1
|
Bertacchini P. Neurofascialvascular training for carpal tunnel syndrome as an evolution of neurodynamic treatment: A case report. J Bodyw Mov Ther 2024; 39:4-12. [PMID: 38876659 DOI: 10.1016/j.jbmt.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 09/03/2023] [Accepted: 10/17/2023] [Indexed: 06/16/2024]
Abstract
INTRODUCTION In this case report a new approach called neurofascialvascular training (NFVT) is described. NFVT consists of two mechanisms which improve mechanosensitivity in carpal tunnel syndrome (CTS). The first involves increased blood flow in the nerve microcirculation, while the second stimulates the reciprocal sliding between the thin sheets of connective tissue inside the nerve. The goal of these two actions is to squeeze, mobilize and reduce intraneural edema. The novelty of this approach is the simultaneous involvement of multiple physiological systems to reduce nerve mechanosensitivity. This case report describes the rehabilitation progress achieved by NFVT in a patient with CTS. MAIN SYMPTOMS AND/OR IMPORTANT CLINICAL FINDINGS A 64-year-old woman complaining of nocturnal pain and tingling with severe impairment of sleep quality for two years was diagnosed at CTS. THERAPEUTIC INTERVENTIONS The patient underwent nine 30-min exercise sessions of NFVT. OUTCOMES At each session and at the last follow-up 3 months after the end of treatment the following tests were performed: the upper limb neurodynamic test1 (ULNT1), the Hand Grip Meter and the Phdurkan test. Furthermore ultrasound, numerical rating scale and the Boston Carpal Tunnel Questionnaire (BCTQ) were also adopted. CONCLUSION NFVT can improve symptoms and motor dysfunction in a patient with CTS. TAKE-AWAY LESSON In the presence of mild carpal tunnel syndrome, active neurofascialvascular training that increases peripheral blood flow and targets fascial tissue within the peripheral nervous system can resolve symptoms and produce significant improvement within a few months of starting treatment.
Collapse
Affiliation(s)
- Paolo Bertacchini
- Master OMPT, University of Bologna, Bologna, Italy; Private Practice, Parma, Italy.
| |
Collapse
|
2
|
Bordoni B, Escher AR, Duczyński M. Proposal for Manual Osteopathic Treatment of the Phrenic Nerve. Cureus 2024; 16:e58012. [PMID: 38606024 PMCID: PMC11007451 DOI: 10.7759/cureus.58012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2024] [Indexed: 04/13/2024] Open
Abstract
The article reviews the anatomical path of the phrenic nerve and its anastomoses, with the most up-to-date knowledge reported in the literature. We have briefly reviewed the possible phrenic dysfunctions, with the final aim of presenting an osteopathic manual approach for the treatment of the most superficial portion of the nerve, using a gentle technique. The approach we propose is, therefore, a theory based on clinical experience and the rationale that we can extrapolate from the literature. We hope that the article will be a stimulus for further experimental investigations using the technique illustrated in the article. To the authors' knowledge, this is the first article that takes into consideration the hypothesis of an osteopathic treatment with gentle techniques for the phrenic nerve.
Collapse
Affiliation(s)
- Bruno Bordoni
- Physical Medicine and Rehabilitation, Don Carlo Gnocchi Foundation, Milan, ITA
| | - Allan R Escher
- Anesthesiology/Pain Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | | |
Collapse
|
3
|
Schmid AB, Tampin B, Baron R, Finnerup NB, Hansson P, Hietaharju A, Konstantinou K, Lin CWC, Markman J, Price C, Smith BH, Slater H. Recommendations for terminology and the identification of neuropathic pain in people with spine-related leg pain. Outcomes from the NeuPSIG working group. Pain 2023; 164:1693-1704. [PMID: 37235637 PMCID: PMC10348639 DOI: 10.1097/j.pain.0000000000002919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 02/16/2023] [Accepted: 02/24/2023] [Indexed: 05/28/2023]
Abstract
ABSTRACT Pain radiating from the spine into the leg is commonly referred to as "sciatica," "Sciatica" may include various conditions such as radicular pain or painful radiculopathy. It may be associated with significant consequences for the person living with the condition, imposing a reduced quality of life and substantial direct and indirect costs. The main challenges associated with a diagnosis of "sciatica" include those related to the inconsistent use of terminology for the diagnostic labels and the identification of neuropathic pain. These challenges hinder collective clinical and scientific understanding regarding these conditions. In this position paper, we describe the outcome of a working group commissioned by the Neuropathic Pain Special Interest Group (NeuPSIG) of the International Association for the Study of Pain (IASP) which was tasked with the following objectives: (1) to revise the use of terminology for classifying spine-related leg pain and (2) to propose a way forward on the identification of neuropathic pain in the context of spine-related leg pain. The panel recommended discouraging the term "sciatica" for use in clinical practice and research without further specification of what it entails. The term "spine-related leg pain" is proposed as an umbrella term to include the case definitions of somatic referred pain and radicular pain with and without radiculopathy. The panel proposed an adaptation of the neuropathic pain grading system in the context of spine-related leg pain to facilitate the identification of neuropathic pain and initiation of specific management in this patient population.
Collapse
Affiliation(s)
- Annina B. Schmid
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Brigitte Tampin
- Department of Physiotherapy, Sir Charles Gairdner Hospital, Perth, Australia
- Curtin School of Allied Health, Faculty of Health Sciences, Curtin University, Perth, Australia
- Faculty of Business and Social Sciences, Hochschule Osnabrueck, University of Applied Sciences, Osnabrueck, Germany
| | - Ralf Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Nanna B. Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Per Hansson
- Department of Pain Management & Research, Norwegian National Advisory Unit on Neuropathic Pain, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Aki Hietaharju
- Department of Neurology, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Kika Konstantinou
- School of Medicine, Keele University, Keele, Staffordshire, United Kingdom
- Haywood Hospital, Midlands Partnership Foundation NHS Trust, Staffordshire, United Kingdom
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- Sydney Musculoskeletal Health, the University of Sydney, Sydney Australia
| | - John Markman
- Translational Pain Research Program, Departments of Neurosurgery and Neurology, University of Rochester, Rochester, NY, United States
| | - Christine Price
- Patient Advocate Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Blair H. Smith
- Division of Population Health and Genomics, University of Dundee, Dundee, Scotland
| | - Helen Slater
- Curtin School of Allied Health, Faculty of Health Sciences, Curtin University, Perth, Australia
- Division of Population Health and Genomics, University of Dundee, Dundee, Scotland
| |
Collapse
|
4
|
Meidinger P, Kéchichian A, Pinsault N. A Model of Triage of Serious Spinal Pathologies and Therapeutic Options Based on a Delphi Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1283. [PMID: 37512094 PMCID: PMC10383224 DOI: 10.3390/medicina59071283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/06/2023] [Accepted: 07/08/2023] [Indexed: 07/30/2023]
Abstract
Background and Objectives: The relevance of red flags in serious spinal pathology (SSP) has evolved throughout the last years. Recently, new considerations have been proposed to expand the consideration of red flags. The purpose of this study was to determine, approve and test a model for the triage and management process of SSPs based on the latest data available in the literature. Materials and Methods: The SSP model was initially built on the basis of a literature review. The model was further determined and approved by an expert panel using a Delphi process. Finally, clinical scenarios were used to test the applicability of the model. Results: After three rounds of the Delphi process, panellists reached a consensus on a final version of the model. The use of clinical scenarios by experts brought about reflexive elements both for the determined model and for the SSPs depicted in the clinical cases. Conclusions: The validation of the model and its implementation in the clinical field could help assess the skills of first-line practitioners managing spinal pain patients. To this end, the development of additional clinical scenarios fitting the determined model should be further considered.
Collapse
Affiliation(s)
- Philippe Meidinger
- TIMC-IMAG UMR CNRS 5525, ThEMAS Team, Université Grenoble Alpes, Domaine de la Merci, 5 Avenue du Grand Sablon, 38700 La Tronche, France
| | - Amélie Kéchichian
- TIMC-IMAG UMR CNRS 5525, ThEMAS Team, Université Grenoble Alpes, Domaine de la Merci, 5 Avenue du Grand Sablon, 38700 La Tronche, France
| | - Nicolas Pinsault
- TIMC-IMAG UMR CNRS 5525, ThEMAS Team, Université Grenoble Alpes, Domaine de la Merci, 5 Avenue du Grand Sablon, 38700 La Tronche, France
| |
Collapse
|
5
|
Fernández-de-Las-Peñas C, Fuensalida-Novo S, Nijs J, Basson A, Plaza-Manzano G, Valera-Calero JA, Arendt-Nielsen L, de-la-Llave-Rincón AI. Carpal Tunnel Syndrome: Neuropathic Pain Associated or Not with a Nociplastic Condition. Biomedicines 2023; 11:1744. [PMID: 37371839 DOI: 10.3390/biomedicines11061744] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
Carpal tunnel syndrome (CTS) has been traditionally classified as primarily a neuropathic condition with or without pain. Precision medicine refers to an evidence-based method of grouping patients based on their susceptibility to biology, prognosis of a particular disease, or in their response to a specific treatment, and tailoring specific treatments accordingly. In 2021, the International Association for the Study of Pain (IASP) proposed a grading system for classifying patients into nociceptive, neuropathic, or nociplastic phenotypes. This position paper presents data supporting the possibility of subgrouping individuals with specific CTS related-pain into nociceptive, neuropathic, nociplastic or mixed-type phenotypes. Carpal tunnel syndrome is a neuropathic condition but can also be comorbid with a nociplastic pain condition. The presence of extra-median symptoms and the development of facilitated pain processing seem to be signs suggesting that specific CTS cases can be classified as the nociplastic pain phenotype. The clinical responses of therapeutic approaches for the management of CTS are inconclusive. Accordingly, the ability to identify the predominant pain phenotype in patients with CTS could likely be problematic for producing efficient treatment outcomes. In fact, the presence of a nociplastic or mixed-type pain phenotype would explain the lack of clinical effect of treatment interventions targeting the carpal tunnel area selectively. We propose a clinical decision tree by using the 2021 IASP classification criteria for identifying the predominant pain phenotype in people with CTS-related pain, albeit CTS being a priori a neuropathic pain condition. The identification of a nociplastic-associated condition requires a more nuanced multimodal treatment approach to achieve better treatment outcomes.
Collapse
Affiliation(s)
- César Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, 28922 Alcorcón, Spain
- Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, DK-9220 Aalborg, Denmark
| | - Stella Fuensalida-Novo
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, 28922 Alcorcón, Spain
| | - Jo Nijs
- Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, 1050 Brussels, Belgium
- Chronic Pain Rehabilitation, Department of Physical Medicine and Physiotherapy, University Hospital Brussels, 1090 Brussels, Belgium
- Unit of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden
| | - Annalie Basson
- Department of Physiotherapy, University of the Witwatersrand, Office 23, Khanya Block-West, 7 York Road, Parktown 2193, South Africa
| | - Gustavo Plaza-Manzano
- Department of Radiology, Rehabilitation and Physiotherapy, Complutense University of Madrid, 28040 Madrid, Spain
- Grupo InPhysio, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - Juan A Valera-Calero
- Department of Radiology, Rehabilitation and Physiotherapy, Complutense University of Madrid, 28040 Madrid, Spain
- Grupo InPhysio, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - Lars Arendt-Nielsen
- Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, DK-9220 Aalborg, Denmark
- Department of Gastroenterology & Hepatology, Mech-Sense, Clinical Institute, Aalborg University Hospital, DK-9000 Aalborg, Denmark
- Steno Diabetes Center North Denmark, Clinical Institute, Aalborg University Hospital, DK-9000 Aalborg, Denmark
| | - Ana I de-la-Llave-Rincón
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, 28922 Alcorcón, Spain
| |
Collapse
|
6
|
Lavoie FA, St-Pierre MO, Paquin JP, Gilbert K, Ellis R, Sobczak S. Mechanical Effects of a Specific Neurodynamic Mobilization of the Superficial Fibular Nerve: A Cadaveric Study. J Athl Train 2023; 58:445-451. [PMID: 35834709 PMCID: PMC11220906 DOI: 10.4085/1062-6050-0154.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT A specific neurodynamic mobilization for the superficial fibular nerve (SFN) has been suggested in the reference literature for manual therapists to evaluate nerve mechanosensitivity in patients. However, no authors of biomechanical studies have examined the ability of this technique to produce nerve strain. Therefore, the mechanical specificity of this technique is not yet established. OBJECTIVES To test whether this examination and treatment technique produced nerve strain in the fresh frozen cadaver and the contribution of each motion to total longitudinal strain. DESIGN Controlled laboratory study. SETTING Laboratory. MAIN OUTCOME MEASURE(S) A differential variable reluctance transducer was inserted in 10 SFNs from 6 fresh cadavers to measure strain during the mobilization. A specific sequence of plantar flexion, ankle inversion, straight-leg raise position, and 30° of hip adduction was applied to the lower limb. The mobilization was repeated at 0°, 30°, 60°, and 90° of the straight-leg raise position to measure the effect of hip-flexion position. RESULTS Compared with a resting position, this neurodynamic mobilization produced a significant amount of strain in the SFN (7.93% ± 0.51%, P < .001). Plantar flexion (59.34% ± 25.82%) and ankle inversion (32.80% ± 21.41%) accounted for the biggest proportions of total strain during the mobilization. No difference was noted among different hip-flexion positions. Hip adduction did not significantly contribute to final strain (0.39% ± 10.42%, P > .05), although high variability among limbs existed. CONCLUSIONS Ankle motion should be considered the most important factor during neurodynamic assessment of the SFN for distal entrapment. These results suggest that this technique produces sufficient strain in the SFN and could therefore be evaluated in vivo for correlation with mechanosensitivity.
Collapse
Affiliation(s)
| | | | | | - Kerry Gilbert
- Institute of Anatomical Sciences, Texas Tech University Health Sciences Center, Lubbock
| | - Richard Ellis
- Active Living and Rehabilitation: Aotearoa New Zealand, Health and Rehabilitation Research Institute, School of Clinical Sciences, Auckland University of Technology, New Zealand
| | - Stephane Sobczak
- Department of Human Kinetics, Université du Québec à Trois-Rivières, Canada
| |
Collapse
|
7
|
Macionis V. Chronic pain and local pain in usually painless conditions including neuroma may be due to compressive proximal neural lesion. FRONTIERS IN PAIN RESEARCH 2023; 4:1037376. [PMID: 36890855 PMCID: PMC9986610 DOI: 10.3389/fpain.2023.1037376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 01/12/2023] [Indexed: 02/22/2023] Open
Abstract
It has been unexplained why chronic pain does not invariably accompany chronic pain-prone disorders. This question-driven, hypothesis-based article suggests that the reason may be varying occurrence of concomitant peripheral compressive proximal neural lesion (cPNL), e.g., radiculopathy and entrapment plexopathies. Transition of acute to chronic pain may involve development or aggravation of cPNL. Nociceptive hypersensitivity induced and/or maintained by cPNL may be responsible for all types of general chronic pain as well as for pain in isolated tissue conditions that are usually painless, e.g., neuroma, scar, and Dupuytren's fibromatosis. Compressive PNL induces focal neuroinflammation, which can maintain dorsal root ganglion neuron (DRGn) hyperexcitability (i.e., peripheral sensitization) and thus fuel central sensitization (i.e., hyperexcitability of central nociceptive pathways) and a vicious cycle of chronic pain. DRGn hyperexcitability and cPNL may reciprocally maintain each other, because cPNL can result from reflexive myospasm-induced myofascial tension, muscle weakness, and consequent muscle imbalance- and/or pain-provoked compensatory overuse. Because of pain and motor fiber damage, cPNL can worsen the causative musculoskeletal dysfunction, which further accounts for the reciprocity between the latter two factors. Sensitization increases nerve vulnerability and thus catalyzes this cycle. Because of these mechanisms and relatively greater number of neurons involved, cPNL is more likely to maintain DRGn hyperexcitability in comparison to distal neural and non-neural lesions. Compressive PNL is associated with restricted neural mobility. Intermittent (dynamic) nature of cPNL may be essential in chronic pain, because healed (i.e., fibrotic) lesions are physiologically silent and, consequently, cannot provide nociceptive input. Not all patients may be equally susceptible to develop cPNL, because occurrence of cPNL may vary as vary patients' predisposition to musculoskeletal impairment. Sensitization is accompanied by pressure pain threshold decrease and consequent mechanical allodynia and hyperalgesia, which can cause unusual local pain via natural pressure exerted by space occupying lesions or by their examination. Worsening of local pain is similarly explainable. Neuroma pain may be due to cPNL-induced axonal mechanical sensitivity and hypersensitivity of the nociceptive nervi nervorum of the nerve trunk and its stump. Intermittence and symptomatic complexity of cPNL may be the cause of frequent misdiagnosis of chronic pain.
Collapse
|
8
|
Nuñez de Arenas-Arroyo S, Martínez-Vizcaíno V, Cavero-Redondo I, Álvarez-Bueno C, Reina-Gutierrez S, Torres-Costoso A. The Effect of Neurodynamic Techniques on the Dispersion of Intraneural Edema: A Systematic Review with Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14472. [PMID: 36361353 PMCID: PMC9655711 DOI: 10.3390/ijerph192114472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/27/2022] [Accepted: 11/01/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND There is evidence for the positive effects of neurodynamic techniques in some peripheral entrapment neuropathies, but the rationale for these effects has not been validated. We aimed to estimate the direct effect of neurodynamic techniques on the dispersion of artificially induced intraneural edema measured by dye spread in cadavers. METHODS We systematically searched the MEDLINE, WOS, Scopus, and the Cochrane databases from inception to February 2020 for experimental studies addressing the efficacy of neurodynamic techniques on the dispersion of artificially induced intraneural edema. The DerSimonian and Laird method was used to compute pooled estimates of the mean differences (MDs) and its respective 95% confidence intervals (CIs). Subgroup analyses were conducted according to the type of neurodynamic technique. In addition, a 95% prediction interval was calculated to reflect the variation in true treatment effects in different settings, including the effect to be expected in future patients. RESULTS Pooled results showed a significant increase in fluid dispersion (MD = 2.57 mm; 95%CI: 1.13 to 4.01). Subgroup analysis showed increased dye spread in the tensioning techniques group (MD = 2.22 mm; 95%CI: 0.86 to 3.57). CONCLUSION Neurodynamic techniques improved the intraneural edema dispersion and should be considered for the management of peripheral compression neuropathies. Furthermore, tensioning techniques appear to be effective in helping to disperse intraneural edema.
Collapse
Affiliation(s)
| | - Vicente Martínez-Vizcaíno
- Health and Social Research Center, Universidad de Castilla-La Mancha, 16071 Cuenca, Spain
- Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Talca 340000, Chile
| | - Iván Cavero-Redondo
- Health and Social Research Center, Universidad de Castilla-La Mancha, 16071 Cuenca, Spain
- Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Talca 340000, Chile
| | - Celia Álvarez-Bueno
- Health and Social Research Center, Universidad de Castilla-La Mancha, 16071 Cuenca, Spain
- Universidad Artística y Politécnica del Paraguay, Asunción 2024, Paraguay
| | - Sara Reina-Gutierrez
- Health and Social Research Center, Universidad de Castilla-La Mancha, 16071 Cuenca, Spain
| | - Ana Torres-Costoso
- Facultad de Fisioterapia y Enfermería, Universidad de Castilla-La Mancha, 45071 Toledo, Spain
| |
Collapse
|
9
|
Feller D, Giudice A, Faletra A, Salomon M, Galeno E, Rossettini G, Brindisino F, Maselli F, Hutting N, Mourad F. Identifying peripheral arterial diseases or flow limitations of the lower limb: Important aspects for cardiovascular screening for referral in physiotherapy. Musculoskelet Sci Pract 2022; 61:102611. [PMID: 35759957 DOI: 10.1016/j.msksp.2022.102611] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 06/08/2022] [Accepted: 06/16/2022] [Indexed: 10/17/2022]
Abstract
Many conditions could potentially cause pain in the lower limbs. One of these is peripheral arterial disease (PAD). PAD is often a real challenge to be recognized for clinicians due to symptoms that commonly mimic musculoskeletal conditions. PAD is defined as a total or partial blockage of the vessels that supply blood from the heart to the periphery. Its prevalence is around 7 percent in subjects between 55 and 59, reaching almost 25% in individuals between 95 and 99 years old. The most dominant symptom of PAD is lower limb pain. Also, PAD can produce other symptoms such as discoloration, altered skin temperature, and, when arterial blood flow is insufficient to meet the metabolic demands of resting muscle or tissue, focal areas of ischemia. In our view, physical therapists should be capable of triaging for PAD in a direct access setting. Therefore, in this Professional Issue, we present the main characteristics of PAD and the physiotherapy role in its management. A supplementary step-by-step guide will provide further resources for testing PAD.
Collapse
Affiliation(s)
- Daniel Feller
- Centre of Higher Education for Health Sciences, Trento, Italy.
| | - Andrea Giudice
- Department of Physical Therapy, Poliambulatorio Physio Power, Brescia, Italy.
| | - Agostino Faletra
- Queen Elizabeth Hospital, Clinical Support & Screening Service, Gateshead, United Kingdom.
| | - Mattia Salomon
- Department of Clinical Science and Translational Medicine, University of Roma "Tor Vergata", Roma, Italy; CST Centro Sanitario Trento s.r.l., 30121, Trento, Italy.
| | - Erasmo Galeno
- Polimedico Specialistico STEMA Fisiolab, Latina, Italy; Dip. Scienze mediche, chirurgiche e neuroscienze Università degli studi di Siena, Italy; Department of clinical science and translation medicine, University of Rome Tor Vergata, Roma, Italy.
| | | | - Fabrizio Brindisino
- Department of clinical science and translation medicine, University of Rome Tor Vergata, Roma, Italy; Department of Medicine and Health Science "Vincenzo Tiberio", University of Molise c/o Cardarelli Hospital, Campobasso, Italy.
| | - Filippo Maselli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Campus of Savona, University of Genoa, Savona, Italy; Sovrintendenza Sanitaria Regionale Puglia INAIL, Bari, Italy.
| | - Nathan Hutting
- Department of Occupation and Health, School of Organisation and Development, HAN University of Applied Sciences, Nijmegen, the Netherlands.
| | - Firas Mourad
- Department of Physiotherapy, LUNEX International University of Health, Exercise and Sports, 4671, Differdange, Luxembourg; Luxembourg Health & Sport Sciences Research Institute A.s.b.l., 50, Avenue du Parc des Sports, 4671, Differdange, Luxembourg.
| |
Collapse
|
10
|
Accuracy of the Most Common Provocation Tests for Diagnosing Carpal Tunnel Syndrome: A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther 2022; 52:522-531. [PMID: 35722757 DOI: 10.2519/jospt.2022.10828] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To estimate the screening performances of the most important provocation tests for diagnosing carpal tunnel syndrome (CTS). DESIGN Diagnostic test accuracy systematic review with meta-analysis. LITERATURE SEARCH We systematically searched the MEDLINE, Scopus, Web of Science, and Cochrane databases from inception to November 2020. STUDY SELECTION CRITERIA Observational studies comparing the accuracies of the Durkan test (DT), the hand elevation test (HET), the Phalen test (PT), the Tinel test (TT), and the upper-limb neurodynamic test specific to the median nerve (ULNT1) with electrodiagnosis for screening for CTS. DATA SYNTHESIS Random-effects models for the diagnostic odds ratio (dOR) values computed by Moses' constant for a linear model and 95% confidence intervals (CIs) were used to calculate the accuracy of these tests. Hierarchical summary receiver operating characteristic curve analyses were used to summarize the overall test performance. RESULTS Thirty-seven studies were included in the meta-analysis, with a total sample of 2662 wrists for DT, 864 wrists for HET, 6361 wrists for PT, 6094 wrists for TT, and 571 wrists for ULNT1. The pooled dORs for screening for CTS were 15.84 (95% CI: 3.78, 66.38) for DT, 128.63 (95% CI: 40.64, 407.12) for HET, 7.23 (95% CI: 4.06, 12.86) for PT, 5.31 (95% CI: 3.49, 8.09) for TT, and 1.78 (95% CI: 0.61, 5.19) for ULNT1. CONCLUSION HET has the best clinical performance for detecting CTS and should be considered the first screening test of choice during the physical examination. The most common tests (DT, PT, and TT) have good accuracies for screening for CTS. J Orthop Sports Phys Ther 2022;52(8):522-531. Epub: 19 June 2022. doi:10.2519/jospt.2022.10828.
Collapse
|
11
|
Easy to treat when the diagnosis is made: Three cases of clunealgia and the advantage of ultrasonography. Turk J Phys Med Rehabil 2022; 68:300-305. [PMID: 35989956 PMCID: PMC9366497 DOI: 10.5606/tftrd.2022.6550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 11/24/2020] [Indexed: 11/21/2022] Open
Abstract
In this article, we present three cases of clunealgia admitted with low back pain. Their pain relieved with superior cluneal nerve block. The posterior side of the iliac crest, which is the location where the superior cluneal nerve passes, was identified using a high-frequency linear transducer. The drug injected separates the erector spinae muscle and thoracolumbar fascia and accumulates between these two structures. All patients were discharged with a complete pain relief. This report highlights the fact that superior cluneal nerve entrapment should be kept in mind in patients with low back pain and that ultrasound guidance can correctly identify the infiltration and eliminate anesthetization of other surrounding structures.
Collapse
|
12
|
Karjalanen T, Raatikainen S, Jaatinen K, Lusa V. Update on Efficacy of Conservative Treatments for Carpal Tunnel Syndrome. J Clin Med 2022; 11:jcm11040950. [PMID: 35207222 PMCID: PMC8877380 DOI: 10.3390/jcm11040950] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 01/31/2022] [Accepted: 02/09/2022] [Indexed: 12/13/2022] Open
Abstract
Carpal tunnel syndrome (CTS) is the most common upper extremity compression neuropathy. Non-operative interventions are usually the first-line treatments, and surgery is reserved for those that do not achieve a satisfactory symptom state by non-operative means. This narrative review summarizes the current evidence regarding the efficacy of orthoses, corticosteroid injections, platelet-rich plasma injections, Kinesio taping, neurodynamic techniques, gabapentin, therapeutic ultrasound, and extracorporeal shockwave therapy in people with CTS. While many trials suggest small short-term benefits, rigorous evidence of long-term patient-important benefits is limited. To improve the utility of healthcare resources, research in this area should focus on establishing efficacy of each treatment instead of comparing various treatments with uncertain benefits.
Collapse
Affiliation(s)
- Teemu Karjalanen
- Department of Hand and Micosurgery, Tampere University Hospital, 33521 Tampere, Finland
- Monash Department of Clinical Epidemiology, Cabrini Institute, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Melbourne 3144, Australia
- Correspondence:
| | - Saara Raatikainen
- Musculoskeletal and Plastic Surgery Department, University of Helsinki and Helsinki University Hospital, 00290 Helsinki, Finland;
| | - Kati Jaatinen
- Central Finland Healthcare District, 40620 Jyväskylä, Finland; (K.J.); (V.L.)
| | - Vieda Lusa
- Central Finland Healthcare District, 40620 Jyväskylä, Finland; (K.J.); (V.L.)
| |
Collapse
|
13
|
Robla-Costales J, Rodríguez-Aceves C, Martínez-Benia F, Socolovsky M. State of the Art and Advances in Peripheral Nerve Surgery. Adv Tech Stand Neurosurg 2022; 45:245-283. [PMID: 35976453 DOI: 10.1007/978-3-030-99166-1_8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
This review is intended to describe and actualize the basic knowledge of the three basic entities that affect the peripheral nerve system and can be treated by surgery: nerve trauma, chronic nerve compressions, and tumors.Regarding trauma, emphasis is given on the timing of surgery, given the fact that the moment in which the surgery is performed and the employed microsurgical reconstruction technique are the most important factors in the final result. Open lesions with associated nerve injury should be managed with an early exploration carried out before 7 days. Closed injuries are usually deferred, with few exceptions, from 3 to 6 months after the trauma.In turn, chronic compressions require an appropriate clinical, neurophysiological, and imaging diagnosis. Isolated sensory symptoms can be treated actively though without surgery: motor signs like atrophy should be regarded as a sign for immediate surgery, as a deferred treatment might cause an irreversible nerve and muscular damage. Endoscopic approaches are a valuable tool for treatment in selected neuropathies.Finally, nerve tumors demand a thorough preoperative evaluation, as benign tumors are treated in a very different way when compared to malignant lesions. Benign tumors can usually be safely and completely resected without sacrificing the nerve of origin. When malignancy is confirmed, extensive resection to optimize patient survival is the main objective, potentially at the expense of neurological function. This may then be followed by adjuvant radiation and/or chemotherapy, depending on the nature of the tumor and the completeness of resection attained. The role of nerve biopsy remains controversial, and several modern diagnostic techniques might be helpful.
Collapse
Affiliation(s)
| | - Carlos Rodríguez-Aceves
- Neurological Center, The American British Cowdray Medical Center campus Santa Fe, Mexico City, Mexico
| | - Fernando Martínez-Benia
- Department of Neurosurgery, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Mariano Socolovsky
- Department of Neurosurgery, Hospital de Clínicas, Universidad de Buenos Aires, Buenos Aires, Argentina.
| |
Collapse
|
14
|
[Quantitative sensory testing for neuropathic pain and its relevance for physiotherapy]. Schmerz 2021; 36:437-446. [PMID: 34424391 DOI: 10.1007/s00482-021-00576-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Neuropathic pain syndromes are typically characterized by high chronification rates as well as long and intensive pain episodes. Early and accurate diagnosis of neuropathic pain is a basic skill of physiotherapists and other medical professionals, may allow for appropriate medical treatment and help to prevent possible consequential damage. Quantitative sensory testing (QST) can be applied as a supplement to conventional neurological bedside testing in the evaluation of neuropathic pain. Over recent decades, QST has come to hold a significant position in the field of pain research. However, despite these developments, the application of QST in clinical practice has lagged behind. OBJECTIVES What is the value of QST in the study of neuropathic pain? Have the conditions for personal clinical use of the QST been established in physiotherapy practice? Have the pathways for specific implementation of the QST been defined? METHOD Literature research as part of a Bachelor thesis in Physiotherapy. RESULTS QST constitutes a valid examination tool that is able to evaluate the complete somatosensory profile. In this way, QST may provide substantial additional benefit in the examination of neuropathic pain patients compared to other conventional testing procedures, especially when it comes to small-fibre neuropathies. These small fibres seem to be particularly affected in asymptomatic patients as well as early phases of neuropathies and cannot be investigated via conventional testing procedures. This makes the use of partial aspects of the QST a proven instrument for physiotherapists and medical staff, which was particularly useful in the decision-making process for neuropathies. DISCUSSION Nonetheless, regarding the results, there are still several limiting factors that hamper the routine use of QST. Some of these can be resolved by precisely adhering to testing protocols and taking precautions. Other highly relevant issues for clinical practice, such as the immense cost of equipment and the excessive time required for testing, have not been satisfactorily overcome as yet. Less comprehensive testing protocols as well as the innovation of handy and cost-effective testing devices might offer initial approaches to enhance the widespread use of QST. Complementing conventional bedside testing by adding thermal discrimination tests and pain detection threshold tests might prove to be another possibility to integrate the benefit of QST into clinical practice. CONCLUSION QST makes a significant contribution to the investigation and diagnosis of neuropathies. Physiotherapists are encouraged to implement partial aspects of the QST in a standard examination in order to have a positive effect on both early detection and treatment.
Collapse
|
15
|
Effects of Neurodynamic Interventions on Pain Sensitivity and Function in Patients with Multiple Sclerosis: A Randomized Clinical Trial. Physiotherapy 2021; 115:36-45. [DOI: 10.1016/j.physio.2021.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Indexed: 11/21/2022]
|
16
|
A Comprehensive Review and Update of Post-surgical Cutaneous Nerve Entrapment. Curr Pain Headache Rep 2021; 25:11. [PMID: 33547511 DOI: 10.1007/s11916-020-00924-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE OF REVIEW This is a comprehensive review of the literature regarding post-surgical cutaneous nerve entrapment, epidemiology, pathophysiology, and clinical presentation. It focuses mainly on nerve entrapment leading to chronic pain and the available therapies. RECENT FINDINGS Cutaneous nerve entrapment is not an uncommon result (up to 30% of patients) of surgery and could lead to significant, difficult to treat chronic pain. Untreated, entrapment can lead to neuropathy and damage to enervated structures and musculature, and significant morbidity and financial loss. Nerve entrapment is defined as pressure neuropathy from chronic compression. It causes changes to all layers of the nerve tissue. It is most significantly associated with hernia repair and other procedures employing a Pfannenstiel incision. The initial insult is usually incising of the nerve, followed by formation of a neuroma, incorporation of the nerve during closing, or constriction from adhesions. The three most commonly involved nerves are the iliohypogastric, ilioinguinal, and genitofemoral nerves. Cutaneous abdominal nerve entrapment could occur during thoracoabdominal surgery. The presentation of nerve entrapment usually involved post-surgical pain in the territory innervated by the trapped nerve, possibly with radiation that tracks the nerve course. Once a suspected neuropathy is identified, it can be diagnosed with relief in pain after a nerve block has been instilled. Treatment is usually started with pharmaceutical solutions, topical first and oral if those fail. Most patients require escalation to a second line of treatment and see good result with injection therapy. Those that require further escalation can choose between ablation and surgical therapies. Post-surgical nerve entrapment is not uncommon and causes serious morbidity and financial loss. It is underdiagnosed and thus undertreated. Preventing nerve entrapment is the best treatment; when it does occur, options include topical and oral analgesics, nerve blocks, ablation therapy, and repeat surgery.
Collapse
|
17
|
Mistry J, Falla D, Noblet T, Heneghan NR, Rushton A. Clinical indicators to identify neuropathic pain in low back related leg pain: a modified Delphi study. BMC Musculoskelet Disord 2020; 21:601. [PMID: 32900367 PMCID: PMC7487834 DOI: 10.1186/s12891-020-03600-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 08/18/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Neuropathic pain (NP) is common in patients presenting with low back related leg pain. Accurate diagnosis of NP is fundamental to ensure appropriate intervention. In the absence of a clear gold standard, expert opinion provides a useful methodology to progress research and clinical practice. The aim of this study was to achieve expert consensus on a list of clinical indicators to identify NP in low back related leg pain. METHODS A modified Delphi method consisting of three rounds was designed in accordance with the Conducting and Reporting Delphi Studies recommendations. Recruitment involved contacting experts directly and through expressions of interest on social media. Experts were identified using pre-defined eligibility criteria. Priori consensus criteria were defined for each round through descriptive statistics. Following completion of round 3 a list of clinical indicators that achieved consensus were generated. RESULTS Thirty-eight participants were recruited across 11 countries. Thirty-five participants completed round 1 (92.1%), 32 (84.2%) round 2 and 30 (78.9%) round 3. Round 1 identified consensus (Kendall's W coefficient of concordance 0.456; p < 0.001) for 10 clinical indicators out of the original 14, and 9 additional indicators were added to round 2 following content analysis of qualitative data. Round 2 identified consensus (Kendall's W coefficient of concordance 0.749; p < 0.001) for 10 clinical indicators out of 19, and 1 additional indicator was added to round 3. Round 3 identified consensus for 8 indicators (Kendall's W coefficient of concordance 0.648; p < 0.001). Following completion of the third round, an expert derived consensus list of 8 items was generated. Two indicators; pain variously described a burning, electric shock like and/or shooting into leg and pain in association with other neurological symptoms (e.g. pins and needles, numbness, weakness), were found to have complete agreement amongst expert participants. CONCLUSIONS Good agreement was found for the consensus derived list of 8 clinical indicators to identify NP in low back related leg pain. This list of indicators provide some indication of the criteria upon which clinicians can identify a NP component to low back related leg pain; further research is needed for stronger recommendations to be made.
Collapse
Affiliation(s)
- Jai Mistry
- St Georges Hospital NHS Foundation Trust, London, UK.,Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, UK
| | - Deborah Falla
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, UK
| | - Tim Noblet
- St Georges Hospital NHS Foundation Trust, London, UK.,Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, UK
| | - Nicola R Heneghan
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, UK
| | - Alison Rushton
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, UK.
| |
Collapse
|
18
|
Mistry J, Heneghan NR, Noblet T, Falla D, Rushton A. Diagnostic utility of patient history, clinical examination and screening tool data to identify neuropathic pain in low back related leg pain: a systematic review and narrative synthesis. BMC Musculoskelet Disord 2020; 21:532. [PMID: 32778086 PMCID: PMC7419221 DOI: 10.1186/s12891-020-03436-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 06/17/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Low back-related leg pain (LBLP) is a challenge for healthcare providers to manage. Neuropathic pain (NP) is highly prevalent in presentations of LBLP and an accurate diagnosis of NP in LBLP is essential to ensure appropriate intervention. In the absence of a gold standard, the objective of this systematic review was to evaluate the diagnostic utility of patient history, clinical examination and screening tool data for identifying NP in LBLP. METHODS This systematic review is reported in line with PRISMA and followed a pre-defined and published protocol. CINAHL, EMBASE, MEDLINE, Web of Science, Cochrane Library, AMED, Pedro and PubMed databases, key journals and the grey literature were searched from inception to 31 July 2019. Eligible studies included any study design reporting primary diagnostic data on the diagnostic utility of patient history, clinical examination or screening tool data to identify NP in LBLP, in an adult population. Two independent reviewers searched information sources, assessed risk of bias (QUADAS-2) and used GRADE to assess overall quality of evidence. RESULTS From 762 studies, 11 studies were included. Nine studies out of the 11 were at risk of bias. Moderate level evidence supports a cluster of eight signs (age, duration of disease, paroxysmal pain, pain worse in leg than back, typical dermatomal distribution, worse on coughing/sneezing/straining, finger to floor distance and paresis) for diagnosing lumbosacral nerve root compression, demonstrating moderate/high sensitivity (72%) and specificity (80%) values. Moderate level evidence supports the use of the StEP tool for diagnosing lumbar radicular pain, demonstrating high sensitivity (92%) and specificity (97%) values. CONCLUSIONS Overall low-moderate level evidence supports the diagnostic utility of patient history, clinical examination and screening tool data to identify NP in LBLP. The weak evidence base is largely due to methodological flaws and indirectness regarding applicability of the included studies. The most promising diagnostic tools include a cluster of 8 patient history/clinical examination signs and the StEP tool. Low risk of bias and high level of evidence diagnostic utility studies are needed, in order for stronger recommendations to be made.
Collapse
Affiliation(s)
- Jai Mistry
- St Georges Hospital NHS Foundation Trust, London, UK.,Centre of Precision Rehabilitation for Spinal Pain, School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, UK
| | - Nicola R Heneghan
- Centre of Precision Rehabilitation for Spinal Pain, School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, UK
| | - Tim Noblet
- St Georges Hospital NHS Foundation Trust, London, UK.,Centre of Precision Rehabilitation for Spinal Pain, School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, UK
| | - Deborah Falla
- Centre of Precision Rehabilitation for Spinal Pain, School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, UK
| | - Alison Rushton
- Centre of Precision Rehabilitation for Spinal Pain, School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, UK.
| |
Collapse
|
19
|
Fernández-de-las-peñas C, Arias-Buría JL, Ortega-Santiago R, De-la-Llave-Rincón AI. Understanding central sensitization for advances in management of carpal tunnel syndrome. F1000Res 2020; 9:F1000 Faculty Rev-605. [PMID: 32595941 PMCID: PMC7308881 DOI: 10.12688/f1000research.22570.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2020] [Indexed: 12/27/2022] Open
Abstract
Carpal tunnel syndrome is the most common nerve compression disorder of the upper extremity, and it is traditionally considered a peripheral neuropathy associated with a localized compression of the median nerve just at the level of the carpal tunnel. Surgery and physiotherapy are treatment approaches commonly used for this condition; however, conflicting clinical outcomes suggest that carpal tunnel syndrome may be more complex. There is evidence supporting the role of peripheral nociception from the median nerve in carpal tunnel syndrome; however, emerging evidence also suggests a potential role of central sensitization. The presence of spreading pain symptoms (e.g. proximal pain), widespread sensory changes, or bilateral motor control impairments in people presenting with strictly unilateral sensory symptoms supports the presence of spinal cord changes. Interestingly, bilateral sensory and motor changes are not directly associated with electrodiagnostic findings. Other studies have also reported that patients presenting with carpal tunnel syndrome exhibit neuroplastic brainstem change supporting central sensitization. Current data would support the presence of a central sensitization process, mediated by the peripheral drive originating in the compression of the median nerve, in people with carpal tunnel syndrome. The presence of altered nociceptive gain processing should be considered in the treatment of carpal tunnel syndrome by integrating therapeutic approaches aiming to modulate long-lasting nociceptive barrage into the central nervous system (peripheral drive) and strategies aiming to activate endogenous pain networks (central drive).
Collapse
Affiliation(s)
- César Fernández-de-las-peñas
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain
- Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - José L Arias-Buría
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain
- Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - Ricardo Ortega-Santiago
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain
- Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - Ana I De-la-Llave-Rincón
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain
- Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| |
Collapse
|
20
|
Mistry J, Falla D, Noblet T, Heneghan NR, Rushton AB. Clinical indicators to identify neuropathic pain in low back-related leg pain: protocol for a modified Delphi study. BMJ Open 2020; 10:e033547. [PMID: 32071181 PMCID: PMC7045101 DOI: 10.1136/bmjopen-2019-033547] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Neuropathic low back-related leg pain (LBLP) can be a challenge to healthcare providers to diagnose and treat. Accurate diagnosis of neuropathic pain is fundamental to ensure appropriate intervention is given. However, to date there is no gold standard to diagnose neuropathic LBLP. A Delphi study will therefore be conducted to obtain an expert-derived consensus list of clinical indicators to identify a neuropathic component to LBLP. METHODS/ANALYSIS Included participants will be considered experts within the field as measured against a predefined eligibility criterion. Through an iterative multistage process, participants will rate their agreement with a list of clinical indicators and suggest any missing clinical indicators during each round. Agreement will be measured using a 5-point Likert scale. Descriptive statistics will be used to measure agreement; median, IQR and percentage of agreement. A priori consensus criteria will be defined for each round. Data analysis at the end of round three will enable a list of clinical indicators to be derived. ETHICS AND DISSEMINATION Ethical approval was gained from the University of Birmingham (ERN_19-1142). On completion of the study, findings will be disseminated in a peer-reviewed journal and presented at relevant conferences.
Collapse
Affiliation(s)
- Jai Mistry
- Physiotherapy, St Georges Hospital NHS Foundation Trust, London, UK
- Centre of Precision Rehabilitation for Spinal Pain, School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Deborah Falla
- Centre of Precision Rehabilitation for Spinal Pain, School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Tim Noblet
- Physiotherapy, St Georges Hospital NHS Foundation Trust, London, UK
- Centre of Precision Rehabilitation for Spinal Pain, School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Nicola R Heneghan
- Centre of Precision Rehabilitation for Spinal Pain, School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Alison B Rushton
- Centre of Precision Rehabilitation for Spinal Pain, School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| |
Collapse
|
21
|
Andersen Hammond E, Pitz M, Steinfeld K, Lambert P, Shay B. An Exploratory Randomized Trial of Physical Therapy for the Treatment of Chemotherapy-Induced Peripheral Neuropathy. Neurorehabil Neural Repair 2020; 34:235-246. [PMID: 31976819 DOI: 10.1177/1545968319899918] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background. Chemotherapy-induced peripheral neuropathy (CIPN) is a common side effect of taxane treatment and cannot currently be prevented or adequately treated. Physical therapy is often used for neural rehabilitation following injury but has not been evaluated in this patient population. Methods. Single-blind, randomized controlled exploratory study compared standard care to a physical therapy home program (4 visits) throughout adjuvant taxane chemotherapy for stage I-III patients with breast cancer (n = 48). Patient questionnaires and quantitative sensory testing evaluated the treatment effect throughout chemotherapy to 6 months post treatment. Nonrandomized subgroup analysis observed effect of general exercise on sensory preservation comparing those reporting moderate exercise throughout chemotherapy to those that did not exercise regularly. Clinical Trial Registration. clinicaltrials.gov (NCT02239601). Results. The treatment group showed strong trends toward less pain (odds ratio [OR] 0.41, 95% confidence interval [CI] 0.17-1.01; P = .053) and pain decreased over time (OR 0.85, 95% CI 0.76-0.94; P = .002). Pain pressure thresholds (P = .034) and grip dynamometry (P < .001) were improved in the treatment group. For the nonrandomized subgroup analysis, participants reporting general exercise had preservation of vibration (Left P = .001, Right P = .001) and normal heat pain thresholds (Left P = .021, Right P = .039) compared with more sedentary participants. Conclusion. Physical therapy home program may improve CIPN pain in the upper extremity for patients with breast cancer, and general exercise throughout chemotherapy treatment was observed to have correlated to preservation of sensory function. Further research is required to confirm the impact of a physical therapy home program on CIPN symptoms.
Collapse
Affiliation(s)
| | - Marshall Pitz
- University of Manitoba, Winnipeg, Manitoba, Canada.,CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | | | | | - Barbara Shay
- University of Manitoba, Winnipeg, Manitoba, Canada
| |
Collapse
|
22
|
Caamaño-Barrios LH, Galán-Del-Río F, Fernández-de-Las-Peñas C, Cleland JA, Plaza-Manzano G, Ortega-Santiago R. Evaluation of neurodynamic responses in women with frequent episodic tension type headache. Musculoskelet Sci Pract 2019; 44:102063. [PMID: 31542684 DOI: 10.1016/j.msksp.2019.102063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 09/07/2019] [Accepted: 09/16/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Current theories associated with the cause of tension type headache are mostly focused on muscle tissues. No study has investigated the presence of role of nerve tissues in this population. OBJECTIVE Our aim was to examine the responses to different mechanical provocation tests of the nerve tissues in women with tension type headache when compared to healthy women. DESIGN A case-control cross-sectional study. METHODS Differences in range of motion and sensory responses (intensity and location) during the Passive Straight-Leg Raise Test (SLR), Long Sitting Slump test (LSS) and Seated Slump test (SLT) were assessed in 32 women with frequent episodic tension type headache (FETTH) and 32 age-matched healthy women. RESULTS Women with FETTH demonstrated bilateral and significantly reduced range of motion in all tests (P < 0.001) and also higher sensory responses in the LSS and SLT (both P < 0.001), but not in the SLR (all P > 0.422), compared to the healthy women. The location of sensory responses was also significantly different for the SLT (P < 0.05). CONCLUSION The current study observed generalized lower mechanical pain thresholds to different provocation tests of the nerve tissues in women with FETTH supporting the presence of heightened nerve sensitivity to mechanical stimuli in this population. Future trials should investigate the efficacy of neurodynamic techniques in the clinical evolution of TTH.
Collapse
Affiliation(s)
- Leandro H Caamaño-Barrios
- Escuela Internacional de Doctorado, Universidad Rey Juan Carlos, Madrid, Spain; Department of Physical Therapy, Escuela Universitaria Gimbernat, Cantabria, Spain
| | - Fernando Galán-Del-Río
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Madrid, Spain; Cátedra de Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, Madrid, Spain
| | - César Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Madrid, Spain; Cátedra de Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, Madrid, Spain.
| | - Joshua A Cleland
- Physical Therapist, Rehabilitation Services, Concord Hospital, NH, USA; Faculty, Manual Therapy Fellowship Program, Regis University, Denver, CO, USA; Department of Physical Therapy, Franklin Pierce University, Manchester, NH, USA
| | - Gustavo Plaza-Manzano
- Department Radiology, Rehabilitation and Physiotherapy, Universidad Complutense de Madrid, Madrid, Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Madrid, Spain
| | - Ricardo Ortega-Santiago
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Madrid, Spain; Cátedra de Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, Madrid, Spain
| |
Collapse
|
23
|
Normalization of Spinal Cord Displacement With the Straight Leg Raise and Resolution of Sciatica in Patients With Lumbar Intervertebral Disc Herniation: A 1.5-year Follow-up Study. Spine (Phila Pa 1976) 2019; 44:1064-1077. [PMID: 30985566 DOI: 10.1097/brs.0000000000003047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A controlled radiologic follow-up study. OBJECTIVE The aim of this study was to ascertain whether changes in cord excursion with straight leg raise test (SLR) at 1.5-year follow-up time accompany changes in clinical symptoms. SUMMARY OF BACKGROUND DATA Lumbar intervertebral disc herniation (LIDH) is known to be a key cause of sciatica. Previously, we found that a significant limitation of neural displacement (66.6%) was evident with the SLR on the symptomatic side of patients with subacute single level posterolateral LIDH. METHODS Fourteen patients with significant sciatic symptoms due to a subacute single-level posterolateral LIDH were reassessed clinically and radiologically at 1.5 years follow-up with a 1.5T MRI scanner. Displacement of the conus medullaris during the unilateral and bilateral SLR was quantified reliably with a randomized procedure and compared between SLRs and to data from baseline. Multivariate regression models and backward variable selection method were employed to identify variables more strongly associated with a decrease in low back pain (LBP) and radicular symptoms. RESULTS Compared with previously presented baseline values, the data showed a significant increase in neural sliding in all the quantified maneuvers (P ≤ 0.01), and particularly of 2.52 mm (P ≤ 0.001) with the symptomatic SLR.Increase in neural sliding correlated significantly with decrease of both radicular symptoms (Pearson = -0.719, P ≤ 0.001) and LBP (Pearson = -0.693, P ≤ 0.001). Multivariate regression models and backward variable selection method confirmed the improvement of neural sliding effects (P ≤ 0.004) as the main variable being associated with improvement of self-reported clinical symptoms. CONCLUSION To our knowledge, these are the first noninvasive data to objectively support the association between increase in magnitude of neural adaptive movement and resolution of both radicular and LBP symptoms in in vivo and structurally intact human subjects. LEVEL OF EVIDENCE 2.
Collapse
|
24
|
Caamaño-Barrios LH, Galán-del-Río F, Fernández-de-las-Peñas C, Plaza-Manzano G, Arendt-Nielsen L, Ortega-Santiago R. Widespread Pressure Pain Sensitivity over Nerve Trunk Areas in Women with Frequent Episodic Tension-Type Headache as a Sign of Central Sensitization. PAIN MEDICINE 2019; 21:1408-1414. [DOI: 10.1093/pm/pnz146] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Abstract
Objective
Previous studies reported the presence of widespread pressure pain sensitivity in patients with tension-type headache. However, most of the studies assessed pressure pain sensitivity over muscle tissue. Our aim was to investigate the difference in pressure pain sensitivity over musculoskeletal and nerve symptomatic and distant areas between women with frequent episodic tension-type headache (FETTH) and healthy subjects.
Methods
Thirty-two women with FETTH and 32 matched healthy women participated. Pressure pain threshold (PPT) was bilaterally assessed over several nerve trunks (greater occipital, median, radial, ulnar, common peroneal, tibialis posterior) and musculoskeletal structures (temporalis muscle, C5/C6 joint, tibialis anterior) by an assessor blinded to the subject’s condition. A four-week headache diary was used to collect the intensity, frequency, and duration of headache. The Hospital Anxiety and Depression Scale was used to determine anxiety and depressive levels.
Results
Analysis of covariance found lower widespread and bilateral PPTs over all nerve trunks and musculoskeletal structures in women with FETTH pain (P < 0.001). No significant effect of anxiety and depressive levels on PPTs was found (all P > 0.222). PPT over the temporalis muscle was significantly negatively correlated with headache intensity.
Conclusions
This study found widespread pressure pain hypersensitivity over both nerve trunks and musculoskeletal structures in women with FETTH, suggesting that the presence of central altered nociceptive processing is not just restricted to musculoskeletal areas, for example, muscles, but also pain evoked from directly provoking the nerve trunks by pressure. It is also possible that nerve tissue treatment could lead to a decrease in central sensitization and headache features.
Collapse
Affiliation(s)
- Leandro H Caamaño-Barrios
- Escuela Internacional de Doctorado, Universidad Rey Juan Carlos, Madrid, Spain
- Department of Physical Therapy, Escuela Universitaria Gimbernat Cantabria, Cantabria, Spain
| | - Fernando Galán-del-Río
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Madrid, Spain
| | - César Fernández-de-las-Peñas
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Madrid, Spain
- Cátedra de Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, Madrid, Spain
- CNAP, Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Gustavo Plaza-Manzano
- Department Radiology, Rehabilitation and Physiotherapy, Universidad Complutense de Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Madrid, Spain
| | - Lars Arendt-Nielsen
- CNAP, Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Ricardo Ortega-Santiago
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Madrid, Spain
- Cátedra de Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, Madrid, Spain
| |
Collapse
|
25
|
Stecco A, Pirri C, Stecco C. Fascial entrapment neuropathy. Clin Anat 2019; 32:883-890. [PMID: 31004463 DOI: 10.1002/ca.23388] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 04/16/2019] [Indexed: 12/26/2022]
Abstract
Entrapment neuropathies are debilitating clinical conditions, creating significant morbidity in the upper and lower extremities in terms of pain, sensory abnormalities, and motor weakness, becoming a challenge to diagnose and treat. Because entrapments can have multiple origins, a misinterpretation of anatomy during examination can lead to incorrect diagnosis and treatment. This review addresses understanding of the anatomy of fascia that can play an important role in this syndrome. There is a specific microenvironment around the nerve composed of connective tissues that include deep fascia, intermuscular septa, epineurium, and perineurium. The microenvironmental modifications can be translated into change in mobility with consequence decreasing of the independency of the nerve from the surrounding structures lading to entrapments and "internal stretch lesion." The entrapments reported in this article reinforce the importance of fascia tissue in generating common symptoms that pose more difficult diagnostic challenges and may often be confused with more common clinical conditions. Clin. Anat. 32:883-890, 2019. © 2019 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Antonio Stecco
- RUSK Rehabilitation, New York University School of Medicine, New York, New York
| | - Carmelo Pirri
- Physical and Rehabilitation Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Carla Stecco
- Molecular Medicine Department, University of Padua, Padua, Italy
| |
Collapse
|
26
|
Escaloni J, Young I, Loss J. Cupping with neural glides for the management of peripheral neuropathic plantar foot pain: a case study. J Man Manip Ther 2019; 27:54-61. [PMID: 30692843 DOI: 10.1080/10669817.2018.1514355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background/purpose: Plantar foot pain of neural origin is a challenging diagnosis to identify and treat. The purpose of this paper is to illustrate the novel way in which cupping was utilized in conjunction with neural glides to better diagnose and manage a patient who presented with symptoms of peripheral neuropathic plantar foot pain. Case description: A 65-year-old male presented to physical therapy with the diagnosis of plantar fasciitis by an orthopedic surgeon. The presentation included a diffuse area of pain toward the medial border of the foot with a peripheral neuropathic pain description. Cupping was used to identify pain in the saphenous nerve distribution and aided in resolving symptoms with the concomitant use of lower quarter neural glides. Outcome: At discharge and 1-year follow-up, the patient had a full resolution of symptoms and a return to prior level of function. Self-report outcomes included the numeric pain rating scale and the lower extremity functional scale. Discussion: This case is the first to describe the use of cupping combined with neural glides in the diagnosis and management of peripheral neuropathic pain from the saphenous nerve that was previously diagnosed as plantar fasciitis. The proposed mechanisms behind this treatment are also reviewed. Conclusion: In patients that present with symptoms of plantar fasciitis, testing neural glides combined with cupping may be warranted to confirm or refute the presence of a peripheral neuropathic pain source. Further studies are necessary to determine the mechanisms and further utility of the combined interventions in well controlled trials. Level of Evidence: Level IV.
Collapse
Affiliation(s)
| | - Ian Young
- CORA Physical Therapy, Savannah, GA, USA
| | | |
Collapse
|