To The Editor:

Following publication of two papers regarding idiopathic arm (nonspecific or medically unexplained arm pain) in The Journal of Bone and Joint Surgery(1,2), I am often asked: “What happens to the patients that you diagnose non-specifically? Do they eventually end up with a specific diagnosis and treatment? Does their pain resolve?” In an attempt to answer these questions we undertook a mail survey of 466 of my patients diagnosed with idiopathic arm pain in 2002, 2003, 2004, and 2005 using an IRB- approved protocol. After a series of 3 mailings we got 87 responses (19%). Although this response rate was disappointing, there were no significant differences between responders and nonresponders with regard to age, gender, or zip code, and we believe the information obtained is of interest.

Seventy percent of patients still had pain. Only 15% had obtained a specific diagnosis including 3 arthritis, 2 thoracic outlet syndrome, 2 repetitive strain injury, 2 ganglions, and one each carpal tunnel syndrome, trigger finger, and fibromyalgia. The majority of these diagnoses can be disputed, either in the existence of the diagnosis or the relationship of this diagnosis to vague, diffuse, arm pains. Only 3 patients had had surgery including 1 first rib resection, 1 ganglion excision, and one “partial carpectomy”.

Forty-six percent of patients felt that I had done my best for them. Fourteen percent of patients made positive comments regarding me personally including, “caring doctor”, “kept me from surgery”, and “scheduled follow-up”. Sixty-two percent of patients made a negative comment, including: “too much emphasis on the psychological over the physical”, “should order more tests”, “failed to identify the problem”, “didn’t operate on me”, “no cure”, and criticism of my behavior.

In my opinion, these survey data support the existence of chronic, nonspecific, medically unexplained arm pains. The majority of patients had persistent, undiagnosed pain, and continued to resent me specifically, and the medical profession in general, for not being able to solve their problem. Many of these patients were also uncomfortable with the manner in which I discussed the psychosocial influences on their illness. While I have made great efforts to improve in this, I have also called on the experts.

Building on the successful use of cognitive behavioral therapy in other chronic, nonspecific pain contexts, my colleagues and I have established a Multidisciplinary Arm Pain Program as part of the MGH Orthoapedic Hand and Upper Extremity service. Our team includes a non- operative musculoskeletal doctor (physiatrist), hand therapists, surgeons, and psychologists that specialize in cognitive behavioral therapy. A survey study recently published in the Journal of Hand Surgery suggested that most patients are receptive to considering the psychosocial aspects of their illness. My impression is that patients with idiopathic arm pain may be more reluctant than the average patient to consider psychological treatment, likely because they are guarded about the possibility that their problem is a somatoform disorder, and because psychological diagnoses and psychological treatments are often stigmatized in our society. In spite of these challenges, we are having substantial success and have developed effective relationships with many patients. I encourage the development of programs that give hope to patients with vague, diffuse, puzzling chronic arm pains. I strongly discourage the indiscriminant use of diagnoses and treatments of questionable validity.

In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from AO Foundation, Wright Medical, Biomet, Smith and Nephew, Small Bone Innovations. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

References:

1. Ring D, Kadzielski J, Malhotra L, Lee SGP, Jupiter JB. Psychological factors associated with idiopathic arm pain. J Bone Surg Am. 2005;87:374-380.

2. Ring D, Guss D, Malhotra L, Jupiter JB. Idiopathic arm pain. J Bone Joint Surg Am. 2004;86:1387-1391.

Dear Editor

We read the paper ‘Idiopathic arm pain’ by Ring et al1. They have stated that 14 percent of patients diagnosed with idiopathic arm pain symptoms did not fit a characteristic or anatomically meaningful pattern.

Many patients with shoulder, arm and elbow pain suffer from atypical carpal tunnel syndrome (ACTS)2. Although we have described this after whiplash injury, it is also frequently seen in industrial injuries, falls, lifting and pulling injuries and after successfully treated upper extremity fractures and shoulder dislocations. In industrial injuries the mechanism of injury is always regarded as ‘minor trauma’ and patients are sent for many unnecessary investigations like CT scan, MRI scan, EMG’s etc. These patients have global sensory changes in the affected upper limbs, all median nerve innovated muscles in the forearm and the hand are weak. Also since they cannot stabilise first CMC joint, there is also weakness of EPL even though the radial nerve is intact. Five millilitres of bupivacaine 0.25% injected around the median nerve at the wrist usually temporarily relieves or decreases arm pain. The only laboratory finding in these cases was post operative normalisation of serum neuropeptide levels which are significantly elevated before the operation. However, neuropeptide studies are still a research tool.

When hyperalgesia and allodynia is situated some distance from the site of injured nerve such responses are often described as inappropriate illness behaviour, but in fact represent behavioural mal-adjustments rather than psychological problems.

Decompression of carpal tunnel (CTD), in 90 percent of these cases are successful and the above mentioned clinical findings and pain disappears along with trapezius spasm. The presence trapezius spasm usually leads to erroneous diagnosis of fibro-myalgia. This muscle is innervated by spinal accessory nerve but decompression of median nerve at the wrist releases trapezius spasm suggest that there is some relation of these two nerves dorsal horns.

When pain is treated successfully the psychological problem also disappears. After the operation many sociological features remain the same but pain disappears. Therefore, we disagree with Dr Ring et al, that psychological and sociological features are reflecting strong influence in the causation of so called idiopathic arm pain. Neural plasticity appears to be the most credible explanation of chronic pain.

Sincerely

Emin Kaya Alpar MD, MCh Orth, FRCS Eng, FRCS Ed Orth

Vijay Vardhan Killampalli D.Orth, DNB Orth, MSc Trauma, MCh Orth

References: 1. Ring D, Guss D, Malhotra L, Jupiter JB. Idiopathic arm pain. J Bone Joint Surg Am. 2004 Jul; 86-A(7):1387-91.

2. Alpar EK, Onuoha G, Killampalli VV, Waters R. Management of chronic pain in whiplash injury. J Bone Joint Surg Br. 2002 Aug; 84(6):807 -11.

To the Editor:

Our paper has resulted in some very enjoyable and interesting correspondence, most of it informal via email, phone, or in person. The letter from Drs. Leban and Riutta is representative of the majority of this correspondence.

First, they note the “absence” of a specific diagnosis that they favor. We certainly saw patients with cervical radiculopathy in our practices; however, in a hand surgeon’s office, this is not a common complaint. As a result, it does not show up in the analysis. To other readers of our article: if you don’t see your diagnosis it may be that it was simply not diagnosed frequently enough to make the list. To quote from the last sentence of the paragraph describing the patients with a discrete diagnosis: “The remaining 2013 patients had multiple diagnoses, bilateral diagnoses, or a less common discrete diagnosis.”

Secondly, they are concerned about giving “short-shrift to the primary sensory complaints of pain and dysesthesias as being less than objective”. In reply, it must be noted that pain and dysethesias are in fact subjective. They are symptoms and not signs. There is no reliable and valid test of pain or dysethesia. In fact, over the last 150 years, psychosomatic complaints have gradually moved away from objectively verifiable complaints such as paralysis and have found their way to the shelter of complaints that cannot be objectively proved or disproved such as pain and fatigue.(1) This is exactly our challenge.

If the magnitude of pain is out of proportion to what would be expected from a cervical radiculopathy, or is not in the distribution of a nerve root, and is not associated with any objectively verifiable findings, then a diagnosis of cervical radiculopathy cannot be substantiated. In our practices, when the patient’s complaints are consistent with a cervical radiculopathy, that diagnosis is provisionally applied and further addressed or investigated. When they are not, we prefer the neutral and reassuring term “idiopathic arm pain” until a more specific diagnosis can be objectively verified. We are comfortable with the fact that a large percentage of pain goes unexplained and poorly treated (headaches, backaches, irritable bowel syndrome, fibromyalgia, etc.).

Our primary responsibility to ensure that dangerous diseases are not neglected and that reliable opportunities for treatment are not overlooked. But the key is still to, “First, do no harm”. When it comes to pain, inaccurate diagnoses have done far more harm than “missed” diagnoses.(2) Pain is the most difficult thing to diagnose and treat.

A hypothesis must be testable or the concept is not scientific. If it is not scientific, then it may be of limited value. Drs. Leban and Riutta present a hypothesis that is testable to some degree. First, the complaints and exam must fit the known anatomy and physiology. Second, in the absence of any objective exam findings, a discrete lesion consistent with the patient’s symptoms and at the expected level on imaging studies is supportive. Finally, if the disease process is treated and the symptoms resolve that is also supportive. But there are traps at every stage and we must avoid fooling ourselves. We can lead the patient and sculpt their complaints into what we want them to be (we should use open-ended interviewing techniques and beware of our own biases). We may over interpret relatively subtle findings on sensitive imaging studies, many of which have been demonstrated to be age-related or anatomical variations (we must order and interpret these tests with caution). And, of course, there is the placebo effect that keeps us from crediting the treatment too much until a scientific study (randomized controlled trial) has demonstrated a strong beneficial effect.

No doubt about it, it is difficult to be scientific about subjective complaints. Let’s keep trying and accept nothing less.

Sincerely,

David Ring, MD

References

1. Shorter E. From paralysis to fatigue. New York: The free press; 1992.

2. Malleson A. Whiplash and other useful illnesses. Montreal: McGill- Queen's University Press; 2002.

To the Editor

Ring et al,(1) must be complimented on their earnest effort to better understand the challenging enigma of idiopathic arm pain. The authors classification of a “distinct diagnosis” was that of an entity which must be substantiated by objective signs and pathology which correlates with the patient’s symptoms, i.e., signs of motor dysfunction. However, this arbitrary classification gives short-shrift to the primary sensory complaints of pain and dysesthesias, as being less than objective.

Relative to the frequency of upper extremity pain complaints, this disregard of pain and dysesthesias as being non-objective is both short sighted and potentially does a woeful disservice to the 3,888 patients in this study. Notable by its absence was that cervical radiculopathy was not even considered as a presumptive cause of “unilateral upper extremity pain,” although it is all too often a primary cause and/or contributes to co-morbidity in a large number of upper extremity pain complaints.

The seminal work of Frykholm (2), and that of Holt and Yates (3) showed that the neuroanatomy of the cervical nerve roots differs from that of the thoracic or lumbar levels. Frykholm found that in approximately half the number of cases there is a distinct demarcation at the cervical neural foraminal levels between the dorsal and ventral spinal roots which merge only distally at the level of the dorsal root ganglia. Unlike the lumbar roots, this discrete separation of the motor and sensory fibers at the neural foramen provides the possibility for an isolated compromise of either the posterior or the anterior root without the involvement of the other. The dorsal roots and their ganglion are larger than ventral roots and lie in close proximity to the zygapophyseal joints. Chronic irritation of these sensory roots due to degenerative changes of the adjacent facet joints often leads to nerve fiber degeneration at a much greater frequency than similar histopathological involvement of the motor roots. In these instances, pain and/or associated dysesthesias may be the preeminent symptoms without associated motor correlate. Conversely, acute ventral root compromise by a degenerative or herniated disc may present with a painless paresis in the myotome distribution of the impaired root. However, with chronic inflammation of the motor root pain may provoke distal myalgias in the myotome distribution of the involved spinal root, i.e., a C7 radiculopathy presenting as chest or breast pain (4) when referred to the pectoralis major muscle. In the particular instance of cervical radiculopathy, other authors have also noted that “the sensitivity of pain and paresthesia symptoms [remains] high, while the sensitivity of neurological findings is lower and highly variable.”(5)

Well recognized patterns of dermatomal and sclerotomal as well as myotome sensory referral associated with cervical radiculopathy become less subjective and more “objective” when the diagnostician is empowered by a deeper understanding of the rather unique pathophysiology of the cervical roots.

Sincerely, Myron M. LaBan, M.D.and Justin C. Riutta, M.D.

REFERENCES

1.Ring D, Guss D, Malhotra L, Jupiter JB. Idiopathic arm pain. J Bone Joint Surg Am. 2004; 86:1387-91.

2.Frykholm R. Lower cervical nerve roots and their investments. Acta Chir Scand. 1951; 101:457-71.

3.Holt S, Yates PO. Cervical spondylosis and nerve root lesions: incidence at routine necropsy. J Bone Surg Br. 1966; 48:407-73.

4.LaBan, MM, Meerschaert JR, Taylor RS. Breast pain: a symptom of cervical radiculopathy. Arch Phys Med Rehabil. 1979; 60:315-17.

5.Lauder, TD, Dillingham TR, Andary M, et al. Predicting electrodiagnostic outcomes in patients with upper limb symptoms: are the history and physical examination helpful? Arch Phys Med Rehabil. 2000; 81:436-41.