L34: Complex Upper Limb Pain Flashcards
What is the neuromatrix?
Pain perception is predictive and protective.
What are 11 best practice care for MSK pain?
- Patient-centered care: Respond to individual context and shared decision making.
- Screen for serious pathology/red flags
- Assess psychosocial factors
- Discourage imaging unless serious pathology, not progressing or it changes management.
- Physical examination of articular, muscular and nervous systems
- Use outcome measures for patient progress
- Provide education about the condition and management options
- Provide physical activity/exercise management.
- Manual therapy may be an adjunct to other evidence based treatment
- Informed non-surgical care offered before surgery
- Facilitate return to work/occupation
What are 3 sesnory stimuli affecting pain?
- Tactile stimuli & psychological expectancy affect pain
- Visual feedback affects pain
- Auditory stimuli affects spinal stiffness
What are 3 tactile stimuli & psychological expectancy affect pain for Sensory Stimuli Affecting Pain?
- Analgesia expectancy group is told that cold water immersion lessens pain
- They felt 77% decrease in sural nerve pain during immersion
- Hyperalgesia group is told that cold water immersion worsens pain
- They felt no change in pain perception
- Changes in pain due to immersion were strongly correlated to the pain expectancy.
- Psychological expectancy cancelled out physiological effect of immersion
What are 3 visual feedback affect pain for Sensory Stimuli Affecting Pain?
- VR to investigate whether manipulating visual proprioceptive cues could alter movement-evoked neck pain.
- Virtual rotation that understated true rotation > pain-free range increased 6%
- Virtual rotation that overstated true rotation > pain-free range decreased 7%
What are 2 auditory stimuli affects spinal stiffness for Sensory Stimuli Affecting Pain?
- Audio of a creaky door hinge in sync with PA spinal pressure was associated with increased perceived stiffness (although no change in actual load)
- Audio of a “whoosh” sound in sync with PA spinal pressure was associated with decreased perceived stiffness
What are 2 limitations of pharmacology for pain for Complex Upper Limb Pain?
- The response to pain medications is
- Typically low
- Varies enormously
- Unpredictable
- Pharmacological management is a trial-and-error process to determine the best medication, which takes lots of time and exposure to side effects with uncertain benefits.
What are 3 patient presentations for Complex Upper Limb Pain?
- PTSD and pain appear to mutually augment
- MVA and sexual assault showed similar pain after 6 weeks.
- Need to consider a combination of PTSD, depression, catastrophising and pain, to understand patient’s presentation and plan their management.
- This suggests that no specific tissue injury is necessary or sufficient to cause post-traumatic neck and back (+/- limb) pain.
What are 3 reconciling pain VS injury for Complex Upper Limb Pain?
- No tissue injury or nociception is necessary to cause pain
- Nociception may not be sufficient to cause severe/constant pain.
- Nevertheless, tissue injury with nociception is a common input
What are 3 pain assessment?
- Biological +/- neuropathic components causing nociceptive input?
- Referred or radicular pain with nociception from somatic or neural tissues?
- Peripheral sensitisation contributing to nociceptive input?
- Central sensitisation contributing to nociceptive input +/- pain perception?
- Psychological components contributing to pain perception
- Coping strategies, aggravating activities +/- MOI?
- Social components contributing to pain perception
- Complex regional pain syndrome or phantom limb pain?
- A need to change patient behaviour, to increase or decrease general activity, load to nervous system and tissues?
What are 4 features of forming hypothesis?
- Body chart symptoms
- History & MOI
- Aggravating & relieving factors
- ○ Check in physical exam TDT
- Patient understanding and goals
- My diagnosis is _______
- Supported by _______
- I excluded _______
- I’m going to treat/facilitate with ________
What are 3 features of neurogenic inlammation?
A delta and C fibres release neuropeptides from their peripheral terminals at the site of injury (antidromic firing causing chemical feedback).
- Substance P
- Glutamate
- Calcitonin gene-related peptide (CGRP) by C fibres
What are 4 features of cervical radiculopathy?
- Cervical radicular pain: Pain perceived as arising in the arm caused by irritation of a cervical spinal nerve/roots.
- Diagnosis is based on a combination of history, clinical examination, and complementary examination.
- Medical imaging may show abnormalities, but those may not correlate with pain.
- Conservative treatment: Medication + physiotherapy.
What are 4 features of neural mobilisation?
Neural mobilisation (level 1 evidence) benefits:
- Nerve-related neck pain (arm pain distal to acromion)
- Nerve-related low back pain (leg pain distal to buttocks)
- Effect is unclear on carpal tunnel syndrome or lateral epicondylalgia.
What are 2 features of entrapment neuropathy?
Diagnosis of entrapment neuropathy can be difficult because S&S vary significantly between patients.
- 1/3 of patients with Cx or Lx radiculopathy have symptoms in dermatomal pattern
- Motor deficits also occur outside the distribution of the affected nerve
What are 4 types of pain?
- Nociceptive pain contributes to warning information, to drive change in behaviour to protect the affected region.
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Neuropathic pain: Pain associated with a lesion of CNS/PNS.
- Neuropathic pain does not serve any useful biological function.
- Nociplastic pain: Altered nociception, despite no tissue damage or disease or lesion of the somatosensory system (exclude CNS) causing the pain .
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Central sensitisation: May have the same presentation as neuropathic pain, but no clear nervous system lesion
- e.g. 30% OA patients have central sensitisation
These conditions can be linked with other neurobiological disorders, such as high comorbidity for chronic pain, sleep disorders, and psychological conditions.
What are 3 Presentation of Neuropathic & Nociplastic Pain?
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Pain quality: Stabbing, shooting, electric-shock or nerve-like pain.
- Input vs output perception suggests hyperalgesia or allodynia.
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Neurological deficits
- Sensory deficits or paresthesia Motor deficits may also be present.
- Autonomic signs (30-50% cases): Changes in colour, temp, swelling, sweating
What are 3 presentation of central sensitisation?
- High severity, duration of acute aggravation, length of time that symptoms have persisted/recurred.
- Low/no stress to tissues when symptoms onset, persist or worsen.
- Diffuse/unclear relationship with anatomical structures.
What aee 3 multiple biological pathways for Complex Regional Pain Syndrome (CRPS)?
- Aberrant inflammation
- Vasomotor dysfunction
- Maladaptive neuroplasticity
What are 5 SNS involvement (may be ACh receptors developed on neurons) for Complex Regional Pain Syndrome (CRPS)?
- Changes in temperature
- Changes in colour
- Sweating
- Swelling at the affected region
- Aggravation of symptoms by cold exposure or stress (e.g. fight or flight response)
What are 4 Diagnostic Criteria (Budapest Criteria)?
Continuing pain that is disproportionate to any inciting event
At least 1 symptom (described) + 1 sign (observed)
- Sensory: Hyperesthesia or allodynia
- Vasomotor: Temperature asymmetry, skin colour changes/asymmetry
- Sudomotor/oedema: Oedema, sweating changes/asymmetry
- Motor/trophic: Decreased ROM, motor dysfunction, or trophic changes (e.g. hair, nail, skin)
Research diagnosis requires 4 symptoms + 2 signs present.
What are 2 Previous Classification and Incidence of CRPS?
- Type 1: CRPS without nerve lesion
- 1-2% after fractures, more common in females ○ 12% after brain injury
- 5% after myocardial infarction
- Type 2: 1-5% after peripheral nerve injury
What are 4 evidence of physiotherapy for CRPS?
- Graded motor imagery (very low quality evidence) may improve pain and functional disability at 6-months follow-up, in CRPS compared to usual physiotherapy.
- Multimodal physiotherapy (very low quality evidence) may be useful for improving “impairments” at 12 months compared to a minimal “social work” interv ention
- Mirror therapy (very low quality evidence) improves in pain and function compared to a covered mirror, at 6-months follow-up in post-stroke CRPS.
- Ineffective for treating pain short-term in CRPS:
- Tactile discrimination training
- Stellate ganglion block via ultrasound
- Pulsed electromagnetic field therapy compared to placebo
- Manual lymphatic drainage combined with and compared to either anti-inflammatories and physiotherapy or exercise.
What are 2 features of Motor imagery increased pain and swelling for Evidence of Physiotherapy for CRPS?
- CRPS patients pain increased 5.3/100 mm and swelling by 8%.
- Non-CRPS patients pain increased by 1.4/100 mm and swelling by 3%.
What are 2 features of Graded motor imagery reduces pain and disability in chronic CRPS?
The number needed to treat for a 50% decrease in pain and a 4-point decline on a 10-point scale of disability is about 4, which is better any other treatment for chronic CRPS, including spinal cord stimulators
What are 3 features of exposure based therapy for evidence of Physiotherapy for CRPS?
- This is cognitive behaviour based therapy for people with pain-related fear
- Aims to readjust expectancies and associations between movement and pain.
- Positive responses with pain and function
What are 10 Integration of Graded Activity & Persistent Pain?
- Listen to the patient’s story and perceptions
- Identify and manage red flags
- Perform a skilled physical evaluation, especially functional aspects for reassessment
- Initial treatment: Reduce pain, especially for acute on chronic presentation.
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Education: Tissue integrity, nervous system sensitivity, interpret investigations.
- Decrease unnecessary fear & catastrophisation.
- Acknowledge biopsychosocial factors to manage modifiable factors
- Collaborate with other health disciplines with the patient.
- Patient responsibility in pain management: Promote self-care, control of symptoms and function.
- Get active ASAP including general fitness. Shift the focus from the symptoms to function.
- Help the patient to identify and experience success.
- The patient needs a sense of mastery with pacing to avoid flare-ups.
- Give positive feedback for all well behaviours, alternative strategies, transferable skills, and coping strategies
- Enable return to work/occupation
What are 3 focus on rehabilitation to improve performance and reduce pain?
- Improving control of posture and movement.
- Graduated stress to the body.
- Graduated stress to the nervous system without causing “flare-ups” of pain that persist after the activity.
Progressive challenge with training load, complexity & context.
What are 4 features for treat or refer?
- Primary biological/somatic nociceptive drivers for pain perception - physio!
- Primary spinal radiculopathy or peripheral nerve entrapment - refer to neurologist if unresponsive/worsening
- Primary psychological/social factors interacting to affect adverse behaviour or driving symptoms - refer to psychologist if fixating on bad beliefs
- Primary neuropathic pain condition: Post neural tissue injury, CRPS or phantom limb perception - refer to neurologist & psychologist
