Sep
5
2023
A once-mysterious neural pathway may have a crucial role in making injured areas overly sensitive to touch, a study in mice suggests.
When a person has any kind of injury — a broken shin, for example, or a sunburn — the pain system becomes hypersensitized, firing up in response to normally painless sensations induced by, for instance, walking or a gentle massage. Normally, this tenderness protects the vulnerable tissue as it heals. But occasionally the pain can overstay its usefulness, becoming chronic in conditions such as arthritis.
Now, neuroscientists Robert Edwards and Allan Basbaum from the University of California, San Francisco, and their colleagues have found that a small subset of nerve fibres, the function of which remained a puzzle since their discovery decades ago1, could be routing innocuous touch sensations to the pain pathway when there’s an injury.
“Surprise would be an understatement,” says Basbaum, referring to the findings. “No one knew anything about what these fibres were doing.”
The team’s findings are published by Nature2.
Getting touchy
The researchers found that the fibres, called unmyelinated low-threshold mechanoreceptors (C-LTMRs), are easily stimulated, unlike classic pain fibres, which respond only when the sensation is intense. But C-LTMRs aren’t usually used to detect light touch — this falls to another another major group of sensory neurons — so their role was unclear. The small population of cells have remained enigmatic because they have been difficult to target specifically.
The authors cleared that hurdle when they discovered that these fibres express VGLUT3, a protein necessary for the cells to send signals to other neurons. Because all of the other sensory neurons going to the spinal cord use a different protein — VGLUT1 or VGLUT2 — the authors could engineer mice lacking VGLUT3 to render all the C-LTMRs silent.
“Surprise would be an understatement. No one knew anything about what these fibres were doing.”
Allan Basbaum UCSF
Mice without functional C-LTMRs responded in exactly the same way as normal mice when exposed to light touch and to most painful stimuli, including extreme cold or heat or being poked in the paw with thin wires. But then the authors tested how the mice responded after being injured in three other ways: by a chemical that causes inflammation, which occurs in situations ranging from muscle injuries to a misaligned back; an incision, mimicking pain after surgery; and nerve damage.
In all three types of injury, normal mice became much more sensitive to wires poking their paws, quickly flicking the wires away. But mice with silent C-LTMRs showed much the same responses as before they were injured. All mice, however, became more sensitive to heat, suggesting that the C-LTMRs were hypersensitizing the animals to touch rather than to temperature.
There was one type of pain that, without injury, the engineered mice were less sensitive to than normal mice: intense, persistent pain, such as that caused by a clip pinching the tail. The finding seems contradictory, because C-LTMRs are easily stimulated. One possibility is that a small minority of neurons with VGLUT3 respond to pain, Basbaum says.
Paths to pain
Before this study, researchers had demonstrated two ways for animals to become hypersensitive after injury. First, sensory fibres can become more sensitive to stimulation; this is thought to lead to temperature hypersensitization, as happens when sunburn makes a warm shower feel excruciatingly hot. Second, another set of fibres that, like C-LTMRs, have a low threshold and are important for detecting light touch, are believed to be recruited into the spinal cord’s pain circuit — any sensation they transmit is then perceived as painful.
“This paper says hold on, there’s a whole other population. It’s another circuit, a potential target from a clinical perspective,” says Basbaum. Basbaum thinks that injury also leads to these fibres’ recruitment into the pain circuitry; they may work with the other low-threshold touch fibres or be important for hypersensitivity to different stimuli.
“We knew these fibres existed, but their function was not at all clear until now,” says neuroscientist Clifford Woolf at Harvard Medical School in Boston, Massachusetts. “The data show that recruitment of these fibres is a new way of producing mechanical hypersensitivity. It’s an exciting example of the specific functions of different sets of sensory neurons.
http://www.nature.com/news/2009/091115/full/news.2009.1084.html
Sep
5
2023
Abstract
Study Design. Systematic Review.
Objectives. To assess the effects of massage therapy for nonspecific low back pain.
Summary of Background Data. Low back pain is one of the most common and costly musculoskeletal problems in modern society. Proponents of massage therapy claim it can minimize pain and disability, and speed return to normal function.
Methods. We searched MEDLINE, EMBASE, CINAHL from their beginning to May 2008. We also searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, issue 3), HealthSTAR and Dissertation abstracts up to 2006. There were no language restrictions. References in the included studies and in reviews of the literature were screened. The studies had to be randomized or quasi-randomized trials investigating the use of any type of massage (using the hands or a mechanical device) as a treatment for nonspecific low back pain. Two review authors selected the studies, assessed the risk of bias using the criteria recommended by the Cochrane Back Review Group, and extracted the data using standardized forms. Both qualitative and meta-analyses were performed.
Results. Thirteen randomized trials were included. Eight had a high risk and 5 had a low risk of bias. One study was published in German and the rest in English. Massage was compared to an inert therapy (sham treatment) in 2 studies that showed that massage was superior for pain and function on both short- and long-term follow-ups. In 8 studies, massage was compared to other active treatments. They showed that massage was similar to exercises, and massage was superior to joint mobilization, relaxation therapy, physical therapy, acupuncture, and self-care education. One study showed that reflexology on the feet had no effect on pain and functioning. The beneficial effects of massage in patients with chronic low back pain lasted at least 1 year after the end of the treatment. Two studies compared 2 different techniques of massage. One concluded that acupuncture massage produces better results than classic (Swedish) massage and another concluded that Thai massage produces similar results to classic (Swedish) massage.
Conclusion. Massage might be beneficial for patients with subacute and chronic nonspecific low back pain, especially when combined with exercises and education. The evidence suggests that acupuncture massage is more effective than classic massage, but this need confirmation. More studies are needed to confirm these conclusions, to assess the impact of massage on return-to-work, and to determine cost-effectiveness of massage as an intervention for low back pain.
Spine:
15 July 2009 – Volume 34 – Issue 16 – pp 1669-1684
doi: 10.1097/BRS.0b013e3181ad7bd6
Sep
5
2023
At the Mayo Clinic in Rochester, Minnesota, they’ve an active research program in the field, including treatments like massage. Brent Bauer is director of Complementary and Integrative Medicine at Mayo.
Brent Bauer said that: We’ve done two studies now, in patients who’ve had cardiovascular surgery. So big a incision down the front of the chest, rib cage spread open, and what we’ve done is taken a group of patients, given them massage on Day 2 and Day 4 after their surgery, and mostly worked in the upper back, because that’s where a lot of the pain and discomfort resides after having your chest opened. And what we found is comparing that group to a group who did not receive massage, we were able to show a statistically significant improvement in pain, anxiety and tension.
This was a certified massage therapist who was fairly free to use the different types of massage that she wanted. She could use light massage, deep massage, Swedish massage and so forth. We didn’t try and restrict her to a certain number of strokes, or certain patterns, we wanted to allow a massage therapist to do the best job she could.
And it’s important to do that though, you have to have some kind of control, because otherwise we can’t be sure if it’s the massage or just the simple fact that somebody’s spending time with you. So we did as we actually had our massage therapist go in the control group, the patients that did not receive massage, and she actually spent about the same amount of time, about 20 minutes, speaking to them, talking to them, and just mostly trying to be a caring presence. So we were matching the amount of time spent in both groups.
The first one was a small study, about 60 patients that did show statistical significance, but the second study which we’re just looking at now, is about 220 patients, and that’s where we’re trying to tease out some of the questions Can we reduce the use of narcotics? Can we reduce the length of stay?
We’ve done a number of studies on herbal products, because that’s very popular with our patients, and we really want to be able to say what’s good, what’s not, and make sure our patients have a an ability to make an informed decision. So this was a study in cancer patients, a wide variety of cancer patients, by and large the number one concern they complain about is fatigue. Ginseng has some old studies that suggest it might be helpful for fatigue. We gave one group a placebo, we gave the other group ginseng, and we found the group that received ginseng less fatigued, better quality of life, overall greater satisfaction.
It was kind of ‘Gemisch’ of different patients. We had different cancer types, different stages and so forth, and that actually probably is a weakness of the study, so we’re actually replicating that study with a much more focused group of cancer patients to see if we can get stronger data.
The problem with previous studies in ginseng in other areas has been which ginseng, there’s different varieties, and what concentration, because you never quite know what you’re buying off the shelf.
It’s a critical component for any herbal medicine, but especially ginseng. We actually are lucky; right across the border here in Wisconsin, we have a group of ginseng growers, and so we’re able to work with them to harvest the single batch in a uniform fashion, all of the same age, processed the same way, we analysed the ginsenoside content, which is the active ingredient, before and also after the study, so we were sure that we didn’t lose potency over time. So doing all those precautions, you then have a much more replicable result. But it also means you can’t just go to the shelf and pick a ginseng and think you’re going to get the same results. You really have to follow the same type of product.
Which is the point. So you’re sitting, listening to this in Perth, Australia, or Adelaide, Australia, and you think ‘Well that sounds good, I’ll just pop down to the local chemist and buy some’. What are you buying, what do you look for?
With any study, you have to go back to the study and the study should identify the product. In this case we used the ginsenoside concentration of 5% and actually the Ginseng Growers Association of Wisconsin actually has a link on their site to a product that is similar to what we used in the study.
And you’ve done a fascinating study, coming more into Australia’s region, a herb from Ambon, just in Indonesia.
Brent Bauer: So there’s a beautiful old text about 350 years old, called the Ambonese Herbal, written by Rumphius who was a Dutch East Indies soldier and ended up on Ambon. Spent his entire life talking to the natives and really recording in a very detailed fashion how they used the herbs and what they used them for. Now we flash forward 350 years later, we now have a translation of the first book of seven. We looked at that first chapter, we found all the references to herbs and how they were used, and then we looked at all the databases subsequent to that time, to see if any of those uses had been validated. And we were able to show that about 80% of the herbal uses in that first book have subsequently been validated. In other words, indigenous knowledge appears to have been correct. So that was pretty cool, and I think that gives a lot of cache to our historical knowledge and historical use. What was really cool though, there were about eight herbs that had not been subsequently studied. So the Ambonese Herbal said, ‘Here are some things that we think work, but nobody’s ever studied them.’ So we actually went to Samoa where one of our PhD students had a connection, it wasn’t the island of Ambon, but harvested some Atun racemosa, which is a kernel, or a little nut-like plant, that’s actually used after their tattooing ceremonies. And if you’ve ever seen the tattoo ceremonies, lots of punctures to the skin, not much infection. So they use it as kind of an antibacterial. Well it turns out in Rumphius’ book that was one of the indications, Atun racemosa was used for infections.
Norman Swan: There’s been a fairly significant move in American hospitals towards having departments such as yours, Integrative Medicine, because of the enormous demand outside. But it’s a difficult area because if you take the cynics here who’ve looked at some of these alternative medicines, or complementary medicines, they say, ‘Look, the bigger the trial, the better the trial, the harder it is to find any effect’, and in the end what you’re doing is patronising patients, to make them feel a bit better, but not really finding real evidence that what they’re doing helps them, and sometimes if they’ve bought it say from India, Ayurvedic medicine, it could be doing them harm.
Brent Bauer: And I think there’s a good distinction here, certainly things with herbs and dietary supplements. Americans have a fascination and we tend to think that we can still smoke, drink too much, never exercise, and eat junk food, ‘But if I take the magic herb, I won’t have that many health problems’. So that is a real challenge, and that’s one of the reasons I think maybe herbal studies don’t come out very positive, because we’re looking for magical qualities instead of how they’re traditionally used. You know, green tea, you could drink five or six cups a day, as in many Asian cultures, you probably get a very different experience than if you pop two extracts of green tea. So there are a lot of challenges there.
Norman Swan: Now just on that, it’s the whole thing which we said often on the Health Report is the stuff in whole foods, which have got benefits working together, which when you extract what you think is the main game, it may not be.
Brent Bauer: We’ve often gotten burned with that type of philosophy, maybe Vitamin E is a good example. Vitamin E in the diet looks like it’s very healthy; Vitamin E as a concentrated alpha tocopherol doesn’t seem to work, and may actually have some negative effects. So I think if you put the broad category of dietary supplements on one side, I think there’s been a lot more hype than delivery.
Now on the other side though, I think the mind-body side, where we talk about meditation, imagery and things, if you look at how the typical American is right now, frazzled, running at full tilt, too many things going on, we know there’s a price to pay for that type of stress. So when you introduce things like meditation, acupuncture and massage, things that might be leading to a slow-down, things that might be leading to reduced response to stress, and that’s what many of these studies do confirm, then we start to get into an idea of maybe this is something important. There’s probably a dividing line between some of the magical thinking, which I think has been over-hyped and we should be very cautious. On the other hand, we shouldn’t throw out the baby with the bathwater. If we’re frazzled, we darn well had better start thinking about ways to take better care of ourselves in that regard.
Norman Swan: And indeed, particularly out of Britain, there’s been some very good randomised trials of mindfulness meditation, Buddhist-style meditation, which show significant benefits.
Brent Bauer: Absolutely. I think you know, what’s the harm from meditation? Very limited. Maybe you spend some money to go to a class, maybe you buy a DVD or a book. If you don’t like it, if it doesn’t fit for you, there’s no harm, you know, you try something else. But if you find it to be useful, if you find that it fits your lifestyle, and it starts to get you off that rapid train of non-stop the brain’s going, the brain’s going, the brain’s going, I think we’re actually starting to see a lot of studies suggesting that kind of stress kills neurones, affects our cognition. So not addressing anything I think would actually be a mistake.
Norman Swan: How do you get the balance in practitioners? Because one of the controversies in Australia is that you tend to get general practitioners who either do one or the other. They kind of say they do both, but some of them are so committed to complementary medicine, that’s kind of all they do. And getting the balance right is the critical issue. How do you deal with that issue?
Brent Bauer: The Mayo Clinic is a very conservative institution. I mean we have a deeply-held vision that the needs of the patient come first. So as long as we live under that, then I’m free to ask ‘What’s going to make my patient do better, feel better, get better’? And so I can pick from either side, and as long as I have evidence, then the colleagues who live over here maybe on the more cynical side, have actually been very accepting. And those who are very much more on the earlier doctor side, may be too quick to adopt. When we show them the evidence that things don’t work, they actually can be brought into kind of that middle ground as well. So I think by bringing science first, doing the research and doing it well, and applying those results locally, we actually can kind of keep to the middle ground where the best benefit for the patient’s going to occur.
Norman Swan: Dr Brent Bauer who’s director of Complementary and Integrative Medicine at the Mayo Clinic in Rochester, Minnesota.
References:
Pruthi S et al. Value of massage therapy for patients in a breast clinic. Clin J Oncol Nurs 2009 Aug; 13(4):422-5
Barton DL et al. Pilot study of Panax quinquefolius (American ginseng) to improve cancer-related fatigue: a randomized, double-blind, dose-findidng evalutation: NCCTG trial NO3CA Support Care Cancer 2009 (Epub ahead of print)
Buenz EJ et al. Searching historical herbal texts for potential new drugs. British Medical Journal December, 2006;333:1314-1315
http://www.abc.net.au/rn/healthreport/stories/2009/2715314.htm
Sep
5
2023
Massage therapy services for healthcare: A telephone focus group study of drivers for clients’ continued use
Joanna M. Smith a, b, John Sullivan b and G. David Baxter b
a Massage Department, Southern Institute of Technology, Private Bag 90114, Invercargill 9840, New Zealand
b Centre for Physiotherapy Research, School of Physiotherapy, University of Otago, PO Box 56, Dunedin 9054, New Zealand
Summary
Objective
To explore opinions of why clients use, value and continue to seek massage therapy as a healthcare option.
Design
Telephone focus group methodology was used. Current and repeat users (n = 19) of either relaxation, remedial or sports massage therapy services participated in three telephone focus groups. Audiotaped semi-structured interviews were conducted.
Setting
Telephone focus group with massage clients from provincial and urban localities in New Zealand.
Main outcome measures
Summary of reported themes of the massage experience and suggested drivers for return to, or continuing with massage therapy. Data were transcribed, categorised (NVivo7) and thematically analysed using the general inductive approach.
Results
Key drivers for return to, or continuing with, massage therapy were: positive outcomes, expectations of goals being met, a regular appointment and the massage therapy culture.
Conclusions
Massage therapy is perceived and valued as a personalised, holistic and hands-on approach to health management, which focuses on enhancing relaxation in conjunction with effective touch, within a positive client–therapist relationship and a pleasant non-rushed environment. Massage therapy as a health service is result and client driven but is reinforced by the culture of the experience.
Sep
5
2023
Results from the 13th annual consumer survey conducted by the American Massage Therapy Association® (AMTA®) indicate that 32 percent of Americans are seeking massage for medical and health
reasons, tying relaxation and stress reduction for the first time as the top reasons people get massages.
Additionally, 25 percent of Americans ages 35-44 have talked to their doctor or healthcare provider about massage therapy this year, compared to 14 percent in 2008. Of those who discussed massage therapy with their doctors, 52 percent say their doctor strongly recommended/encouraged them to get a massage. These survey results are announced in conjunction with National Massage Therapy
Awareness Week®, October 25-31.
A vast majority of Americans, 86 percent, agree that massage can be effective in reducing pain, and 85 percent agree that massage can be beneficial for
health and wellness. “Even with the ongoing economic crisis, people are not willing to compromise their health,” says Judy Stahl, AMTA president. “It’s a clear signal of massage’s value when those making less than $35,000 a year are the second most active income bracket getting massage therapy.”
For the second year in a row, the survey results showed that massage therapy use is fairly steady, despite the lagging economy. Thirty-two percent of stressed out Americans are getting massages to relieve their stress and 57 percent of Americans say they feel more stressed this year than last year, particularly among females (61 percent) and those ages 18-24 (66 percent).
“Consumers understand that massage therapy is essential to a healthy balance between stress and relaxation,” said Stahl. “We are pleased to see that consumers are prioritizing massage to help them through these difficult times.”
Sep
5
2023
Book review
J.-P. Barral and A. Croibier, Manual Therapy for the Peripheral Nerves , Churchill Livingstone (2007) ISBN 0-4431-0307-0 288 pages, £34.99.
Karen McCreesha, Department of Physiotherapy, University of Limerick, Limerick, Ireland
Physiotherapy
The aim of this text is to present, from an osteopathic perspective, a new system of assessment and treatment of dysfunction of the nervous system. The book is an English translation from an original French text, which was published in 2004. The authors are osteopaths with extensive experience in the practice and teaching of manual therapy and visceral manipulation. It is intended for practising manual therapists in osteopathy, chiropractic and physiotherapy.
The book is well organised, with the first three chapters dedicated to a detailed and comprehensive review of the anatomy, physiology and pathology of the peripheral nervous system. These would make useful reading for any therapist interested in revising their knowledge of these areas, and gaining further knowledge on mechanisms of neural blood flow, intra- and extraneural pressure and links to the visceral system. Subsequent chapters are devoted to an explanation of the authors’ system of assessment and treatment of nerves, dealing separately with the cervical, brachial, lumbar and sacral plexuses, with additional detailed review of the topographical anatomy of each area. The techniques are well illustrated; however, as is often the case with practical skills, it is difficult to gain an exact understanding of the ‘listening’ and ‘manipulation’ techniques described. This issue is often addressed in other comparable textbooks by supplying an accompanying CD-ROM with demonstrations of the techniques, which could be considered for future editions of this text.
The early chapters reference much of the classic literature in the areas of neuroanatomy and physiology. However, there is no reference to the more recent, extensive body of published work in the area of nerve movement, which, in the context of this book, would seem a significant omission. It is also disappointing that the text contains both unsubstantiated assertions and clinical anecdotes, detracting from the potential of this text as an evidence-based educational resource.
From a physiotherapy perspective, this text is interesting in that it demonstrates another profession’s approach to the management of neural pathology. As a complete text, it would be of use to experienced manual therapists as a practical and clinical guide to this particular treatment approach, while the anatomy and physiology sections would be a useful refresher for all therapists treating pain of neural origin.
Sep
5
2023
Book Review
L. Chaitow, Neuropathic Physical Medicine: Therapy and Practice for Manual Therapists and Neuropaths , Elsevier-Churchill Livingstone (2008) ISBN 9780443103902 Price £41,99, No. of pages 594.
Edzard Ernsta, (Manual therapy, in press)
This multi-author book covers those aspects of neuropathic medicine which are not pharmacological or mind-body by nature. I did ask myself whether there is a physical medicine that is not neuropathic. The answer was, I thought, no. So perhaps this book is about physical medicine and, having been a professor of physical medicine once, I thought this is right up my street.
As it turns out, I was wrong. The book embraces all sorts of concepts which a scientific mind is likely to think of as mumbo jumbo. Examples are ‘Constitutional considerations, (p. 89) and ‘detoxification’ (p. 81). I know that most neuropaths would disagree with me, but I fail to see any good evidence for there validity. More disturbingly I found that the concept of scientific evidence was dealt with in a most peculiar and misleading way. This culminates in a graph which implies that data from clinical trials and meta-analyses are just as relevant as case reports and in vitro studies for evaluating the effectiveness of a therapy. I don’t think this is true and I am sure that most methodologist would agree with me. The last part of the book is devoted to treatment of specific conditions. I was unconvinced by much of this too. For example, the implication that one can effectively treat serious heart conditions with manipulation worries me. Similarly the notion that “irrespective of the named condition”, patients can be helped by physical medicine simply does not tally with my scientific knowledge nor my clinical experience. I am sorry not to be able to strike a more positive note after reading this book.
Sep
5
2023
In a paper evaluated by f1000 Medicine, six studies tested relationships between reminders of money, social exclusion and physical pain.
In The symbolic power of money: reminders of money alter social distress and physical pain published in the journal Psychological Science, Xinyue Zhou, Kathleen Vohs and Roy Baumeister explored how money could reduce a person’s feeling of pain and also negate their need for social popularity.
Harriet de Wit, Faculty Member for f1000 Medicine, said: “This research extends our understanding of relationships between social pain and physical pain, and remarkably, shows how acquired symbolic value of money, perhaps because of associations with power or control, can influence responses to both emotional and physical pain.”
She also noted: “These findings have great importance for a social system such as ours that is characterized by wide disparities in financial wellbeing.”
Zhou, Vohs and Baumeister determined that interpersonal rejection and physical pain caused desire for money to increase. They said: “Money can possibly substitute for social acceptance in conferring the ability to obtain benefits from the social system. Moreover, past work has suggested that responses to physical pain and social distress share common underlying mechanisms.”
“Handling money (compared with handling paper) reduced distress over social exclusion and diminished the physical pain of immersion in hot water. Being reminded of having spent money, however, intensified both social distress and physical pain,” the authors said.
Sep
5
2023
Health Policy. 2005 Dec;75(1):85-98.
Cost-effectiveness of an active implementation strategy for the Dutch physiotherapy guideline for low back pain.
Hoeijenbos M, Bekkering T, Lamers L, Hendriks E, van Tulder M, Koopmanschap M.
Institute for Medical Technology Assessment, during research, Erasmus Medical Centre Rotterdam, The Netherlands.
BACKGROUND AND PURPOSE: The treatment for patients with low back pain varies considerably. The Dutch Physiotherapy Association issued an evidence-based physiotherapy guideline for non-specific low back pain. To establish changes in daily practice an active implementation strategy was developed. We evaluated the cost-effectiveness of this implementation strategy.
SUBJECTS: 113 physiotherapists included 500 patients with low back pain.
METHODS: In the intervention group the guideline was implemented actively, in the control group the standard method of dissemination was used. The patients filled in questionnaires at baseline and 6, 12, 26 and 52 weeks later. Direct medical costs, productivity costs (due to absenteeism) and quality of life (EQ-5D) were calculated.
RESULTS: During the 1-year follow up, no differences were found in the quality of life, direct medical costs and productivity costs.
CONCLUSION: The active implementation strategy appears not to be cost effective as compared to the standard strategy.
