MSK II FINAL EXAM: Chronic Pain, CRPS, FM, TMJ, Pelvic health, Work comp, Fear Avoidance/CBT

What are the associations of transitioning from acute to chronic low back pain due to increased lumbar radiography?

-PCP/MDs prescribing patients opioids

-PCPs referring out for unnecessary imaging

-PCPs referring out for unnecessary referrals like a spine surgeon

What is the alarm system metaphor when trying to educate patients on their pain symptoms?

-Nerves in the body act as an "alarm system" in which it uses electrical signals to the brain to indicate a "danger" if there's pain provoking stimulus

-The nervous system can become hypersensitive if the patient is afraid of movement causing a smaller threshold to cause pain due to lack of movement

What triggers the nervous systems "alarm system"?

-Movement

-Negative thoughts/depression

- Fear Avoidance to movement

-Stress

-Change in temperature

-Lack of sleep

-Fear

What ramps up the nervous system's "alarm?"

-Failed treatment

-Different explanations for their ailment

-Job issues

-Ongoing pain

-Fear & Anxiety

-Family concerns

How does our choice of words affect a patient's perception of their pain/ailment?

-Avoid using medical terms in educating patients, as they have been more linked to causing patients to go for more invasive options like surgery

-Limit words like pain, herniation, wear and tear, disc degeneration, bone on bone, torn, bulging disc

-USE WORDS LIKE: Normal age related changes, wear and repair, hurt does not equal harm, you may be sore but safe

What type of exercise helps with chronic low back pain?

-ANY exercise based on patient or therapist preferences, therapist training cost and safety

-Physical inactivity is an INDEPENDENT RISK FACTOR for pain development

-Regular physical activity helps with reducing pain catastrophization in patients with LBP, reduces inflammatory cytokines and increases anti-inflammatory cytokines in dorsal horn, and reduces excitability and improves inhibition of brainstem and immune system for pain

What is motivational interviewing for chronic low back pain?

-Counseling method that helps people absolve ambivalent feelings and insecurities

-Find internal motivation needed to change behavior

-Goal = motivate the patient to change behavior

-Best for those unmotivated or unprepared for change

-Listen, reflect, and encourage without judgement

What is the acronym used for motivational interviewing (OARS) with chronic pain patients?

O- Open Ended Questions

A- Affirm

R-Reflective listening

S- Summarize patient's thoughts/story

-Helps decrease patient resistance and ambivalence (doubt)

-NEED TO CREATE A STRONG SUPPORTIVE AND EMPATHETIC RELATIONSHIP with patient to be affective

What are the psychological factors of chronic low back pain?

-Depression, anxiety, and fear have all been linked to persistent chronic low back pain if untreated or poorly managed

-Any psychological distress seems to lead to development of chronic LBP/pain overall

-Always address psychological symptoms

-Increased stress and lack of sleep all lead to chronic pain development

How can we silence the alarm system (nervous system) to calm it down for chronic pain patients?

-Acknowledge patient's feelings

-Address fear and anxiety

-Reassure and educate

-Build trust

-Provide compassion and empathy

-Calm work environment

What is the correlation of the financial impact on returning to full-time employment within the first 3 months of injury?

The longer someone is out of work from injury the longer it takes them to return to full-time employment

What is a functional capacity evaluation?

-Process typically takes 4-5 hours and involves:

-Subjective history

-MSK eval

-Material and non-material handling activities

-Evaluates psychosocial response to pain

-Effort and reliability testing with distracted observation to see if patient is truthfully depicting inability to work

What are important job descriptions needed during a workers comp evaluation?

-Essential functions needed to do join

-Materials handled during job

-Mobility needed during job

-Posture needed in a static position

-Other environmental differences

-Sensation requirements for job

-Personal protective equipment needed for job

What is the physical demand classification for a sedentary worker?

-Occasional: 10 pounds

-Frequent: 0 pounds

-Constant: 0 pounds

What is the physical demand classification for a light activity worker?

-Occasional: 20 pounds

-Frequent: 10 pounds

-Constant: 0 pounds

What is the physical demand classification for a medium activity worker?

-Occasional: 50 pounds

-Frequent: 25 pounds

-Constant: 10 pounds

What is the physical demand classification for a heavy activity worker?

-Occasional: 100 pounds

-Frequent: 50 pounds

-Constant: 20 pounds

What is the physical demand classification for a very heavy activity worker?

-Occasional: 100+ pounds

-Frequent: 50+ pounds

-Constant: 20+ pounds

What is the physical demand classification for the amount workday hours?

-Rare: 0.1 - 0.5 hours

-Occasional: 0.6-2.5 hours

-Frequent: 2.6-5.0 hours

-Constant: 5.1-8 hours

What is the physical demand classification for the amount mins worked per hour?

-Rare: 1-3 hours

-Occasional: 04-20 hours

-Frequent: 21-40 hours

-Constant: 41-60 hours

What is the physical demand classification for the amount mins worked per work day?

-Rare: 1-25 hours

-Occasional: 26-140 hours

-Frequent: 148-300 hours

-Constant: >63 hours

What is important information to collect during a workers comp subjective for an evaluation?

-Get all the details of injury and job duties

-Make sure to talk to and know who the nurse case manager is

-Understand dictionary definition for the workers job

-Talk to the occupational information network

-Do a detailed job analysis

How are goals and the plan of care established for worker's comp patients?

-Always ask yourself how continued therapy will improve patients chances to return to work (impairment vs function)

-Documents the patient's current physical demand classification as it pertains to the level needed to return to work (even if they are post-op day one)

-Define how specific therapeutic exercises and activities relate to essential function's of the job

-Use job descriptions and physical performance tests to set goals and determine plan of care

-ALWAYS TALK ABOUT ALL INJURIES RELATED TO INJURY EVEN IF NOT PRIMARY AILMENT

What objective measures are used to measure a workman's comp patient?

-Pain

-ROM

-MMT

-And how these three things effect their ADLs and job duties and responsibilities

What is the prevalence of fibromyalgia?

-Prevalence globally is 2.7%

-4:1 female to male ratio

-More likely in woman >/= 30 years old

What is "Indicator A" for diagnosing fibromyalgia?

Testing for generalized hyperalgesia by quantifying hyper-perceptive components of pain sensation using a standardized algometric measure

What is "Indicator B" for diagnosing fibromyalgia?

Examining the Widespread Pain Index (WPI) body chart for the fulfillment of bilateral axial pain symmetric pain distribution, usually fulfilled when there are >/= 3 pairs of WPI marks

What is "Indicator C" for diagnosing fibromyalgia?

Use of the symptom severity screen as a brief stress screen with the cut off of >/= 5. Decide whether a more detailed exploration of psychological stress is required.

What happens if a patient has three ABC indicators for fibromyalgia diagnosis?

Then it can be confirmed that the patient truthfully has fibromyalgia

What is the number of daily steps increased needed to improve fibromyalgia pain and function?

>5,000 steps from original daily step amount

What is the strongest predictor for widespread pain and fibromyalgia?

-Poor sleep increases pain, tenderness, and fatigue

-Long awake times

What interventions are beneficial for fibromyalgia?

-Aerobic conditioning

-Strength training

-Tai chi/yoga for improvement in pain, sleep, depression, quality of life through relaxation and mindfulness

-Aquatic therapy or exercise

-Massage/manual can help with pain, anxiety, and depression

-TENS for short term pain relief

-CBT for lifestyle changes and motivation to manage symptoms actively

-Educate on good nutrition and sleep

Do NSAIDs help with fibromyalgia?

No

Do opioids help with fibromyalgia?

No

Do cannabinoids help with fibromyalgia?

Yes, helps with pain and quality of life

What do tricyclic depressants do to help fibromyalgia patients?

Improves pain and quality of sleep

What do Serotonin and Norephinephrine Reuptake Inhibitors do to help fibromyalgia patients?

-Duloxetine: Improves pain and depression

-Minacipran: Improves and fatigue in 40% of patients

What do selective serotonin reuptake inhibitors (SSRIs) do to help fibromyalgia patients?

Fluoxetine: Improvement in pain, fatigue, depression, and overall symptoms

What do anti-epileptic drugs do to help with fibromyalgia?

-Gabapentin: Improves pain

-Pregabalin: Improves sleep disturbance, pain, fatigue, and quality of life

What is CRPS I?

-Reflex sympathetic dystrophy

-Occurs from a noxious/painful event in the distal part of the extremity

What is CRPS II?

-Causalgia

-Occurs from a known nerve injury that causes nerve damage

What are the characteristics of CRPS I?

-Occurs from a noxious event

-Changes in skin and blood flow with edema likely

-Can have hyperalgesia, allodynia, disproportionate pain

-Occurs from distal injury in an UE or LE

What are the characteristics of CRPS II?

-Region of limb after partial nerve injury or a branch innovating that region is damaged-Pain

-Burning sensation- Allodynia (light touch is painful)

What is the incidence of CRPS?

-3:1 female to male ration

-Peak age from 45-55-3:2 UE to LE ratio

What does the objective exam look like for a CRPS patient using the Budapest Criteria?

Use Budapest criteria:

-1. Sensation testing for allodynia, hyperalgesia, deep pressure tolerance

-2. Vasomotor testing for skin temperature changes and skin changes

-3. Sudomotor testing for edema and sweating of body region

-4. Motor testing for ROM, MMT< tremor, dystpnoa, trophic changes of skin, hair, nails, muscle length

-Neuro screen to rule out other diagnoses

-NEED 3/4 to diagnose CRPS

In stage 1 one of Graded Motor Imagery, what is Laterality Training in CRPS patients?

-Presented with photos of specific extremities in various postures and orientations

-Without adjusting the cards positioning, attempt to determine whether it is a right or left upper limb and sort the cards into 2 separate piles.

-When patient performs at 80% success rate or when deemed appropriate, they will be progressed to the next phase.

In stage 2 of Graded Motor Imagery, what is Explicit Motor Imagery in CRPS patients?

-25 of the 50 images (those which represent the affected side) will be used.

-In this phase, the participant will select and view a single card and then imagine moving the limb into a unique posture and imagine experiencing any relevant sensations

-The participant will repeat the procedure with all 25 photos (3x per visit or 10 total minutes)

In stage 3 of Graded Motor Imagery, what is Mirror Therapy in CRPS patients?

-During this phase, the participant will execute the movement depicted by the 25 cards representing the non-affected limb -They will move the non-affected limb slowly and gently, five to 10 times, while watching the reflection in the mirror

-The affected limb remains immobile, hidden in the mirror box -Therefore, the participant views the illusion of moving their injured hand and wrist

What are the benefits of mirror therapy in CRPS patients according to Louw 2017?

-Decreased pain castastrophization

-Decreased pain intensity

-Decreased fear avoidance

-Increased ROM by 14.5 degrees

How can CBT/Cognitive Functional Therapy help with chronic LBP?

-A personalized, behavioral, self‐ management approach:

-Helps make sense of pain from a biopsychosocial perspective

-Build confidence to engage with normal movement and activities related to goals and adopting a healthy lifestyle

What is step 1 of using CBT/Cognitive Functional Therapy with patients?

-Making sense of pain:

-This "cognitive component" helped the patient "make sense" of their pain

-Identified within the interview and clinical examination

-Using metaphors/concepts to better understand the multi-dimensional aspect of pain

-Unhelpful beliefs were dispelled and goals for behavior change were agreed upon

What is step 2 of CBT/Cognitive Functional Therapy with patients?

-Exposure with "control":

- Used functional movement exercises with graded exposure strategies to normalize postural and movement behaviors that patients nominated as painful, feared or avoided.

-This was reinforced with feedback and awareness of disengaging in protective body responses

-Functional integration: The new postural and movement behaviors were integrated into each person's nominated pain provocative functional activities linked to their goals to generalize learning and build self efficacy

What is step 3 of CBT/Cognitive Functional Therapy with patients?

-Lifestyle Change

-This included promotion of gradually increasing physical activity

-If not already doing sufficient, to 3-5 days a week based on preference

-Tailored to clinical presentation

-As well as advice regarding sleep habits and stress management if relevant

What is the relationship of TMJ dysfunction and fear avoidance?

-Fear of movement (Tampa Scale of Kinesiophobia) strongly related to functional deficits with Inability to open mouth, locking of jaw, and Chewing

-Fear of movement more significant of a behavior modifier than pain itself

How are chronic LBP and fear avoidance to movement related?

-Fear avoidance in acute LBP increases likelihood of subacute LBP

-Fear avoidance and disability associated

-Occupational injuries associated with high FABQ-W scores

-Unhealthy beliefs -> unhealthy behaviors -> negative mindset = Fear Avoidance

-Coaching for confidence = self efficacy = Evidenced education = Understand patient fears and belief

What is the associated of fear avoidance and falls within the elderly population?

-Mobility tasks, such as walking and reaching, are often avoided by the elderly with fear of falling

-Fear avoidance of activities is correlated to Reduced physical performance, General physical frailty, Postural control and maximal muscle strength

-Fear-related avoidance of activities is predictive of future falls

What is the correlation to fear avoidance to movement and return to sport for athletes?

-Fear of re-injury

-Lack of trust of injury site

-Elevated Fear Avoidance at 7 months post-op ACL elevates re-injury risk

-Altered muscle recruitment strategies

-Decreased dynamic knee stability

-Impact muscle endurance

-Psychologically informed practice

-Re-injury anxiety

-Negative thoughts around the injury

What is correlation of fear avoidance and pediatric patients?

-Poor outcomes with pain related to fear avoidance in children

-Parental distress and behaviors are highly influential on child

-Fear of pain closely related to parents

What are behaviors linked to negative outcomes with chronic pain patients and fear avoidance?

-Anxiety, Depression, Stress, Lack of sleep

-Unrealistic beliefs on pain

-Patients think their injury is never going to get better

-Think movement is going to make their injury worse

-Don't think treatment with PT will work

-Failed treatment in the past

What are parafunctional behaviors of TMJ disorder?

-Repetitive oral behavior not normally associated with normal function

-Clenching of jaw

-Bruxism or excessive teeth grinding

-Nail biting

-Chewing gum

-Mouth breathing

What is jaw deviation of TMJ disorders?

Indicates the mandible deviating from the central pathway/alignment during mouth opening and returns to the center

What is the C-pattern deviation of TMJ disorders?

Attributed to either mobility or capsular origin

What is the S-pattern deviation of TMJ disorders?

Attributed to deficits in motor control of the muscles around the jaw

What is deflection of TMJ disorders?

-Used to indicate the mandible deflects to one side without returning to the center position

-Observed in anterior disc displacement without reduction towards the affected side

-Capsular hypomobility towards affected side unilaterally

What is occlusion of the jaw?

Defined as the functional anatomical relationship between the maxilla and mandible

What is malocclusion of TMJ disorders?

Defined as malalignment of the teeth or lack of symmetry between the maxillary and mandibular arches

What is a class I malocclusion of the jaw?

Normal alignment

-Maxillary teeth slightly in front of mandible

-Overjet between 3-6 mm

What is a class II malocclusion of the jaw?

-"Overbite"

-Overjet/maxilla teeth > 6 mm

What is a class III malocclusion of the jaw?

-"Underbite"

-Mandible protrudes in front of the maxilla

How do myalgia muscle disorders of TMJ present?

-Palpable trigger points of the muscles of mastication

-Often presents bilaterally

-Associated psychosocial factors of anxiety and stress

-Associated with clenching of teeth and bruxism

-Often desribed with referral pain beyond muscle being palpated with spreading of pain present

-Commonly temporalis and masseter are most affected

How do disc displacement disorders of TMJ present?

-Associated with pain and joint noises

-Clicking or popping

-Limited motion depending on subtype

-Disc displacement sub-types

-With reduction associated with two reciprocal clicks at the beginning and end of mouth opening/closing

-Can also be clicking with excursion and protrusion

-Without reduction with no joint noises but limited motion

-Associated with limited mouth opening and interferes with ability to ear

What is the trismus checklist for TMJ patients to refer for X-ray imaging?

IF YES to any of the question below GET IMAGING

1. Mouth Opening less than 15 mm

2. Progressively worsening trismus

3. Absence of history of jaw clicking

4. Pain of non-myofascial origin

5. Swollen lymph glands

6. Suspicious intra-oral soft tissue lesion

How does cervical spine involvement look like for referred symptoms with TMJ disorder?

-Generally present across all patients with TMJ disorders

-Upper cervical spine and/or head pain accessory movement restrictions

-Multiple levels may be involved unilateral or bilateral

-Confirmed through manual therapy and symptom reduction

Why are headaches common with TMJ disorders?

Due to the the V3 nerve of trigeminal being near the ear/temporal bone where the temporalis can become tight and cause tension headaches or increase the risk of migraine headaches

How do arthrogenic disorders of TMJ present?

-Associated with pain and limited ROM

-Inflammatory pattern with morning stiffness that improves with motion

-Worsens with overloading of jaw

-Has joint line tenderness, crepitus, and accessory motion irregularities

-Pain in face, jaw, temple, in front of ear or in ear in the last month + palpation joint pain or pain with mouth opening/lateral excursion

What are axis of diagnosis of TMJ?

-Axis I: Myogenic, disc displacements, and arthrogenic pain

-Axis II: Psychosocial and pain disability

How does a disc displacement with reduction in TMJ present?

-Has two reciprocal clicks at the beginning and end of mouth opening/closing

-Can also be clicking with excursion and protrusion

How does disc displacement present with NO reduction in TMJ present?

-Has no joint noises but limited motion

-Associated with limited mouth opening and interferes with ability to ear

What are normal ROM for depression/mouth opening?

-Normal ROM: 40-55 mm

-Function ROM: 25-35 mm

What are normal ROM for protrusion of the mouth?

3-10 mm

What are normal ROM for retrusion of the mouth?

Normal ROM: 3 mm

What are normal ROM for lateral excursion of the mouth?

Normal ROM: 8-15 mm

What are the 5 "S's" for the functions of the Pelvic Floor?

-Support: holds up internal organs

-Sphincteric: open and close sphincters for bladder and bowel control

-Sexual: contraction with intercourse to increase pleasure

-Stability: strong, functioning system provides stability

-Sump pump: active and healthy muscles help to move fluid

-Important for posture and breathing

-Pelvic floor and diaphragm relationship

What are common diagnoses seen in male pelvic floor patients?

-Urinary incontinence post prostatectomy

-Prostatitis

-Benign prostate hyperplasia

-Pelvic pain

-Erectile dysfunction

-Issues with urination: Pain, incomplete emptying, straining, increased frequency

What is urinary incontinence?

Involuntary loss of urine

What is stress urinary incontinence?

Leaking urine with increase in intra-abdominal pressure due to urethral sphincter and/or pelvic floor weakness (sneezing, coughing, pulling)

What is urge urinary incontinence?

Leaking urine that is preceded or accompanied by a sense of urinary urgency due to detrusor overactivity

What is mixed urinary incontinence?

Combination of urge and stress incontinence

What is overflow urinary incontinence?

Leaking urine from overdistended bladder due to impaired detrusor contractility (neurologic diseases) and/or bladder outlet obstruction (external compression from pelvic masses, prolapse, and benign prostatic hyperplasia).

What is functional urinary incontinence?

Leaking urine due to environmental or physical barriers to toileting

What is first line of treatment for stress urinary incontinence?

PELVIC FLOOR MUSCLE STRENGTHENING especially in post prostectomy patients

What is a pelvic organ prolapse?

-Occurs when muscles and/or tissues supporting the pelvic organs (bladder, uterus, rectum) weaken or loosen

-Causes pelvic organs to drop or press into or out of the vagina

What is a cystocele?

Herniation of the bladder into the vagina

What is a rectocele?

Herniation of the rectum into the vagina

What is uterine prolapse?

Uterine herniation into the vagina

What is a vaginal vault prolapse?

A condition in which the upper portion of the vagina loses its normal shape and sags or drops down into the vaginal canal or outside of the vagina

What symptoms associated with a pelvic organ prolapse?

-Bulge in the vaginal area, "sitting on a small ball"

-Feeling of pressure or discomfort that worsens with standing and/or end of day

-Leaking urine and/or incomplete emptying of bowels

What are positional recommendations for a pregnant patient?

-Prone: Avoid after 12-16 week as uterus moved above pelvic brim

-Supine: Avoid after ~6 months Some research indicated 28-30 weeks

-Based on comfort and when in doubt perform reclined

-Side-lying: Side-lying is best in later states of pregnancy

-Low level evidence suggests L side-lying is better than R

How frequent should someone be voiding urine?

Normal voiding should be about every 2-4 hours