27 abril, 2008

The Osteopath - "The battle for ideas: a discussion..."

What do other health care professionals without our concepts or tactile skills consider is happening when patients come to them with back pain of no obvious pathological cause?

Usually they don’t know. Even when they have allotted diagnostic labels to some patients, such as torn muscles, sprained ligaments, osteo-arthritic facet joints, and internal disc derangements (for which there is next to no evidence), most are honest enough to admit to being unable to make a diagnosis in the many remaining cases.

Active in the face of pain

Once the lack of a theory on which to base rational treatment was openly recognised in the early eighties, there was a need to fill this conceptual vacuum, but any osteopathic ideas were quite beyond the orthodox pale at that time. So when the concept was proposed that psychosocial factors largely determine the persistence of back pain beyond the acute episode, there being no rival theory in the field, that model became accepted with haste. This also reflected the government’s desperate search for answers to their ballooning bill for back pain disability. To accord with natural history data, a rational application of this model required the cascade of fearful cognition, anxiety, activity avoidance, depression, functional deterioration, unemployment, isolation and loss of confidence to be initiated early in the course of an episode. Rational management was therefore to involve a positive message of maintaining activity in the face of pain from the outset; rest must not be thought of as treatment if this regime was to
succeed. To an osteopath, used often to palpating increasing signs of dysfunction in patients unable or unwilling to unload the paingenerating structures, the practice of encouraging further pain confrontation would seem quite unreasonable and part of management would usually be the appropriate use of temporary activity reduction to initiate recovery. A rational basis for this attitude seemed to be offered in the elucidation by modern neurophysiology of positive feedback effects, by which the wind-up of spinal cord sensitivity through ongoing pain input steadily increases the resultant reflex muscle spasm and further pain generation of the dysfunctioning structures.

Somatic dysfunction vs abnormal illness

In the face of the impasse between professionals who diagnose and treat on the basis of somatic dysfunction, and those who diagnose and treat on the basis of abnormal illness or behaviour, evidence from clinical trials should be the key justification. It is in the selection and treatment of this evidence by the committees tasked with developing guidelines that we see the unconscious effect of theoretical allegiances and preconceptions. Evidence carefully testing the effects of rest during episodes of acute back pain is discarded and trials of lesser design and execution are included and over-interpreted. Without a strong theoretical preconception it would be difficult to see how the committees involved could have reached their conclusions. It must be acknowledged that rest has been over-prescribed in the past, though not in the main, it must be said, by osteopaths. Of course, like many effective treatments that can be costly and have side effects, it should be prescribed within rational parameters, which are clearly negotiated with patients. However, to discourage an individual patient from using an effective remedy for them is a serious error especially if the main justification is that this discouragement can be shown to have a beneficial total population effect; we treat patients as individuals.

What are the lessons to be learned from this situation?

Firstly, to realise that none of us can view evidence totally objectively: we all have a predisposition to see each observation from a prior conceptual viewpoint from which an alternative interpretation may not be apparent. When that viewpoint derives from a long education and experience, it may not be easy for others to share it. Consequently, while evidencebased healthcare is an aspiration we should all adopt, it should be qualified with the realisation of our propensity, almost inevitable tendency, to want our treatments to accord with our deeply held convictions. If a group has concepts that it believes are valuable and worth promoting, it must enter the battle of ideas and not expect any other group to provide the expertise or resources to produce the quite specific evidence that may be required. If it’s worthwhile, it’s worth fighting for.

In The Osteopath
Nota: Este artigo é apenas uma parte do artigo "The battle for ideas: a discussion" .

25 abril, 2008

Pain from a synovial cyst in the lumbar spine

A synovial cyst is a relatively uncommon cause of spinal stenosis in the lumbar spine (lower back). It is a benign condition, and the symptoms and level of pain or discomfort may remain stable for many years.

A synovial cyst is a fluid-filled sac that develops as a result of degeneration in the spine. Because a synovial cyst develops from degeneration it is not often seen in patients younger than 45 and is most common in patients older than 65 years old.

The fluid-filled sac creates pressure inside the spinal canal and this in turn can give a patient all the symptoms of spinal stenosis. Spinal stenosis is a condition that occurs when degeneration in the facet joints causes pressure on the nerves as they exit the spine.

Causes of a synovial cyst

Synovial cysts develop as a result of degeneration in the facet joint in the lumbar spine. It is typically a process that only happens in the lumbar spine, and it almost always develops at the L4-L5 level (rarely at L3-L4).

The pain probably comes from the venous blood around the nerves not being able to drain and this leads to pain and irritation of the nerves. Sitting down allows the blood to drain and relieves the pressure.

The facet joint of the lumbar spine is just like any other joint in the body (such as the hips or knees):

>It is composed of two opposing surfaces that are covered with cartilage.

>The cartilage is the smooth, very slippery surface that allows a joint to move.

>A thick capsule surrounds the entire joint, and within this is the synovium.

>The synovium is a thin film of tissue that generates fluid within the joint that helps further lubricate the joint.

>As the joint degenerates it can produce more fluid.

As it degenerates, the cartilage looses its smooth, frictionless surface and the extra fluid can help by adding extra lubrication.

It is thought that the synovial cyst develops in response this extra fluid. The fluid escapes out of the joint capsule through a one-way ball valve type hole, but stays within a synovial covering. This functionally pumps fluid one way into the fluid sac. The fluid, however, is not under a lot of pressure, as neurological deficits or cauda equina syndrome (loss of bowel and bladder control) is extremely uncommon even for very large cysts.

By: Stephen H. Hochschuler, MD September 9, 2002

21 abril, 2008

Osteoarthritis treatments: Glucosamine and chondroitin sulfate supplements

Glucosamine and chondroitin introduction

For patients who have evidence of osteoarthritis in their spine (as seen on an x-ray) and who have had other causes of back pain and neck pain ruled out by their health care provider, glucosamine sulfate and chondroitin sulfate may be a treatment option.

While glucosamine sulfate and chondroitin have been taken orally since the 1960’s in Europe, it is only recently that these supplements have been used in the United States as an alternative treatment for osteoarthritis or degenerative joint disease.

However, more research is needed before it can be said that glucosamine sulfate and chondroitin are safe and/or are effective in the treatment of osteoarthritis.

What is osteoarthritis?

When cartilage becomes worn, exposed bones can rub together and the painful symptoms of osteoarthritis may appear. Osteoarthritis can affect any joint, including those throughout the spine.

Conventional medicine does not yet have a proven treatment to stop or slow the progression of osteoarthritis. Traditional medical treatment includes drug therapy to control the pain associated with osteoarthritis.

These treatments are sometimes disappointing for physicians and patients because medications may not provide complete relief and can have unwanted side effects. Some of these patients may be candidates for nutritional supplements like glucosamine and chondroitin sulfate.

Use of glucosamine and chondroitin as nutritional supplements

Many Americans are using nutritional supplements, such as glucosamine and chondroitin, in hopes of improving general health and for treating a specific disease. One survey by Reuters found that 36% of Americans use nutritional supplements, and that many of those people believe their use resulted in a cure .
Some of these alternative therapies have recently gained acceptance by traditional medical doctors due to an increase in demand by health care consumers as well as increasing evidence that some of these supplements actually help patients.

However, in general, very little scientific information exists on nutritional supplements in relation to diseases of the spine.
Por, Christopher D. Chaput, MD November 29, 2000