Abstract
Pain referral can pose a serious problem for the diagnosis and treatment of muscle pain because it leads to a mislocalization of the pain by the patient. Referral of pain originating in muscles can be elicited experimentally in a relatively high proportion of healthy subjects. Pain and tenderness can be referred to muscle from other muscles, joints, viscera, and as pain originating in the central nervous system. Clinically, muscle pain referred from other muscles has the typical characteristics of deep-tissue pain and can be elicited, e.g., by local pressure also from muscles that appear to be normal. Referral of pain from joint to muscle is frequent; it often occurs in muscles crossing the joint. Finally, pain can be experienced in muscle as an expression of central pain, i.e., pain due to lesions of the central nervous system. A prominent example of such a muscle pain is phantom limb pain. In the second part of the chapter, potential mechanisms of pain referral are discussed as well as the differences between Head zones and referred pain in the strict sense. Basically, pain referral appears to result from nociceptive information taking a wrong path in the spinal cord and reaching (somatotopically) inappropriate dorsal horn neurons. The convergence-projection theory by Ruch is still the central concept for the explanation of referred pain. It states that a given dorsal horn neuron receives synaptic connections from two separate innervation areas (convergent input), and that the neuron induces subjective pain in only one (and always the same) area, even when it is excited from the other area. The theory explains the referred pain in the skin from painful viscera. Typical examples of muscle pain referred from viscera include the chest-wall pain of cardiac infarction and the flank pain of renal calculi. A more recent version of the theory states that normally only one of the convergent connections is sufficiently effective to fire the neuron; the other elicits just subthreshold potentials in the neuron. However, the ineffective connections can become effective if there is a long-lasting lesion in the region of the ineffective connection (somatotopically inappropriate connections are opened). Thus, the nociceptive information takes a wrong course in the spinal cord and the pain is mislocalized.
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References
Arendt-Nielsen L, Graven-Nielsen T (2003) Central sensitization in fibromyalgia and other musculoskeletal disorders. Curr Pain Headache Rep 7:355–361
Bajaj P, Bajaj P, Graven-Nielsen T et al. (2001) Osteoarthritis and its association with muscle hyperalgesia: an experimental controlled study. Pain 93:107–114
Birch L, Arendt-Nielsen L, Graven-Nielsen T et al. (2001) An investigation of how acute muscle pain modulates performance during computer work with digitizer and puck. Appl Ergon 32:281–286
Bird GC, Han JS, Fu Y et al. (2006) Pain-related synaptic plasticity in spinal dorsal horn neurones: role of CGRP. Mol Pain 2:31
Bogduk N (1980) Lumbar dorsal ramus syndrome. Med J Aust 2:537–541
Bogduk N, Simons DG (1993) Neck pain: joint pain or trigger points? In: Vaeroy H, Merskey H (eds) Progress in fibromyalgia and myofascial pain, Vol 6 of Pain research and clinical management. Elsevier, Amsterdam
Bouhassira D, Danziger N (2006) Investigation of brainstem: descending pain modulation in animals and humans. Suppl Clin Neurophysiol 58:134–149
Cervero F (1983) Somatic and visceral inputs to the thoracic spinal cord of the cat: effects of noxious stimulation of the biliary system. J Physiol 337:51–67
Cervero F, Jänig W (1992) Visceral nociceptors: a new world order? Trends Neurosci 15:374–378
Devor M, Wall PD, McMahon SB (1984) Dichotomizing somatic nerve fibers exist in rats but they are rare. Neurosci Lett 49:187–192
Doran FS, Ratcliffe AH (1954) The physiological mechanism of referred shoulder-tip pain. Brain 77:427–434
Ervilha UF, Arendt-Nielsen L, Duarte M et al. (2004) The effect of muscle pain on elbow flexion and coactivation tasks. Exp Brain Res 156:174–182
Falace DA, Reid K, Rayens MK (1996) The influence of deep (odontogenic) pain intensity, quality, and duration on the incidence and characteristics of referred orofacial pain. J Orofac Pain 10:232–239
Feinstein B, Langton JNK, Jameson RM et al. (1954) Experiments on pain referred from deep somatic tissues. J Bone Joint Surg Am 36:981–997
Flor H (2008) Maladaptive plasticity, memory for pain and phantom limb pain: review and suggestions for new therapies. Expert Rev Neurother 8:809–818
Foreman RD, Blair RW, Weber RN (1984) Viscerosomatic convergence onto T2–T4 spinoreticular, spinoreticular-spinothalamic, and spinothalamic tract neurones in the cat. Exp Neurol 85:597–619
Giamberardino MA, Vecchiet L (1995) Visceral pain, referred hyperalgesia and outcome: new concepts. Eur J Anaesthesiol 12:61–66
Giamberardino MA, Vecchiet L, Albe-Fessard D (1990) Comparison of the effects of ureteral calculosis and occlusion on muscular sensitivity to pain stimulations in rats. Pain 43:227–234
Giamberardino MA, Dalal A, Vecchiet L (1996) Changes in activity of spinal cells with muscular input in rats with referred muscular hyperalgesia from ureteral calculosis. Neurosci Lett 203:1–4
Gibson W (2006) Referred pain and hyperalgesia in human tendon and muscle belly tissue. Pain 120:113–123
Graven-Nielsen T (2006) Fundamentals of muscle pain, referred pain, and deep tissue hyperalgesia. Scand J Rheumatol 35:1–43
Graven-Nielsen T, Arendt-Nielsen L, Svensson P et al. (1997a) Experimental muscle pain: a quantitative study of local and referred pain in humans follwing injection of hypertonic saline. J Musculoskel Pain 5:49–69
Graven-Nielsen T, Arendt-Nielsen L, Svensson P et al. (1997b) Quantification of local and referred muscle pain in humans after sequential i.m. injections of hypertonic saline. Pain 69:111–117
Graven-Nielsen T, Arendt-Nielsen L, Svensson P et al. (1997c) Stimulus–response functions in areas with experimentally induced referred muscle pain — a psychophysical study. Brain Res 744:121–128
Graven-Nielsen T, Babenko V, Svensson P et al. (1998) Experimentally induced muscle pain induces hypoalgesia in heterotopic deep tissues, but not in homotopic deep tissues. Brain Res 787:203–210
Graven-Nielsen T, Kendall SA, Henriksson KG et al. (2000) Ketamine reduces muscle pain, temporal summation, and referred pain in fibromyalgia patients. Pain 85:483–491
Graven-Nielsen T, Gibson SJ, Laursen RJ et al. (2002) Opioid-insensitive hypoalgesia to mechanical stimuli at sites ipsilateral and contralateral to experimental muscle pain in human volunteers. Exp Brain Res 146:213–222
Graven-Nielsen T, Jansson Y, Segerdahl M et al. (2003) Experimental pain by ischaemic contractions compared with pain by intramuscular infusions of adenosine and hypertonic saline. Eur J Pain 7:93–102
Grigg P, Schaible H-G, Schmidt RF (1086) Mechanical sensitivity of group III and IV afferents from posterior articular nerve in normal and inflamed cat knee. J Neurophysiol 55:635–643
Guilbaud G (1991) Central neurophysiological processing of joint pain on the basis of studies performed in normal animals and in models of experimental arthritis. Can J Physiol Pharmacol 69:637–646
Handwerker HO, Kilo S, Reeh PW (1991) Unresponsive afferent nerve fibres in the sural nerve of the rat. J Physiol 435:229–242
Harman JB (1948) The localization of deep pain. Br Med J 1:188–192
Head H (1893) On disturbances of sensation with especial reference to the pain of visceral disease. Brain 16:1–133
Hockaday JM, Whitty CWM (1967) Patterns of referred pain in the normal subject. Brain 90:481–496
Hoheisel U, Mense S (1989) Long-term changes in discharge behaviour of cat dorsal horn neurones following noxious stimulation of deep tissues. Pain 36:239–247
Hoheisel U, Mense S (1990) Response behaviour of cat dorsal horn neurones receiving input from skeletal muscle and other deep somatic tissues. J Physiol 426:265–280
Hoheisel U, Mense S, Simons DG et al. (1993) Appearance of new receptive fields in rat dorsal horn neurons following noxious stimulation of skeletal muscle: a model for referral of muscle pain? Neurosci Lett 153:9–12
Hoheisel U, Koch K, Mense S (1994) Functional reorganization in the rat dorsal horn during an experimental myositis. Pain 59:111–118
Hoheisel U, Unger T, Mense S (2005) Excitatory and modulatory effects of inflammatory cytokines and neurotrophins on mechanosensitive group IV muscle afferents in the rat. Pain 114:168–176
Hoheisel U, Unger T, Mense S (2007) Sensitization of rat dorsal horn neurones by NGF-induced subthreshold potentials and low-frequency activation. A study employing intracellular recordings in vivo. Brain Res 1169:34–43
Hong C-Z (1996) Pathophysiology of myofascial trigger point. J Formos Med Assoc 95:93–104
Hong C-Z, Chen Y-N, Twehous D et al. (1996) Pressure threshold for referred pain by compression on the trigger point and adjacent areas. J Musculoskel Pain 4:61–79
Inman VT, Saunders JB, de CM (1944) Referred pain from skeletal structures. J Nerv Ment Dis 99:660–667
Jensen K, Norup M (1992) Experimental pain in human temporal muscle induced by hypertonic saline, potassium and acidity. Cephalalgia 12:101–106
Johansen MK, Graven-Nielsen T, Olesen AS et al. (1999) Generalised muscular hyperalgesia in chronic whiplash syndrome. Pain 83:229–234
Just S, Heppelmann B (2001) Neuropeptide Y changes the excitability of fine afferent units in the rat knee joint. Br J Pharmacol 132:703–708
Kellgren JH (1938) Observations on referred pain arising from muscle. Clin Sci 3:175–190
Laursen RJ, Graven-Nielsen T, Jensen TS et al. (1997) Quantification of local and referred pain in humans induced by intramuscular electrical stimulation. Eur J Pain 1:105–113
Laursen RJ, Graven-Nielsen T, Jensen TS et al. (1999) The effect of compression and regional anaesthetic block on referred pain intensity in humans. Pain 80:257–263
Lewis T (1942) Pain. Macmillan, London
Lewit K (1991) Manipulative Therapy in Rehabilitation of the Locomotor System, 2nd edn. Butterworth Heinemann, Oxford
Li P, Zhuo M (2001) Substance P and neurokinin A mediate sensory synaptic transmission in young rat dorsal horn neurons. Brain Res Bull 55:521–531
Mantyh PW (2002) Neurobiology of substance P and the NK1 receptor. J Clin Psychiatr 63:6–10
McCall IW, Park WM, O’Brian JP (1979) Induced pain referral from posterior lumbar elements in normal subjects. Spine 4:441–446
McKenzie J (1909) Symptoms and their interpretation. Shaw and Sons, London
Mense S (1994) Referral of muscle pain: new aspects. APS J 3:1–9
Mense S, Craig AD (1988) Spinal and supraspinal terminations of primary afferent fibers from the gastrocnemius–soleus muscle in the cat. Neuroscience 26:1023–1035
Mense S, Gerwin RD (eds) (2010) Muscle pain: diagnosis and treatment. Springer, Heidelberg
Mense S, Meyer H (1985) Different types of slowly conducting afferent units in cat skeletal muscle and tendon. J Physiol 363:403–417
Mense S, Light AR, Perl ER (1981) Spinal terminations of subcutaneous high-threshold mechanoreceptors. In: Brown AG, Réthelyi M (eds) Spinal Cord Sensation. Scottish Academic Press, Edinburgh
Meyers DER, Snow PJ (1984) Somatotopical inappropriate projections of single hair follicle afferent fibres to the cat spinal cord. J Physiol 347:59–73
Ness TJ, Gebhart GF (1990) Visceral pain: A review of experimental studies. Pain 41:167–234
O’Neill S, Manniche C, Graven-Nielsen T et al. (2007) Generalized deep-tissue hyperalgesia in patients with chronic low-back pain. Eur J Pain 11:415–420
Pierau F-K, Fellmer G, Taylor DCM (1984) Somato-visceral convergence in cat dorsal root ganglion neurones demonstrated by double-labelling with fluorescent tracers. Brain Res 321:63–70
Procacci P, Zoppi M, Maresca M (1999) Heart, vascular and haemopathic pain. In: Wall PD, Melzack R (eds) Textbook of pain. Churchill Livingstone, Edinburgh
Qerama E, Fuglsang-Frederiksen A, Kasch H et al. (2004) Evoked pain in the motor endplate region of the brachial biceps muscle: an experimental study. Muscle Nerve 29:393–400
Ruch TC (1949) Visceral sensation and referred pain. In: Fulton JF (ed) Howell’s Textbook of Physiology, 16th edn. Saunders, Philadelphia
Schaible H-G, Grubb BD (1993) Afferent and spinal mechanisms of joint pain. Pain 55:5–54
Schaible H-G, Schmidt RF (1983) Activation of groups III and IV sensory units in medial articular nerve by local mechanical stimulation of knee joint. J Neurophysiol 49:35–44
Schaible H-G, Schmidt RF (1984) Mechanosensibility of joint receptors with fine afferent fibers. Exp Brain Res Suppl 9:284–297
Schaible H-G, Schmidt RF (1988) Time course of mechanosensitivity changes in articular afferents during a developing experimental arthritis. J Neurophysiol 60:2180–2195
Schaible H-G, Schmidt RF, Willis WD (1987) Convergent inputs from articular, cutaneous and muscle receptors onto ascending tract cells in the cat spinal cord. Exp Brain Res 66:479–488
Simons DG, Travell JG, Simons L (1999) Myofascial pain and dysfunction: The trigger point manual, Vol 1. Upper half of body. Williams and Wilkins, Philadelphia
Sinclair DC, Weddell G, Feindel WH (1948) Referred pain and associated phenomena. Brain 71:184–211
Sörensen J, Graven-Nielsen T, Henriksson KG et al. (1998) Hyperexcitability in fibromyalgia. J Rheumatol 25:152–155
Staff PH (1988) Clinical consideration in referred muscle pain and tenderness — connective tissue reactions. Eur J Appl Physiol 57:369–372
Stawowy M, Rössel P, Bluhme C et al. (2002) Somatosensory changes in the referred pain area following acute inflammation of the appendix. Eur J Gastroenterol Hepatol 14:1079–1084
Suter MR, Wen YR, Decosterd I et al. (2007) Do glial cells control pain? Neuron Glia Biol 3:255–268
Svensson P, De Laat A, Graven-Nielsen T et al. (1998) Experimental jaw-muscle pain does not change heteronymous H-reflexes in the human temporalis muscle. Exp Brain Res 121:311–318
Svensson P, List T, Hector G (2001) Analysis of stimulus-evoked pain in patients with myofascial temporomandibular pain disorders. Pain 92:399–409
Tobias CA, Dhoot NO, Wheatley MA et al. (2001) Grafting of encapsulated BDNF-producing fibroblasts into the injured spinal cord without immune suppression in adult rats. J Neurotrauma 18:287–301
Torebjörk HE, Ochoa JL, Schady W (1984) Referred pain from intraneural stimulation of muscle fascicles in the median nerve. Pain 18:145–156
Travell J, Rinzler SH (1952) The myofascial genesis of pain. Postgrad Med 11:425–434
Travell JG, Simons DG (1992) Myofascial pain and dysfunction: The trigger point manual, vol 2. The lower extremities. Williams and Wilkins, Baltimore
Vecciet L, Giamberardino MA, Dragani L et al. (1990) Referred muscular hyperalgesia from viscera: clinical approach. In: Lipton S (ed) Advances in pain research and therapy, vol 13. Raven, New York
Wall PD, Woolf CJ (1984) Muscle but not cutaneous C-afferent input produces prolonged increases in the excitability of the flexion reflex in the rat. J Physiol 356:443–458
Whitty CWM, Willison RG (1958) Some aspects of referred pain. Lancet 2:226–231
Wolff HG (1963) Headache and other head pain. Oxford University Press, New York
Woolf CJ, Wall PD (1986) Relative effectiveness of C primary afferent fibers of different origins in evoking a prolonged facilitation of the flexor reflex in the rat. J Neurosci 6:1433–1442
Yu X-M, Mense S (1990) Response properties and descending control of rat dorsal horn neurons with deep receptive fields. Neurosci 39:823–831
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Graven-Nielsen, T., Mense, S. (2010). Referral of Musculoskeletal Pain. In: Mense, S., Gerwin, R. (eds) Muscle Pain: Understanding the Mechanisms. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-540-85021-2_5
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