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Dorsal arachnoidal webs are condensations of arachnoidal tissue densely adherent to the pial surface of the posterior aspect of the dorsal spinal cord. Infrequently described in literature they disrupt the flow of CSF in the spinal subarachnoid space leading to syringomyelia and myelopathy. While there are several theories on their origin, the “scalpel sign” on magnetic resonance imaging is considered to be pathognomonic of this condition. An illustrative case of a 58 year old man with syringomyelia and dorsal cord indentation who presented with spastic paraparesis, gait instability, parasthesias and bilateral non radicular upper limb pain that resolved following excision of the web is described to highlight the importance of considering this diagnosis when cases of so called “idiopathic” syringomyelia are encountered.

Objective This study is conducted to investigate the effects of occupational therapy (OT) with or without combined acupuncture for upper limb pain and hand functions among children with spastic hemiplegic cerebral palsy. Methods A total of 90 patients who met the inclusion criteria were enrolled in a three-arm randomized, placebo-controlled trial, and were allocated to mono-occupational therapy (OT) group (patients= 30), OT combined with real-acupuncture (ORA) group (patients= 30), and OT combined with placebo-acupuncture (OPA) group (patients= 30), respectively. In addition to receiving the conventional OT program as the basic treatment for total 8 weeks, patients in ORA and OPA group also received corresponding acupuncture treatment 5 days per week for the first two weeks, 3 days per week for the next two weeks, 2 days per week for another two weeks, and 1 day per week for the last two weeks. Non-communicating children's pain checklist-revised scale (NCCPC-R) was used for assessing the upper limb pain among patients. Squeeze dynamometry, modified Ashworth scale (MAS), manual muscle testing (MMT), Jebsen-Taylor hand function test (JTHFT) and box and block test (BBT) were used for assessing various aspects of upper limb and hand functions among patients. Meanwhile, adverse effects were monitored and recorded. Results After 8-week treatment, NCCPC-R global scores witnessed a dramatic decline in ORA group (P 0.05) or OT group (P > 0.05). Dramatic increases were identified in both squeeze dynamometry scores and MMT scores in all three groups (all P 0.05). The BBT global scores of all three groups significantly increased (all P Conclusion ORA is a potential and promising alternative therapy for mitigating upper limb pain as well as improving both upper limb and hand functions among children with spastic hemiplegic cerebral palsy.

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 .

Background Tattoo artists are an understudied population with regards to musculoskeletal (MSK) pain. Aims To explore the characteristics of MSK pain among Israeli tattoo artists and determine whether they are similar to those of dental workers. Methods An online survey including demographics and the Hebrew version of the Extended Nordic Musculoskeletal Questionnaire was disseminated via Israeli social media groups. We directly compared tattoo artists, dental workers and office workers as a reference group. Results Altogether, 114 tattoo artists, 161 dental workers and 296 office workers responded. The most prevalent pain sites were lower back (56%), neck (47%) and hand (36%) among office workers; neck (67%), lower back (62%) and upper back (42%) among the dental workers; and lower back (72%), neck (66%) and hand (55%) among tattoo artists. Contrast analysis suggested office workers were less likely to report pain in the previous 12 months compared with dental workers and tattoo artists (adjusted odds ratios [95% confidence intervals]: ORs [95% CIs] for upper limb pain: 1.13 [1.01–1.28], neck pain: 1.3 [1.15–1.47], upper back pain: 1.27 [1.12–1.43] and low back pain: 1.15 [1.02–1.3]). No significant differences were observed between dental workers and tattoo artists (upper limb pain: 1.18 [0.9–1.54], neck pain: 1.06 [0.81–1.4], upper back pain: 1.22 [0.94–1.58] and low back pain: 1.24 [0.95–1.64]). Conclusions Tattoo artists and dental workers have similar MSK pain characteristics and are different from those of office workers. These characteristics are seemingly a direct result of the physical demands associated with their line of work.

Introduction Carpal tunnel syndrome (CTS) and lateral epicondylitis are both highly prevalent conditions. Our objective was to determine the prevalence of B-mode ultrasound abnormalities of the common extensor tendon (CET) in patients with CTS and establish the relationship between CET stiffness as measured by shear wave elastography (SWE) and CTS severity. Methods Patients without symptoms or signs of lateral epicondylitis were recruited from referrals to a Neurophysiology laboratory for possible CTS. These patients were examined for clinical features of CTS before undergoing electrodiagnostic testing followed by an ultrasound examination, consisting of B-mode, power Doppler and SWE. Results 39 limbs with clinically diagnosed CTS and 20 control limbs were included. 61.5% of CTS limbs had sonographically abnormal CET compared to 35% of controls. The mean CET sonographic abnormality score was higher in CTS patients compared to controls (p=0.006). CTS patients with sonographically abnormal CET had more severe CTS by electrophysiological criteria. The mean CET stiffness in CTS patients was lower than in controls (p=0.033). Discussion Sonographic abnormalities of the CET are common in CTS patients with no clinical evidence of lateral epicondylitis and may relate to common pathogenetic mechanisms. These findings suggest that isolated ultrasound abnormalities in the CET are not diagnostically useful in patients presenting with upper limb pain unless there are clinical features of lateral epicondylitis. This article is protected by copyright. All rights reserved.

To evaluate the frequency and characteristics of trunk and upper limb pain in women diagnosed with breast cancer, in different movement planes, during task-oriented training (TOT) 3, 6, and 9 months after surgery. A prospective cohort study with 20 women. The body pain diagram (BPD), VAS, and McGill questionnaire were used. The TOT consisted of 20 exercises based on the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH) questionnaire. BPD overlay was performed in GIMP® image editor. The chi-square test was applied to the relationship between population characteristics and pain. Freedman's ANOVA and the Cochran's Q test were used in the comparison of pain site frequencies and intensity over time. In total, 297 BPDs were generated, which identified the affected upper limb as the body area with the highest frequency of pain at the three moments. However, at 9 months, the unaffected upper limb presented the same frequency as the affected limb. Radiotherapy presented a statistically significant relationship (p

Spinal cord stimulation (SCS) is an established therapy for chronic neuropathic pain and most frequently utilised for Failed Back Surgery Syndrome (FBSS). BurstDR™ also known as DeRidder Burst-SCS, a novel waveform, has demonstrated superiority to conventional tonic stimulation of the thoracic spine in FBSS. There are case reports of an improvement in multidimensional pain outcomes using DeRidder Burst-SCS in the cervical spine for chronic neck and cervical radicular pain. The safety and efficacy of cervical DeRidder Burst-SCS stimulation still however remain undetermined. This is a prospective, multicentre feasibility trial evaluating the safety and therapeutic efficacy of DeRidder Burst-SCS stimulation for the treatment of chronic intractable neck pain with or without radiation to the arm, shoulder, and upper back. After baseline evaluation, subjects will undergo an SCS trial using the Abbott Invisible Trial system according to standard clinical procedures. During the trial phase, SCS leads will be implanted in the cervical epidural space. At the end of the SCS trial, subjects experiencing at least 50% pain relief will be considered for permanent implant. Pain intensity, medication usage, and other multidimensional pain outcomes will be collected. The timing of these will be at baseline, end of the SCS trial and at 3-, 6-, and 12-month visits. Incidence of adverse events will be collected throughout the study duration. The results of this feasibility study will validate the efficacy and safety of DeRidder Burst-SCS stimulation in the cervical spine. The results obtained in this study will potentially be used to generate a level 1 evidence-based study with formal statistical hypotheses testing. www.clinicaltrials.gov Identifier: NCT03159169.

Objectives It is important to validate self-reported musculoskeletal pain used in epidemiological studies for evaluation of pain outcome measures. The main objective of this paper was to assess the association between self-reported neck/shoulder/upper limb pain and clinical signs of disorders in the region, especially by comparing a measure that only used pain intensity with a measure that combined pain intensity and pain duration. Methods Four hundred and twenty technical school students of both genders were included with a median age of 17 years (16–28). The students stated the pain in four intensity grades and the pain duration in four period lengths within the preceding four weeks period. A pain severity index was calculated by multiplying the pain intensity (0–3) and the duration (1–4). A clinical examination was performed within a week after completing the form. The associations were evaluated by agreement, correlation and symmetric strength of association (contingency). Results The study found low correlation and low positive agreement for neck/shoulder and upper limb pain related to clinical signs of disorders in the region. However, the relationship showed high negative agreement and high contingency. The negative agreement increased for the neck/shoulder region with higher cut-off points for dichotomization, but not for the upper limb region. The index combining reports of pain intensity with pain duration, do not improve agreement, correlation or contingency with clinical signs compared to use of pain intensity alone. Conclusions This study showed an association between self-reported neck/shoulder/upper limb pain intensity and clinical signs of musculoskeletal disorders of the region. An index combining pain intensity and duration (Pain Severity Index) did not increase this association. From the results we suggest using pain intensity reports alone and if dichotomizing is wanted, choosing a cut-off point at high pain levels, especially for neck and shoulder pain.

Background Chronic upper extremity pain (UEP) has complex etiologies and is often disabling. It has been shown that 10 kHz SCS can provide paresthesia-free and durable pain relief in multiple pain types and improve the quality of life of patients. Objective To gain additional evidence on the safety and effectiveness of 10 kHz SCS for the treatment of chronic UEP. Study design It was a prospective, multicenter, and observational study. The study was registered on ClinicalTrials.gov prospectively (clinical trial identifier: NCT02703818). Setting Multicenter. Patients intervention and main outcomes A total of 43 subjects with chronic UEP of ≥5 cm (on a 0-10 cm visual analog scale; VAS) underwent a trial of 10 kHz SCS, and subjects with ≥40% pain relief received a permanent implant. All subjects had upper limb pain at baseline, while some had concomitant shoulder or neck pain. Subject outcomes were assessed for 12 months, and the primary outcome was the responder rate (percentage of subjects experiencing ≥50% pain relief from baseline) at three months. Results Thirty-eight subjects successfully completed the trial (88.3% success rate), 33 received permanent implants (five withdrew consent), and 32 had device activation (per protocol population). There were no paresthesias or uncomfortable changes in stimulation related to changes in posture during the study and there were no neurological deficits. Responder rates at 12 months for upper limb, shoulder, and neck pain in per protocol population (N=32) were 78.1%, 85.2%, and 75.0%, respectively. At 12 months, 84.4% of subjects were satisfied or very satisfied with 10 kHz SCS, and 38.7% either reduced or eliminated opioid usage. Conclusion This study further supports the effectiveness of 10 kHz SCS for chronic UEP treatment and documents the safety profile of the therapy. Clinical trial identifier NCT02703818.

Summary of Background DataNo study has evaluated the relationship between contrast dispersion patterns and outcomes after fluoroscopically guided cervical transforaminal epidural steroid injection (CTFESI).ObjectivesDetermine whether contrast dispersion patterns predict pain and functional outcomes after CTFESI.MethodsSecondary analysis of data collected during two prospective studies of CTFESI for the treatment of refractory radicular pain. Contrast dispersion patterns visualized by true anteroposterior (AP) projections during CTFESIs were categorized by flow: 1) completely external to the lateral border of the neuroforamen (zone 1); 2) within the neuroforamen but without entry into the lateral epidural space (zone 2); and 3) with extension into the lateral epidural space (zone 3). At baseline and at 1 month post-CTFESI, neck pain, arm pain, and “dominant index pain” (the greater of arm or neck pain) were evaluated using a numeric rating scale (NRS); physical function was assessed using the Five-Item Version of the Neck Disability Index (NDI-5).ResultsOne-month post-CTFESI, neck pain, arm pain, and “dominant index pain” reductions of ≥50% were observed in 39.4% (95% confidence interval [CI], 28.2–51.8), 55.6% (95% CI, 43.0–67.5), and 44.1% (95% CI, 32.7–56.2) of participants, respectively. Regarding “dominant index pain,” 72.7% (95% CI, 40.8–91.2), 39.4% (95% CI, 24.2–57.0), and 37.5% (95% CI, 20.5–58.2) of participants reported ≥50% pain reduction when zone 1, zone 2, and zone 3 contrast flow patterns were observed. Contrast dispersion zone was not significantly associated with subgroup differences in neck pain, arm pain, or NDI-5 scores (P>0.05).ConclusionImprovements in pain and function 1 month after treatment with CTFESI did not differ significantly based on the contrast dispersion pattern. Future study is needed to confirm or refute these findings in other procedural settings, in broader patient populations, and with longer-term outcome assessment.

The aim of this systematic review was to summarise the effects of ergonomics interventions on work-related upper limb musculoskeletal pain and dysfunction, and on productivity in sonographers, surgeons and dentists. A total of 31 studies were included. All studies reported effects on upper limb pain. Nine studies reported effects on dysfunction and only two studies reported effects on productivity. Moderately strong evidence in reducing upper limb pain was found for instigation of microbreaks into long duration surgical procedures, and the use of wider, lighter handles in dental instruments. Moderate evidence was also found for use of prismatic glasses and favourable positioning in reducing upper limb pain. Weak, inconsistent or no evidence was found for all other ergonomics interventions in reducing upper limb pain and dysfunction and increasing productivity. The lack of high quality research, particularly in sonographers and in the outcome of productivity, should be addressed. Practitioner summary: This systematic review investigates the effectiveness of ergonomics interventions on upper limb pain, dysfunction and productivity in sonographers, dentists and surgeons. Instigation of microbreaks during long duration procedures and the use of wider, lighter instrument handles were most effective in reducing upper limb work-related pain. Abbreviations: ANOVA: analysis of variance; CLS: conventional laparoscopic surgery; DMAIC: define, measure, analyze, improve and control; GRADE: grading of recommendations, assessment, development and evaluations; HD: high definition; PRISMA: preferred reporting items for systematic reviews and meta-analyses; PROSPERO: The International Prospective Register of Systematic Reviews; RCT: randomised control trial; SILS: single incision laparoscopic surgery; VITOM: video telescopic operative microscope; WNSWLHD: Western New South Wales Local Health District; WMSD: work related musculoskeletal disorder.

Background Although spinal decompression surgery is an effective treatment for myelopathy-induced upper limb pain, some postoperative patients suffer from residual pain in spite of adequate decompression. However, the neural mechanism underlying the poor outcome of pain relief is still unclear. The goal of this study was to explore the brain mechanisms involved in the poor recovery of upper limb pain after the spinal decompression surgery by using functional connectivity (FC) analysis. Methods In this cross-sectional study, 17 patients who underwent cervical spinal decompression surgery were included. Functional MRI (fMRI) during a tactile stimulus for each hand was performed at 1 day before and 7 days after the surgery. In total, 34 fMRI scans (17 left and right upper limbs, respectively) were obtained before and after the surgery, respectively. The patients were divided into poor-recovery and good-recovery groups, and then we searched for the FC that was related to poor-recovery. Results The poor-recovery group (n = 15) showed significantly stronger connectivity between the postcentral gyrus (postCG) and dorsolateral prefrontal cortex (DLPFC) than the good-recovery group (n = 12) preoperatively. When the cutoff value of the preoperative FC between the left postCG and right middle frontal gyrus included in DLPFC was >0.17, the sensitivity and specificity for poor recovery were 73% and 75%, respectively. Conclusions Our study showed that FC between the postCG and DLPFC may be a predictor of pain relief. This result suggested that assessing FC can lead to more informed surgical interventions for cervical spondylotic myelopathy.

Intractable upper limb and neck pain has traditionally been a challenging pain condition to treat, with conventional spinal cord stimulation (SCS) often inducing positional variation in paraesthesia and/or inadequate coverage of axial neck pain. The purpose of this Australian multi-centre prospective, clinical trial was to assess the safety and effectiveness of paraesthesia-independent 10 kHz SCS for the treatment of upper limb and neck pain. Subjects with chronic, intractable neck and/or upper limb pain of ≥ 5 cm (on a 0–10-cm visual analogue scale) were enrolled (ACTRN12614000153617) following human research ethics committee approval. Subjects were implanted with two epidural leads spanning C2–C6 vertebral bodies. Subjects with successful trial stimulation were implanted with a Senza® system (Nevro Corp., Redwood City, CA, USA) and included in the safety and effectiveness evaluation at 3 months post-implant (primary endpoint assessment, PEA) and followed to 12 months. Overall, 31/38 (82.6%) subjects reported a successful 10 kHz SCS trial and proceeded to a permanent implant. Twenty-three of 30 subjects (76.7%) met the PEA. Subjects reported a reduction in neck pain and upper limb pain from baseline at the PEA (8.1 ± 0.2 cm vs. 2.9 ± 0.5 cm, 7.3 ± 0.3 cm vs. 2.5 ± 0.5 cm, respectively, p ≤ 0.0001). Disability, as measured by pain disability index score, decreased from 42.6 ± 2.6 at baseline to 22.7 ± 3.2 at PEA. Results were maintained 12 months post-implant. No neurological deficits, nor reports of paraesthesia, were observed. Stable, long-term results demonstrated that 10 kHz SCS is a promising therapy option for intractable chronic upper limb and neck pain.

Objectives: To analyze the surgical outcome of cervical spine osteo-facetectomy discectomy, and modified Cloward procedure.Materials and Methods: A prospective study was conducted at the Neurospinal & cancer care institute, Karachi. The duration of study was from 1st June 2017 to 25th November 2019. Patients having prolapsed intervertebral cervical discs included in the study, while those with trauma, cervical radiation, previous cervical surgery andmultiple level involvement were excluded. Pre and post-surgical data was collected. Titanium Hashmi cage was used in all operated patients at single level instrumentation.Results: A total of 113 patients satisfied the inclusion criteria and were considered in the study. Among them, 77 patients were male and 36 were female. The age range from 26 to 65 with a base age of 53 years ± 2.5. C5 – C6 was the commonest level for fusion C6 – C7, C3 – C4 and C4 – C5 were less common. For the outcome of theprocedure Odom’s criteria, was followed the results showed excellent improvement in 88 (77.87%), Good results in 18 (15.9%), fair in 5 (4.42%) and 2 patient had Poor (1.76%) results. Fusion was seen in 86 patients, superficial infection in two cases.Conclusion: Patients with single-level degenerative disc and treated with modified titanium Hashmi cage provided a good fusion with the relief of upper limb pain without donor site morbidity at anterior iliac spine.

Background Trigeminal autonomic cephalalgias and complex regional pain syndrome are rare conditions, and their co-occurrence has not been reported previously. Clinical findings: In two patients, ipsilateral trigeminal autonomic cephalalgias developed after the onset of upper limb complex regional pain syndrome. Hyperalgesia to thermal and mechanical stimuli extended beyond the affected limb to encompass the ipsilateral forehead, and was accompanied by ipsilateral hyperacusis and photophobia. In addition, examination of the painful limb and bright light appeared to aggravate symptoms of trigeminal autonomic cephalalgias. Detailed examination of the association between facial and upper limb pain indicated that both sources of pain cycled together. Furthermore, in one case, stellate ganglion blockade inhibited pain for an extended period not only in the affected limb but also the face. Conclusions These findings suggest some overlap in the pathophysiology of complex regional pain syndrome and trigeminal autonomic cephalalgias. Specifically, central sensitization and/or disruption of inhibitory pain modulation on the affected side of the body in complex regional pain syndrome might trigger ipsilateral cranial symptoms and increase vulnerability to trigeminal autonomic cephalalgias.

Neuropathic pain in cancer can result in severe debilitation to a patient with limited treatment options. Interventional modalities like nerve destruction can provide relief but at the expense of motor paralysis. Sympathetic pain is often an undiagnosed and undertreated condition that may accompany cases of chronic pain. We describe a case of severe neuropathic pain in brachial plexopathy in a middle-aged woman caused by metastatic breast cancer that was managed by chemical neurolysis of brachial plexus. Residual pain was treated by neurolysis of stellate ganglion due to the presence of sympathetic pain. This case report highlights the importance of the dual nature of pain and its management by chemical neurolysis in severe refractory neuropathic and sympathetic mediated pain.

The aim of cross-sectional study was to investigate the association between loneliness, increased social isolation, and pain following the COVID-19 outbreak. A total of 25,482 participants, aged 15–79 years, were assessed using an internet survey; the University of California, Los Angeles Loneliness Scale (Version 3), Short Form 3-item (UCLA-LS3-SF3) was used to assess loneliness, and a modified item of the UCLA-LS3-SF3 was used to measure the perception of increased social isolation during the pandemic. The outcome measures included the prevalence/incidence of pain (i.e., headache, neck or shoulder pain, upper limb pain, low back pain, and leg pain), pain intensity, and the prevalence of past/present chronic pain. Pain intensity was measured by the pain/discomfort item of the 5-level version of the EuroQol 5 Dimension scale. Odds ratios of pain prevalence/incidence and past/present chronic pain prevalence according to the UCLA-LS3-SF3 scoring groups (tertiles) and the frequency of the perceived increase in social isolation (categories 1–5) were calculated using multinomial logistic regression analysis. The mean pain intensity values among different loneliness and social isolation levels were tested using an analysis of covariance. Increased loneliness and the severity of the perceived social isolation were positively associated with the prevalence/incidence of pain, pain intensity, and the prevalence of past/present chronic pain.

Axillary web syndrome (AWS) is defined as a visible and palpable network of cords in the skin of the axillary cavity that are tensed by shoulder abduction following surgery for breast cancer, causing significant functional limits of the ipsilateral upper limb (UL) and pain. The purpose of this narrative review is to discuss rehabilitation approaches for greater efficacy with respect to pain and novel suggestions. AWS is a frequent complication of axillary lymphadenectomy that necessitates a thorough follow-up in the medium to long term. Physiotherapy is effective in the treatment of functional limb deficits, the management of pain, and the treatment of upper limb disability. The best management approach involves the use of soft tissue techniques to slow the natural course of the syndrome, in association with therapeutic exercises for functional recovery and muscle strengthening. AWS is linked secondary lymphedema, requiring integration with manual lymphatic drainage. The physiotherapy management of AWS is currently fragmented, and insufficient information is available on the nature of the disease. Thus, randomized and controlled studies that compare rehabilitation approaches in AWS are desirable, including the possibility of using mesotherapy in the treatment of axillary and upper limb pain.

Location-specific pain, such as back, neck, arm, and hip pain is associated with short- and long-term health effects, ranging from minor discomfort to musculoskeletal impairment (1), diminished quality of life (2), and escalating health care costs (3). Existing studies of location-specific pain are mostly limited to small or special populations with limited generalizability (4-6). This report provides national estimates of any pain regardless of body region as well as estimates of back, lower limb (hips, knees, or feet), and upper limb (hands, arms, or shoulders) pain in the past 3 months among U.S. adults aged 18 and over by selected sociodemographic characteristics.

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.

Rationale Upper limb dysfunction is well recognised in survivors of intensive care (Gustafson et al Crit Care Med 2018;46:1769-1774). A mainstay of respiratory support through the COVID-19 pandemic has been use of repeated patient prone positioning to improve ventilation. Potential complications reported with prone positioning of sedated patients include brachial plexopathy, shoulder subluxation and peripheral nerve injury. We hypothesised that there would be a high prevalence of upper limb dysfunction, disability and pain in survivors of COVID-19 requiring mechanical ventilation, particularly in those who were prone positioned. Methods Eligible patients were laboratory-confirmed swab positive for SARS-CoV-2, mechanically ventilated for a minimum of 72 hours on the Royal Brompton Hospital Adult Intensive Care Units. We measured handgrip strength (HGS), normalised for age and sex, the Disability of Arm Shoulder Hand (DASH) questionnaire (Beaton et al J Hand Ther 2001;14:128-146) and Upper limb Pain Numerical Rating Scale (from 0-10). Health related quality of life was measured using the EuroQol-5 dimensions 5-level (EQ5D5L Utility Index (UI) and Visual Analogue Score (VAS)). Patients were stratified according to whether they received prone positioning or not. Results Twenty-seven consecutive patients were assessed at mean 45 days after hospital discharge. Baseline demographics, admission characteristics, and follow-up upper limb assessment data are shown in Table 1. There was evidence of upper limb weakness (mean (SD) right HGS: 44.77(19.31) %predicted;left HGS 47.69 (18.41) %predicted), with 63% showing upper limb dysfunction (DASH ≥ 16) and 33% showing severe upper limb dysfunction (DASH ≥40). Median (IQR) pain scores were 4 (0.75-6.25) with 53% reporting severe pain (≥ 5). DASH correlated significantly with EQ5D5L UI and VAS (r=-0.69 and r=-0.73 respectively;both p

Purpose The present study aimed to assess the prevalence of upper limb pain and disability and to investigate potentially correlated factors among university students in Jordan. Methods This was a cross-sectional questionnaire-based survey study that was conducted among university students. The upper limb pain and disability were assessed by the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome questionnaire. The DASH outcome questionnaire was distributed to 2100 students from the population of 2 public and 2 private universities in the north of Jordan. Demographic and personal information were collected. Data were analyzed using descriptive statistics and linear regression analysis. Results A total of 1929 DASH outcome questionnaires were returned, with a high response rate of 91.86%. The age of the subjects was between 18-28 years (52% male; 48% female). The majority of subjects (85.2%) used at least one smartphone. The majority of them had been using a smartphone for more than 5 years. The prevalence of upper limb pain and disability among university students was 24%. Several factors were found to be significantly connected with upper limb pain and disability among university students, such as smartphone use, computer use, the presence of musculoskeletal problems, not living with their families, using public transport (bus), and daily housekeeping. Conclusion The results of this study can be used globally to promote the health and well-being of university students, improve their academic performance and future career. Identifying high-risk groups will assist in early identifications and prevention programs for upper limb pain and disability among university students.

Background and aims In 2008, the International Association for the Study of Pain Special Interest Group on Neuropathic Pain (NeuPSIG) proposed a clinical grading system to help identify patients with neuropathic pain (NeP). We previously applied this classification system, along with two NeP screening tools, the painDETECT (PD-Q) and Leeds Assessment of Neuropathic Symptoms and Signs pain scale (LANSS), to identify NeP in patients with neck/upper limb pain. Both screening tools failed to identify a large proportion of patients with clinically classified NeP, however a limitation of our study was the use of a single clinician performing the NeP classification. In 2016, the NeuPSIG grading system was updated with the aim of improving its clinical utility. We were interested in field testing of the revised grading system, in particular in the application of the grading system and the agreement of interpretation of clinical findings. The primary aim of the current study was to explore the application of the NeuPSIG revised grading system based on patient records and to establish the inter-rater agreement of detecting NeP. A secondary aim was to investigate the level of agreement in detecting NeP between the revised NeuPSIG grading system and the LANSS and PD-Q. Methods In this retrospective study, two expert clinicians (Specialist Pain Medicine Physician and Advanced Scope Physiotherapist) independently reviewed 152 patient case notes and classified them according to the revised grading system. The consensus of the expert clinicians’ clinical classification was used as “gold standard” to determine the diagnostic accuracy of the two NeP screening tools. Results The two clinicians agreed in classifying 117 out of 152 patients (ICC 0.794, 95% CI 0.716–850; κ 0.62, 95% CI 0.50–0.73), yielding a 77% agreement. Compared to the clinicians’ consensus, both LANSS and PD-Q demonstrated limited diagnostic accuracy in detecting NeP (LANSS sensitivity 24%, specificity 97%; PD-Q sensitivity 53%, specificity 67%). Conclusions The application of the revised NeP grading system was feasible in our retrospective analysis of patients with neck/upper limb pain. High inter-rater percentage agreement was demonstrated. The hierarchical order of classification may lead to false negative classification. We propose that in the absence of sensory changes or diagnostic tests in patients with neck/upper limb pain, classification of NeP may be further improved using a cluster of clinical findings that confirm a relevant nerve lesion/disease, such as reflex and motor changes. The diagnostic accuracy of LANSS and PD-Q in identifying NeP in patients with neck/upper limb pain remains limited. Clinical judgment remains crucial to diagnosing NeP in the clinical practice. Implications Our observations suggest that in view of the heterogeneity in patients with neck/upper limb pain, a considerable amount of expertise is required to interpret the revised grading system. While the application was feasible in our clinical setting, it is unclear if this will be feasible to apply in primary health care settings where early recognition and timely intervention is often most needed. The use of LANSS and PD-Q in the identification of NeP in patients with neck/upper limb pain remains questionable.

Background: Cervical epidural injections for treating neck and upper limb pain are performed by 2 methods: transforaminal and interlaminar. Many serious complications caused by inadvertent intravascular injection have been reported with the use of cervical transforaminal epidural steroid injection through the anterior-lateral approach. Despite international practical guidelines that have been proposed, cervical transforaminal epidural injection is still less recommended than cervical interlaminar epidural injection. Objectives: The objective of this study is to introduce Th1-transforaminal epidural injection (Th1- TFEI) through the posterior-lateral approach, compare the injectate spread in Th1-TFEI with that of Th1/2-parasaggital interlaminar epidural injection (Th1/2-pILEI), and clarify the clinical characteristics of Th1-TFEI. Study Design: This research involved a prospective study of 30 patients receiving both Th1-TFEI and Th1/2-pILEI. Methods: Thirty patients with unilateral upper limb pain were enrolled for this prospective study. Th1-TFEI and Th1/2-pILEI were administered on each case in random order under fluoroscopy, and computed tomographic (CT) epidurograms were compared. Changes in circulatory dynamics, presence of Horner’s syndrome, changes in the Numerical Rating Scale (NRS-11), and adverse events were investigated. Results: Patients included 15 men and 15 women and included 24 cases of cervical spine disease and 6 cases with other upper limb pain. The Th1-TFEI group had significantly higher rates of “Th1 root filling” (100%), “ventral spread” (70.0%), and “lateral limitation” (26.7%) compared to the Th1/2-pILEI group. In the Th1-TFEI group, cephalad spread averaged 2.97 vertebral bodies, reaching approximately up to C6. The Th1/2-pILEI group had an average of 4.76 vertebral bodies, approximately up to C4. The 2 groups showed significant differences in cephalad spread. Horner’s syndrome appeared in the Th1-TFEI group at a rate of 56.7%, significantly higher than that in the Th1/2-pILEI group at 17.2%. The presence of Horner’s syndrome showed significant correlations with “ventral spread” and “spread up to C6.” There were no significant differences in NRS-11 improvement and changes in circulatory dynamics between the groups. There were no major complications. Limitations: The components of injectate were standardized; however, the needle gauge numbers were varied. In addition, interpretation of the CT-epidurogram was not blinded. The sample size was small; therefore, multivariate analysis was not possible. Conclusions: CT-epidurogram comparison revealed that Th1/2-pILEI was not localized on the injection side, and there was better dorsal spread – although ventral spread was small. Contrarily, Th1-TFEI was localized on the injection side, and better ventral spread was shown while cephalad spread was limited. We expected the addition of a sympathetic block effect suggested by the Horner’s syndrome as well as the merits of the ventral spread. However, short-term clinical effects were equal to those of Th1/2 pILEI. In future research, we need to standardize the diseases to include and to increase the number of cases to enable evaluation of clinical effectiveness.Key words: Epidural, cervical, transforaminal, interlaminar, fluoroscopy, CT-epidurogram, dorsal, ventral, cephalad, Horner’s syndrome

Background It has been reported that long working hours are hazardous to the workers’ health. Especially, work-related musculoskeletal disorders (WMSDs) have been considered as one of the significant health issues in workplace. The objective of this study was to identify the association between long working hours and work-related musculoskeletal symptoms. Methods The analysis was conducted using data from the Fourth Korean Working Conditions Survey (KWCS). Subjects of this study were 24,783 wage workers and divided into three groups according to the weekly working hours, which were ≤ 40, 41–52 and > 52 h. The relationship between long working hours and work-related musculoskeletal symptoms was analyzed by multivariate logistic regression method after adjusting for general, occupational characteristics including specific working motions or postures and psychosocial factors. Results Approximately 18.4% of subjects worked more than 52 h per week and 26.4 and 16.4% of male subjects and 33.0 and 23.4% of female subjects experienced work-related upper and lower limb pains, respectively, over the last 12 months. Moreover, the prevalence of upper and lower limb pain was increased in both genders as the weekly working hours increased. The odds ratios (ORs) of upper limb pain for those working 41–52 h and more than 52 h per week when adjusted for general, occupational characteristics including specific motions or postures and psychosocial factors were 1.36 and 1.40 for male workers and 1.26 and 1.66 for female workers compared to the reference group, respectively. Furthermore, ORs of lower limb pain for the same weekly working hour groups were 1.26 and 1.47 for male workers and 1.20 and 1.47 for female workers, respectively. Conclusions Long working hours were significantly related to work-related musculoskeletal symptoms in Korean wage workers and appropriate interventions should be implemented to reduce long working hours that can negatively affect workers’ health.

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 changeswith 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.

Objectives. So far, dysfunction in mental rotation has been assessed in relation to the left- or right-sided CRPS. Here we examined mental rotation in patients with upper or lower limb CRPS. Considering the potential role of socio-emotional functioning on the perception of body image, we further investigated the association between performance on mental rotation and socio-emotional characteristics. Methods. We examined the performance of 36 patients with upper or lower limb CRPS on the limb laterality recognition. Accuracy and response times for pictures of hands and feet at 4 rotation angles were evaluated. Socio-emotional functioning was measured by the Interpersonal Reactivity Scale and the Toronto Alexithymia Scale. Results. Patients with upper limb pain showed longer RTs to recognize the laterality of hands than feet (P = 0.002), whereas patients with lower limb pain showed longer RTs for feet than hands (P = 0.039). Exploratory correlation analyses revealed that RTs for feet were negatively correlated with the levels of empathic ability to take another’s perspective (P = 0.006) and positively correlated with the level of emotional difficulty in identifying feelings (P = 0.006). Conclusions. This study is the first to report selectively impaired mental rotation of hands vs feet in patients with upper or lower limb CRPS. The findings suggest that impaired mental rotation derives from relative deficits in the representation of the affected limb. Correlations between impaired mental rotation and socio-emotional inability indicate that an altered body schema may be closely associated with impaired social cognitive aspects in CRPS patients.

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.

Successful treatment of painful cervical spine disorders hinges on the accurate assessment of the underlying tissue injury, which can involve a broad range of biomechanical and biochemical disorders. The clinician needs to conceptualize a process of diagnosis and treatment that incorporates an understanding of the pathophysiology of cervical spine injury and the associated potential symptom manifestations, an awareness of the advantages and disadvantages of the myriad of diagnostic tools, and knowledge of the potential therapeutic options. The initial step in this process is the history taking. It is important that one distinguish between cervical axial pain (neck pain) and upper limb pain. Evaluating and treating common cervical spine disorders requires the completion of a probability analysis of what injured structure is most likely responsible for the patient’s presentation. An astute spine clinician recognizes individual symptom composites to accurately diagnose and treat these injuries. This chapter is intended to be a foundation for approaching common painful cervical spine disorders, and provides a view of a tiered treatment algorithm, which incorporates appropriate therapeutic interventions across a spectrum of care.

Objectives: Quantitative sensory testing (QST) is a noninvasive technique to evaluate functioning of the somatosensory system. In many women surgically treated for breast cancer (BC), somatosensory functioning is disturbed with high prevalence of sensory loss and/or pain. The aims of this systematic review were (1) to summarize literature about QST methods; (2) to summarize the results within women surgically treated for BC (patients and survivors); (3) to compare QST results between women surgically treated for BC with and without pain; and (4) to compare the results between women surgically treated for BC and women without history of BC. Methods: A systematic literature search was conducted up to February 2020. Included studies had to report on QST methods (mechanical or thermal detection-pain thresholds, pressure pain thresholds [PPT], temporal summation [TS], or conditioned pain modulation [CPM]) in women over 18 years with-without pain, who had undergone unilateral surgery for BC. Results: Twenty-eight studies were included. Discrepancies in QST methods were greatest for TS and CPM. A local disturbance in thermal detection and an increased pain facilitation were found in BC survivors with pain in the surgical area. BC survivors with upper limb pain had significantly lower PPT at the surgical area and PPT were also significantly lower compared with women without history of BC, at affected and nonaffected sides for both local and remote body regions. Discussion: Standardized QST incorporating assessments of CPM is warranted in order to draw conclusions about neurobiological mechanisms of pain and somatosensory disturbances after surgical treatment for BC and to enhance mechanism-based management of these sequelae.

Musculoskeletal disorders of the upper limb are common and can involve structures such as bone, joint, ligament, tendon, and muscle. This chapter begins with a description of physical examination maneuvers that can be used to assist with the identification of upper limb pathology. This is followed by a description of the rehabilitation principles that can be used to treat these disorders. The remainder of the chapter discusses the identification and management of upper limb conditions frequently encountered by physiatrists. This information can be applied to accurately diagnose and appropriately treat upper limb conditions, thus maximizing the patient’s functional outcome.

Botulinum toxin (BoNT) has been widely employed to treat poststroke spasticity, cervical dystonia and muscle hyperactivity. Recently, BoNT injections are increasingly used in treating musculoskeletal pain. The mechanism of BoNT in pain relief comprises relaxation of overused muscles and inhibition of inflammatory nociceptive cytokines/neurotransmitters. As BoNT injections seem promising in treating painful musculoskeletal disorders, we aimed to investigate its effectiveness in shoulder and upper limb pain. Although the present article is a narrative review, we employed a systematic approach to search for relevant articles in PubMed. A total of 19 clinical studies were included. Here, we observed that intramuscular BoNT injections were helpful in stroke patients with hemiplegic shoulder pain. In shoulder joint pain, intra-articular and intrabursal BoNT injections achieved a longer period of pain relief than corticosteroid injections. Similarly, a more durable effect of intramuscular BoNT than saline injections was seen in shoulder myofascial pain. Its use in complex regional pain syndrome and persistent upper limb pain in breast cancer survivors was insufficient, necessitating more studies. Since not all of the included studies could provide Class I of evidence based on the efficacy criteria used by American Academy of Neurology, controlled clinical trials in a larger number of patients are necessary to verify validity of these findings in the future.

Objectives Work‐related musculoskeletal disorders (WMSDs) are common occupational injuries for nurses. Furthermore, rotating and irregular shift work may exacerbate muscle tension and pain in nurses. The objective of this study was to examine the differences between fixed day shift (FDS) nurses and rotating and irregular shift (RS + IS) nurses in WMSDs using a systematic literature review and meta‐analysis. Methods Databases including PubMed, CINAHL, Cochrane Library, EBSCOhost, and Google Scholar were searched for relevant studies published between 2010 and 2020 using the target keywords. Results This study obtained data on a total of 18 199 nurses, among which 12 786 comprised the RS + IS group and 5413 constituted the FDS group. The result of the heterogeneity test was Q = 79.27 (P

Background Psychological distress is one of the major determinants for the experience progression, and recovery of chronic pain. However, it is unclear whether physical pain in specific body sites could be predictive of psychological illness. In this study, we aim to investigate the link between chronic pain in specific anatomical sites and psychological distress represented in the General Health Questionnaire-12 (GHQ-12 items). Methods A population-based cross-sectional study was conducted in Al Kharj region of Saudi Arabia. We included 1003 participants. Data were collected using the GHQ-12, and a subjective report on eight anatomical pain sites. Data analysis used statistical software SPSS version 26.0 for Windows statistical package. Results Chronic musculoskeletal pain in the neck and head regions was significantly associated with higher psychological distress. Other sites (back, lower limb, chest, abdominal and upper limb pain) were not associated with psychological distress. In multiple regression analysis, chronic ‘general’ pain was significantly associated with higher psychological distress (unstandardized Beta regression coefficient = 2.568; P P = 0.038). Females were more likely to have higher psychological distress than males (unstandardized Beta = 2.464, P = 0.003). Single (not-married) people have a higher risk of psychological distress than married people (unstandardized Beta = 2.518, P = 0.025). Also, job type/status whether being unemployed (not working) or ‘civilian’ (civil servant/worker) was positively and significantly associated with an increased probability of psychological distress (unstandardized Beta = 1.436, P = 0.019). Conclusion Chronic ‘general’ pain was significantly associated with negative psychological disorders. The government of Saudi Arabia needs to focus on patients with chronic ‘general’ pain, females, young and unmarried individuals as potentially ‘high-risk’ population subgroups for adverse psychological disorders, and subsequent long-term complications.

STUDY DESIGN This was a retrospective study. OBJECTIVE The main question of this study is whether the change of postoperative T1 slope will affect the clinical and imaging recovery of patients with single-level anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA The T1 slope after ACDF is different from that preoperatively, however, the clinical significance of this change has not been reported. MATERIALS AND METHODS A retrospective analysis was conducted on 87 patients with single-level ACDF. Visual Analogue Scale was used to compare neck and upper limb pain before and after surgery. Neurological improvement was assessed by the Japanese Orthopaedic Association Scores and Neck Disability Index. Preoperative and postoperative T1 slope, occipital-C2 angle, C2-C7 overall curvature and functional spinal unit curvature were measured and analyzed by lateral cervical spine x-ray. RESULTS All patients were followed up for 23.98±12.17 months. The Japanese Orthopaedic Association, Visual Analogue Scale, and Neck Disability Index scores as well as the overall curvature and change of C2-C7 and functional spinal unit were significantly improved in the last postoperative follow-up. At 12 months after surgery and the last follow-up, patients with increased T1 slope had more severe neck pain symptoms than those with decreased T1 slope (P

Background: Six million adults in the U.S. are living with painful diabetic neuropathy (PDN) and current treatments are ineffective for many. Preliminary data suggest 10 kHz spinal cord stimulation (SCS) relieves pain and may improve sensation in refractory patients. Methods: Prospective, multicenter, randomized controlled trial (SENZA-PDN) with 216 subjects assigned 1:1 to 10 kHz SCS (Nevro Corp.) combined with conventional medical management (CMM) or CMM alone. Patients with PDN symptoms ≥12 months, lower limb pain intensity ≥5cm (0-10cm visual analog scale [VAS]), hemoglobin A1c ≤10%, and upper limb pain intensity Results: Randomization of 113 subjects to 10 kHz SCS+CMM and 103 to CMM resulted in groups well-matched at baseline. There were 2 procedure-related infections in the 10 kHz SCS+CMM group (1.8%). At 3-month follow-up, there were clear differences in lower limb pain scores (Fig 1A) and Diabetes Quality of Life (Fig 1B). Patients in the 10 kHz SCS+CMM group demonstrated improvements in sensation on physical examination (Fig 1C) and by patient report of numbness (Fig 1D). In addition, differences between treatment groups were observed in 6-minute walk test distance (Fig 1E) and sleep (Fig 1F). Conclusion: SENZA-PDN is the largest RCT to-date of SCS management of PDN and will inform the treatment continuum. Disclosure E. Petersen: Consultant; Self; Abbott, Medtronic, Neuros Medical, Nevro. Research Support; Self; Medtronic, Neuros Medical, Nevro, ReNeuron. T. Stauss: None. J.L. White: Research Support; Self; Allergan plc., Astellas Pharma Inc., Bayer Healthcare Pharmaceuticals Inc., Bristol-Myers Squibb, Eli Lilly and Company, Fitbit, Inc., Nevro, NovMetaPharma Co. Ltd., Theracos, Inc. S.M. Sills: None. K. Amirdelfan: Consultant; Self; Biotronik, Medtronic, Nevro Corporation, Saluda. M. Guirguis: Consultant; Self; Boston Scientific, nevro incop, spr. J. Xu: None. C. Yu: None. A. Nairizi: None. D.G. Patterson: Research Support; Self; Nevro Corporation. V. Galan: None. N. Mehta: Advisory Panel; Self; Nevro. Research Support; Self; Nevro. S.P. Lad: None. D. DiBenedetto: None. P.W. Wu: None. C.E. Nasr: Other Relationship; Self; Exilxis, Neurogastrx, Nevro Corp. R. Taylor: Consultant; Self; Nevro. E.S. Brooks: Employee; Self; Nevro. J. Subbaroyan: Employee; Self; Nevro Corp. B. Gliner: Employee; Self; Nevro Corp. D.L. Caraway: Employee; Self; Nevro. N. Mekhail: Consultant; Self; Boston Scientific, Nevro, Nuvectra, Relievant, Saluda, Sollis Therapeutics, Vertos Medical. Research Support; Self; Halyard, Mallinckrodt Pharmaceuticals, Mesoblast, Neuros Medical. Funding Nevro Corp.

Background: Neurosarcoidosis is a rare disease. In the spine, it commonly presents as an intramedullary lesion. Epidural spinal lesions are extremely rare. Case Description: A 29-year-old patient presented with a 22-month history of progressive neck, upper limb pain, and myelopathy. The cervical MRI showed a large epidural mass infiltrating the paraspinal soft tissue. After an open biopsy, the diagnosis of neurosarcoidosis was established and was followed-up by appropriate medical management. Conclusion: To manage cervical epidural neurosarcoidosis, first, you must obtain a tissue diagnosis and then follow with appropriate medical management.

Objectives It has been reported that South Korea ranked as one of the longest‐working nations among OECD countries. This study sought to examine the association between long working hours and musculoskeletal pain among Korean medical residents. Methods We analyzed a cross‐sectional survey of 1,077 medical residents in South Korea. Working hours per week were categorized as follows

Upper limb chronic exertional compartment syndrome (CECS) has been described in amateur and professional motorcycle racers, but there is no published data about its prevalence. The purpose of this study was to define the awareness, prevention and prevalence of this syndrome in licensed motorcycle racers in competition in France. Secondary purposes were to determine the functional impact of CECS and post-treatment outcomes. The 20,641 licensed racers in competition of the French Motorcycle Federation were sent a self-assessment questionnaire about upper limb pain and CECS physical examination findings, functional impact and treatment outcomes. The satisfaction level was assessed after each type of treatment. Acceptability rate was 6.35% with 1311 racers responding. CECS was unknown by 29% of racers. Prevention methods were unknown by 10% of racers. Less than 50% of racers modified their bikes. The prevalence of upper limb CECS in competitive racers was 9%: 8.7% forearm, 0.2% thenar, 0.1% hypothenar and 0.4% first dorsal interosseus compartments. The prevalence was 16% in international level racers, 11% in national level racers and 7.3% in regional level racers. A quarter of racers were satisfied or very satisfied with the outcomes of conservative therapy and rehabilitation. Only 67 racers underwent surgical treatment for their upper limb CECS: 31 by open fasciotomy, 23 by minimally invasive fasciotomy and 13 by endoscopy-assisted compartment release. In these 67 racers, the mean visual analog score for pain improved significantly (p 0.001 95% CI [3.1-4.5]) with 81% satisfied or very satisfied with surgery outcomes. This epidemiologic self-assessment questionnaire for upper limb CECS is a new concept. This study screened for CECS and offer information regarding evaluation, treatment, and management.

Tyrimo pagrindimas. Pasireiškus Th4 sindromui, sutrinka vegetacinės nervų sistemos (VNS) funkcija (Karas, Pannone, 2017). Tai būklė, kuri gali atsirasti, kai kaklinės ir krūtininės stuburo dalies slanksteliai yra hipomobilūs, ir tai gali sukelti rankų parestezijas, tirpimą, šalimą arba prakaitavimą. Esant Th4 sindromui, gali sutrikti rankų judesių valdymas, atsirasti sunkumas, patinimas. Rankų skausmai gali būti susiję su sąstingiu ir galvos skausmu. Skausmas ir sąstingis pasireiškia menčių srityje, priekinėje arba nugarinėje krūtinės dalyje (Fernández-de-las-Peñas et al., 2015; Conroy, Schneiders, Tyrimo tikslas – įvertinti krūtininės stuburo dalies mobilizacijos ir savimobilizacijos poveikį rankų ir kaklo skausmui, funkcijai bei gyvenimo kokybei esant Th4 sindromo Metodai. Buvo tiriama 20 asmenų, kurie skundėsi galvos, rankų, pečių srities skausmu bei tirpimu. Buvo įvertinti pokyčiai miotomose ir dermatomose, rankų refleksai ir judesių amplitudės, rankų raumenų jėga, skausmas, Rezultatai. Tyrimo rezultatai parodė, kad MOB grupės kaklo srities ir rankų skausmas po mobilizacijos sumažėjo nuo 4,8 ± 1,55 iki 3,3 ± 0,71 (p < 0,05) ir nuo 4,5 ± 0,71 iki 2,8 ± 1,34 (p < 0,05). SAVIMOB grupės kaklo ir rankų skausmas po savimobilizacijos sumažėjo nuo 3,6 ± 0,84 iki 2,3 ± 1,7 (p > 0,05) ir nuo 4 ± 1,56 iki 3 ± 2,49 (p > 0,05). Po mobilizacijos nustatyta, kad iš visų gyvenimo kokybės rodiklių labiausiai pagerėjo socialinis funkcionavimas, fizinė būklė, sumažėjo kūno skausmai ir veiklos apribojimas dėl emocinių ir fizinių Išvados. Kineziterapija, kurios metu taikoma mobilizacija, veiksmingiau mažina kaklo ir rankos skausmą, turi tendenciją labiau pagerinti stuburo paslankumą ir gyvenimo kokybę nei kineziterapija, kai atliekama savimobilizacija.Raktažodžiai: Th4 sindromas, krūtininės stuburo dalies mobilizacija, savimobilizacija.

Background: Rotator cuff tendinopathy (RCT), subacromial impingement (SAIS), and medial (MEP) and lateral (LEP) epicondylitis are the most common causes of upper limb pain caused by microtrauma and degeneration. There are several therapeutic choices to manage these disorders: extracorporeal shockwave therapy (ESWT) has become a valuable option. Methods: A systematic review of two electronic medical databases was performed by two independent authors, using the following inclusion criteria: RCT, SAIS, MEP, and LEP, ESWT therapy without surgical treatment, with symptoms duration more than 2 months, and at least 6 months of follow-up. Studies of any level of evidence, reporting clinical results, and dealing with ESWT therapy and RCT, SAIS, MEP, and LEP were included. Results: A total of 822 articles were found. At the end of the first screening, following the previously described selection criteria, we selected 186 articles eligible for full-text reading. Ultimately, after full-text reading, and reference list check, we selected 26 articles following previously written criteria. Conclusions: ESWT is a safe and effective treatment of soft tissue diseases of the upper limbs. Even in the minority cases when unsatisfied results were recorded, high energy shockwaves were nevertheless suggested in prevision of surgical treatment.

A 20-year-old male swimmer presented to the emergency department with right arm pain and swelling several days after a weight training session following swim team practice. The initial diagnosis was muscle strain, and the patient was discharged. The next day, he was evaluated by his swim team physician, who ordered right upper extremity duplex ultrasonographic imaging, which revealed no flow and thrombosis in the subclavian and axillary veins, and Paget-Schroetter syndrome was diagnosed. He subsequently had a mechanical thrombectomy and catheter-directed thrombolysis was initiated with placement of a lytic catheter for continuous infusion of tissue type plasminogen activator.

Neurogenic thoracic outlet syndrome (nTOS) due to compression of the brachial plexus under the pectoralis minor insertion, also called pectoralis minor syndrome, is characterized by pain and decreased function in the upper limb. When the diagnosis is confirmed by a pectoralis minor muscle block or botulinum toxin infiltration, the compression can be released by a minimally invasive procedure under general anesthesia.

Objective To assess the effect depression has on outcomes after cervical epidural steroid injections (CESIs). Design Retrospective review of a prospectively collected database. Setting Single institution tertiary care center. Subjects Fifty-seven patients with cervical spondylosis and cervical radicular pain who were deemed appropriate surgical candidates but elected to undergo CESI first were included. Methods Twenty-one of 57 (37%) patients with depression (defined as Zung Depression Scale >33) were included. Patient-reported outcomes including Neck Disability Index (NDI), numeric rating scale (NRS) for arm pain (AP), NRS for neck pain (NP), and EuroQol-5D (EQ-5D) were collected at baseline and three-month follow-up. Minimal clinically important differences were then calculated to provide dichotomous outcome measures of success. Results Overall, 24 and 28 patients achieved at least 50% improvement in AP and NP, respectively. In terms of disability, 25/57 (43.9%) patients achieved >13.2-point improvement on the NDI overall. In patients with depression, 4/21 (19.0%) and 5/21 (23.8%) achieved at least 50% improvement on the NRS for AP and NP, respectively, compared with 20/36 (55.5%) and 23/36 (63.8%) in patients without depression. This difference was statistically significant for both pain measures (P

Background: Neck pain with upper limb pain is a common complaint of patients seen in Out Patient Department (OPD). Such pain may be because of a pinched nerve. There is inflammation in the nerve which causes radicular symptoms. The available clinical tests for cervical radiculopathy are provocative tests, difficult to perform and techniques vary from author to author. The reliability of these tests is only when done in clusters. We devised a novel non-provocative clinical sign to diagnose cervical radiculopathy and a method to reduce upper limb radicular pain and thereby improving the function of the upper limb. Method: Patient’s bilateral pronated wrists were palpated dorsomedially on the ulnar styloid. This elicited tenderness over the Dorsal Cutaneous branch of Ulnar Nerve (DCU). The painless active degree of movement at shoulder and elbow joints was noted. Nerve block at the palpated tender point was given using 2% lignocaine in 95 patients. We used Visual Analogue Scale score to measure radicular pain intensity before and 5 minutes after injection Results: All patients had tenderness at the DCU on the symptomatic upper limb. All patients had reduction in VAS of radicular pain from 7.36±0.89 before injection to 1.89±0.98 after injection with improvement of shoulder and elbow active movement.Conclusion: We recommend palpation of DCU in both upper limbs in all cases of suspected cervical radiculopathy. Palpation to elicit tenderness over DCU in cervical radiculopathy, was documented as Pote’s sign positive. Injection of local anesthetic agent over DCU reduces pain and improves upper limb function and it was documented as Pote’s test positive. This test is of diagnostic and therapeutic significance. This test is minimally invasive and can be done in an OPD set-up.

Objective: N-(2-methoxy) benzyl-phenethylamine (NBOMe) derivatives have a high affinity to the serotonin receptor 2A and emerged as new psychedelic agents. We report the case of a 30-year-old man admitted to the hospital because of acute ischemia of the left arm with clinical symptoms of pallor, pulselessness, paresthesia, and a motoric deficit. The patient had a history of schizophrenia and drug abuse and disclosed during the hospital stay the sublingual intake of a substance bought as 25I-NBOMe the night before the ischemic event. Methods: Routine clinical diagnostics including among others color-coded duplex sonography and computed tomography angiography (CTA) were performed. The remainder of the drugs was analyzed using high performance liquid chromatography. Results: Initial color-coded duplex sonography of the upper left limb showed pathological flow profiles of the axillary, brachial, ulnar, and radial artery with a reduced diameter of the ulnar (0.9 mm) and radial (1.1 mm) artery. In consequence, peripheral vasospasm, distal arterial thrombosis, or arterial embolization was anticipated. As therapeutic measures, the patient immediately received intravenous systemic vasodilators (alprostadil) and therapeutic anticoagulation with low molecular weight heparin. Instant symptom improvement was observed within the first day after therapy initiation. The subsequently performed CTA of the heart and left arm showed no signs of thrombotic material. Treatment was continued for five days and the patient was released thereafter having completely normalized perfusion in his left arm. Outpatient treatment was continued with calcium-channel blockers, as the patient had also displayed arterial hypertension. Drug analysis retrieved a composition of the isomers 25I-NBOMe, 25C-NBOMe, and 25H-NBOMe as well as traces of pentylon. Conclusion: NBOMe ingestion implicates the risk of peripheral vasospasms with severe, limb-threatening ischemia.

Objective: To evaluate the effectiveness of bloodletting puncture and cupping in relieving breast cancer-related lymphedema. Methods: We conducted a non-randomized controlled study at the Galactophore Department of the 3rd Affiliated Hospital of Beijing University of Chinese Medicine from March 2013 to December 2014. Seventy-five patients undergoing treatment for breast cancer-related lymphedema were divided into two groups in accordance with the patients’ treatment choices: the treatment group (n = 50) underwent bloodletting puncture and cupping every 5 days for 15 min/session (one session per day) combined with exercise training once a day for 30 minutes; the control group (n = 25) underwent the same exercise training alone. Evaluation indexes were measured before and after treatment; these included arm circumference (at the wrist crease, 10 cm distal to the wrist crease, the elbow crease, and 10 cm distal to the elbow crease) and visual analogue scale (VAS) score for pain. The safety of the treatment was also evaluated. Results: The treatment period was 50 days for all 75 patients. At the end of the treatment period, the mean reduction in arm circumference was 1.21 (0.65) cm the treatment group, and 0.58 (0.78) cm in the control group. Compared with the control group, the treatment group had a significantly greater reduction in arm circumference (P = .03) and a significantly lower VAS score for pain (P = .01). No patient in either group experienced any adverse events. Conclusion: Bloodletting puncture and cupping effectively reduces arm circumference and relieves upper limb pain in patients with breast cancer-related lymphedema. Our results provide sufficient basis for exploring cupping as long-term therapy for managing breast cancer-related lymphedema. Keywords: Breast cancer-related lymphedema (BCRL), Bloodletting puncture and cupping, Effect observation