From: J Electromyogr Kinesiol. 2012 Jan 28. [Epub ahead of print]

The objectives of this article are to (1) describe spinal manipulation use by time, place, and person, and (2) identify predictors of the use of spinal manipulation. We conducted a systematic review of the English-language literature published from January 1, 1980 through June 30, 2011. Of 822 citations identified, 213 were deemed potentially relevant; 75 were included after further consideration. Twenty-one additional articles were identified from reference lists. The literature is heavily weighted toward North America, Europe, and Australia and thus largely precludes inferences about spinal manipulation use in other parts of the world.

In the regions covered by the literature, chiropractors, osteopaths, and physical therapists are most likely to deliver spinal manipulation, often in conjunction with other conservative therapies. Back and neck pain are the most frequent indications for receiving spinal manipulation; non-musculoskeletal conditions comprise a very small percentage of indications. Although spinal manipulation is more commonly used in adults than children, evidence suggests that spinal manipulation may be more likely used for non-musculoskeletal ailments in children than in adults. Patient satisfaction with spinal manipulation is very high.

From: Arthritis Rheum. 2012 Jan 27. doi: 10.1002/art.33462. [Epub ahead of print]

This study addressed the association of overweight and obesity to the presence, extent, and severity of lumbar disc degeneration on MRI in adults. A population-based cross-sectional study of 2,599 Southern Chinese volunteers. Radiographic and clinical assessment, including weight and height, was conducted. Sagittal T2-weighted MRIs of the lumbar spine were obtained. The presence, extent, and severity of disc degeneration as well as additional radiographic and clinical findings were assessed. Asian-modified BMI (kg/m2) categories were utilized.

There were 1,040 males and 1,559 females (mean age= 41.9 years). Disc degeneration was noted in 1,890 (72.7%) subjects. BMI was significantly higher in subjects with disc degeneration compared to subjects without degeneration. A significant increase in the number of degenerated levels, global severity of disc degeneration, and end stage disc degeneration with disc space narrowing was noted with elevated BMI, in particular in overweight and obese individuals. In the adjusted multivariate logistic regression model, there was a positive linear trend between BMI categories and the overall presence of disc degeneration for overweight and obese. End stage disc degeneration with disc space narrowing was significantly more pronounced in obese individuals.

In one of the largest studies to systematically assess lumbar disc degeneration on MRI, our study noted a significant association between the presence, increased extent, and global severity of disc degeneration in overweight and obese adults.

From: Mymensingh Med J. 2011 Oct;20(4):645-51.

In order to find out the fluctuation of pain by weather change, a descriptive cross-sectional study was conducted among 138 individuals having musculoskeletal disorders (MSDs) attending the out patient department (OPD) of Physical Medicine and Rehabilitation, Bangabandhu Sheikh Mujib Medical University (BSMMU) Hospital, Dhaka, during March 2004 to June 2004. Data were collected by face to face interview employing a pre-tested interview schedule containing structured questions. Among 138 respondents, male were predominant (52.2%). Mean age of the respondents was 39.42±10.79 years, while the most common age group was found as ’31 to 40 years’. By occupation, majority were housewives (40.58%), followed by businessmen (29.71%), service holder (15.22%), laborer (7.97%), and students (6.52%). The primary sites of pain were back and low back (38.4%), knee (24.6%), leg (8.7%), ankle and heel (8.0%), hand and wrist (6.5%), neck (5.8%), shoulder (5.8%), and elbow (2.2%). Highest number (47.8%) patients reported aching pain, while one fifth (20.3%) of them experienced burning pain.

About 36.2 percent respondents mentioned ‘prolonged standing’ as the main cause of pain aggravation, while almost half (48.6%) of the patients perceived that ‘application of heat’ was the key relieving factor of their pain. About two third (63%) of the respondents were sensitive to weather change; among them 56.3 percent reported that their pain increased during cold weather. Moreover, more than two third (67.4%) study-patients experienced deterioration of pain due to seasonal variation; of them 59.1 percent reported that their pain was exacerbated in winter season. Of all respondents, less than one third (30.4%) experienced aggravation of pain due to lunar change; of them majority (85.7%) experienced increased pain during dark fortnights. The study concluded that weather change might have an important role in fluctuation of pain among individuals having musculoskeletal disorders.

From: Front Physiol. 2011;2:64. Epub 2011 Sep 21.

Piercings (body art, i.e., with jewelry) are more and more widespread. They can induce various complications such as infections, allergies, headaches, and various skin, cartilage, or dental problems, and represent a public health problem. We draw attention to possible side effects resulting from face piercing complications observed on four young adults such as eye misalignment, decreased postural control efficiency, and non-specific chronic back pain with associated comorbidity. The authors found that the origin was pierced jewelry on the face. Removing the jewelry restored eye alignment, improved postural control, and alleviated back pain in a lasting way.

The authors suggest that pierced facial jewelry can disturb somaesthetic signals driven by the trigeminal nerve, and thus interfere with central integration processes, notably in the cerebellum and the vestibular nucleus involved in postural control and eye alignment. Facial piercings could induce sensory-motor conflict, exacerbate, or precipitate a pre-existing undetermined conflict, which leads pain and complaints. These findings are significant for health; further investigations would be of interest.

For face pierced jewelry, it is important to emphasize that trigeminal primary afferent neurons and their sensory receptors provide information for the perception of the orofacial region, and contribute to various types of sensorimotor integration such as postural control while quiet standing. These afferences project to the cerebellum, the reticular formation, and the vestibular nucleus which are located at the base of the spinal motor neurons and oculomotor efferents.

Body piercings with jewelry, at least on the face, could more or less rapidly induce other complaints than the medical complications described in the relevant literature; the authors report here body pain, impaired postural control, and vertical eye misalignment (heterophoria). If these side effects were confirmed in a larger population, health professionals need to deal with them taking into account sociological and psychological aspects. The authors hope this study of a few cases could stimulate further experimental and clinical research to complete the investigation on risk factors linked to body piercing, and lead to public health recommendations and prevention. More knowledgeable clinicians could thus better inform patients thus helping to reduce possible future complaints.

Health professionals and researchers should be aware of the possible side effects of piercings, i.e., impaired motor control, body pain, and additional comorbidity – known in chronic back pain including postural disorders, and the presence of vertical heterophoria.

From: Man Ther. 2011 Aug 6. [Epub ahead of print]

Absence of the trapezius muscle is a relatively rare occurrence but instances have been recorded in both cadaveric and in vivo clinical case reports. The two main causes that have been proposed are congenital and embryonic. The absence of trapezius may occur in isolation or in combination with other muscles such as the sternocleidomastoid or the pectoralis major muscles. Where there is co-involvement with the pectoralis major muscle in particular, the condition is often thought to be a variant of Poland’s Syndrome, which is a rare congenital anomaly characterised by unilateral chest wall hypoplasia and ipsilateral hand deformities. From an embryological viewpoint, the trapezius and sternocleidomastoid muscles are both innervated by the accessory nerve, and are derived from the mesoderm of the occipital and cervical somites. This suggests that the absence of trapezius in isolation may be an incomplete failure of the myotome compartment of either the occipital or cervical somites. Potential genetic links have also been proposed in instances where identical muscle absences have been observed in siblings and in three generations of males within a family.

Observations of absences of the whole or portions of the tripartite trapezius muscle alone have also been reported. A search of the literature identified six cases (four males, two females) revealed in cadaveric dissections. In five cases, unilateral absences of the left trapezius were reported. All parts of the trapezius muscle were absent in two cases, the upper portion in one and the inferior portion in another two cases. One case of complete bilateral absence of the trapezii was also reported. Cadaveric studies, although informative, limit any comment on a possible genetic predisposition in these individuals or any functional or symptomatic relevance as a possible consequence of the absence.

Structural MRI measures confirmed clinical observations that the inferior portion of the trapezius muscle was absent in three family members , which may suggest a genetic aetiology. The MR images of the healthy male subject demonstrated typical anatomy of the inferior portion of the trapezius muscle. The muscle size was reasonably symmetrical right to left. The CSA diminished from T3–4 to T9–10, with a gradual decline, which is within previously reported normal limits. In the sisters, the inferior portion of the trapezius was absent bilaterally. In the son, the absence was predominantly unilateral. The left trapezius was absent at the lower two measured points and the CSA was substantially reduced at T3–4 in contrast to the basic symmetry present in the healthy subject. The right trapezius was present at least down to the T6–7 spinal level. The absence of the inferior portion of trapezius appeared to be in isolation in all family members. The clinical examination did not reveal concomitant absence of any other muscle groups such as the sternocleidomastoid or pectoralis major muscles, which tends to negate other congenital causes.

Of the six cases of isolated absence of the trapezius muscle found in the literature, only one documented a bilateral absence of this muscle as found in the two sisters in this study. However, in that case, the muscle was completely absent whereas these subjects had a partial absence. The authors found a variable absence of the inferior portion of trapezius, which is in line with previous reports. The inferior portion of the trapezius was present bilaterally at T3–4 in the 56-year-old female, but was absent on the left side at this level in her sister. In both, the trapezius was bilaterally absent at the two distal measurement sites (T6–7, T9–10). In the son, the right inferior portion of trapezius was present although it was fascial in appearance at the T9–10 level. The left trapezius was absent at the T6–7 and T9–10 measurement sites. Although a possible serendipitous finding, it is of interest that in the cadaveric cases and the present case, the trapezius was consistently absent on the left side.

Despite the importance of the lower trapezius muscle in scapular kinematics, neither the 21-year-old son nor the 44-year-old female reported functional limitations. The 56-year-old sister, however, did report aching in the region of the upper trapezius, possibly due to compensatory overuse of this portion of trapezius with the lack of the supporting forces from the inferior portion of trapezius. The elevated and protracted resting posture of the shoulder girdles in both sisters is consistent with the absence of balanced forces between the upper and lower portions of the trapezeii. It is also inviting to speculate on the reason why the 56-year-old sister has difficulty with the freestyle stroke in swimming, which she reported in both the reach and pull through phases. As swimming performance has not improved substantially with extensive stroke coaching it most likely represents the absence of an appropriate force couple around the scapulae with the absence of the inferior portions of the trapezeii.

This study used structural MRI to confirm clinical observations and reports three instances of absence of the inferior portion of trapezius muscle. The absences were present in three family members, which suggests that a genetic link may be the cause of this aplasia.

From: Curr Med Res Opin. 2011 Jun 23. [Epub ahead of print]

About 10% of the population experiences tinnitus, a common and distressing symptom characterized by the perception of sound in the absence of external stimuli. There is, however, marked heterogeneity in etiology, perception, and extent of distress among those who experience tinnitus. Reactions to tinnitus vary from simple awareness to severe irritation; some people have difficulty in hearing because of the loudness of the noise. Severe tinnitus causes many, often psychological, symptoms (e.g., tension, frustration, impaired concentration, disrupted sleep). For some, tinnitus is temporary, for others it is longstanding. Although many people adjust successfully, others are disabled by tinnitus; approximately 5% experience persistent and severe symptoms affecting their lifestyle and significantly reducing their quality of life. Because tinnitus is poorly understood and no single therapeutic approach is effective for all patients, many patients are told that ”nothing can be done” and they must ”learn to live with it.”

Tinnitus, often referred to as ‘ringing in the ears’, is highly prevalent. However, patients may also present with a number of other symptoms.

To review the broad range of symptoms of tinnitus, to evaluate their impact on patient quality of life and to explore methods of diagnosis and assessment. An electronic literature search was performed in PubMed between September and December 2010.

Accumulating evidence suggests that the symptoms of tinnitus are not confined to the characteristic ‘ringing in the ears’, but instead encompass wide-ranging symptoms that include emotional components such as sleep disturbance, anxiety, depression, irritation, and concentration difficulties.

Patients with tinnitus experience a spectrum of distressing symptoms that impact their quality of life and there is a clear need for action. Clinicians need to recognize and diagnose tinnitus that occurs with other wide-ranging symptoms to ensure that these symptoms are identified and patients receive effective treatment.

Tinnitus, a widespread, often intractable condition, affects millions of people; there is considerable debate about its causes. Tinnitus is distressing and may be severe enough to affect lifestyle and quality of life. Affected patients need considerable support and advice on healthcare options, encouragement to try different treatments and recognition that help and hope are available. Though patients may have to learn to live with tinnitus, the most important thing is that they recognise that help is available.

Recently, in Tinnitus in elderly patients and prognosis of mild-to-moderate congestive heart failure: a cross-sectional study with a long-term extension of the clinical follow-up, BMC Medicine 2011, 9:80,

Tinnitus is the perception of a sound that cannot be attributed to an external source. It is a nonspecific symptom generally referable to a largely unknown dysfunction of the hearing system. A comprehensive definition has been proposed to differentiate normal ear noises from pathological tinnitus defined as a head noise lasting at least five minutes and that occurs more than once per week. A distinction can also be made between subjective and objective tinnitus. The former is more common and refers to an individual sound that is perceived only by the patient. From the epidemiological point of view, tinnitus affects a remarkable number of adults and is frequently associated with a hearing loss of various degrees as expression of a cochlear disorder.

In the United Kingdom approximately 4.7 million of patients are affected by tinnitus and about 5% of them have experienced a severe and persistent disorder that affects their quality of life. The American Tinnitus Association has reported a prevalence of about 19% (37 to 40 million), which increases with age and the degree of hearing impairment. The prevalence of tinnitus has been reported to be higher in men than in women, and this difference might be related to higher hearing thresholds in the male population. Interestingly, only 1% of patients under 45 years of age experience tinnitus, while the prevalence is about 12% in those 60 to 69 years of age and 25 to 30% in those who are >70. Similar data recently have also been reported in a large cross-sectional study carried out with participants in the 1999 to 2004 US National Health and Nutrition Examination Surveys.

Several anatomical regions could contribute to the generation of tinnitus, even if a causative relationship between neurophysiological functions and tinnitus generation has not yet been demonstrated. Moreover, several pathophysiological hypotheses have recently been proposed to explain the genesis of different kinds of tinnitus: from genetic to iatrogenic, from neurological to vascular. However, a final and unique explanation is not actually available. In this complex scenario, tinnitus associated clinical conditions, such as vascular diseases, middle ear diseases, diabetes, hypertension, autoimmune disorders, and degenerative neural disorders with or without concomitant hearing loss, a functional component leading to an impaired regulation of the peripheral vascular tone can be demonstrated.

For that reason, at least partly, tinnitus could be the expression of a circulatory impairment of the microcirculation of the inner ear resulting from a detrimental feedback loop between the control of systemic blood pressure and the reflex activation of the neurohumoral system (for example, sympathetic nervous system and renin-angiotensinaldosterone system. Accordingly, any clinical condition leading to a reduction in systemic and/or regional blood flow at the ear level can trigger the onset of tinnitus or promote its exacerbation in patients already affected by this disorder.

Chronic heart failure could be an ideal biological model to test the vascular disregulatory hypothesis of tinnitus since it is often associated with a reduced cardiac output, as well as with a reflex activation of vasoconstrictive systems, including the sympathetic nervous system and RAAS. The prevalence of chronic heart failure is significantly increased in the elderly population, who also have a higher rate of tinnitus and afford researchers with a reliable clinical setting to investigate the circulatory origin of hearing disorders.

To date, this is the first large, cross-sectional, clinical study supporting an association between tinnitus and chronic heart failure control in elderly patients. Data suggest that the onset of tinnitus might be affected by the degree of decline in LV function and is probably the consequence of an insufficient autoregulatory mechanism at the level of the circulation of the inner ear. These data can have some important clinical implications including the possibility that the onset and/or worsening of tinnitus can antedate the destabilization of chronic heart failure. This would allow for the early identification of patients who deserve a more aggressive management of heart failure or an adjustment of drug treatment, including a cautious administration of NSAIDs. If confirmed by larger prospective studies, this evidence would indirectly contribute to improve the quality of life of patients with chronic heart failure and might reduce the rate of hospitalization, as well as the huge economic burden of the management of chronic heart failure.

From: J Bone Joint Surg Am. 2011 Apr;93(7):662-70.

Little is known regarding juvenile disc degeneration in individuals with normal spinal alignment. Consequently, the purpose of this study was to assess the prevalence, determinants, and clinical relevance associated with juvenile disc degeneration of the lumbar spine in individuals without spinal deformities.

A cross-sectional assessment of disc degeneration in juveniles was performed as part of a population-based study of 1989 Southern Chinese volunteers. Adolescents and young adults from thirteen to twenty years of age were defined as “juveniles.” Juvenile subjects with no spinal deformity (n = 83) were stratified into two groups, those with and those without juvenile disc degeneration. Sagittal T2-weighted magnetic resonance images (MRI) were evaluated for the presence and extent of disc degeneration as well as other spinal findings. Demographics were assessed and clinical profiles were collected with use of standardized questionnaires.

Juvenile disc degeneration was present in 35% (twenty-nine) of the juveniles without spinal deformity. Disc bulging or extrusion, high-intensity zones on MRI, and greater weight and height were significantly more prevalent in subjects with juvenile disc degeneration. Adjusted multivariate logistic regression modeling demonstrated that Asian-modified body-mass index (BMI) values in the overweight or obese range had a significant association with juvenile disc degeneration. Overweight and obese individuals had greater severity of disc degeneration than underweight and normal-weight individuals. Furthermore, individuals with juvenile disc degeneration had an increased prevalence of low back pain and/or sciatica, greater low back pain intensity, diminished social functioning, and greater physical disability than individuals without disc degeneration.

This study demonstrated that the presence of juvenile disc degeneration was strongly associated with overweight and obesity, low back pain, increased low back pain intensity, and diminished physical and social functioning. Furthermore, an elevated BMI was significantly associated with increased severity of disc degeneration. This study has public health implications regarding overweight and obesity and the development of lumbar disc disease.

From: Eur Spine J. 2010 Oct 31. [Epub ahead of print]

With aging of society, clarification of the relationship between quality of life and abnormal posture in the elderly may allow improvement of quality of life through any preventive methods and training. However, sagittal balance has not been studied widely and most studies have focused on postmenopausal patients with osteoporosis. In this report, we provide the first evaluation of the simultaneous effects of degenerative changes on radiograph, spinal range of motion, sagittal balance, and back muscle strength, and examine the influence of these effects on quality of life of the middle-aged and elderly male subjects.

The subjects were 100 Japanese males who underwent a basic health checkup. Lumbar lateral radiograph, sagittal balance and spinal mobility determined and back muscle strength were measured. The thoracic/lumbar angle ratio was used as an index of sagittal balance. SF-36 physical component summary scores showed a significant negative correlation with age, osteophyte score and thoracic/lumbar angle ratio, and a significant positive correlation with lumbar lordosis angle, thoracic spinal range of motion, and back muscle strength. Multiple regression analysis indicated that thoracic spinal range of motion and back muscle strength were significantly associated with SF-36 physical component summary.

In conclusion, quality of life of the middle-aged and elderly male subjects was related to sagittal balance, lumbar lordosis angle, spinal range of motion, and back muscle strength. Exercise including muscle strength and spinal range of motion may be able to influence these primary factors related to quality of life. Back muscle strength and thoracic range of motion impact on improvement of quality of life in the middle-aged and the elderly

From: BMC Musculoskelet Disord. 2010 Jul 30;11(1):171.

Metabolic syndrome has become increasingly common worldwide. Metabolic syndrome is a cluster of risk factors defined by high fasting glucose and triglycerides, low HDL cholesterol, high blood pressure, and abdominal obesity that increases the risk for cardiovascular diseases, type 2 diabetes mellitus, and all-cause mortality. The prevalence of metabolic syndrome in the US population is approximately 35%. In Eastern Finland the corresponding prevalence has been found to be 37%. Neck pain is also a common symptom among the middle-aged population. In a large Finnish population-based study, 24% of men and 37% of women aged at least 30 years had suffered from neck pain during the preceding month.

There are few studies in which the prevalence of pain has been assessed in subjects with metabolic syndrome. In one study females with chronic pain from fibromyalgia were at an increased risk of metabolic syndrome. Another study found that subjects with metabolic syndrome were more likely to have problems with pain symptoms. It has been suggested that stress is related to both metabolic syndrome and neck pain. Low physical activity has been found to be associated with metabolic syndrome and musculoskeletal pain. Some studies have found an association between obesity and neck pain. Because visceral obesity is one of the main features of metabolic syndrome, it could be proposed that metabolic syndrome is also related to neck pain. It has been speculated that both metabolic syndrome and persistent chronic pain syndromes are related to hypothalamus-pituitary-adrenal stress axis dysfunction. Therefore, it could be expected that the prevalence of neck pain is elevated in subjects with metabolic syndrome. Thus, if there were common features in the background of these disorders, the authors hypothesized that neck pain is more prevalent among subjects with metabolic syndrome than among those without metabolic syndrome. In this study the authors aimed to analyse the prevalence of neck pain in subjects with metabolic syndrome.

Neck pain was assessed by asking about neck pain during the preceding month. The presence of neck pain was dichotomized: (0) no neck pain or neck pain only occasionally and (1) daily or almost daily neck pain. Hence, in this study we regarded neck pain as daily or almost daily occurring neck pain.

This study showed that males and females with metabolic syndrome have an increased prevalence of neck pain. This association was stronger in males, but the prevalence of neck pain was higher in females. In accordance with previous studies, psychological distress was associated with neck pain especially in females. Although psychological distress was taken into account, metabolic syndrome was statistically associated with neck pain.

BMI was higher and waist circumference larger in males with neck pain. Previous studies have suggested that obesity is a risk factor of neck pain. Subjects with metabolic syndrome are often obese and waist size is among the criteria of metabolic syndrome. However, BMI and waist size were similar in females regardless of neck pain. Therefore, it is not plausible that the association between metabolic syndrome and neck pain is related solely to obesity. Compared with females, males with neck pain had higher cholesterol and triglyceride levels and a higher BMI. Psychological distress was associated with neck pain in both genders. However, a lower lever of distress was associated with neck pain in females, but in males only severe distress had that association. In general, the level of psychological distress was higher among females than among males. According to a large population-based study, concurrent psychological distress is more prevalent among females.

One background hypothesis for the connection between neck pain and metabolic syndrome found in this study is that there is a common factor resulting in the development of both neck pain and metabolic syndrome. Two such factors could be stress and physical inactivity. Stress has been suggested to be a risk factor of metabolic syndrome. A recent study has suggested that workers with neck, shoulder, or back pain have elevated levels of stress-related biomarkers. Further, it can be speculated that neck pain is an indicator of stress. A recent study has shown that in a specified population, physical inactivity is a risk of metabolic syndrome, whereas perceived stress was not associated with metabolic syndrome. The association between development of metabolic syndrome and low physical inactivity has also been shown in a previous study. A large epidemiological follow-up study indicated that physical inactivity is related to chronic musculoskeletal complaints. It has been suggested that chronic musculoskeletal pain is associated with cardiovascular-related mortality. Hence, physical inactivity may be an intervening factor between metabolic syndrome and neck pain. Further studies with a longitudinal setting could explore the potential causal association between neck pain and metabolic syndrome as well as the potential common background factors of neck pain and metabolic syndrome.

Metabolic syndrome was associated with neck pain. This association was stronger in males but the prevalence of neck pain was higher in females. Prospective studies focusing on the causal relationship between neck pain and metabolic syndrome are needed.

Source: Prevalence of neck pain in subjects with metabolic syndrome – a cross-sectional population-based study

From: J Headache Pain. 2010 May 13. [Epub ahead of print]

According to recent observations, there is worldwide vitamin D insufficiency in various populations. A number of observations suggest a link between low serum levels of vitamin D and higher incidence of chronic pain. A few case reports have shown a beneficial effect of vitamin D therapy in patients with headache disorders. Serum vitamin D level shows a strong correlation with the latitude. Here, we review the literature to delineate a relation of prevalence rate of headaches with the latitude. The authors noted a significant relation between the prevalence of both tension-type headache and migraine with the latitude. There was a tendency for headache prevalence to increase with increasing latitude. The relation was more obvious for the lifetime prevalence for both migraine and tension-type headache. One year prevalence for migraine was also higher at higher latitude.

There were limited studies on the seasonal variation of headache disorders. However, available data indicate increased frequency of headache attacks in autumn-winter and least attacks in summer. This profile of headache matches with the seasonal variations of serum vitamin D levels. The presence of vitamin D receptor, 1alpha-hydroxylase and vitamin D-binding protein in the hypothalamus further suggest a role of vitamin D deficiency in the generation of head pain.