Movement Pain PT

17/08/2024

Just published 💥

How to Distinguish Non-Inflammatory from Inflammatory Pain in Rheumatoid Arthritis (RA)?

👉 Rheumatoid arthritis is a chronic, inflammatory, autoimmune disease that mainly affects joints but is known to have extra articular effects on pulmonary, nervous and cardiovascular systems. (https://pubmed.ncbi.nlm.nih.gov/22150039/)

👉 In RA, pain is often disproportionate to disease activity measures and frequently persists even where clinical, biochemical and imaging evidence of inflammation has resolved. (https://pubmed.ncbi.nlm.nih.gov/32841455/)

📘 In a brand-new publication, Khot and colleagues outline the latest research relevant to distinguishing non-inflammatory from inflammatory RA pain and review the current understanding of its neurobiology and management. (https://pubmed.ncbi.nlm.nih.gov/39120749/)

👉 The authors use the term 'inflammatory pain' to describe pain that is proportionate to the level of RA activity, as measured by inflammatory markers and joint imaging, and 'non-inflammatory pain' to describe pain disproportionate to RA presentation.

🔥 Inflammatory joint pain in RA is a type of nociceptive pain initiated by pro-inflammatory mediators such as prostaglandins, bradykinins and neurotrophic growth factors released during synovial inflammation (https://pubmed.ncbi.nlm.nih.gov/11460811/). These proinflammatory mediators induce an inflammatory cascade and the synoviocytes interact with cells of the adaptive and innate immune system further causing a hyperplastic synovium, bone erosions and cartilage destruction. (https://pubmed.ncbi.nlm.nih.gov/29736302/).

🔥 Nociceptors innervating the synovium and subchondral bone are responsible for arthritic pain; these include joint nociceptors specialised in the detection of chemical stimuli, including the above inflammatory mediators, as well as mechanical or thermal noxious stimuli (https://pubmed.ncbi.nlm.nih.gov/30128836/). Inflammation sensitises nociceptors to noxious and innocuous stimulation reducing firing thresholds.

🔥 Inflammatory pain tends to be worse after inactivity so typically early morning (> 30 min). It is also associated with stiffness. Joint swelling and tenderness are the signs and symptoms of synovial membrane inflammation following immune activation and can be elicited via clinical examination and imaging (e.g. joint ultrasound).

🔥 Elevations of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level are consistent with the presence of an inflammatory state and can reflect the degree and extent of (local) synovitis and systemic inflammation in RA.

💡 Unsurprisingly, raised CRP levels are also associated with greater pain in RA (https://pubmed.ncbi.nlm.nih.gov/33385862/). Interestingly, systemic inflammation and autoimmunity are detectable several years prior to the onset of detectable joint inflammation (https://pubmed.ncbi.nlm.nih.gov/24247116/) and autoantibody positivity and pain is highly predictive for development of RA (https://pubmed.ncbi.nlm.nih.gov/26395501/), suggesting pain symptoms may precede diagnosis of RA, and highlighting the nuanced dichotomy of inflammatory and non-inflammatory pain.

🧠 A third of patients diagnosed with RA report significant and severe widespread pain (out of proportion to measures of systemic inflammation (https://pubmed.ncbi.nlm.nih.gov/32841455/). This out-of-proportion pain is often labelled 'non-inflammatory'.

🧠 Non-inflammatory pain in RA rarely presents in isolation but instead is usually found alongside inflammatory pain aetiologies in something of a continuum. There is evidence that non-inflammatory and inflammatory pain share common aetiologies during the earlier stages of the disease, with pro-inflammatory pathways causing hyper-nociception in early RA and providing an environment for the potential development of nociplastic pain.

🧠 Non-inflammatory pain in rheumatoid arthritis (RA) is maintained via altered nociceptive processing in the central nervous system (CNS). This manifests as pain out of proportion to underlying RA disease activity, including nociceptive amplification from joint inflammation and from typically innocuous stimuli (e.g. pressure delivered to non-joint regions, such as the medial border of the scapula).

🧠 Nociplastic pain mechanisms are often obscure, however risk factors for nociplastic pain are well described: family history, past pain experience, and psycho-social factors including psychological, emotional and physical trauma, are all recognised to increase the risk of developing nociplastic pain. An 'initiating' risk-factor may be considered a 'trigger', and include stressors that might be psychosocial, or as is often the case for secondary fibromyalgia in RA, underlying inflammatory disease (https://pubmed.ncbi.nlm.nih.gov/34062144/). Pain severity disproportionate to RA disease activity, disabling fatigue, sleep disturbances or unrefreshed sleep, mood disturbances/disorders, neuropathic symptoms, brain fog, worsening physical and mental health, are all clues indicative of nociplastic pain. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886964/, https://pubmed.ncbi.nlm.nih.gov/27659057/)

💡 Maintaining a high index of suspicion for presence of non-inflammatory pain in early RA is key to instituting an early biopsychosocial approach to patient assessment and promoting appropriately combined pharmacological and non-pharmacological therapeutic modalities early in the course of their disease (https://pubmed.ncbi.nlm.nih.gov/34062144/, https://pubmed.ncbi.nlm.nih.gov/37372912/). The NICE Chronic Pain Guidelines visual summary is helpful here (s. comments, https://www.nice.org.uk/guidance/ng193/resources/visual-summary-pdf-9073473517, https://www.nice.org.uk/guidance/ng193).

📷Illustration: Mechanisms of non-inflammatory pain in RA, https://pubmed.ncbi.nlm.nih.gov/39120749/

27/10/2023

Just published in PAIN 🔥

Effectiveness of neural mobilisation for the treatment of nerve-related cervicobrachial pain🙋‍♂️

👉 Neck pain is among the top 10 causes of global disability and among the top 5 causes of disability in middle-income and high-income countries, (https://pubmed.ncbi.nlm.nih.gov/30496104/) and the number of prevalent cases, incident cases, and years lived with disability continues to grow (https://pubmed.ncbi.nlm.nih.gov/32217608/).

👉 Fifty percent to 75% of patients will experience recurrent episodes in the following one to five years, (https://pubmed.ncbi.nlm.nih.gov/18204403/) and 68% will endure chronic pain (https://pubmed.ncbi.nlm.nih.gov/16103840/).

👉 Nerve-related cervicobrachial pain is more common than neck pain alone (up to two-thirds of people with neck pain may experience nerve-related cervicobrachial pain) and is associated with higher levels of disability (https://pubmed.ncbi.nlm.nih.gov/12973155/, https://pubmed.ncbi.nlm.nih.gov/27846187/).

👉 Pathophysiology and clinical presentation of nerve-related cervicobrachial pain differ between distinct subgroups. Nerve-related cervicobrachial pain secondary to painful cervical radiculopathy is caused by a lesion or disease involving the cervical nerve roots resulting in nerve conduction block and clinically manifests with pain and objective neurological deficits, such as dermatomal sensory loss, myotomal weakness, and hyporeflexia (https://pubmed.ncbi.nlm.nih.gov/30586071/, https://pubmed.ncbi.nlm.nih.gov/34333881/).

👉 Radicular pain is most likely evoked by ectopic discharges generated at a highly excitable dorsal root or its ganglion (https://pubmed.ncbi.nlm.nih.gov/19762151/, https://pubmed.ncbi.nlm.nih.gov/33992884/, https://pubmed.ncbi.nlm.nih.gov/32710604/) and can occur in the absence of loss of function (https://pubmed.ncbi.nlm.nih.gov/19762151/, https://pubmed.ncbi.nlm.nih.gov/33370389/).

👉 Patients with nerve-related cervicobrachial pain may also present with signs of heightened neural mechanosensitivity, which manifests clinically by pain in response to limb movements causing nerve elongation and by local tenderness of nerve trunk palpation (https://pubmed.ncbi.nlm.nih.gov/23364214/, https://pubmed.ncbi.nlm.nih.gov/22980746/). In this situation, in the absence of any nerve damage and presence of normal nerve, pain is most likely nociceptive, caused by the activation of peripheral nerve connective tissue nociceptors (https://pubmed.ncbi.nlm.nih.gov/35050963/, https://pubmed.ncbi.nlm.nih.gov/10392853/).

👉 Neural mobilisation (NM) has been advocated for the treatment of nerve-related cervicobrachial pain (https://pubmed.ncbi.nlm.nih.gov/12151246/, https://pubmed.ncbi.nlm.nih.gov/28704626/).
Neural mobilisation involves either active or passive specific movements of the limbs and/or the spine that aim to mobilise the nervous system itself or facilitate movement between neural structures and its surrounding tissues.

👉 Biomechanically, NM may be divided into tensioners, where movements of 2 or more joints longitudinally load the neural tissue in opposite directions (eg, cervical contralateral side flexion and elbow/wrist extension), or sliders, where loading created by movement of one joint is counterbalanced by movement of other joints (eg, cervical contralateral side flexion and elbow/wrist flexion). In vivo studies in human participants have shown that the former cause greater strain of the nerve and lower longitudinal excursion, whereas the latter cause lower strain and greater longitudinal excursion (https://pubmed.ncbi.nlm.nih.gov/26304637/, https://pubmed.ncbi.nlm.nih.gov/17398140/, https://pubmed.ncbi.nlm.nih.gov/22711174/).

💡 Lascurain-Aguirrebena and colleagues published a brand-new systematic review with subgroup meta -analysis concerning the question, what types of patients with nerve-related cervicobrachial pain (if any) may benefit. https://journals.lww.com/pain/abstract/9900/effectiveness_of_neural_mobilisation_for_the.435.aspx

🔀Studies were classified according to their inclusion/exclusion criteria as radiculopathy, Wainner cluster, Hall, and Elvey cluster or other.

➡ Studies were classified as Wainner cluster if their inclusion criteria was based on the reported specific cluster of signs by Wainner et al. (https://pubmed.ncbi.nlm.nih.gov/12544957/) where at least 3 of the following 4 tests had to be positive:
1. upper limb neurodynamic test;
2. ipsilateral cervical rotation range of movement ,60˚;
3. distraction test;
4. Spurling test (s. picture)

➡ Studies were classified as Hall and Elvey cluster if their inclusion criteria made reference to the cluster of signs proposed by Hall and Elvey (https://pubmed.ncbi.nlm.nih.gov/10509060/):
1. reduced active/passive cervical range of movement;
2. evidence of heightened neural mechanosensitivity (positive upper limb neurodynamic test); and
3. evidence of local cervical dysfunction (eg, through intervertebral movement testing).

➡ Studies not suitable for any of these subgroups (ie, the above criteria were not met) were classified as other.

📊 Twenty-seven studies were included. For pain and disability reduction, NM was found to be more effective than no treatment, increased the effectiveness of standard physiotherapy as an adjuvant when compared with standard physiotherapy alone, but was not more effective than cervical traction. NM was found to be more effective than exercise.

👉 For exact effect sizes and 95% confidence intervals, s. comments

📊 Consistently, NM was more effective than all alternative interventions (no treatment, traction, exercise, and standard physiotherapy alone) in 13 out of 14 studies classified as Wainner cluster, of which all but one (that reported no difference) reported more favourable outcomes following NM.

📊 Effect sizes were small (pain) to moderate (disability) when compared with traction, moderate (pain and disability) when compared with standard physiotherapy alone, and large when compared with no treatment (pain and disability) and exercise (disability).

📊 Although limited to a single study (https://scholar.cu.edu.eg/?q=nawal/publications/multimodal-intervention-high-intensity-laser-neurodynamic-mobilization-cervical-r), this finding is in agreement with 2 previous studies (https://pubmed.ncbi.nlm.nih.gov/23633626/, https://pubmed.ncbi.nlm.nih.gov/21116662/) that have noted poorer outcome following NM in patients with radiculopathy.

☝️ Take away:

NM seems to be more effective in patients with cervicobrachial pain who fulfil the criteria of Wainner, although with a low certainty of evidence. None of the cluster signs by Wainner are indicative of a loss of function, they rather indicate a GAIN OF FUNCTION as pain provocative manoeuvres.

NM might be less effective in patients cervicobrachial pain and a LOSS OF FUNCTION (cervical radiculopathy).

15/10/2023

Exercise-based intervention as a nonsurgical treatment for patients with (radial) carpal instability ✋🤚
https://pubmed.ncbi.nlm.nih.gov/37777444/

✋Carpal instability is one of the most common conditions affecting the hand and wrist region and is usually caused by ligamentous laxity, overuse due to sports or repetitive motion work, or secondary to trauma (eg, sprains or fractures of the wrist or carpal bones). https://pubmed.ncbi.nlm.nih.gov/27633260/, https://www.sciencedirect.com/science/article/pii/S0363502319314728

✋The cumulative incidence of carpal instability, as defined by radiological assessments and clinical provocation testing, can be as high as 44% in the second year after injury in people who have fallen on an outstretched hand. https://www.sciencedirect.com/science/article/pii/S0268089007000722

✋ Carpal instability can be classified into radial, ulnar, or midcarpal instability. https://pubmed.ncbi.nlm.nih.gov/33509029/
Radial instability is characterized by partial or complete injury to the scaphoid-lunate ligament, which may lead to carpal instability, that is, dorsal rotation of the triquetrum and lunate, while the scaphoid rotates in the volar direction. This deformity pattern is referred as dorsal intercalated segment instability (DISI). https://pubmed.ncbi.nlm.nih.gov/33509029/

✋The clinical presentation, which is sometimes delayed, is characterized by radial sided wrist pain, edema, sensation of instability, and loss of function. https://pubmed.ncbi.nlm.nih.gov/23678318/

✋In general, surgery is not indicated in cases of mild impairment with preserved range of motion and handgrip strength (eg, >80% of contralateral hand). Although the important role of proprioception and neuromuscular control in carpal instabilities and their potential implications for rehabilitation is well recognized, https://pubmed.ncbi.nlm.nih.gov/26115684/, only a few studies have transferred this knowledge in clinical practice. https://pubmed.ncbi.nlm.nih.gov/19963343/, https://pubmed.ncbi.nlm.nih.gov/27264903, https://pubmed.ncbi.nlm.nih.gov/29922497/, https://journals.sagepub.com/doi/10.1177/1758998316685469

👉 Cheuquelaf-Galaz and colleagues published a brand-new case series of an exercise-based intervention as a nonsurgical treatment for 39 adult patients with carpal instability, combining proprioceptive and strengthening exercises (s. figure, https://pubmed.ncbi.nlm.nih.gov/37777444/).

Patients with radial carpal instability performed strengthening exercises of the following muscles (s. figure):

1⃣ Abductor pollicis longus, using an elastic band to provide resistance to the thumb separation movement;
2⃣ Extensor carpi radialis longus (ECRL), by means of wrist extension movement with slight radial deviation favoring supination of the distal row of the carpus;
3⃣ Flexor carpi radialis (FCR): radial deviation with the forearm in neutral pronosupination position, which allows scaphoid supination; https://pubmed.ncbi.nlm.nih.gov/27264901/and
4⃣ Pronator quadratus: strengthening starting in neutral pronosupination position, advancing to supination and then returning to neutral position, in order to keep the distal radioulnar joint stable. https://pubmed.ncbi.nlm.nih.gov/1018088/, https://pubmed.ncbi.nlm.nih.gov/28751170/

👉 Training was initiated with small loads (0.25 and 1 kg, reps. only the weight of the hand if patiens experienced a feeling of instability with these loads). https://pubmed.ncbi.nlm.nih.gov/30905496/
👉 The exercise volume was 4 sets of 8-10 repetitions with emphasis on the eccentric phase, 1 min rest between the sets, with a progressive load increase of 20% every 1-2 weeks. All patients received treatment for 6-8 weeks, with 2-3 weekly sessions.
👉 Patients were asked to perform the exercise in a range of motion where a feeling of stability was perceived in the affected area or minimal pain (ie,

22/01/2023

Nearly one-fourth of patients undergoing lumbar discectomy demonstrated radiographic evidence of recurrent disc herniation at the level of prior surgery, the majority of which were asymptomatic.
Asymptomatic disc herniation was not associated with clinical consequences by 2 years.

https://pubmed.ncbi.nlm.nih.gov/21343849/

24/11/2022

Here is the third of our Achilles Tendinopathy exercise program from the upcoming

Collections will take the hard work out of having to trawl the web for trustworthy information when it comes to answering clinical questions 🙌

The first one is on

Learn more here 👉 http://ow.ly/nfFJ50LFrkK

21/11/2022

🚨What should we being doing for ACL rehabilitation? 🤷‍♀️

NEW summarises the findings from the recent OPTIKNEE systematic review

See the below for the ✅

👉 https://bit.ly/3g5Adrc

28/08/2022

A lot of very good ideas have had a positive influence on clinical practice. Simple concepts such as washing one’s hands, restricting unnecessary care from those who don’t need it, […]

24/10/2021

25/09/2021

It is essential for clinicians to include behavioural change in the management of people with musculoskeletal problems and provide ways of working collaboratively with the patient to identify WHAT needs to change and HOW it could be introduced!

https://www.sciencedirect.com/science/article/abs/pii/S0031940621000572

20/08/2021

The role of social as a predictor of future pain is often underestimated. On the other hand, often issues such as posture and movement patterns are hype. 🤦🏻‍♂️

Where do we go from here?

Pain and loneliness are consistently associated, but the direction of the relationship is uncertain. We assessed bidirectional associations over a 4-year period in a sample of 4906 men and women (mean 65.1 ± 8.72 years) who were participants in the English Longitudinal Study of Ageing. The role of ...

09/08/2021

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