PAIN SYNDROMES Clinical Features

 Pain
PAIN - occur in one or more extremities
- unpleasant sensory and emotional experience associated with actual or potential tissue damage - all tactile stimulation of the skin mahy be perceived as painful
- sensation that demands to be felt - paroxysmal dysesthesias and lancinating pain
- considered to be the 5th vital sign - burning deep aching pain
- Allodynia: abnormal interpretating of sensation
Chronic Pain  Skin Changes
- pain that still persists 3-6months after the initiating event - skin: shiny, dry or scaly
- hair: may intially grow coarse and then thin
Biopsychosocial - Nails: more brittle, groq faster and then slower
- pain is influence by the social factos and etc. - rushes, pustulkes and ulcers
- abnormal sympathetic activity
CHRONIC REGIONAL PAIN SYNDROME - Hyperhidrosis: increase in sweating —> sudomotor changes
 Swelling
Types - localized, initially pitting and later brawny
 Suddecks Atrophy - edema may be sharply demarcated along a line on the skin surface
 Sympathetic dyustrophy - more common anteriorly
 Algodystrophy  Movement Disorder
 Shoulder-Hand Syndrome - may develop dystonia
 Causalfia - tremors and incoluntary jerking of extremties may be present
- disuse atrophy sets in natural history
Features  Spreading Symtomes
- pain is out of proportion to the inciting cause - Continuity Type: going proximal but skips intervening joints
- vasomotor instability - Mirror- Image Type: contralateral side will be affected
- trophic skin changes (specific to the area of the CRPS) - Independent Type:
- regional osteoporosis - Total Body RSD: all parts of the body
- functional impairement (small movement could cause pain)
TYPES
Definition
- a multi-symptom, multi-system syndromw usually affectiong one or more extremities but may CRPS 1 CRPS 2
affecrsvirtually any part of the body - Suddecks - “causalgia”
- affects the sympathetic tract - occurs after the injury of the nerve
Etiology - skin changes, vasomotor problem - follow the distrubution of the nerve
- microtrauma - occurs after an illness or injury that did not
- ischemic heart disease and myocardial infarctions directrly damage a nervce oin the affectec are
- spinal cord disorderews a
- cerebral lesions - pain, allodynia, hyperalgesia which is dispr
- infections oportionate to the intial
- surgery
Stages
Pathophysiology  Stage I: Acute
- abnormal tonic firing of the nociceptive pathway - last up to 3mos
- injury to tge central or peripheral tissue - burning pain with increasing sensitivity(hyperalghesia)
- elevated levels of soluble tumor necrosis factor receptor1 (sTNF-R1) and enhances tumor necro - pain scale: 1-4/10
sis factor alpha - more constant and long lasting even at sleep
TNF - followed by swelling and joint stiffness
- detect abnormal cell tissues - increase warmth and redness
- releases cytoskines - hair and nail has fater growth
- distal degeneration of small-diameter peripheral axons may be responsible for the pain, vasomo - hyperhidrosis - pseudomotor changes
tor ibnstability, edema, osteopenia and skin hypersensitivity of CRPS-1  Stage II: Dystrophic
- cortical changes, suggesting a possible role in pathophysiology - 3-12m months
 - pain becomes even more severe and more diffuse - most effective
- pain scale 5-7/10  Sympathetic Blockade
- swelling is more constant and skin wrinkles may disappear - uses medication injected to specific sympathic nerve that go to the leg on the same s
- skin temperature becomes cooler to touch ide of the injected part
- hair becomes coarse  Sympathectomy
- nails grows faster then slower until brittle - damaged sympathetic nerve is surgical cut or throught chemicals
- heavily grooved
- increase stiffness PT ASSESSMENT
- osteoposis occurs early but may become severe and diffuse but only limited to the ar - Patient History
e a - pain
- muscle wasting begins - integumentary
 Stage III: Atrophic - vital signs
- occurs after 1year - neuro assessment : sensation, Reflexes are intact so no need
- marked wasting of the tissues - musculo assessment : ROM, MMT, Functional Mechanism
- becomes irreversable
- diuse atrophy P T M A N A G E M E N T
- pain is intractable and may involve the entire limb
- may develop to generalized RSD  Mirror Therapy
- Psychoneuromuscualr Theory
Prognosis - mirror serves as an imagery
- better in young patients and with institution of early treatment - whatever the brain is imagining, the motor parts are also functioning
- if uhndiagnosed and untreated, CRPS can spread to all extremtiierws  Tactile Discrimination
- introduction of different sensation
Complication - indentification and familiarization of different stimulus
- deconditioning: muscle wasting, tightness, contractures due to immobilization  TENS
- depression - High Frequency: contralateral to the nerve injury reduces mechanical allodynia
- anger - Low Frequency: reduces thermal allodynia
- fatigue - electrical impulses are sent to the body throught electrodes that interfere with pain si
gnals
Diagnosis  Desensitization
- VAPs - familiarization of the different stimulus starting with soft texture to rough textures
- Body Diagram - sensation is felt over the pain and will eventually get used to it
- pain questionnaires: most common McGill pain Questionnaire
MYOFASCIAL PAIN SYNDROME
Medical Management - Chronic pain disorder due to repetitive activity of the patient
- pain associated with inflammation: NSAID agents - trigger point: pressure on sensitive parts in the muscles
- pain not associated with inflammation: agents acting on the CNS by an atypical mechanism, tra - referred pain: pain on seemingly inrelated parts of the body
madol - occurs in:
- parocysmal jabs and sleep disturbances: anti-depressants and oral lidocaine  Repeated contraction
- spontanepous parocysmal jabs: anti-convulsants  Repetitive motions used in job or hobbies
- severe pain: oral opoids  Stress-related tension in
- sympathetic maintained pain: clonidine patches Etiology
- muscle cramps(spasms or dystonia): clonazepam and baclofen - idiopathic
- LLD, poor posture, stress and muscle overuse
Surgical Managment - poor body mechanics resulting in excessive strain on muscles
 Regional Block - anxiety and depression
- torniquet the proximal part of the painful area for 20-30mins then injects guanathidi
ne to block sympathetic nerves then releasing the torniquet to spread to other areas Signs and symptoms
- increase HR: decrease BP due to sympathetic mechanism - deep aching pain in the muscles
 Morphine Pump - tender knot in the muscle (trigger point)
- morphine is injected in the spine to produce a generalize analgesia - clinical characteristics: referred pain and local twitch response (brisk contraction of a taut band
- effective for patients with Total RSD or Mirror-Image Type )
- pain that worsens  Mid point of the upper border of the trapezius
-  Supraspinatus above the scapular line
TRIGGER POINTS  Gluteal line the iupper quarter quadrant
 Active trigger point  Superior to the
- always sore leading to weakness and decreased ROM
 Latent trigger point PT MANAGEMENT
- does not cause pain in normal activites; more common - Hot bath for relaxation nightly for 20mins
 Key trigger point - NSAIDS
- one muscle that has a referral pattern along a nerve pathway - muscle relaxants : MPS
 Satellite trigger point - Antidepressants
- results of a key trigger point - Massage and trigger point release
 Primary & Secondary trigger point - muscle reeducation using biofeedback
- each trigger point is independent from each other but secondary occurs due to the pr - ultrasound
esence of the primary - injections of pain relieving medication into the trigger point
- pain management and relaxation techniques
FIBROMYALIGIA - laser
- non-inflammatory condition appearing with generalized pain in conjunction with tender to touc - shockwave
h - dry needling
- W > M ; female has lower pain tolerance - HMP
-tender point - IFC Tens

Pathophysiology
- genetics
- dysregulation of the neurohormonal and autonomic nervous system
- triggered by viral infection, traumatic events or stress
- inadequate thryoid hormones regulation

Signs and Synmptoms

- myalgia
- fatigue
- sleep disturbances
- restless leg syndrome
- 18 tender points on palpation
- chest wall pain
- temperature dysregulation
- headache
- morning stiffness
- paresthesia
- mechanical lbp
- weight gain
- cognitive difficulties

TENDER POINTS
- 11/18 activated upon palpation
- pain lasting more than 3mos
Anterior
 lower bilateral cervical at C5-C7
 2nd rib at second costochondral junction
 Lateral epicondyle
 Medial fat pad of the knee
Posterior
 Sub occipital