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

When pain is not only pain: Inserting needles into the body evokes distinct reward-related brain responses in the context of a treatment.

Denne beskriver hvordan smerte ikke alltid er smerte, at konteksten smerte gis i bestemmer hvordan det oppleves. Forklart med dry needling, så vil nåle-smerten være mindre smertefullt og oppleves positivt om det blir gitt i en kontekst som oppleves postivit vet at det er en del av behandlingsopplegget for å bli smertefri.

http://www.ncbi.nlm.nih.gov/pubmed/25528104

Abstract

The aim of this study was to compare behavioral and functional brain responses to the act of inserting needles into the body in two different contexts, treatment and stimulation, and to determine whether the behavioral and functional brain responses to a subsequent pain stimulus were also context dependent. Twenty-four participants were randomly divided into two groups: an acupuncture treatment (AT) group and an acupuncture stimulation (AS) group. Each participant received three different types of stimuli, consisting of tactile, acupuncture, and pain stimuli, and was given behavioral assessments during fMRI scanning. Although the applied stimuli were physically identical in both groups, the verbal instructions differed: participants in the AS group were primed to consider the acupuncture as a painful stimulus, whereas the participants in the AT group were told that the acupuncture was part of therapeutic treatment. Acupuncture yielded greater brain activation in reward-related brain areas (ventral striatum) of the brain in the AT group when compared to the AS group. Brain activation in response to pain stimuli was significantly attenuated in the bilateral secondary somatosensory cortex and the right dorsolateral prefrontal cortex after prior acupuncture needle stimulation in the AT group but not in the AS group. Inserting needles into the body in the context of treatment activated reward circuitries in the brain and modulated pain responses in the pain matrix. Our findings suggest that pain induced by therapeutic tools in the context of a treatment is modulated differently in the brain, demonstrating the power of context in medical practice.

What is the evidence that neuropathic pain is present in chronic low back pain and soft tissue syndromes? An evidence-based structured review.

Denne beskriver hvordan det er en nevropatis komponent i nesten all kronisk ryggsmerte og mykvevsmerte.

http://www.ncbi.nlm.nih.gov/pubmed/24118776

In each grouping, 100% of the studies reported some prevalence of NP (none reported zero prevalence).

The Enduring Impact of What Clinicians Say to People With Low Back Pain

Beskriver hvilken påvirkning ord har på pasienter. Spesielt når helsepersonell forteller at man på beskytte f.eks. ryggen ved ryggsmerter. Helsepersonells ideer om ryggsmerter smitter over på pasientene, derfor er det viktig at helsepersonell holder seg oppdatert på forskning, spesielt smerteforskning siden det er stort sett smerte folk kommer til behandling for.

http://www.annfammed.org/content/11/6/527.full

Many messages from clinicians were interpreted as meaning the back needed to be protected. These messages could result in increased vigilance, worry, guilt when adherence was inadequate, or frustration when protection strategies failed.

CONCLUSIONS Health care professionals have a considerable and enduring influence upon the attitudes and beliefs of people with low back pain. It is important that this opportunity is used to positively influence attitudes and beliefs.

The magnitude of nocebo effects in pain: A meta-analysis

Denne viser atnocebo effekten er like stor som placebo effekten.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4213146

The overall magnitude of the nocebo effect was moderate to large (lowest g = 0.62 (0.24-1.01) and highest g = 1.03 (0.63-1.43)) and highly variable (range of g = −0.43-4.05). The magnitudes and range of effect sizes was similar to those of placebo effects (d = 0.81) in mechanistic studies. In studies where nocebo effects were induced by a combination of verbal suggestions and conditioning, the effect size was larger (lowest g = 0.76 (0.39-1.14) and highest g = 1.17 (0.52-1.81)) than in studies where nocebo effects were induced by verbal suggestions alone (lowest g = 0.64 (−0.25-1.53) and highest g = 0.87 (0.40-1.34)). These findings are similar to those in the placebo literature. Since the magnitude of the nocebo effect is variable and sometimes large, this meta-analysis demonstrates the importance of minimizing nocebo effects in clinical practice.