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.

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.

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.

Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses.

Denne sammenligner effekten av forskjellige behandlingsformer mot isjas og konkluderer med at f.eks. manipulering, akupunktur og anti-inflammatoriske biologiske midler (renger med dette inkluderer kosttilskudd) er en bedre løsning enn opioider, hvile, treningsterapi, m.m. Den sier også at kirurgi er en god løsning generelt, men ikke for smerte.

http://www.ncbi.nlm.nih.gov/pubmed/24412033

For overall recovery as the outcome, compared with inactive control or conventional care, there was a statistically significant improvement following disc surgery, epidural injections, nonopioid analgesia, manipulation, and acupuncture.

For pain as the outcome, epidural injections and biological agents were significantly better than inactive control, but similar findings for disc surgery were not statistically significant.

The findings support the effectiveness of nonopioid medication, epidural injections, and disc surgery. They also suggest that spinal manipulation, acupuncture, and experimental treatments, such as anti-inflammatory biological agents, may be considered. The findings do not provide support for the effectiveness of opioid analgesia, bed rest, exercise therapy, education/advice (when used alone), percutaneous discectomy, or traction.

Peripheral Nerve Entrapment and Injury in the Upper Extremity

Denne beskriver flere innklemningsnevropatier som kan oppstå i skuldre og armer.

Spesielt to prinsipper er smarte å ha med:

1: ved smerte eller svakhet i å løfte armen over hodet: suprascapular nerven

2: ved smerte eller svakhet i å skru inn en skrue: carpal tunnel eller pronator syndrom (median nerven)

http://www.aafp.org/afp/2010/0115/p147.html