L34: Complex Upper Limb Pain

Question 1

What is the neuromatrix?

Answer 1

Pain perception is predictive and protective.

Question 2

What are 11 best practice care for MSK pain?

Answer 2

1. Patient-centered care: Respond to individual context and shared decision making.
2. Screen for serious pathology/red flags
3. Assess psychosocial factors
4. Discourage imaging unless serious pathology, not progressing or it changes management.
5. Physical examination of articular, muscular and nervous systems
6. Use outcome measures for patient progress
7. Provide education about the condition and management options
8. Provide physical activity/exercise management.
9. Manual therapy may be an adjunct to other evidence based treatment
10. Informed non-surgical care offered before surgery
11. Facilitate return to work/occupation

Question 3

What are 3 sesnory stimuli affecting pain?

Answer 3

1. Tactile stimuli & psychological expectancy affect pain
2. Visual feedback affects pain
3. Auditory stimuli affects spinal stiffness

Question 4

What are 3 tactile stimuli & psychological expectancy affect pain for Sensory Stimuli Affecting Pain?

Answer 4

1. Analgesia expectancy group is told that cold water immersion lessens pain
   
   • They felt 77% decrease in sural nerve pain during immersion
2. Hyperalgesia group is told that cold water immersion worsens pain
   
   • They felt no change in pain perception
3. Changes in pain due to immersion were strongly correlated to the pain expectancy.
   
   • Psychological expectancy cancelled out physiological effect of immersion

Question 5

What are 3 visual feedback affect pain for Sensory Stimuli Affecting Pain?

Answer 5

1. VR to investigate whether manipulating visual proprioceptive cues could alter movement-evoked neck pain.
2. Virtual rotation that understated true rotation > pain-free range increased 6%
3. Virtual rotation that overstated true rotation > pain-free range decreased 7%

Question 6

What are 2 auditory stimuli affects spinal stiffness for Sensory Stimuli Affecting Pain?

Answer 6

1. Audio of a creaky door hinge in sync with PA spinal pressure was associated with increased perceived stiffness (although no change in actual load)
2. Audio of a “whoosh” sound in sync with PA spinal pressure was associated with decreased perceived stiffness

Question 7

What are 2 limitations of pharmacology for pain for Complex Upper Limb Pain?

Answer 7

1. The response to pain medications is
   
   1. Typically low
   2. Varies enormously
   3. Unpredictable
2. 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.

Question 8

What are 3 patient presentations for Complex Upper Limb Pain?

Answer 8

1. PTSD and pain appear to mutually augment
   
   • MVA and sexual assault showed similar pain after 6 weeks.
2. Need to consider a combination of PTSD, depression, catastrophising and pain, to understand patient’s presentation and plan their management.
3. This suggests that no specific tissue injury is necessary or sufficient to cause post-traumatic neck and back (+/- limb) pain.

Question 9

What are 3 reconciling pain VS injury for Complex Upper Limb Pain?

Answer 9

1. No tissue injury or nociception is necessary to cause pain
2. Nociception may not be sufficient to cause severe/constant pain.
3. Nevertheless, tissue injury with nociception is a common input

Question 10

What are 3 pain assessment?

Answer 10

1. Biological +/- neuropathic components causing nociceptive input?
2. Referred or radicular pain with nociception from somatic or neural tissues?
3. Peripheral sensitisation contributing to nociceptive input?
4. Central sensitisation contributing to nociceptive input +/- pain perception?
5. Psychological components contributing to pain perception
   
   • Coping strategies, aggravating activities +/- MOI?
6. Social components contributing to pain perception
7. Complex regional pain syndrome or phantom limb pain?
8. A need to change patient behaviour, to increase or decrease general activity, load to nervous system and tissues?

Question 11

What are 4 features of forming hypothesis?

Answer 11

1. Body chart symptoms
2. History & MOI
3. Aggravating & relieving factors
4. ○ Check in physical exam TDT
5. Patient understanding and goals
6. My diagnosis is _______
7. Supported by _______
8. I excluded _______
9. I’m going to treat/facilitate with ________

Question 12

What are 3 features of neurogenic inlammation?

Answer 12

A delta and C fibres release neuropeptides from their peripheral terminals at the site of injury (antidromic firing causing chemical feedback).

1. Substance P
2. Glutamate
3. Calcitonin gene-related peptide (CGRP) by C fibres

Question 13

What are 4 features of cervical radiculopathy?

Answer 13

1. Cervical radicular pain: Pain perceived as arising in the arm caused by irritation of a cervical spinal nerve/roots.
2. Diagnosis is based on a combination of history, clinical examination, and complementary examination.
3. Medical imaging may show abnormalities, but those may not correlate with pain.
4. Conservative treatment: Medication + physiotherapy.

Question 14

What are 4 features of neural mobilisation?

Answer 14

Neural mobilisation (level 1 evidence) benefits:

1. Nerve-related neck pain (arm pain distal to acromion)
2. Nerve-related low back pain (leg pain distal to buttocks)
3. Effect is unclear on carpal tunnel syndrome or lateral epicondylalgia.

Question 15

What are 2 features of entrapment neuropathy?

Answer 15

Diagnosis of entrapment neuropathy can be difficult because S&S vary significantly between patients.

1. 1/3 of patients with Cx or Lx radiculopathy have symptoms in dermatomal pattern
2. Motor deficits also occur outside the distribution of the affected nerve

Question 16

What are 4 types of pain?

Answer 16

1. Nociceptive pain contributes to warning information, to drive change in behaviour to protect the affected region.
2. Neuropathic pain: Pain associated with a lesion of CNS/PNS.
   
   • Neuropathic pain does not serve any useful biological function.
3. Nociplastic pain: Altered nociception, despite no tissue damage or disease or lesion of the somatosensory system (exclude CNS) causing the pain .
4. 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.

Question 17

What are 3 Presentation of Neuropathic & Nociplastic Pain?

Answer 17

1. Pain quality: Stabbing, shooting, electric-shock or nerve-like pain.
   
   • Input vs output perception suggests hyperalgesia or allodynia.
2. Neurological deficits
   
   • Sensory deficits or paresthesia Motor deficits may also be present.
3. Autonomic signs (30-50% cases): Changes in colour, temp, swelling, sweating

Question 18

What are 3 presentation of central sensitisation?

Answer 18

1. High severity, duration of acute aggravation, length of time that symptoms have persisted/recurred.
2. Low/no stress to tissues when symptoms onset, persist or worsen.
3. Diffuse/unclear relationship with anatomical structures.

Question 19

What aee 3 multiple biological pathways for Complex Regional Pain Syndrome (CRPS)?

Answer 19

1. Aberrant inflammation
2. Vasomotor dysfunction
3. Maladaptive neuroplasticity

Question 20

What are 5 SNS involvement (may be ACh receptors developed on neurons) for Complex Regional Pain Syndrome (CRPS)?

Answer 20

1. Changes in temperature
2. Changes in colour
3. Sweating
4. Swelling at the affected region
5. Aggravation of symptoms by cold exposure or stress (e.g. fight or flight response)

Question 21

What are 4 Diagnostic Criteria (Budapest Criteria)?

Answer 21

Continuing pain that is disproportionate to any inciting event

At least 1 symptom (described) + 1 sign (observed)

1. Sensory: Hyperesthesia or allodynia
2. Vasomotor: Temperature asymmetry, skin colour changes/asymmetry
3. Sudomotor/oedema: Oedema, sweating changes/asymmetry
4. Motor/trophic: Decreased ROM, motor dysfunction, or trophic changes (e.g. hair, nail, skin)

Research diagnosis requires 4 symptoms + 2 signs present.

Question 22

What are 2 Previous Classification and Incidence of CRPS?

Answer 22

1. Type 1: CRPS without nerve lesion
   
   • 1-2% after fractures, more common in females ○ 12% after brain injury
   • 5% after myocardial infarction
2. Type 2: 1-5% after peripheral nerve injury

Question 23

What are 4 evidence of physiotherapy for CRPS?

Answer 23

1. Graded motor imagery (very low quality evidence) may improve pain and functional disability at 6-months follow-up, in CRPS compared to usual physiotherapy.
2. Multimodal physiotherapy (very low quality evidence) may be useful for improving “impairments” at 12 months compared to a minimal “social work” interv ention
3. 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.
4. 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.

Question 24

What are 2 features of Motor imagery increased pain and swelling for Evidence of Physiotherapy for CRPS?

Answer 24

1. CRPS patients pain increased 5.3/100 mm and swelling by 8%.
2. Non-CRPS patients pain increased by 1.4/100 mm and swelling by 3%.

Question 25

What are 2 features of Graded motor imagery reduces pain and disability in chronic CRPS?

Answer 25

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

Question 26

What are 3 features of exposure based therapy for evidence of Physiotherapy for CRPS?

Answer 26

1. This is cognitive behaviour based therapy for people with pain-related fear
2. Aims to readjust expectancies and associations between movement and pain.
3. Positive responses with pain and function

Question 27

What are 10 Integration of Graded Activity & Persistent Pain?

Answer 27

1. Listen to the patient’s story and perceptions
2. Identify and manage red flags
3. Perform a skilled physical evaluation, especially functional aspects for reassessment
4. Initial treatment: Reduce pain, especially for acute on chronic presentation.
5. Education: Tissue integrity, nervous system sensitivity, interpret investigations.
   
   • Decrease unnecessary fear & catastrophisation.
   • Acknowledge biopsychosocial factors to manage modifiable factors
6. Collaborate with other health disciplines with the patient.
7. Patient responsibility in pain management: Promote self-care, control of symptoms and function.
8. Get active ASAP including general fitness. Shift the focus from the symptoms to function.
9. 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
10. Enable return to work/occupation

Question 28

What are 3 focus on rehabilitation to improve performance and reduce pain?

Answer 28

1. Improving control of posture and movement.
2. Graduated stress to the body.
3. Graduated stress to the nervous system without causing “flare-ups” of pain that persist after the activity.

Progressive challenge with training load, complexity & context.

Question 29

What are 4 features for treat or refer?

Answer 29

1. Primary biological/somatic nociceptive drivers for pain perception - physio!
2. Primary spinal radiculopathy or peripheral nerve entrapment - refer to neurologist if unresponsive/worsening
3. Primary psychological/social factors interacting to affect adverse behaviour or driving symptoms - refer to psychologist if fixating on bad beliefs
4. Primary neuropathic pain condition: Post neural tissue injury, CRPS or phantom limb perception - refer to neurologist & psychologist