Screening for Visceral Referred Pain in the Thoracic Spine

in this video you will learn how to

screen for visceral pain from organ

tracks which can mask as thoracic pain

enroll in our online course now link is

in the video description hi and welcome

back to physio tutors one of the major

challenges for clinician seeing patients

with low back pain is determining the

source of the symptoms even though we

know that ninety percent of low back

pain is a specific and we cannot

accurately determine a source of

nociception we will have to rule out

serious pathology first one such source

that is often overlooked but it has to

be ruled out during your screening

process are true and referred visceral

pain true visceral pain arises as a

poorly defined sensation usually

perceived in a midline of the body at

the lower sternum or upper abdomen this

diffused nature and difficulty in

locating visceral pain is due to a low

density of visceral sensory innervation

and extensive divergence of visceral

input within the central nervous system

visceral pain is therefore perceived

more diffusely than noxious cutaneous

stimulation with respect to location and

timing subsequent symptoms may entail

referred pain to somatic structures that

share the same segmental innovation and

that are more densely innervated this

way this Aurora third pain can mask as

pain from musculoskeletal structures we

have linked a video in the top right

corner that digs deeper into the neuro

physiological mechanism behind this

phenomenon tsukanai down in the year

2012 point out that somatic pain can be

distinguished from visceral pain as a

letter is often associated with marked

motor and autonomic reflexes including

pallor profuse sweating nausea GI

disturbances and changes in body

temperature blood pressure and heart


and at the same time it often produces

strong affective responses and therefore

can be reinforced by anxiety and

depression so which organs have their

segmental innovation in the forensic

spine and can potentially refer pain to

the mid and upper back these are the

following in case a patient complains

about radiating symptoms along the other

side of the arm mimicking see aid

radiculopathy all ulnar nerve entrapment

is a Pancoast tumor for a cardiovascular

system you could ask the following items


questions you could ask for the

pulmonary system are the following the

organs of the digestive system generally

refer pain to the thoracic spine with

the exception of the large intestine

sigmoid colon and esophagus




during your interview you could ask for

the following things


you can imagine that some of these

questions are very straightforward and

private and probably not what a new

patient expects during the intake for

this reason it's important to explain

why you are asking these questions in

our experience it makes sense to start

with more general questions for example

do you have abdominal pain and then dig

deeper with the more specific questions

if the initial questions were positive a

more general tract that is often

overlooked as it is not specific to a

certain area is the local motor tract if

the patient describes insidious onset of

symptoms in multiple joints the

therapist should be wary of the presence

of inflammatory disorders such as

rheumatoid arthritis or systemic lupus

etcetera as opposed to multiple areas

exhibiting pure mechanical

musculoskeletal dysfunction questions

you could ask for the locomotor tract

are if there is pain swelling or

movement restriction in other joints in

the body next to the joint the patient

is primarily complaining about at last

there are a couple of general evaluation

principles that will help you to

distinguish visceral pain of this oral

referred pain from musculoskeletal pain

these are number one pain from muscular

skeletal structures can be related to a

change in body or limb position or to

specific movements so if the symptoms do

not vary regardless of body position and

movement and a present at rest

especially if the pain is most severe

waking them up at night a pathological

disorder should be suspected too we have

already mentioned that visceral pain is

described to be poorly localized diffuse

dull and vague in character it can be

constant but may rhythmically build up

to a peak and then recede sensations of

cramping pain have been attributed to

spasm of the muscle wall of the hollow

viscus and have been described in

gastroenteritis constipation

menstruation gall bladder disease and

material obstruction 3 the behavior of

symptoms from visceral organs will vary

depending on the function of the organ

they might be related to eating habits

or ingestion of certain fruits may occur

with bowel or bladder fullness or

constipation or be associated with the

actual acts of urination or defecation 4

contrary to musculoskeletal pain in

which patients often report an incident

accident or trauma marking the onset of

complaints a serious pathology might be

suspected in case of an insidious onset

with unexplained symptom development 5

questions about general health may also

reveal critical information signs and

symptoms like fever chills nausea

unexplained weight loss malaise vomiting

changes in bowel habits or rectal and

vaginal bleeding for more than one or

two weeks might be an indicator of a

more serious pathology make sure that

you are aware of conditions that the

patient is currently treated for or has

been treated for in the past as many can

have a history of recurrence and ask for

family history as well 6 last patient

information including age gender

occupation and an ethnicity may place

people at higher risk for the

development of specific diseases be

aware that no single question allows you

to reach a conclusion what we are

looking for is a pattern that might

indicate serious pathology it has to be

said that you are not trying to make a

specific diagnosis for certain organ

pathology here this is out of the scope

of a physio and the expertise of an MD

the message that we want to bring across

here is that it should become routine to

include screening for visceral pathology

during your screening process as well so

you can refer out if serious pathology

is suspected

okay this was our video on screening for

visceral pathology for the mid and upper

back if you are curious about screening

for visceral pathology referring to the

neck and shoulder click on a video right

next to me videos like this and much

more can be found on our soon to be

released online course on the spine on

our webpage study dot physio tutors comm

it's always thanks a lot for watching

this was careful physio tutors see you