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Case history: 2 week history of low back pain at thoracolumbar junction following a squat session, struggling to sleep. Pain on left rotation, side flexion bilaterally and in extension on left over T/L junction. Eased on flexion. Treated with directional preference in to flexion and 1x manual therapy & education, ODI 20 to 0 in 6 days. In my view the real work starts now as 70% have an aggravation in the following year. I think we need to avoid being "too positive" as there a re clear risk factors for recurrence patients can work on as part of working towards their goals.
9.3.3 Hypoglutaminergic State
A decrease in glutamate in the medial prefrontal cortex has been extensively found in animal models of chronic pain. The medial prefontal cortex is implicated in emotional appraisal, cognition and extinction of fear. Thus Naylor et al (2019) wondered if a potential decrease in glutamate could be associated with increased pessimistic thinking, fear and worry symptoms commonly found in people with chronic pain? To investigate this they put 19 chronic pain subjects and 19 age- and gender matched control subjects without pain through magnetic resonance spectroscopy. Both groups also completed the Temperament and Character Inventory, the Beck Depression and the State Anxiety Inventories to measure levels of harm avoidance, depression and anxiety, respectively. As is typically found subjects with chronic pain had significantly higher scores in harm avoidance, depression and anxiety, as well as significant decreases in medial prefrontal cortex glutamate levels compared to control subjects. Furthermore, the lower the concentration of glutamate in the medial prefrontal cortex, the greater the total scores of harm avoidance. High scores are associated with fearfulness, pessimism and fatigue-proneness, typical of yellow flags associated with worse outcomes in chronic low back pain patients and of the psychological symptoms seen in chronic overlapping pain conditions. Naylor et al (2019) suggest that chronic pain, particularly the stress-induced release of glucocorticoids, induces changes in glutamate transmission in the medial prefrontal cortex, thus influencing cognitive and emotional processing.
References
Naylor, B., Hesam-Shariati, N., McAuley, J., Boag, S., Newton-John, T., Rae, C. and Gustin, S.M., 2019. Reduced glutamate in the medial prefrontal cortex is associated with emotional and cognitive dysregulation in people with chronic pain. Frontiers in Neurology, 10, p.1110.
Rationale For Short Foot Exercises
Okamura et al (2019) produced fantastic results with a randomized controlled single-blind trial involving 20 participants with pes planus who were randomly allocated to a short-foot exercise group (exercise) or a control group (controls). Exercise patients performed a progressive short-foot exercise three times per week for 8 weeks; controls received no intervention. Before and after the 8-week intervention, foot kinematics during gait, including dynamic navicular drop—the difference between navicular height at heel strike and the minimum value—and the time at which navicular height reached its minimum value were assessed, using three-dimensional motion analysis. We assessed static foot alignment by foot posture index and navicular drop test, and the thickness of the intrinsic and extrinsic foot muscles using ultrasound. All measurements were performed by one investigator (KO) blinded to the participants' allocation. After the 8-week intervention in the exercise group, foot posture index scores with regard to calcaneal inversion/eversion improved significantly. Moreover, the time required for navicular height to reach the minimum value decreased significantly. These results whilst theoretically plausible seem almost too good to be true.
References
Okamura, K., Fukuda, K., Oki, S., Ono, T., Tanaka, S. and Kanai, S., 2019. Effects of plantar intrinsic foot muscle strengthening exercise on static and dynamic foot kinematics: A pilot randomized controlled single-blind trial in individuals with pes planus. Gait & Posture.
Theoretically the superior cluneal nerve may be sensitised at;
1. The origin from the nerves of T11-L4 or their posterior branches. Thus sensitivity could arise from direct irritation of the nerve roots secondary to disc lesions, or lateral recess stenosis.
2. Compression or potentially inflammation from the psoas major or erector spinae as the nerve passes through them.
3. Compression from the thoracolumbar fascia or in the osteofibrous canals over the iliac crest if the patient has them.
4. Obesity could lead to increased fat deposition both within the nerve itself (SEE SCIATIC NERVE SECTION) and outside which may lead to compression.
5. Trauma could lead to direct trauma to the nerves as the traverse the iliac crest or irritation of the nerves secondary to bruising or inflammation.
6. Error during bone graft harvest at the iliac crest has also been suggested as a possible cause of neuropathy (Tubbs et al 2010).
In addition a combination of these factors may lead to a sensitivity in the superior cluneal nerve distribution.
7.7 Religion. Is God Causing Your Low Back Pain?
Religion is sometimes asked for on admissions forms, usually as a form of monitoring who is gaining access to healthcare resources and sometimes so that religious preferences can be respected. However, religion has received only a little attention as a mediator of the pain experience.
7.7.1 The Low Back of a Buddhist and a Christian are Running On Different Software
Wallden & Chek (2018) argue the case that currently medicine lacks “soul”. They highlight that the majority of clinicians and patients are not atheists. Furthermore an awareness of how unconscious behavioral programming accounts for the majority of lifestyle habits and perceptions, may facilitate more effective outcomes. Our religious beliefs greatly influence these behaviours. Meaning the “software” that runs a Christian is different to that of a Buddhist or and Atheist. For example In a meta-analysis of 147 independent studies of religiousness and depressive symptoms, religiousness appeared to protect against depression, particularly in times of major life stress. The Bio-Psycho-Social-Spiritual Model suggests individuals’ spirituality and spiritual forms may play an important role in coping with illness and pain (Wachholtz et al 2007). Whilst everyone enjoys adding new parts to models perhaps spirituality should just be considered as a potential mediator of pain in low back pain patients within whichever framework or model clinicians are already using.