633:, referred pain in a certain portion of the body can lead to a diagnosis of the correct local center. Somatic mapping of referred pain and the corresponding local centers has led to various topographic maps being produced to aid in pinpointing the location of pain based on the referred areas. For example, local pain stimulated in the esophagus is capable of producing referred pain in the upper abdomen, the oblique muscles, and the throat. Local pain in the prostate can radiate referred pain to the abdomen, lower back, and calf muscles.
648:, a disease characterized by joint and muscle pain and fatigue. These patients were looked at specifically due to their increased sensitivity to nociceptive stimuli. Furthermore, referred pain appears in a different pattern in fibromyalgic patients than non-fibromyalgic patients. Often this difference manifests as a difference in terms of the area that the referred pain is found (distal vs. proximal) as compared to the local pain. The area is also much more exaggerated owing to the increased sensitivity.
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311:(CNS) perceives pain from the heart as coming from the somatic portion of the body supplied by the thoracic spinal cord segments 1-4(5). Classically the pain associated with a myocardial infarction is located in the mid or left side of the chest where the heart is actually located. The pain can radiate to the left side of the jaw and into the left arm. Myocardial infarction can rarely present as referred pain and this usually occurs in people with
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366:. Bifurcated fibers do exist in muscle, skin, and intervertebral discs. Yet these particular neurons are rare and are not representative of the whole body. Axon-Reflex also does not explain the time delay before the appearance of referred pain, threshold differences for stimulating local and referred pain, and somatosensory sensibility changes in the area of referred pain.
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precision in terms of the stimulus and the measurement of the response. The method is easier to carry out than the injection method as it does not require special training in how it should be used. The frequency of the electrical pulse can also be controlled. For most studies a frequency of about 10 Hz is needed to stimulate both local and referred pain.
354:. Central sensitization occurs when neurons in the spinal cord's dorsal horn or brainstem become more responsive after repeated stimulation by peripheral neurons, so that weaker signals can trigger them. The delay in appearance of referred pain shown in laboratory experiments can be explained due to the time required to create the central sensitization.
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majority of experimental evidence from studies including studies of healthy individuals. Furthermore, referred pain generally appears within seconds in humans as opposed to minutes in animal models. Some scientists attribute this to a mechanism or influence downstream in the supraspinal pathways. Neuroimaging techniques such as
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muscle stimulation. Pain was felt in a receptive field that was some distance away from the original receptive field. According to hyperexcitability, new receptive fields are created as a result of the opening of latent convergent afferent fibers in the dorsal horn. This signal could then be perceived as referred pain.
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Studies have reported that the majority of patients that experienced centralization were able to avoid spinal surgery through isolating the area of local pain. However, the patients who did not experience centralization had to undergo surgery to diagnose and correct the problems. As a result of this
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Referred pain can be indicative of nerve damage. A case study done on a 63-year-old man with an injury sustained during his childhood developed referred pain symptoms after his face or back was touched. After even a light touch, there was a shooting pain in his arm. The study concluded that his pain
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Using this method it has been observed that significantly higher stimulus strength is needed to obtain referred pain relative to the local pain. There is also a strong correlation between the stimulus intensity and the intensity of referred and local pain. It is also believed that this method causes
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Hyperexcitability hypothesizes that referred pain has no central mechanism. However, it does say that there is one central characteristic that predominates. Experiments involving noxious stimuli and recordings from the dorsal horn of animals revealed that referred pain sensations began minutes after
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referred pain in the ventral portion of the ankle; however referred pain moving in the opposite direction has not been shown experimentally. Lastly, the threshold for the local pain stimulation and the referred pain stimulation are different, but according to this model they should both be the same.
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This represents one of the earliest theories on the subject of referred pain. It is based on the work of W.A. Sturge and J. Ross from 1888 and later TC Ruch in 1961. Convergent projection proposes that afferent nerve fibers from tissues converge onto the same spinal neuron, and explains why referred
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electrical stimulation (IMES) of muscle tissue has been used in various experimental and clinical settings. The advantage to using an IMES system over a standard such as hypertonic saline is that IMES can be turned on and off. This allows the researcher to exert a much higher degree of control and
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Thalamic convergence suggests that referred pain is perceived as such due to the summation of neural inputs in the brain, as opposed to the spinal cord, from the injured area and the referred area. Experimental evidence on thalamic convergence is lacking. However, pain studies performed on monkeys
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was used instead. Through various experiments it was determined that there were multiple factors that correlated with saline administration such as infusion rate, saline concentration, pressure, and amount of saline used. The mechanism by which the saline induces a local and referred pain pair is
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of this region of the body wall and upper limb have their neuronal cell bodies in the same dorsal root ganglia (T1-5) and synapse in the same second order neurons in the spinal cord segments (T1-5) as the general visceral sensory fibers from the heart. The CNS does not clearly discern whether the
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Several characteristics are in line with this mechanism of referred pain, such as dependency on stimulus and the time delay in the appearance of referred pain as compared to local pain. However, the appearance of new receptive fields, which is interpreted to be referred pain, conflicts with the
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Criticism of this model arises from its inability to explain why there is a delay between the onset of referred pain after local pain stimulation. Experimental evidence also shows that referred pain is often unidirectional. For example, stimulated local pain in the anterior tibial muscle causes
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and have their cell bodies located in thoracic dorsal root ganglia 1-4(5). As a general rule, in the thorax and abdomen, general visceral afferent (GVA) pain fibers follow sympathetic fibers back to the same spinal cord segments that gave rise to the preganglionic sympathetic fibers. The
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Pain is studied in a laboratory setting due to the greater amount of control that can be exerted. For example, the modality, intensity, and timing of painful stimuli can be controlled with much more precision. Within this setting there are two main ways that referred pain is studied.
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was possibly due to a neural reorganization which sensitized regions of his face and back after the nerve damage occurred. It is mentioned that this case is very similar to what phantom limb syndrome patients experience. This conclusion was based on experimental evidence gathered by
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One example of this is referred pain in the calf. McKenzie showed that the referred pain would move closer to the spine when the patient bent backwards in full extension a few times. More importantly, the referred pain would dissipate even after the movements were stopped.
421:(the loss of blood flow to a part of the heart muscle tissue) is possibly the best known example of referred pain; the sensation can occur in the upper chest as a restricted feeling, or as an ache in the left shoulder, arm or even hand.
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Convergence facilitation was conceived in 1893 by J MacKenzie based on the ideas of Sturge and Ross. He believed that the internal organs were insensitive to stimuli. Furthermore, he believed that non-nociceptive afferent inputs to the
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pain is believed to be segmented in much the same way as the spinal cord. Additionally, experimental evidence shows that when local pain (pain at the site of stimulation) is intensified the referred pain is intensified as well.
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Conscious perception of visceral sensations map to specific regions of the body, as shown in this chart. Some sensations are felt locally, whereas others are perceived as affecting areas that are quite distant from the involved
613:. He concluded that centralization occurs when referred pain moves from a distal to a more proximal location. Observations in support of this idea were seen when patients would bend backward and forward during an examination.
452:, a type of referred pain, is the sensation of pain from a limb that has been lost or from which a person no longer receives physical signals. It is an experience almost universally reported by amputees and quadriplegics.
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created what he termed "an irritable focus". This focus caused some stimuli to be perceived as referred pain. However, his ideas did not gain widespread acceptance from critics due to its dismissal of visceral pain.
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There are several proposed mechanisms for referred pain. Currently there is no definitive consensus regarding which is correct. The cardiac general visceral sensory pain fibers follow the sympathetics back to the
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has not officially defined the term; hence, several authors have defined it differently. Referred pain has been described since the late 1880s. Despite an increasing amount of literature on the subject, the
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could either be referred or radiating pain from the chest. Referred pain is when the pain is located away from or adjacent to the organ involved; for instance, when a person has pain only in their
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pain is coming from the body wall or from the viscera, but it perceives the pain as coming from somewhere on the body wall, i.e. substernal pain, left arm/hand pain, jaw pain.
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Witting N, Svensson P, Gottrup H, Arendt-Nielsen L, Jensen TS (2000). "Intramuscular and intradermal injection of capsaicin: a comparison of local and referred pain".
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can cause visceral pain in the ureter as the stone is slowly passed into the excretory system. This can cause immense referred pain in the lower abdominal wall.
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From the above examples one can see why understanding of referred pain can lead to better diagnoses of various conditions and diseases. In 1981 physiotherapist
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Modality-specific somatosensory changes occur in referred areas, which emphasize the importance of using a multimodal sensory test regime for assessment.
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Kosek E, Hansson P (2003). "Perceptual integration of intramuscular electrical stimulation in the focal and the referred pain area in healthy humans".
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a larger recruitment of nociceptor units resulting in a spatial summation. This spatial summation results in a much larger barrage of signals to the
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perceive pain, but the pain also spreads ("radiates") out from this origin point to cause the pain to be perceived in a wider area in addition.
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in the throat and the palate, respectively, transmit pain signals following rapid cooling and rewarming of the capillaries in the sinuses.
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Graven-Nielsen, T; et al. (1999). "Ketamine reduces muscle pain, temporal summation, and referred pain in fibromyalgia patients".
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spread of referred muscle pain is seen in patients with chronic musculoskeletal pain and very seldom is it seen in healthy individuals.
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858:"Ice cream evoked headaches (ICE-H) study: randomised trial of accelerated versus cautious ice cream eating regimen"
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unknown. Some researchers have commented that it could be due to osmotic differences, however that is not verified.
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study there has been a further research into the elimination of referred pain through certain body movements.
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Patients with chronic musculoskeletal pains have enlarged referred pain areas to experimental stimuli. The
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In recent years several different chemicals have been used to induce referred pain including bradykinin,
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in 1993, with the difference being that the arm that is in pain is still attached to the body.
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Referred pain is often experienced on the same side of the body as the source, but not always.
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The size of referred pain is related to the intensity and duration of ongoing/evoked pain.
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revealed convergence of several pathways upon separate cortical and subcortical neurons.
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may visualize the underlying neural processing pathways responsible in future testing.
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Recently this idea has regained some credibility under a new term, central
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Manusov EG (September 2012). "Evaluation and diagnosis of low back pain".
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Travell & Simons' Myofascial Pain and
Dysfunction: Upper half of body
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Pain perceived at a location other than the site of the painful stimulus
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Central hyperexcitability is important for the extent of referred pain.
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433:" or "brain freeze" is another example of referred pain, in which the
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of referred pain is unknown, although there are several hypotheses.
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Demco, LA (May 2000). "Pain referral patterns in the pelvis".
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is a potent mechanism for generation of referred muscle pain.
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Kaczorowski, Maya; Kaczorowski, Janusz (21 December 2002).
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perceived at a location other than the site of the painful
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congenital insensitivity to pain with partial anhidrosis
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attack), where pain is often felt in the left side of
701:"Referred muscle pain: basic and clinical findings"
60:. Unsourced material may be challenged and removed.
940:Simons, D.G.; Travell, J.G.; Simons, L.S. (1999).
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640:Further, recent research has found that
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202:. An example is the case of
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315:or older age. Also, the
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1549:
1544:
1539:
1534:
1532:Pain tolerance
1529:
1527:Pain threshold
1523:
1521:
1517:
1516:
1514:
1513:
1508:
1503:
1498:
1492:
1490:
1484:
1483:
1481:
1480:
1475:
1470:
1465:
1459:
1457:
1451:
1450:
1448:
1447:
1442:
1437:
1435:Hot plate test
1432:
1427:
1422:
1417:
1411:
1409:
1405:
1404:
1401:
1400:
1398:
1397:
1392:
1387:
1382:
1376:
1374:
1370:
1369:
1367:
1366:
1365:
1364:
1359:
1349:
1344:
1339:
1334:
1329:
1324:
1319:
1314:
1309:
1304:
1302:Pain asymbolia
1299:
1293:
1291:
1285:
1284:
1282:
1281:
1276:
1271:
1263:
1258:
1249:
1247:
1241:
1240:
1238:
1237:
1232:
1226:
1224:
1218:
1217:
1215:
1214:
1209:
1201:
1196:
1191:
1185:
1183:
1176:
1172:
1171:
1164:
1163:
1156:
1149:
1141:
1134:
1133:
1106:(3): 483–491.
1090:
1075:
1052:
1009:
966:
952:
932:
897:
848:
826:
775:
740:
667:
665:
662:
661:
660:
653:
650:
626:
623:
611:centralization
607:Robin McKenzie
602:
599:
589:
586:
565:
562:
540:
537:
531:
528:
525:
524:
518:
514:
513:
508:
504:
503:
486:
485:Left shoulder
482:
481:
475:
471:
470:
461:
454:
453:
447:
443:
442:
427:
423:
422:
416:
412:
411:
408:
401:
398:
392:
389:
371:
368:
359:
356:
338:
335:
325:
322:
298:
295:
294:
293:
290:
287:
280:
277:
271:
266:
263:
243:Radiating pain
190:, also called
183:
182:
173:
167:
166:
161:
155:
154:
150:
149:
145:
137:
136:
128:
127:
110:September 2020
42:
40:
33:
26:
9:
6:
4:
3:
2:
2268:
2257:
2254:
2252:
2249:
2248:
2246:
2225:
2222:
2221:
2220:
2219:
2215:
2213:
2210:
2208:
2205:
2203:
2202:Caput medusae
2200:
2198:
2195:
2194:
2192:
2190:
2186:
2178:
2175:
2174:
2173:
2172:
2168:
2166:
2163:
2159:
2158:Lines of Zahn
2156:
2155:
2154:
2153:
2149:
2147:
2146:
2142:
2138:
2135:
2134:
2133:
2132:
2128:
2124:
2121:
2120:
2119:
2118:
2114:
2110:
2109:Oliver's sign
2107:
2105:
2102:
2101:
2100:
2099:
2095:
2094:
2092:
2090:
2086:
2083:
2081:
2077:
2067:
2064:
2060:
2057:
2056:
2055:
2054:
2050:
2048:
2045:
2043:
2040:
2038:
2036:
2032:
2031:
2029:
2025:
2019:
2016:
2014:
2011:
2009:
2005:
2001:
2000:
1998:
1996:
1992:
1986:
1983:
1981:
1977:
1974:
1972:
1969:
1967:
1963:
1962:
1960:
1958:
1953:
1947:
1944:
1942:
1939:
1937:
1936:MĂĽller's sign
1934:
1932:
1929:
1927:
1924:
1922:
1919:
1918:
1916:
1914:
1910:
1907:
1905:
1901:
1895:
1891:
1889:
1886:
1884:
1881:
1879:
1876:
1874:
1871:
1870:
1868:
1866:
1862:
1856:
1854:
1851:
1847:
1844:
1843:
1842:
1839:
1837:
1836:CĹ“ur en sabot
1834:
1830:
1827:
1826:
1825:
1822:
1821:
1819:
1815:
1809:
1806:
1802:
1799:
1797:
1794:
1793:
1792:
1789:
1787:
1784:
1782:
1779:
1777:
1774:
1773:
1771:
1769:
1765:
1757:
1754:
1753:
1752:
1749:
1747:
1744:
1742:
1739:
1733:
1730:
1729:
1728:
1727:
1723:
1721:
1718:
1716:
1713:
1709:
1706:
1704:
1701:
1700:
1699:
1696:
1692:
1689:
1687:
1684:
1683:
1682:
1679:
1678:
1677:
1674:
1670:
1669:Gallop rhythm
1667:
1665:
1662:
1660:
1657:
1655:
1652:
1651:
1650:
1647:
1646:
1644:
1642:
1638:
1630:
1629:Levine's sign
1627:
1626:
1625:
1622:
1620:
1619:Referred pain
1617:
1616:
1614:
1612:
1608:
1604:
1600:
1593:
1588:
1586:
1581:
1579:
1574:
1573:
1570:
1558:
1555:
1553:
1550:
1548:
1545:
1543:
1540:
1538:
1535:
1533:
1530:
1528:
1525:
1524:
1522:
1518:
1512:
1509:
1507:
1504:
1502:
1499:
1497:
1494:
1493:
1491:
1489:
1485:
1479:
1476:
1474:
1471:
1469:
1466:
1464:
1461:
1460:
1458:
1456:
1452:
1446:
1443:
1441:
1438:
1436:
1433:
1431:
1430:Grimace scale
1428:
1426:
1423:
1421:
1418:
1416:
1413:
1412:
1410:
1406:
1396:
1395:Low back pain
1393:
1391:
1388:
1386:
1383:
1381:
1378:
1377:
1375:
1371:
1363:
1360:
1358:
1355:
1354:
1353:
1350:
1348:
1347:Referred pain
1345:
1343:
1340:
1338:
1335:
1333:
1330:
1328:
1325:
1323:
1320:
1318:
1315:
1313:
1310:
1308:
1307:Pain disorder
1305:
1303:
1300:
1298:
1295:
1294:
1292:
1290:
1286:
1280:
1279:Delayed-onset
1277:
1275:
1272:
1270:
1264:
1262:
1259:
1257:
1251:
1250:
1248:
1246:
1242:
1236:
1233:
1231:
1228:
1227:
1225:
1223:
1219:
1213:
1210:
1208:
1202:
1200:
1197:
1195:
1192:
1190:
1187:
1186:
1184:
1182:Head and neck
1180:
1177:
1173:
1169:
1162:
1157:
1155:
1150:
1148:
1143:
1142:
1139:
1129:
1125:
1121:
1117:
1113:
1109:
1105:
1101:
1094:
1086:
1079:
1072:(7): 348–352.
1071:
1067:
1063:
1056:
1048:
1044:
1040:
1036:
1032:
1028:
1024:
1020:
1013:
1005:
1001:
997:
993:
989:
985:
981:
977:
970:
955:
953:9780683083637
949:
945:
944:
936:
928:
924:
920:
916:
912:
908:
901:
893:
889:
884:
879:
875:
871:
867:
863:
859:
852:
836:
830:
822:
818:
813:
808:
803:
798:
794:
790:
786:
779:
771:
767:
763:
759:
755:
751:
744:
736:
732:
728:
724:
719:
714:
710:
706:
702:
695:
693:
691:
689:
687:
685:
683:
681:
679:
677:
675:
673:
668:
659:
658:Visceral pain
656:
655:
649:
647:
643:
638:
636:
635:Kidney stones
632:
622:
618:
614:
612:
608:
598:
596:
585:
583:
579:
573:
570:
569:Intramuscular
561:
558:
554:
550:
546:
536:
522:
519:
517:Palm of Hand
516:
515:
512:
511:Low back pain
509:
506:
505:
502:
498:
494:
490:
487:
484:
483:
480:
476:
473:
472:
469:
465:
462:
460:
457:Right tip of
456:
455:
451:
448:
445:
444:
440:
436:
432:
428:
425:
424:
420:
417:
414:
413:
409:
406:
405:
397:
388:
386:
382:
376:
367:
365:
355:
353:
352:sensitization
348:
345:
334:
330:
321:
318:
314:
310:
305:
291:
288:
285:
281:
278:
275:
272:
269:
268:
262:
260:
256:
252:
248:
244:
240:
238:
233:
229:
225:
221:
217:
213:
209:
205:
201:
197:
193:
189:
188:Referred pain
178:
172:
168:
165:
162:
160:
156:
151:
143:
138:
135:Referred pain
133:
124:
121:
113:
102:
99:
95:
92:
88:
85:
81:
78:
74:
71: –
70:
66:
65:Find sources:
59:
55:
49:
48:
43:This article
41:
37:
32:
31:
19:
2216:
2169:
2165:Adson's sign
2150:
2143:
2137:Allen's test
2129:
2115:
2096:
2051:
2047:Aschoff body
2033:
2018:Ewart's sign
2013:Beck's triad
2002:
1980:Osler's node
1966:endocarditis
1964:
1946:Mayne's sign
1892:See further
1888:Distributive
1824:Palpitations
1790:
1724:
1676:Heart murmur
1649:Heart sounds
1641:Auscultation
1618:
1346:
1342:Phantom pain
1327:Hyperalgesia
1322:Chronic pain
1206:(swallowing)
1204:Odynophagia
1103:
1099:
1093:
1084:
1078:
1069:
1065:
1055:
1022:
1018:
1012:
979:
975:
969:
957:. Retrieved
942:
935:
913:(3): 471–9.
910:
907:Primary Care
906:
900:
865:
861:
851:
841:December 26,
839:. Retrieved
829:
792:
788:
778:
756:(2): 181–3.
753:
749:
743:
708:
704:
646:fibromyalgia
639:
628:
619:
615:
610:
604:
591:
574:
567:
542:
533:
410:Description
394:
377:
373:
361:
349:
340:
331:
327:
300:
258:
242:
241:
191:
187:
186:
116:
107:
97:
90:
83:
76:
64:
52:Please help
47:verification
44:
1995:Pericardium
1971:Roth's spot
1957:endocardium
1883:Hypovolemic
1878:Obstructive
1873:Cardiogenic
1781:Bradycardia
1776:Tachycardia
1746:Heart click
1552:Cancer pain
1478:Substance P
1463:Nociception
1425:Dolorimeter
1380:Pelvic pain
1337:Hyperpathia
1332:Hypoalgesia
1253:Arthralgia
1235:Pleurodynia
1230:Sore throat
711:(1): 11–9.
705:Clin J Pain
578:dorsal horn
545:substance P
497:Kehr's sign
468:gallbladder
435:vagus nerve
364:dorsal horn
358:Axon-reflex
344:spinal cord
304:spinal cord
153:Identifiers
2245:Categories
1853:Hyperaemia
1715:Continuous
1611:Chest pain
1501:Anesthesia
1488:Management
1415:Pain scale
1385:Proctalgia
1289:Neurologic
1189:Eye strain
664:References
474:Umbilicus
317:dermatomes
80:newspapers
1829:Apex beat
1698:Diastolic
1537:Suffering
1506:Cordotomy
1496:Analgesia
1317:Allodynia
1297:Neuralgia
1261:Bone pain
1212:Toothache
584:neurons.
582:brainstem
553:serotonin
549:capsaicin
407:Location
383:scans or
297:Mechanism
2152:thrombus
2089:Arterial
1681:Systolic
1654:Split S2
1542:SOCRATES
1268:(muscle)
1266:Myalgia
1194:Headache
1128:23064301
1120:10781923
1047:24594646
1039:14499428
1004:27403703
996:10666547
927:22958556
892:12493658
821:20027423
795:(2): i.
770:10806259
735:27091223
727:11289083
652:See also
642:ketamine
629:As with
477:Pain in
446:General
400:Examples
313:diabetes
284:proximal
253:or left
220:shoulder
200:stimulus
1791:doubled
1756:carotid
1255:(joint)
959:May 20,
812:4327510
459:scapula
437:or the
218:, left
164:D053591
94:scholar
2189:Venous
2059:J wave
1955:Other
1624:Angina
1126:
1118:
1045:
1037:
1002:
994:
950:
925:
890:
883:139031
880:
819:
809:
768:
733:
725:
557:saline
551:, and
493:spleen
228:thorax
222:, and
147:organ.
96:
89:
82:
75:
67:
2027:Other
1865:Shock
1817:Other
1768:Pulse
1751:Bruit
1373:Other
1274:Acute
1124:S2CID
1043:S2CID
1000:S2CID
731:S2CID
507:Back
479:ovary
464:Liver
426:Head
212:heart
194:, is
175:[
101:JSTOR
87:books
2251:Pain
1390:Back
1199:Neck
1168:Pain
1116:PMID
1100:Pain
1035:PMID
1019:Pain
992:PMID
976:Pain
961:2015
948:ISBN
923:PMID
888:PMID
843:2011
817:PMID
766:PMID
723:PMID
580:and
501:lung
385:fMRI
224:back
216:neck
196:pain
159:MeSH
73:news
2053:EKG
1108:doi
1027:doi
1023:105
984:doi
915:doi
878:PMC
870:doi
866:325
862:BMJ
807:PMC
797:doi
758:doi
713:doi
499:),
381:PET
259:can
255:arm
251:jaw
56:by
2247::
1664:S4
1659:S3
1122:.
1114:.
1104:85
1102:.
1070:46
1068:.
1064:.
1041:.
1033:.
1021:.
998:.
990:.
980:84
978:.
921:.
911:39
909:.
886:.
876:.
864:.
860:.
815:.
805:.
791:.
787:.
764:.
752:.
729:.
721:.
709:17
707:.
703:.
671:^
547:,
491:,
466:,
2037::
2010::
2006:/
1978:/
1968::
1591:e
1584:t
1577:v
1160:e
1153:t
1146:v
1130:.
1110::
1049:.
1029::
1006:.
986::
963:.
929:.
917::
894:.
872::
845:.
823:.
799::
793:3
772:.
760::
754:7
737:.
715::
495:(
429:"
210:(
179:]
123:)
117:(
112:)
108:(
98:·
91:·
84:·
77:·
50:.
20:)
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