Expression and role of connective tissue growth factor in painful disc fibrosis and degeneration
From: Spine. 2009 Mar 1;34(5):E178-82
Low back pain is a common clinical symptom, which will affect majority of the population at some time during the course of their lives. Although the causes of the low back pain remain unclear at present, theoretically, each structural component of the lumbar spine that is innervated, such as the vertebrae, intervertebral discs, facet joints, muscles and ligaments, may be the origin of low back pain. The degree of disc degeneration and the incidence of low back pain increase in parallel with age, suggesting that disc degeneration may be the main cause of low back pain. However, disc degeneration is common in patients without low back pain, particularly in those aged older than 50 years. Disc degeneration usually appears in magnetic resonance imaging (MRI) T2-weighted images as a decline in signal intensity, i.e., the so-called black disc. Both a normal aging disc and a pathologically painful disc appear as an area of decreased signal intensity on T2-weighted images. MRI cannot differentiate between these 2 disease entities. Many studies have reported regarding the histologic changes and the possible mechanisms underlying normal age-related disc degeneration. However, the main histologic changes and the exact molecular mechanisms underlying the painful pathologic disc remain unknown.
Recent researches have shown that connective tissue growth factor is the downstream effector mediated by transforming growth factor-β1, and is closely associated with the regulation of cell proliferation and differentiation and the fibrosis of tissues and organs, and can induce the in vivo expression of the gene involved with fibroblast extracellular matrix composition. This article reports the histologic findings of surgically excised specimens from patients with discogenic low back pain and studies the connective tissue growth factor expression and distribution in the disc, using immunohistochemical staining, with the aim of investigating the histologic characteristics of the painful pathologic disc, and exploring the role of connective tissue growth factor in painful disc degeneration.
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Chronic psoas syndrome caused by the inappropriate use of a heel lift
From: J Am Osteopath Assoc. 2008 Nov;108(11):629-30
Heel lifts are commonly recommended for patients to manage the pain and discomfort of leg length discrepancies. However, used inappropriately, orthotics can create additional pain instead of alleviating it. In the case described, a 79-year-old male physician used a recommended heel lift for a perceived leg length discrepancy after right hip arthroplasty. Six months postsurgery, chronic, intractable pain developed in his hip and groin. He underwent a battery of tests to locate the pain, but its source remained elusive. Osteopathic evaluation and radiographic examination revealed an absence of leg length discrepancy and the presence of chronic psoas syndrome. Osteopathic manipulative treatment was prescribed and heel lift therapy discontinued, and the patient reported complete remission from pain.
Leg length discrepancies contribute to myriad conditions in patients, including low back pain, knee pain, and abnormal gait. Such discrepancies, which can occur naturally or postsurgically, can often be resolved through the use of heel lifts. However, used inappropriately, these corrective devices can worsen—or even cause—leg length discrepancies, leading to somatic dysfunction. Although leg length discrepancies have not been reported previously in the medical literature as contributing to psoas syndrome, the current case illustrates the use of inappropriate heel lifts to be a plausible, underlying factor in the occurrence of this chronic condition.
Psoas syndrome can be defined as a muscular imbalance, strain, spasm, tendonitis, or flexion contracture of the iliopsoas muscle (consisting of the iliac and psoas major). This syndrome may result in a number of symptoms including:
- flexion deformity of the leg on the affected side
- increased pain when standing or walking
- lordosis when supine
- nonneutral somatic dysfunction of the lumbar vertebra 1 or 2 (L1 or L2)
- pain in the lower back, pain radiating anteriorly toward the groin, or both
- pelvic shift to the opposite side
- point tenderness medial to the ASIS or femoral triangle
- psoatic gait
- sacral dysfunction on an oblique axis
- spasm of the contralateral piriformis muscle
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Head and neck control varies with perturbation acceleration but not jerk: Implications for whiplash injuries
From: J Physiol. 2009 Feb 23. [Epub ahead of print]
Recent studies have proposed that a high rate of acceleration onset, i.e., high jerk, during a low speed vehicle collision increases the risk of whiplash injury by triggering inappropriate muscle responses and/or increasing peak head acceleration. Our goal was to test these proposed mechanisms at realistic jerk levels and to then determine how collision jerk affects the potential for whiplash injuries. Twenty-three seated volunteers (8F, 15M) were exposed to multiple experiments involving perturbations simulating the onset of a vehicle collision in both eyes open and eyes closed conditions. In the first experiment, subjects experienced 5 forward and 5 rearward perturbations to look for the inappropriate muscle responses and “floppy” head kinematics previously attributed to high jerk perturbations. In the second experiment, we independently varied the jerk and acceleration of the perturbation to assess their effect on the electromyographic responses of the sternocleidomastoid, scalene and cervical paraspinal muscles and the kinematic responses of the head and neck. In the first experiment, we found neither inappropriate muscle responses nor floppy head kinematics when subjects had their eyes open, but observed two subjects with floppy head kinematics with eyes closed. In the second experiment, we found that about 70% of the variations in the sternocleidomastoid and scalene responses and about 95% of the variations in head/neck kinematics were explained by changes in perturbation acceleration in both the eyes open and eyes closed conditions. Less than 2% of the variation in the muscle and kinematic responses was explained by changes in perturbation jerk and, where significant, response amplitudes diminished with increasing jerk. Based on these findings, collision jerk appears to have little or no role in the genesis of whiplash injuries in low speed vehicle crashes.
The immediate effects of mobilization technique on pain and range of motion in patients presenting with unilateral neck pain
From: Arch Phys Med Rehabil. 2009 Feb;90(2):187-92
The objective of this study was to determine the immediate effects on both pain and active range of motion of the unilateral posteroanterior mobilization technique on the painful side in mechanical neck pain patients presenting with unilateral symptoms. This was a triple-blind, randomized controlled trial in an outpatient physical therapy, institutional clinic. Patients (N=60), 2 physical therapists, and 1 assessor involved in this study. The patients were randomly allocated into either preferred or random mobilization group by using an opaque concealed envelope. The first therapist performed the screening, assessing, prescribing the spinal level(s), and the grade of mobilization. The second therapist performed the mobilization treatment according to their allocated group stated in an envelope. The assessor who was blind to the group allocation conducted the measurements of pain and active cervical range of motion.
Pain intensity, active cervical range of motion, and global perceived effect were measured at baseline and 5 minutes posttreatment. After mobilization, there were no apparent differences in pain and active cervical range of motion between groups. However, within-group changes showed significant decreases in neck pain at rest and pain on most painful movement with a significant increase in active cervical range of motion after mobilization on most painful movement. The results of this study did not provide support for the preference of the unilateral posteroanterior mobilization on the painful side to the random mobilization.
Qigong and Exercise Therapy for Elderly Patients With Chronic Neck Pain
From: J Pain. 2009 Feb 20. [Epub ahead of print]
The aim of this study was to evaluate the effectiveness of qigong compared with exercise therapy and no treatment. Elderly patients with chronic neck pain (>6 months) were randomly assigned to qigong or exercise therapy (each 24 sessions over a period of 3 months) or to a waiting list control. Patients completed standardized questionnaires at baseline and after 3 and 6 months. The main outcome measure was average neck pain on the visual analogue scale after 3 months. Secondary outcomes were neck pain and disability and quality of life. One hundred seventeen patients (age, 76 +/- 8 years, 95% women) were included in the intention-to-treat analysis. The average duration of neck pain was 19.0 +/- 14.9 years. After 3 months, no significant differences were observed between the qigong group and the waiting list control group or between the qigong group and the exercise therapy group. Results for the neck pain and disability were similar. We found no significant effect after 3 months of qigong or exercise therapy compared with no treatment. Further studies should include outcomes more suitable to elderly patients, longer treatment, and patients with less chronic pain.
In a randomized controlled study, this study evaluated whether a treatment of 24 qigong sessions over a period of 3 months is (1) superior to no treatment and (2) superior to the same amount of exercise therapy in elderly patients (age, 76 +/- 8 years, 95% women) with long-term chronic neck pain (19.0 +/- 14.9 years). After 3 and 6 months, they found no significant differences for pain, neck pain, disability, and quality of life among the 3 groups.
This study is in contrast with Qigong and exercise for neck pain from a study in Spine. 2007;32:2415-2422 which indicated improvement in neck pain was significant (> 50%) in both groups (qigong or exercise therapy) immediately after treatment, and this was maintained at 6 and 12 month follow-ups in 5 of 8 outcome variables.
Abnormal resting-state cortical coupling in chronic tinnitus
From: BMC Neurosci. 2009 Feb 19;10(1):11. [Epub ahead of print]
Patients that suffer from chronic tinnitus complain of an ongoing perception of a phantom sound in the absence of any physical source for it. About 5-15 % of the population in western societies experience a phantom tinnitus sound and 1-3% of the population suffer from severe tinnitus that affects their daily life and is accompanied in 50 % of the cases by depression, in 40 % of the cases by insomnia and about 20% of the patients complain of an important decrease in their quality of life. Unfortunately, the underlying mechanisms responsible for the tinnitus perception is currently not known. Tinnitus therapies typically concentrate on coping with the tinnitus but there is no therapy that reliably reduces the perception of tinnitus.
Tinnitus is often accompanied by damage to the peripheral hearing system and a series of plastic changes in the central auditory system are observed in parallel to that. It is thought that a deafferentation of the hearing system triggers a series of reorganization processes at all levels of the auditory system. Indeed, abnormal neuronal activity in tinnitus has been demonstrated for the auditory nerve fibers, the dorsal cochlear nucleus, the inferior colliculus, the primary and the secondary auditory cortex. Furthermore, it has been found that a dissection of the auditory nerve in tinnitus patients does not lead to relief in tinnitus and most of the patients still experience tinnitus after surgery. Thus, there is an agreement that the tinnitus phantom sound is generated in the central nervous system – most likely as a result of the reorganization that is going on in the auditory system after hearing loss.
However, there are also studies that demonstrated tinnitus-related cortical abnormalities outside the auditory system. Using methods as different as Positron Emission Tomography (PET), Voxel Based Morphometry (VBM) and Magnetoencephalography (MEG) differences in cortical activity have been shown for the frontal cortex, the parietal lobe, mesial posterior regions and the subcollosal region including the nucleus accumbens. As hypothesized earlier by Jastreboff it might be that tinnitus is generated within the auditory system while non-auditory regions are involved in encoding the conscious percept well as the emotional evaluation of it. This idea also fits with a recently established model of the global neuronal workspace by Deheane and colleagues. This group suggests the existence of workspace neurons that are located mainly in the parietal lobe, the frontal, the cingulate cortex and the sensory systems. In order to form a conscious percept of a stimulus, two conditions are required: First, neuronal activity of the sensory cortex of the respective modality. Second, an entry into the global neuronal workspace and thus long-range coupling between the widely distributed workspace neurons. According to this model, coupling within this frontoparietal-cingulate network is needed for conscious perception (i.e. awareness of the stimulus). Activity of the sensory areas without this coupling would remain preconscious.
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Recovery in Whiplash Associated Disorders: Do You Get What You Expect?
From: J Rheumatol. 2009 Feb 17. [Epub ahead of print]
Positive expectations predict better outcome in a number of health conditions, but the role of expectations in predicting health recovery after injury is not well understood. We investigated whether early expectations of recovery in whiplash associated disorders predict subsequent recovery, and studied the role of “expectations” to predict recovery as determined by pain cessation and resolution of pain-related limitations in daily activities.
A cohort of 6,015 adults with traffic-related whiplash injuries was assessed, using multivariable Cox proportional hazards analysis, for association between these expectations and self-perceived recovery over a 1-year period following the injury. Recovery was assessed using 3 indices: self-perceived global recovery (primary outcome); resolution of neck pain severity; and resolution of pain related limitations in daily activities.
After adjusting for the effect of sociodemographic characteristics, post-crash symptoms and pain, prior health status and collision related factors, those who expected to get better soon recovered over 3 times as quickly as those who expected that they would never get better. Findings were similar for resolution of pain related limitations and resolution of neck pain intensity, although the effect sizes for the latter outcome were smaller.
Patients’ early expectations for recovery are an important prognostic factor in recovery after whiplash injury, and are potentially modifiable. Clinicians should assess these expectations in order to identify those patients at risk of chronic whiplash, and future studies should focus on the effect of changing these early expectations.
Disability and related factors in patients with chronic cervical myofascial pain
From: Clin Rheumatol. 2009 Feb 18. [Epub ahead of print]
Neck pain is a major causal factor leading to disability loss of work days. One of the common causes of neck pain in the general population is myofacial pain syndrome. Myofacial pain is found in over 35% of individuals who have musculoskeletal complaints and is characterized by the presence of regional pain and painful trigger points in a taught band of muscle which produces patterns of pain referral on palpation in areas of neck strain.
The global estimate of disability may not be the most appropriate outcome measure for neck pain population. Measures of symptom severity and patient reported questionnaires have been advocated as the optimal methods of evaluating the effect of neck pain on the patient and in monitoring change over time. A number of studies have investigated the direct relationships among neck pain impairments and disability. But disability has not been evaluated and associated factors in a homogeneous patient group which includes only cervical myofascial pain patients using neck specific disability scales such as the Neck Pain and Disability Scale.
The aim of this study is to detect whether cervical myofascial pain leads to disability and to determine factors associated with disability in patients with chronic cervical myofascial pain. One hundred-three female patients with chronic cervical myofascial pain and 30 age-matched healthy females participated. Main outcome measurements are visual analog scale, Neck Pain and Disability scale, Beck Depression Inventory and pain pressure threshold measurements from the most usual trigger-point locations of trapezius, levator scapula, multifidus, and splenius capitis muscles.
The Neck Pain and Disability scale and Beck Depression Inventory scores of the patient group were higher than controls. In the patient group, the total Neck Pain and Disability scale scores were significantly correlated with the pain pressure threshold values of the trapezius and levator scapula muscles and Beck Depression Inventory scores. Regression analyses showed that increased disease duration, decreased pain pressure threshold values of trapezius muscle, unilateral disease and increased Beck Depression Inventory scores were associated with higher disability. Cervical myofascial pain is a reason for disability in chronic neck pain population. Disease duration was found as the strongest predictor of disability.
Low back pain: prevalence and associated risk factors among hospital staff
From: J Adv Nurs. 2009 Mar;65(3):516-524
This paper is a report of a study conducted to describe the prevalence and risk factors for lower back pain amongst a variety of Turkish hospital workers including nurses, physicians, physical therapists, technicians, secretaries and hospital aides.
Hospital workers experience more low back pain than many other groups, the incidence varies among countries. Work activities involving bending, twisting, frequent heavy lifting, awkward static posture and psychological stress are regarded as causal factors for many back injuries.
A 44-item questionnaire was completed by 1600 employees in six hospitals associated with one Turkish university using a cross-sectional survey design. Data were collected over nine months from December 2005 to August 2006 and analysed using Chi square and multivariate logistic regression techniques.
Most respondents (65.8%) had experienced low back pain, with 61.3% reporting an occurrence within the last 12 months. The highest prevalence was reported by nurses (77.1%) and the lowest amongst secretaries (54.1%) and hospital aides (53.5%). In the majority of cases (78.3%), low back pain began after respondents started working in the hospital, 33.3% of respondents seeking medical care for ‘moderate’ low back pain while 53.8% (n = 143) had been diagnosed with a herniated lumbar disc. Age, female gender, smoking, occupation, perceived work stress and heavy lifting were statistically significant risk-factors when multivariate logistic regression techniques were conducted.
Preventive measures should be taken to reduce the risk of lower back pain, such as arranging proper rest periods, educational programmes to teach the proper use of body mechanics and smoking cessation programmes.
Disc prolapse: evidence of reversal with repeated extension
From: Spine. 2009 Feb 15;34(4):344-50
Numerous studies have investigated the loading mechanisms necessary to cause disc failure. Collectively, this work suggests that repeated forward bending causes stresses both in the nucleus and in the anulus resulting in prolapse and herniation. Repeated extension is a treatment used by manual therapists as it is thought to assist in returning the displaced portion of the nucleus back towards the center of the disc. This study was designed to enhance understanding of this possible mechanism.
McKenzie proposed that the direction of spine movement that centralizes radiating symptoms precisely corresponds with the direction in which a portion of the nucleus has abnormally migrated. Further, successful centralization is dependant on a hydrostatically intact nucleus that is contained within the outer anulus. Donelson et al reported that patients, who could not achieve centralization of symptoms as a result of repeated movements, did not respond well to conservative therapy and generally had a poor treatment outcome. Subsequently, Donelson et al investigated the theory that centralization is dependent on a competent anulus (the outer border not breached) by investigating the correlation of the McKenzie classification of the symptom response to movement, to whether or not the anulus was competent, as determined by discogram. Ninety-one percent of those that centralized had an intact anulus suggesting possible grounds for this component of the McKenzie theory.
From a biomechanical perspective, the McKenzie explanation seems possible. Flexion postures cause an increase in the hydraulic stress (flow-related) on the posterior anulus, and a large increase in the in vivo nuclear pressure (static). Supporting this argument, Aultman et al, repeatedly flexed specimens where the flexion axis was moved 30° to the left of the sagittal plane. Herniations were developed in the right postero-lateral portion of the disc. Thus, the site of the nucleus breach of the inner anulus was determined by the bending axis, and subsequent stress distribution, a finding also reported by Tsantrizos et al. Tampier et al further elucidated the herniation process by documenting the formation of small clefts in between the layers of the anulus through which the nucleus pulposus was pumped. In this way, the herniation progressed layer by layer as the anulus fibers delaminated to allow flow through small separations between anulus collagen fibers.
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