O09 Recurring brachial plexopathy- the zebra among the horses

Case report - Introduction A case study of a teenage boy presenting with severe upper limb pain and recurring loss of upper limb function with no clear mechanism of injury. His progress in therapy was initially as expected; however, symptoms would recur despite consistency and compliance with treatment from the patient. This led to a referral for further investigations where a diagnosis of a rare inflammatory neurological condition was made. This case study is relevant for paediatric physiotherapists working in non-inflammatory, musculoskeletal and pain services as it highlights a lesser-known pathology that presents in a similar way to a more common condition. Case report - Case description M is a 13-year-old boy that presented with a 5-week history of stabbing pains followed by loss of motor function and sensation in his right arm after swinging a remote. A diagnosis of brachial nerve plexopathy had been suggested. M had been diagnosed with Hypermobile Ehlers-Danlos Syndrome (hEDS) but was otherwise fit and well with no significant birth, developmental or family history. He experienced similar episodes of loss of motor function throughout the entire right upper limb following an episode of acute pain aged 4 and aged 12. The episodes were presumed to be a brachial plexus injury following a shoulder subluxation; however, there was no real mechanism of injury to suggest this and symptoms self-resolved after several months in both instances. Age 8 he lost function and sensation in the left arm after a minor pulled elbow, he underwent elbow surgery at another centre to help restore the function of the left arm; however, function didn’t return for approximately 1 year. On examination he had diminished reflexes throughout the right upper limb and reduced sensation along a C3-8 & T1 distribution. He had a correctable thoracic spine kyphosis with significant medial boarder scapula winging on the right. His right shoulder sat lower than the left and he had muscle atrophy at right supraspinatus, infraspinatus, and serratus anterior and deltoid with tight pectoral muscles. He was compensating using upper trapezius to achieve 90—100 degrees of shoulder flexion and abduction with 2/5 muscle power. His elbow muscle strength was reduced to 4/5 in all movements on the right. He could only actively extend his right wrist to 30 degrees and only had flickers of active radial deviation. He lacked active finger extension in digits 2-5 and had 0/5 muscle activity at the right thumb. Case report - Discussion M underwent exercise therapy with a focus on regaining scapula control in lying and isometric rotator cuff strengthening as he had such significant wasting and was unable to control the upper limb in sitting. We also worked on improving his thoracic spine posture and on active assisted finger and wrist exercises to prevent contractures. I initially provided a sling to be worn at school and in busy environments to prevent any subluxations in view of his significant rotator cuff weakness and history of hEDS. The sling also served as a thoracic posture reminder for M. After just 2—3 weeks of input and initially making gains in strength and function, M had an episode of severe pain in the right shoulder followed by worsening motor and sensory symptoms. The recurrent nature of episodes and the weak mechanism of injury, led me to discuss M with a consultant. The consultant referred M to genetics where it was discovered he had idiopathic neuralgic amyotrophy (INA; also known as Parsonage—Turner Syndrome), a rare inflammatory neurological disorder. M had the classic signs and symptoms of INA but as he had presented to various different clinicians and centres with each episode a correlation wasn’t made until this latest presentation to pain clinic Case report - Key learning points The insubstantial mechanism of injury for his current presentation (motor loss from swinging a remote) led me to probe further into past episodes of his upper limb pain. This information spurred me to research alternative causes of his symptoms and discuss the case with a consultant who made an onward referral. As physiotherapists we are highly likely to receive referrals for patients like M, with little more information than ‘shoulder pain’ or ‘brachial plexus injury’ given, which is why our subjective is such an important part of the overall assessment. M’s case highlights how important collating an extensive medical history is to proper investigation and eventual diagnosis. M had a long history of upper limb events for which he had seen a variety of clinicians at various centres. Each event had been treated as an individual episode rather than one larger recurring pattern. Drawing that history together gave a more holistic picture which triggered the referral that identified a diagnosis 8 years after his first presentation to healthcare. M’s case also highlighted the importance of a good patient—therapist relationship. Motivating a patient with this type of condition is challenging; their progress is not linear and they often have to take steps backwards before they can progress again. This is exceptionally difficult for children and their parents, as it is a frustrating and repetitive cycle. They need to trust that you are giving them the correct therapy and as a therapist you need to trust that the patient is compliant with recommendations and exercise. Finally, the shoulder rehabilitation for M was, clinically speaking, the same as any other brachial plexus type injury. The main key difference was the need to intermittently take the exercises down a level in the incidence of a new episode of pain and motor loss.

Back, Lower Limb, and Upper Limb Pain Among U.S. Adults, 2019

This report provides national estimates of any pain regardless of body region as well as estimates of back, upper limb (hips, knees, or feet) pain in the past 3 months among U.S. adults aged 18 and over by selected sociodemographic characteristics.

THE EFFECTIVENESS OF SELECTED PHYSIOTHERAPEUTIC METHODS IN THE TREATMENT OF PAIN IN THE COURSE OF LATERAL EPICONDYLITIS OF THE HUMERUS

Introduction Lateral epicondylitis, otherwise known as the tennis elbow syndrome, occurs in 1–3% of the general population, of which tennis players account for only 10%. It is one of the most common causes of upper limb pain. Currently, due to the lack of uniform and consistent therapeutic methods, various treatment techniques are used. These include techniques such as shock wave therapy, ultrasound and cryotherapy. Aim The aim of the study is to assess the effectiveness of three physiotherapeutic methods – shock wave therapy, ultrasound and cryotherapy – in reducing pain in the course of treating tennis elbow syndrome. The secondary goal is to assess the grip strength of the hand. Material and methods As a result of the review of search engines and databases, such as Polish Medical Bibliography, Google Scholar, PubMed and ScienceDirect, 10 research works from 2010–2019 were used, assessing the effectiveness of shock wave therapy, ultrasound and cryotherapy to treat lateral epicondylitis of the humerus. Results 310 people diagnosed with tennis elbow syndrome participated in the analysis. According to the results, most of the patients were female. The average age of the respondents was 45.2 years. Conclusions The research analysis proves that shock wave therapy, cryotherapy and ultrasound are effective physiotherapeutic methods in the treatment of lateral epicondylitis of the humerus. The shockwave is superior to other forms of treatment due to its shorter sessions and application time. Keywords: tennis elbow, rehabilitation, cryotherapy

Investigating the Depression Status in Patients with Upper Limb Pain

Introduction: Depression is considered as the most common psychological problem in societies. Depression, anxiety disorders, and substance abuse are more common in patients with pain compared to the general population. In this study, the state of depression in patients with upper limb pain with radiculopathy or without paraclinical signs of radiculopathy has been investigated. Material and Methods: We conducted the depression status in patients with upper limb pain with and without radiculopathy in a descriptive cross-sectional study in Sari in 2017. Beck Depression Inventory (BDI-II), Short Form (36) Health Survey (SF-36), short-form McGill pain questionnaire was used to evaluate the status of major depressive disorder, health status and quality of life, and severity of pain in them, respectively. The data was analyzed by SPSS 22. Results: From 120 patients with the mean age 44.97±9.77 years, 19% had mild depression, 18% moderate depression and 11% severe depression. The mean score of SF36 was 29.94±6.86. The mean scores of McGill pain scale was 13.31±6.02. The mean depression score had a significant difference between the two groups studied (P=0.04). The McGill pain score had also a significant difference between the two study groups (P=0.012). The mean score of SF36 had no significant difference in both groups (P=0.41).Conclusion: The depression score and the prevalence of moderate and severe depression were also higher in patients with chronic upper limb pain with cervical radiculopathy than in patients without cervical radiculopathy.

Bilateral Motor Cortex tDCS Effects on Post-Stroke Pain and Spasticity: A Three Cases Study

Stroke patients frequently suffer from chronic limb pain, but well-suited treatment approaches have been not established so far. Transcranial direct current stimulation (tDCS) is a safe and non-invasive brain stimulation technique that alters cortical excitability, and it has been shown that motor cortex tDCS can reduce pain. Some data also suggest that spasticity may be improved by tDCS in post-stroke patients. Moreover, multiple sessions of tDCS have shown to induce neuroplastic changes with lasting beneficial effects in different neurological conditions. The aim of this pilot study was to explore the effect of multiple anodal tDCS (atDCS) sessions on upper limb pain and spasticity of stroke patients, using a within-subject, crossover, sham-controlled design. Brain damage was of similar extent in the three patients evaluated, although located in different hemispheres. The results showed a significant effect of 5 consecutive sessions of atDCS, compared to sham stimulation, on pain evaluated by the Adaptive Visual Analog Scales -AVAS-, and spasticity evaluated by the Fugl-Meyer scale. In two of the patients, pain was completely relieved and markedly reduced, respectively, only after verum tDCS. The pain improvement effect of atDCS in the third patient was considerably lower compared to the other two patients. Spasticity was significantly improved in one of the patients. The treatment was well-tolerated, and no serious adverse effects were reported. These findings suggest that multiple sessions of atDCS are a safe intervention for improving upper limb pain and spasticity in stroke patients, although the inter-individual variability is a limitation of the results. Further studies including longer follow-up periods, more representative patient samples and individualized stimulation protocols are required to demonstrate the efficacy and safety of tDCS for improving limb symptoms in these patients.

Successful application of burst spinal cord stimulation for refractory upper limb pain: a case series

Spinal cord stimulation (SCS) has been used to treat sustained pain that is intractable despite various types of treatment. However, conventional tonic waveform SCS has not shown promising outcomes for spinal cord injury (SCI) or postamputation pain. The pain signal mechanisms of burst waveforms are different to those of conventional tonic waveforms, but few reports have presented the therapeutic potential of burst waveforms for the abovementioned indications. This current case report describes two patients with refractory upper limb pain after SCI and upper limb amputation that were treated with burst waveform SCS. While the patients could not obtain sufficient therapeutic effect with conventional tonic waveforms, the burst waveforms provided better pain reduction with less discomfort. However, further studies are necessary to better clarify the mechanisms and efficacy of burst waveform SCS in patients with intractable pain.

Superior vena cava obstruction with thrombolytic therapy in primary antiphospholipid syndrome

We report a case of superior vena cava obstruction of a 39 years old female patient with primary antiphospholipid syndrome presented with upper limb pain and swelling ,which improved on thrombolytic therapy ,we review patients with Antiphospholipid syndrome and management with thrombolytic therapy .