Point To Area of Pain: A Clinically Useful Telehealth Physical Exam Technique for Focal Nociceptive and Neuropathic Pain.

BACKGROUND: Chronic pain is a leading cause of disease burden and disability globally. The COVID-19 pandemic catalyzed a major paradigm shift in health care delivery with the universal adoption of telemedicine. Telehealth physical examination is particularly challenging and little guidance is available on this topic. OBJECTIVES: We attempt to describe the Point To the Area of Pain (PTAP) test and establish a consensus regarding its utility for musculoskeletal examination (MSK) via telehealth. STUDY DESIGN: The authors drafted an online survey. SETTING: The survey was sent to physicians and nurse practitioners within the authors' respective departments and institutions who routinely use telemedicine to treat pain METHODS: Respondents (n = 61) were asked about their primary specialty, comfort level in evaluating patients in pain, use of the PTAP test and its perceived clinical relevance to patient management, and other relevant questions. RESULTS: Respondents were predominantly trained in Physiatry (47.5%), Anesthesiology (23%), Neurology (13.1%) and Family Medicine (11.5%); 67.2% of providers treat pain related diseases > 75% of the time; 50.8% of respondents were "somewhat comfortable" at performing a virtual MSK exam and 29.5% were "not comfortable"; 65.5% utilize the PTAP test and 88.5% agree or strongly agree that this test provides extrinsic clinically relevant information. LIMITATIONS: The relatively small number of respondents. CONCLUSION: PTAP tests should not replace the standard accepted in-person or virtual physical examination in practice, but in the absence of a hands-on exam, the PTAP test is a clear and concise test that can easily be performed in conjunction with other techniques via telehealth, and in the context of assessing pain provides useful clinical information that can help guide medical decision making.

Aging with multiple sclerosis.

Multiple sclerosis is a chronic, disabling disease frequently striking young adults. Caring for a patient with this uncertain and progressive disease requires a comprehensive and multidisciplinary approach. Many patients with multiple sclerosis will have near normal lifespan, therefore it is vital that the health care professional be aware of the potential complications that these patients face from their disease and from the aging process. Understanding the challenges faced by an aging patient with multiple sclerosis can help the health care professional minimize morbidity and disability.

Rehabilitation implications of non-traumatic subarachnoid haemorrhage.

OBJECTIVE: Subarachnoid haemorrhage (SAH) remains an important cause of stroke in the rehabilitation population, whose incidence has not been changed by pre-morbid medical treatment. The understanding of the pathophysiological changes that occur after SAH has been more clearly defined, therefore the treatment and outcomes of these patients have undergone drastic changes over the past few years. The purpose of this review is to update and familiarize the rehabilitation professional on the state of the art treatment and common complications associated with this disease and how this may affect the rehabilitation programme. Also, the current literature on the outcomes of these patients will be reviewed to help advise the rehabilitation professional on potential predictors. DATA SOURCES: Literature review. STUDY SELECTION: Articles of relevance to the current management of SAH. DATA EXTRACTION: Information that was deemed significant in the understanding of the pathophysiology, treatment and results of outcomes in patients with SAH. DATA SYNTHESIS: Subarachnoid haemorrhage (SAH) is the one sub-type of stroke whose incidence has not declined. Due to advances in medical care, mortality rate is on the decline. Outcomes data was analysed to look for common predictors for this patient population. CONCLUSIONS: While the incidence of SAH has not declined, improving medical treatment has reduced mortality. The rehabilitation professional should be familiar with the latest advances, potential complications and likely outcomes in order to plan the most appropriate therapy course for these patients.

Clinically significant placebo analgesic response in a pilot trial of botulinum B in patients with hand pain and carpal tunnel syndrome.

OBJECTIVE: We conducted a pilot trial to assess the effect of botulinum toxin B on palmar pain and discomfort in carpal tunnel syndrome (CTS) patients. Design. Randomized, double-blind, placebo-controlled. PATIENTS: Twenty ambulatory CTS patients. Intervention. Botulinum toxin B or placebo injections into three hypothenar muscles anatomically linked or attached to the carpal tunnel and its tentorium, that is, the Opponens Digiti Minimi and Flexor Digiti Minimi, located with electromyography (EMG), and the Palmaris Brevis Muscle, anatomically located without EMG. SETTING: New York City hospital. OUTCOME MEASURES: Outcomes were measured with numeric ratings, with higher scores indicating worse outcomes. Daily, subjects recorded their 0-10 numeric ratings of overall pain levels and pain-related sleep disturbances. During weekly telephone calls, they reported their 0-10 ratings for overall pain, pain-related sleep disturbance, and CTS-related tingling during the night and day as experienced over the preceding 24 hours. For each of four clinic visits, we averaged each subject's ratings of nine quality of life indicators from the West Haven-Yale Multidimensional Pain Inventory (WHYMPI), each measured on a 0-6 numeric scale. RESULTS: Over the 13-week trial, compared to baseline scores, the following outcomes predominantly showed decreases of statistical significance (P < or = 0.050) or borderline significance (0.050 < P < or = 0.10) for weeks 2 through 8: overall pain per daily diary entries and per weekly telephone reports, and pain-related sleep disturbance in the placebo group per phone report and in the botulinum toxin B group per diary report. CTS painful night tingling and day tingling, as well as the average scores of the WHYMPI quality of life indicators, showed improvements with statistical or borderline significance for almost each follow-up week. Between-group analyses, however, demonstrated that at each follow-up week, there was no statistically significant difference between the two study groups regarding changes from baseline in any study outcome. CONCLUSION: Botulinum toxin B is not dramatically superior to placebo for the relief of CTS symptoms. Possible explanations of the improvements in each study group are explored.

Treatment of chronic mechanical spinal pain with intravenous pamidronate: a review of medical records.

We explored the effect of intravenous infusions of a bisphosphonate, pamidronate, in the management of chronic mechanical spinal pain, a worldwide public health problem in terms of lost workdays, medical treatment costs, and suffering. Bisphosphonates have an anti-nociceptive effect in animals. In humans, intravenous pamidronate relieves numerous painful conditions, including metastatic bone pain, ankylosing spondylitis, rheumatoid arthritis, and complex regional pain syndrome. We reviewed the charts of 25 patients who had experienced disabling spinal pain for several years, and whom we treated with intravenous pamidronate. None had a history of osteoporotic vertebral fractures or metastatic disease. Pain rating scores decreased in 91% of patients: on a 0-10 numeric rating scale, the mean pain change was -3.6 points and mean percentage change was -41% (P<0.0001). There was no increase in opioid or nonopioid analgesic medications associated with pain relief. The apparent analgesic effect of pamidronate for chronic mechanical spinal pain needs to be confirmed with placebo-controlled trials.