Journal of Back and Musculoskeletal Rehabilitation - Volume 8, issue 2
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Journal of Back and Musculoskeletal Rehabilitation is a journal whose main focus is to present relevant information about the interdisciplinary approach to musculoskeletal rehabilitation for clinicians who treat patients with back and musculoskeletal pain complaints. It will provide readers with both 1) a general fund of knowledge on the assessment and management of specific problems and 2) new information considered to be state-of-the-art in the field. The intended audience is multidisciplinary as well as multi-specialty.
In each issue clinicians can find information which they can use in their patient setting the very next day. Manuscripts are provided from a range of health care providers including those in physical medicine, orthopedic surgery, rheumatology, neurosurgery, physical therapy, radiology, osteopathy, chiropractic and nursing on topics ranging from chronic pain to sports medicine. Diagnostic decision trees and treatment algorithms are encouraged in each manuscript. Controversial topics are discussed in commentaries and rebuttals. Associated areas such as medical-legal, worker's compensation and practice guidelines are included.
The journal publishes original research papers, review articles, programme descriptions and cast studies. Letters to the editors, commentaries, and editorials are also welcomed. Manuscripts are peer reviewed. Constructive critiques are given to each author. Suggestions for thematic issues and proposed manuscripts are welcomed.
Abstract: An increasing number of physicians from a variety of disciplines are specializing in the treatment of patients with pain, and reporting treatment success using disparate interventions. Due to the lack of standardized evaluations of patients with pain, however, it has been impossible to reasonably assess the claims of any facility and even more difficult to compare the types of treatments from a variety of treatment settings. This paper will describe the process of the fomation of the Uniform Outcome Measures Committee of the American Academy of Pain Medicine. The deliberations of the Committee and the status of the development of…a data collection system package will be described.
Abstract: Decades of debate have yet to yield a universal solution to the treatment of low back pain, a problem that afflicts 80% of adults in the United States at some point of their lives [1,2]. Exercise, in general, has become widely recognized as playing a large role in the rehabilitation of back pain sufferers. Yet, there is no consensus on which types of exercises to utilize. Most exercise techniques address the muscles with the specific purpose of impacting the skeleton or the spinal cord and nerve roots, rather than the muscles themselves. This reinforces the notion that muscles are not…the direct source of pain, but rather only reflect pathology elsewhere. We reintroduce a rational exercise regimen first developed by Hans Kraus, M.D. in 1949. This regimen was shaped over a period of several years, through usage by thousands of back pain sufferers. It directly addresses specific trunk muscle deficiencies and tension, which are postulated by the authors to be the major factors producing low back pain. The exercise protocol has shown to be highly effective and inexpensive to administer on a wide-scale basis. Recent clinical experiences utilizing the Kraus techniques are discussed.
Abstract: Although Myofascial Pain Syndrome (MPS) is the most common diagnosis for injured workers , there is no uniform description or definition of MPS in the medical literature. Often the phrase myofascial pain is used to describe a variety of difficult to classify pain syndromes, resulting in confused and contradictory treatment approaches. Correct diagnosis and successful treatment of patients suffering from MPS must be based on a firm understanding of the muscular component of chronic pain syndromes. The New York Pain Treatment Program protocol in use at Lenox Hill Hospital is based on classification, diagnosis and treatment guidelines, developed by Dr.…Hans Kraus, that recognize four types of muscle pain (tension, spasm, deficiency, and trigger points). It is the author's hope that this presentation will assist other clinicians in developing optimal rehabilitation programs.
Abstract: Purpose: To review the indications for imaging in patients with back pain. Methods: The author's experience as a clinical neuroradiologist in dealing with both referring physicians and their patients with back pain form the basis of this manuscript. Several texts and recent peer reviewed papers dealing with imaging of the spine were consulted. Results: There are controversies over when to image and the appropriate imaging modality to be used. The author presents his views on the sources of these controversies and his philosophy on imaging patients with back pain. A brief review of the major imaging findings in degenerative and…non-degenerative causes of back pain is presented. To fully appreciate and see examples of these imaging findings, the reader should read texts devoted to spinal imaging. Conclusion: Controversy over the decision of when to perform imaging of patients with back pain persist. From the perspective of the radiologist there is little controversy over the choice of imaging studies to be performed. MRI is superior to all other tests in the identification of degenerative and non-degenerative causes of back pain. CT without intrathecal contrast is an excellent test for degenerative disease but will often fail to detect non-degenerative (e.g. neoplastic) causes of back pain.
Abstract: Objective: While there is an extensive body of literature concerning the use of epidural steroid injections in the treatment of sciatica, most of the literature is descriptive or anecdotal. There are few controlled studies regarding efficacy of this treatment modality. While there are few published reports of serious complications of this therapy, warnings about the hazards of epidural steroid injections occasionally appear in both medical and lay literature. It is the purpose of this review to assess the existing evidence for efficacy of epidural steroid injections for sciatica and to assess the risks of this procedure. Data sources:…Peer reviewed medical literature from 1930 to the present was reviewed in order to survey reports regarding pathophysiology of radiculopathy, mechanism of action of epidural corticosteroids, controlled efficacy studies, reports on series of epidural steroid injections for sciatica, reports of adverse effects of epidural and intrathecal steroid injections, review articles of epidural and intrathecal steroid injections, and studies of the behavioral and histological effects of epidural steroids and their vehicle in animals. Study selection: Studies and review articles were selected from Medline search and from the author’s files of older literature. Data synthesis: Results of this review are qualitative. It was felt that there was insufficient controlled data to analyze efficacy or safety studies in a quantitative fashion. Results: Radiculopathy following disc herniation appears to produce either mechanical or chemical nerve root inflammation. Epidurally injected corticosteroids most likely exert a beneficial effect through anti-inflammatory rather than direct analgesic mechanisms. Most descriptive studies report beneficial effects of epidural steroids in the majority of cases of radiculopathy, but not for other causes of low back pain. Most of the few controlled studies report epidural steroids to be more efficacious than placebo or epidural local anesthetic alone. Most patients who respond favorably continue to show improvement for many months. Several neurologic complications have been reported after intrathecal steroid injections, most following multiple intrathecal injections. Four cases of epidural abscess, one case of bacterial meningitis, and one case of aseptic meningitis have been reported following epidural steroid injections. Conclusions: The majority of the published literature supports the notion that epidural steroids provide relief of pain from lumbosacral radiculopathy. There is anecdotal evidence that multiple intrathecal steroid injections may be associated with neurological dysfunction, but there is very little evidence that epidural steroids are neurotoxic.
Abstract: Purpose: This is a review article to update the clinical applications of pressure pain sensitivity (PPS) measurement by pressure algometry (PA) [1,2]. Basic procedures: The basic literature on pressure algometry has been reviewed with emphasis on new developments. The author’s and his co-workers’ experience with PA, extending several years, are also included along with some unpublished research results. Findings: The high reliability and validity of PA for quantification of PPS has been proven by several authors. The specificity and sensitivity of PA in detection of trigger points (TrPs) is also very good. PA is also useful…in evaluation of treatment results. PA can document the decreased PPS after âĂŸpreinjection (regional) blocks’ administered prior to trigger point injections (TPIs). A study of ten patients with failed back surgery included 20 muscles. PA documented long-term improvement (150 days) which corresponded to a decrease in pain rating. Treatment consisted of needling and infiltration of the entire trigger point (TrP) extending to taut band. Another study showed that physicians were unable to produce 4 kg of pressure, which is critical for diagnosis of fibromyalgia. Conclusions: Quantification of fibromyalgia diagnosis by PA is necessary for abnormal tenderness (pain on 4 kg pressure). The critical pressure for TrP, tender spots is a pressure pain threshold lower by 2 kg/cm2 relative to a normally sensitive corresponding control point.
Abstract: Objective: To determine why patients with normal function of the pituitary-thyroid axis, myofascial pain, and other symptoms resembling those of hypothyroidism respond to a slightly supraphysiological dose of levothyroxin administration. Design: Review and analysis of author’s records drawn from a data base of therapeutic trials. Intervention: Oral administration of levothyroxin, 0.2 mg daily for at least 3 months. Main Outcome Measures: Patient interviews and physical examinations by author. Measurement of differences in paired BMR, serum cholesterol, and subjective response after 3 or more months of thyroid hormone administration, using each patient as his or…her own control. Summary: Fifty-seven chemically euthyroid adults of both sexes with myofascial pain and hypothyroid-like symptoms were treated with a slightly supraphysiological dose, 0.2 mg, of levothyroxin daily. Cases were selected recently from a database of 367 therapeutic trials performed by the author between 1954 and 1983. All patients had a normal thyroid profile, and a serum TSH measurement before initiating levothyroxin replacement. BMRs and serum cholesterol determinations before and after at least 3 months of thyroid hormone therapy were compared. A graph was constructed in which each point displayed three responses for each patient: change in resting oxygen consumption, following a 12-h fast (BMR); change in serum cholesterol; and symptom response score. Thirteen TSH levels were slightly elevated. Analysis of the graph suggests that almost all patients with: (1) normal function of the pituitary thyroid axis; (2) non-inflammatory myofascial pain refractory to physical medicine and trigger point therapy; and (3) symptoms and signs resembling hypothyroidism, responded to thyroid hormone therapy. The responses suggest correction of a peripheral block to thyroid hormone in patients with normal pituitary thyrotroph function.