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.

Interpreting change scores for pain and functional status in low back pain: towards international consensus regarding minimal important change.

Denne nevner at for å kunne kalle en behandling for «klinisk relevant» så må man kunne se en 30% forbedring fra utgangspunktet når man måler før-og-etter hos pasienten. For 0-10 skalaen som vi ofte bruker vil disse forfatterene regne en forbedring på 2 punkter som klinisk relevant. Om vi bruker 0-5 vil egentlig en endring på 1,5 være riktig, men sannsynligvis bedre å forholde seg til en endring på 2 punkter da, som blir 40%.

http://www.ncbi.nlm.nih.gov/pubmed/18165753/

Proposed MIC values are: 15 for the Visual Analogue Scale (0-100), 2 for the Numerical Rating Scale (0-10), 5 for the Roland Disability Questionnaire (0-24), 10 for the Oswestry Disability Index (0-100), and 20 for the QBDQ (0-100). When the baseline score is taken into account, a 30% improvement was considered a useful threshold for identifying clinically meaningful improvement on each of these measures.

For a range of commonly used back pain outcome measures, a 30% change from baseline may be considered clinically meaningful improvement when comparing before and after measures for individual patients.

A CLASSIFICATION-BASED COGNITIVE FUNCTIONAL APPROACH FOR THE MANAGEMENT OF BACK PAIN

Denne beskriver et ganske så komplett opplegg for behandling og undervisning av klienter med nesten alle typer muskel og leddplager.

Click to access OSullivanIFOMPT-Oct2012.pdf

Pathoanatomical factors: F.eks. funn på røntgen og MRI, som spiller liten rolle i kroniske muskel og leddplager.

Physical factors: muskelspenning og bevegelsesmønster endres ved smertetilstander. F.eks. kjermuskulatur spenner seg mer i bevegelser hos smertepasienter.

Lifestyle factors: interessant at mat og kosthold er det eneste av livsstilsfaktorer som ikke nevnes på denne listen. Ellers er trening, stress, søvn, røyk, overvekt, m.m. med.

Cognitive and psychosocial factors: angst, depresjon, frykt, katastrofering, og særlig ideen om at (f.eks.) ryggen må beskyttes pga smertene.

Social factors: trivsel i jobb, familie, forhold, og livssituasjon.

Neurophysiological factors: endringer i hjernen, som f.eks. mindre går materie, økt hjerneaktivitet i hvile, endres kroppsbilde, mindre nedregulering av smerte.

Individual factors: mål med behandling, forventninger, grunnleggende helsekunnskap, m.m.

Genetic factors: Visse gener gir økt disponering for smertetilstander.

Jeg likte spesielt dette sitatet:

Manual therapy is only used as a window of opportunity to change behaviors where movement impairments are present.

Placebo effects in trials evaluating 12 selected minimally invasive interventions: a systematic review and meta-analysis

Helt ny studie som har gjennomgått placebokontrollerte studier av kirurgi og konkluderer med at placebokirurgi ikke er etisk utfordrende siden reell kirurgi uansett ikke har noen særlig bedre effekt. Og komplikasjonene er ikke større ved placebokirurgi heller.

http://bmjopen.bmj.com/content/5/1/e007331.full

Conclusions The generally small differences in ES between active treatment and sham suggest that non-specific mechanisms, including placebo, are major predictors of the observed effects. Adverse events related to sham procedures were mainly minor and short-lived. Ethical arguments frequently raised against sham-controlled trials were generally not substantiated.

 

Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: a systematic review of randomized clinical trials

Denne har sammenlignet mange forskjellige behandingsformer, både aktive og passive og medikamenter, mot korsryggplager og sett at neste alle følger samme behandlingsrespons kurve.

http://rheumatology.oxfordjournals.org/content/49/12/2346.long

Overall response to treatment in clinical trials, cohorts or clinical practice, is not only influenced by the active or specific components of the treatment, but can also be influenced by various other factors. Some of these factors relate to characteristics of the pain problem (as described above), or to the patients themselves [36] such as their beliefs, expectations and experiences with other illnesses, previous episodes of the illness or with previous use of the current treatment or other treatments [37].

An important finding from our review is the large response to treatment common in all trial arms, active as well as placebo, usual care or waiting list arms. It seems ironic that we clearly have evidence for a large overall improvement in back pain symptoms in all arms of clinical trials, while more and more trials are unable to show clear evidence for the effectiveness of the active treatments.

Immediate effects from manual therapy: much ado about nothing?

Her diskuteres hvordan et stort antall behandlingsteknikker gir umiddelbare resultater, men at disse umiddelbare resultatene ikke nødvendigvis gir langvarige og kliniske resultater. Mange blir glade når studier viser en umiddelbar bedring i f.eks. smerte etter en korsryggmanipulasjon, men vi må være oppmerksomme på at denne ummidelbare bedringen ikke alltid er en langvarig effekt. Og vi må også være oppmerksom på at svært mange behandlingsteknikker gir slike resultater. Alt fra laser til menipulering. Den ene er hverken bedre eller dårligere enn den andre.

Jeg mener vi må ta de umiddelbare effektene for det de er; umiddelbare effekter, og bruke dem for det de er verdt. Det gir et overraskelsesmoment og håp når man kjenner at smerten blir mindre og funksjonen bedre. Man kan bruke det for å vise at smerten KAN reduseres. Men ikke la de stå iveien for det som trengs for langvarige resultater, som livsttilsendringer (trening, mat, stress, søvn, osv) og livssituasjonsendringer (jobb, forhold, hjem, osv.)

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3172950/

The measurable treatment effect may take many forms. Within the last few years, immediate effects of thrust and non-thrust manipulation have been shown to: improve proprioception,1 standing balance,2reduce pain,3,4 increase nociceptive flexion reflex threshold,5 thermal pain sensitivity (temporal summation),6 provide a widespread hypoalgesic effect,7 improve range of motion,4,8 alter EMG signals,9and modify sensorimotor integration.10 In fairness, the studies represented here were both mechanistic- and clinically-oriented.

But before we get too excited about these results, let’s look at literature outside main-stream manual therapy, because thrust and non-thrust manipulation aren’t alone in their ability to provide immediate measurable treatment effects.

Immediate effects have been reported with superficial heat, long-wave ultrasound, short-wave diathermy, and specific exercises.11 In addition, immediate effects have been identified using massage,12 kinesio-taping,13 passive physiological movements,14 acupressure,15,16 ischemic compression,17 thermal ultrasound,18 simple touch,19 ice massage,20 and strain–counterstrain.21 Even more notable and dubious are the immediate effects findings of improved active mouth opening after hamstring stretching,22improved hamstring mobility after suboccipital stretching,23 and improved spatial cognitive tasking after breathing through the left nostril only.24

 

We know the carry-over effect of some immediate findings (within-session changes) lead to between-session changes,26but there is little to support these changes having any effect on long-term functional outcome.2628

 

 

Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study)

Denne viser hvordan det vi ser på MRI av kne som ofte ansees som medisinske funn egentlig er aldringstegn og helt normale, og med svært liten relasjon til smerte. Den viser også at det er lite sammenheng mellom BMI (fedme) og artrose sett på MRI.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3430365/

The higher the age, the higher the prevalence of all types of abnormalities detectable by MRI. There were no significant differences in the prevalence of any of the features between BMI groups. The prevalence of at least one type of pathology (“any abnormality”) was high in both painful (90-97%, depending on pain definition) and painless (86-88%) knees.

MRI shows lesions in the tibiofemoral joint in most middle aged and elderly people in whom knee radiographs do not show any features of osteoarthritis, regardless of pain.

Fig 2 Knee with multiple abnormalities on MRI indicating early stage osteoarthritis despite lack of radiographic osteoarthritis. A: coronal fat suppressed proton density weighted image shows several features of early OA detectable only by MRI. White arrowhead shows focal full thickness cartilage defect at central weight bearing part of medial femur. In addition there is adjacent subchondral bone marrow lesion presenting as area of ill defined hyperintensity (arrows). Black arrowheads show meniscal extrusion at medial joint line causing bulging of neighbouring medial collateral ligament (no arrow). B: sagittal proton density weighted image shows isolated degenerative horizontal oblique tear of posterior horn of medial meniscus extending to undersurface of meniscus adjacent to posterior tibial surface (arrows). No associated cartilage damage or subchondral bony alterations are seen

Discussion

We found that MRI detected features of osteoarthritis are highly prevalent in the tibiofemoral joint of knees that did not have any radiographic features of osteoarthritis in participants both with and without knee pain. Nearly 90% of our participants had at least one feature of osteoarthritis on MRI. Osteophytes were the most common, followed by cartilage damage and bone marrow lesions. In general, the older the age group, the higher the prevalence of features of osteoarthritis, although differences among age groups were not significant for synovitis and effusion and of borderline significance for ligamentous lesions and bone marrow lesions. Only meniscal lesions were more prevalent in men than women. No significant differences were observed for any type of lesions by BMI.

Our data showed that the prevalence of these MRI detected features is high irrespective of the knee pain status. When we compared the prevalence of MRI abnormalities in knees in people with and without pain, there were two trends. Firstly, and most importantly, the prevalence of MRI findings was extremely high in those without pain, suggesting that using MRI as a diagnostic test for people with normal knee radiographs in this age group would have poor specificity. Secondly, the prevalence of findings was modestly higher in those with pain than in those without, with the difference sometimes reaching significance. These differences, however, were not particularly informative—for example, the highest prevalence of MRI abnormalities was actually in those with mild pain rather than moderate or severe pain.

We did not find high BMI to be associated with higher prevalence of MRI features overall compared with low BMI, but rather that these MRI abnormalities were equally highly prevalent in all BMI groups. We speculate that BMI is important for progression of later stages of osteoarthritis, but potentially age is a much more relevant trigger of early stages of osteoarthritis.

It is important for the clinical community to recognise that findings that would be interpreted as abnormal and suggestive of disease are in fact present in most knees without any pain, even when different definitions of pain are used. That means that the clinical significance of these MRI findings is questionable. The same message has been reported for radiographic findings in patients with low back pain (similar highly prevalent abnormalities were seen in those without low back pain), and this led to discouraging radiographic evaluations in those with low back pain.35

Conclusions

Changes indicative of osteoarthritis are commonly present in the knees of most people aged 50 and over who have no radiographic evidence of tibiofemoral osteoarthritis. Osteophytes, cartilage damage, and bone marrow lesions are especially common among middle aged and older people. These features are common in knees with pain and in those that are painless and can potentially represent pre-radiographic or early stage osteoarthritis. A longitudinal study is needed to determine what proportion of people without radiographic osteoarthritis but with MRI abnormalities subsequently develop radiographic osteoarthritis.

Guideline for diagnosis and treatment of subacromial pain syndrome

Beskriver det meste om behandling av innklemninger som fører til smerter når man løfter armen. Alle studier på behandling har blitt gradert med «level of evidence», hvor 1 er best. Operative inngrep har fått evensgrad 3, altså svært dårlig, selv når det er snakk om Rotator Cuff Tear.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4062801/

1. A diagnosis of SAPS can only be made after a combination of tests; the Hawkins-Kennedy test, the painful arc test, and the infraspinatus muscle strength test are advisable.

5. Prescribe therapy or home exercises of low intensity and high frequency, combining eccentric training with stabilization training of the scapula and focusing on relaxation and proper posture.

6. Treatment of myofascial trigger points (including stretching of the muscles) can support exercise therapy.

Psychosocial factors in the workplace–do they predict new episodes of low back pain? Evidence from the South Manchester Back Pain Study.

Studie fra 1997 som forteller at å være misfornøyd med arbeidssituasjonen sin gir dobbelt så stor sjangse for ryggsmerter enn om man er fornøyd med arbeindssituasjonen.

http://www.ncbi.nlm.nih.gov/pubmed/9160473/

Abstract

STUDY DESIGN:

A prospective, population-based cohort study of working adults.

OBJECTIVES:

To determine whether work-related psychosocial factors and social status predict the occurrence of new episodes of low back pain and influence consultation behavior.

SUMMARY AND BACKGROUND DATA:

Dissatisfaction with work and social status has been associated with low back pain in several studies; few of these studies have been prospective or population based.

METHODS:

An initial postal survey was returned by 4,501 (59%) adults (18-75 years old) registered with two primary care practices. From this, a cohort of 1,412 people currently in employment and free of low back pain was identified, and baseline information on work-related psychosocial factors and psychologic distress was obtained. Social class was derived from current occupation using a standardized classification. New episodes of low back pain occurring in the next 12 months were identified by continuous monitoring of primary care consulters and by mailing a second questionnaire a year later to identify occurrences of low back pain for which no consultation was sought.

RESULTS:

The baseline cross-sectional survey showed modest but significant associations between low back pain and perceived inadequacy of income (risk ratio 1.3), dissatisfaction with work (risk ratio 1.4) and social class IV/V (risk ratio 1.2). In the follow-up year, the risk of reporting low back pain for which no consultation was sought doubled in those dissatisfied with their work. Both perceived inadequacy of income (odds ratio 3.6) and social class IV/V (odds ratio 4.8) were strongly associated with consulting with a new episode of low back pain during the follow-up year, an association more marked in women. The associations with work dissatisfaction and perceived adequacy of income were not explained by general psychologic distress or social status.

CONCLUSION:

People dissatisfied with work are more likely to report low back pain for which they do not consult a physician, whereas lower social status and perceived inadequacy of income are independent risks for working people to seek consultation because of low back pain.

The meaning of mechanically produced responses

Fra 1994, forskeren Max Zusman. Nevner veldig mange interessante perspektiver på hvordan mekanisk stimuli (percussor, DNM, SI, osv) demper smerte.

http://www.sciencedirect.com/science/article/pii/S0004951414604529

Abstract: The precise source and cause of mechanically evoked sensory and motor responses can sometimes be surprisingly difficult to identify. Accurate interpretation of these responses may be confounded by peripheral as well as central nervous system mechanisms. Examples of such peripheral nervous system mechanisms likely to be of relevance to therapists have been selected from basic and clinical research. Symptomatic relief has been inferred to endorse the diagnostic specificity of mechanical stimulation. The extent to which this would be valid for relief acquired by neurological means is discussed in terms of endogenous pain inhibitory systems

Some degree of local inhibition with mechanical stimuli delivered directly to a pathological site may be mainly a consequence of supplementary input in large diameter cutaneous afferents. Unlike those afferents supplying deep tissue such as joint, muscle etc., small diameter cutaneous afferents appear to be largely impervious to mechanical sensitisation by chemical mediators of the inflammatory response (Handwerker and Reeh 1991).

Therefore, mechanical stimulus parameters which maximise large diameter afferent input from the skin and at the same time minimise sensitised small diameter afferent input from deep tissue such as joint, muscle etc. would be therapeutically effective

Spontaneously occurring clinically relevant symptoms and signs are ultimately a product of both peripheral and central nervous system mechanisms. As  such, they are complexly derived and displayed. Their true origin and significance are sometimes obscure and liable to misinterpretation. Rather than being invariably diagnostically definitive, provocative mechanical manoeuvres can compound these uncertainties. The provocative mechanical manoeuvres used by therapists are, neurologically speaking, relatively crude. They do not have the necessary specificity to always distinguish between pathologically and non pathologically involved tissues and sites, Since their specific systemic effects have not been investigated,  the responses produced with such stimuli are subject to variously influenced and informed interpretation.

The reasons for symptomatic relief produced asa result of these mechanical manoeuvres are not known for certain. Neurologically, this appears to involve inhibitions in the central nervous system. Input conveyed centrally by different classes of primary afferents stimulated at a variety of sites has the potential to produce therapeutically effective inhibitions. Mechanical provocation can confirm the presence of clinically relevant sensory and motor responses. However, understanding what these responses might actually mean in terms of their source and cause would frequently require additional input from the basic sciences.