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.

http://www.pain-ed.com/wp-content/uploads/2013/07/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