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Are psychological factors prognostic indicators of outcome in patients with sub-acute neck pain?

Basert på resultatene fra denne studien virker det som at det er bare én faktor som hemmer resultater for de som kommer til muskel- og leddbehandling: Hvor redd er du for at plagen blir værre med bevegelse?

http://www.manualtherapyjournal.com/article/S1356-689X(09)00140-4/abstract

The short and long term results for the three outcomes were very diverse. The sub-scales of the used questionnaires, i.e. the Pain Coping and Cognition List (PCCL), and the 4 Dimensional Symptom Questionnaire (4DSQ), did not contribute significantly to all of the multilevel models. Only the factor ‘fear of movement’ was consistently and significantly present in the univariable analysis for all outcomes at both follow-up measurements. The explained variance in the short term ranged from 16% to 30%, and from 6% to 34% in the long term. This can be considered to be low.

We conclude that all psychological factors showed a considerable variation on the specific measurement and time point used. Only ‘fear of movement’ consistently impedes short term and long term recovery.

A single question was as predictive of outcome as the Tampa Scale for Kinesiophobia

http://www.ncbi.nlm.nih.gov/pubmed/23177227

The correlation coefficient between the TSK and its substitute question was r=0.46 (p<0.001). The substitute question was better at predicting pain severity in the leg at 1 year follow-up than the TSK (addition of explained variation of 11% versus 4% in a logistic regression analysis). The TSK and its substitute question did not significantly differ in their prediction of global perceived effect at 1 year follow-up. The other substitute questions and both the RDQ and EQ-5D did not contribute significantly to one or both of their prediction models.

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Heart rate variability and experimentally induced pain in healthy adults: A systematic review

Svært interessant studie som gjennomgår hele 20 studier som viser hvordan HRV forholder seg til smerte, lav HRV = høy smerte og motsatt. Den nevner blandt annet at SNS reagerer i løpet av sekunder, mens PNS reagerer i løpet av millisekunder. Så når vi ser på variasjoner i hjerterytme (HRV), eller kurven på StressEraser eller StressDoctor App, er det PNS sin funksjon vi ser.

http://robjellis.net/papers/Koenig_et_al_2013_EJP.pdf

Non-pathologic acute pain is a complex sensory and emotional experience (Fernandez and Turk, 1992) that signals the organism to somatic damage, leading to an appropriate motor response of protection (Loeser and Melzack, 1999). Because pain is a stressor and environmental challenge (which in turn requires that organism to respond), it has been dis- cussed as a specific emotion that reflects homeostatic behavioural drive, similar to temperature, itch, hunger and thirst (Craig, 2003).

A comprehensive framework to investigate the way in which organisms function and adapt to diverse types of stressor such as pain is the model of neurovis- ceral integration (Thayer and Lane, 2000, 2007), which posits flexibility in the face of changing physiological and environmental demands as a hallmark of success- ful adaptation. The authors proposed that a core set of neural structures provides an organism with the ability to continuously assess the environment for signs of threat and safety and to prepare the organism for appropriate action. Heart rate variability (HRV) has been proposed to serve as index of the degree to which this system provides flexible, adaptive regulation (Thayer et al., 2012).

Like many organs in the body, the heart is dually innervated. Although a wide range of physiologic factors determine cardiac functions such as HR, the ANS is the most prominent (Thayer et al., 2012). Chronotropic (i.e., the timing of heartbeats) control of the heart is achieved via the complex interplay of the sympathetic nervous system (SNS) and parasympa- thetic nervous system (PNS) branches of the ANS. More importantly, the HR is under tonic inhibitory control by the PNS influences (Jose and Collison, 1970).

Relative increases in SNS activity are associated with HR increases and relative increases in PNS activity are associated with HR decreases. While SNS effects are slow on the timescale of seconds, PNS effects are faster on the timescale of milliseconds (Levy, 1997). There- fore, the PNS influences are the only ones capable of producing rapid changes in the beat-to-beat timing of the heart (Uijtdehaage and Thayer, 2000).

Findings from these studies may have important clinical implications as a large variety of health condi- tions are associated with changes in ANS function that can be indexed by HRV (Rajendra Acharya et al., 2006).

Addressing the field of pain, reduced HRV is reported in patients with complex regional pain syn- drome (Terkelsen et al., 2012), fibromyalgia patients (Mork et al., 2013), patients with chronic neck pain (Kang et al., 2012), irritable bowel syndrome (Mazurak et al., 2012) or headache (Micieli et al., 1993; Tubani et al., 2003). Furthermore, lower HRV is associated with extended pain-related sick leave in employees (Kristiansen et al., 2011).

Thus, HRV is of interest as a potential biomarker for specific pain- related diseases (Lerma et al., 2011) and a potential outcome measure for the relief of pain due to thera- peutic interventions (Storella et al., 1999; Zhang et al., 2006; Toro-Velasco et al., 2009). Evidence on the rela- tion of HRV and experimentally induced pain in healthy subjects may help gain further insights on changes in autonomic function in patients with pathological pain states.

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NF-κB Links CO2 Sens ing to Innate Immuni ty and Inflammation in Mammalian Cells

Viktig studie som nevner at økt CO2 kan dempe betennelser.

http://www.jimmunol.org/content/185/7/4439.long

In this study, we demonstrate that mammalian cells (mouse embryonic fibroblasts and others) also sense changes in local CO2 levels, leading to altered gene expression via the NF-κB pathway. IKKα, a central regulatory component of NF-κB, rapidly and reversibly translocates to the nucleus in response to elevated CO2. This response is independent of hypoxia-inducible factor hydroxylases, extracellular and intracellular pH, and pathways that mediate acute CO2-sensing in nematodes and flies and leads to attenuation of bacterial LPS-induced gene expression. These results suggest the existence of a molecular CO2 sensor in mammalian cells that is linked to the regulation of genes involved in innate immunity and inflammation.

FIGURE 7.Hypercapnia promotes an anti-inflammatory profile of gene expression. A PCR array of genes known to be involved in the NF-κB signaling cascade was performed on A549 cells exposed to ambient or 10% CO2 ± LT (100 ng/ml) for 4 h. A selection of differentially expressed genes from the array were chosen for validation. CCL2 (A), ICAM1 (B), TNF-α (C), and IL-10 (D) message levels were determined by quantitative real-time PCR and expressed as a percentage of LT-induced gene expression at 0.03% CO2 (n = 3 ± SEM, one-way ANOVA, Tukey post-test).

Traditionally, CO2 has been considered a waste product of respiration, and its biologic activity is poorly understood in terms of gene expression. However, a recent study reported differential gene expression in elevated CO2 (9).

This study suggests the existence of an intracellular CO2 sensor that is associated with anti-inflammatory and immunosuppressive signaling, is independent of intracellular and extracellular pH, and could account for the above clinical observations. CO2 can profoundly influence the transcriptional activation of the NF-κB pathway but its transcriptional effects may extend to other as yet uncharacterized pathways. Understanding the molecular mechanisms of CO2-dependent intracellular signaling could lead to new therapies in which the suppression of immunity or inflammation is clinically desirable.

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Stop Chasing Pain… It’s Not In The Body, It’s In The Brain!

Reception – Protection – Integration – Modulation – Discrimination

Dette skjer i nervesystemet:

1. sanseceller registrerer huden/omverdenen og det interne miljøet, balanse, sanser, osv.

2. signalene går videre igjennom reptilhjernens amygdala og hippokampus, som kobler det til tidligere opplevelser og erfaringer og avgjør om vi skal inn i en fight-or-flight/freeze modus. Avgjør om vi er i en trussel-situasjon og aktiveres som en refleks.

3. videre opp til cerebellum, lillehjernen, hvor signalene plasseres i hjernens «kart» over kroppen og den forhold til omgivelsene, som resten av hjernen kan bruke til å avgjøre hva den skal gjøre.

4. Derifra reagerer det autonome nervesystem for å modulere effekten basert på hva hjernen velger å gjøre. Sympaticus stimulerer, parasympaticus beroliger.

5. Og deretter kan frontallappen utføre sin diskriminering og bevisste valg som kan tilby nye reaksjonsmønstre til reptilhjernen. I trusselsituasjoner får ikke frontallappen sjangsen til å gjøre jobben sin. Reaksjonene skjer før frontallappen rekker å vurdere situasjonen. Skal man lære nye reaksjonsmønstre må man oppleve reduksjon i trusselsituasjonen først.

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How to make stress your friend

Spennende perspektiv på stress. Nevner at de som trodde at stress var farlig, hadde større sjanse for å dø av det. De som trodde stress ikke var farlig, hadde samme dødelighet som alle andre. Å vite hva stress er kan redde liv. Så neste gang du opplever stress, vit at «dette er kroppen min som hjelper meg å løfte energien til det nivået jeg trenger for å løse problemet», som hun sier i foredaget. Men gi også kroppen mulighet til å ta seg ned noen nivåer igjen når stresset er ferdig.

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Biochemicals Associated With Pain and Inflammation are Elevated in Sites Near to and Remote From Active Myofascial Trigger Points

Spennende studie som viser biokjemiske endringer i triggerpunkter i trapezius. Nevner at bl.a. pH var lavere i ømme områder.  Noe som kanskje er et problem med denne studien er at nålen ble stående i 1 minutt før de tok sine prøver. Kanskje vil nålen i seg selv også øke betennelsesfaktorer lokalt i løpet av den tiden. Men uansett tok de sine prøver der det var en twitchrespons, og de fikk statistiske forskjeller i normal muskel vs triggerpunktdelen av muskelen.

http://www.sciencedirect.com/science/article/pii/S0003999307017522

Hele studien: http://www.archives-pmr.org/article/S0003-9993(07)01752-2/fulltext

We followed a predetermined sampling schedule; first in the trapezius muscle and then in normal gastrocnemius muscle, to measure pH, bradykinin, substance P, calcitonin gene-related peptide, tumor necrosis factor alpha, interleukin 1β (IL-1β), IL-6, IL-8, serotonin, and norepinephrine, using immunocapillary electrophoresis and capillary electrochromatography.

Within the trapezius muscle, concentrations for all analytes were higher in active subjects than in latent or normal subjects (P<.002); pH was lower (P<.03).

At all times within the gastrocnemius, the active group had higher concentrations of all analytes than did subjects in the latent and normal groups (P<.05); pH was lower (P<.01).

Subjects with active MTPs in the trapezius muscle have a biochemical milieu of selected inflammatory mediators, neuropeptides, cytokines, and catecholamines different from subjects with latent or absent MTPs in their trapezius.

The needle was kept stationary in situ for 1 minute, after which collection of the sample commenced. Five minutes after insertion, the needle was advanced into the muscle until an LTR was obtained in the active and latent subjects. Again, this was confirmed by surface electromyography. Depth of penetration was estimated to be between 0.5 and 1.0cm.

Analyte concentrations in the trapezius combining previous and current data. Collection for (A) pH and (B) SP.

 

Analyte concentrations in the trapezius for (A) CGRP and (B) bradykinin.

Analyte concentrations in the trapezius for (A) TNF-α and (B) IL-1β.

Analyte concentrations in the trapezius for (A) IL-6 and (B) IL-8.

Analyte concentrations in the trapezius for (A) 5-HT and (B) norepinephrine.

 

There is a unique biochemical milieu of substances associated with pain and inflammation in the vicinity of an active MTP in the upper trapezius that includes elevated concentrations of protons, SP, CGRP, bradykinin, TNF-α, IL-1β, IL-6, IL-8, 5-HT, and norepinephrine. Concentrations of analytes from the milieu of the upper trapezius differ quantitatively from a remote uninvolved site in the medial gastrocnemius muscle. Furthermore, compared with the other groups, subjects with active MTPs in the trapezius had elevated levels of inflammatory mediators, neuropeptides, catecholamines, and cytokines in the gastrocnemius muscle. This suggests that elevations of biochemicals associated with pain and inflammation may not be limited to localized areas of active MTPs.

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Three-Dimensional Mathematical Model for Deformation of Human Fasciae in Manual Therapy

Spennende studie som viser at tykkere bindevevsområder som fascia latae og plantar fascia ikke kan deformeres i strukturell integrering, men mykere bindevev som f.eks. rundt nesen kan det. Den forteller at det kreves enormt med strykk og strekk for å skape endringer i bindevev, så den releasen for opplever i strukturell integrering er sannsynligvis heller endringer i «twisting or extension forces» i vevet. Bindevevet blir ikke lengre eller deformert på noen som helst måte, det blir mer fleksibelt.
http://www.jaoa.org/content/108/8/379.long

The palpable sensations of tissue release that are often reported by osteopathic physicians and other manual therapists cannot be due to deformations produced in the firm tissues of plantar fascia and fascia lata. However, palpable tissue release could result from deformation in softer tissues, such as superficial nasal fascia.

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Rolfing, which is also referred to as structural integration in osteopathic medicine, is a manual technique in which the practitioner is trained to observe both obvious movement of the skeleton and more subtle motion evidenced by slight muscle contraction visible through the overlying skin.1,22 Rolfers are not trained in diagnosis and treatment of specific conditions—as are osteopathic physicians—but rather in therapies to improve posture and general ease of function.1,22

The therapist manipulated the nasal fascia of the subject with two fingers oriented caudally at a 30-degree angle to the surface of the skin just superior to the cartilaginous structure of the nose. Both normal and tangential pressure were applied with the rolfing technique (ie, structural integration).1

We used available in vitro data for dense fasciae7,11 to evaluate the magnitude of forces required to produce specific deformations in these fasciae. We concluded that the magnitude of these evaluated forces is outside the physiologic range of manual therapy. This conclusion is supported by the findings of Sucher et al6 that in vitro manipulation of the carpal tunnel area on human cadavers leads to plastic deformation only if the manipulation is extremely forceful or lasts for several hours.

Ward25 describes manual techniques central to osteopathic medicine (integrated neuromusculoskeletal release, myofascial release) that are designed to stretch and reflexively release restrictions in soft tissue. These techniques incorporate fascial compression, shear, traction, and twist. Our results indicate that compression and shear alone, within the normal physiologic range, cannot directly deform the dense tissue of fascia lata and plantar fascia, but these forces can impact softer tissue, such as superficial nasal fascia.

Our calculations reveal that the dense tissues of plantar fascia and fascia lata require very large forces—far outside the human physiologic range—to produce even 1% compression and 1% shear. However, softer tissues, such as superficial nasal fascia, deform under strong forces that may be at the upper bounds of physiologic limits. Although some manual therapists3,4 anecdotally report palpable tissue release in dense fasciae, such observations are probably not caused by deformations produced by compression or shear. Rather, these palpable effects are more likely the result of reflexive changes in the tissue—or changes in twisting or extension forces in the tissue.25