Cold hyperalgesia
Cold hyperalgesia
Cold hyperalgesia can be assessed quantitatively using quantitative sensory testing (QST) or clinically using the ice-pain test. The presence of cold hyperalgesia indicates abnormal sensory (thermal) pain processing.
How to
Quantitative sensory testing (QST)
1. Apply a descending temperature (usually 30ºC to 5ºC) using QST equipment (eg MSA Thermal Stimulator, Somedic, Sweden) via a thermode at local sites (neck and upper trapezius) and remote sites (tibialis anterior).
2. Record the temperature at which the stimulus stops feeling cold and starts feeling painful.
Clinical ice-pain test
1. Apply an ice cube to the patient’s skin at the sites above.
2. Ask the patient to rate pain on an NRS scale ranging from 0/10 (no pain) to 10/10 (maximum possible pain).
When and why
- Indicated when the presence of abnormal sensory (thermal) processing is suspected after the subjective examination (e.g. the patient reports being sensitive to cold or pain worsening in the cold). The test is an objective way to confirm the presence of cold hyperalgesia.
- Cold hyperalgesia is associated with poor outcome in neck pain states such as whiplash.
Results
Example of data from Rebbeck et al. (2015)
|
Neck pain |
Controls |
|
|---|---|---|
| CPT ºC | 22.31 (18.58) | 5.0 (0.74) |
|
Ice pain test NRS 0-10 |
2.0 (5.0) | 0.0 (1.0) |
References
1. Rebbeck et al. Physical Therapy 2015; 95:1536-46.
Pressure hyperalgesia
Pressure hyperalgesia
Pressure hyperalgesia can be determined via the measurement of pressure pain thresholds (PPT) using an algometer. The presence of widespread pressure hyperalgesia (local to the neck and at remote body sites) indicates the presence of abnormal pain processing most likely within the central nervous system.
How to
1. Using an algometer (eg Somedic or Wagner) apply a pressure force perpendicular to the body site being tested.
2. Ask the patient to nominate the point at which the pressure sensation first changes to one of pressure and pain. Recorded this value.
3. Repeat the test 3 times at each location and take a mean of the values used.
Pressure pain thresholds can be measured over the cervical spine, in the upper limbs and over the muscle belly of tibialis anterior as the remote site.
When and why
- Indicated when the presence of mechanical hyperalgesia is suspected after the subjective examination (eg patient reports being sensitive to clothing or touch) or after physical assessment (eg pain with manual examination or palpation of neck, upper and lower limbs). The test is an objective way to confirm the presence of pressure hyperalgesia.
- Some studies have shown that lowered pressure pain thresholds are predictive or poor outcome in neck pain conditions (eg WAD).1,2
Results
PPT (neck): Abnormal if
< 185 kPa (females)
< 210kPa (males)
PPT (med N): Abnormal if
< 210 kPa (females)
< 250 kPa (males)
Units: 1 kg/cm2 (clinical device) = 98 kPa (lab algometer)
References
1. Walton et al. Journal of Orthopaedic & Sports Physical Therapy 2011; 41:658-65.
2. Sterling et al. Pain 2003; 104:509-17.
Brachial plexus provocation test (BPPT)
Brachial plexus provocation test (BPPT)
The Brachial Plexus Provocation Test (BPPT) (also known as the upper limb tension test) is a valid and reliable test most commonly used to assess for mechanosensitive peripheral nerve tissue in the upper limb. However, it has also been argued that it is a test of sensitivity of the nervous system in general and for this reason has been proposed for use to assess for the presence of central sensitisation.
How to
- The BPPT is performed in the following sequence: Neutral Shoulder Depression
- Glenohumeral Abduction to 90° and External Rotation in the coronal plane
- Forearm Supination
- Wrist and Finger Extension.
Elbow Extension to pain threshold only is then performed manually by the clinician.
When and why
- The BPPT can be used in conjunction with the patient history and interview and other sensory tests in patients where the presence of central sensitisation is suspected.
- Whilst the BPPT is not generally considered a test of central hyperexcitability, it is in effect a measure of pain threshold in response to a mechanical stimulus, in this case movement. Clinicians would generally be expecting a unilateral response with the BPPT that corresponds to the side of symptoms, particularly arm pain.1
- However it has been shown that participants with whiplash (and sensory hypersensitivity) demonstrate hypersensitive responses to the BPPT, including a bilateral (not unilateral) loss of elbow extension at pain threshold and higher reported levels of pain when compared to healthy asymptomatic controls.2
- These responses are present in individuals with chronic whiplash2 as well as those with higher pain and disability levels in the acute stage of the condition.3
Results
For the assessment of peripheral nerve tissue, a positive response is indicated by reproduction of the patient’s pain which often correlates with reduced range of movement measured at the elbow suggested to be related to the onset of protective muscle activity. For the assessment of possible central sensitization, a marked bilateral reduced range of elbow extension is seen. The range of elbow extension at pain threshold can be used as an outcome measure.
References
1. Coppieters et al. Journal of Orthopaedic & Sports Physical Therapy 2003; 33:369-78.
2. Sterling et al. Pain 2003; 104:509-17.
4. Sterling et al. Manual Therapy 2002; 7:89-94.
Central sensitisation inventory
Central sensitisation inventory
The Central Sensitisation (CS) Inventory1 is a questionnaire comprised on two assessment parts.
- Part A is a quantitative score with the range from 0-100. Higher scores indicate more central sensitisation symptoms.
- Part B asks how many diagnoses (associated with an increased risk of developing central sensitization) that the patient has.
About
Part A
For each of 25 questions, the patient selects one of 5 responses (never, rarely, sometimes, often, always) which are assigned a score of 0→4. The maximum score for the questionnaire is 100 and the minimum 0.
Part B
The patient selects how many conditions associated with central sensitisation they have been diagnosed with.
When and why
Administer to patients where CS is suspected after the subjective examination. Subjective indications are widespread, disproportionate pain, reported sensitivity to light, cold and pressure and sleep disturbances.2–4
Results
Patients with known central sensitisation syndromes score higher on the CSI than controls.
Consider the CSI score together with other subjective and clinical features (such as widespread cold and pressure hyperalgesia) to decide if CS symptoms are present. Such patients are less likely to respond to conventional inventions such as manual therapy and exercise. Consider alternate pain medications.
References
1. Mayer TG et al. Pain Practice 2012; 12:276–85.
2. Nijs J et al. Pain Physician 17:447–57.
3. Nijs J et al. Manual Therapy 15: 135-41.
4. Smart et al. Manual Therapy 2012; 17:336–44.
View the Central Sensitisation Inventory questionnaire
S-LANSS
S-LANSS
The Self-administered Leeds assessment of neuropathic symptoms and signs (S-LANSS) was first published in 2005.1 It aims to assist the clinician to detect if neuropathic pain may be present.
About
The S-LANSS has 7 questions.
The first 5 questions concern symptoms of neuropathic pain, to which the patient answers Yes or No. Answering ‘yes’ is assigned a score of 5 and ‘no’, a score of 0.
The final 2 questions ask the patient to do a self-assessment of allodynia or pressure hyperalgesia.
When and why
Administration of the S-LANSS is recommended when neuropathic pain may be suspected after the patient interview. Such symptoms may include pins and needles in the area of pain and pain referred in a dermatomal or cutaneous distribution.2
Assist specialists in determining if neuropathic pain type is present in people with whiplash.
Results
An overall score of >12 indicates pain of predominantly neuropathic origin.
References
1. Bennett et al. Pain 2005; 6:149-58.
2. Smart et al. Manual Therapy 2012; 17:345-51.