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Pain Medicine > MSK > Flashcards

MSK Flashcards

1
Q

FM tender point areas?

A

Occiput, lower cervical, trapezius, supraspinatus, 2nd rib, laetral epicondyle, gluteal, greater trochanter, medial knee

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2
Q

Quebec Task force WAD

A

0 - No symptoms and no physical exam findings nothing I - Neck complaints of pain, stiffness, or tenderness but no physical signs II - Neck complaints of pain, stiffness, or tenderness and MSK signs of decreased ROM and tenderness III- Neck complaints of pain, stiffness, or tenderness AND neurological signs (motor weakness, sensory deficits and decreased DTR) AND MSK signs of decreased ROM and tenderness IV - Neck complaints and # or dislocation

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3
Q

Differential Diagnosis for shoulder pain?

A
  1. Bone
    1. Fracture
    2. Osteosarcoma
  2. Joint
    1. arthritis - OA
    2. Infection
    3. inflammatory arthritis
    4. joint dislocation
  3. Nerve
    1. plexopathy
  4. Muscle - Trigger points, MPS, injury
  5. Ligament - tendonopathy, labral tears
  6. Bursitis
  7. Adhesive capsulitis - 1st loss ROM - ext rotation, abduction
  8. Referred
    1. Gallbladder
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4
Q

What are some clinical signs for CTS?

A
  1. median nerve conduction abnormalities
    1. fingers - thumb, 3rd, 4th and 5th digits
    2. sensory before motor
    3. prolonged latency, decreased conduction velocity
  2. thumb abduction weakness
  3. thenar eminance wasting
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5
Q

What are the symptoms of CTS?

A
  1. night pain
  2. pain with maximal wrist flexion or extension
  3. decreased grip strength
  4. decreased dexterity
  5. postive phalens
  6. tinels
  7. compression of carpal tunnel
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6
Q

Carpal tunnel contents?

A

all finger flexors (FDS, FDP, FPL) and the median nerve

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7
Q

What are the signs and symptoms of ulnar neuropathy when compression is at the elbow?

A

Symptoms:

  • palmar and dorsal aspect of the hand paresthesias

Signs:

  • small finger abduction weaknes
  • paper pulling sign
  • clawing of the hand
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8
Q

What are tools to measures signs of CRPS?

A
  • thermography (>1 degree difference)
  • QST
  • QSART (quanititative sudomotor axon reflex testing)
  • Triple phase bone scan/scintigraphy (will see changes in 3rd phase)
  • Plain radiographs - osteopenia
  • Sympathetic blocks
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9
Q

What are possible mechanisms that contribute to CRPS?

A

nerve injury

central sensitization

peripheral sensitization

altered sympathic NS function

abnormal sympathoafferent coupling

autonomic dysfunction

inflammatory and immune related factors

psychological factors and disuse

ischemia reperfusion injury or oxiadtive stress

brain changes

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10
Q

Treatment of CRPS?

A
  1. multidisciplinary
  2. PT/OT
    1. graded motor imagery
    2. mirror therapy
    3. progressive desensitization
    4. isometric strengthening
    5. aerobic conditioning
    6. ROM exercises
  3. Pharmacological
    1. Prevention - Vit C 500mg OD
    2. Prednisone - acute
    3. Bisphosphonates
    4. Calcitonin
    5. Neuropathic pain treatments (TCAs, GPN, etc.)
    6. Topical lidocaine
    7. Topical DMSO 50% for warm CRPS (acute)
    8. Oral NAC cold CRPS
    9. Opioids (methdone, tramadol)
  4. Ketamine Infusion
  5. Sympathetic ganglion block
  6. SCS
  7. intrathecal baclofen (only if accompanied by dystonia)
  8. Psychotherapy - CBT, relaxation, biofeedback)
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11
Q

What is your differential for hip pain?

A
  1. Extraarticular
    1. Referred pain - SIJ, facet
    2. GT bursitis
    3. Iliopsoas tendinitis
    4. Muscle strain and contusion
    5. Snapping hip
  2. Intrinsic
    1. labral pathology
    2. osteonecrosis of the hip
    3. loose bodies
    4. OA, inflamm arthritis. septic arthritis
    5. femoral neck stress fractures
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12
Q

Physical exam tests specific to hip pain?

A
  1. decreased ROM
  2. Pain with ROM
  3. Thomas test
  4. leg length discrepancy
  5. trendelenberg test
  6. FADIR
  7. FABER (Patrick)
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13
Q

Pharmacological recommendations for hip OA?

A

Acetaminophen

NSAIDs

Tramadol

Intra-articular injections

*conditionally recommned to not use condroitin sulfate and glucosamine

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14
Q

Non-pharm treatments of hip OA?

A

lifestyle:

  • pool therapy
  • weight loss
  • cardiovascular and/or resistance land-based exercise

conditionally recommend:

  • self-management programs
  • manual therapy with supervised exercise
    • possible thermal therapy
  • psychosocial interventions
  • gait aid
    *
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15
Q

Pharmacological recommendations for the knee?

A
  • Acetaminophen
  • NSAIDS
  • intra-articualr steroids
  • topical NSAIDs
  • tramadol

Conditionally recommend not using:

  • chondroitin sulfate and glucosamine
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16
Q

Non-pharm approaches for knee OA?

A

Strongly recommend:

  • pool therapy
  • weight loss
  • cardiovascular and/or resistance land-based exercise

conditionally recommend:

  • self-management programs
  • manual therapy with supervised exercise
    • possible thermal therapy
  • psychosocial interventions
  • gait aid
  • medially directed patellar taping
  • wedged insoles (opposite of compartment OA)
  • tia chi
  • acupuncture
  • TENS
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17
Q

What are the WAD criteria?

A
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18
Q

What are the diagnostic criteria for

A
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19
Q

What are the three stages of adhesive capsulitis?

A

painful stage - ROM OK but decreasing; 2-9 m

frozen stage - ROM gone but less pain; 4-12m

thawing stage - slowing increasing ROM

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20
Q

What are the diagnostic categories of cervicogenic headaches?

A

A. Any headache fulfilling criterion C

B. Clinical and/or imaging evidence1 of a disorder or lesion within the cervical spine or soft tissues of the neck, known to be able to cause headache

C. 2 of 4:

  • headache has developed in temporal relation to the onset of the cervical disorder or appearance of the lesion

headache has significantly improved or resolved in parallel with improvement in or resolution of the cervical disorder or lesion

cervical range of motion is reduced and headache is made significantly worse by provocative manœuvres

headache is abolished following diagnostic blockade of a cervical structure or its nerve supply

D. Not accounted by another ICHD-3

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21
Q

Diagnostic criteria for TTH?

A
  • 10 attacks
  • Duration 30m-7d
  • two of:
    • bilateral
    • mild to moderate severity
    • not worsened by physical activity
    • non-pulsating
  • Both of:
    • no nausea or vomiting
    • no more than one of photophobia or phonophobia
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22
Q

Diagnostic criteria for new daily persistent headache?

A
  • Persistent headache fulfilling criteria B and C
  • Distinct and clearly-remembered onset, with pain becoming continuous and unremitting within 24 hours
  • Present for >3 months
  • Not better accounted for by another ICHD-3 diagnosis
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23
Q

List 3 common causes of neck pain

A

Facet joint 55%

Discogenic pain 16%

AA Joint 9%

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24
Q

Tietze’ Syndrome involves what cartilages?

A

2nd and 3rd costal cartilages

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25
Q

AP Diameter Epidural Space in Csp

A

C3-6 (2mm)

C6-T1 (3-4mm)

vs.

Lsp (5-6mm)

26
Q

What is the innervation of the Csp

A

Posterior neck - Facet joints - Cervical dorsal ramus (medial branch)

Lateral AA joint - C2 ventral ramus

AO joint - C1 ventral ramus

27
Q

Anterior chest wall pain is potentially from what source if it is not releived by intrecostal nerve block?

A

Pectoralis myofascial pain (innervated by brachial plexus)

28
Q

Disabilities, as defined by the WHO, encompass:

  1. Impairment
  2. Activity limitation
  3. Participant restriction

Define each.

A
  1. Impairment - problem in body function or structure
  2. Activity limitation - difficulty encountered by an individual in exectuting a task or action
  3. Participant restriction - problem experienced by an individual in involvement in life situations
29
Q

Treatment for costochondritis?

A

NSAIDS

Acetaminophen

intercostal NBs

local infiltration with LA and steroid

TENS

Heat

30
Q

OA typically affects what joints?

A

Hands, spine, weight bearing joints (knees and hips)

31
Q

Typical radiological changes seen in OA?

A

subchondral cysts

bony erosions

osetophyte formation

loss of joint space

32
Q

Name 4 DMARDS for RA treatment

A

Methotrexate

Sulfasalzine

hydrochloroquine

leflunomide

33
Q

Name 4 TNF-alpha inhibitors for RA treatment

A

etanercept

inflixumab

adalinumab

golimumab

certolizumab

34
Q

What are the 4 main categories for RA classification?

A
  1. joint involvement
  2. Duration of symptoms
  3. Serology
  4. Acute phase reactants
35
Q

Name 4 possible triggers for CRPS

A

nerve injury

infection

surgery

inflammation

stroke

immobilization

36
Q

In adults CRPS usually effects _____ limbs and in pediatrics it effects _____ limbs

A

upper; lower

37
Q

What are the 3 components of graded motor imagery that is used in the treatment of CRPS?

A
  1. Left-right discrimination
  2. Motor imagery exercises
  3. Mirror box therapy
38
Q

Name one mechanism that is thought to underlie myofascial pain syndrome/

A
  • abnormal motor end plate mechanism causes taut bands that extend between myotendinous junctions
  • injured or inflammed muscle leads to central sensitization, lowering threshold for nociception and non-nociceptive input causing hyperalgesia and allodynia and referred pain
39
Q

Name 5 common myofascial pain syndromes:

A
  1. piriformis pain syndrome
  2. TOS
  3. Headache (chronic tension type headache)
  4. interscalene compartment syndrome
  5. adhesive capsultis
  6. TMJ syndrome
40
Q

What are some diagnostic criteria for myofascial pain syndrome?

Phys Med Rehabil Clin N Am 25 (2014) 341–355

A

Essential to Dx:

  1. Taut band within the muscle
  2. Tenderness at a point on the taut band
  3. Reproduction of the patient’s pain

Not essential to Dx

  1. Local twitch response
  2. Referred pain
  3. Weakness
  4. Restricted range of motion
  5. Autonomic signs (skin warmth or erythema, tearing, piloerection)
41
Q

What are the primary forms of treatment for MPS?

A
  • Local TP compression
  • Local TP stretch
  • Myofascial release
  • Muscle play
  • Therapeutic stretch
  • Self-stretch
  • Muscle re-education
42
Q

What are the adjunctive forms of treatment for MPS?

A
  • intermittent cold
  • postisometric relaxation
  • strain-counterstrain
  • dry needling
  • massage
  • ultrasound
  • TENS
  • acupuncture
44
Q

Name 4 common post-surgical pain syndromes

A
  • post-mastectomy
  • post-thoracotomy
  • post-amputation
  • post-sternotomy
45
Q

Phantom limb pain usually occurs within _____ of amputation

46
Q

Name 4 risk factors for phantom limb pain

A
  • elevated pre-amputation pain
  • amputation for cancer vs traumatic
  • post-op residual limb pain
  • non-painful phantom limb paresthesias
47
Q

What are the pathophysiological mechanisms thought to underlie post-surgical pain syndromes?

A
  • glia contribution to CeS by release of inflammatory cytokines
  • CeS mechanisms that leads to hyperalgesia and allodynia
  • Nerve injury at surgical sites
  • PeS mechanisms such as ectopic discharges, sprouting
48
Q

Post-thoracotomy pain syndrome characteristics?

Pain quality

When occurs

natural history

Incidence

A
  • Pain quality - burning, aching
  • When occurs - within first weeks post-op
  • natural history - severe 1st month then subsides by one year
  • Incidence - may exceed 50%
49
Q

Risk factors for Post-thoracotomy pain syndrome?

A
  1. pre-op and peri-op pain
  2. female gender
  3. anxiety
  4. catastrophization
  5. severity of post-op pain
50
Q

The PROSPECT website suggests to do what to prevent post-thoracotomy pain syndrome?

A
  • pre-op - thoracic epidural with LA and opioid bolus and infusion or paravertebral block
  • intra-op - thoracic epidural, paravertebral block or intercostal block with infusion of LA
  • Post-op - thoracic epidural, paravertebral block or intercostal block with infusion of LA + opioid. And NSAIDs, acetaminophen, PO opioid, PCA,
51
Q

Post-mastectomy pain syndrome risk factors?

A
  • pre-op breast pain
  • mastectomy with reconstruction (with implant)
  • mastectomy with axillary dissection
  • post-op pain severity
  • post-radiation
  • altered sensation in intercostovertebral nerve
52
Q

Post-inguinal hernia pain syndrome risk factors?

A
  • ambulatory surgery
  • pre-op pain
  • post-op pain immediate (and at 1 week and 4 weeks post-op)
  • age < 40
  • Mesh repair
  • poor outlook
  • repeat surgery
53
Q

Post-sternotomy pain risk factors

A
  • younger age
  • repeated surgery
  • pre-op pain
  • severe post-op pain (day 3)
  • female gender
  • urgent surgery
  • higher NYHA class
54
Q

Post-sternotomy pain treatment?

A
  • diclofenac
  • gabapentinoids
  • in non-responsive PSP - intercostal nerve blocks, epidural injections, SCS
55
Q

Mechanism of PLP

A
  • Central
    • Unmasking
    • Sprouting
    • Cortical re-organization
    • Disinhibition
    • Microglial release of cytokines
  • Peripheral
    • Ectopic discharges
    • Ephaptic transmission
    • Sympathetic-afferent coupling
    • Increased release of nociceptive neuropeptides (Sub P)
56
Q

5 Prognostic Indicators for WAD Level Gr 1-3

A
  • Catastrophizing
  • High initial disability
  • High initial Pain
  • Education level
  • Low self effiacy
  • Cold sensitivity
57
Q

What are the WADDELL signs? DOReST

A
  • Distraction
    • Neg Slump test vs + SLR
  • Overreaction
    • For what you ask them to do
  • Regionalization
    • Pain in non-dermatomal or normal nerve distribution
  • Simulation
    • Axial load
    • Rotn enBloc
  • Tenderness
    • Superficial palpation causes signifcant pain
  • >=3/5 Clinically Significant
58
Q

According to Quebec Task Force, what are recommeded Rx’s for Acute

A

Acute

  • Reassurance/Education
  • Non-Pharm
    • Activity
    • Mobilization
    • Modalities
      • Heat, ice
    • Massage
  • Pharmacology
    • Simple analgesics - NSAIDs
59
Q

Quebec Task Force Recommendations for Chronic WAD

A
  • Education+reassurance /multi-modal Rx
  • Non-Pharm
    • Activity
      • Func Ex, ROM ex’s
      • Strengthening - scapular, deep neck flexors
    • PT
      • Mobilizations/Manipulations
      • Vestibular Training
    • Psych
      • CBT
  • Interventions
    • RFA
    • SC sterile water injections
60
Q

Quebec Task Force Recommenations AGAINST

A

Acute/Chronic

  • Rest/immobilization
  • Cervical collar
  • IA + IT injections
  • IV Methylprednisone
  • Cervical pillow

Chronic

  • Botox
  • Electrotherapy
  • Analgesic injections

Pain Medicine (14 decks)

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