Pain & Neurological Testing Flashcards
What are the subjective indicators of peripheral neuropathic pain?
Smart et al 2012
Burning, sharp, shooting, electric shock like pains
Dermatomal distribution
High severity and irritability
History of nerve injury, pathology or mechanical compromise
Pins and needles, numbness and weakness
Aggravating and easing factors related to movement, loading or compression of neural tissues
What are the objective findings of peripheral neuropathic pain (nerve root pain)?
Smart et al 2012
Positive reflexes, myotomes, dermatomes and neurodynamic testing
On neurodynamic testing ROM R - L may be similar but this will reproduce symptoms
Pain on palpation of nerves
What is radicular pain?
Dermatomal and myotomal pain
What are the objective findings of nerve trunk pain?
Weakness and sensation deficits but will not follow a dermatome and myotome pattern
Negative reflexes
When should you do a neruological exam?
Petty, 2010 stated when symptoms refer beyond the ischial tuberosity
Numbness
Pins and needles
Weakness
Other neurological symptoms
What does dermatomes test?
Nerve conduction
Light touch - A-beta fibres
Pin prick - A-delta fibres
Compare to opposite side
Name the lower limb myotomes
L2 - Hip Flexion
L3 - Knee Extension
L4 - Ankle DF
L5 - Extension of Big Toe
S1 - Ankle Eversion
S2 - Knee Flexion
S3/4 - Pelvic Floor
What does myotomes test?
Nerve conduction through muscle strength
Isometric mid-range contractions
What does reflexes test?
Nerve conduction
By taping the tendon this causes a stretch reflex and stimulates the muscle spindle to fire = forms a reflex arc from the spinal cord and activates the muscle and relaxes the antagonist
What are the Lower Limb reflexes?
Knee jerk: L3-L4
Medial hamstrings: L5
Ankle jerk: S1-S2
How are reflexes graded?
– or 0 = absent
- or 1 = diminished
+ or 2 = average
++ or 3 = exaggerated
+++ or 4 = clonus
How do you know if a reflex is normal?
Compare to the other side
What does a reduced or absent reflex indicate?
LMN lesion e.g. radiculopathy/nerve root compression
What does an exaggerated or clonus reflex indicate?
UMN lesion e.g. stroke, MS, brain injury, parkinson’s
What does neurodynamic testing test?
A way to test the mechanosensitivity of the nervous system
It’s ability to distribute load
Differentiate between neural and non-neural structures
What are you looking/feeling for with neurodynamic testing?
Quality of the movement
ROM
Resistance through range
Pain behaviour - when it comes on, severity, burning, tingling, numbness
When is neurodynamic tests positive?
ROM is different R - L
Reproduces patients symptoms
Move something far away and theres a change in symptoms
In what population is neurodynamic testing as a treatment effective? and not effective?
Effective - altered mechanosensitivity
Not effective - altered nerve conduction problems e.g. +ve myotomes, dermatomes and reflexes due to high irritability
How do you complete neurodynamic testing?
Sequentially load the nervous system until you start to get symptoms
Move something that is neural and far away e.g. neck during slump
If this changes symptoms then the test is positive and you can treat the patient with neurodynamics
Questionable specificity, is it only the neural tissues that are moving?
Name 3 neurodynamic tests
Slump and SLR - tests sciatic nerve
Both have high sens but low spec
Prone knee bend - tests femoral nerve
What is the sequence of the slump test?
- Tx and Lx flexion
- Cx flexion
- AROM knee extension
- PROM DF
How can you complete neurodynamic tests safely?
Tell the patients what you are going to do and what symptoms they might experience
For slump get patient to complete test actively first
Go slowly and feel for barriers to movement or resistance
Name and explain the 2 different neuro dynamic mobilisation techniques
Sliders - add tension at 1 end and take tension off at the opposite end
Tensioners - both end of the nerve get drawn together
Start with sliders then progress to tensioners
What are the effects of neurodynamic mobilisation?
Improve circulation within the nerve
Help with the healing process by improving viscoelastic flow
Which is better sliders or tensioners?
Study by Ellis et al 2012 stated there was more movement of the sciatic nerve with a slider compared to a tensioner
More movement = greater therapeutic effects
What is hyperalgesia and allodynia?
Hyperalgesia - increased response to something that is normally painful
Allodynia - pain due to a stimulus that is not normally painful
What are the mechanisms of nociceptive pain?
Includes bones, tendons, muscles and fascia
What are the mechanisms of neuropathic pain?
Peripheral and central
What type of pain is acute pain and its functions?
Nociceptive pain
Acts as preventative measure to stop further injury
Starts the healing process
What is nociception?
Sensory component of pain
Receptors that respond to damage
What are the 2 types of nociceptors?
C fibres (Chemical/thermal) - ache and vague pain
A delta fibres (mechanical) - sharp and localised
What are the subjective indicators of nociceptive pain?
Smart et al 2012
Clear aggravating and easing factors
Pain in proportion to trauma/pathology
Pain localised to injury site
Resolves with expected tissue healing
Responds to NSAIDs, paracetamol, opioids
Pain is intermittent and sharp with provocation e.g. movement, may be constant dull ache or throb at rest
Pain in association with other inflammation symptoms i.e. swelling, redness and heat
Acute pain
What are the objective indicators of nociceptive pain?
Smart et al 2012
Clear, consistent and anatomical pattern of pain reproduction on movement testing of target area
Localised pain on palpation
Absence or expected hyperalgesia
Pain relieving postures
Explain the pain gate theory
A delta and c fibres are nociceptive fibres that are small/moderately in diameter and myelinated
A beta fibres are non-nociceptive fibres with large diameter and myelination
A beta fibres activate the inhibitory neurone that inhibits the nociceptive fibres and activates the projection neurone
Pain is caused when the nociceptive fibres inhibit the inhibitory neurone and activate the projection neurone
A beta fibres are faster and easier to stimulate due to a lower threshold
How do you manage someone with nociceptive pain?
Manual therapy
Exercise induced hypoalgesia
Explain the physiological process of nociceptive pain
Sensitisation of tissues at the site of injury, which reduces the transduction threshold (H+ ions) = easier firing of nociceptors to the dorsal horn that causes pain
What is central sensitisation?
Sensitisation within the central nervous system
Explain the physiology of central sensitisation
Sensory reorganisation that occurs in the cortex with acute pain becomes permanent due to constant nociceptive excitation
Name the phases of nociceptive pain
Transduction
Conduction
Transmission (neurotransmitter into synapse)
Perception (in cortex)
Modulation
What type of pain is central sensitisation commonly involved with?
Chronic pain (persists beyond the normal healing time of the tissue)
What is the function of the descending system? And how does this change in chronic pain and central sensitisation?
Function - Inhibits pain
Chronic pain - Facilitates pain, feedback loop
What factor causes central sensitisation and chronic pain?
Psychological factors - patients feelings, thoughts and perception
Patients will have pain with just thoughts, even if the area of injury has healed
What does increased psychological symptoms e.g. anxiety, depression, pain catastrophising lead to?
Increased pain and pain on movement
Increased disability
What are the subjective indicators of central sensitisation?
Smart et al., 2012
Non-anatomical, inconsistent and disproportionate pattern of pain provocation in response to movement
Pain persists beyond tissue healing times
Pain disproportionate to the injury healing times
Widespread, non-anatomical distribution
Hx of failed interventions
Psychological factors
Unresponsive to NSAIDs
Night pain
Constant/unremitting pain
Pain associated with burning, coldness, crawling
High severity and irritavility
What are the objective indicators of central sensitisation?
Smart et al 2012
Absence of signs of tissue injury
Non-anatomical, inconsistent and disproportionate pattern of pain provocation in response to movement
Hyperalgesia and/or allodynia
Psychological factors
What patient reported outcome measure is useful for patients with central sensitisation?
Central sensitisation inventory - determine if someone has central sensitisation or not
Would you do a manual therapy technique on someone with central sensitisation?
No, because this increases the peripheral stimulation and the nociceptive signals to the spinal cord = re-enforces central sensitisation and increases pain
What is somatic referred pain?
Nociceptive pain that refers pain e.g. pain into the leg and buttock
How can you differentiate between somatic referred pain and radicular pain of the Lx?
Somatic Referred Pain
More proximal
Dull ache over a wide area, NOT dermatomal, myotomal and -ve relfexes
Deep only and doesnt affected the skin
Radicular pain
Travels along entire leg (bellow the knee)
Sharp shooting thin band, dermatomal, myotomal, +ve reflexes and neurodynamic testing
Deep and superficial
