The effect of adding forward head posture corrective exercises in the management of lumbosacral radiculopathy: a randomized controlled study.

Denne nevner at å korrigere FHP i tillegg til annen behandling gir bedring i symptomer i beina.

http://www.ncbi.nlm.nih.gov/pubmed/25704221/?ncbi_mmode=std

Abstract

OBJECTIVE:

The purpose of this study was to determine the immediate and long-term effects of a multimodal program, with the addition of forward head posture correction, in patients with chronic discogenic lumbosacral radiculopathy.

METHODS:

This randomized clinical study included 154 adult patients (54 females) who experienced chronic discogenic lumbosacral radiculopathy and had forward head posture. One group received a functional restoration program, and the experimental group received forward head posture corrective exercises. Primary outcomes were the Oswestry Disability Index (ODI). Secondary outcomes included the anterior head translation, lumbar lordosis, thoracic kyphosis, trunk inclination, lateral deviation, trunk imbalance, surface rotation, pelvic inclination, leg and back pain scores, and H-reflex latency and amplitude. Patients were assessed at 3 intervals (pretreatment, 10-week posttreatment, and 2-year follow-up).

RESULTS:

A general linear model with repeated measures indicated a significant group × time effect in favor of the experimental group on the measures of ODI (F = 89.7; P < .0005), anterior head translation (F = 23.6; P < .0005), H-reflex amplitude (F = 151.4; P < .0005), H-reflex latency (F = 99.2; P < .0005), back pain (F = 140.8; P < .0005), and leg pain (F = 72; P < .0005). After 10 weeks, the results revealed an insignificant difference between the groups for ODI (P = .08), back pain (P = .29), leg pain (P = .019), H-reflex amplitude (P = .09), and H-reflex latency (P = .098). At the 2-year follow-up, there were significant differences between the groups for all variables adopted for this study (P < .05).

CONCLUSIONS:

The addition of forward head posture correction to a functional restoration program seemed to positively affect disability, 3-dimensional spinal posture parameters, back and leg pain, and S1 nerve root function of patients with chronic discogenic lumbosacral radiculopathy.

Correlated Variability in the Breathing Pattern and End-Expiratory Lung Volumes in Conscious Humans

Ny studie som går omfattende igjennom pust-til-pust fysiologien og mekanismen.

De fleste studier som gjøres ser på gjennomsnittsverdier, f.eks. pustefrekvens og hjerterytme. Innen hjerterytme har forskerne funnet HRV, som er variasjoner i slag-til-slag, istedet for et gjennomsnitt av slag i et minutt (hjerterytme). Med all forskning på HRV og nervesystemet kan man også anta at varibailitet i pusterytme kan bidra til like mye interessant.

Her nevner de bl.a. at mage-området hadde den største variasjonen over tid (de målte i 16 minutter, altså flere hundre pust).

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0116317

In particular, the abdominal compartment had the largest exponent implying the strongest control on the fluctuations over long time scales.

In summary, we measured the cycle-by-cycle variations of several respiratory physiological variables and found that these fluctuations show long-range correlations that are highly reproducible in individual subjects. Using a novel neuromechanical model, we propose that the correlations in the timing and amplitude of the physiological variables originate from the brain with the exception of end-expiratory lung volume which shows the strongest correlations due to the contribution of the viscoelastic properties of the tissues. Finally, we also suggest that since cells in the respiratory system are exposed to fluctuation in cycle-by-cycle stretch related to variability in tidal volume, these finding may have implications on general cell function in the respiratory system.

The pain matrix reloaded: a salience detection system for the body.

Salience Detection System (SDS) beskriver en måte hjernen forholder seg til sine opplevelser på. Salience betyr fremtredende. I et virrvar av input er det det som er fremtredende vi legger merke til. SDS har som formål å sile ut det som er uviktig og fremheve det som er viktig. Dette er en viktig del av alle sansesystemer: syn, hørsel, smak, berøring, bevegelse, m.m.

Det kan også brukes til å forklare mange av de feneomenene som oppstår ved kronisk smerte. Istedet for en lineær sammenheng mellom nocicepsjon og smerte (noe som er avkreftet for flere tiår siden), forholder man seg til nettverk (neuromatrix) i hjernen. Men nå, istedet for å forholde seg til nettverk, forholder man seg til det systemet som avgjør hvilke aspekter av nettverket som skal fremheves som en erfart opplevelse.

Hva hjernen avgjør skal være fremtredende avhenger sterkt av hvilken kontekst vi setter det i.

http://www.ncbi.nlm.nih.gov/pubmed/21040755

Abstract

Neuroimaging and neurophysiological studies have shown that nociceptive stimuli elicit responses in an extensive cortical network including somatosensory, insular and cingulate areas, as well as frontal and parietal areas. This network, often referred to as the «pain matrix», is viewed as representing the activity by which the intensity and unpleasantness of the perception elicited by a nociceptive stimulus are represented. However, recent experiments have reported (i) that pain intensity can be dissociated from the magnitude of responses in the «pain matrix», (ii) that the responses in the «pain matrix» are strongly influenced by the context within which the nociceptive stimuli appear, and (iii) that non-nociceptive stimuli can elicit cortical responses with a spatial configuration similar to that of the «pain matrix». For these reasons, we propose an alternative view of the functional significance of this cortical network, in which it reflects a system involved in detecting, orienting attention towards, and reacting to the occurrence of salient sensory events. This cortical network might represent a basic mechanism through which significant events for the body’s integrity are detected, regardless of the sensory channel through which these events are conveyed. This function would involve the construction of a multimodal cortical representation of the body and nearby space. Under the assumption that this network acts as a defensive system signaling potentially damaging threats for the body, emphasis is no longer on the quality of the sensation elicited by noxious stimuli but on the action prompted by the occurrence of potential threats.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3719078/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3644802/

Kan man fejle ‘sensibilisering’?

Denne blogposten på dansk beskriver på en underhåndende måte en diskusjon som pågår mellom forskere om konseptet Sentral Sensitering. Jeg linker til denne her pga et interessant bilde som viser progresjonen på Sentral Sensitering, og hvordan det lett blir forvirring i diagnosen i forskjellige steder av progresjonen.

Det er bildet helt nederst i artikkelen.

I starten er det lett å se at en vevsskade gir smerte. Etter hvert blir selve vevvskaden mindre, mens smerten sprer seg utover i nervesystemet og tar større og større plass. Til sist er det smerte over alt, men ingen tegn til vevsskade.

https://videnomsmerter.wordpress.com/2015/03/19/kan-man-fejle-sensibilisering/

Cervical joint position sense in neck pain – Immediate effects of muscle vibration versus mental training interventions.

En studie som nevner at vibrasjon på muskler i nakke ga bedre bevegelighet og høyere smerteterskel. Den viste også at visualisering av bevegelsen ga bedre bevegelighet, men det gang ingen endring i smerteterskel.

http://www.ncbi.nlm.nih.gov/pubmed/25779914

Abstract

BACKGROUND:

Impaired cervical joint position sense is a feature of chronic neck pain and is commonly argued to rely on abnormal cervical input. If true, muscle vibration, altering afferent input, but not mental interventions,, should have an effect on head repositioning acuity and neck pain perception.

AIM:

The aim of the present study was to determine the short–term effects of neck muscle vibration, motor imagery, and action observation on cervical joint position sense and pressure pain threshold in people with chronic neck pain.

DESIGN:

45 blinded participants with neck pain received concealed allocation and were randomized in three treatment groups. A blinded assessor performed pre– and post–test measurement SETTING: Patients were recruited from secondary outpatient clinics in the southwest of Germany POPULATION: Chronic, non specific neck pain patients without arm pain were recruited for this study.

METHODS:

A single intervention session of 5 minutes was delivered to each blinded participant. Patients were either allocated to one of the following three interventions: i) neck muscle vibration, ii) motor imagery, and iii) action observation. Primary outcomes were cervical joint position sense acuity and pressure pain threshold. Repeated measures ANOVAs were used to evaluate difference between groups and subjects.

RESULTS:

Repositioning acuity displayed significant time effects for vibration, motor imagery, and action observation (all p<0.05), but revealed no time*group effect. Pressure pain threshold demonstrated a time*group effect (p= 0.042) as only vibration significantly increased pressure pain threshold (p=0.01).

CONCLUSION:

Although motor imagery and action observation did not modulate proprioceptive, afferent input, they nevertheless improved cervical joint position sense acuity. This indicates that, against the common opinion, changes in proprioceptive input are not prerequisite to improve joint repositioning performance. However, the short–term applications of these cognitive treatments had no effect on pressure pain thresholds, whereas vibration reduced pressure pain thresholds. This implies different underlying mechanisms after vibration and mental training.

CLINICAL REHABILITATION IMPACT:

Mental interventions were effective in improving cervical joint position sense and are easy to integrate in rehabilitation regimes. Neck muscle vibration is effective in improving cervical joint position sense and pressure pain thresholds within 5 minutes of application.

What clinicians say they advise for low back pain is not what they actually do in clinical practice

Denne blogposten beskriver en studie som viser at det terapeuter sier at de gjør med klienter ikke er det samme som de faktisk gjør. Jeg synes man kan ta alle terapeuter med en klype salt uansett hvilken progesjon. F.eks. sier kirurger at de har strenge retningslinjer for hvem som tilbys operasjon, likevel viser forskning at 80% av alle artroskopi operasjoner for kne og skulder er unødvendige. Kirurgene må også taes med en klype salt.

http://www.pain-ed.com/blog/2015/02/14/what-clinicians-say-they-advise-for-low-back-pain-is-not-what-they-actually-do-in-clinical-practice/

In conclusion, this study showed that healthcare professionals (physiotherapists) do not make the decisions they say they would make for people with low back pain.

Her er studien: http://www.ncbi.nlm.nih.gov/pubmed/25652442/

Red flags to screen for malignancy and fracture in patients with low back pain: systematic review

Røde flagg ved ryggsmerter som der er viktig å være klar over for å sende pasienter videre. Alderdom, kortikosteroider (betennelsedempende), sår eller blåmerker er de viktigste. Ved flere av disse samtidig er det større sjanse for brudd, og en historie på alvorlige lidelser i ryggen er det største røde flagget for alvorlige lidelser i ryggen (f.eks. kreft).

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3898572/

The red flags with the highest post-test probability for detection of fracture were older age (9%, 95% confidence interval 3% to 25%), prolonged use of corticosteroid drugs (33%, 10% to 67%), severe trauma (11%, 8% to 16%), and presence of a contusion or abrasion (62%, 49% to 74%). Probability of spinal fracture was higher when multiple red flags were present (90%, 34% to 99%). The red flag with the highest post-test probability for detection of spinal malignancy was history of malignancy (33%, 22% to 46%).

Physiopathology of intratendinous calcific deposition

Kalsium ansamlinger i sener eller andre strukturer i bevegelsesapparatet kan bidra til smertetilstander. Denne studien går igjennom hvordan disse oppstår slik at vi kan få en bedre forståelse av hva vi kan gjøre med det. Store ansamlinger kan sees på røntgen, men man kan også ha mikroskopiske ansamlinger som bidrar til plager uten å være synling på røntgen.

Det er spesielt vanlig blant de med diabetes (30%) og assosieres ofte med tyroidea problemer eller andre hormonproblemer. Genetisk predisposisjon er også en viktig faktor.

Ofte starter det med en skade, hvor det så skjer en kursendring i helbredelsesprosessen som gjør at kalsiumavleiringer eller andre problemer fremtrer og bidrar til smerteproblematikk.

http://www.biomedcentral.com/1741-7015/10/95

In calcific tendinopathy (CT) calcium deposits in the substance of the tendon. CT is particularly common in the rotator cuff tendons (RCTs) and supraspinatus tendon, and Achilles tendon and patellar tendon. CT of the rotator cuff is common in Caucasian populations, with a reported prevalence of 2.7% to 22%, mostly affecting women between 30 and 50 years. The most frequently involved tendon is the supraspinatus tendon, and in 10% of patients the condition is bilateral (Figure 1[1].

(kalsiumansamlinger vises ytterst og øverst på humerus)

(kalsiumansamling vises i ackillesenen)

Clinical manifestations of the calcific process within the tendons include chronic activity-related pain, tenderness, localized edema and various degrees of decreased range of motion (ROM). CT of the rotator cuff shows a tendency toward spontaneous resorption of the deposits and symptoms often resolve spontaneously, although some authors described persistent pain at long time follow-up and persistent reduction of ROM [5,6].

Microscopic calcifications which are not detectable at plain radiography can also occur in chronic tendinopathy. A histological study showed high incidence of small calcium deposits in tendinopathic supraspinatus tendons [8]. Microscopic calcium deposits are frequent also in diabetic patients [9].

Specimens of RCTs obtained during surgery consist of a gritty mass of sandy material or a toothpaste-like fluid, and the deposits were described as a white amorphous mass composed of many small round or ovoid bodies. Later, X-ray diffraction and infrared spectrometry and other techniques identified the material of calcific deposits as calcium carbonate apatite [1820].

Uhthoff and coworkers hypothesized that a favorable environment permits an active process of cell-mediated calcification, usually followed by spontaneous phagocytic resorption [28]. They describe four stages in the calcifying process of the rotator cuff: precalcific phase, calcific phase, resorptive phase, and repair phase. All phases may occur concomitantly in the same tendon.

Finally, bone is deposited and the spur is formed. No inflammatory cells or microtears were identified. The authors believe that the increased surface at the tendon-bone junction may represent an adaptive mechanism to increased mechanical loads.

An association between CT and diabetes and thyroid disorders has been shown, but the precise mechanism is still unknown [1]. Patients with associated endocrine disorders present earlier onset of symptoms, longer natural history, and they undergo surgery more frequently compared to a control population [61,62]. More than 30% of patients with insulin-dependent diabetes have tendon calcification [63]. The exposure of proteins to high levels of sugar moieties cause the glycosylation of several extra-cellular matrix proteins, which can modify the extracellular matrix by cross-linking proteins.

Beyond nociception: the imprecision hypothesis of chronic pain

Denne forklarer på eksepsjonelt elegant måte veldig mange problemer rundt kronisk smerte som nocicepsjon og sentralsensitering ikke når frem til. Den nevner at jo mer generalisert hjernens output er, jo letter vil det oppstå kronisk smerte. Når hjernen ikke lenger greier å skille mellom bevegelse som tidligere har vært smertefull (pga akutt skade eller annen nocicepsjon) og bevegelse som ikke har en involvert skade eller nocicepsjon, så utvikler den en generell og uspesifikk smertetilstand.

F.eks. når det å bøye seg fremover gjør vondt uansett hvordan man gjør det. Hjernens «output» er uspesifikk og greier ikke skille hva som tidligere har gjort vondt ved en spesifikk måte å bøye seg fremover, og alle andre måter å bøye seg fremover på.

Smertefunksjonen har gått fra å være beskyttende til å bli begrensende.

http://www.researchgate.net/publication/270098694_Beyond_nociception_the_imprecision_hypothesis_of_chronic_pain

 

When a cause cannot be found

Artikkel som nevner mye av problemen rundt behandling av f.eks. ikke-spesifikke ryggplager, IBS eller firbomyalgi. Dette er plager det ikke er noe tydelig årsak-virkning forhold, som ikke kan forklares med et molekyl eller anatomisk utgangspunkt som er felles for alle som har disse plagene, og hvor det ikke er noe klart skille mellom kropp og sinn.

https://raniblogsaboutcausation.wordpress.com/2014/08/14/when-a-cause-cannot-be-found/

This is not a small problem in medicine. By some estimates, such unexplained conditions amount to 30 percent of all symptoms reported to doctors, and they are linked to a 20-50% increase in outpatient costs and a 30% increase in hospitalisation.

This is, basically, what evidence based medicine means: statistical evidence from population studies are applied directly to a patient. This means that each patient is treated as a statistical average, not as a unique individual.

Rather than being dismissed as marginal, therefore, these unexplained conditions should be taken as exemplary for understanding health and disease in general.