Gydytojo Jono Girskio pranešimo tarptautiniame gydytojų kongrese (Kalifornija, JAV) santrauka
International Congress of Anti-Aging, Psychosomatic, Preventive and Sports Medicine
Barnes Meeting Center. San Diego, California, USA. 8 - 14 September, 2007
Dr. Jonas Girskis M.D.
Neurologist, Vilnius, Lithuania
Summary of Presentation
Panorama of musculoskeletal disorders and their treatment
New scientific technologies of our times have influence on medical science with modern methods of treatment. Therefore this has changed the patient’s and doctor’s relationship. Doctor often associate with patient only through laboratory findings and MRI.
Information gained from computers often pushes out living language. In medicine as in life, all values are concentrated in the classic. Accordingly during treatment of the musculoskeletal system we should remember classic medicine.
There is not always a correlation between pain and findings of MRI. Sometimes patients suffer from low back pain, but they have normal MRI. Hence the cause of the pain is hidden somewhere in the patient’s musculoskeletal system. Therefore, if we would like to diagnose and treat this system correctly, we must remember a long time ago forgotten classic medicine e.g. physical examination of the total patient. Only physical examination together with modern medicine will bring success.
Principles of classic medicine allow us to make structural diagnosis and to evaluate reserves of musculoskeletal system. If we don’t do this, we will have a serious complication post operative period such as the failed back syndrome.
Structural diagnosis in manual medicine is specifically directed toward evaluation of the musculoskeletal system with the goal of identification of the presence and significance of somatic dysfunction(s). It is a component part of the physical examination of the total patient. Structural diagnosis uses traditional physical diagnostic methods of observation, palpation, percussion, and auscultation. Of these, observation and palpation are the most useful. Structural diagnosis of the musculoskeletal system should never be done in isolation and should always be done within the context of total patient history, findings of MRI and physical evaluation of the patient.
The diagnostic entity sought by structural diagnosis is somatic dysfunction.
Somatic dysfunction: impaired or altered function of related components of the somatic (body framework) system; skeletal, arthrodial, and myofascial structures; and related vascular, lymphatic, and neural elements. The classical diagnostic criteria for somatic dysfunction can be identified with the mnemonic S.T.A.R. I would like to spell it now ( ES - TI: - EI -A:)
S means – Sensitivity changes are the patient’s subjective experiences at the sites of dysfunction, in response to the palpation performed by the doctor.These sensations include tenderness, numbness, radiation, warmth, irritation, throbbing and so on.
T means - Tissue texture changes are the soft tissue conditions as found by palpation by the doctor. They can be chronic (prolonged blanching of the skin, ropy or fibrous texture of the muscles and fascia, coolness, dryness, vascular changes) or acute (increased redness, swelling and oedema, moist and/or increased temperature). The findings may worsen with palpation, to a slight degree.
A means - Asymmetry is the utilisation of the non-dysfunctional side of the patient in comparison with the dysfunctional side. An area of dysfunction should be compared to the analogous structure on the other side of the body. An imaginary line down the middle of the body should reveal an almost mirrored functional symmetry of one side to the other side.
R means - Restriction of motion is the most important determinant of dysfunction, especially when the range of motion shows asymmetry. The restriction can be by quantity (number of degrees of motion) and quality (stiffness, tremors, cogwheel rigidity, ) Although one or more elements may be present, and the patient may or may not complain of a decrease in available motion, abnormal movement is perhaps the most important determinant of somatic dysfunction.
The causes and the results of local and general somatic dysfunction, whether traumatic, functional, postural, pathological or psychological in origin, require a brief overview as we explore different aspects of the issues and the tissues involved, so that some of their possible solutions might become apparent.
The ability to move is an essential activity of the living human body which is made possible by the unique function of contractility in muscles. Muscles allow us to move our bodies from place to place (locomotion) as well as move individual parts of the body. During treatment of the musculoskeletal system we have to understand movements of the human body more completely by studying its biomechanical characteristics and principles. It is difficult for a person to visualize his or her body as a system of levers. A person moves through the use of his or her system of levers.
Usually disorders in the system of levers occur, when imbalance between agonist and antagonist of muscles develops. These functional disorders if not treated, may cause structural changes in the musculoskeletal system in the future.
Because the most important feature of the musculoskeletal system is locomotion, therefore the principal drug during of treatment this system must be motion! The exercises during the treatment should be prescribed to solve the concrete biomechanical problem. They must not be for general purpose.
Proprioception: Neurological Feedback
The performance of various activities is significantly dependent upon neurological feedback from the body. Very simply, we use the various senses to determine a response to our environment, as when we use sight to know when to lift our hand to catch a flying ball. We are all familiar with the senses of smell, touch, sight, hearing, and taste. We are also aware of other sensations, such as pain, pressure, heat and cold, but we often take for granted the sensations associated with neuromuscular activity through proprioception. Proprioceptors are internal receptors located in the skin, joints, muscles and tendons which provide us feedback relative to the tension, length, and contraction state of muscle, the position of the body and limbs, and movements of joints. These proprioreceptors in combination with the other sense organs of the body are vital in locomotion, which is the perception of the position and movement of the body in space.
Proprioceptive and neuromuscular responses are other potentially important mechanisms associated with somatic dysfunction. The sudden strain that accompanies many injuries engages the myotatic reflex arc. These events may account for the development of myofascial trigger points, protective muscle spasm, reduced range of motion and decreased muscle strength.
Pain in the musculoskeletal system emerging, the hyperstimulation of nociceptive receptors prevails and the centripetal afferentation from proprioreceptive organs is significantly reduced. The feeling of a normal movement in space is subsequently disturbed, the pattern of movement is changing and the fear of movement (kinezophobia) occurs. As the pain continues the fear grows.
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