Do I have inflammation?

If you watch too much TV you could end up thinking that all pain was due to 'inflammation'.  Interestingly while there are certainly times when the physical tearing of connective tissues occurs most spinal pain is not generated by the significant swelling of the joints.  Even arthritis is mostly non inflammatory.

And thank goodness for that because some people do have conditions which produce significant inflammation, joint irritation and destruction.

Rheumatology is a lifetime of study but there are useful tips which may help guide the individual towards recognising the more complex (and likely) inflammatory conditions which tend to involve amongst other structures, the spine (spondyloarthropathies)

These are typical presentations.  If there are any suspicions it is recommended that you seek advice.  The diagnosis of these conditions often only becomes apparent over time and may involve various blood tests.  Other clues are unusual joint problems in the family. In clinical practise these patients will not respond in the expected manner.  For example response to treatment will vary and lifestyle factors become far more important.

1. Males look out for Seronegative spondyloarthropathies such as Ankylosing Spondylitis

They are inflammatory arthritides affecting the axial skeleton.

Usually present in patients under 40 years of age
Commonly include thoracic pain (commonly with an advancing stoop) , sacroiliitis (low back/pelvis) and enthesopathy - inflammation of tendon insertions in the legs and problems with other connective tissues (the eyes, gut, etc)

Are often more problematic at night with morning stiffness taking > 30 minutes to dissipate.

2. Females are more likely to be affected by Rheumatoid Arthritis which typically begins to affect the hands and is not so evident in the spine.

Our main contribution in these cases is to help improve overall mobility and quality of life.  In some cases education and reassurance are the most significant things we can offer.

DS

EDIT:  Try these links for more recent dietary approaches to AS.

http://www.kickas.org/londondiet.shtml

http://paleohacks.com/questions/7392/did-paleo-improve-your-ankylosing-spondylitis#axzz24DorTDGu

Diagnosis - just a label? A patients perspective

There is always a risk of over diagnosis and over 'medicalisation' of what may indeed just be parts of 'normal'.

Using hypermobility as an example (we can also use Idiopathic Scoliosis, Asbergers Syndrome and ADHD/DD) a patient recently remarked "We all know flexible people.  Isn't it just normal?"

I responded by saying she was correct - labels are only useful if you understand their limitations.  However a diagnosis (an accurate one) if used wisely can dramatically influence the overall health and wellbeing of an individual over their entire life.  As in any situation if we can identify strengths and weaknesses we can more effectively navigate our way through life's challenges.  Or we can ignore them and hope for the best.

Fortunately research continually expands our knowledge base and our understanding of the phenomena which affect us. 

Perhaps that is how we should view diagnosis.  In many cases (those where life and death is concerned for example) it is quite apparent that an accurate diagnosis is essential. However it is also apparent that most things which ail the population do not involve death but rather they affect the quality of life and it is just as important to accurately determine how specific types of conditions manifest themselves in each unique individual.

Hypermobility - is it 'normal'?

One of the most underdiagnosed conditions are the family of genetic disorders which affect collagen, the proteins which form the skin, ligaments and tendons, blood vessels and other structural body parts.

But is it even a disorder?  It's thought to affect 10-20% of Western populations and is even more common in people of Indian, Chinese and Middle Eastern origin.

Ehlers-Danlos Syndrome (Marfans Syndrome is related but somewhat unique) occupies the extreme end of what is becoming accepted as a spectrum of collagen synthesis disorders.  The most common is Familial Joint Hypermobility Syndrome in which the most obvious trait is the ability to 'contort' the joints (see scale at left).  At the other 'end' of this spectrum individuals display traits which simply blend into the population norm.
Being a disorder of collagen formation individuals can also display vascular fragility, dislocate joints easily, be prone to uterine prolapse and typically suffer from diffuse musculoskeletal pain. There is a tendency towards joint degeneration and osteoporosis as well.
Although common it is still not widely understood even by many health practitioners.  Indeed like fibromyalgia it will usually go undiagnosed for years. Furthermore the various labels including Benign Joint Hypermobility imply mild, non-progressive conditions (as opposed to the full blown ED syndrome). Coupled with a perceived lack of a definitive diagnosis and specific pharmacological or surgical treatments it is easy to see why this family of disorders can be so common yet so misunderstood.

Fibromyalgia can also present as diffuse musculoskeletal pain which is why it is so important to ask questions regarding family members (siblings and children).  It is this line of enquiry that often yields valuable information in making the correct diagnosis and as a result being able to appropriately treat and advise.  After all this is a characteristic of the person as a whole, not simply a collection of unrelated injuries as it so often appears to be.

Douglas Scown

Musculoskeletal Injury, thinking and emotions

The specialist field of Neuropsychology is involved in the diagnosis of disorders of cognition (roughly thinking and emotions)
In the past few years there has been a surprising overlap between this field and musculoskeletal disorders.
It is not immediately apparent to relate the two, after all although the body has a brain science has considered thinking and physical movement to be two separate and distinct brain processes.
However for years practitioners in various fields have noted the common presentations of learning and behavioural disorders coupled with motor or movement dysfunction.  Even in apparently normal cases it's common to observe how musculoskeletal problems appear to interfere with judgement, decision making, alertness and emotional control.  In fact not only can patients report pain but will perform poorly at tasks which test accuracy of movement and balance, aspects of human function which display not only limb movement but how well the brain is perceiving and controlling it.

Many of us are fully aware that it is difficult to concentrate when you have pain but what is the reason?  Is it just a distraction or is it more complex?

The brain is currently the most complex structure in the universe.  Not only do it's cells and connections create an almost infinite number of patterns but it changes from second to second in response to whatever is going on in and around you.  And it does it without 'you'.

Technically you only have pain when the signal from a damaged or potentially damaged part reaches the brain.  The brain then filters the signal based on innate responses which are continually being modified by past experience (basically good, bad, don't care).  This signal then goes to more complex cognition centers for further 'evaluation'.  Most of these processes are also not consciously controlled. 

In short although the underlying causes are not completely understood, it appears that physical injury or dysfunction may inhibit other more complex brain functions.  Head and neck pain sufferers often report feeling 'dull', 'muzzy' or 'off' in conjunction with their presenting complaint.  In particular those who also demonstrate poor postural control appear more affected.

Thanks for reading.

Regards  DS

Migraine and Colic

The following article comes courtesy of Matthew Long and Anthony Nicholson at CDI and http://www.spinepartners.com.au/

Approximately 20 to 40% of patients who consult a chiropractor do so for the chief complaint of 'headache' and it may seem surprising but many respond favourably following physically based treatments of the spine.  It has even been controversially reported that chiropractors can treat Colic in infants but what on earth has this got to do with headache?

Can chiropractors 'cure' these ailments or are we looking at a far more complex condition which responds to many different types of stimuli?  What do we know?

The highlights are mine.

Migraine, Colic and Complexity

13/03/12 13:52 Filed in: From the Research

The results of a recent study to be presented next month at the American Academy of Neurology (AAN) 64th Annual Meeting has focused attention yet again upon the complexity of migraine. Dr Amy Gelfand will discuss the findings of an investigation into the relationship between mothers with migraine and the tendency for their children to suffer infantile colic. In summary, maternal migraine is associated with a greater-than two-fold increase in the chance of having a colicky baby. But what underlies this relationship?

Migraine is a genetic neurological disease that is frequently misunderstood. While the condition certainly can cause headache, it should not be defined by headache symptoms nor restricted to a category of headache pain. In essence, migraine represents a fundamentally flawed brain that struggles to regulate neuronal activity and maintain equilibrium. One could describe the migrainous brain as a genetically predisposed, serotonin depleted, nor-adrenaline deficient, dopamine sensitive, calcium channel deformed, ATP constrained, magnesium compromised, bundle of hyper-excitable circuitry in a state of precarious membrane stability. The end result - a highly reactive brain that is unduly sensitive to both internal and external stimuli. Furthermore, the way in which this instability manifests is not limited to 'bad headaches' or even the more complex aura symptoms.

Many migraineurs go through life experiencing signs and symptoms of their disease that are never attributed as such. It now appears that these symptoms may well manifest in infants as colicky behaviour. The concept of 'abdominal migraine' in children has gained greater acceptance in recent years (2), with Carson et al suggesting that it accounts for 4-15% of recurrent idiopathic abdominal pain. Furthermore, as childhood progresses even more complex 'migraine equivalents' start to appear and challenge our notions of what exactly constitutes a migraine. Such migraine equivalents include abdominal migraine and cyclical vomiting syndrome, acephalgic migraine (visual), acute confusional migraine, migrainous vertigo and torticollis (3). The trouble is, these episodes are often unrecognised as an expression of the underlying disease that lies at its core.

To return to the subject of colic, we must ask ourselves what this new insight might do for colic management? Chiropractors have long claimed efficacy for treating infantile colic, but the evidence is definitely patchy (4,5). However, we must also understand that the diagnosis of colic is subjective and there is no firm agreement on an underlying pathophysiology. With so much confusion and uncertainty it is of no surprise that controversy reigns. But what if we included migraine as a possible aetiology for 'colicky behaviour'? How would this change our approach? If colic was now viewed as a brain disorder what would this mean for contemporary chiropractic and medical theories about treating the condition?
Migraine illness represents a condition of undue sensitivity to both internal and external stimuli. Whether the stimulus is a flashing light, a loud noise or the distension of an internal organ such as the bowel, a migraineur's brain responds with increasing intensity. Many studies have catalogued the broad-spectrum sensitivities of migraine. But irritable bowel syndrome (IBS) is probably one of the better studied examples, and the most relevant to infant colic. Indeed, one could easily propose that IBS sits on the migraine disorder spectrum. Sufferers of IBS also exhibit a generalised sensitivity to non-bowel stimuli (6) , "including back pain, migraine headaches, heartburn, dyspareunia and muscle pain in body regions somatotopically distinct from the gut. Collectively, these somatic symptoms suggest that IBS patients may also suffer from central hyperalgesic dysfunction" (7). This has been described as a failure of a central analgesic mechanism known as diffuse noxious inhibitory controls (DNIC) (8). As such, irritable bowel syndrome has been conceived as a problem of how the brain perceives the gut, rather than an intrinsic gut disorder itself. In just the same way, infant colic might represent an unduly sensitive brain that allows normal levels of gut distension to register as pain.

So what does this mean for chiropractors?

If migraine and colic exist on a continuum of brain disorders in which descending pain modulation is compromised, can we claim that spinal dysfunction somehow 'causes' colic or migraine headache? Probably not. However, spinal dysfunction may well act as a 'trigger' for acute episodes in just the same way that flashing lights, loud sounds or gut distension might. If this is the case, it would make sense that adjustments to the spine may reduce the burden of irritation flooding the sensory system that allow other noxious pathways from the gut to reach threshold. We could also conceive of a manipulation as a 'sensory lever' that alters modulation of the pain pathways and facilitates greater inhibition of pain from other sources - including the gut.

Something to think about...
Dr Matthew D. Long - BSc. M.Chiro

References:

1. Gelfand, A. American Academy of Neurology (AAN) 64th Annual Meeting. Abstract 113. April 21 - 28, 2012. First results released February 20, 2012.
2. Carson, L., Lewis, D., Tsou, M., McGuire, E., Surran, B., Miller, C., & Vu, T.-A. (2011). Abdominal migraine: an under-diagnosed cause of recurrent abdominal pain in children. Headache, 51(5), 707–712. doi:10.1111/j.1526-4610.2011.01855.x
3. Al-Twaijri, W. A., & Shevell, M. I. (2002). Pediatric migraine equivalents: occurrence and clinical features in practice. Pediatric neurology, 26(5), 365–368.
4. Wiberg, J. M., Nordsteen, J., & Nilsson, N. (1999). The short-term effect of spinal manipulation in the treatment of infantile colic: a randomized controlled clinical trial with a blinded observer. Journal of manipulative and physiological therapeutics, 22(8), 517–522.
5. Wiberg, K. R., & Wiberg, J. M. M. (2010). A retrospective study of chiropractic treatment of 276 danish infants with infantile colic. Journal of manipulative and physiological therapeutics, 33(7), 536–541. doi:10.1016/j.jmpt.2010.08.004
6. Piché, M., Arsenault, M., Poitras, P., Rainville, P., & Bouin, M. (2010). Widespread hypersensitivity is related to altered pain inhibition processes in irritable bowel syndrome. Pain, 148(1), 49–58. doi:10.1016/j.pain.2009.10.005
7. Zhou, Q., Fillingim, R. B., Riley, J. L., Malarkey, W. B., & Nicholas Verne, G. (2010). Central and peripheral hypersensitivity in the irritable bowel syndrome. Pain, 148(3), 454–461. doi:10.1016/j.pain.2009.12.005
8. Heymen, S., Maixner, W., Whitehead, W. E., Klatzkin, R. R., Mechlin, B., & Light, K. C. (2010). Central processing of noxious somatic stimuli in patients with irritable bowel syndrome compared with healthy controls. The Clinical journal of pain, 26(2), 104–109. doi:10.1097/AJP.0b013e3181bff800

Fibromyalgia (FM) - A new understanding

The following illustrates how research can dramatically improve outcomes for individuals suffering complex pain disorders.


Not long ago Fibromyalgia was thought to be an inflammatory condition of the muscles.  Individuals hurt pretty much all over.  They would also commonly have other conditions such as headache, gut disturbance and odd limb sensations and they would be prone to depression and anxiety.
These people were often labelled hypochondriacs and Dr shoppers and unfortunately the frustration and sense of helplessness often magnified the problem.

Now FM is classified as a genetically linked condition involving abnormalities in the dopamine pathways of the brain, resulting in widespread allodynia and multiple sensitivities.

Allodynia is a pain due to a stimulus which does not normally provoke pain so FM is actually a 'pain processing problem'

According to one FM website it still takes an average of 5 years for this collection of apparently unrelated symptoms (co-morbidities) to be recognised as manifestations of the single disorder.

What can a chiropractor offer?  There is a body of information regarding FM which should determine treatment choices irrespective of which profession the individual consults.

Officially there is actually a paucity of literature for the support of chiropractic care in the management of this condition.  According to Schneider et al "Strong evidence supports aerobic exercise and cognitive behavioral therapy. Moderate evidence supports massage, muscle strength training, acupuncture, and spa therapy (balneotherapy). Limited evidence supports spinal manipulation, movement/body awareness, vitamins, herbs, and dietary modification." (courtesy of CDI).

Perhaps the main role of physically based modalities in the co-managment of FM is to reintroduce normal movement in a non painful way.  Traditional spinal and joint manipulation is generally not tolerated well in these cases and usually leads to aggravation.  Gentle joint and muscle movements, often in areas of the body not badly affected are followed by more robust manouvers as tolerance increases.

Education and reassurance are vital while the individual gradually increases exercise and attends to any psychological issues which may exist.

What we have to offer is only part of a much broader approach and communication with the medical practitioner and other providers is essential to form a tailored, coherent and effective approach which gives the individual the tools to understand and effectively self manage their problem.

It's perhaps useful to consider that the brain is just one organ of the body and while it may malfunction we do possess the ability to control it's reactions.  Our responses to pain (technically nociception) is a function of many processes we cannot directly control however pain 'levels' are strongly determined by learnt responses.  In essence our minds experiences.

Ultimately we are in the drivers seat where the brain is concerned.

DS

Born to Run

...and walk. 

At Brisbane city chiropractor here in the CBD we deal mainly with the effects of a LACK of normal movement which compounds preexisting simple injuries.

If you've read the book Born to Run you'll be up to date with the dramatic change in our understanding of human movement and what we appear to be made for. Ultra marathons!?

I'm a doco addict and This documentary is another great insight into human 'design'.

Running has really had a bum wrap in the past few decades but it appears we have caused most of the problems.  We developed this idea (based on NO science) that big shock absorbing shoes would protect us from injury.  But one study showed that wearing 'shock absorbing' shoes INCREASED the forces through the leg compared with barefoot running.  Indeed shoes for marathon runners have LESS padding. Why?

Human feet appear to be designed to absorb shock.  That's what all those arches (3 each foot) are for AND even if you have 'flat feet' (very common) most peoples arches appear as soon as they begin to walk and run.

Maybe you don't want to begin a career as a marathon runner but this all applies to walking as well and we know the average city dweller walks less than 2km per day!

One study into chronic back pain simply asked people to walk for 30minutes a day and the effects were quite significant.  More was better and less was markedly less effective.

Last. If you're worrying about your bottom getting flat with age it's because you're not running, squatting or jumping.  Walking doesn't use the largest of our muscles (the gluts or bum muscles).

You have been warned:)