Nociplastic P!, Neck P! and Bone healing - Exam 2 Flashcards
describe nociplastic p!
altered P! perception without complete evidence of actual or threatened tissue compromise
S&S of sensitization are present - an underlying mechanism of nociplastic P!
how does nociplastic P! happen?
thinning of myelin sheath in spots (PNS)
–nerves lose their protection (aka loose wires)
Nociplastic pain happens to increased sensitivity and misinterpretation
- -peripheral nociceptors (a-delta and c-fibers) (PNS)
- -central structures (CNS)
what’s happening with increased sensitivity and misinterpretation by peripheral nociceptors? (PNS)
persistent excitation of A-delta and C fibers inhibits A-beta fibers pre-synaptically so it is also harder to override P! with motion
- carrying P! more frequently and more intensely
what is happening with increased sensitivity and misinterpretation by central structures? (CNS)
-increased excitability of:
-lowered synaptic resistance so:
-loss of descending anti-nociceptive mechanisms so
-segmental dorsal horn neurons
-P! sensations occur easier
-less P! control with typical endogenous opiate release in the body
what happens to the C-fibers in somatic convergence (referred P!)?
give example
C-fibers split and travel at least 2 spinal segments superiorly and inferiorly
example: persistent symptoms with C5,6 hypermobility/instability can eventually spread and create symptoms through the entire UQ (C3-T1)
–(2 levels up and 2 down)
– domino effect
explain how the brain perceives somatic convergence?
brain perceives pain as coming from even more areas with persistent symptoms
- downward spiral
what happens to the homunculus with somatic convergence?
it gets smudged
small parts of the body can get perceived as large pain areas
persistent fatigue syndrome
fibromyalgia
LBP
age-related joint changes
lateral elbow pain
shoulder pain
migraine
neck pain - traumatic & non-traumatic
prevalence of conditions (growing number of conditions) related to nociplastic pain
what are “possible” nociplastic p! S&S/criteria?
> 3 months of P!
regional or spreading symptoms
P! that cannot be entirely explained by nociceptive or neuropathic pathways
P! hypersensitivity or allodynia (nonpainful stimuli causing P!)
what are “probable” nociplastic P! S&S/criteria?
(in addition to “possible” criteria)
sensitivity to sound, light and/or odor (picks up sensitivity to other sensations)
sleep disturbances
fatigue
cognitive problems
** can seem unrelated
-sweaty hands/feet
-pitting edema with lymph compromise
-decreased skin mobility and sensitivity
-scratch test (+) excessive reddening
ANS S&S of nociplastic P!
decreased sebaceous (oil) gland and hair follicle activity
– skin appears scaly and fragile
– decreased skin mobility/rolling and increased sensitivity
– + scratch test - excessive reddening response
ANS S&S of nociplastic pain
sweaty hands/feet
ANS S&S of nociplastic pain
decreased peripheral arterial shunting leading to coldness/clamminess
ANS S&S of nociplastic P!
loss of laterality - can’t differentiate sides, particularly around spine
ANS S&S of nociplastic P!
increased erector pili muscle activity (goose bumps)
ANS S&S of nociplastic P!
+ graphesthesia - can’t differentiate drawn letters/numbers on skin
ANS S&S of nociplastic P!
what are the reasons for prescribing JM, including manipulation for nociplastic P!
most accepted!
stimulates descending inhibitory P! mechanisms (more endorphins)
includes presynaptic inhibition
– limit P! transmission by A-delta and C fibers
– better overriding of P! by A-beta stimulation
reduces dorsal horn excitability
decreases inflammatory mediators
What MET parameters would you prescribe a patient with nociplastic P!
low to moderate intensity global aerobic and resistance activities
2-3 x/wk
30-90 minutes per session
at least 7 weeks duration
what benefits does MET provide to a patient with nociplastic P!
endogenous/opiate analgesia (inhibits spinal nociceptive processing)
helps pt to interpret P! and motion as non-threatening
reorganize homunculus
why would you “prescribe” neuroscience education/behavioral therapy to a patient with nociplastic P!
not just mind over matter
explains increased sensitivity and misinterpretation to reduce stress/anxiety of misperceived tissue injury
– challenge’s patient’s reasoning of fears and P!
– ensure safety of exercise
transition to adaptive pain coping
what is the prognosis for nociplastic p!
varying degrees of improvement - lots of variables
longer recovery (at least 7 weeks)
likely not full resolution of symptoms
True or false. Most of the population experiences neck P!, with almost half having persistent neck P!
true
true or false. younger males are more likely to experience cervical neck P!
false - older females experience more C neck P!
what are two of the strongest risk factors for neck P!
female (specifically > 40)
history of neck P!
if a patient with LBP complains about neck P!, are they making it up? why or why not?
no - LBP can cause neck P! because “one breaker controls lots of muscles” therefore the pain in the low back can shoot up the back
what is the etiology for neck P!
most often unidentified
typically classified as mechanical neck disorder (MND) or nerve root compromise
are we looking to get the patient back to more normal ROM or more functional ROM?
functional ROM
what degree range is full extension to look up?
40-50 degrees
what degree range is functional ROM for driving?
60-70 degrees
what are S&S for neck P!
varied in the cervical spine and possibly into the upper extremity
impaired scapular mechanics (don’t just address the painful area)
Is imaging good for identifying related structures with neck P!?
no, fails to find related structures
- most patients don’t have a pathoanatomical cause or known tissue producing symptoms
what are 3 asymptomatic MRI findings in the neck?
- bulging and herniated discs (50-73%)
- annular tears (94%)
- cord compression (13%)
are clinical tests good screening tools?
no, poor screening tools and/or lack strong diagnostic accuracy measures necessary for clinical decision making
what does cervical JM do for neck P!
modulate neck muscle function
– increased deep muscle recruitment
– reduced superficial muscles recruitment
more effective and greater cost savings vs primary care physician
what are the predictors of success for cervical manipulation CPR?
- neck disability index < 11.5
- bilateral involvement
- sedentary work < 5 hrs/day
- feeling better with movement
- extension does not increase symptoms
- OA without radiculopathy
how many predictors of success for cervical manipulation CPR need to happen for moderate-high success?
> _ 4
> 4 LR+ = 5.33
5 = infinity
what are the most recent predictors of success for cervical manipulation CPR?
- symptoms < 38 days
- (+) expectation manipulation will help
- > 10 difference in rotation
- P! with PA springs
how many of the most recent predictors of success need to be present for very high success rate?
> _ 3
LR+ 13.5 if > 3 present
what are predictors of success for thoracic manipulation CPR?
- symptoms for < 30 days
- no symptoms distal to shoulder
- extension does not increase symptoms
- fear avoidance Beliefs Questionnaire Physical Activity Scale < 12
- diminished T3-T5 kyphosis = flatter back between shoulder blades
- cervical extension < 30
how many predictors of success need to be present for thoracic manipulation CPR success?
> _ 3 = success
5 = moderate success
> 3 LR+ = 5.49
4 = 12
5& 6 = infinity
true or false. there is weak evidence for MET effectiveness for Neck P!
false - strong evidence
what are the MET parameters for nociplastic P! in the neck?
motor control and strengthening exercises for stabilization
30-60 minute sessions
2-3 x/wk
7-12 weeks
additive benefit to manual therapy
what regions (4) should be included in MET exercises for neck P!?
cervical, thoracic, scapular and shoulder regions
what does those 4 regions do to support optimal improvement for neck P!?
stabilization
strength and endurance parameters
what load type are you looking to endurance train both local and global muscles with MET?
low load endurance (6 weeks)
what type of isolation exercises are most effective to perform for a patient with neck P! and what region are you performing them in?
- isotonic and isometric forward nodding
- isometric cervical rotation
- isotonic and isometric scapular exercises
what position should you place your patient in if you want to train local muscles with forward nodding with low load endurance?
lying down - non-WB
what position should you place your patient in if you want to train local muscles with forward nodding with high load endurance?
sitting up - weight bearing
give an example of training local muscles for functional activity?
maintain forward nod during balance training and external loads
integration with function while maintaining a forward nod
what are examples of MET progressions for neck P!
- proprioceptive training
- eye fixation w and w/o head movement
- seated wobble board training/bosu ball
- head relocation with eyes open and focused light and then eyes closed
- increasing speed and range - sit tall - postural training beneficial to a lesser degree
Are MET exercises only needed to be done for a short period of time? explain
no - muscles need to be activated over a long period of time to improve pain
3x/week over 1 year helped pain for 3 years
2x/week for 6 weeks benefits only lasted less than 6 months
– at least 6 weeks and even better results if worked into your routine
How is MET best utilized with neck P!
best progress with exercise and JM - worked into daily routine
true or false. stretching is most beneficial in isolation
false - stretching is not beneficial in isolation
what does stretching need to be combined with to be effective?
MET
however, greater benefits from MT and MET
is there beneficial support for mechanical traction as a prescription for neck pain?
no support for static traction - hold-relax would be better but not beneficial in isolation
some support for SHORT and INTERMEDIATE term neck and neck related arm P! (radiculopathy) more so when following CPRs and added to other interventions (MT, exercise)
what are the CPR parameters for radiculopathy?
- < 54 year old
- non-dominant UE affected
- looking down does not worsen symptoms
- > 30 flexion
> 3 for moderate success
what would be prescribed for radiculopathy?
mechanical traction
no STM
multi-modal with manual therapy and local muscle training
thoracic thrust manipulation
modalities can be prescribed for neck pain but why is it not recommended?
evidence is lacking, limited or conflicting
true or false. education/counseling has strong evidence of being a good prescription for neck pain
true
what is an instance where neck pain prognosis has good outcomes?
acute trauma
- symptoms not as bad at first –> good recovery
when does most recovery occur for neck P!
in 1st 12 weeks with little after 12 months
what are reasons a patient would have a worse prognosis with neck pain?
P! > 6/10
neck disability index questionnaire > 30%
P! catastrophizing > 20
post traumatic stress > 33
cold hypersensitivity
which injection type that a dr might prescribe is most effective?
intra-muscular injection
which type of injection surrounds the dura of the spinal nerve?
is it effective?
epidural
limited evidence of effectiveness
what is most associated with whiplash associated disorder? (WAD)
strains (muscles)
sprains (ligaments)
possible head injuries including concussions
acceleration-deceleration event
what happens to the brain during a concussion? do you have to hit your head to get a concussion?
brain moves within the skull
no
what tests would you perform for WAD?
craniovertebral scan initially with all neck trauma
eventually, cervicothoracic scan and biomechanical exam
what are the most often involved structures with WAD?
Z jt sprains (like ligament sprain) - most common C2-3
– C1-3 (C1-2 is horizontal and C3 is 45 degrees)
muscle strain
– guarding
what is a less involved structure with WAD?
dens fracture
- typically occurs before transverse ligament tears
- unique S&S - splinted, particuarly with SB because Alar ligament pulling on dens
what are S&S for most fractures anywhere?
trauma hx
splinting
pain with palpation, compression, vibration w tuning fork, limited ROM with empty P!ful end feels, weak and P!ful w resisted testing, crepitus
possible + neuro tests in spine
special tests + - percussion with stethoscope, CDRs and CPRs for fxs
what is the function of bone?
support, protection and muscle attachment
produces blood cells and houses minerals and fats
highly vascular throughout and highly neural, particularly in periosteum
what are elements of bone?
organic
mineral
type I collagen - resists tension
1. cortical - 80% skeletal tissue, outer layer
2. cancellous (trabecular) - 20% skeletal tissue, inner layer
describe the timing of healing for bone?
timing varies - many factors
inflammatory phase
what happens in the repair phase for bone healing? how many weeks does that take?
1-3 weeks
a soft callous or fibrous cartilage patch forms from fibro and chondroblasts
what happens in the modeling phase for bone healing? typically occurs between how many weeks?
4-8 weeks up to 12 weeks
osteoclastic activity replaces cartilage and osteoblastic bony or hard callus formed
what is it called when a fracture line is no longer visible? what does the indicate for PTs?
clinical union
we can start PT now –> bone is safe to have greater stress on it now
true or false. cancellous (lighter) bone transitions to more abundant compact or cortical (denser) bone
true
what are some factors that complicate bone healing?
deficient bone health and hormone levels (OA, amenorrhea, etc)
not meeting energy expenditure - high stress, limited sleep, inadequate diet
impaired circulation
infection
poor load management (too much too soon)
complicating factors may lead to: (3)
delayed union - slow uniting
non-union - never unites
malunion - misalignment (unites but unaligned)
If patient has a fracture, what needs to happen first?
possible fragment reduction and maintenance of alignment
closed reduction - no surgery, breaks like chalk
open reduction and internal fixation - surgery and hardware
when would someone with a fracture start PT?
when clinical union occurs - 4-8 weeks
- any pain not typically from bone
- PT focuses more on consequences of prolonged immobilization (tissues)
