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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. Fibromyalgia 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” ISPInstitute.com 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 lexicon. 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 Dickson-Diveley 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 info@ISPInstitute.com 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 ISPInstitute.com 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 WHIPLASH 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 STUDIES 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 occurred. 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. ISPInstitute.com 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- ISPInstitute.com 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. ISPInstitute.com Page 6 March 2008 Newsletter Volume 4, Issue 3 2008 Course Schedule Download registration forms and information from ISPInstitute.com, 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 ISPInstitute.com 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- ISPInstitute.com International Spine & Pain Institute PO Box 1574 Raymore MO 64083 Phone: 866-235-4289 Fax: 816-331-1877 Email: info@ISPInstitute.com 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, 2008 Lorimer Moseley, PT, PhD Understand & Explain Pain
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