Summer 2020 (Volume 30, Number 2)
Top Ten Things Rheumatologists Should (And Might Not) Know About the Physiatrist’s Perspective on Rehabilitation Strategies and Interventions for Neuromusculoskeletal Conditions
By Jaime C. Yu, MD, MEd, FRCPC, CSCN(EMG);
Brian Rambaransingh, MD, FRCPC, CSCN(EMG),
and Arun T. Gupta, MD, FRCPC, CSCN(EMG)
Rehabilitation strategies and interventions encompass a broad range of treatment modalities, from activity modification and exercise prescriptions to medication management and interventional procedures. Physical medicine and rehabilitation is a broad specialty, caring for individuals with a wide range of neurological and musculoskeletal disorders. This article provides insight into the physiatrist’s perspective regarding neuromusculoskeletal conditions frequently encountered by rheumatologists.
- Low back pain, a leading cause of disability, requires determination of potential pain generators to guide interventional treatments. Non-inflammatory back pain is divided as axial, affecting the back itself, or radicular, with pain radiating to the buttocks or legs. Facet-joint-mediated pain contributes to 40% of axial low back pain and can be successfully treated with radio-frequency denervation techniques. For radicular pain, transforaminal epidural steroid injections can provide significant symptomatic relief and expedite recovery. In refractory cases, neurostimulation is an emerging therapy. Surgical management is usually restricted to patients with progressive neurological deficits.1-3
- Greater trochanteric pain syndrome is commonly labelled as bursitis but should instead be considered a tendinopathy affecting the gluteus medius/minimus and iliotibial band. True bursitis is present in only a minority of patients. Gluteal tears can be evaluated using the resisted external derotation test. Ultrasound-guided needle tenotomy, in combination with physiotherapy, can provide reasonable medium- to long-term relief, and represents a better option than corticosteroid injections. 4-6
- The sacroiliac joint (SIJ) is an important pain localization
in non-inflammatory back pain. Pain generators in
the SIJ include the joint capsule, surrounding ligaments,
and the intra-articular portion of the joint, all
innervated by the lateral branches of the S1-S3 nerve
roots. Due to this complex anatomy, physical examination
maneuvers may not be as accurate and intra-articular
injections may not adequately interrogate all
pain generators, resulting in false negative diagnoses.
Techniques utilizing imaging-guided blocks to the
posterior sacral network may represent a new gold
standard in diagnosis and management of SIJ-mediated
- Myofascial pain syndrome needs to be differentiated
from fibromyalgia. Clinical features of palpable taut
bands and trigger points are usually present, and the
area of pain involvement is more focal, compared to
the widespread pain typical of fibromyalgia. Treatment
includes targeted stretching and active strengthening
exercises of the involved muscles, while techniques
such as intramuscular stimulation (“dry needling”) and
trigger point injections with local anesthetic can be
helpful for short-term pain reduction to facilitate active
- Nerve conduction studies (NCS) and electromyography
(EMG) testing have technical limitations and knowing
when to order them is important. Standard NCS and
EMG testing is very useful for identifying abnormalities
in the major large-fiber peripheral nerves, such
as focal entrapment neuropathies (e.g. carpal tunnel
syndrome) or traumatic nerve injuries. EMG studies are also helpful for distinguishing acute inflammatory
myopathies from chronic myopathies. However, pathology
involving small-fiber peripheral nerves, a common
cause of painful distal polyneuropathies, is more difficult
to measure and standard NCS/EMG can be normal
in these cases.14
- Small-fiber polyneuropathy (SFPN), involving the myelinated
Aδ-fibers and unmyelinated C-fibers, is found
in approximately 40-50% of patients with fibromyalgia. Symptoms of dysautonomia and paresthesias may predict
underlying SFPN, and abnormalities in sural and
medial plantar sensory NCS can aid diagnosis. Identifying
this overlap is important to rule-out reversible
causes of SFPN and identify patients who may respond
better to antiepileptics or antidepressants for pain.
Opioids are discouraged, but adjuvant treatments including
topical local anesthetics, capsaicin, and acupuncture
may be helpful.15-18
- Complex regional pain syndrome (CRPS) is a rehabilitative
emergency, and requires urgent treatment with
appropriate analgesic medication, possible oral corticosteroids,
and aggressive active rehabilitation strategies. When early treatment is not possible or there is
a lack of response, CRPS unfortunately develops into a
chronic neurological and pain condition. The key feature
of CRPS is regional pain out of proportion to any
inciting event, with features of neuropathic pain, skin
and temperature changes, and significant loss of functional
movement. Level 1 evidence exists for use of oral
corticosteroids in early or acute cases, and appropriate
analgesia is important to promote participation in active
rehabilitation exercises and modalities.19,20
- Post stroke joint pain is often complex and may arise
from multiple etiologies. Shoulder pain can arise from
subluxation due to neuromuscular weakness, rotator
cuff tendinopathy or glenohumeral osteoarthritis
flare due to altered mechanics, spasticity of the shoulder
girdle muscles, or adhesive capsulitis. If hand and
shoulder pain is noted, assess for shoulder-hand syndrome,
a form of post-stroke CRPS. Post-stroke knee
pain is common, due to altered mechanics aggravating
underlying knee osteoarthritis or flares of gout
from the acute medical event and associated medications.
Consider use of functional electrical stimulation
(FES), topical NSAIDs, and short courses of oral
NSAIDs. Targeted injections of intra-articular corticosteroids
are effective in providing medium-term
pain relief to promote active rehabilitation for neurological
- Inflammatory arthritis may remit on the hemiparetic
side after stroke, but the pathophysiology of this phenomenon
is unclear. Case reports have suggested that
inflammatory arthritis resolves on the hemiparetic side
following stroke or other significant central nervous
system injury. Proposed mechanisms include altered
mechanical factors on the hemiparetic side, changes
in the autonomic nervous system affecting inflammation,
or changes in limb perfusion. Hemiparetic limbs
frequently develop autonomic changes such as edema,
altered temperature, and altered skin colour and sweat
pattern. Further work to elucidate the role of the central
nervous system on inflammation will be helpful to
understand this anecdotal phenomenon.22,23
- Plantar fasciitis is a common cause of heel pain and can
be related to systemic inflammatory conditions or specific
biomechanical issues. Predisposing factors include
pes cavus deformity, limited range of ankle dorsiflexion,
tightness of the gastrocnemius and soleus, and excessive
foot pronation/supination. Correction of biomechanical
abnormalities with measures such as targeted stretching,
modified shoe wear, use of orthoses (e.g. heel lift),
strengthening of the intrinsic foot muscles, and deep
friction massage can resolve this condition. In refractory
cases, imaging-guided corticosteroid injections provide
short-term relief, allowing rehabilitation techniques to
be better tolerated and more effective. Other options
include extracorporeal shock-wave therapy, botulinum
toxin A intramuscular injections, prolotherapy and autologous
platelet-rich plasma, but these interventions
have conflicting evidence regarding efficacy. Surgical
management is reserved for rare cases.24-28
Jaime C. Yu, MD, MEd, FRCPC, CSCN(EMG)
Division of Physical Medicine and Rehabilitation
University of Alberta, Edmonton, Alberta
Brian Rambaransingh, MD, FRCPC, CSCN(EMG), RMSK
Associate Clinical Professor,
Division of Physical Medicine and Rehabilitation,
University of Alberta, Edmonton, Alberta
Arun T. Gupta, MD, FRCPC, CSCN(EMG), Dip. Sports
Clinical Assistant Professor,
Section of Physical Medicine and Rehabilitation,
University of Calgary, Calgary, Alberta
1. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain?
JAMA 1992; 268(6):760-765.
2. Patrick N, Emanski E, Knaub MA. Acute and chronic low back pain. Med Clin North Am 2014; 98(4):777-
89, xii. doi: 10.1016/j.mcna.2014.03.005 [doi].
3. Hooten WM, Cohen SP. Evaluation and treatment of low back pain: A clinically focused review for primary
care specialists. Mayo Clin Proc 2015; 90(12):1699-1718. doi: 10.1016/j.mayocp.2015.10.009 [doi].
4. Long SS, Surrey DE, Nazarian LN. Sonography of greater trochanteric pain syndrome and the rarity of
primary bursitis. AJR Am J Roentgenol 2013; 201(5):1083-1086. doi: 10.2214/AJR.12.10038 [doi].
5. Jacobson JA, Rubin J, Yablon CM, Kim SM, Kalume-Brigido M, Parameswaran A. Ultrasound-guided fenestration of tendons about the hip and pelvis: Clinical outcomes. J Ultrasound Med 2015; 34(11):2029-
2035. doi: 10.7863/ultra.15.01009 [doi].
6. Reiman MP, Goode AP, Hegedus EJ, Cook CE, Wright AA. Diagnostic accuracy of clinical tests of the
hip: A systematic review with meta-analysis. Br J Sports Med 2013; 47(14):893-902. doi: 10.1136/
7. Szadek KM, Hoogland PV, Zuurmond WW, De Lange JJ, Perez RS. Possible nociceptive structures in the
sacroiliac joint cartilage: An immunohistochemical study. Clin Anat 2010; 23(2):192-198. doi: 10.1002/
8. Schneider BJ, Ehsanian R, Rosati R, Huynh L, Levin J, Kennedy DJ. Validity of physical exam maneuvers in
the diagnosis of sacroiliac joint pathology. Pain Med 2020; 21(2):255-260. doi: 10.1093/pm/pnz183 [doi].
9. Roberts SL, Burnham RS, Ravichandiran K, Agur AM, Loh EY. Cadaveric study of sacroiliac joint innervation:
Implications for diagnostic blocks and radiofrequency ablation. Reg Anesth Pain Med 2014; 39(6):456-
464. doi: 10.1097/AAP.0000000000000156 [doi].
10. Roberts SL, Burnham RS, Agur AM, Loh EY. A cadaveric study evaluating the feasibility of an ultrasound-guided diagnostic block and radiofrequency ablation technique for sacroiliac joint pain. Reg Anesth
Pain Med 2017; 42(1):69-74. doi: 10.1097/AAP.0000000000000515 [doi].
11. Cibulka MT, Koldehoff R. Clinical usefulness of a cluster of sacroiliac joint tests in patients with and without low back pain. J Orthop Sports Phys Ther 1999; 29(2):83-2. doi: 10.2519/jospt.19184.108.40.206 [doi].
12. Borg-Stein J, Iaccarino MA. Myofascial pain syndrome treatments. Phys Med Rehabil Clin N Am 2014;
25(2):357-374. doi: 10.1016/j.pmr.2014.01.012 [doi].
13. Saxena A, Chansoria M, Tomar G, Kumar A. Myofascial pain syndrome: An overview. J Pain Palliat Care
Pharmacother 2015; 29(1):16-21. doi: 10.3109/15360288.2014.997853 [doi].
14. Chemali KR, Tsao B. Electrodiagnostic testing of nerves and muscles: When, why, and how to order. Cleve
Clin J Med 2005; 72(1):37-48. doi: 10.3949/ccjm.72.1.37 [doi].
15. Lawson VH, Grewal J, Hackshaw KV, Mongiovi PC, Stino AM. Fibromyalgia syndrome and small fiber, early
or mild sensory polyneuropathy. Muscle Nerve 2018; 58(5):625-630. doi: 10.1002/mus.26131 [doi].
16. Lodahl M, Treister R, Oaklander AL. Specific symptoms may discriminate between fibromyalgia patients
with vs without objective test evidence of small-fiber polyneuropathy. Pain Rep 2017; 3(1):e633. doi:
17. Grayston R, Czanner G, Elhadd K, et al. A systematic review and meta-analysis of the prevalence of small
fiber pathology in fibromyalgia: Implications for a new paradigm in fibromyalgia etiopathogenesis. Semin
Arthritis Rheum 2019; 48(5):933-940. doi: S0049-0172(18)30363-9 [pii].
18. Swiecka M, Maslinska M, Kwlatkowska B. Small fiber neuropathy as a part of fibromyalgia or a separate
diagnosis? International Journal of Clinical Rheumatology 2018; 13(6):353-359. doi: 10.4172/1758-
19. Shim H, Rose J, Halle S, Shekane P. Complex regional pain syndrome: A narrative review for the practising
clinician. Br J Anaesth 2019; 123(2):e424-e433. doi: S0007-0912(19)30235-1 [pii].
20. Harden RN, Oaklander AL, Burton AW, et al. Complex regional pain syndrome: Practical diagnostic and
treatment guidelines, 4th edition. Pain Med 2013;14(2):180-229. doi: 10.1111/pme.12033 [doi].
21. Wiener J, Cotoi A, Viana R, et al. Chapter 11: Hemiplegic shoulder pain and complex regional pain syndrome. In: Teasell R, Cotoi A, Wiener J, Illiescu A, Hussein N, Salter K, eds. The stroke rehabilitation evidence-based review: 18th edition (www.ebrsr.com). Canadian Stroke Network; 2018.
22. Sofat N, Malik O, Higgens CS. Neurological involvement in patients with rheumatic disease. QJM 2006;
99(2):69-79. doi: hcl005 [pii].
23. Keyszer G, Langer T, Kornhuber M, Taute B, Horneff G. Neurovascular mechanisms as a possible cause
of remission of rheumatoid arthritis in hemiparetic limbs. Ann Rheum Dis 2004; 63(10):1349-1351. doi:
24. Arnold MJ, Moody AL. Common running injuries: Evaluation and management. Am Fam Physician 2018;
97(8):510-516. doi: 13485 [pii].
25. Becker BA, Childress MA. Common foot problems: Over-the-counter treatments and home care. Am Fam
Physician 2018; 98(5):298-303. doi: 13813 [pii].
26. Cotchett M, Lennecke A, Medica VG, Whittaker GA, Bonanno DR. The association between pain catastrophising and kinesiophobia with pain and function in people with plantar heel pain. Foot (Edinb) 2017;
32:8-14. doi: S0958-2592(16)30051-7 [pii].
27. Lai TW, Ma HL, Lee MS, Chen PM, Ku MC. Ultrasonography and clinical outcome comparison of extracorporeal shock wave therapy and corticosteroid injections for chronic plantar fasciitis: A randomized controlled
trial. J Musculoskelet Neuronal Interact 2018; 18(1):47-54.
28. Petraglia F, Ramazzina I, Costantino C. Plantar fasciitis in athletes: Diagnostic and treatment strategies. A systematic review. Muscles Ligaments Tendons J 2017; 7(1):107-118. doi: 10.11138/mltj/2017.7.1.107 [doi].