouze, H. (2022). Clinical image: bone erosions in a young man. Annals of the Rheumatic Diseases, 81, 1330 - 1330. https://doi.org/10.1136/annrheumdis-2022-222609
Wu, J., Beaton, D., Smith, P., & Hagen, N. (2010). Patterns of pain and interference in patients with painful bone metastases: a brief pain inventory validation study.. Journal of pain and symptom management, 39 2, 230-40. https://doi.org/10.1016/j.jpainsymman.2009.07.006
Vascular Pain
Vascular pain is described as:
- A deep ache
- Comes on with exercise
- Relieved quickly by rest
This type of pain is often associated with peripheral arterial disease and can be mistaken for other conditions, making diagnosis challenging at times[2].
Clinical Presentation of Vascular Pain (Claudication)
Nature of Pain:
Claudication is characterized by pain or discomfort in the muscles of the calf, thigh, or buttock that occurs during walking and is relieved by rest (Stewart et al., 2002; Tew et al., 2020).
The pain is often described as crampy and is typically located in the calf muscles (Johansson et al., 1982).
Onset with Exercise:
The pain is induced by walking or other forms of exercise and does not abate with continued activity (Stewart et al., 2002).
It occurs due to the obstruction or narrowing of the large arteries of the lower limbs, leading to impaired oxygen supply to the muscles during exercise (Harwood et al., 2021).
Relief with Rest:
The pain is consistently relieved by resting the leg, typically within 10 minutes of stopping exercise (Abraham et al., 2022).
Complete relief of symptoms is often achieved by assuming a recumbent position (Johansson et al., 1982).
Key Features:
Claudication is a manifestation of systemic atherosclerosis and peripheral vascular disease (Stewart et al., 2002).
It is a severe medical event with long-term morbidity and mortality risks similar to other arterial events such as stroke or myocardial infarction (Abraham et al., 2022).
The condition is more common in older adults and those with risk factors such as smoking, diabetes, dyslipidemia, and hypertension (Harwood et al., 2021).
Diagnosis often involves noninvasive arterial testing and may include Doppler testing to evaluate the significance of arterial lesions (Johansson et al., 1982; Jj et al., 1978).
Treatment options include supervised exercise programs, revascularization procedures, and vasodilator therapy (Tew et al., 2020).
Summary
Vascular pain (claudication) is characterized by exercise-induced pain in the lower limb muscles, primarily the calves, which is relieved by rest. It is commonly associated with peripheral arterial disease and systemic atherosclerosis. The pain pattern is consistent, with relief typically occurring within minutes of stopping exercise. Diagnosis involves noninvasive testing, and treatment includes exercise programs and, in severe cases, surgical interventions.
References
Johansson, J., Barrington, T., & Ameli, M. (1982). Combined Vascular and Neurogenic Claudication. Spine, 7, 150-158. https://doi.org/10.1097/00007632-198203000-00010
Stewart, K., Hiatt, W., Regensteiner, J., & Hirsch, A. (2002). Exercise training for claudication.. The New England journal of medicine, 347 24, 1941-51. https://doi.org/10.1056/NEJMRA021135
Abraham, P., Lecoq, S., Hersant, J., & Henni, S. (2022). Arterial claudication. Vascular Investigation and Therapy, 5, 68 - 74. https://doi.org/10.4103/2589-9686.360872
Harwood, A., Pymer, S., Ibeggazene, S., Parmenter, B., & Chetter, I. (2021). Non-pharmaceutical alternatives or adjuncts to exercise programmes for people with intermittent claudication. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD014677
Jj, G., Jk, C., Flanigan, P., , B., Kudrna, J., Schafer, M., Bergan, J., & Yao, J. (1978). Rational approach to the differentiation of vascular and neurogenic claudication.. Surgery, 84 6, 749-57.
Tew, G., Allen, L., Askew, C., Chetter, I., Cucato, G., Doherty, P., Garnham, A., Harwood, A., Ingle, L., Jenkins, M., Michaels, J., Pittack, S., Seenan, C., & Trender, H. (2020). Infographic. Exercise for intermittent claudication. British Journal of Sports Medicine, 54, 1443 - 1444. https://doi.org/10.1136/bjsports-2019-101930
Diagnostic Approach
Dan emphasizes the importance of thinking about pain types rather than focusing solely on specific diagnoses. This approach allows for more effective pain management while continuing to investigate the underlying cause.
First-Line Management
The episode outlines first-line management strategies, including:
1. Appropriate imaging (X-ray, CT, ultrasound)
2. Blood tests for inflammatory markers
3. Referral to allied health professionals
4. Minimizing losses (preventing muscle wasting and altered motor patterns)
5. Maintaining conditioning through adapted exercise programs
Conclusion
Understanding the nociceptive pain algorithm enables healthcare providers to manage pain more effectively while working towards a specific diagnosis. This approach allows for immediate intervention and prevents further complications associated with chronic pain.