Jaro Karppinen

Pathobiology of Modic changes

PurposeLow back pain (LBP) is the most disabling condition worldwide. Although LBP relates to different spinal pathologies, vertebral bone marrow lesions visualized as Modic changes on MRI have a high specificity for discogenic LBP. This review summarizes the pathobiology of Modic changes and suggests a disease model.MethodsNon-systematic literature review.ResultsChemical and mechanical stimulation of nociceptors adjacent to damaged endplates are likely a source of pain. Modic changes are adjacent to a degenerated intervertebral disc and have three generally interconvertible types suggesting that the different Modic change types represent different stages of the same pathological process, which is characterized by inflammation, high bone turnover, and fibrosis. A disease model is suggested where disc/endplate damage and the persistence of an inflammatory stimulus (i.e., occult discitis or autoimmune response against disc material) create predisposing conditions. The risk to develop Modic changes likely depends on the inflammatory potential of the disc and the capacity of the bone marrow to respond to it. Bone marrow lesions in osteoarthritic knee joints share many characteristics with Modic changes adjacent to degenerated discs and suggest that damage-associated molecular patterns and marrow fat metabolism are important pathogenetic factors. There is no consensus on the ideal therapy. Non-surgical treatment approaches including intradiscal steroid injections, anti-TNF-α antibody, antibiotics, and bisphosphonates have some demonstrated efficacy in mostly non-replicated clinical studies in reducing Modic changes in the short term, but with unknown long-term benefits. New diagnostic tools and animal models are required to improve painful Modic change identification and classification, and to clarify the pathogenesis.ConclusionModic changes are likely to be more than just a coincidental imaging finding in LBP patients and rather represent an underlying pathology that should be a target for therapy.

Chronic pain affects the whole person – a phenomenological study

Abstract Purpose: The aim of this qualitative study was to explore participants’ perspectives on the effects of chronic pain on the psychophysical unity. Methods: Thirty-four chronic pain outpatients were interviewed, and the transcribed interviews were analysed with Giorgi’s four-phase phenomenological method. The mean age of the participants was 48 years, and 19 of them were women. For 21 of the participants, the pain duration was more than 5 years, and most had degenerative spinal pain. Results: The results of this whole research project indicated that the phenomenon chronic pain consisted of four essential themes: Pain affects the whole person, invisibility, negativity, and dominance of pain. This study concentrates only on one theme “Chronic pain affects the whole person”, in which were found eight subthemes in the interviews. The strongest argument made by the participants was not the physical pain itself but the psychosocial consequences, such as distress, loneliness, lost identity, and low quality of life which were their main problems. Conclusions: In multidisciplinary holistic rehabilitation, it is essential to take care of the patient’s psychological distress. A potential source of psychosocial symptoms may be the subjective responses to experience of chronic pain due to the subjective meanings of pain. Implications for Rehabilitation About chronic pain Pain is an experience, not only an aversive sensation. Intensity of pain describes only the sensation, not the experience of pain. In chronic pain, the main complaint may be not the physical pain, but the distress. In rehabilitation, the patient needs to be taken as a whole person. Multidisciplinary rehabilitation, including patient counselling should be the fundamental part of treatment. In rehabilitation, the individual meaning of chronic pain needs to be disclosed.

Novel diagnostic and prognostic methods for disc degeneration and low back pain

Low back pain (LBP) is the world’s leading debilitating condition [1]. It is estimated that 80% of the general population in the United States will develop LBP at one point in time [2,3]. Such pain can lead to diminished daily function and quality of life and work disability [4,5]. Not surprisingly, spine surgery to address LBP is one of the top five surgeries performed in the United States [6] where approximately 90-billion US dollars in health-care expenses are used annually to treat LBP [7]. As data indicate, LBP is clearly related with detrimental socioeconomic and health-care consequences that motivate efforts to identify LPB risk factors to develop improved prevention and treatment strategies. n nAlthough the etiology of LBP is multifaceted, disc degeneration (DD) has been suggested to be one of the most prominent risk factors [8–11]. However, whether DD is synonymous with LBP continues to be a topic of immense controversy. In this article, we review the current data regarding pain generating pathways and epidemiological evidence associating DD with LBP. In further support of this association, we review novel disc imaging techniques that may increase LBP diagnostic sensitivity and specificity. Finally, we discuss relevant aspects of the field of pain genes that may shed further light as to the links between DD and pain.

Declining incidence of acromioplasty in Finland

Background and purpose — An increased incidence rate of acromioplasty has been reported; we analyzed data from the Finnish National Hospital Discharge Register. Patients and methods — During the 14-year study period (1998–2011), 68,877 acromioplasties without rotator cuff repair were performed on subjects aged 18 years or older. Results — The incidence of acromioplasty increased by 117% from 75 to 163 per 105 person years between 1998 and 2007. The highest incidence was observed in 2007, after which the incidence rate decreased by 20% to 131 per 105 person years in 2011. The incidence declined even more at non-profit public hospitals from 2007 to 2011. In contrast, it continued to rise at profit-based private orthopedic clinics. Interpretation — We propose that this change in clinical practice is due to accumulating high-quality scientific evidence that shows no difference in outcome between acromioplasty and non-surgical interventions for rotator cuff disease with subacromial impingement syndrome. However, the exact cause of the declining incidence cannot be defined based solely on a registry study. Interestingly, this change was not observed at private clinics, where the number of operations increased steadily from 2007 to 2011.

Although unseen, chronic pain is real—A phenomenological study

Abstract Background Research has emphasised the essential role of psychosocial risk factors in chronic pain. In practice, pain is usually verified by identifying its physical cause. In patients without any distinct pathology, pain is easily defined as imaginary pain. The aim of this qualitative study was to explore the invisibility of chronic pain, from the patients’ perspective. Methods Thirty-four participants with chronic pain were interviewed. The mean age of the participants was 48 years, and 19 of them were women. For 21 of the participants, the duration of pain was more than five years, and most of the participants had degenerative spinal pain. The transcribed interviews were analysed using Giorgi’s four-phase phenomenological method. Results The participants’ chronic pain was not necessarily believed by health care providers because of no identified pathology. The usual statements made by health care providers and family members indicated speculation, underrating, and denial of pain. The participants reported experience of feeling that they had been rejected by the health care and social security system, and this feeling had contributed to additional unnecessary mental health problems for the participants. As a result from the interviews, subthemes such as “Being disbelieved”, “Adolescents’ pain is also disbelieved”, “Denying pain”, “Underrating symptoms”, “The pain is in your head”, “Second-class citizen”, “Lazy pain patient”, and “False beliefs demand passivity” were identified. Conclusions In health care, pain without any obvious pathology may be considered to be imaginary pain. Despite the recommendations, to see chronic pain as a biopsychosocial experience, chronic pain is still regarded as a symptom of an underlying disease. Although the holistic approach is well known and recommended, it is applied too sparsely in clinical practice. Implications The Cartesian legacy, keeping the mind and body apart, lives strong in treatment of chronic pain despite recommendations. The biopsychosocial approach seems to be rhetoric.

Determinants of lumbar artery occlusion among patients with sciatica: A three-year follow-up with magnetic resonance angiography

We showed previously that chronic Chlamydia pneumoniae infection increases the risk of lumbar artery occlusion. We did not evaluate, however, the effect of other risk factors for cardiovascular diseases in combination with this chronic infection. The purpose of this study was to investigate the combined effect of chronic C. pneumoniae infection and other known determinants of artery occlusion in a population of sciatica patients. Two-dimensional time-of-flight magnetic resonance angiography (MRA) was used to evaluate lumbar arteries at baseline and threexa0years. The arteries on both sides (L1–L4) were evaluated visually and scored as normal, narrowed or occluded. Logistic regression analysis was performed separately for baseline total arterial stenosis and each L1–L4 segmental artery pair, and for incident new stenosis during the follow-up period. The determinants analyzed included age, body mass index (BMI, kg/m2), education, gender, and smoking, in addition to presence of chronic C. pneumoniae infection. MRA was obtained at baseline for 147 patients and at 3xa0years for 134 patients. Sixty-four (47.8%) of 134 patients had new arterial stenosis. Total incidence of new arterial stenosis was distributed quite evenly between the individual segmental levels, varying from 12.7 to 18.6%. BMI was the only predictor of new arterial stenosis (odds ratio (OR) 1.13). A reasonable logistic model could be established only for baseline L4 and total arterial scores. At L4, education was a protective factor (OR 0.07), whereas age (OR for the oldest age group 6.7) and BMI (OR 1.17) were associated with increased risk of occlusion. For total arterial score, chronic C. pneumoniae infection was an independent determinant of arterial occlusion, increasing the risk to almost eightfold. Additionally, BMI (OR 1.16), and age (for the oldest age group OR 11.4) were significant determinants for stenosis. Smoking was not statistically significant. As chronic C. pneumoniae infection was an independent determinant of lumbar artery occlusion, treatments of this chronic infection may have an impact on lumbar diseases. The importance of BMI for new arterial stenosis suggests that weight reduction may also have a beneficial effect in lumbar artery disease.

Revising the negative meaning of chronic pain – A phenomenological study

Objectives Chronic pain may disable the body, depress the mind and ruin the quality of life. The aim of this study was to use the participants’ personal experiences to explore the meaning of the experience of chronic pain and to find successful ways to manage chronic pain. Methods Thirty-four participants with chronic pain were interviewed. The transcribed interviews were analysed using Giorgi’s phenomenological method consisting of four phases: (1) reading the transcriptions several times, (2) discriminating meaning units, (3) collecting meaning units into groups and (4) the synthesis. Results The participants stated that the key to managing chronic pain was to reconsider the individual meaning of the experience of pain. As a result of the interviews, seven subthemes were found based on the ‘Negativity of chronic pain’, namely, ‘State of reflection’, ‘Reconsidering values’, ‘Acceptance of pain’, ‘Support network’, ‘Altered self’, ‘Joys in life’ and ‘Pain dissociation’. Conclusions Pain is an aversive sensation, which leads to the conclusion that the meaning of the experience is also negative, but it can be reversed. In clinical practice, the focus should be on revising the subjective meaning of pain in order to manage pain and to restore positivity in personal life.

Structural vertebral endplate nomenclature and etiology: a study by the ISSLS Spinal Phenotype Focus Group

PurposeVertebral endplate abnormalities may be associated with disc degeneration and, perhaps, pain generation. However, consensus definitions for endplate findings on spine MRI do not exist, posing a challenge to compare findings between studies and ethnic groups. The following survey was created to characterize the variability among the global spine community regarding endplate structural findings with respect to nomenclature and etiology.MethodsA working group within the International Society for the Study of the Lumbar Spine (ISSLS) Spinal Phenotype Focus Group was established to assess the endplate phenotype. A survey which consisted of 13 T2-weighted sagittal MRIs of the human lumbar spine illustrating the superior and inferior endplates was constructed based on discussion and agreement by the working group. A list of nomenclature and etiological terms with historical precedence was generated. Participants were asked to describe the endplates of each image and select from 14 possible nomenclatures and 10 etiological terms along with the option of free text response. The survey was entered into RedCap and was circulated throughout the ISSLS membership for data capture. Participants’ demographics were also noted.ResultsThe survey was completed by 55 participants (87% males; 85% above 45xa0years of age, 39 clinicians, and 16 researchers). Sixty-eight percent of researchers and seventy-four percent of clinicians reported more than 16 and 20xa0years of research and clinical experience. Considerable variation existed in selection of nomenclature, etiology, and degree of severity of the endplate structural findings (reliability coefficients for single measures in each case were 0.3, 0.08, and 0.2, respectively). Sixty-seven percent regarded Modic changes as being a structural endplate finding. Approximately 84 and 80% of clinicians and researchers, respectively, agreed that a standardized endplate nomenclature and understanding the etiology is clinically important and needed.ConclusionsThis study found that variations exist with respect to endplate nomenclature and etiology between clinicians and basic scientists, and paves the way for a consensus process to formalize the definitions.

Lifestyle Risk Factors Increase the Risk of Hospitalization for Sciatica: Findings of Four Prospective Cohort Studies

BACKGROUNDnThe purpose of this study is to assess the effects of lifestyle risk factors on the risk of hospitalization for sciatica and to determine whether overweight or obesity modifies the effect of leisure-time physical activity on hospitalization for sciatica.nnnMETHODSnWe included 4 Finnish prospective cohort studies (Health 2000 Survey, Mobile Clinic Survey, Helsinki Health Study, and Young Finns Study) consisting of 34,589 participants and 1259 hospitalizations for sciatica during 12 to 30 years of follow-up. Sciatica was based on hospital discharge register data. We conducted a random-effects individual participant data meta-analysis.nnnRESULTSnAfter adjustment for confounding factors, current smoking at baseline increased the risk of subsequent hospitalization for sciatica by 33% (95% confidence interval [CI], 13%-56%), whereas past smokers were no longer at increased risk. Obesity defined by body mass index increased the risk of hospitalization for sciatica by 36% (95% CI 7%-74%), and abdominal obesity defined by waist circumference increased the risk by 41% (95% CI 3%-93%). Walking or cycling to work reduced the risk of hospitalization for sciatica by 33% (95% CI 4%-53%), and the effect was independent of body weight and other leisure activities, while other types of leisure activities did not have a statistically significant effect.nnnCONCLUSIONSnSmoking and obesity increase the risk of hospitalization for sciatica, whereas walking or cycling to work protects against hospitalization for sciatica. Walking and cycling can be recommended for the prevention of sciatica in the general population.

Short-term assessment of autonomic nervous system as a potential tool to quantify pain experience

Various pain conditions may result in altered autonomic nervous system regulation. We evaluated whether autonomic regulation, analyzed with short-term heart rate variability (HRV), differs between low back pain (LBP) patients and healthy controls. Additionally, we tested if short-term HRV recordings are feasible and informative in planning home monitoring of LBP patients. The study population consisted of 16 volunteers (8 LBP patients and 8 healthy subjects) (age 42±10 years, body mass index 26±4 kg/m2, 7 men and 9 women). Usually 3- to 5-minute R-R interval recordings have been used as short-term recordings of HRV, but recent evidence supports even shorter R-R interval recording procedure for short-term HRV assessment. We collected R-R interval data for 1 minute in sitting, standing and bending down tasks. Mean heart rate (HR) and vagally mediated beat-to-beat variability (SD1 and rMSSD) were analyzed. The results showed that autonomic nervous system function assessed with the short-term measurement HRV method differentiates LBP patients from healthy controls in sitting and standing. Vagally mediated SD1 and rMSSD were significantly lower and the HR was higher among the patients compared to the controls. A novel finding was also the feasibility of 1-minute measurement of HRV, which may open entirely new opportunities to assess accurately concomitant changes in autonomic nervous system function and self-reported individual pain experience. This could lead to a more personalized pain treatment and more efficient health care resource allocation as the new measurement methods is more suitable for home monitoring than the previously used ones.