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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.

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.

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.

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.

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.

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

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.