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The fascia: the forgotten structure.

Nyeste oppdateringen om bindevet her, som gir en klar definisjon av hva det faktisk er. Nevner forholdet mellom superficial og deep facia.

Dropbox fil her: https://dl.dropboxusercontent.com/u/17457302/Forskning%20mappe%20for%20terapi/The%20fascia%20-%20the%20forgotten%20structure.pdfAbstract: http://www.ncbi.nlm.nih.gov/pubmed/22852442

In 1987, Myers wrote: “the traditional approach that studies the muscles as inde- pendent units, has been a barrier to understand the bigger picture of fascial func- tion”. Indeed, the whole musculoskeletal system is usually studied only with respect to its bone and muscle components, the fasciae being traditionally relegated to the role of deftly holding ‘parts’ together.

It is increasingly evident that the fasciae may play important roles in venous return (Caggiati, 2000), dissipation of tensional stress concentrated at the sites of entheses (Benjiamin et al., 2008), etiology of pain (Langevin et al., 2001; Langevin, 2006), interactions among limb muscles (Huijing et al., 1998; Huijing, 1999; Huijing and Baan, 2001a,b; Yucesoy et al., 2006) and movement perception and coordina- tion (Vleeming et al., 1995, 1996; Stecco L., 1996, 2004; Stecco L. and Stecco C., 2009), due to their unique mechanical properties and rich innervation. Huijing et al. (2003) showed that only 70% of muscle tension transmission is directed through tendons, which thus definitely play a mechanical role, but 30% of muscle force is transmitted to the connective tissue surrounding muscles, highlighting the role of the deep fasciae in the peripheral coordination of agonist, antagonist and synergic muscles. The many functions of the fasciae include the roles of the ectoskeleton for muscle attachments and protective sheets for underlying structures (Wood Jones, 1944; Benjiamin, 2009). Lastly, recent studies have emphasized the continuity of the fascial system between regions, leading to presume its role as a body-wide proprioceptive/communicating organ (Langevin, 2006; Langevin et al., 2006; Lindsay, 2008; Kassolik et al., 2009).

This ample list of functions partly also derives from the fact that the term ‘fas- cia’ has been applied to a large number of very different tissues, ranging from well- defined anatomical structures, such as the fascia lata, thoracolumbar fascia, plantar and palmar fasciae, and cervical and clavipectoral fasciae, to the loose packing tissues which surround all the moving structures within the body. In fact, according to the American Heritage Stedman’s Medical Dictionary (2007), a fascia is “a sheet or band of fibrous connective tissue enveloping, separating, or binding together muscles, organs, and other soft structures of the body”, so that only the well-defined fibrous connective tissue layers may appropriately be called “fascia”, and it is consequently incorrect to use this term to mean all the connective tissue of the body.

Functionally, the superficial fascia may play a role in the integrity of the skin and support for subcutaneous structures, particularly veins, by ensuring their patency.

The deep fascia is a fibrous membrane forming an intricate network which envel- ops and separates muscles, forms sheaths for nerves and vessels, strengthens liga- ments around joints, and binds all the structures together into a firm compact mass. The deep fasciae envelop all the muscles of the body, but have different features according to region.

Under the deep fascia, the muscles are free to slide because of their epimysium. Loose connective tissue rich in hyaluronic acid lies between the epimysium and the deep fasciae (McCombe et al., 2001).

In the last few years, several studies have demonstrated the presence of many free, encapsulated nerve endings, particularly Ruffini and Pacini corpuscles, inside the deep fasciae (Stilwell, 1957; Yahia et al., 1992; Stecco C. et al., 2007), although dif- ferences exist according to the different regions; retinacula seem to be the most highly innervated structures. Analysis of the relationship between these nerve endings and the surrounding fibrous tissue shows that the corpuscle capsules and free nerve end- ings are closely connected to the surrounding collagen fibers, indicating that these nerve endings may be stretched, and thus activated, every time the surrounding deep fascia is stretched.

Some recent studies have reported possi- ble alterations of the retinacula (Demondion et al., 2010), particularly in ankle sprain outcomes (Stecco A. et al., 2011), in that they sometimes show more intense signal ascribable to local edema and inflammation; in patellofemoral malalignment, the medial and lateral retinacula of the knee show different thicknesses and/or degrees of tension. Despite these data, the fascial system is usually not analysed, by either radiologists or surgeons, and only a few papers report the visualization of possible alterations of the fasciae.

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Investigation of the mechanical properties of the human crural fascia and their possible clinical implications.

Om at bindevevet kan endres med stretching over 120s, og kan dermed redusere sitt «stress» med 40%.

http://www.ncbi.nlm.nih.gov/pubmed/23793789

The stress relaxation tests showed that the crural fascia needs 120 s to decrease stress of 40 %, suggesting a similar time also in the living so that the static stretching could have an effect on the fascia

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You said biomechanics? Its «fuzzy» mechanics!!

Dekonstruksjon av biomekanikk paradigmet og hvordan det ikke passer inn i vår organisme.

http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/mo64_fuzzy_mechanics/index.shtml

The acquired reflex to think according to Mechanics must absolutely be lost when dealing with Biomechanics. That is the reason why with some exceptions, engineers in Industrial Mechanics may sometimes be poor biomechanics. In fact, Biomechanics deals with a four dimensional space, where «the time dimension» does not have the same value as that involved in Industrial Mechanics.

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What nervous systems do: early evolution , inputoutput, and the skin brain thesi s

Viktig studie som hinter til den virkelige oppgaven til nervesystemet, som ikke er sende info inn til eller ut fra hjernen… Om vitenskapens forstelse av nervesystemet opp igjennom tidene og hvordan alt vi trodde om nervesystemet er feil.
http://adb.sagepub.com/content/21/2/67.abstract
Hele studien på dropbox: https://dl.dropboxusercontent.com/u/17457302/Forskning%20mappe%20for%20terapi/Keizer%202013%20What%20nervous%20systems%20do-%20early%20evolution%2C%20input%C2%96output%2C%20and%20the%20skin%20brain%20thesis.pdf

We hold that the fundamental problem here was not so much to act intelligentlya problem that had already been solved in various ways without a nervous system (Section 3.3)but to act as a single multicellular unit.

Nervous systems arose as a source and coordinator of patterned activity across extensive areas of contractile tissue in a way that was only loosely constrained by sensor activity.

In this view, the central direction of nervous system connections runs transverseat right anglesto the through-conducting stream that runs between sensors and effectors: early nervous systems evolved as connec- tions across a contractile tissue and in close connection to the animal epithelium or skin.

Adopting the phrase skin brain introduced by Holland (2003), we will refer to this idea as the skin brain thesis, or SBT.

Although the inputoutput view is deeply entrenched, there are issues involving nervous system functioning that are highly puzzling or awkward when the input output view is taken as a fundamental account of ner- vous systems.

The current inputoutput interpretation of nervous sys- tems is closely linked to a computational information- processing interpretation. This linkage is intrinsic to the classic neuron doctrine, according to which neurons are individual entities that receive and send electrical signals to one another through synapses in an all-or-none fashion that is basically similar to electrical switches. Consistent with the neuron doctrines one-way flow of information, nervous systems could be interpreted as electronic circui- try, which may be far more complex than artificial circui- try, but not intrinsically different.

The problem with this input-output interpretation is that the neuron doctrine on which it is based has been seriously undermined (e.g., Bullock et al., 2005; Guillery, 2007; Kruger & Otis, 2007) since it was first advanced by Ramon y Cajal in the late 19th century. Famously, Cajal formulated what came to be called the neuron doctrine explicitly in opposition to the then-current idea that ner- vous systems are reticular organizations of nerve cells directly connected to one another, through which electri- cal activity flows diffusely in all directions (Guillery, 2007; Kruger & Otis, 2007).

The neu- ron doctrine can not plausibly explain the diversity of neuromodulatory substances, such as amines and neu- ropeptides, that remodel neuron behavior and circuitry within minutes and hours instead of the standard milli- second time scale (Bullock et al., 2005). Many of these neuromodulatory molecules are not recent evolutionary developments but have a deep genomic history. More recently, immune system elements, such as cytokines, have been shown to play critical roles in modulating neural plasticity under normal as well as challenged conditions (McAfoose and Baune, 2009; Yirmiya and Goshen, 2011), and these associations are also very old (Maier and Watkins, 1998). The neuron doctrine cannot explain these associations either. Moreover, in many neurons, action potentials can travel backward from the axon and cell body to the dendrites.

Clue 2: The detailed operation of neurons and nervous sys- tems is much more complex and diverse than can be readily accounted for by the inputoutput view.

Clue 3: The reflex arc organization may very well be a sec- ondary optimization of nervous systems.

The inputoutput interpretation stresses that nervous systems function as information processing devices. However, in recent years serious claims concerning the complexity, and even cognitive, nature of the behavior of single-celled organisms have come to the fore. For example, John Allman (1999) discusses how the most fundamental features of brains such as sensory integra- tion, memory, decision-making, and the control of behavior, can already be found in simple organisms such as bacteria (pp. 56).

While this is presumably true of complex ner- vous systems, the point does not seem to apply to basic forms. When one systematically compares organisms with basic nervous systems, they do not show more complex behavior than creatures without a nervous sys- tem.

According to Jennings, the possession of a nervous system brings with it no observable essential changes in the nature of behavior. We have found no important additional features in the behavior when the nervous system is added (p. 263).

Clue 4: Basic nervous systems do not lead to more complex behavior than is often present in organisms without a nervous system.

Clue 5: Many of the biomolecular characteristics of neurons are already present in non-neural precursor contexts.

Clue 6: Understanding what nervous systems do is a question that requires an answer at the level of the whole animal.

Clue 7: The main animal effector consists of muscle tissue that requires spatiotemporal coordination.

Clue 8: Coordinating extensive areas of muscle tissue requires endogenous activity.

Nowadays, the picture has changed again. While Mackies scenario for the origins of nervous systems is still influential (e.g., Arendt, 2008; Je kely, 2011; Miller, 2009), it faces important difficulties. A key problem is that nervous systems are found more widely among animal phyla and classes than electri- cally coupled conductive epithelia. Notably, while all four major cnidarian classes have a nervous system, there is substantial evidence that only the Hydrozoa have functional gap junctions (Mackie, Anderson, & Singla, 1984; Satterlie, 2011).

Clue 9: Chemical transmission between adjacent cells can have provided the basis for primitive conductive epithelia that formed a half-way station to nerve nets.

Clue 10: Chemically transmitting conductive (myo)epithelia can have provided a basic form of muscle coordination.

Clue 11: Specialized axodendritic connections can have sub- sequently evolved to broaden the existing possibilities for muscle coordination.

Under this interpretation, the core business of such nerve nets consisted of organizing and integrating activity across contractile effector surfaces (e.g., mus- cle) spread out beneath an external epithelium. Such a task would involve parallel organization and coordina- tion requiring signaling across a surface rather than a through-conducting, sequential organization based on a set of pre-existing sensors and effectors. No stimulus can specify by itself the behaviorally relevant contrac- tion patterns across such a surface. Patterns that workthat is, patterns that lead to movements that are appropriate under the circumstancesare a func- tion of the particular effector surface that is present in the animals rather than of any triggering stimulus. Also, based on what we know about organisms today, movement is likely to have been self-induced, while external stimuli acted rather as modulating factors on continuous effector activity.

While modern nervous sys- tems have various other functions, it is evident that enabling an organism to move and manipulate its envi- ronment in specific ways is the prime reason for the huge investment in these metabolically expensive organs (Allman, 1999).

Such cellular con- tractions must be coordinated with respect to one another, however. Uncoordinated contractions by indi- vidual cells would not result in whole-body motility. This, we believe, is where nervous systems come in. Nerve nets are intrinsically tied up with muscle surfaces.

The SBT can now be formulated as the proposition that early nerve nets evolved when some conducting cellseither within or connected to the myoepithelium evolved elongated processes and synaptic connections in a way that modified and enhanced the patterning capabil- ities of a pre-existing myoepithelium. Rather than pro- viding specific connections from sensors to effectors, the proper function of such nerve nets was to control, modify and extend the available self-organized pattern- ing across a Pantin surface. The key adaptation pro- vided by early nerve nets was the way in which they added to the generic self-organizing properties of pre- existing epithelial and muscular tissues.

To summarize, the SBT claims that nerve nets origi- nated as a new mechanism by which Pantin surfaces could be more intricately and flexibly patterned to accommodate efficient motility at larger bodily scales. At a fundamental level nerve nets are fitted to spatial patterning and to accommodating spatially patterned feedback.

The SBT offers a genuinely new conceptual approach for understanding nervous systems at a whole systems level. Starting with the most primitive neural organiza- tionsproto-neural myoepithelia and nerve netswe argue that both are characterized by connections trans- verse to the standard sensor-effector direction and evolved their characteristics to bind the many cellular units of muscle sheets together into a unitary system. Nervous systems are in this view not organized aroundor rather betweensensors and effectors. They are themselves a precondition for both extended con- tractile effectors as well as multicellular sensory arrays.

We have stressed from the beginning that the SBT provides a conceptual reinterpretation of nervous system functioning.

The skin brain pro- posal casts animal behavior as a dynamical phenotype, necessarily tied to the species or class of animals under consideration. Sherrington once observed that posture follows movement like a shadow (Stuart, 2005). We would like to stress that dynamically changing body pos- ture is a precondition for all task-oriented animal beha- vior. Animal behavior is a part of animal organization.

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Melatonin as an antioxidant: biochemical mechanisms and pathophysiological implications in humans

Viktig studie som nevner alt om hvordan melatonin virker som en antioksidant. Hele studien er her, men den er ikke gjennomgått enda.

http://www.actabp.pl/pdf/4_2003/1129s.pdf

Melatonin’s functions as an antioxidant include: a), direct free radical scavenging, b), stimulation of antioxidative enzymes, c), increasing the efficiency of mitochon- drial oxidative phosphorylation and reducing electron leakage (thereby lowering free radical generation), and 3), augmenting the efficiency of other antioxidants.

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Melatonin induces γ- glutamylcysteine syn thetase mediated by activator protein-1 in human vascular en dothelial cells

Det første bildet viser hvordan melatonin dobler glutathion konsentrasjon. Dette er interessant med tanke på at diafragmiske pust øker melatonin. Melatonin hemmer enzymet som bryter ned glutathion, derfor økes konsentrasjonen.

http://www.sciencedirect.com/science/article/pii/S0891584999001318

In the present study, we show that melatonin induces the expression of γ-glutamylcysteine synthetase (γ-GCS), the rate-limiting enzyme of glutathione (GSH) synthesis, in ECV304 human vascular endothelial cells.

As conclusion, induction of GSH synthesis by melatonin protects cells against oxidative stress and regulates cell proliferation.

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Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement

Stor studie om det aller meste rundt forskjellige diagosekriterier og individuelt det er fra terapeut til terapeut, men også fra studie til studie.

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007427.pub2/full

Shoulder pain and dysfunction are common in the general population. A systematic review reported point prevalences for shoulder pain ranging from 7% to 26% with some indication that prevalence increases with age (Luime 2004a). Data from the US National Ambulatory Medical Care Survey (NAMCS) 1993 to 2000 indicate that one per cent of all office visits to physicians are for shoulder pain, and that a quarter of these visits are to primary care physicians (Wofford 2005). Moreover, shoulder pain has little tendency to resolve quickly or completely; according to a Dutch study, one half of all sufferers still report problems a year after their initial consultation (Van der Heijden 1997).

Impingement was originally characterised by Neer and Welsh (Neer 1977) as pinching of the soft-tissue structures between the humerus (upper arm bone) and the bone-and-ligament coraco-acromial arch of the scapula (shoulder blade) on movement. These structures include the contents of the so-called subacromial outlet: the ‘rotator cuff’ of muscles and tendons that surrounds the shoulder joint and the large lubricating sac (the subacromial bursa) that overlies it; and also the biceps tendon, which arches over the humerus, deep to the rotator cuff and within the shoulder joint itself. Neer 1977 proposed a continuum of impingement severity, from irritation of the bursa and cuff (normally due to overuse, and reversible by conservative management) to full thickness tears of the cuff. It has since been theorised that any abnormal reduction in the subacromial outlet’s volume (e.g. by bone shape, soft-tissue thickening, posture or minor joint instability) may predispose to, contribute to, perpetuate or aggravate this train of events (discussed by Hanchard 2004).

When a person presents with a history and symptoms suggestive of shoulder impingement, the clinician performs a series of physical (non-invasive) tests that aim to establish the diagnosis, and inform treatment and prognosis. Such tests may include the ‘painful arc’ test, intended to identify impingement in general terms (Cyriax 1982); tests to identify subacromial impingement (e.g. Neer 1977) or internal impingement (e.g. Meister 2004); tests to differentiate subacromial from internal impingement (Zaslav 2001); tests to diagnose rotator cuff involvement, including tears (e.g. Gerber 1991a; Gerber 1996; Hertel 1996a), or biceps tendon involvement (e.g. Yergason 1931); or tests to diagnose glenoid labrum tears (e.g. Kim 2001; Liu 1996b; O’Brien 1998a). These tests are described in Table 1, and include tests that were identified in studies included in this review.

Physical tests involve clinical and interpretative skills, and results have been shown to differ with testers’ expertise (Hanchard 2005). This has implications for the generalisation of results relating to test performance from individual studies.

Other tests, usually conducted subsequently and in secondary care settings by specialists, include ultrasonography, arthrography, bursography, magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA). Those considered as potential reference standards for this review are described in Table 3. Some of these tests are invasive and none is completely valid (Dinnes 2003). Specifically, the generally accepted gold standard of diagnosis, direct observation at open or arthroscopic (‘keyhole’) surgery (Table 3), is not completely valid because tears within the substance of the rotator cuff are not directly visible (Fukuda 2003) and conversely, visible tears may be asymptomatic (Dinnes 2003; MacDonald 2000a; Milgrom 1995; Sher 1995). Surgery carries a risk of complications (Blumenthal 2003;Boardman 1999; Borgeat 2001), and is not applicable in the primary care setting where the majority of consultations and treatment prescriptions occur. Moreover, approximately 70% of patients with shoulder impingement respond to conservative treatment (Morrison 1997a) and so those having surgery cannot be considered representative (spectrum bias).

Whether intentional or unintentional, variations in index tests’ procedure or interpretation were prevalent, such that, as observed above, there were only six instances of any index test being performed and interpreted (in terms of criteria for, and implications of, a positive result) similarly in two studies; and no instances of three studies or more using any one test similarly.

Between-tester agreement

Few studies addressed this aspect, although it is fundamental to the validity of clinical tests. Agreement is best evaluated using the kappa coefficient, since this takes account of the fact that agreements may occur by chance. The coefficient ranges from 0 to 1, and interpretation has been recommended as follows by Altman 1991: less than 0.20 = poor; 0.21 to 0.40 = fair; 0.41 to 0.60 = moderate; 0.61 to 0.80 = good; 0.81 to 1 = very good. By these criteria, and based on point estimates, very good between-rater agreement was achieved for only one test, the biceps load II test (Kim 2001). Good agreement was obtained for the passive compression test (Kim 2007b) and resisted lateral rotation from neutral rotation (Michener 2009). Agreement for the painful arc test was moderate (Michener 2009), while that for Neer’s test was fair to moderate (Michener 2009; Razmjou 2004). For the empty can test (Michener 2009) and Hawkins’ test (Michener 2009; Razmjou 2004), agreement was only fair.

There is insufficient evidence upon which to base selection of physical tests for shoulder impingements, and local lesions of bursa, tendon or labrum that may accompany impingement, in primary care.The large body of literature revealed extreme diversity in the performance and interpretation of tests, which hinders synthesis of the evidence and/or clinical applicability.

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Pasient fikk 31 diagnoser

Artig artikkel om hva som skjer når 100 leger skal sette diagnose på samme pasient: 31 forskjellige diagnoser.

http://www.dagensmedisin.no/nyheter/-pasient-fikk-31-diagnoser/

Vanligste diagnose var psykiske lidelser, generelle uspesifikke helseplager og muskel- og skjelettlidelser. Flertallet ble henvist til psykologisk behandling, hos fastlege eller hos spesialist. Nesten 60 prosent av legene ga ulik hoved- og sekundærdiagnose.