Back, chest and abdominal pain: How good are spinal signs at identifying musculoskeletal causes of back, chest or abdominal pain?

Background: Spinal signs found in association with atypical chest and abdominal pain may suggest the pain is referred from the thoracic spine. However, the prevalence of such signs in these conditions has rarely been compared with that in those without pain. In this study, the prevalence of spinal signs and dysfunction in patients with back, chest and abdominal pain is compared with that in pain free controls. The aim of the study is to determine the significance of spinal findings in patients with such pain. Methods: A general practitioner blinded to the patients' histories performed a cervical and thoracic spinal examination on general practice patients with back, chest and/or abdominal pain and on controls without pain. Thoracic intervertebral dysfunction was diagnosed on the basis of movement and palpation findings. Results: Seventy three study patients plus 24 controls, were examined. For cervical spinal signs, pain in the back, chest and/or abdomen was associated with pain with active movements and overpressure at end range and with loss of movement range. For thoracic spinal signs, this association held for pain with active movements and overpressure, but not with loss of movement range. The prevalence of thoracic intervertebral dysfunction was 25.0% in controls, 65.5% with chest/abdominal pain, 72.0% with back pain and 79.0% with back pain with chest/abdominal pain. This prevalence was higher with chest pain than with abdominal pain. Conclusions: The results show an association, but not a causal link between thoracic intervertebral dysfunction and atypical chest/abdominal pain. A spinal examination should be performed routinely assessing these conditions. The minimum examination for the detection of intervertebral dysfunction is testing for pain with spinal movements and palpation for tenderness. The interpretation of positive signs requires knowledge of their prevalence in pain free controls and in patients with visceral disease

Long-Term Effects of Specific Stabilizing Exercises for First-Episode Low Back Pain

Study Design. A randomized clinical trial with 1-year and 3-year telephone questionnaire follow-ups. Objective. To report a specific exercise intervention’s long-term effects on recurrence rates in acute, first-episode low back pain patients. Summary of Background Data. The pain and disability associated with an initial episode of acute low back pain (LBP) is known to resolve spontaneously in the short-term in the majority of cases. However, the recurrence rate is high, and recurrent disabling episodes remain one of the most costly problems in LBP. A deficit in the multifidus muscle has been identified in acute LBP patients, and does not resolve spontaneously on resolution of painful symptoms and resumption of normal activity. Any relation between this deficit and recurrence rate was investigated in the long-term. Methods. Thirty-nine patients with acute, first-episode LBP were medically managed and randomly allocated to either a control group or specific exercise group. Medical management included advice and use of medications. Intervention consisted of exercises aimed at rehabilitating the multifidus in cocontraction with the transversus abdominis muscle. One year and three years after treatment, telephone questionnaires were conducted with patients. Results. Questionnaire results revealed that patients from the specific exercise group experienced fewer recurrences of LBP than patients from the control group. One year after treatment, specific exercise group recurrence was 30%, and control group recurrence was 84% (P , 0.001). Two to three years after treatment, specific exercise group recurrence was 35%, and control group recurrence was 75% (P , 0.01). Conclusion. Long-term results suggest that specific exercise therapy in addition to medical management and resumption of normal activity may be more effective in reducing low back pain recurrences than medical management and normal activity alone. [Key Words: multifidus, low back pain, rehabilitation]

Mid-thoracic tenderness: a comparison of pressure pain threshold between spinal regions, in asymptomatic subjects

Palpation for tenderness forms an important part of the manual therapy assessment for musculoskeletal dysfunction, In conjunction with other testing procedures it assists in establishing the clinical diagnosis. Tenderness in the thoracic spine has been reported in the literature as a clinical feature in musculoskeletal conditions where pain and dysfunction are located primarily in the upper quadrant. This study aimed to establish whether pressure pain thresholds (PPTs) of the mid-thoracic region of asymptomatic subjects were naturally lower than those of the cervical and lumbar areas. A within-subject study design was used to examine PPT at four spinal levels C6, T4, T6, and L4 in 50 asymptomatic volunteers. Results showed significant (P < 0.001) regional differences. PPT values increased in a caudal direction. The cervical region had the lowest PPT scores, that is was the most tender. Values increased in the thoracic region and were highest in the lumbar region. This study contributes to the normative data on spinal PPT values and demonstrates that mid-thoracic tenderness relative to the cervical spine is not a normal finding in asymptomatic subjects. (C) 2001 Harcourt Publishers Ltd.

The effect of musculoskeletal pain on motor activity and control

Aberrant movement patterns and postures are obvious to clinicians managing patients with musculoskeletal pain. However, some changes in motor function that occur in the presence of pain are less apparent. Clinical and basic science investigations have provided evidence of the effects of nociception on aspects of motor function. Both increases and decreases in muscle activity have been shown, along with alterations in neuronal control mechanisms, proprioception, and local muscle morphology. Various models have been proposed in an attempt to provide an explanation for some of these changes. These include the vicious cycle and pain adaptation models. Recent research has seen the emergence of a new model in which patterns of muscle activation and recruitment are altered in the presence of pain (neuromuscular activation model). These changes seem to particularly affect the ability of muscles to perform synergistic functions related to maintaining joint stability and control. These changes are believed to persist into the period of chronicity. This review shows current knowledge of the effect of musculoskeletal pain on the motor system and presents the various proposed models, in addition to other shown effects not covered by these models. The relevance of these models to both acute and chronic pain is considered. It is apparent that people experiencing musculoskeletal pain exhibit complex motor responses that may show some variation with the time course of the disorder. (C) 2001 by the American Pain Society.

Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity

Recent findings that spinal manual therapy (SMT) produces concurrent hypoalgesic and sympathoexcitatory effects have led to the proposal that SMT may exert its initial effects by activating descending inhibitory pathways from the dorsal periaqueductal gray area of the midbrain (dPAG). In addition to hypoalgesic and sympathoexcitatory effects, stimulation of the dPAG in animals has been shown to hal e a facilitatory effect on motor activity. This study sought to further investigate the proposal regarding SMT and the FAG by including a test of motor function in addition to the variables previously investigated, Using a condition randomised, placebo-controlled, double blind, repeated measures design, 30 subjects with mid to lon er cervical spine pain of insidious onset participated in the study. The results indicated that the cervical mobilisation technique produced a hypoalgesic effect as revealed by increased pressure pain thresholds on the side of treatment (P = 0.0001) and decreased resting visual analogue scale scores (P = 0.049). The treatment technique also produced a sympathoexcitatory effect with an increase in skin conductance (P < 0.002) and a decrease in skin temperature (P = < 0.02). There was a decrease in superficial neck flexor muscle activity (P < 0.0002) at the lower levels of a staged cranio-cervical flexion test. This could imply facilitation of the deep neck flexor muscles with a decreased need for co-activation of the superficial neck flexors, The combination of all findings,would support the proposal that SMT may, at least initially, exert part of its influence via activation of the PAG, (C) 2000 Harcourt Publishers Ltd.

Patterns of community integration 2-5 years post-discharge from brain injury rehabilitation

Outcome after traumatic brain injury (TBI) is characterized by a high degree of variability which has often been difficult to capture in traditional outcome studies. The purpose of this study was to describe patterns of community integration 2-5 years after TBI. Participants were 208 patients admitted to a Brain Injury Rehabilitation Unit between 1991-1995 in Brisbane, Australia. The design comprised retrospective data collection and questionnaire follow-up by mail. Mean follow-up was 3.5 years. Demographic, injury severity and functional status variables were retrieved from hospital records. Community integration was assessed using the Community Integration Questionnaire (CIQ), and vocational status measured by a self administered questionnaire. Data was analysed using cluster analysis which divided the data into meaningful subsets. Based on the CIQ subscale scores of home, social and productive integration, a three cluster solution was selected, with groups labelled as working (n = 78), balanced (n = 46) and poorly integrated (n = 84). Although 38% of the sample returned to a high level of productive activity and 22% achieved a balanced lifestyle, overall community integration was poor for the remainder. This poorly integrated group had more severe injury characterized by longer periods of acute care and post-traumatic amnesia (PTA) and greater functional disability on discharge. These findings have implications for service delivery prior to and during the process of reintegration after brain injury.

Hemiplegic shoulder pain: defining the problem and its management

Purpose: Hemiplegic shoulder pain can affect up to 70% of stroke patients and can have an adverse impact on rehabilitation outcomes. This article aims to review the literature on the suggested causes of hemiplegic shoulder pain and the therapeutic techniques that can be used to prevent or treat it. On the basis of this review, the components of an optimal management programme for hemiplegic shoulder pain are explored. Method: English language articles in the CINAHL and MEDLINE databases between 1990 and 2000 were reviewed. These were supplemented by citation tracking and manual searches. Results: A management programme for hemiplegic shoulder pain could comprise the following components: provision of an external support for the affected upper limb when the patient is seated, careful positioning in bed, daily static positional stretches, motor retraining and strapping of the scapula to maintain postural tone and symmetry. Conclusions: Research is required to evaluate the effectiveness of the components of the proposed management programme for the prevention and treatment of hemiplegic shoulder pain and to determine in what combination they achieve the best outcomes.

Post-traumatic amnesia: Consistency-of-recovery and duration-to-recovery following traumatic brain impairment

The aim of this research was to examine the nature and order of recovery of orientation and memory functioning during Post-Traumatic Amnesia (PTA) in relation to injury severity and PTA duration. The Westmead PTA Scale was used across consecutive testing days to assess the recovery of orientation and memory during PTA in 113 patients. Two new indices were examined: a Consistency-of-Recovery and a Duration-to-Recovery index. a predictable order of recovery was observed during PTA: orientation-to-person recovered sooner and more consistently than the following cluster; orientation-to-time, orientation-to-place, and the ability to remember a face and name. However, the type of memory functioning required for the recall face and name task recovered more consistently than that required for memorizing three pictures. An important overall finding was that the order-of-recovery'' of orientation and memory functioning was dependent upon both the elapsed days since injury, and the consistency of recovery. The newly developed indices were shown to be a valuable means of accounting for differences between groups in the elapsed days to recovery of orientation and memory. These indices also clearly increase the clinical utility of the Westmead PTA Scale and supply an objective means of charting (and potentially predicting) patients' recovery on the different components of orientation and memory throughout their period of hospitalization.

Post-transcriptional regulation of the GLI1 oncogene by the expression of alternative 5 ' untranslated regions

The oncogene GLI1 is involved in the formation of basal cell carcinoma and other tumor types as a result of the aberrant signaling of the Sonic hedgehog-Patched pathway. In this study, we have identified alternative GLI1 transcripts that differ in their 5' untranslated regions (UTRs) and are generated by exon skipping. These are denoted (alpha -UTR, beta -UTR, and gamma -UTR according to the number of noncoding exons possessed (three, two, and one, respectively). The alpha- and beta -UTR forms represent the major Gli1 transcripts expressed in mouse tissues, whereas the gamma -UTR is present at relatively low levels but is markedly induced in mouse skin treated with 12-O-tetradecanoylphorbol 13-acetate, Transcripts corresponding to the murine beta and gamma forms were identified in human tissues, but significantly, only the gamma -UTR form was present in basal cell carcinomas and in proliferating cultures of a keratinocyte cell line. Flow cytometry analysis determined that the gamma -UTR variant expresses a heterologous reporter gene 14-23-fold higher than the alpha -UTR and 5-13-fold higher than the beta -UTR in a variety of cell types. Because expression of the gamma -UTR variant correlates with proliferation, consistent with a role for GLI1 in growth promotion, up-regulation of GLI1 expression through skipping of 5' noncoding exons may be an important tumorigenic mechanism.

Hydromorphone-3-glucuronide - A more potent neuro-excitant than its structural analogue, morphine-3-glucuronide

In humans, hydromorphone (HMOR) is metabolised principally by conjugation with glucuronic acid to form hydromorphone-3-glucuronide (H3G), a close structural analogue of morphine-3-glucuronide (M3G), the major metabolite of morphine. In a previous study we described the biochemical synthesis of H3G together with a preliminary evaluation of its pharmacology which revealed that it is a neuro-excitant in rats in a manner analogous to M3G. Thus the aims of the current study were to quantify the neuro-excitatory behaviours evoked by intracerebroventricular (icv) H3G in the rat and to define its potency relative to M3G. Groups of adult male Sprague-Dawley rats received icy injections (1 muL) of H3G (1 - 3 mug), M3G (2 - 7 mug) or vehicle via a stainless steel guide cannula that had been implanted stereotaxically seven days prior to drug administration. Behavioural excitation was monitored by scoring fifteen different behaviours (myoclonic jerks, chewing, wet-dog-shakes, rearing, tonic-clonic-convulsions, explosive motor behaviour, grooming, exploring, general activity, eating, staring, ataxia, righting reflex, body posture, touch evoked agitation) immediately prior to icy injection and at the following post-dosing times: 5, 15, 25, 35, 50, 65 and 80 min. H3G produced dose-dependent behavioural excitation in a manner analogous to that reported previously for M3G by our laboratory and reproduced herein. H3G was found to be approximately 2.5-fold more potent than M3G, such that the mean (+/- S.D.) ED50 values were 2.3 (+/- 0.1) mug and 6.1 (+/- 0.6) mug respectively. Thus, our data clearly imply that if H3G crosses the BBB with equivalent efficiency to M3G, then the myoclonus, allodynia and seizures observed in some patients dosed chronically with large systemic doses of HMOR, are almost certainly due to the accumulation of sufficient H3G in the central nervous system, to evoke behavioural excitation. (C) 2001 Elsevier Science Inc. All rights reserved.