Soft tissue determinants of low back pain

The Specifics of Non-specific Low Back Pain: Re-evaluating the Current Paradigm to Improve Patient Outcomes

Low back pain (LBP) is the leading cause of pain and debility worldwide and the most frequent reason for work-related disability. Global expenditures related to LBP are staggering and amount to billions of dollars each year in the United States alone. Yet, despite the considerable healthcare resources consumed, the care provided to patients with LBP has regularly been cited as both ineffective and exorbitant. Among the myriad reasons for this suboptimal care, the current approach to evaluation and management of patients with LBP is a likely contributor and is hitherto un-investigated. Following the current methodology, over 90% of patients with LBP are provided with no specific diagnosis, are managed inconsistently, and receive no express preventative care. We believed that this approach added costs and promoted chronic unresolved pain and disability. This narrative review highlights problems with the current methodology, proposes a novel concept for categorizing patients with LBP, and recommends strategies for improvement. Stratifying patients according to the etiology, in lieu of the prospects for morbidity, the strategy proposed in this article may help ascertain the cause of patient's LBP early, consolidate treatments, permit timely preventative measures, and, as a result, may improve patient outcomes.

Differential Diagnosis in a Patient Presenting With Both Systemic and Neuromusculoskeletal Pathology: Resident's Case Problem

Study Design Resident's case problem. Background Patients presenting with multiple symptomatic areas pose a diagnostic challenge for the physical therapist. Though musculoskeletal and nonmusculoskeletal symptoms typically present separately, they can occur simultaneously and mimic each other. Consequently, the ability to differentiate between musculoskeletal and nonmusculoskeletal symptoms is an important skill for physical therapists. The purpose of this resident's case problem was to describe the clinical-reasoning process leading to medical and physical therapy management of a patient presenting with upper and lower back pain, bilateral radiating arm and leg pain, and abdominal pain. Diagnosis The patient was a 30-year-old woman referred to physical therapy for upper and lower back pain. A detailed history and thorough examination revealed that the patient had signs and symptoms consistent with a possible abdominal aortic aneurysm. She was referred for medical management and was diagnosed with symptomatic cholelithiasis. She subsequently had a cholecystectomy, which ultimately resolved her abdominal pain and reduced her pain in other areas significantly. Although many of her symptoms resolved postoperatively, her pain in other areas remained and was potentially musculoskeletal in origin. Following re-evaluation and 3 physical therapy treatments over a 2-month period, she was relatively symptom free at discharge and had achieved all functional rehabilitation goals. Discussion This resident's case problem provides an opportunity to discuss the differential diagnosis, clinical reasoning, and outcome of a patient who presented with both systemic and neuromusculoskeletal pathology. Level of Evidence Differential diagnosis, level 5. J Orthop Sports Phys Ther 2018;48(6):496-503. Epub 6 Feb 2018. doi:10.2519/jospt.2018.7652.

Osteopathic Manipulative Treatment Including Specific Diaphragm Techniques Improves Pain and Disability in Chronic Nonspecific Low Back Pain: A Randomized Trial

OBJECTIVE

To investigate the effects of an osteopathic manipulative treatment (OMT), which includes a diaphragm intervention compared to the same OMT with a sham diaphragm intervention in chronic nonspecific low back pain (NS-CLBP).

DESIGN

Parallel group randomized controlled trial.

SETTING

Private and institutional health centers.

PARTICIPANTS

Participants (N=66) (18-60y) with a diagnosis of NS-CLBP lasting at least 3 months.

INTERVENTIONS

Participants were randomized to receive either an OMT protocol including specific diaphragm techniques (n=33) or the same OMT protocol with a sham diaphragm intervention (n=33), conducted in 5 sessions provided during 4 weeks.

MAIN OUTCOME MEASURES

The primary outcomes were pain (evaluated with the Short-Form McGill Pain Questionnaire [SF-MPQ] and the visual analog scale [VAS]) and disability (assessed with the Roland-Morris Questionnaire [RMQ] and the Oswestry Disability Index [ODI]). Secondary outcomes were fear-avoidance beliefs, level of anxiety and depression, and pain catastrophization. All outcome measures were evaluated at baseline, at week 4, and at week 12.

RESULTS

A statistically significant reduction was observed in the experimental group compared to the sham group in all variables assessed at week 4 and at week 12 (SF-MPQ [mean difference -6.2; 95% confidence interval, -8.6 to -3.8]; VAS [mean difference -2.7; 95% confidence interval, -3.6 to -1.8]; RMQ [mean difference -3.8; 95% confidence interval, -5.4 to -2.2]; ODI [mean difference -10.6; 95% confidence interval, -14.9 to 6.3]). Moreover, improvements in pain and disability were clinically relevant.

CONCLUSIONS

An OMT protocol that includes diaphragm techniques produces significant and clinically relevant improvements in pain and disability in patients with NS-CLBP compared to the same OMT protocol using sham diaphragm techniques.

Effects of Myofascial Release in Nonspecific Chronic Low Back Pain: A Randomized Clinical Trial

STUDY DESIGN

Double-blind, randomized parallel sham-controlled trial with concealed allocation and intention-to treat analysis.

OBJECTIVE

To investigate the effects of an isolate myofascial release (MFR) protocol on pain, disability, and fear-avoidance beliefs in patients with chronic low back pain (CLBP).

SUMMARY OF BACKGROUND DATA

MFR is a form of manual medicine widely used by physiotherapists in the management of different musculoskeletal pathologies. Up to this moment, no previous studies have reported the effects of an isolated MFR treatment in patients with CLBP.

METHODS

Fifty-four participants, with nonspecific CLBP, were randomized to MFR group (n = 27) receiving four sessions of myofascial treatment, each lasting 40 minutes, and to control group (n = 27) receiving a sham MFR. Variables studied were pain measured by means Short Form McGill Pain Questionnaire (SF-MPQ) and visual analog scale (VAS), disability measured with Roland Morris Questionnaire, and fear-avoidance beliefs measured with Fear-Avoidance Beliefs Questionnaire.

RESULTS

Subjects receiving MFR displayed significant improvements in pain (SF-MPQ) (mean difference -7.8; 95% confidence interval [CI]: -14.5 to -1.1, P = 0.023) and sensory SF-MPQ subscale (mean difference -6.1; 95% CI: -10.8 to -1.5, P = 0.011) compared to the sham group, but no differences were found in VAS between groups. Disability and the Fear-Avoidance Beliefs Questionnaire score also displayed a significant decrease in the MFR group (P < 0.05) as compared to sham MFR.

CONCLUSION

MFR therapy produced a significant improvement in both pain and disability. Because the minimal clinically important differences in pain and disability are, however, included in the 95% CI, we cannot know whether this improvement is clinically relevant.

LEVEL OF EVIDENCE

2.

Das myofasziale Schmerzsyndrom

Hintergrund

Schmerzen und/oder Funktionsstörungen, wie Schwäche oder Bewegungskontrollstörungen, sind häufig myofaszial verursacht. Das pathophysiologische Substrat myofaszialer Probleme sind myofasziale Triggerpunkte (mTrP) und reaktive Bindegewebsveränderungen. Typisch für myofaszialen Schmerzen ist, dass der Ort der Schmerzursache und der Ort der Schmerzwahrnehmung oft nicht an derselben Stelle liegen („referred pain“). Myofasziale Störungen können primär oder sekundär verursacht sein; häufig tragen sie wesentlich zu Reizsummationsproblemen bei. Im Prozess des „clinical reasoning“ ist zu erkunden, welchen Stellenwert mTrP und Faszienveränderungen für das konkret vorliegende Problem haben (z. B. primär, sekundär, Beitrag zur Reizsummation).

Methoden

Die kausale und nachhaltige Therapie myofaszialer Störungen behandelt je nach Notwendigkeit sowohl die kontraktilen Teile des Muskels (Kontrakturknoten) als auch die nichtkontraktilen Anteile (reaktive Bindegewebsveränderungen). Je nach vorliegender Situation müssen prädisponierende und aufrechterhaltende Faktoren erkannt und nach Möglichkeit in die Therapie mit einbezogen werden. Die Triggerpunkt-Therapie IMTT® (Interessengemeinschaft für Myofasziale Triggerpunkt-Therapie) umfasst manuelle Techniken und ggf. Dry Needling zur Deaktivierung des Störpotenzials der mTrP, Dehnen/Detonisieren und funktionelles Training bzw. Ergonomie.

Stretching of the back improves gait, mechanical sensitivity and connective tissue inflammation in a rodent model

The role played by nonspecialized connective tissues in chronic non-specific low back pain is not well understood. In a recent ultrasound study, human subjects with chronic low back pain had altered connective tissue structure compared to human subjects without low back pain, suggesting the presence of inflammation and/or fibrosis in the low back pain subjects. Mechanical input in the form of static tissue stretch has been shown in vitro and in vivo to have anti-inflammatory and anti-fibrotic effects. To better understand the pathophysiology of lumbar nonspecialized connective tissue as well as potential mechanisms underlying therapeutic effects of tissue stretch, we developed a carrageenan-induced inflammation model in the low back of a rodent. Induction of inflammation in the lumbar connective tissues resulted in altered gait, increased mechanical sensitivity of the tissues of the low back, and local macrophage infiltration. Mechanical input was then applied to this model as in vivo tissue stretch for 10 minutes twice a day for 12 days. In vivo tissue stretch mitigated the inflammation-induced changes leading to restored stride length and intrastep distance, decreased mechanical sensitivity of the back and reduced macrophage expression in the nonspecialized connective tissues of the low back. This study highlights the need for further investigation into the contribution of connective tissue to low back pain and the need for a better understanding of how interventions involving mechanical stretch could provide maximal therapeutic benefit. This tissue stretch research is relevant to body-based treatments such as yoga or massage, and to some stretch techniques used with physical therapy.

Sensory innervation of the nonspecialized connective tissues in the low back of the rat

Chronic musculoskeletal pain, including low back pain, is a worldwide debilitating condition; however, the mechanisms that underlie its development remain poorly understood. Pathological neuroplastic changes in the sensory innervation of connective tissue may contribute to the development of nonspecific chronic low back pain. Progress in understanding such potentially important abnormalities is hampered by limited knowledge of connective tissue's normal sensory innervation. The goal of this study was to evaluate and quantify the sensory nerve fibers terminating within the nonspecialized connective tissues in the low back of the rat. With 3-dimensional reconstructions of thick (30-80 μm) tissue sections we have for the first time conclusively identified sensory nerve fiber terminations within the collagen matrix of connective tissue in the low back. Using dye labeling techniques with Fast Blue, presumptive dorsal root ganglia cells that innervate the low back were identified. Of the Fast Blue-labeled cells, 60-88% also expressed calcitonin gene-related peptide (CGRP) immunoreactivity. Based on the immunolabeling with CGRP and the approximate size of these nerve fibers (≤2 μm) we hypothesize that they are Aδ or C fibers and thus may play a role in the development of chronic pain.

A randomized, controlled study comparing a lidocaine patch, a placebo patch, and anesthetic injection for treatment of trigger points in patients with myofascial pain syndrome: evaluation of pain and somatic pain thresholds

BACKGROUND

Myofascial pain syndrome (MPS), a regional pain condition caused by trigger points in muscle or muscle fascia, produces muscle pain, tenderness, and disability. The gold standard of treatment for MPS-infiltration of trigger points with anesthetic-may provoke discomfort to the patients and require medical intervention.

OBJECTIVES

This study was designed to compare the effects of a topical lidocaine patch, a placebo patch, and injection of anesthetic (infiltration) for the symptoms of MPS in terms of pain, disability, and local tissue hypersensitivity, and to determine the acceptability of the lidocaine patch to the patients.

METHODS

Patients were randomly allocated to receive 1 of 3 treatments: a lidocaine patch applied to the trigger point for 4 days (replacement every 12 hours; total daily dose, 350 mg), a placebo patch applied to the trigger point for 4 days (replacement every 12 hours), or infiltration of the trigger point with two 1-mL injections of 0.5% bupivacaine hydrochloride given 2 days apart. Treatment with the patches was double-blinded, whereas treatment with infiltration was single-blinded. The number of pain attacks, pain intensity at rest and on movement, and pain-related interference with daily activity, work activity, mood, and quality of life were recorded before, during, and after treatment using a visual analog scale (VAS). Pressure and electrical pain thresholds of the skin, subcutis, and muscle in the trigger point, target area, and a pain-free area were evaluated before starting therapy (day 1) and on days 5 and 9. A VAS was used to measure discomfort from therapy, and a diary was given to each patient to record requests for additional treatment (if needed) and adverse effects.

RESULTS

Sixty white patients (46 women and 14 men) 19 to 76 years of age were studied. Mean (SD) age was 46.88 (15.37) years, and mean (SD) weight was 69.58 (13.94) kg. Twenty patients were assigned to each treatment group. Subjective symptoms did not change with placebo, but decreased significantly with the lidocaine patch and infiltration (both, P < 0.001) relative to baseline. Pain thresholds did not vary with the placebo patch, but increased significantly with the lidocaine patch and infiltration (all, P < 0.001); effects at muscle trigger points and target areas were greater with infiltration. Discomfort from therapy was greater with infiltration than with the lidocaine patch. Only patients in the placebo group requested additional treatment (P < 0.001). No adverse events occurred in any group.

CONCLUSION

Lidocaine patches were effective in, and highly acceptable to, these patients with MPS and high tissue hypersensitivity.

Biological treatment for degenerative disc disease: implications for the field of physical medicine and rehabilitation

Spine care is a fast-growing sector of the outpatient practice for physiatrists. Current nonsurgical treatment modalities and surgical options for severe symptomatic intervertebral disc degeneration have limited and inconsistent clinical results. Thus, the development of novel approaches, such as biological treatments that offer the potential to halt or even reverse disc degeneration and restore physiologic disc function, are very attractive. In this article, we first review the structural changes that occur during intervertebral disc degeneration and their relationship with discogenic back pain. Subsequently, we review the treatment approaches currently under clinical trial and laboratory investigation. Physiatrists specializing in spine care have the skill set required for administering intradiscal injections and supervising a comprehensive rehabilitation program after the procedures. Ultimately, the clinical use of any biological treatment discussed herein would require the collective efforts of physicians (such as physiatrists and surgeons) and researchers (such as chemical and biomedical engineers, biologists, and chemists).

Dorsal horn neurons having input from low back structures in rats

The mechanisms of nociception in the low back are poorly understood, partly because systematic recordings from dorsal horn neurons with input from the low back are largely missing. The purpose of this investigation was to (1) identify spinal segments and dorsal horn neurons receiving input from the low back, (2) test the effect of nerve growth factor (NGF) injected into the multifidus muscle (MF) on the neurons' responsiveness, and (3) study the influence of a chronic MF inflammation on the responses. In rats, microelectrode recordings were made in the segments L2, L3, and L5 to find dorsal horn neurons having input from the low back (LB neurons). In control animals, the proportion of LB neurons in L2 was larger than in L3 and L5. Most LB neurons had a convergent input from several tissues. Injections of NGF into MF increased the proportion of LB neurons significantly. A chronic MF inflammation likewise increased the proportion of LB neurons and the input convergence. The centers of the neurons' receptive fields (RFs) were consistently located 2-3 segments caudally relative to their recording site. The results show that (1) input convergence from various tissues is common for LB neurons, (2) the input from structures of the low back is processed 2-3 segments cranially relative to the vertebral level of the RFs, and (3) the responsiveness of LB neurons is increased during a pathologic alteration of the MF. The above findings may be relevant for some cases of chronic low back pain in patients.

Myofascial pain syndromes and their evaluation

Myofascial pain refers to a specific form of soft-tissue rheumatism that results from irritable foci (trigger points) within skeletal muscles and their ligamentous junctions. It must be distinguished from bursitis, tendonitis, hypermobility syndromes, fibromyalgia and fasciitis. On the other hand it often exists as part of a clinical complex that includes these other soft-tissue conditions, i.e., it is not a diagnosis of exclusion. The clinical science of trigger points can be traced to the pioneering work of Kellgren in the 1930s, with his mapping of myotomal referral patterns of pain resulting from the injection of hypertonic saline into muscle and ligaments. Most muscles have characteristic myotomal patterns of referred pain; this feature forms the basis of the clinical recognition of myofascial trigger points in the form of a tender locus within a taut band of muscle which restricts the full range of motion and refers pain centrifugally when stimulated. Although myofascial pain syndromes have been described in the medical literature for about the last 100 years, it is only recently that scientific studies have revealed objective abnormalities.