Bengt H. Sjölund

Acupuncture for chronic low back pain: a randomized placebo-controlled study with long-term follow-up.

ObjectiveThe authors sought to determine whether a series of needle acupuncture treatments produced long-term relief of chronic low back pain. DesignA blinded placebo-controlled study with an independent observer. The patients were randomized to receive manual acupuncture, electroacupuncture, or active placebo (mock transcutaneous electrical nerve stimulation). Subjects were examined and monitored by an investigator who was blinded to the treatment given. SettingA tertiary-level pain clinic at a Swedish university hospital. PatientsFifty consecutive patients (33 women, 17 men; mean age, 49.8 years) with chronic low back pain (mean pain duration, 9.5 years) and without rhizopathy or history of acupuncture treatment were included in the study. InterventionsTreatments were given once per week for 8 weeks. Two further treatments were given during the follow-up assessment period of 6 months or longer. Outcome MeasuresThe independent observer made a global assessment of the patients 1, 3, and 6 months after treatment. The patients kept pain diaries to score pain intensity twice daily, analgesic intake, and quality of sleep daily, and activity level weekly. ResultsAt the 1-month independent assessment, 16 of 34 patients in the acupuncture groups and 2 of 16 patients in the placebo group showed improvement (p <0.05). At the 6-month follow-up assessment, 14 of 34 patients in the acupuncture groups and 2 of 16 patients in the placebo group showed improvement (p <0.05). A significant decrease in pain intensities occurred at 1 and 3 months in the acupuncture groups compared with the placebo group. There was a significant improvement in return to work, quality of sleep, and analgesic intake in subjects treated with acupuncture. ConclusionsThe authors found a long-term pain-relieving effect of needle acupuncture compared with true placebo in some patients with chronic nociceptive low back pain.

TENDER OR NOT TENDER: TEST-RETEST REPEATABILITY OF PRESSURE PAIN THRESHOLDS IN THE TRAPEZIUS AND DELTOID MUSCLES OF HEALTHY WOMEN

OBJECTIVE To examine the test-retest repeatability of pressure pain thresholds in the shoulder muscles of healthy women. DESIGN Four experimental sessions (days 1, 3, 28, 30), each including 4 consecutive pressure pain threshold measurements at 10-minute intervals. SUBJECTS Twenty-four healthy female volunteers, mean age 42 years. METHODS Two examiners measured pressure pain thresholds bilaterally over the trapezius and deltoid muscles with an electronic algometer. Students paired t-test, intraclass correlation coefficient, ANOVA repeated measures, 95% confidence interval and mean maximal absolute measurement error, were used for statistics. RESULTS Reliability for each point in all sessions was high; ICC range 0.70-0.94, mean maximal differences; 53-102 kPa (all 4 muscles), and between points in each muscle: ICC right trapezius 0.59-0.77, left 0.67-0.84, right deltoid 0.66-0.83, left 0.70-0.90. Mean maximal differences were 69-101 kPa and 65-111 kPa for the trapezius and deltoid muscles, respectively. The inter-individual variation was 5-fold (trapezius 88-574 kPa; deltoid 91-529 kPa). At the group level, the variation was limited when the first measurement was excluded. Inter-rater and intra-rater repeatability was high without significant differences. Only small side-to-side differences were seen. CONCLUSION Repeated measurements show stable intra-individual values. The method can be recommended when used by trained and experienced examiners.

Pressure pain thresholds and electromyographically defined muscular fatigue induced by a muscular endurance test in normal women.

OBJECTIVE This study was undertaken to examine the relation between muscular tenderness measured as pressure pain thresholds (PPTs) and electromyographic (EMG) signs of fatigue before and after a local standardized static muscle contraction. DESIGN Pressure pain thresholds were measured in the shoulder region before, immediately after, and 10 minutes after a standardized static endurance test while monitoring the EMG signs of local muscular fatigue and its recovery. The study did not address local biochemical issues. SETTING The study was conducted at the Department of Rehabilitation, Lund University Hospital, Lund, Sweden. SUBJECTS Twenty-five healthy female volunteers without musculoskeletal problems participated in this study. INTERVENTION A static endurance test was performed, which consisted of a submaximal unilateral activation of the right trapezius and deltoid muscles for as long as possible. OUTCOME MEASURES Bilateral PPTs over the trapezius and deltoid muscles were measured with an electronic pressure algometer. Established surface EMG parameters of local muscular fatigue were assessed. The Borg Rating of Perceived Exertion scale was used. RESULTS The average endurance time was 330 seconds. Immediately after the test, significant bilateral increases in the normalized PPTs over both muscles were found, although the increase was more pronounced on the test side: over the right trapezius muscle by 13% (p <0.001), over the right deltoid muscle by 23% (p <0.001), and over the left trapezius and deltoid muscles by 6% (p = 0.04) and (p = 0.009), respectively. These increases persisted 10 minutes after the end of the test. The subjects developed significant signs of fatigue as defined by EMG criteria in both muscles on the right side during the test. The recovery from fatigue was approximately half complete 15 seconds after the end of the test and complete or almost complete 10 minutes thereafter. CONCLUSIONS Pressure pain thresholds over shoulder muscles remained elevated up to 10 minutes after a unilateral static endurance test. This time course was completely different from that of EMG-defined muscle fatigue, which showed a fast recovery. These findings indicate that the mechanisms of recovery from fatigue and nociception are independent of each other. The bilateral PPT increases might be explained by central antinociceptive mechanisms activated by static muscle work.

Constraint-induced movement therapy in patients with stroke: a pilot study on effects of small group training and of extended mitt use

Objective: (1) To evaluate constraint-induced movement therapy for chronic stroke patients modified into group practice to limit the demand on therapist resources. (2) To explore whether extended mitt use alone may enhance outcome. Design: A combined case-control and randomized controlled study with pre- and post-treatment measures by blinded observers. Setting: A university hospital rehabilitation department. Participants: Sixteen stroke patients (nine men and seven women; mean age 56.7 years; on average 28.9 months post stroke, five of whom were 6-9 months post stroke) with moderate motor impairments in the contralateral upper limb. Intervention: Constraint-induced therapy (mitt on the less affected hand 90% of waking hours for 12 days) with 2-3 patients per therapist and 6 h of group training per day. After the training period, the patients were randomized either to using the mitt at home every other day for two-week periods for another three months (in total 21 days) or to no further treatment. Outcome measures: Modified Motor Assessment Scale, Sollerman Hand Function Test, Two-Point Discrimination test and Motor Activity Log. Results: The mean motor performance improved significantly after two weeks of constraint-induced group therapy on Motor Assessment Scale (1.44 (95% confidence interval (95% CI) 0.59-2.28) points; P = 0.003) and on Sollerman Hand Function Test (3.81 (95% CI 0.26-7.36) points; P = 0.037) but showed no sensory change in the Two-Point Discrimination Test (P = 0.283). The median difference in self-reported motor ability (Motor Activity Log) also improved (P B=0.001). However, no additional effect was seen from wearing a mitt for another three months. Conclusion: Constraint-induced group therapy, allowing several patients per therapist, seems to be a feasible alternative to improve upper limb motor function. The restraint alone, extended in time, did not enhance the treatment effect.

Shortened constraint-induced movement therapy in subacute stroke - no effect of using a restraint : a randomized controlled study with independent observers

OBJECTIVE To examine the effect of using a mitt during shortened constraint-induced movement therapy for patients in the subacute phase after stroke. SUBJECTS Twenty-four patients with stroke (mean age 57.6 (standard deviation (SD) 8.5) years; average 7 weeks post-stroke) with mild to moderate impaired hand function. METHODS The patients were randomized to mitt use or no mitt use on the less affected hand for 90% of waking hours for 12 days. All patients received 3 h of arm and hand training per day for 2 weeks. Assessments were made by blinded observers using the modified Motor Assessment Scale, the Sollerman hand function test, the 2-Point Discrimination test and Motor Activity Log test. RESULTS Patients in both groups showed significant improvements in arm and hand motor performance and on self-reported motor ability after 2 weeks of therapy and at 3 months follow-up. However, no statistically significant differences between the groups were found in any measures at any point in time. CONCLUSION In this study, no effect of using a restraint in patients with subacute stroke was found. Thus, this component in the constraint-induced therapy concept seems to be of minor importance for the outcome.

Do Multidimensional Pain Inventory Scale score changes indicate risk of receiving sick leave benefits 1 year after a pain rehabilitation programme

Purpose. To study whether scale score changes in the Multidimensional Pain Inventory ((MPI)) can predict which persons disabled by pain will receive sick leave benefits 1 year after completing a pain rehabilitation programme. Method. An observational study of MPI data derived from 1468 patients, 388 men and 1080 women, who had participated in multidisciplinary cognitive-behavioural oriented pain rehabilitation programmes in Sweden, collected from the Swedish Quality Register for Pain Rehabilitation, before, at the end and 1 year after the programme. Results. Most MPI scale scores showed improvements after completing a pain rehabilitation programme and this improvement was sustained after 1 year. Moreover, we found that a decrease in MPI scales scores for Pain severity and Interference immediately after the pain rehabilitation programme decreased the risk of being on full-time sick leave 1 year later [[OR 0.85, ((95%% CI 0.73–0.99)) and OR 0.73, ((95%% CI 0.61–0.87)), respectively]]. The Interference scale, which may be considered to include ICF components of both activities and participation, might represent the core of suffering among persons disabled with pain. Conclusions. A rehabilitation intervention directed to combating the consequences of pain in activities and participation rather than against pain per se might lead to improved working capacity.

Mode of hand training determines cortical reorganisation: A randomized controlled study in healthy adults

OBJECTIVE To evaluate two commonly used forms of hand training with respect to influence on dexterity and cortical reorganization. SUBJECTS Thirty healthy volunteers (mean age 24.2 years). METHODS The subjects were randomized to 25 min of shaping exercises or general activity training of the non-dominant hand. The dexterity and the cortical motor maps (number of excitable positions) of the abductor pollicis brevis muscle were evaluated pre- and post-training by the Purdue Peg Board test and transcranial magnetic stimulation, respectively. RESULTS After shaping exercises the dexterity increased significantly (p < or = 0.005) for both hands, mostly so in the non-dominant hand. The cortical motor map of the abductor pollicis brevis muscle shifted forwardly into the pre-motor area without expanding. After general activity training, no significant improvements in dexterity were found for the non-dominant hand. The cortical motor map of the non-dominant abductor pollicis brevis muscle expanded significantly (p = 0.03) in the posterior (sensory) direction. CONCLUSION These results indicate that shaping exercises, but not general activity training, increase dexterity of the trained non-dominant hand in parallel with a shift of location of active transcranial magnetic stimulation positions. Shifts of active cortical areas might be important for the interpretation of brain plasticity in common behavioural tasks.

Sensory functions in the foot soles in victims of generalized torture, in victims also beaten under the feet (falanga) and in healthy controls – A blinded study using quantitative sensory testing

BackgroundFalanga torture (beatings on the foot soles) produces local chronic pain and severe walking difficulties. We have previously reported signs of neuropathic pain in the feet of falanga victims. The objective here was to clarify underlying pain mechanisms by quantifying sensory impairments in the feet of torture victims who had experienced both generalized torture and those who had been exposed to falanga in addition. An ethnically matched control group was available.MethodsWe employed quantitative sensory testing (QST) by investigators blinded to whether the patients, 32 male torture victims from the Middle East, had (n=15), or had not (n=17) been exposed to falanga. Pain intensity, area and stimulus dependence were used to characterize the pain as were interview data on sensory symptoms. QST included thresholds for touch, cold, warmth, cold-pain, heat-pain, deep pressure pain and wind-up to cutaneous noxious stimuli in the foot soles. Clinical data on anxiety and depression were retrieved.ResultsAlmost all falanga victims had moderate or strong pain in their feet and in twice as large an area of their foot soles as other torture victims. One-third of the latter had no pain in their feet and many reported slight pain; in spite of this, there were no differences in foot sole QST data between the tortured groups. A comparison with normal data indicated that both tortured groups had hypoesthesia for all cutaneous sensory fibre groups except those transmitting cold and heat pain, in addition to deep mechano-nociceptive hyperalgesia.ConclusionA comparison of the QST data between victims having been exposed to generalized torture and victims who in addition had been exposed to falanga, showed no differences on the group level. The sensory disturbances in relation to our control group are compatible with central sensitization and de-sensitization, pointing to a core role of central mechanisms. A further analysis to create individual sensory profiles from our measurements is in progress.

Pain when walking: individual sensory profiles in the foot soles of torture victims - a controlled study using quantitative sensory testing

BackgroundWith quantitative sensory testing (QST) we recently found no differences in sensory function of the foot soles between groups of torture victims with or without exposure to falanga (beatings under the feet). Compared to matched controls the torture victims had hyperalgesia to deep mechano-nociceptive stimuli and hypoesthesia to non-noxious cutaneous stimuli. The purpose of the present paper was to extend the group analysis into individual sensory profiles of victims’ feet to explore possible relations between external violence (torture), reported pain, sensory symptoms and QST data to help clarify the underlying mechanisms.MethodsWe employed interviews and assessments of the pain and sensory symptoms and QST by investigators blinded to whether the patients, 32 male torture victims from the Middle East, had (n=15), or had not (n=17) been exposed to falanga. Pain intensity, area and stimulus dependence were used to characterize the pain. QST included thresholds for touch, cold, warmth, cold-pain, heat-pain, deep pressure pain and wind-up to cutaneous noxious stimuli. An ethnically matched control group was available.The normality criterion, from our control group data, was set as the mean +/− 1.28SD, thus including 80% of all values.QST data were transformed into three categories in relation to our normality range; hypoesthesia, normoesthesia or hyperesthesia/hyperalgesia.ResultsMost patients, irrespective of having been exposed to falanga or not, reported severe pain when walking. This was often associated with hyperalgesia to deep mechanical pressure. Hypoesthesia to mechanical stimuli co-occurred with numbness, burning and with deep mechanical hyperalgesia more often than not, but otherwise, a hypoesthesia to cutaneous sensory modalities did not co-occur systematically to falanga, pain or sensory symptoms.ConclusionIn torture victims, there seem to be overriding mechanisms, manifested by hyperalgesia to pressure pain, which is usually considered a sign of centralization. In addition there was cutaneous hypoesthesia, but since there was no obvious correlation to the localization of trauma, these findings may indicate centrally evoked disturbances in sensory transmission, that is, central inhibition. We interpret these findings as a sign of changes in central sensory processing as the unifying pathological mechanism of chronic pain in these persons.

Changes in multidimensional pain inventory profile after a pain rehabilitation programme indicate the risk of receiving sick leave benefits one year later

OBJECTIVES To determine whether coping profile changes after rehabilitation, assessed with the Multidimensional Pain Inventory (MPI), can predict which persons disabled by chronic musculoskeletal pain will be in receipt of sick leave benefits in the long term. METHODS Study of MPI data from 2,784 patients (709 men and 2,075 women) collected from the Swedish Quality Register for Pain Rehabilitation (SQRP) before and at the end of rehabilitation and compared with independent sick leave data for 1 year later. RESULTS After rehabilitation there was a significantly decreased share of Dysfunctional profiles (DYS) among both men (44% before, 31% after) and women (39% before, 26% after), but an increased share of Adaptive Coper profiles (men 15% before, 24% after, women 14% before, 24% after). The number of patients on full-time sick leave decreased significantly among men (from 57% to 46%) and women (from 57% to 50%). Persons with a DYS profile after rehabilitation had a low probability of having no or part-time sick leave. CONCLUSION The number of persons with DYS profiles decreased after rehabilitation. Those with other profiles had less full-time sick leave one year later than those with DYS profiles, indicating that leaving the DYS profile is a positive prognostic sign long-term. Furthermore, the gender differences observed suggest the need to tailor rehabilitative strategies differently for men and women.