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									                                  International Spine & Pain Institute

March 1, 2008

Volume 4, Issue 3
                                                         March 2008 Newsletter
Inside this issue:

Editorial                  1
                                 This month’s editorial is to           typical 9-5 job Monday to             hero’s – the people behind the
MD Q & A                   2     acknowledge the dedicated              Friday, but usually spend             scenes. For a well-orchestrated
                                 people that bring continuing           endles s hours s tudying,             event to occur, office and
Research                   3-5   education to you, day-after-           preparing and perfecting their        administrative personnel have to
                                 day, week-after-week and               skills. Add to this the hours and     process registrations, deal with
Schedule of courses        6     year-after-year. Having been           days away from family and             phone calls, inquiries,
                                 on both sides of the operation         friends to further this wonderful     complaints, special requests and
Research                   7     (attendee of courses/                  craft we are all a part of –          a lot more. These people do not
                                 conferences) as well as an             physical therapy.                     get the glory on the stage but
Mark Jones’s US Trip       8     organizer, instructor and host,                                              often have to deal with angry,
                                 we believe that most people            Seminar organizers roll in the        upset and plain rude people –
                                 that attend courses have little        money!! At least that is what a       sorry,    professional PHYSICAL
                                 understanding of the work,             quick calculation may have you        THERAPISTS – who should
 Research this month:            time, money and resources it           believe. Let me see if you have       know better. Our hats off to these
                                 takes to orchestrate an                it right (as you sit in the back of   people – we appreciate all you
 • Psychological issues          evening lecture, weekend                                                     do.
                                                                        the class): You count 30 people
   and whiplash                  seminar or conference. No –            in the class, each one paid
 • Subgroups of whiplash         this is not an editorial to                                                        This editorial is a small
                                 glorify seminar companies                                                          reminder that many people
 • Legislation & whiplash
                                 or instructors, but rather                                                         work very hard to help you
 • Aquatic therapy and           an attempt for therapists                                                          become a better therapist.
   Fibromyalgia                  to see that it takes a lot of                                                      It never hurts to say thank
 • Brain changes in              effort,      time       and                                                        you or even when
   Fibromyalgia                  commitment to bring high-                                                          conveying a concern, to do
                                 quality education to your                                                          so in a constructive and
 • Adrenaline and                doorstep.                                                                          respectful way.
                                 Everyone        (usually)
 • LBP in scoliosis              appreciates            the                                                         There – now let us all have
 • Failure rate of X-stop        instructors – hang on to their         $400, so you assume these             fun and continue to promote this
                                 e v e r y wo r d . O b v i o u s l y   guys are making a whopping            wonderful profession for what it is
 • Muscle activity in golf
                                 instructors appreciate this and        $12 000 this weekend! Have            – an awesome avenue to help
   players                                                                                                    people in need.
                                 it makes their efforts well worth      you ever thought that? Well I did
 • Antidromic impulses in        it. Instructors do, however,           – when I attended my first CEU
   nerves                        have to deal with bad                  class in the US. One needs to         Adriaan Louw - ISPI
 • Ion channels and              comments, attacks on                   realize there is a substantial
                                 philosophy as well as just plain       cost involved in putting on
   neuropathic pain
                                 nasty remarks. It is important         seminars – speakers, travel,
 • Spinal deformities in         to realize that most instructors       accommodation, CEU’s,
   athletes                      arrived where they are based           advertising, food, office help,
                                 on years of experience and             administration fees, etc. Realize
                                 excelling in a specific field of       there are people working
                                 their practice – usually through       extremely hard on a daily basis
                                 additional study, dedication to        to help you stay abreast of the
                                 their profession and plain hard        latest developments in your
                                 work.      I would (definitely)        profession.
                                 vouch for the fact that most
                                 instructors do not work the            And finally, there are the “silent”       
Page 2                      March 2008 Newsletter                                                      Volume 4, Issue 3

                               What have you found works best for RSD/CRPS? (i.e.,
MD                                              meds, PT, other?)

                               What happened to the           ease is not well understood       blocks and neuromodula-

Q&A                       easy questions? Let’s start
                          this by discussing the diagno-
                          sis. Firstly the current name
                                                              we change the name often,
                                                              so be ready for the new
                                                                                                tion are used in order to
                                                                                                reduce pain to promote PT/
                                                                                                OT.     Psychological inter-
                          of this disorder is Complex              In short there is no         vention is necessary for
                          Regional Pain Syndrome. It          GOOD treatment for CRPS.          patients to develop coping
                          has two subtypes, type 1,           We do have several treat-         and pain tolerance skills.
                          which arises without pres-          ments available which in-             The best treatment for
                          ence of incident and type 2         clude PT/OT, medications,         CRPS is early treatment.
                          which is resultant from a           interventional procedures         The longer the process con-
                          known injury. This is also          and psychological counsel-        tinues the more difficult it is
                          known by other names off the        ing. By enlarge the best          to arrest.
                          top of my head, these are           treatment is a multi-pronged
                          Reflex Sympathetic Dystro-          approach. A multifaceted
                          phy, Shoulder Hand Syn-             pain rehabilitation program
                          drome, Sudek’s atrophy and          includes all of these. Inter-
                          Causalgia. You must under-          ventional pain procedures
Dr. C LanFotopoulos, MD   stand that whenever a dis-          inc lud in g s ym pat heti c
Orthopedics                   Could you please explain the nerve ablation procedure
                                        including post-treatment rehab?
                               Wit Radiofrequency Abla-            Prior to performing the      same visit but sometimes I
                          tion (RFA) we are treating a        Ablation we must first confirm    need to for numerous rea-
                          very specific type of back          our diagnosis to the best of      sons. The reason this is
                          pain. We are treating facet         our ability. This is done first   important is that the multi-
                          mediated pain and facet me-         by patient history and physi-     fius is thought to play a
                          diated pain only. I stress this     cal exam. Next we block the       part in propriocetion of the
                          because I find a significant        medial branch on two sepa-        spine.    So rehabilitation
                          number of physicians do not         rate occasions using a long       should include spinal stabi-
                          actually try to diagnosis facet     and short acting anesthetic.      lization and care towards
                          mediated pain accurately.           If the patient has an appropri-   proprioception. The proce-
                          They merely consider it after       ate response to both of these     dure cannot be undone by
                          epidural injections and sacro-      differential blocks we then       any therapeutic modalities
                          iliac joint injections fail. I am   proceed to the RFA.               or maneuvers, remember
                          not going to discuss the diag-           In a RFA, we percutane-      we just burned the nerve.
                          nosis of facet mediated low         ously ligate the medial           So no specific therapies
                          back pain here because you          branch using radio waves to       should be avoided.        Of
                          all understand it unlike a few      heat a needle to eighty de-       note, the nerve can and will
                          of my colleagues.                   grees centigrade. We apply        regenerate in six to ten
                               Anatomically there is a        the heat to the nerve for         months at which time we
                          nerve called the Medial             ninety seconds assuring cell      may need to repeat the
    Questions for Dr.                                                                           procedure.
                          branch (not the median). It         death.       Even transected
    Fotopoulos? Just      separates medially from the         nerves can continue to con-
      send them to        dorsal root and innervates          duct electrical impulses for
                          the multifidus and the facet        up to twenty-one days. With    joint. It innervates both the       this in mind the patient may
                          facets of the exiting level and     not experience a reduction in
                          the level below. Our mission        pain for three weeks.
                          is to ligate this nerve to block     Post procedure rehab is
                          the sensation of pain from the next phase. I prefer not
                          the offending facet joint.       perform bilateral RFAs at the

March 2008 Newsletter                                                       Volume 4, Issue 3              Page 3

Legislative Change Is Associated With                      change-the 2001 and 2003               Conclusion. Health status of people
                                                           groups). Health status was as-         with whiplash improved after legislative
Improved Health Status in People With
                                                           sessed 2 years after injury by a       change. Design of compensation
Whiplash. Spine. 33(3):250-254, February 1,                telephone interviewer blinded to       schemes should be undertaken with
2008.                                                      the study hypotheses. The main         the understanding that the scheme
                                                           outcome measure was disability,        structure
Whiplash was the most prevalent injury in a compul-
                                                           as assessed by the Functional          m a y
sory, fault based, third party motor vehicle insurance
                                                           Rating Index (FRI). Pain and           h a v e
scheme in New South Wales, Australia. Legislative
                                                           health-related quality of life was     substan-
change removed financial compensation for "pain and
                                                           also assessed.                         tial   ef-
suffering" for whiplash, introduced clinical practice
                                                                                                  fects on
guidelines for its treatment; and changed regulations to Results. The mean FRI at 2 years
                                                                                                  the long-
permit earlier acceptance of compensation claims, and after injury was 38.0% for the
                                                                                                  t e r m
earlier access to treatment, for all types of injury.    1999 group, 31.8% for the 2001
                                                                                                  health of
                                                         group, and 30.1% for the 2003
Methods. Three independent groups of people with                                                  injured
                                                         group. Improvement in secondary
whiplash were identified from insurance data (before                                              people.
                                                         outcomes, including pain, also
legislative change-the 1999 group and, after legislative

A systematic literature review of psychological factors and                               associations between psychological factors
                                                                                          and LWS. Data on 21 possible psychological
the development of late whiplash syndrome. Pain. 2008                                     risk factors were included. The majority of find-
Mar;135(1-2):20-30. Epub 2007 Jun 13                                                      ings were inconclusive. Limited evidence was
This systematic literature review aims to    Methodological quality was assessed          found to support an association between lower
assess the prognostic value of psycho-       independently by two assessors. Data         self-efficacy and greater post-traumatic stress
logical factors in the development of late   extraction were carried out using a stan-    with the development of LWS. No association
whiplash syndrome (LWS). We included         dardised data extraction form. Twenty-       was found between the development of LWS
prospective cohort studies that provided     five articles representing data from 17      and personality traits, general psychological
a baseline measure of at least one psy-      cohorts were included. Fourteen articles     distress, wellbeing, social support, life control
chological variable and used outcome         were rated as low quality with 11 rated as   and psychosocial work factors. The lack of
measures relating to LWS (i.e. pain or       adequate quality. Meta-analysis was not      conclusive findings and poor methodological
disability persisting 6 months post in-      undertaken due to the heterogeneity of       quality of the studies reviewed highlights the
jury). A search of electronic databases      prognostic factors, outcome measures         need for better quality research. Self-efficacy
(Pubmed, Medline, Cinahl, Embase and         and methods used. Results were tabu-         and post-traumatic distress may be associated
Psychinfo) up to August 2006 was done        lated and predefined criterion applied to    with the development of LWS but this needs
using a predetermined search strategy.       rate the overall strength of evidence for    further investigation.

Quality of life in subgroups of individuals with
whiplash associated disorders. Eur J Pain. 2008 Jan
28 [Epub ahead of print]

BACKGROUND: The term whiplash                METHODS: Twenty-six pa-
associated disorders (WAD) includes a        tients with WAD and 18
wide range of complaints, with neck          healthy pain-free controls took
pain as predominating symptom. Living        part in the study. Thermal pain
with long term pain influences quality of    thresholds were measured in
life. In previous studies of other chronic   two sites (over the thenar and
pain patients, subgrouping has been          the trapezius muscle) using
made according to thermal pain thresh-       quantitative sensory testing
olds measured in quantitative sensory        (QST). Health related quality of
testing (QST).                               life (HRQoL) was assessed
                                             using the SF-36. The visual                  pain insensitive and pain sensitive. The pain
AIMS: The aims of the present study
                                             analogue scale was used to rate pain         insensitive group differed significantly from the
are threefold, (1) to evaluate thermal
                                             intensity and unpleasantness related to      pain sensitive group in the Role Emotional
pain thresholds and health related qual-
                                             the experimental situation.                  subscale of SF-36 (p=0.025).
ity of life in WAD patients compared to
healthy pain-free individuals, (2) to ex-    RESULTS: WAD patients are more sen-          CONCLUSIONS: Thermal pain hyperalgesia,
plore whether subgrouping of the WAD         sitive to thermal pain, and scored lower     especially for cold, seems to be a determinant
patients is possible according to thermal    on the SF-36 in all scales when com-         for subgrouping WAD patients. These results
pain thresholds over trapezius, and if so    pared with healthy pain-free individuals.    support that such a classification of a hetero-
(3) to explore differences between the       After analyzing clusters (K-means algo-      genous group could be of importance in tailor-
subgroups.                                   rithm) two subgroups of WAD emerge,          ing treatment and early interventions.

Page 4                             March 2008 Newsletter                                                           Volume 4, Issue 3

Attenuated adrenergic responses to exercise in women with                                         FM group compared with the control
                                                                                                  group. Significantly higher EMG ampli-
fibromyalgia--a controlled study. Eur J Pain. 2008 Apr;12(3):351-60.                              tude (%EMG(max)) during the contrac-
Epub 2007 Sep 10.                                                                                 tion phases was found in the FM than in
                                                                                                  the control group. Perceived exertion
The pathogenesis of widespread pain and         and self-reported physical activity, partici-     and pain responses to exercise were
fibromyalgia (FM) is unknown. Altered re-       pated. Maximal voluntary contraction              higher in the FM group than in the con-
sponses from the hypothalamus-pituitary-        (MVC), repetitive isometric contractions (6s      trols, without relationship to the sym-
adrenal axis, sympathetic nervous system        contraction and 4s resting phases) were           pathoadrenal responses. In conclusion;
and muscular system have been suggested         performed with both quadriceps muscles at         the exercise was perceived as being
as being of importance. The present study       30% of MVC until exhaustion. Muscle activ-        more painful and strenuous in the FM
was undertaken to determine: (i) whether the    ity was recorded from the quadriceps mus-         group. Muscle performance was altered
sympathoadrenal response to repetitive iso-     cles by surface electromyography (EMG).           with increased muscle activity during
metric contractions until exhaustion is al-     Plasma adrenalin (Adr), noradrenalin              the exercise. Women with FM showed
tered in patients with FM, and (ii) whether     (NAdr) and cortisol were measured and             an attenuated Adr response to repetitive
sympathoadrenal responses are associated        perceived exertion and pain reported during       isometric exercise.
with muscle fatigue and pain during exer-       exercise. Attenuated Adr responses with
cise. Nineteen women with FM, and 19            normal plasma NAdr and cortisol re-
healthy women matched for age, smoking          sponses were found during exercise in the

Effectiveness of aquatic therapy in the treatment of
fibromyalgia syndrome: a randomized controlled open study.
Rheumatol Int. 2008 Feb 16 [Epub ahead of print]
                                                                                                  The average of reduction in pain scores
The aim of this study was to investigate the    FIQ). All assessment parameters were              was 40% in Group1 and 21% in Group
efficacy of aquatic exercises in fibromyalgia   measured at baseline, and at weeks 4, 12,         II. However, this was still significant at
syndrome (FMS). A total of 63 patients were     and 24. There were statistically significant      week 24 only in the aquatic therapy
included and allocated to two groups. Group     differences in FIQ and NTP in both groups         group. A comparison of the two groups
I (n = 33) received an aquatic exercise pro-    at the end and during follow-up. Group I          showed no statistically significant differ-
gram and Group II (n = 30) received a home      showed a statistically significant decrease       ence for FIQ, NTP, and BDI scores ex-
-based exercise program for 60 min, 3x a        in BDI scores after 4 and 12 weeks that           cept VAS. Our results showed that both
week, over 5 weeks. Patients were evalu-        remained after 24 weeks. In Group II, a           aquatic therapy and home-based exer-
ated for pain (visual analogue scale, VAS),     significant decrease in BDI scores was            cise programs have beneficial effects on
number of tender points (NTP), Beck de-         observed at the end and during follow-up.         FIQ, BDI, and NTP. In pain manage-
pression inventory (BDI), and functional ca-    Also, a significant improvement was found         ment, only aquatic therapy seems to
pacity (fibromyalgia impact questionnaire,      in VAS at weeks 4 and 12 in both groups.          have long-term effects.

Striatal grey matter increase in patients suffering from fibromyalgia--a voxel-based
morphometry study. Pain. 2007 Nov; 132 Suppl 1: S109-116. Epub 2007, Jun 22
                                                             classified as a so-called dys-       nosis of primary fibromyalgia and 22
                                                             functional pain syndrome.            healthy controls. VBM revealed a con-
                                                             Patients with fibromyalgia           spicuous pattern of altered brain mor-
                                                             suffer     from      widespread,     phology in the right superior temporal
                                                             "deep" muscle pain and often         gyrus (decrease in grey matter), the left
                                                             report concomitant depres-           posterior thalamus (decrease in grey
                                                             sive episodes, fatigue and           matter), in the left orbitofrontal cortex
                                                             cognitive deficits. Clear evi-       (increase in grey matter), left cerebel-
                                                             dence for structural abnor-          lum (increase in grey matter) and in the
                                                             malities within the muscles or       striatum bilaterally (increase in grey
                                                             soft tissue of fibromyalgia          matter). Our data suggest that fi-
                                                             patients is lacking. There is        bromyalgia is associated with structural
                                                             growing evidence that clinical       changes in the CNS of patients suffer-
                                                             pain in fibromyalgia has to be       ing from this chronic pain disorder. They
                                                             understood in terms of patho-        might reflect either a consequence of
                                                             logical activity of central struc-   chronic nociceptive input or they might
                                                             tures involved in nociception.       be causative to the pathogenesis of
                                                             We applied MR-imaging and            fibromyalgia. The affected areas are
                                                             voxel-based morphometry, to          known to be both, part of the somato-
Fibromyalgia (FM), among other chronic          determine whether fibromyalgia is associ-         sensory system and part of the motor
pain syndromes, such as chronic tension         ated with altered local brain morphology.         system.
type headache and atypical face pain, is        We investigated 20 patients with the diag-
March 2008 Newsletter                                                         Volume 4, Issue 3             Page 5

Analysis of Low Back Pain in Adults with Scoliosis. Spine. 33(4):402-405, February 15, 2008.
Low back pain is a frequent complaint in        and the intensity of the pain were sought.    Conclusion. The pain felt by scoliotic adults
subjects with adult lumbar scoliosis. Few                                                     has several semiological features, in particu-
                                                Results. There was no difference be-
studies have taken an interest in the semi-                                                   lar the frequency of inguinal pain and crural-
                                                tween the 2 groups with regard to pain
ological specificities of lumbar pain in such                                                 gia. Lumbar scoliosis with a great curvature
                                                severity (duration and intensity). The pain
patients.                                                                                     and/or rotatory olisthesis increases the in-
                                                evolved more steadily in scoliotic pa-
                                                                                              tensity of low back pain in adults. These
Methods. Fifty adults with lumbar scoliosis     tients. Inguinal pain and cruralgia were
                                                                                              findings suggest that the magnitude of the
and suffering from chronic low back pain        particularly associated with scoliosis. In
                                                                                              curvature and the existence of rotatory olis-
and 50 non-scoliotic adults with chronic        scoliotics, the severity of the low back
                                                                                              thesis must be targeted for prevention and
low back pain, matched for age and gen-         pain correlated well with the radiologic
                                                                                              treatment of the chronic low back pain in
der underwent a standard examination.           aspects: Cobb angle, vertebral rotation
                                                                                              subjects with a lumbar scoliosis.
The characteristics of the pain described       and rotatory olisthesis. Cruralgia was
in the 2 groups were compared. Relation-        significantly associated with the presence
ships between the features of the scoliosis     of rotatory dislocation.

High failure rate of the interspinous                                   Electromyography of the trunk and abdomi-
distraction device (X-Stop) for the treatment                           nal muscles in golfers with and without low
of lumbar spinal stenosis caused by                                     back pain.
degenerative spondylolisthesis. European Spine                          J Sci Med Sport. 2008 Apr;11(2):174-81. Epub 2007 Apr
Journal; Volume 17 (2), February 2008; 188-192.                         12

The X-Stop interspinous distraction device has shown to be an           Twelve male golfers who experienced low back pain (LBP) whilst
attractive alternative to conventional surgical procedures in the       playing or practicing golf and 18 asymptomatic golfers were re-
treatment of symptomatic degenerative lumbar spinal stenosis.           cruited and divided into handicap-specific groups; low-handicap
However, the effectiveness of the X-Stop in symptomatic degen-          golfers, with a handicap between 0 and 12 strokes; and high-
erative lumbar spinal stenosis caused by degenerative spondylo-         handicap golfers, with a handicap of between 13 and 29 strokes.
listhesis is not known.
                                                                        The myoelectric activity of the lumbar erector spinae (ES) and
A cohort of 12 consecutive patients with symptomatic lumbar spi-        the external obliques (EO) was recorded via surface electromy-
nal stenosis caused by degenerative spondylolisthesis were              ography (EMG), whilst the golfers performed 20 drives. The root
treated with the X-Stop interspinous distraction device. All patients   mean square (RMS) was calculated for each subject and the
had low back pain, neurogenic claudication and radiculopathy. Pre       data for the ES and EO were normalised to the EMGs recorded
-operative radiographs revealed an average slip of 19.6%. MRI of        whilst holding a mass equal to 5% of the subjects' body mass at
the lumbosacral spine showed a severe stenosis. In ten patients,        arms length and whilst performing a double-leg raise, respec-
the X-Stop was placed at the L4–5 level, whereas two patients           tively.
were treated at both, L3–4 and L4–5 level. The mean follow-up
was 30.3 months.                                                        The results showed that the low-handicap LBP golfers tended to
                                                                        demonstrate reduced ES activity at the top of the backswing and
In eight patients a complete relief of symptoms was observed post       at impact and greater EO activity throughout the swing. The high-
-operatively, whereas the remaining 4 patients experienced no           handicap LBP golfers demonstrated considerably more ES activ-
relief of symptoms. Recurrence of pain, neurogenic claudication,        ity compared with their asymptomatic counterparts, whilst EO
and worsening of neurological symptoms was observed in three                                                activity tended to be similar
patients within 24 months. Post-operative radiographs and MRI                                               between the high-handicap
did not show any changes in the percentage of slip or spinal di-                                            groups. The reduced ES ac-
mensions. Finally, secondary surgical treatment by decompres-                                               tivity demonstrated by the
sion with posterolateral fusion was performed in seven patients                                             low-handicap LBP group may
(58%) within 24 months.                                                                                     be associated with a reduced
                                                                                                            capacity to protect the spine
In conclusion, the X-Stop interspinous distraction device showed                                            and its surrounding struc-
                                       an extremely high failure                                            tures at the top of the back-
                                       rate, defined as surgical re                                         swing and at impact, where
                                       -intervention, after short                                           the torsional loads are high.
                                       term follow-up in patients                                           When considering this with
                                       with spinal stenosis                                                 the increased EO activity
                                       caused by degenerative                                               demonstrated by these golf-
                                       spondylolisthesis. We do                                             ers, it is reasonable to sug-
                                       not recommend the X-                                                 gest that these golfers may
                                       Stop for the treatment of                                            be demonstrating character-
                                       spinal stenosis complicat-                                           istics/mechanisms that are
                                       ing degenerative spondy-                                             responsible for or are a
                                       lolisthesis.                                                         cause of LBP.

Page 6                   March 2008 Newsletter                              Volume 4, Issue 3

                 2008 Course Schedule

    Download registration forms and information from, or even register online

  Mar       1&2           Spinal Manipulation                        Kansas City, MO
  Mar       13            KC Evening Series: MCL & ACL Injuries      Kansas City, MO
  Mar       15 & 16       Manual Therapy for the Thoracic Spine      Lawrence, KS    SOLD OUT

  Mar       29 & 30       Manual Therapy for the Cervical Spine      Lincoln, NE     SOLD OUT

  Apr       5&6           Differential Diagnosis: Lower Quadrant     Liberty, MO
  Apr       5&6           Mobilization of the Nervous System (NOI)   Moscow, ID
  Apr       10            Saint Louis Evening Series: Shoulder       Saint Louis, MO
  Apr       19 & 20       Explain Pain (NOI)                         Medford, OR
  Apr       26 & 27       Differential Diagnosis: Upper Quadrant     Ankeny, IA      SOLD OUT

  Apr       26 & 27       Differential Diagnosis: Upper Quadrant     Las Vegas, NV
  May       3&4           Explain Pain (NOI)                         Baltimore, MD
  May       3&4           Lumbar Spine Surgery Rehab                 Dallas, TX
  May       15            Kansas City 1010 Evening Class             Kansas City, MO
  May/June 31 & 1         Mobilization of the Nervous System (NOI)   Glendale, CA
  May/June 31 & 1         Explain Pain (NOI)                         Portland, OR
  July      22            Understand & Explain Pain: Lorimer Moseley Kansas City, MO
  Sept      6&7           Explain Pain (NOI)                         Salina, KS
  Oct       18 & 19       Manual Therapy for the Lumbar Spine        Dallas, TX
  Oct       25 & 26       Mobilization of the Nervous System (NOI)   Jefferson City, MO
  Nov       08 & 09       Explain Pain (NOI)                         Overland Park, KS
  Nov       15 & 16       Spinal Manipulation                        Las Vegas, NV
  Nov       15 & 16       Explain Pain (NOI)                         Albuquerque, NM
  Dec       06 & 07       Segmental Spinal Stabilization             Liberty, MO

March 2008 Newsletter                                                          Volume 4, Issue 3                Page 7

Neurophysiological Evidence of Antidromic Activation of Large Myelinated Fibres in Lower
Limbs During Spinal Cord Stimulation. Spine. 33(4):E90-E93, February 15, 2008.
This study was designed to verify the          have been conducted on this subject.               Results. The results confirmed the hypothe-
hypothesis of a constant, antidromic                                                              sis that cutaneous afferents were regularly
                                               Methods. Sixteen patients undergoing a
activation of fibers traveling along pe-                                                          activated by SCS.
                                               percutaneous test trial of SCS for chronic
ripheral sensory nerves during spinal
                                               pain in the lower limb (4 males, 12 females,       Conclusion. The authors hypothesize that
cord stimulation (SCS).
                                               mean age of 54.2, and age range 41-77              this antidromic activation could represent a
Objective. To investigate the neuro-           years) were enrolled. Diagnoses included:          possible antalgic mechanism of SCS in pa-
physiological characteristics (latency,        failed back surgery syndrome, complex              tients with peripheral neuropathic pain, but
amplitude, waveform) of potentials re-         regional pain syndrome type I, painful lum-        further neurophysiological studies will be
corded in peripheral sensory nerves            bosacral radiculopathy, and painful periph-        needed to elucidate this hypothesis.
during the SCS.                                eral neuropathy. All patients had a lead
                                               percutaneously implanted in the epidural
Summary of Background Data. SCS is
                                               space at a vertebral level ranging from T9-
widely used for the relief of chronic be-
                                               T12. Nerve action potentials were generally
nign pain resistant to conservative
                                               recorded in nonpainful leg but, when the
therapies, but its antalgic mechanism is
                                               pain was outside the investigated nerve
poorly understood. Antidromic activation
                                               territory, a bilateral recording was per-
of peripheral nerve fibers is one of the
                                               formed. Twenty-one different studies were
hypothesized antalgic mechanisms, but
                                               carried out on 16 patients.
very few neurophysiological studies

Ionic channels and neuropathic pain: physiopathology and                                                                     could cause a
                                                                                                                             membrane transi-
applications. J Cell Physiol. 2008 Apr; 215 (1):8-14.                                                                        tory modification,
                                                                                                                             turning    preva-
Neuropathic pain is defined by the Inter-      presence of ionic channels. In neuropathic                                    lently permeable
national Association for Pain research         pain impulses can be originated even from                                     to Na+ more than
as a pain associated to a primary lesion       ectopic sites. Ectopic discharges originated                                  to K+ as during a
or a dysfunction of the central or periph-     in a peripheral neuropathic system have an                                    release    phase.
eral system. Over the past few years           important role in the early stage of neuro-                                   Neuropathy gen-
the causes of the neuropathic pain were        pathic pain development in two different                                      erates a local
not known and there were not good              ways. First they give an excess of sponta-         accumulation of sodium channels, with a
treatments for it, now we have a better        neous and evoked electric impulses to the          consequent increase of density. This re-
knowledge of the physiopathological            central nervous system, causing a primitive        model seems to be the basis of neuro hyper-
aspects and there is a wider diffusion of      neuropathic pain signal; then the ectopic          execitably. Calcium channels have also an
the research for target aimed therapies.       activity develops and maintains the central        important role in cell working. Intracellular
The physiologic genesis of nervous             sensitisation process. All this amplifies the      calcium increase contributes to depolariza-
messages occurs exclusively in skin            afferent signals deriving from residual effer-     tion processes, through kinase and deter-
sensorial endings or in nerve tissues as       ents that go on innerving cutaneous areas          mines the phosphorylation of membrane
a consequence of an adequate senso-            damaged and partly disnerved, causing              proteins that can make powerful the efficacy
rial stimulus and depends on the quick         tactile allodynie. Sodium channels are the         of the channels themselves. In the future
variations of the electric potential differ-   greatest responsible for electrogenesis,           new diagnostic opportunities of physiopa-
ence at the endings of ionic mem-              that is the basis of the action potential gen-     thologist mechanism leading to neuropathic
branes. These variations of even 500V          eration and its propagation. Action potential      pain will allow treatments aimed at specific
a second are possible because of the           begins after a depolarization such that it         molecular changes of ionic channels.

Spinal deformity in athletics. Sports Med Arthrosc. 2008 Mar;16(1):26-31
Exercise and athletic competition for the      mentation are used for operative correction.
young individual has become increas-           Athletic activity and sports participation is
ingly more important in society. Scolio-       usually allowed for patients undergoing
sis and Scheurmann kyphosis are spi-           nonoperative treatment. Return to sport after
nal deformities prevalent in up to 2% to       surgical correction is variable, often decided
3% and 7% of the population respec-            by the treating surgeon, and based on the
tively, requiring nonoperative and occa-       level of fusion and sporting activity. Although
sionally operative treatment. Curve pro-       most treating surgeons promote some form of
gression and patient physiologic age           activity regardless of treatment modality cho-
dictate treatment regimens. Bracing and        sen, caution should be taken when deciding
physical therapy is the mainstay for           on participation in collision activities such as
nonoperative treatment, whereas soft           football and wrestling.
tissue releases and fusion with instru-
 International Spine & Pain
PO Box 1574
Phone: 866-235-4289
Fax: 816-331-1877

Education is Therapy...

                                                                       Here are some
                                                                    images from Mark
                                                                    Jones’s recent trip
                                                                      through the US,
                                                                        teaching on
                                    How Woman Bend Over Backwards   Clinical Reasoning
                                        for Baby - Heidi Ledford
                                                                        & Shoulder
                                                                     Impingement and
                                                                     Instability in New
                                                                       York, Chicago,
                                                                        Saint Louis,
                                                                        Kansas City,
                                                                    Omaha and Dallas.

                                          Coming to
                                        Kansas City
                                            July 22,
                               Lorimer Moseley, PT, PhD

                        Understand & Explain Pain

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