Introduction

Chronic upper limb pain (CULP) is relatively prevalent in the general population and is associated with physical dysfunction in patients [1]. Some studies estimate that about 30% of the population will suffer from CULP [2], which increases with age and varies depending on some factors related to activity, being more frequent in those with jobs that involve repetitive movements or intensive use of the hands [3].

The diagnosis of CULP is often complex due to the variety of factors that contribute to its development. Musculoskeletal injuries have been traditionally linked with diagnosed disorders such as shoulder tendinitis, adhesive capsulitis, lateral epicondylitis, and more specifically, when dealing with hand pain, carpal tunnel syndrome or de Quervain’s disease [4]. However, psychosocial factors and patient context have been identified as prognostic factors in this type of disorder [5, 6], therefore, these factors may play an important role in the management of CULP.

Regarding treatments, traditional approaches to the treatment of chronic pain have included the use of pharmacology and manual physical therapy techniques [7]. However, recent evidence suggests that interventions combining pain neuroscience education (PNE) and therapeutic exercise (TE) may have more lasting effects on reducing pain and improving function in these complex patients [8–10]. Furthermore, integrating an appropriate, well-designed, biopsychosocial model, has been shown to offer a promising framework for the comprehensive care of individuals with musculoskeletal pain conditions [11].

This case report describes a multimodal physiotherapy treatment approach grounded in a biobehavioral perspective for a patient with CULP. It is one of the first studies to utilize a biobehavioral framework for this patient profile, contrasting with more traditional physiotherapy methods, which had not provided any previous improvement to the patient presented. Thus, the objective of this case report was to describe the assessment and treatment of an actual patient with CULP by using a multimodal physical therapy treatment based on a biobehavioral approach, as such an approach is grounded in a patient-centered biobehavioral model.

Case report

Case history

The patient was a 23-year-old woman who had been experiencing chronic pain for a duration of 1 year and 2 months. The reason for consultation was the presence of pain in her right hand with irradiation to the forearm. Besides, she also presents with neck pain. Her injury mechanism occurred while working, catching an object. Since then, she began to feel pain and was functionally impaired in her hand.

The patient did not present any relevant medical history or condition. In the first instance, after a few days since the acute episode, a simple wrist radiography did not find any signs of injury. After a month, during which pain persisted, she underwent a local imaging study by ultrasound, with no conclusions, and a magnetic resonance, with no findings. Subsequently, the patient received a medical diagnosis of early wrist osteoarthritis and had her arm immobilized for 4 months. After that, she presented incapacitating symptoms while writing, night awakenings, and upon waking up in the morning. Because of that, she attended a doctor’s consultation again (11 months since the episode) and she underwent a bone scintigraphy that revealed “bone inflammation in both hands”. The medical assistance concluded here, with no study of other regions, advising not to “force” the hand when dealing with pain and to think about changing jobs.

Clinical findings

The primary symptomatology reported by the patient during the initial interview included three distinct pain locations: pain in the thumb and hand (P1), pain in the anterior and lateral aspects of the forearm (P2), and neck pain (P3). The intensity of these pains was assessed using a Visual Analogue Scale (VAS). P1 was assigned a VAS score of 6.5/10. She described it as deep and constant, with no relief maneuvers and worsening when writing or picking up something heavy. P2 had a VAS score of 3/10. It was described as superficial, mechanical, with tingling to the elbow and associated with P1. It improved with myofascial treatment. P3 received a VAS score of 5/10. It was described as superficial and constant, with no relationship with the others, and improving with rest while worsening with stress and mechanical load. The baseline body chart, illustrating the distribution of symptoms, along with pre-intervention measurements of pain characteristics, is provided in Figure 1.

Display full size

Figure 1. 

Pre-intervention body chart with symptom distribution

Therapeutic intervention

The therapeutic intervention lasted 3 months. The patient agreed to undergo the treatment and signed the informed consent documents for treatment, data protection, and permission for academic use, and consent for telephone and e-mail communications. Over the course of the 12-week treatment period, the patient attended a total of 9 sessions, with each session lasting approximately 60 minutes. During the first two weeks, the patient attended two sessions per week, while from the third to the fourth week, the rehabilitation was carried out once a week. After that, in the second month of treatment, she received one session every 15 days, and finally, in the third month, she received only one session. The biobehavioral physiotherapy approach included PNE, motion representation methods (MRMs), orthopedic manual physical therapy (OMPT), TE, and sensory retraining (SR). All the modules were gradually supplied from session one, except MRM, which was implemented in the second week. Figure 2 contains the schedule of sessions. As for PNE, it was applied during the first 5 sessions. The contents implemented were as follows: session 1: pain and context; session 2: influence of psychosocial factors on pain; session 3: peripheral and central sensitization; session 4: neuroplasticity; and session 5: benefits of TE. Regarding the OMPT used, this included neural mobilization and joint mobilization techniques. As for TE, it contained both unloaded and loaded exercises, the latter using mainly elastic bands. In terms of SR, the focus was on improving sensitivity to vibration, touch, and pressure. Finally, the MRMs used were action observation, motor imagery, and mirror therapy.

Display full size

Figure 2. 

Timetable of the intervention with the content of each of the sessions

Results

Regarding the overall results of the treatment, a significant improvement in the patient’s condition was achieved. As for the pain, both P1 and P2 disappeared. P3, despite not receiving a “topographic” approach, also remitted a favourable response by attaining adequate pain relief. In addition, the somatosensory, motor-functional, and affective-cognitive factors were rated below the basal point. Table 1 shows all the measurements collected after the intervention in detail. In addition, Figure 3 shows a graph depicting the temporal change of the patient’s symptoms over time.

Display full size

Figure 3. 

Graph depicting the temporal progression of symptoms

Discussion

This case report provides a comprehensive description of the multimodal physiotherapy treatment administered to an adult female patient with CULP, along with the results achieved. The proposed treatment successfully eliminated the intensity of pain. Furthermore, significant improvements were observed in the somatosensory, motor-functional, and affective-cognitive abilities.

In the literature, there are other case reports in which physiotherapy has been employed to alleviate hand pain, such as the case described by Özüdoğru and Ceylan [20]. In contrast to our report, this case focuses on a more conventional approach to physiotherapy, utilizing only passive techniques.

Moreover, this is not the first time that this approach is able to obtain significant improvements in a patient with chronic pain. There are previous reports focused on chronic non-specific neck pain [21], which have gotten positive results. Marcos-Martín et al. [22] and Forner-Álvarez et al. [23] also obtained significant improvements when applying this kind of multimodal intervention in patients with chronic cervico-craniofacial pain and chronic low back pain, respectively.

Notwithstanding sharing the same basis of clinical reasoning and management, this report differs from the one mentioned above, and other ones reported, in some key points. Firstly, the patient presented with chronicity in topographically separated locations. Despite there is plenty of literature describing the link between upper limb and neck disfunctions [24], this patient’s clinical history implied greater complexity when reasoning and subsequent decision-making.

Furthermore, despite having literature that explores the biopsychosocial approach to address the loss of upper limb functionality [25], the literature has traditionally focused on structural reasoning approaches when dealing with hand pain [26] that persist to our days [27], proposing frameworks which leave aside patients who are not governed by provocative orthopedic tests, as the one presented in this case. In this sense, this report provides a correct management guide aligned with the proposed biopsychosocial approach, which has previously been successful in other pathologies, and which here demonstrates to do so in the same way.

As for the motor-functional aspect, focusing on hand strength, the significant improvement in this outcome after the implementation of the therapeutic intervention may be caused mainly by TE, as seen in the current literature [28–30].

Regarding the somatosensory factors, some studies have pointed out that these factors are directly related to the symptoms of pain, such as intensity or expansion [31, 32]. Therefore, the significant pain score regression presented in this case could be linked to the somatosensorial management developed. In line with our proposal, the use of the MRMs has been used before in other kinds of conditions dealing with upper limb disfunction, achieving positive results [33, 34].

As for the affective-cognitive aspects, multimodal intervention based on TE and PNE may explain the results obtained. Similar to previous literature, besides its hypoalgesic effect [35], TE has been employed as a useful tool, expecting to downgrade the patient’s disability [36]. Otherwise, the improvement observed in catastrophism or kinesiophobia could be partly explained by the employment of the PNE [37].

From a broader perspective, considering the combined effects of these techniques, the therapeutic potential of the biopsychosocial model in generating neurophysiological changes is highly relevant to clinicians. Since chronic pain induces changes in the neurocognitive domain [38], physiotherapists’ clinical reasoning should be guided by models aimed at producing central-level changes [39, 40]. Strong evidence already supports the added benefits of combining therapies within this model, such as exercise and education [41, 42] or showing how manual therapy can be applied not merely to achieve peripheral effects on the treated area but rather to modulate the pain process under this framework, emphasizing the patient’s interpretative process as a key factor to achieve these neurophysiological goals [43, 44].