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Mechanical or inflammatory low back pain. What are the potential signs and symptoms

Studie som beskriver forskjellen mellom betennelses og mekansik smerte. Dog det er liten forskjell med tanke på kronisk smerte, nevner denne studien mange interessante poenger.

http://www.ncbi.nlm.nih.gov/pubmed/18555728
Hele som pdf: http://www.researchgate.net/publication/5300497_Mechanical_or_inflammatory_low_back_pain._What_are_the_potential_signs_and_symptoms/file/d912f50e6f8ae9e751.pdf

«NSLBP is commonly described as being ‘‘mechanical’’ (Batt and Todd, 2000; Chaudhary et al., 2004; Valat, 2005) or ‘‘inflammatory’’ (Saal, 1995; Ross, 2006). Although these labels have no universally accepted defini- tions, there is evidence to support the involvement of both mechanical and inflammatory factors in the generation of LBP (Biyani and Andersson, 2004; Hurri and Karppinen, 2004; Igarashi et al., 2004; Abbott et al., 2006; Al-Eisa et al., 2006; Ross, 2006).»

«The relationship between inflammation and pain, however, is not clear. Although a recent study found that the mean intensity of pain over 24 h was indepen- dently associated with high levels of high sensitivity C reactive protein in patients with acute sciatica (less than 8 weeks), this association was not found in patients with chronic LBP (Stu ̈ rmer et al., 2005).»

«Similarly, the relationship between pain that wakes a patient up and inflammation is not clear.»
«Although the levels of inflammatory cytokines, such as interleukin-6 may alter sleep behaviour (Mullington et al., 2001), there did not appear to be an association between improvements in pain and joint stiffness»
«Although pain on lifting is commonly thought to rep- resent mechanical pain, the relationship between spinal load and pain is not clear.»

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Subacromial impingement syndrome and rotator cuff tendinopathy: The dilemma of diagnosis

Studie presentert på Fysioterapeuten som viser at diagonstisk spesifisitet ikke er tilfredsstillende i vurdering av strukturelle funn. Dette er, etter min mening, helt åpenbart og selvfølgelig straks man innser at menneskekroppen er en organisme og ikke en (bio)mekanisme. I «organismer» er det flere levende systemer som påvirker hverandre på mange nivåer, så å finne ETT enkelt årsaksutgangspunkt er nytteløst. Ikke minst når det gjelder smertesymptomer.

http://fysioterapeuten.no/Fag-og-vitenskap/Fagartikler/Subacromial-impingement-syndrome-and-rotator-cuff-tendinopathy-The-dilemma-of-diagnosis

«Sometimes the specificity of a test may only be 50% (16, 17) which would not allow the clinician to develop an informed opinion as to where the symptoms were coming from. Calis et al (18) reported a sensitivity of 88.7% and a specificity of  30.5% for the Neer impingement sign. Litaker et al (19) reported values of 97.4% and 9.0% for the same test. Calis et al (18) reported sensitivity and specificity values of 92.1% and 25% for the Hawkin’s test. These figures clearly question the ability to arrive at a definitive diagnosis. Hegedus et al (20) have recently published a comprehensive review investigating clinical shoulder tests. They concluded that the use of any single shoulder orthopaedic tests to make a conclusive diagnosis is questionable. »

«Currently it appears that the process of making a diagnosis using a combination of clinical tests supported by imaging findings will not allow a clinician to arrive at a structural diagnosis with certainty (26). This has been recognized by clinicians treating other areas of the body (33, 34).»

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Neurological examination of the peripheral nervous system to diagnose lumbar spinal disc herniation with suspected radiculopathy: a systematic review and meta-analysis.

Studie som viser dårlig spesifisitet i diagnose av korsrygg plager og utstråling.

http://www.ncbi.nlm.nih.gov/pubmed/23499340

«Pooled data for sensory testing demonstrated low diagnostic sensitivity for surgically (0.40) and radiologically (0.32) confirmed disc herniation, and identification of a specific level of disc herniation (0.35), with moderate specificity achieved for all the three reference standards (0.59, 0.72, and 0.64, respectively). Motor testing for paresis demonstrated similarly low pooled diagnostic sensitivities (0.22 and 0.40) and moderate specificity values (0.79 and 0.62) for surgically and radiologically determined disc herniation, whereas motor testing for muscle atrophy resulted in a pooled sensitivity of 0.31 and the specificity was 0.76 for surgically determined disc herniation.»

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Diagnostic accuracy of the clinical examination in identifying the level of herniation in patients with sciatica.

Nevner at diagnostisk spesifisitet ikke er tilfredsstillende. Med tanke på at konvensjonell medisin legger så mye av sin yrkesstolthet i spesifikke diagnoser viser denne studien at vi kanskje må revurdere vårt mekaniske kroppsbilde og heller gå over til et organisk kroppsbilde hvor vi tar hensyn til at mange forkjellige systemer påvirker hverandre.

http://www.ncbi.nlm.nih.gov/pubmed/21224761

«The dermatomal pain location was generally the most informative individual neurologicaltest. »

«The current study did not find evidence to support the accuracy of individual tests from the neurologicalexamination in identifying the level of disc herniation demonstrated on MRI.»

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Why does my shoulder hurt? A review of the neuroanatomical and biochemical basis of shoulder pain

Beskriver smertefunksjon og perifere forklaringsmodeller for skuldersmerter.

http://m.bjsm.bmj.com/content/early/2013/02/20/bjsports-2012-091492.long?view=long&pmid=23429268

«This means that any cause of inflammation in or around the shoulder may give rise to the so-called ‘irritable’ shoulder joint. Therefore, clinically it may be difficult to discriminate between rotator cuff tendinopathy and calcific tendinitis or inflammatory joint disease, for example; there is a clear lack of clarity with regard to whether common diagnostic tests used in clinical examination are useful in differentially diagnosing pathologies of the shoulder.68 ,72»

«A variety of factors including patient expectation, emotions such as anxiety and mood all have significant effects on the complex neurobiological process that lies behind placebo analgesia.79 ,80«

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INCREASED INTERSTITIAL CONCENTRATIONS OF PYRUVATE AND LACTATE IN THE TRAPEZIUS MUSCLE OF PATIENTS WITH FIBROMYALGIA: A MICRODIALYSIS STUDY

Om at fibromyalgi innebærer høyere grad av melkesyre i musklene, og at dette er en av bidragene til den kroniske smerten.

http://www.medicaljournals.se/jrm/content/?doi=10.2340/16501977-0581&html=1

«There was a significant group effect (p = 0.039) with higher interstitial lactate concentrations in FMS compared with CON (Fig. 2a).»

«There was a highly significant difference in interstitial concentration of pyruvate (p < 0.001) between the 2 groups; the concentrations were higher among the FMS patients (Fig. 2b).»

«One possible explanation for the higher [pyruvate] in FMS of the present study is changes in the lactate-pyruvate metabolism via lactate dehydrogenase isoforms (18). Another alternative is that a reduction in tissue oxygenation in FMS (8) may result in higher [pyruvate] due to a shift towards an anaerobic state. Such a circumstance might also cause the significantly higher [lactate].»

«The aerobic capacity of the muscle is largely governed by the number of mitochondria and their enzymes (20). Lindh et al. reported lower capillary density and enzymes associated with aerobic metabolism in FMS (21); however, it is unknown if a general deconditioning in FMS involves the postural trapezius. The mitochondrial density increases as result of exercise (see (22) for references) and affects the level of metabolites (i.e. enhanced aerobic capacity).»

«Lactate is also involved in peripheral nociception, and it appears to facilitate the response of acid-sensing ion channel 3 (ASIC-3) to low pH (26). Such ASIC channels are considered as molecular transducers for nociception and mechanosensation (26).»

«It has been reported that FMS has abnormal cardiovascular responses to low-grade mental stress (35). Several studies indicate altered sympathetic activation in FMS (36–39), which in turn may affect [lactate] (40). Sympathetic activation may also cause decreased blood flow even without hypoxia (26, 41).»

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painDETECT

Online spørsmålskjema som viser om smertene kommer fra nevropati eller ikke.

Klikk for å få tilgang til painDETECT-Questionaire-01.pdf

Denne Studien viser helel 88% sikkerhet som diagnoseverktøy: http://www.ncbi.nlm.nih.gov/pubmed/17022849

«Simple, patient-based, easy-to-use screening questionnaires can determine the prevalence of neuropathic pain components both in individual LBP patients and in heterogeneous cohorts of such patients.»

«The PD-Q is a reliable screening tool with high sensitivity, specificity and positive predictive accuracy; these were 84% in a palm-top computerised version and 85%, 80% and 83%, respectively, in a corresponding pencil-and-paper questionnaire.»

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Breathing pattern disorders, motor control, and low back pain

Viktig artikkel fra Leon Chaitow om pustens rolle i ryggsmerter. Beskriver hva som skjer med nervesystemet, med bindevevet og muskelkontroll i ryggraden. Og nevner hvordan progesteron og blodsukker påvirker pusten.

http://leonchaitow.com/wp-content/uploads/pdfs/Breathing%20Pattern%20Disorders%20and%20back%20pain.pdf

«Nixon and Andrews16 have summarised the emerging symptoms resulting from hypocapnoea in a deconditioned individual, as follows: “Muscular aching at low levels of effort; restlessness and heightened sympathetic activity; increased neuronal sensitivity; and, constriction of smooth- muscle tubes (e.g. the vascular, respiratory and gastric- intestinal) can accompany the basic symptom of inability to make and sustain normal levels of effort.” »

«Lum7 notes, “Alkalosis alone cannot fully explain the symptoms [of chronic hyperventilation]. Altitude adaptation allows residents of high altitudes to remain well, despite chronic respiratory alkalosis. In symptomatic hyperventilation however, the PCO2 fluctuates, often wildly, causing constantly changing pH in nerve cells and tissue fluid to which no adaptation is possible…significant amounts of CO2 can be lost in a few minutes of overbreathing, immediately causing respiratory alkalosis. Compensation, by excretion of bicarbonate, is relatively slow and may take hours or days.” »

«Seyal et al36 note that hyperventilation increases the excitability of both cutaneous and motor axons, and that in experimental animals, HVS increases excitability of hippocampal neurons. Their research, involving healthy humans, demonstrates that hyperventilation increases the excitability of the human corticospinal system. »

«Lum 38 reports,: “During moderate hyperventilation, loss of CO2 ions from neurons stimulates neuronal activity, causing increased sensory and motor discharges, muscular tension and spasm, speeding of spinal reflexes, heightened perception (photophobia, hyperacusis) and other sensory disturbances. More profound hypocapnoea, however, increasingly depresses activity. This parallels the clinical state: initial alertness with increased activity, progressing through decreased alertness, to stupor and coma.” »

«An altered pH in the local chemical environment of peripheral nociceptors, such as occurs with respiratory alkalosis, helps to induce mechanical sensitisation and ischaemic pain.47,48 »

«Hodges further hypothesises: “Although investigation of spinal mechanics is required to confirm the extent to which spinal control is compromised by increases in respiratory demand, it is hypothesised that such a compromise may lead to increased potential for injury to spinal structures and reduced postural control. During strenuous exercise, when the physical stresses to the spine are greater, the physiological vulnerability of the spine to injury is likely to be increased.”

«Progesterone is a respiratory stimulant, making patients with BPD most vulnerable during the post-ovulation phase of the menstrual cycle.10 »

«Blood sugar levels are, “clinically the most important of these non-ventilatory factors. When blood glucose is below the middle of the normal range (i.e. below 4.4 mmol/L) the effects of overbreathing are progressively enhanced at lower levels.” 81 «

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Breathing pattern disorders and physiotherapy: inspiration for our profession

Nevner hva pustetrening kan gjøre for fysioterapeuters behandlingseffekt og hvorfor det er viktig å jobbe med pusten. Viktig studie som også nevner og bekrefter Chaitows arbeid.

«Currently in western medicine, a fundamental push is to encourage healthy life style skills. Education in one of the most fundamental tools, and yet breathing has not been emphasized enough as part of this healthy lifestyle package. »

http://xa.yimg.com/kq/groups/23948119/856437899/name/Breathing%20pattern%20disorders%20and%20physiotherapy.pdf

«The potential for improving the patient’s state, by optimizing their breathing pattern in all their activities, is an important development in physiotherapy. It is a developing area of knowledge which is pertinent to physiotherapy practice as it develops in a biopsychosocial model. »

«Hyperventilation results in altered (CO2) levels, and this is most commonly seen as lowered end tidal CO2 (PET CO2), or fluctuating CO2 levels, and a slower return to normal CO2 levels.34 »

«Research by Hodges et al.56–58 examines the relationship between trunk stability and low back pain. It supports the vital role the diaphragm plays with respect to truck stability and locomotor control. The diaphragm has the ability to perform the dual role of respiration and postural stability. When all systems are challenged, however, breathing will remain as the final driving force.59

In other words ‘Breathing always wins’.60 »

hyperventilering faktorer

 

«Breathing re-education is drug free, appealing to the new paradigm of health for all, and a practice that requires little or no machinery so a low running cost, and initial set-up is minimal for the therapist. »