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Rheumatoid arthritis is an autoimmune disease that causes inflammation of the joints. It is the most common autoimmune disease of the joints and left untreated the uncontrolled inflammation not only causes pain but also bony remodelling of the joints, which can lead to deformation and disability. The condition often requires lifelong treatment with medications that are not without side-effects. A team of boffins (they look about 12 years old to me, I must be getting old) at Friedrich-Alexander Universitat in Erlangen, with the help of research from an international project, has discovered that a type of cell called innate lymphoid cells are instrumental in the resolution of inflammation. Furthermore, in patients with Rheumatoid Arthritis it appears that these cells become dormant, they, in effect, go into a state of hibernation. When they are awoken they put an end to the inflammatory process and the pain and destruction associated with it. The possibility of treatments which increase the numbers of innate lymphoid cells in future may lead to much better outcomes for patients with, not just rheumatoid arthritis but also potentially any condition based on chronic inflammation, these might include conditions as varied as Crohns disease and ulcerative colitis, psoriasis and even cirrhosis of the liver. Read the press release here
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The body needs to find time to repair itself and schedules downtime so that structures can be restored to better function. Did you know that nostrils are periodically switched throughout the day and night, with one fully open and the other partially blocked in order that it can rest and repair from the fast moving particles you inhale? The intervertebral discs also have a repair cycle. When we lie down and take the weight off them, they decompress and fluid and nutrients are sucked in so that they are plumper by about 10% and we are actually measurably taller at the beginning as opposed to the end of the day by about 1.5-2cm. However, the rhythm is not just a response to our activity, scientists at the University of Manchester have discovered, there is an intrinsic diurnal rhythm in the DNA of the substance of the discs. Genes concerned with homeostasis (repair through the restoration of the balanced state) are switched on when we rest at night. It was found that chronic inflammation and ageing both reduced the ability of the disc tissue to respond to the circadian rhythms. Furthermore the loss of circadian rhythms led to accelerated deterioration of intervertebral disc tissue. Read more here Another team at University of Manchester, looking at the mechanisms behind the inflammation causing Rheumatoid Arthritis have found that the body also secretes natural anti-inflammatories (notably cryptochrome) to reduce inflammation during the night and again this is disrupted if we don't have a period of rest and darkness, read more here. So, what are the implications? The suggestion is that a regular sleep pattern, in darkness, is perhaps important to both mediate inflammation and to maintain disc health. The understanding that long term inflammation reduces the effectiveness of the circadian disc repair system means that a poorly regulated body clock could lead to a double whammy of decreased inflammatory suppression and of that inflammation then leading to a degraded intervertebral disc repair mechanism. There are some positives though; understanding how the body suppresses inflammation during the 'night' phase means we could potentially develop methods to artificially trigger that state, which could be especially useful for those with autoimmune conditions where inflammation is chronic and damaging, and understanding how ageing interferes with triggering nocturnal intervertebral disc repair may mean that we could find a way to reverse that also. In the meantime though, all in all, perhaps your grandparents were right when they exhorted you that 'early to bed, early to rise makes a man healthy, wealthy and wise'...well the first part, at least! No apologies. This week’s blog contains an abundance of anatomical terms. The good news is that there is a summary at the end, so you can skip straight to that if you just want the gyst. Mark Laslett – Identified that the SIJ can be implicated in dysfunction in two different ways: 1. pain derived from the joint, this has been proven to exist by injecting anaesthetic into the joint space which causes the pain to abate, showing it derives from there. Bussey and Milosavljevic found that there are nociceptors throughout the joint capsule, ligaments and potentially throughout the subchondral bone suggesting that trauma or tension to any of these structures could lead to pain and Vleeming et al propose that this pain could be driven by assymetric tension across the joint. Furthermore sacroiliac joints are prone to degenerative changes. A report delivered at the National Association of Spinal Surgeons suggested that in the studied cohort, with a mean age of 53, 35% of joints had serious degeneration and a further 30% minor and that it tended to occur more in men. 2. contribution, as a load bearing mechanical junction between the pelvis and spine, to dysfunction, leading to pain elsewhere. Mark Laslett was sceptical about how much a joint with little rotational or translational movement could influence other structures but let us see the avenues that other researchers are pursuing A pelvic torsion will cause a functional leg length discrepancy, conversely a leg length discrepancy of 1 cm can cause increase a fivefold increase in pelvic forces. Vleeming et al suggested that the sacroiliac joint can adopt a constantly braced force closure when there is load unpredictability or constant high loading and this can become a dysfunctional norm with muscular bracing and indeed muscular hypertonia and fatigue, furthermore, Iliacus can pull the ilium forward causing a relative counternutation of the sacrum in such positions as lying supine and straight leg raise, if the patient hasn’t braced and force closed adequately. In pregnancy, pelvic girdle pain can be caused by insufficient bracing. People tend to brace the contralateral (good) SIJ using Biceps femoris and External Oblique when flexing bad sij, Sjödahl et al found evidence that, when performing an assymetric straight leg raise, women with pelvic girdle pain fail to tense their pelvic floor…is it also part of that force closure process? One muscle that doesn’t appear to be directly part of the process despite a longstanding belief it was involved is transversus abdominus, according to studies in vitro by Gnat et al. McGrath et al have found another source of sacroiliac region pain. The posterior rami of the sacral nerves form a plexus (network) in the gluteal region close to the sacroiliac joints. They identified two potential places areas where it is proposed that entrapment may occur: 1. under Long Posterior Sacroiliac Ligament 2. where the medial branches of the posterior rami penetrate the deep fascial layer to innervate sacral multifidus and become cutaneous You can think of this nerve entrapment as very similar to sciatica but much more localised. So to sum up. The sacroiliac joints themselves have pain responsive nerves and may be responding to trauma or degeneration. The long-standing assumption that sacroiliac movement could lead to a pelvic torsion and contribute to dysfunction and pain elsewhere is now being questioned but new models involving uneven soft tissue tensions and bony plasticity may provide an alternative mechanism but a similar outcome and finally the area around the sacroiliac joints may be prone to sciatica type neuropathic pain, this may also be influenced by uneven forces and soft-tissue tensions. So how much and how does the sacroiliac joint move? Well, we can’t look at the joint in isolation we need to look at the whole pelvis and that means also looking at the pubic symphysis which is the joint at the front. After all it is a closed ring so if one joint moves then it must be compensated for elsewhere. A study looking at people in the flamingo stance showed that one side of the pubic symphysis moved 1.4 mm relative to the other in men, 1.6mm in nulliparous women and 3.1mm in multiparous women. One of the newer developments in research has been the use of Roentgen stereogrammetry. This uses tiny metal balls embedded in the bone either side of the joint and 2 x-ray devices to create a stereo image that can be used to calculate movement of the markers relative to each other in all planes. This is a more accurate method than others which have been prone to error. The sacroiliac joints do move…but not very much at all. The main movement is the nutation (nodding forward) of the sacrum between the ilia and that is typically of the order of a couple of degrees (although it does vary according to position) and is in fact 40% less in men than in women. Kibsgård et al looked at women with confirmed SIJ mediated pelvic girdle pain and used tiny metal balls inserted into the bones either side of the joints to accurately measure movement of one side relative to the other. They found very little sacroiliac joint movement despite significant movement of one side of the pubic symphysis compared to the other. So, what is happening? How can the pubic symphysis move significantly without the sacroiliac joint following suit? Kibsgård et al suggested that this unexpected finding was likely to be either down to setup error or plasticity of the bones of the innominate bones, the latter of which would concur with a study by Paul Goudzwaard et al who showed that the innominate bones could deform up to 3.5mm whilst the pubic symphysis moves mainly in the transverse plane (rather than rotating). One final piece of the puzzle, Adhia et al discovered that although there wasn’t significant difference in the degree of SIJ movement there was increased asymmetry of iliac rotational motion in patients with SIJ pain. So they didn’t rotate more, or less but they moved differently. To sum up, the studies using the most accurate techniques currently available indicate that the sacroiliac joints don’t usually move very much and that sacroiliac pain and reduced movement don’t appear to be linked but there is a difference in how the ilia move in affected patients and it seems that the innominates are deformable to account for pubic symphysis movement Finally! I am ready to write about the sacroiliac joint. I haven’t been as comprehensive in my research as I hoped but I have realised that trying to be perfect is stopping me from being ‘good enough’. It’s time to synthesise the information. I don’t intend to pepper my blog entries with references, although I will include some, where the idea is particularly novel or controversial. If you do want to know where I got a piece of information you can always email me. I’ll try and make these readable for those without a medical background but invariably they won’t be quite as easy as some of my other writing. This first article is about the structure of the Sacroiliac joint and how it might differ from our understanding. A quick reminder, the sacroiliac joints are paired joints between the sacrum (the triangular bone between the main spine and coccyx) and the ilia (the ilium is one of 3 bones that fuse in adulthood to form the innominate bone, the two of which form the rest of the pelvis). Clear as mud no doubt! This week’s blog entry is about the structure of the joint and next week about function but for this week’s entry to make sense it is important to discuss the fact that there has been ongoing controversy about how much movement occurs and therefore how it can go wrong. Research was very contradictory until 1940s when it was determined that they basically didn’t move and therefore couldn’t cause problems, this persisted until 1980s when that position was reversed, although there is still debate about the subject. Suffice it to say most osteopaths became heretics during that period and maintained that the joint could move, and could indeed move out of place. More of that next week. The bony structure The first surprise is how common significant asymmetry is. Not just in shape, size and orientation but also, the presence of additional non-continuous mini-joints. It is also not uncommon for there to be a midpoint inter articular tubercle (imagine this as a bony pivot), especially in men. The joint surface is a comparatively large one shaped like an ear (it is described as auricular) and is ridged, this increases the friction acting between the surfaces and acts to restrict available movement Women generally have a much smaller interarticular area which implies less and potentially insufficient friction, especially in girls aged 10-20 who notably have many more pelvic problems than men. The joint does move! Ankylosis (bony fusion) is not the norm. It almost never occurs in women and most old men maintain mobility. Where it does occur it seems to relate to lack of movement, especially in teenage years. The neuromuscularligamentous connections The sacroiliac joint is not one that can be flexed, rotated or otherwise affected at will to create significant movement (I would query maximal hip extension) and therefore is not considered to have muscles acting across it in the commonly understood sense, but there are a large number of muscles and other important soft-tissue structures which partially attach into the ligaments and capsule which surround and support the joint including iliolumbar ligament, gluteus maximus, multifidus, piriformis and in many cases hamstring muscles. They have an effect on the orientation and integrity of the joint as will be discussed in later blogs. The ligaments holding the the joint together themselves are some of the strongest in the body. Finally, nerves from the posterior sacral rami (that just means some of the nerves that exit the spinal column at the level of the sacrum) form a plexus (network) in the area of the sacroiliac joint, could they be relevant in pain in the area? So we have a large stable joint supported by very strong ligaments but it doesn't often fuse and that suggests that not only does it move but that it is meant to. the presence of muscular slips perhaps also suggests that the movement is either not entirely passive or is actively controlled and a previously under-described plexus of nerves bang smack in the area. More next week... picture Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. - Own work There is a lovely clip on the BBC today of Dr Bill Frankland, a medical Doctor and still working at 105 years old. He ascribes his continued ability to work to a regime of exercises which he undertakes every morning. The clip is set to a jaunty tune that is meant to lighten the segment and perhaps implies a degree of eccentricity on the good Doctor's part and the article rightly points out that there must have been a degree of biological good fortune in preserving his health and mobility so well and for so long...but...his belief in movement preserving his health is not pure whimsy. Movement can improve the health of almost every bodily system:
Musculo-skeletal - as well as maintaining strength and suppleness of muscles and other soft-tissues and creating the forces which cause your bone to be replenished, most of your joints are lined with hyaline cartilage, which has a very poor blood supply, it is nourished by synovial fluid which is pumped and wiped across the surfaces of the joints during movement through a full range of motion. Circulatory - The body contains lots of pumps, not just the heart. A well known example is the calf-pump; each time the big calf muscles contract during walking they squeeze the vein lying between them and because of the valves in the vein the blood flows in one direction back to the heart. The heart is designed to operate in conjunction with these pumps, if they aren't operational the heart has to work harder than it should and/or venous return may be compromised causing swelling of the legs and varicose eczema. Of course the main function of the circulatory system is to deliver nutrients and remove waste. Anything that improves circulation will improve the health of every tissue of your body from your brain to your digestive system, to your nerves, skin and sensory organs, not to mention your brain. Respiratory - Your diaphragm is a muscle and your ribs are joined to your spine with joints, they also have muscles between them. Don't exercise and you'll find you are not able to take as deep a breath as once you were. Less breath, less oxygen, less energy and more CO2 and free-radicals scooting around and potentially causing mischief Digestive - your digestive system needs to be massaged to maintain health and it achieves that through the movement of the muscles around it Immune - Your immune system relies on cells moving around, guess how they move, you guessed it, they rely in large part on musculoskeletal pumping through the lymphatic system. Historical records showing that patients in the great flu epidemic 100 years ago survived much better when they had osteopathic treatment, so a recent series of studies set out to understand the mechanisms. Osteopathic pumping techniques were shown to increase the rapidity of immune response and the effectiveness of the immune cells in destroying combating pneumonia and the number of immune cells presented at the site of infection, as well as increasing the number overall...exercise was shown to do the same, the techniques were only repeating the mechanisms the body had created for itself (still very useful in a bedbound patient). Regular movement has so many life-enhancing and potentially prolonging benefit before you even consider the obvious counteraction of our modern tendency to consume more calories than we burn Congratulations Dr Frankland. We can learn a lot from you http://www.bbc.co.uk/news/av/uk-politics-39815946/the-105-year-old-still-working-how in Some recent research published by Journal of Orthopaedic & Sports Physical Therapy suggests that a combination of neck and median nerve manual therapy techniques alongside stretches at home has as good an effect on carpal tunnel syndrome pain and associated grip weakness as surgery...and the benefits start sooner. In this instance the manual therapists were physiotherapists but we osteopaths take a similar approach and I have had excellent results with patients with this problem. Click here for the article in Arthritis Digest. ps I am till working on my articles about the sacroiliac joint. It is a complicated beast! Pic citation Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. - Own work When is something not normal? When do you concern and inconvenience your patient by asking them to go to see their GP? Do you risk making yourself look a fool? Much of the training to be an osteopath is about conditions we don't treat. Why is that? Well, many systemic conditions present with symptoms that mimic musculoskeletal problems. Fibroids that refer to the low back, deep vein thrombosis which the patient thinks is a torn calf muscle, prostate cancer metastasised to the low back and causing back ache there. That's why we ask so many questions to try and differentiate between something which is probably musculokeletal in nature from something that may have a systemic and possibly sinister origin and requires further investigation. We have a duty to maintain our continuous professional development through a mix of self-study, talks and courses and recently I have been on a couple that were specifically about spotting people who needed to be referred. The first was a course on neurological and intracranial anatomy and pathology. This was part lecture, part looking at preserved specimens of intracranial pathologies and part handling of dissected human neurological and intracranial anatomy. It was fascinating and a little daunting and I am very grateful to the people who expressed a wish that their mortal remains should be used in this way...I didn't just do it so I had something interesting to write about here, by seeing and handling the structures in 3D and as near to their natural state as possible it is much easier to picture, to understand how, for example, different types of intracranial bleed progress and how they effect the patient. A more common pathology I am likely to spot is skin cancer. I attended a talk on skin cancer and the strongest message I took home from it was that they aren't always easy to spot. Skin cancers can look benign and equally there are many benign lesions which often show features associated with skin cancers. I suggest everyone brush up on their ABCDE of Melanomas but remember that it's only a guide...the only one of the 5 criteria that is a very strong warning is E - evolving. Anything that looks like a melanoma and is changing faster than anything else on the back, needs urgent investigation. I only attended the course 3 weeks ago and have already referred one patient on for further investigation, her GP has made an appointment to use a dermatoscope to look further into it (pun intended) - so that probably gives you the answer to the questions I posed at the beginning. When is something not normal? - Most of the time I am unsure When do you concern and inconvenience your patient by asking them to go to see their GP? - When something may not be normal and leaving it may be deleterious to their health Do you risk making yourself look a fool? - Every time there is anything above the lowest suspicion of something not being musculoskeletal, better to look a fool than risk a patient's health - but bear in mind I have trained for 4 years, kept up to date on courses and asked the patient a lot of questions so it is required less than you'd think Last week I was treating a patient with whom I share a sense of humour. we were chatting away as I do, when it is appropriate (don't worry I won't force you to chat if you would rather not!) and I kept making her laugh. At the time I was setting her up for a series of 'lumbar rolls', these are 'manipulations' where we lie the patient on the side and twist and flex them so that the point of tension lies at the segment we wish to manipulate. I always think of it like a ribbon, if you put one twist in a ribbon you can twist it from the top or bottom and move the point where it twists round itself up and down the length of the ribbon. Now imagine I can also flex your back in such a way that in that direction of motion the forces are focused at the same point. I can then compress through the area and further focus the forces to the one joint. At this point the normal technique would be for me to drop slightly and use gravity to deliver a small impulse which would be enough to manipulate the joint and achieve the desired outcome, resetting local muscle tone so the joint moves more normally and often with the pop or click of cavitation and any potential benefits that may confer. Except in this case, every time I set the joint, either before or after I added the compression, Ms X would laugh and the joint would release and cavitate. The involuntary tightening of the abdominal muscles and the movement associated with that, coupled with the increased intra-abdominal pressure were working to act as extra levers and were enough to initiate the process in a gentle and enjoyable way. Sadly I don't think I can be reliably funny enough to make this a part of my everyday practice but it does go to show how effectively some techniques minimise the force required to perform a manoeuvre and how a good set up can increase the probability of success. for low back pain. Actually they do but not very much. Hot on the heels of the Cochrane review demonstrating the lack of efficacy of paracetamol for low back pain the BMJ journal 'Annals of the Rheumatic Diseases' has published a systematic review with meta-analysis (a review of all of the papers out there and a combination and synthesis of the results) of Non-Steroidal Anti-Inflammatories for spinal pain and has found that although there is some limited demonstrated effectiveness it is not enough to be considered clinically important. They also found that use of NSAIDs increased the likelihood of gastrointestinal reactions 2.5 times. I take ibuprofen when I need it, it is a very useful anti-inflammatory and painkiller so am in no way suggesting that these drugs are useless, but it is interesting to read these results and indeed the findings of the authors that 'At present, there are no simple analgesics that provide clinically important effects for spinal pain over placebo'. Read the abstract here http://ard.bmj.com/content/early/2017/01/20/annrheumdis-2016-210597 Back to the SIJ next time - it's taking ages to read, digest and formulate an opinion on the information but I am finding it really interesting. |
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February 2024
AuthorDamian is the principal osteopath at Vauxhall Village Osteopathy and Oval Osteopathy Categories
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