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MSK Practical Exam > Pain & Neurological Testing > Flashcards

Pain & Neurological Testing Flashcards

1
Q

What are the subjective indicators of peripheral neuropathic pain?

A

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

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2
Q

What are the objective findings of peripheral neuropathic pain (nerve root pain)?

A

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

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3
Q

What is radicular pain?

A

Dermatomal and myotomal pain

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4
Q

What are the objective findings of nerve trunk pain?

A

Weakness and sensation deficits but will not follow a dermatome and myotome pattern

Negative reflexes

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5
Q

When should you do a neruological exam?

A

Petty, 2010 stated when symptoms refer beyond the ischial tuberosity

Numbness

Pins and needles

Weakness

Other neurological symptoms

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6
Q

What does dermatomes test?

A

Nerve conduction

Light touch - A-beta fibres

Pin prick - A-delta fibres

Compare to opposite side

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7
Q

Name the lower limb myotomes

A

L2 - Hip Flexion

L3 - Knee Extension

L4 - Ankle DF

L5 - Extension of Big Toe

S1 - Ankle Eversion

S2 - Knee Flexion

S3/4 - Pelvic Floor

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8
Q

What does myotomes test?

A

Nerve conduction through muscle strength

Isometric mid-range contractions

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9
Q

What does reflexes test?

A

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

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10
Q

What are the Lower Limb reflexes?

A

Knee jerk: L3-L4

Medial hamstrings: L5

Ankle jerk: S1-S2

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11
Q

How are reflexes graded?

A

– or 0 = absent

  • or 1 = diminished

+ or 2 = average

++ or 3 = exaggerated

+++ or 4 = clonus

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12
Q

How do you know if a reflex is normal?

A

Compare to the other side

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13
Q

What does a reduced or absent reflex indicate?

A

LMN lesion e.g. radiculopathy/nerve root compression

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14
Q

What does an exaggerated or clonus reflex indicate?

A

UMN lesion e.g. stroke, MS, brain injury, parkinson’s

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15
Q

What does neurodynamic testing test?

A

A way to test the mechanosensitivity of the nervous system

It’s ability to distribute load

Differentiate between neural and non-neural structures

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16
Q

What are you looking/feeling for with neurodynamic testing?

A

Quality of the movement

ROM

Resistance through range

Pain behaviour - when it comes on, severity, burning, tingling, numbness

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17
Q

When is neurodynamic tests positive?

A

ROM is different R - L

Reproduces patients symptoms

Move something far away and theres a change in symptoms

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18
Q

In what population is neurodynamic testing as a treatment effective? and not effective?

A

Effective - altered mechanosensitivity

Not effective - altered nerve conduction problems e.g. +ve myotomes, dermatomes and reflexes due to high irritability

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19
Q

How do you complete neurodynamic testing?

A

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?

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20
Q

Name 3 neurodynamic tests

A

Slump and SLR - tests sciatic nerve

Both have high sens but low spec

Prone knee bend - tests femoral nerve

21
Q

What is the sequence of the slump test?

A
  1. Tx and Lx flexion
  2. Cx flexion
  3. AROM knee extension
  4. PROM DF
22
Q

How can you complete neurodynamic tests safely?

A

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

23
Q

Name and explain the 2 different neuro dynamic mobilisation techniques

A

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

24
Q

What are the effects of neurodynamic mobilisation?

A

Improve circulation within the nerve

Help with the healing process by improving viscoelastic flow

25
Q

Which is better sliders or tensioners?

A

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

26
Q

What is hyperalgesia and allodynia?

A

Hyperalgesia - increased response to something that is normally painful

Allodynia - pain due to a stimulus that is not normally painful

27
Q

What are the mechanisms of nociceptive pain?

A

Includes bones, tendons, muscles and fascia

28
Q

What are the mechanisms of neuropathic pain?

A

Peripheral and central

29
Q

What type of pain is acute pain and its functions?

A

Nociceptive pain

Acts as preventative measure to stop further injury

Starts the healing process

30
Q

What is nociception?

A

Sensory component of pain

Receptors that respond to damage

31
Q

What are the 2 types of nociceptors?

A

C fibres (Chemical/thermal) - ache and vague pain

A delta fibres (mechanical) - sharp and localised

32
Q

What are the subjective indicators of nociceptive pain?

A

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

33
Q

What are the objective indicators of nociceptive pain?

A

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

34
Q

Explain the pain gate theory

A

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

35
Q

How do you manage someone with nociceptive pain?

A

Manual therapy

Exercise induced hypoalgesia

36
Q

Explain the physiological process of nociceptive pain

A

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

37
Q

What is central sensitisation?

A

Sensitisation within the central nervous system

38
Q

Explain the physiology of central sensitisation

A

Sensory reorganisation that occurs in the cortex with acute pain becomes permanent due to constant nociceptive excitation

39
Q

Name the phases of nociceptive pain

A

Transduction

Conduction

Transmission (neurotransmitter into synapse)

Perception (in cortex)

Modulation

40
Q

What type of pain is central sensitisation commonly involved with?

A

Chronic pain (persists beyond the normal healing time of the tissue)

41
Q

What is the function of the descending system? And how does this change in chronic pain and central sensitisation?

A

Function - Inhibits pain

Chronic pain - Facilitates pain, feedback loop

42
Q

What factor causes central sensitisation and chronic pain?

A

Psychological factors - patients feelings, thoughts and perception

Patients will have pain with just thoughts, even if the area of injury has healed

43
Q

What does increased psychological symptoms e.g. anxiety, depression, pain catastrophising lead to?

A

Increased pain and pain on movement

Increased disability

44
Q

What are the subjective indicators of central sensitisation?

A

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

45
Q

What are the objective indicators of central sensitisation?

A

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

46
Q

What patient reported outcome measure is useful for patients with central sensitisation?

A

Central sensitisation inventory - determine if someone has central sensitisation or not

47
Q

Would you do a manual therapy technique on someone with central sensitisation?

A

No, because this increases the peripheral stimulation and the nociceptive signals to the spinal cord = re-enforces central sensitisation and increases pain

48
Q

What is somatic referred pain?

A

Nociceptive pain that refers pain e.g. pain into the leg and buttock

49
Q

How can you differentiate between somatic referred pain and radicular pain of the Lx?

A

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

MSK Practical Exam (11 decks)

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