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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6032_Библиотеки_им_академика_М_И_Перельмана
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increase in loose connective tissue) correlates with increased pain. A recent
study using ultrasonography found a correlation between a decrease in range
of motion and increase in deep fascial thickness in the neck.48 A value of
0.15 mm of sternocleidomastoid fascia was proposed as a cutoff value that
allows the diagnosis of myofascial disease in patients with chronic neck pain.
In addition, there are changes in both the histologic structure (increased
inflammation and microcalcifications) and the degree of innervation (loss of
nerve fibers) of the thoracolumbar fascia in patients with chronic low back
pain, which indicate a possible role of fascia in lumbar pain.49 A recent study
found thoracolumbar fascia shear strain was approximately 20% lower in
patients with low back pain, potentially implicating the intrinsic connective
tissue pathology of decreased gliding in these patients.
50
A Cochrane review of massage therapy for adults with nonspecific low
back pain included 25 randomized controlled trials with more than 3,000
participants.51 The quality of evidence was deemed low or very low because
of bias and imprecision. Results showed that for acute low back pain,
massage was better than inactive controls for pain, but not for function in the
short term (less than 3 months). For subacute and chronic low back pain,
massage was better than inactive controls for pain and function in the short
term, but not in the long term (more than 3 months). However, when
compared with active controls, which included manipulation, mobilization,
transcutaneous electrical nerve stimulation, acupuncture, traction, relaxation,
physical therapy, exercises, or self-care education, massage was better for
pain both in the short- and long-term follow-ups, but no differences were
found for function. There were no reports of serious adverse events in any of
the massage therapy trials. Increased pain intensity was the most common
adverse event reported in 1.5% to 25% of the participants.
A few trials have been performed to specifically analyze fascial
manipulation. In a recent randomized controlled trial of 24 patients, the
effectiveness of fascial manipulation with physical therapy was compared
with physical therapy alone.52 Results showed those receiving fascial
manipulation had statistically and clinically significant improvement in the
short term (end of treatment) for all outcomes (assessed with the visual
analog scale and brief pain inventory, function with the Roland-Morris
Disability Questionnaire, and state of well-being with the Medical Outcomes
Study 36-Item Short Form Health Survey) and in the medium term (1 to 3
months; assessed with the visual analog scale and brief pain inventory)
compared with physical therapy alone. Another study showed fascial
manipulation may improve cervical range of motion more than standard
therapy in patients with whiplash.53 There also have been a few trials
studying myofascial release. A recent study showed that dynamic ultrasound
evaluation can be used to monitor effective sliding motion of fascial layers in
vivo, and myofascial release is an effective manual technique to release the
areas of impaired sliding fascial mobility and improve pain perception over a
short term (3 days) in individuals with nonspecific neck pain or low back
pain.54 In a randomized, single-blinded, parallel group study of 59 patients
with neck pain, 29 patients were treated with manual therapies and 30
patients were treated with myofascial release.55 The study showed that after
five sessions, the group treated with myofascial release had better advanced
position of the head, better range of motion in side bending and rotation, and
improved quality of life compared with the manual treatment group. Another
study analyzed myofascial release compared with sham control for chronic
low back pain, with both treatments used as an adjunct to specific back
exercises.56 The study found that the myofascial release group performed
better than the control group after 8 weeks of treatment and at 12 weeks
based on the McGill Pain Questionnaire and the Quebec Back Pain Disability
Scale.
Herbal Medicines and Supplements
A recent Cochrane review of herbal medicines for low back pain included 14
randomized controlled trials with more than 2,000 participants with acute,
subacute, and chronic low back pain.57 The results of the included trials
suggest that specific herbal medicines may be effective for short-term
improvement in pain (4 to 6 weeks) and functional status for individuals with
acute flare-ups of chronic, nonspecific low back pain. The review found that
topical Capsicum frutescens (cayenne) had the best evidence for reducing
pain more than placebo. Other herbal medicines, such as Harpagophytum
procumbens (devil’s claw), Salix alba (white willow bark), Symphytum
officinale (comfrey), Solidagochilensis Meyen (Brazilian arnica), and
lavender essential oil also seem to reduce pain more than placebo, although
evidence for these supplements was of moderate quality at best. No
substantial adverse events were noted in these trials, but a few patients
reported mild gastrointestinal discomfort and skin irritation. Capsicum, better
known as chili peppers, contains a chemical called capsaicin, which is a
neurotoxin that irritates the skin to reduce pain by causing
defunctionalization of nociceptive pain fibers. Devil’s claw is an herb native
to Africa that has fruit covered in hooks, and it contains chemicals that might
decrease inflammation, swelling, and pain. White willow bark contains a
chemical called salicin that acts similar to aspirin. Comfrey is a plant that
contains allantoin, which is thought to stimulate cell growth and repair, while
depressing inflammation. However, it also contains hepatotoxic chemicals
called pyrrolizidine alkaloids and, therefore, should only be used topically.
Brazilian arnica is a plant from the daisy family; the flower of the plant is
used to make medicines with anti-inflammatory properties.
A review of randomized controlled trials analyzing cannabinoids for
chronic pain associated with rheumatic conditions (back pain, fibromyalgia,
osteoarthritis, rheumatoid arthritis) found that superiority of cannabinoids
over controls (placebo, amitriptyline) was inconsistent. Cannabinoid
receptors are widely distributed throughout the central and peripheral nervous
systems and also may be found in peripheral nonnervous tissue. It is
hypothesized that cannabinoids function to reduce sensitization of
nociceptive sensory pathways and induce alterations in cognitive and
autonomic processing in states of chronic pain. Engaging the system may
provide therapeutic effects for pain and inflammation. Cannabinoids were
generally well tolerated and safe during study duration despite some
troublesome side effects. Currently, there is insufficient evidence for
recommendation of any cannabinoid preparations for symptom management
in patients with chronic pain associated with rheumatic diseases.58 There are
some limited clinical studies that show cannabis or cannabis derivative can
improve symptoms of neuropathic pain in patients with HIV, general
peripheral neuropathic pain, spasticity caused by multiple sclerosis or spinal
cord injury, and central pain caused by multiple sclerosis.
59
Yoga
Yoga is derived from the Sanskrit word yug, which means to put to active and
purposeful use, and is described as a method of discipline.60 Once solely an
oral tradition, the yogic philosophy was transcribed into the Yoga Sutra, a
manuscript teaching ways of dealing with the challenges of life. There are
numerous styles of yoga, but among the most commonly practiced in the
United States is Hatha yoga, which is the willful or forceful physical practice
of yoga postures with the original purpose of preparing for meditation.
Similar to other meditative exercises, the practice of yoga in the United States
has grown significantly to 9.5% of adults and 3.1% of children in 2012.
35,61
Of those who practice yoga for specific health conditions, back pain is the
most commonly cited (19.7%).62 Figure 4 demonstrates a few common yoga
poses that patients with low back pain may find beneficial.
A recent systematic review evaluated 14 randomized controlled trials to
assess the effectiveness of yoga on chronic low back pain.63 Most of the
studies reported beneficial effects for patients with low back pain, including
improvements in pain relief, flexibility, function, depression, balance, and
gait parameters. Yoga was more effective in reducing pain severity compared
with control methods. A study among low-income populations with chronic
low back pain found similar improvements in pain and function when
comparing once-weekly yoga classes with twice-weekly yoga classes.
64
Another systematic review evaluated three randomized controlled trials
totaling 184 participants with chronic neck pain to assess the effectiveness of
yoga.65 Participants were assigned to yoga practice for either a 90-minute
session weekly for 9 weeks or a 60-minute session 5 days per week for 3
months. Neck pain and functional disability were significantly lower among
yoga participants versus the control group, which included no treatment,
general exercise, or manual self-care. Adverse effects were generally mild,
including transient worsening of neck pain, low back pain, muscle soreness,
migraine, and vertigo.
Figure 4
Illustrations show three common yoga posses found helpful
by indviduals with low back pain. A, Cat-cow pose. B,
Child’s pose. C, Upward-facing dog.
Tai Chi
Tai chi is a Chinese martial art that has been practiced for several hundred
years and is based on the balance principles of yin and yang. Tai chi involves
deep breathing combined with a series of continuous, slow, graceful
movements with the purpose of allowing qi to flow unencumbered
throughout the body and promote better health. Tai chi is thought to be
suitable for all age groups,66 but there has been tremendous interest among
older adults because of its beneficial effects for reducing falls, improving
psychological well-being, and improving general health.67 Although most
studies have reviewed other aspects of health, there is some evidence for the
use of tai chi for neck and back pain.
At 24-week follow-up, one study found that 12 weeks of tai chi or
instruction in conventional neck exercises both provided patients with similar
improvements in neck pain, disability, and physical functioning compared
with a waitlist control group.68 Both exercise groups had a progressive
decline in group attendance over 12 weeks, but 68% of those practicing tai
chi attended at least 80% of the sessions. A similar study found that 18 group
sessions (40 minutes each) of tai chi at a community venue provided greater
improvement in chronic low back pain, disability, and physical functioning at
10-week follow-up compared with results from a waitlist control group.
69
Summary
With the increased use of alternative medicine treatments, orthopaedic
practitioners should have some familiarity with the various treatments
available. Acupuncture is safe when performed by properly trained
individuals and has the most evidence supporting its use as a stand-alone or
adjunctive treatment for patients with chronic low back pain and neck
disorders. Dry needling has been shown to decrease local inflammation and
normalize abnormal muscle electrical activity. Cupping can be effective for
managing chronic low back and neck pain in the immediate and short term.
Chiropractic care is one of the most widely used alternative treatments and
can provide improvement in acute and subacute neck and low back pain.
Patients should be aware of an association between cervical manipulation
therapy and cervical dissection (vertebral artery or internal carotid artery),
although the incidence is probably low. Massage therapy can provide
effective management of acute, subacute, and chronic low back pain,
although the quality of evidence is low. Recent research has shown that
dysfunctional fascia with poor gliding may play a major role in chronic neck
and low back pain. Several studies of herbal medicines and supplements
show that specific compounds can provide short-term improvement in pain
and function for patients with acute flare-ups of chronic low back pain.
Clinical trials involving cannabinoids in chronic low back pain and
fibromyalgia showed inconsistent results, although there is some evidence
that it may be effective in managing neuropathic pain and spasticity. Yoga
and tai chi appear to improve pain and function in patients with chronic low
back and neck pain, and the latter may be particularly suitable for elderly
patients.
Key Study Points
Acupuncture has moderate evidence supporting its use in chronic low back
pain and neck disorders and may work in part by treating the myofascial
meridians.
Dry needling can be considered a Western medicine form of acupuncture
and involves using acupuncture needles to deactivate trigger points.
Chiropractic manipulations can provide immediate and medium-term relief
of acute or subacute neck or low back pain, but there is a potential risk of
carotid artery dissection with neck manipulations.
Research on the fascial system is increasing, and fascia has been identified
as a potential source of pain and dysfunction.
Annotated References
1. Shin JS, Lee J, Kim MR, et al: The short-term effect of integrated complementary and
alternative medicine treatment in inpatients diagnosed with lumbar intervertebral disc
herniation: A prospective observational study. J Altern Complement Med
2016;22(7):533-543.
A prospective observational study of 524 patients with low back and leg pain
hospitalized for lumbar intervertebral disk herniation reported good improvement in
pain and function, with most patients receiving only complementary and alternative
medicine treatments and a smaller percentage also receiving nonsurgical conventional
medicine treatments. Level of evidence: IV.
2. Gunn CC, Ditchburn FG, King MH, Renwick GJ: Acupuncture loci: A proposal for
their classification according to their relationship to known neural structures. Am J Chin
Med (Gard City N Y) 1976;4(2):183-195.
3. Langevin HM, Yandow JA: Relationship of acupuncture points and meridians to
connective tissue planes. Anat Rec 2002;269(6):257-265.
4. Hyvärinen J, Karlsson M: Low-resistance skin points that may coincide with
acupuncture loci. Med Biol 1977;55(2):88-94.
5. Helms JM: An overview of medical acupuncture. Altern Ther Health Med
1998;4(3):35-45.
6. Siedentopf CM, Golaszewski SM, Mottaghy FM, Ruff CC, Felber S, Schlager A:
Functional magnetic resonance imaging detects activation of the visual association
cortex during laser acupuncture of the foot in humans. Neurosci Lett 2002;327(1):53-
56.
7. Myers T: Anatomy Trains: Myofascial Meridians for Manual and Movement
Therapists, ed 3. Tw M, ed. London, Churchill Livingstone Elsevier, 2014.
This textbook, first published in 2001, describes functionally integrated body-wide
continuities within the fascial webbing forming traceable meridians of myofascia.
8. Stecco L, Stecco C: Fascial Manipulation Practical Part. Padova, Italy, Piccin Nuova
Libraria S.p.A, 2009.
fibroblast cytoskeletal remodeling induced by acupuncture: Evidence for a
mechanotransduction-based mechanism. J Cell Physiol 2006;207(3):767-774.
contributes to connective tissue tension. J Cell Physiol 2011;226(5):1166-1175.
The results of this original research study showed that the viscoelastic behavior of
areolar connective tissue under tension is substantially affected by cellular activity.
narcotic antagonist naloxone. Brain Res 1977;121(2):368-372.
2002;17(1):49-62.
(PENS) for treating ECT-induced headaches. Headache 1999;39(7):502-505.
effects of acupuncture in 97 733 patients. Arch Intern Med 2004;164(1):104-105.
and their economic impact: A prospective study in 73,406 patients with low back or
neck pain. Eur J Pain 2011;15(2):193-197.
A prospective observational study of 73,406 patients who received acupuncture for
chronic low back or neck pain showed that adverse events occurred approximately 7%
of the time, with bleeding, hematoma, and pain the most common events. Level of
evidence: IV.
back pain: A systematic review and meta-analysis. Spine (Phila Pa 1976)
2013;38(24):2124-2138.
A systematic review of 32 studies, including a meta-analysis of 25 studies, of
randomized controlled trials of acupuncture for nonspecific chronic low back pain
showed that acupuncture may have a favorable effect on self-reported pain and
functional limitations. Level of evidence: II.
(GERAC) for chronic low back pain: Randomized, multicenter, blinded, parallel-group
trial with 3 groups. Arch Intern Med 2007;167(17):1892-1898.
simulated acupuncture, and usual care for chronic low back pain. Arch Intern Med
2009;169(9):858-866.
acute non-specific low back pain: A randomised, controlled, double-blind, placebo trial.
Acupunct Med 2014;32(2):109-115.
A prospective, randomized, parallel-group, double-blind, placebo-controlled trial of 80
men and women with acute nonspecific low back pain showed that Yamamato’s new
scalp acupuncture was more effective than sham treatment with regard to decrease in
pain, NSAID use, and improvement in function and quality of life. Level of evidence: I.
Cochrane Database Syst Rev 2016;5:CD004870.
This Cochrane review, which included 27 studies of acupuncture for neck pain
(whiplash-associated disorders, chronic myofascial neck pain, chronic pain due to
arthritis, chronic nonspecific neck pain, neck pain with radicular signs, and mechanical
neck pain), reported moderate-quality evidence that acupuncture relieves pain and
improves disability. Level of evidence: II. Study withdrawn.
for patients with chronic neck pain. Pain 2006;125(1-2):98-106.
review and meta-analysis. Complement Ther Med 2013;21(5):535-556.
This systematic review and meta-analysis of acupuncture trials for lumbar spinal
stenosis included six randomized controlled trials and six nonrandomized controlled
clinical trials. There was no conclusive evidence of the effectiveness and safety of
acupuncture for this diagnosis because of high or uncertain risk of bias and the limited
generalizability of included studies. Level of evidence: III.
Acupuncture for chronic pain: Individual patient data meta-analysis. Arch Intern Med
2012;172(19):1444-1453.
This systematic review was performed to identify randomized trials of acupuncture for
chronic pain in which allocation concealment was adequate; 31 trials were included.
Individual patient data meta-analysis was performed using data from 17,922 patients.
Acupuncture was shown to be superior to both sham therapy and no acupuncture for
nonspecific back or neck pain, chronic headache, and osteoarthritis. Level of evidence:
II.
dry needling: A prospective survey of chartered physiotherapists. J Man Manip Ther
2014;22(3):134-140.
A prospective survey was undertaken of 39 physiotherapists who had completed David
G. Simons Academy dry needling and trigger point therapy training to evaluate the
incidence of adverse events. Common adverse events included bruising, bleeding, and
pain; however, there were no significant adverse events. Level of evidence: IV.
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