Pelvic
PT distance journal club 3/5/14
Beth
Shelly PT, DPT, WCS, BCB PMD
Mechanism
based clinical guidelines using medical diagnosis and history, clinical
examination
·
Primary
hyperalgesia - acute pain - several days - sensitization of the nociceptors to
protect from further damage - local phenomenon
·
Secondary
hyperalgesia - chronic pain - increased
responsiveness of dorsal horn neurons in the spinal segments of the primary
nociceptors - central sensitization
Central
sensitization (CS) - defined by Meyer 1995 - "an augmentation of
responsiveness of central neurons to input from unimodal and polymodal
receptors."
·
Altered
sensory processing in the brain
·
Impaired
descending inhibition of pain
·
Overactive
ascending pain facilitatory pathways
·
Temporal
summation of secondary pain = wind up
·
Long
term enhancement of synapses in some areas of the brain
·
Net
result
o Augmented
nociceptive signal
o Increase
responsiveness to a variety of peripheral stimuli
o Decrease
tolerance of senses
Figure
2 gives decision tree
1.
Medical diagnosis - it is not possible to label CS only be the medial
diagnosis. Fibromyalgia and chronic
fatigue syndrome most often include CS.
Other diagnosis like chronic LBP, chronic whiplash, TMJ, MF pain, OA,
RA, chronic HA and IBS may have CS components.
Presence of these diagnosis should alter PT to look for other
indications of CS
2.
History taking
·
Generalized
increased responsiveness and decreased tolerance of a variety of stimuli - 2 or
3 of these warrant further investigation of CS
o Hypersensitivity
to bright lights, sound, smell
o Hypersensitivity
to chemicals, pesticides, medication
o Hypersensitivity
to hot or cold
o Hypersensitivity
to pressure, touch, mechanical loading - active / passive movement
o Increased
responsiveness to stress, emotions, and mechanical load
·
Possibly
related
o Fatigue,
concentration difficulties
o Sleep
disturbances, un-refreshing sleep
o Swollen feeling,
tingling, numbness
·
Pre-existing
pain - local or generalized, in any area of the body before the onset of the
current pain increases the possibly of CS
·
Abnormal
disease course - slow recovery, recurrent pain
3.
Examination - diagnose, establish severity, monitor progress and response to
treatment, determine treatment parameters
·
Pressure
pain threshold at sites remote to symptoms - pressure algometer showing
pressure pain threshold below 4 kg/cm2
·
Sensitivity
to touch at sites remote to symptoms
·
Pain
in response to cold pack at sites remote to symptoms
·
Pain
in response to vibration at sites remote to symptoms
·
Heightened
bilateral brachial plexus provocation - inconsistent pain with provocation
·
Heighten
pain in comparison to pressure or tension at end feel - ie small stretch with large pain
·
Increased
pain response to exercise
4.
Analyzing treatment response - CS may become apparent during treatment often
with increased physical and emotional stress. Treatment including too
aggressive MFR, exercise, mobs may contribute to the development of CS
·
New
symptom development
·
Expansion
and aggravation of symptoms
·
Altered
treatment response
o Non-responder
o Post-exertional
malaise
o Decreased pain
threshold in manual treatments
Mechanisms-based
Classifications of Musculoskeletal pain (Hilton 2011, Smart 2011 'chronic
LBP')
·
There is no direct measure or single assessment
tool
·
Predictive rules are about 90% to 96% accurate -
do your best and watch for evidence of an incorrect judgment
·
Can have combinations of various classifications
- 50/50 or 40/60 etc
Nociceptive pain
·
Often found in acute pain and inflammation
states
·
Strongest predictor - symptoms localized to area
of injury or dysfunction even with some somatic referral.
·
Second most important criterion - absence of
dysesthesias
·
Pain usually intermittent and sharp with
movement
·
Maybe constant, dull, throb with rest
·
Aggravating and easing factors follow common
musculoskeletal pattern
·
Responds easily to mechanical treatment
·
Absence of burning, shooting, electrical shock
pain, night pain
·
Pain generators include: inflammation / chemical
irritation, ischemic / trigger points, mechanical pain
Peripheral neuropathic pain or peripheral sensitization (ie
pudendal neuralgia)
·
Strongest predictor - pain referred in a
dematomal or cutaneous pattern
·
Adverse neural tension signs – parasthesia,
itching, dysesthesia
·
History of nerve injury, pathology or mechanical
injury to nerve
·
Local irritation, swelling, muscle spasm
·
Motor weakness
·
History of trauma with poor healing
·
Lack of typical response to mechanical treatment
·
Pain generators include: Mechano-sensitive,
ischemic-sensitive, chemo-sensitive, cross excitation
Central sensitization
·
Strongest predictor = disproportionate,
non-mechanical pain, and unpredictable pattern of pain provocation
·
Pain disproportionate to type of injury or
pathology
·
Pain longer than 12 weeks
·
Pain responds to stress and anxiety
·
Pain increased by small movement or no movement,
·
Diffuse and bilateral pain and tenderness
·
Burning shooting, crushing, non-dermatomal,
allodynia or hyperalgesia (painDETECT questionnaire)
·
Multiple systems involved – sleep, bladder,
bowel, muscles, joints, immune system
·
Depression, fear avoidance, catastrophization
·
Previous treatment failure
·
Pain generators: dorsal horn mediated, forebrain mediated descending facilitation,
loss of spinal cord inhibitory interneurons
Hilton S, Vandyken C. The puzzle of pelvic pain – a
rehabilitation framework for balancing tissue dysfunction and central
sensitization I: pain physiology and evaluation for the physical
therapist. J of Women’s health PT.
2011;35(3):103-113.
Smart KM, et al. The discriminative validity of
“nociceptive,” “peripheral neuropathic”, and “central sensitization” as
mechanism-based classifications of musculoskeletal pain. Clin J Pain
2011;27(8):655-663
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