Cutaneous nerve transection for the management of intractable upper extremity pain caused by invasive squamous cell carcinoma

A recurrent clinical dilemma in the management of patients with painful metastatic lesions is achieving a balance between effective analgesic therapies versus intolerable side effects, in particular altered mental status. We present the case of an immunosuppressed patient post-lung transplant who was suffering from intractable pain caused by widely metastatic squamous cell carcinoma. The patient's progressive, excruciating neuropathic pain was localized to the area of the left wrist and forearm. Additionally, the patient complained of moderate pain at sites of tumor involvement on her right arm and scalp. Attempts to adequately manage her left upper extremity pain included a combination of pharmacologic treatments intended to treat neuropathic pain (gabapentin, SNRI, ketamine, opioids) and focused regional analgesia (infraclavicular infusion of local anesthetic). However, the patient developed intolerable side effects including altered mental status and delirium associated with the systemic agents and suboptimal control with the infraclavicular infusion. Given that the most severe pain was well localized, we undertook a diagnostic block of the cutaneous nerves of the left forearm. As this intervention significantly reduced her pain, we subsequently performed neurectomies to the left superficial radial nerve, lateral cutaneous nerve of the forearm and the posterior cutaneous nerve of the forearm. This resulted in immediate and continued relief of her left upper extremity pain without an altered mental status. Residual focal pain from lesions over her right arm and scalp was successfully managed with daily topical applications of lidocaine and capsaicin cream. Successful pain control continued until the patient's death five months later.     

Immediate and lasting effects of a thoracic spine manipulation in a patient with signs of cervical radiculopathy and upper extremity hyperalgesia: A case report

Patients with cervical radiculopathy (CR) may present with accompanying symptoms of hyperalgesia, allodynia, heaviness in the arm, and non-segmental pain that do not appear to be related to a peripheral spinal nerve. These findings may suggest the presence of central or autonomic nervous system involvement, requiring a modified management approach. The purpose of this case report is to describe the treatment of a patient with signs of CR and upper extremity (UE) hyperalgesia who had a significant decrease in her UE pain and hypersensitivity after a single thoracic spine manipulation (TSM). A 48-year-old female presented to physical therapy with acute neck pain radiating into her left UE that significantly limited her ability to sleep and work. After a single TSM, the patient demonstrated immediate and lasting reduction in hyperalgesia, hypersensitivity to touch, elimination of perceived heaviness and coldness in her left UE, and improved strength in the C6-8 myotome, allowing for improved functional activity capacity and tolerance to a multi-modal PT program. Based on these results, clinicians should consider the early application of TSM in patients with CR who have atypical, widespread, or severe neurological symptoms that limit early mobilization and tolerance to treatment at the painful region.     

T2 radiculopathy: A differential screen for upper extremity radicular pain

Radicular pain in the upper extremity can have a cervical origin terminating at the cervicothoracic junction (C8, T1). Review of the literature suggests cutaneous representations of T2 nerve root to the axilla, posteromedial arm, and lateral forearm, suggesting yet another source of upper extremity radicular pain. A 53-year-old female experienced insidious right upper thoracic pain radiating into the right axilla, upper arm, and lateral forearm (10/10 numerical pain rating scale (NPRS)) of 1-week duration. Medical referral suggested cervical radiculopathy, however, cervical spine examination was unremarkable. She presented with mechanical dysfunction of C8, T1; T1, T2; and T2, T3 vertebral segments with restricted cervical extension. Firm compression over the right lateral aspect of the second and third thoracic vertebrae reproduced her symptoms markedly. There was a predominance of right axillary pain. Cervical extension reproduced local upper thoracic pain. Nine treatment visits for a period of 3 weeks addressed mechanical dysfunction at the cervicothoracic junction and upper thoracic region, comprising manual therapy, corrective exercise, and pain modalities. Reduction of local tenderness, and radiating axillary and right arm pain was observed (2/10 NPRS), with improved cervical extension. The second thoracic intercostal nerve and the adjoining intercostobrachial nerve, medial antebrachial cutaneous nerve, and the posterior brachial cutaneous branch of the radial nerve are speculated to be potential symptom mediators. They have a representation to the axilla, medial and posterior arm, and lateral forearm – a representation supporting the speculation of upper extremity radicular symptoms following mechanical dysfunction of the upper thoracic vertebrae.     

The Use of Upper Thoracic Manipulation in a Patient With Headache

Abstract

This case study describes how thrust manipulation in the upper thoracic spine was effective in reducing symptoms in a patient with complaint of headache; it discusses potential theories and interrelationships. The study describes a 29-year-old female with onset of occipital headaches who noted no change in symptoms after five treatments over a period of three weeks. Treatment included soft tissue mobilization, passive stretching, postural instruction/exercise and nonthrust manipulation to occipito-atlantal (O/A), atlanto axial (A/A) and cervical facet joints. The patient's sixth visit, that occurred 5 days after the fifth treatment session, included a thrust manipulation to the upper thoracic spine (T1/2) after which she noted a significant reduction in symptoms. The patient was then seen for two additional visits which included nonthrust manipulation techniques. Two days after her final visit, the patient noted full resolution of symptoms. The patient continued to note full resolution of symptoms for six weeks. The patient then returned to physical therapy with similar complaints but at approximately 50% of the earlier intensity. Two treatments, over a period of one week, utilizing nonthrust manipulation techniques yielded no relief in symptoms. One week later, the patient received a thrust manipulation at T2/3 after which she noted full resolution of symptoms. At follow up, seven weeks later, the patient remained symptom free.     

Complex regional pain syndrome involving the lower extremity: a report of 2 cases of sphenopalatine block as a treatment option

We report 2 cases of complex regional pain syndrome (CRPS) involving the lower extremity; in both, a sphenopalatine ganglion (SPG) block was performed as part of a pain management program. In the first case, a woman in her late twenties presented with CRPS in the left lower extremity that was inadequately controlled with typical oral medications. Sympathetic block of the extremity did not provide significant pain relief. However, a noninvasive sphenopalatine block with 4% tetracaine resulted in a 50% reduction in pain level. The patient was shown how to self-administer the sphenopalatine block and was provided with exercises and therapy to help improve her functional status. The second case involved a woman in her mid forties with CRPS in the right lower extremity that was partially controlled with oral medications. The patient experienced a 50% reduction in pain level when SPG block with 4% tetracaine was given. Further study is needed to determine the effects of SPG blocks on symptoms related to chronic regional pain syndrome.     

Chiropractic care of a patient with vertebral subluxations and unsuccessful surgery of the cervical spine

OBJECTIVE: The chiropractic care of a patient with vertebral subluxations, neck pain, and cervical radiculopathy after a cervical diskectomy is described. CLINICAL FEATURES: A 55-year-old man had neck pain and left upper extremity radiculopathy after unsuccessful cervical spine surgery. INTERVENTION AND OUTCOME: Contact-specific, high-velocity, low-amplitude adjustments (i.e., Gonstead technique) were applied to sites of vertebral subluxations. Rehabilitation exercises were also used as adjunct to care. The patient reported a decrease in neck pain and left arm pain after chiropractic intervention. The patient also demonstrated a marked increase in range of motion (ROM) of the left glenohumeral articulation. CONCLUSION: The chiropractic care of a patient with neck pain and left upper extremity radiculopathy after cervical diskectomy is presented. Marked resolution of the patient's symptoms was obtained concomitant with a reduction in subluxation findings at multiple levels despite the complicating history of an unsuccessful cervical spine surgery. This is the first report in the indexed literature of chiropractic care after an unsuccessful cervical spine surgery.     

A Severe Case of Complex Regional Pain Syndrome I (Reflex Sympathetic Dystrophy) Managed with Spinal Cord Stimulation

Complex regional pain syndrome is a condition that usually affects the upper or lower extremities. The cause is not clearly understood. We report a case of a severe form of a rapidly progressive complex regional pain syndrome type I developing after a right shoulder injury managed with spinal cord stimulation (SCS). After failed conservative treatments, a rechargeable SCS system was implanted in the cervical spine. Allodynia and dystonia improved but the patient subsequently developed similar symptoms in lower right extremity followed by her lower left extremity. The patient became wheelchair bound. A second rechargeable SCS with a paddle electrode was implanted for the lower extremity coverage. The patient's allodynia and skin lesions improved significantly. However, over time, her initial symptoms reappeared which included skin breakdown. Due to the need for frequent recharging, the system was removed. During explantation of the surgical paddle lead, it was noted by the neurosurgeon that the contacts of the paddle lead were detached from the lead. After successful implantation of another SCS system, the patient was able to reduce her medications and is now able to ambulate with the use of a left elbow crutch.     

Impairment level SumScore for lower extremity Complex Regional Pain Syndrome type I

Objectives : To construct a single indicator on impairment level for lower extremity Complex Regional Pain syndrome type I (CRPS I).

Design : The Impairment level SumScore (ISS) for upper extremity CRPS I was adapted to be used for lower extremity evaluation. Medline literature search and research findings were used to adapt the upper extremity version of the ISS, with emphasis on reliability, responsiveness and validity of measurement instruments. Where needed, additional patient data was gathered to evaluate these aspects for different measurement instruments.

Setting : An outpatient clinic of a university hospital in the Netherlands.

Participants : Two groups consisting of 17 and 26 healthy volunteers, and two groups of respectively 40 and 18 lower extremity CRPS I patients according to Veldman's criteria.

Main outcome measures : VAS and McGill pain scores, water displacement volumeter values, and physicians' and patients' assessment of CRPS I severity.

Results : A combination of measurements, incorporating pain (VAS and McGill), temperature (infrared thermometer), volume (water displacement volumeter) and active range of motion (universal goniometer), was converted in a single score ranging from 5 to 50. The reliability, as well as the responsiveness was adequate.

Conclusions : The lower extremity ISS permits evaluation of the most prominent symptoms in CRPS I, and can be used to monitor changes in CRPS I.     

Evidence-Based Approach to the Physical Therapy Diagnosis and Management of Neck and Upper Extremity Pain using Cervical and Thoracic Spine Thrust Manipulation: A Case Report

Abstract

Neck and upper extremity pain are common medical diagnoses for patients seeking physical therapy care. The purpose of this case report is to describe an evidence-based approach to the physical therapy diagnosis and management of a 46-year-old female reporting insidious onset neck pain and bilateral upper extremity paraesthesiae of two years duration. Evaluation of examination data, based on research data with regard to diagnostic accuracy of the tests and measures used, indicated a diagnosis of cervical radiculopathy. Management was based on a treatment-based classification approach and focused on restoring mobility by way of thrust manipulations directed at the thoracic and cervical spine. At the completion of the physical therapy plan of care (8 visits), the patient rated her perceived improvement on the Global Rating of Change Scale as "a very great deal better." The Numerical Pain Rating Score improved from 6/10 to 0/10. Patient-perceived disability, as measured by the Neck Disability Index, improved from 26% to 0%, and the patient's score on the modified Oswestry Disability Index improved from 30% to 0%. Bilateral upper extremity paraesthesiae also had completely resolved. These clinically meaningful improvements in pain and perceived disability were maintained six weeks after discharge. While a cause-and-effect relationship cannot be inferred from a case report, it is plausible that an orthopaedic manual physical therapy approach in the management of patients with both neck and upper extremity pain may result in decreased pain and improved function. Further clinical trials are needed to test this hypothesis.     

Complex Regional Pain Syndrome I: Management through the Use of Vertebral and Sympathetic Trunk Mobilization

Abstract

The purpose of this study was to describe the clinical differential diagnostic process and effective management of an individual presenting with lower-extremity complex regional pain syndrome I (CRPS I). A 50-year-old female 8-weeks status post ORIF right tibia/fibula presented with a warm, red, edematous, hyperhidrotic right lower extremity. She also exhibited hyperalgesia, allodynia, and a positive slump test on the right. The patient satisfied clinical diagnostic criteria for a diagnosis of CRPS I. The subject was treated for 10 sessions over a 3-month period using progressive desensitization, weight-bearing activities, thoracolumbar mobilizations, and a neural mobilization technique referred to as slump long sitting with sympathetic emphasis (SLSSE). An analysis of outcome measures at the time of discharge and at a one-year follow-up demonstrated a significant improvement in both pain and function. Effective management was achieved by addressing both the patient's proximal and distal impairments including thoracolumbar segmental lesions and positive neurodynamic tests. It is speculated that the influence of neural mobilizations to the ipsilateral sympathetic ganglia directly affected the pathophysiology associated with autonomic dysregulation and pain in this subject. This case report provides initial evidence that the SLSSE may be an effective neural mobilization technique in reducing the magnitude of symptoms and improving function in patients with CRPS.     

Use of cervical spine manipulation under anesthesia for management of cervical disk herniation, cervical radiculopathy, and associated cervicogenic headache syndrome

OBJECTIVE: To demonstrate the benefits of cervical spine manipulation with the patient under anesthesia as an approach to treating a patient with chronic cervical disk herniation, associated cervical radiculopathy, and cervicogenic headache syndrome. CLINICAL FEATURES: The patient had neck pain with radiating paresthesia into the right upper extremity and incapacitating headaches and had no response to 6 months of conservative therapy. Treatment included spinal manipulative therapy, physical therapy, anti-inflammatory medication, and acupuncture. Magnetic resonance imaging, electromyography, and somatosensory evoked potential examination all revealed positive diagnostic findings. INTERVENTION AND OUTCOME: Treatment included 3 successive days of cervical spine manipulation with the patient under anesthesia. The patient had immediate relief after the first procedure. Her neck and arm pain were reported to be 50% better after the first trial, and her headaches were better by 80% after the third trial. Four months after the last procedure the patient reported a 95% improvement in her overall condition. CONCLUSION: Cervical spine manipulation with the patient under anesthesia has a place in the chiropractic arena. It is a useful tool for treating chronic discopathic disease complicated by cervical radiculopathy and cervicogenic headache syndrome. The beneficial results of this procedure are contingent on careful patient selection and proper training of qualified chiropractic physicians.     

Complex regional pain syndrome type I treated with topical capsaicin: a case report. (Erasmus University Medical Center, Rotterdam, The Netherlands) Arch Phys Med Rehabil. 2001;82:851–852.

This report described the case of a multitrauma patient who underwent an amputation of the left arm and had a complicated left crural fracture with a delayed union. He was treated in an inpatient setting for preprosthetic training for a myoelectric prosthesis and to regain walking abilities. After consolidation of the crural fracture, complex regional pain syndrome type I (CRPS I) developed in the left foreleg, which hindered mobilization. Topical capsaicin 0.075% was prescribed and a stress-loading mobilization schema was instituted. No other treatment modalities directed at CRPS I were added. After 6 weeks, no signs or symptoms of CRPS I were present and capsaicin was discontinued. Capsaicin is a well-accepted and documented treatment modality in neuropathic pain states such as postherpetic neuralgia. However, it has rarely been described in CRPS I. Capsaicin is discussed within the framework of recent insights in the neurobiology of nociception, and it is concluded that it may provide a theory-driven treatment for CRPS I, especially in the acute stage, which facilitates physical therapy and prevents peripheral and spinal sensitization.     

Complex regional pain syndrome type I treated with topical capsaicin: a case report

This report describes the case of a multitrauma patient who underwent an amputation of the left arm and had a complicated left crural fracture with a delayed union. He was treated in an inpatient setting for preprosthetic training for a myoelectric prosthesis and to regain walking abilities. After consolidation of the crural fracture, complex regional pain syndrome type I (CRPS I) developed in the left foreleg, which hindered mobilization. Topical capsaicin .075% was prescribed and a stress-loading mobilization schema was instituted. No other treatment modalities directed at CRPS I were added. After 6 weeks, no signs or symptoms of CRPS I were present and capsaicin was discontinued. Capsaicin is a well-accepted and documented treatment modality in neuropathic pain states such as postherpetic neuralgia. However, it has rarely been described in CRPS I. Capsaicin is discussed within the framework of recent insights in the neurobiology of nociception, and it is concluded that it may provide a theory-driven treatment for CRPS I, especially in the acute stage, that facilitates physical therapy and prevents peripheral and spinal sensitization.     

Examination of motor and hypoalgesic effects of cervical vs thoracic spine manipulation in patients with lateral epicondylalgia: a clinical trial

Objectives

The purpose of this study was to compare the effects of a cervical vs thoracic spine manipulation on pressure pain threshold (PPT) and pain-free grip strength in patients with lateral epicondylalgia (LE).

Methods

A single-blind randomized clinical trial was completed with 18 participants with LE. Each subject attended 1 experimental session. Participants were randomized to receive either a cervical or thoracic spine manipulation. Pressure pain threshold over the lateral epicondyle of both elbows pain-free grip strength on the affected arm and maximum grip force on the unaffected side were assessed preintervention and 5 minutes postintervention by an examiner blind to group assignment. A 3-way analysis of variance with time and side as within-subject variable and intervention as between-subject variable was used to evaluate changes in PPT and pain-free grip.

Results

The analysis of variance detected a significant interaction between group and time (F = 31.7, P < .000) for PPT levels. Post hoc testing revealed that the cervical spine manipulation produced a greater increase of PPT in both sides compared with thoracic spine manipulation (P < .001). For pain-free grip strength, no interaction between group and time (F = .66, P = .42) existed.

Conclusions

Cervical spine manipulation produced greater changes in PPT than thoracic spine manipulation in patients with LE. No differences between groups were identified for pain-free grip. Future studies with larger sample sizes are required to further examine the effects of manipulation on mechanisms of pain and motor control in upper extremity conditions.     

Signs and symptoms in complex regional pain syndrome type I/reflex sympathetic dystrophy: judgment of the physician versus objective measurement.

OBJECTIVE: To assess the relation between the subjectively assessed and objectively measured diagnostic signs and symptoms in complex regional pain syndrome type I (CRPS I) and to quantify their severity. DESIGN: Diagnostic signs and symptoms were recorded in patients suffering from CRPS I of one upper extremity for less than 1 year. Independent assessors measured (a) pain by using four visual analog scales (VAS) and the McGill Questionnaire list of adjectives (MPQ), (b) edema with a hand volumeter, (c) skin temperature with an infrared thermometer, and (d) active range of motion (AROM) with goniometers. SETTING: Two university hospitals. PATIENTS: Ninety-five women and 40 men with CRPS I of one upper extremity. RESULTS: Four signs and symptoms were diagnosed in 50 patients, and five in the remaining 85 patients. The mean score for present pain intensity was 31.5 mm and that for pain resulting from exertion of the affected extremity was 71.9 mm. A median of 11.5 words was chosen from the MPQ, with the highest number from its evaluative part. The difference in volume between both hands was 30.4 ml. The mean difference in temperature between the two hands was 0.78 degrees C dorsally and 0.66 degrees C palmarly. The largest decrease in mobility was seen in the wrist and fingers; the thumb was relatively less affected and the little finger relatively more affected than the other fingers. CONCLUSIONS: Bedside evaluation of CRPS I with Veldman's criteria was in good accord with psychometric or laboratory testing of these criteria.     

Knowledge-Based Practice

Abstract

Rib injuries are common in collegiate rowing. The purpose of this case report is to provide insight into examination, evaluation, and treatment of persistent costochondritis in an elite athlete as well as propose an explanation for chronic dysfunction. The case involved a 21 year old female collegiate rower with multiple episodes of costochondritis over a 1-year period of time. Symptoms were localized to the left third costosternal junction and bilaterally at the fourth costosternal junction with moderate swelling. Initial interventions were directed at the costosternal joint, but only mild, temporary relief of symptoms was attained. Reexamination findings included hypomobility of the upper thoracic spine, costovertebral joints, and lateral ribs. Interventions included postural exercises and manual therapies directed at the lateral and posterior rib structures to improve rib and thoracic spine mobility. Over a 3-week time period pain experienced throughout the day had subsided (visual analog scale – VAS 0/10). She was able to resume running and elliptical aerobic training with minimal discomfort (VAS 2/10) and began to reintegrate into collegiate rowing. Examination of the lateral ribs, cervical and thoracic spine should be part of the comprehensive evaluation of costochondritis. Addressing posterior hypomobility may have allowed for a more thorough recovery in this case study.     

A case of pain,motor impairment,and swelling of the arm after acute herpes zoster infection

Complex regional pain syndrome (CRPS) and postherpetic neuralgia (PHN) represent neuropathic pain syndromes that may appear with similar clinical signs and symptoms. Medical history and clinical distribution of symptoms and signs (PHN typically at the thorax; CRPS typically at the limbs) is obvious in most cases, helping to discriminate between both disorders. Here, we present a patient suffering from CRPS II following PHN of one upper extremity. This case demonstrates that both etiology and part of the body affected by a neuropathy influence the pain phenotype.     

Acute Knee Haemarthrosis: A Case Report Describing Diagnosis and Management for a Patient on Anticoagulation Medication

Background and Purpose. A 63‐year‐old woman was referred to physical therapy with a 3 day history of constant anterior left knee pain that was atraumatic in nature. The patient was taking anticoagulation medication for chronic atrial fibrillation. Her international normalized ratio (INR) was within normal limits when assessed 3 weeks prior to her initial physical therapy evaluation. Method. Physical examination revealed an antalgic gait, moderate left knee effusion, limited painful knee range of motion, normal ligamentous testing and negative joint line or patellofemoral joint palpation. The patient was instructed in the use of a single‐point cane, use of ice, positional comfort and relative rest from weight‐bearing activities. Upon re‐assessment 2 days later, the patient's knee pain and effusion had worsened despite compliance with day 1 instructions. Given that there was no clear mechanism of injury and the worsening nature of the disorder, the physical therapist discussed the case with the patient's physician, and immediate appointments for laboratory testing and potential knee aspiration were obtained. Results. Laboratory testing demonstrated that INR values had elevated to a supratherapeutic level of anticoagulation. Fluid from the patient's left knee was aspirated, revealing a haemarthrosis. The patient's symptoms immediately improved following aspiration. After suspending her anticoagulation medication dose for 1 day, her INR value returned to therapeutic range. She was symptom free within 3 weeks with physical therapy intervention and had remained symptom free at 1 year following the knee haemarthrosis. Conclusion. We recommend that physical therapists screen all patients for whether or not they are taking anticoagulation medications, especially before implementation of manual therapy or therapeutic exercise interventions. Copyright © 2010 John Wiley & Sons, Ltd.     

Use of thoracic spine manipulation in the treatment of adhesive capsulitis: a case report

Abstract

Adhesive capsulitis (AC) is a common and disabling shoulder condition seen in physical therapy, and there is no clear consensus as to the best treatment approach. Recently there has been emerging evidence that manual therapy directed at the thoracic spine may be beneficial for patients with shoulder pain; however, this has not been examined specifically in patients with AC. The purpose of this paper is to present the case of 59-year-old female referred to physical therapy with a diagnosis of AC. The patient presented with complaints of left shoulder pain and significant limitations in range of motion (ROM) and upper extremity function. The initial treatment included exercises and manual therapy directed at the glenohumeral and scapulothoracic joints, and after 10 visits only minimal progress had been made. Further examination revealed mobility and ROM deficits in the thoracic spine, and manual therapy directed at this region was incorporated into her treatment. After the first session of thoracic spine manual therapy (TSMT) a 25 degree improvement was noted in active shoulder flexion. After four total visits of TSMT substantial improvements in pain, ROM, and function were noted compared to those made during the first 10 visits. This case adds to the emerging evidence that manual therapy directed at the thoracic spine should be considered for patients with shoulder pain.