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The relationships between the distorted body image of neck and clinical profile in patients with chronic nonspecific neck pain

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Several studies have demonstrated that perceived body image of pain region is distorted in patients with complex regional pain syndrome (CRPS), chronic non–specific lower back pain and phantom limb pain. Moreover, perceived body image was associated with abnormal pain sensation in patients with these conditions. However, it is not well known whether patients with chronic non–specific neck pain (CNSNP) have symptoms and distorted perceived body image like chronic non–specific lower back pain. The purpose of the present study was to examine based on body image drawings whether two point discrimination (TPD) and selected clinical findings are different in subgroups of individuals with CNSNP. Twenty patients with CNSNP and healthy volunteers were assessed through perceived body image, TPD. CNSNP patients were also assessed through clinical profiles (pain intensity, pain catastrophizing, and fear avoidance beliefs). Perceived body image of neck was assessed by drawing their own outline of neck as they feel in their mind. Of patients with CNSNP, 50% reported that they had distorted body image and significantly different to control group. This result suggested that pathological condition of CNSNP was associated with cortical dysfunction as well as CRPS, chronic non–specific lower back pain and phantom limb pain. In the secondary analysis, we divided patients with CNSNP into two groups by the presence or absence of distorted body image (normal image; NI group, distorted image; DI group) and compared TPD threshold and clinical symptoms in three group (NI , DI and control group). TPD threshold of NI–pain side and DI–pain side were significantly higher than control. All other clinical symptoms were not significantly different in three groups. We couldn’t find the factor that was specifically associated with distorted body image of patients with CNSNP in the present study. Further study is needed to elucidate the clinical factors associated with perceived body image.
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Original Article
PAIN RESEARCH 30(2015)30–36
30
PAIN RESEARCH Vol.30 2015
The relationships between the distorted body image
of neck and clinical profile in patients
with chronic nonspecific neck pain
Akira Mibu1, Tomohiko Nishigami2, Syuzou Kishishita1,
Kouki Son1, Syougo Yamamoto1, Katsuyoshi Tanaka1,
Saori Kajiwara1, and Akihito Tanabe1
1Department of Rehabilitation, Tanabe Orthopedic Clinic
2Department of Nursing and Physical Therapy, Konan Womans University
Abstract
Several studies have demonstrated that perceived body image of pain
region is distorted in patients with complex regional pain syndrome (CRPS),
chronic non–specific lower back pain and phantom limb pain. Moreover,
perceived body image was associated with abnormal pain sensation in
patients with these conditions. However, it is not well known whether
patients with chronic non–specific neck pain (CNSNP)have symptoms and
distorted perceived body image like chronic non–specific lower back pain.
The purpose of the present study was to examine based on body image
drawings whether two point discrimination (TPD)and selected clinical
findings are different in subgroups of individuals with CNSNP.
Twenty patients with CNSNP and healthy volunteers were assessed
through perceived body image, TPD. CNSNP patients were also assessed
through clinical profiles (pain intensity, pain catastrophizing, and fear
avoidance beliefs). Perceived body image of neck was assessed by drawing
their own outline of neck as they feel in their mind.
Of patients with CNSNP, 50
%
reported that they had distorted body
image and significantly different to control group. This result suggested that
pathological condition of CNSNP was associated with cortical dysfunction
as well as CRPS, chronic non–specific lower back pain and phantom limb
pain. In the secondary analysis, we divided patients with CNSNP into two
groups by the presence or absence of distorted body image (normal image;
NI group, distorted image ; DI group)and compared TPD threshold and
clinical symptoms in three group (NI , DI and control group). TPD threshold
of NI–pain side and DI–pain side were significantly higher than control. All
other clinical symptoms were not significantly different in three groups. We
couldn’t find the factor that was specifically associated with distorted body
image of patients with CNSNP in the present study. Further study is needed
to elucidate the clinical factors associated with perceived body image.
はじめに
非特異的頚部痛とは,背部痛のうち,頚部
上背部全体み,こり,りといった
し,上肢神経症状がみられないものと
されている。近年厚生労働省国民生活基礎調
においても,頚背部痛腰痛とともに
訴者上位位置しており,有訴者率軽減
められていない。
性非特異的頚部痛chronic non–specific
neck pain: CNSNPについては,X線所見上
頚椎変性頚部痛および能力障害関連がな
いとの がなされている 13
。このような
CNSNP 症例して,一般的治療として,
投薬温熱療法電気刺激療法牽引療法およ
徒手療法などの末梢器質的要因治療
われているが,その有効性については根拠
しく 3,16
治療難渋することがある。
CNSNP 症例症状類似している慢性非特
異的腰痛症例において,腰部輪郭拡大
じる,あるいは縮小してじる身体
メージの変質および 2点識別覚two point dis-
crimination: TPD)の 閾値増加報告されて
12
。こ イメージの変質
TPD 閾値増加難治性疼痛症例
複合性局所疼痛症候群症例complex regional
pain syndrome: CRPS)や幻肢痛症例において
められ,患肢病的痛みに関与することが
らかになっている 5,11,14
CNSNP 症例においては,Lauche 7
頚部
身体イメージの変質指摘しているが,6
みの検討であり,CNSNP 症例において頚部身
イメージの変質じるかはらかでは
なく,また,臨床症関連しているかについて
らかでない。そこで研究では,
CNSNP
症例において頚部身体イメージの変質じて
いるか,頚部身体イメージの変質とどのよう
臨床症状関与しているか検討た。
方  法
1
. 対象
対象頚部痛6月以上持続する頚部痛群
31
Distorted body image of neck in patients with neck pain
PAIN RESEARCH Vol.30 2015
Keywords
Neck pain; Body image ; Tactile acuity; Cortical reorganization
Received:
9
October
2014
Accepted:
13
January
2015
慢性非特異的頚部痛症例における頚部身体イメージの変質臨床症状との関係
壬生 彰
1
/西上 智彦
2
/岸下 修三
1
/孫 康基
1
/山本 昇吾
1
田中 克宜
1
/梶原 沙央里
1
/田辺 曉人
1
1
田辺整形外科 上本町クリニック リハビリテーション科
2
甲南女子大学 看護リハビリテーション学部
20 男性 4女性 16 平均年齢 55.9±
11.7頚部痛さない対照群男性 5
15 平均年齢 57.7± 11.7)とした。
頚部痛群除外基準は, 著明
頚椎する外科的手術既往がある
神経根症状するとした。本研究
南女子大学倫理委員会承認実施した。
事前研究目的方法十分説明し,同意
られたのみを対象とした。
2
. 測定項目および方法
1
頚部身体イメージ
Lauche 7方法参考に,頚背部
上半身Fig.1–Aい,頚背部輪郭
のイメージを対象者自身記入させた。その
指示Moseley 10方法参考に,以下
ように口頭った。「あなたのから
けてさい。あなたがじるから
輪郭をこのけているところにいてくだ
さい。そのからにはらないでくださ
い。じるままにいてください。じない
かないでください。どのようにえるか
ではなく,じるりにいてください。
入後「あなたのいたイメージは正常
ましたか,それとも拡大しているようにじた
り,縮小しているようにじましたか」と対象
口頭確認した。対象者記入した頚部身
イメージを評価者確認し,かれた輪郭線
解剖学的正常きさおよび形態一致
ており,対象者正常じた場合正常
剖学的正常きさおよび形態一致してお
らず,対象者拡大している,または縮小して
いるようにじた場合変質ありとした。
2
TPD
測定Moberg 9および Wand 15方法
準拠してった。測定部位7頚椎棘突起
さとし,両側について測定した。キャリ
パーを脊柱して垂直にあて,2点間距離
0mm から 5mm ずつ増加させたascending
runに,
2点間距離100 mm から 5mm
ずつ減少させdescending run対象者
は,られた1であるか 2であるか
えるように指示し,2じる
した。Ascending run および descending run
のそれぞれの閾値平均値対象者TPD
として採用した。
3
臨床症状
頚部痛群については以下臨床症状評価
た。頚部痛強度visual analogue scaleVAS:
0mm = みなし,100 mm = えることので
きないみ)をいて測定した。両側性疼痛
するは,痛側し,
解析使用した。みにする破局的思考
として pain catastrophizing scalePCS
する恐怖指標として Tampa scale for
kinisiophobia
TSK)を 測定した。
3
. 統計解析
頚部痛群対照群における頚部身体イメージ
変質有無Fisher 正確確率検定
いてった。頚部痛群頚部身体イメージ
32
A. Mibu et al.
PAIN RESEARCH Vol.30 2015
Fig.1Body image drawing.
:Presented sheet to the patients
:Representative example of DI group
A B
変質有無2け,頚部身体イメージ
正常群normal image : NI )と頚部身体
メージ変質群distorted image: DI VAS
PCS および TSK 比較Mann–Whitney’s U
test いてった。また,正常群変質群
対照群3群間での TPD 閾値比較一元配
置分散分析いてい,多重比較検定として
Dunnet った。TPD については,頚部
痛群疼痛側非疼痛側け,対照群左右
平均値解析使用した。統計解析には
JMP®11
SAS Institute Inc., Cary, NC, USA
使用し,統計学的有意水準はすべて 5%未満
した。
結  果
各群対象者年齢性別罹患期間および
各測定項目結果Table 1す。頚部痛群
対照群年齢性別有意められな
かった。
1
. 頚部身体イメージの比較
頚部身体イメージの変質頚部痛群10
50対照群15)においてめら
れ,対照群比較して頚部痛群有意変質
められた(p<0.01Table 2頚部身体
33
Distorted body image of neck in patients with neck pain
PAIN RESEARCH Vol.30 2015
Table 1Sample characteritics, clinical symptoms and TPD threshold
Normal Distored Control group pvalue
Age (years) 55.7± 14.0 56.0± 13.0 57.7± 11.80.902
Female sex 7915 0.487
Pain duration (months) 70.1± 109.1 38.2± 29.00.386
VAS (mm) 51.1± 20.2 48.6± 24.30.806
PCS 25.1± 8.0 23.5± 8.70.587
TSK 39.7± 5.0 38.9± 5.00.941
TPD (mm) Pain side 43.0± 17.4 42.5± 15.50.034
Non–pain side 33.5± 13.1 40.5± 14.2 29.375 ± 9.7
TPD was compared between pain side, non–pain side of each pain group (NI, and DI group) and control
group by ANOVA. Dunnett test was performed as a post–hoc analysis.
Table 2Comparison of the existance of distorted body image by Fisher's exact test
Neck body image
pvalue
Normal (%) Distored (%)
Neck pain group 10 (50%) 10 (50%)
0.0017
Control group 19 (95%) 1(5%)
メージの変質められた 10 のうち,8
疼痛部位身体メージ拡大しており,2
については縮小していた。頚部痛群対象者
頚部身体イメージ異常代表例
Fig.1–B す。
2
VASTPDPCS およびT SK の比較
TPD は,DI NI 疼痛側対照群
であった(p<0.05Fig.2
VASPCSTSK については NI DI
よび対照群3群間での比較において有意
められなかったTable 1
考  察
本研究CRPS 症例慢性非特異性腰痛症
同様CNSNP 症例において頚部身体
イメージの変質められるか,さらには,
イメージの変質有無臨床症状関連する
かを検討し,CNSNP 症例において有意頚部
身体イメージの変質められた。また,NI
および DI 疼痛側TPD 対照群
有意増加していた。CRPS 慢性非特異
性腰痛身体イメージの変質TPD 増加
一次体性感覚野受容野可塑的変化との関連
報告されており,さらに,この可塑的変化
病的痛みに関与していることがらかになって
いる 1,2,4,8,10,11
。このことから,CNSNP 症例
おいても一次体性感覚野受容野可塑的変化
じている可能性示唆される。
一次体性感覚野受容野可塑的変化改善
することによって,疼痛軽減する可能性
されている。Pleger 14は,CRPS 症例
する段階的感覚運動再教育プログラムに
よりTPD 閾値改善一次体性感覚野
ける受容野再構築められ,さら
に , 疼痛軽 減 したことを報 告 している。
Foell 6
幻肢痛症例して鏡療法い,
疼痛軽減効果められたにおいては,
一次体性感覚野受容野再構築められて
いたことを報告している。以上より,CRPS
幻肢痛症例同様身体イメージの変質
TPD 閾値という中枢神経系機能異常
疼痛 している可能性がある CNSNP
症例においても,感覚再教育プログラムや鏡療
によって疼痛軽減められる可能性
される。
本研究では,NI DI において,TPD
閾値みのPCS および TSK 有意
められず,頚部身体イメージの変質
する臨床症状らかにすることができな
かった。慢性非特異的腰痛症においては,身体
イメージの変質がないべ,腰部輪郭
拡大しているTPD 閾値増加していた 12
この頚部腰部結果いは,身体イメージ
変質いが関与している可能性がある。
34
A. Mibu et al.
PAIN RESEARCH Vol.30 2015
Fig.2Comparison of TPD threshold.
The results of histogram are expressed as means ±
SD of TPD. TPD threshold of NI group–pain side
and DI group–pain side were significantly higher
than that of control group. p<0.05
性非特異性腰痛症においては,身体イメージが
正常 42.8 拡大いる
28.5輪郭縮小している28.5であっ
た。CNSNP においては身体イメージが正常
50.0輪郭している40.0
縮小している10.0であった。慢性
非特異性腰痛症では身体イメージが拡大してい
のみ身体イメージが正常より TPD
増加していた。本研究においては,症例数
なく,身体イメージの変質拡大縮小
群分けすることが不可能であったため,今後
症例数増加させ,群分けすることによって,
TPD 閾値いを検出できるかもしれない。
また,本研究横断的研究であるために,
身体イメージの変質臨床症状関係について
十分らかにできていない。今後CNSNP
症例して,感覚再教育プログラムをうこ
とによって,身体イメージ,TPD 閾値および
疼痛がどのように変化するかについて縦断的
検討必要がある。
結  語
今回CNSNP 症例 において,頚部身体
メージの変質存在するかどうかについて検討
し,対照群比較して,頚部痛群有意頚部
身体イメージの変質められた。CRPS
肢痛慢性非特異的腰痛などと同 様 に ,
CNSNP においても慢性的みの病態中枢
神経系機能異常関与している可能性示唆
された。また,身体イメージの変質関連する
臨床症状についても検討したが,本研究では
らかにすることはできなかった。今後さらなる
検討必要であるとえる。
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Address for correspondence:Akira Mibu
Department of Rehabilitation, Tanabe Orthopedic
Clinic
Fudegasaki-cho 5-52, Tennoji-ku, Osaka 543-0027,
Japan
Tel: 06-6774-1151
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... Agreement between raters in formal screening was 95% for titles/abstracts screening, and 91% in fulltexts inclusion: all disagreements were resolved upon discussion and clarification of eligibility criteria, and the intervention of the third independent assessor (MT) was not needed. A graphical distribution of included studies grouped by clinical conditions examined is shown in Figure 3. Twenty-five studies (Grod and Diakow, 2002;Moseley, 2008;Wand et al., 2010Wand et al., , 2013bWand et al., , 2014Wand et al., , 2016Docherty et al., 2012;Lauche et al., 2012a;Valenzuela-Moguillansky, 2013;Hirakawa et al., 2014;Gilpin et al., 2015;Mibu et al., 2015;Nishigami et al., 2015Nishigami et al., , 2017Nishigami et al., , 2018Treleaven and Takasaki, 2015;Beales et al., 2016;Janssens et al., 2017;Moreira et al., 2017;Adamczyk et al., 2018a,b;Ehrenbrusthoff et al., 2018;Magni et al., 2018;Martínez et al., 2018) studies concerned the assessment of SoP dysfunctions, while twelve interventional studies (Barker et al., 2008;Preston and Newport, 2011;Wand et al., 2011Wand et al., , 2013aMorone et al., 2012;Paolucci et al., 2012;Diers et al., 2013;Vetrano et al., 2013;Ryan et al., 2014;Louw et al., 2017;Stanton et al., 2018;Nishigami et al., 2019) investigated the effects of perception-based intervention to reduce pain or to correct perceptual distortions. One study, (Lauche et al., 2012a) was included both in assessment and in intervention studies: it is a qualitative study investigating the explicit SoP in chronic neck pain (CNP) patients at baseline, and also at follow-up because it was embedded in a RCT study investigating the effect of cupping therapy (Lauche et al., 2012b). ...
... The majority of selected assessment studies evaluated the explicit SoP: five studies adopted the Body Image Drawing (BID) task (Moseley, 2008;Lauche et al., 2012a;Mibu et al., 2015;Nishigami et al., 2015;Moreira et al., 2017), eight studies used the FreBAQ (Wand et al., 2014Wand et al., 2013a;Beales et al., 2016;Janssens et al., 2017;Nishigami et al., 2017Nishigami et al., , 2018Ehrenbrusthoff et al., 2018) or the FreKAQ (Nishigami et al., 2017), two studies used the Neglect-Like Symptoms Questionnaire (NLSQ) (Hirakawa et al., 2014;Magni et al., 2018), one study investigate the visual size estimation in an experimental setting (Gilpin et al., 2015), one study investigated the rubber hand illusion (RHI) (Martínez et al., 2018), and one was a qualitative study on subjectively referred body perception (Valenzuela-Moguillansky, 2013). ...
... Of the five study using the BID task, two were conducted on CLBP patients (Moseley, 2008;Nishigami et al., 2015) and three on Chronic Neck Pain (CNP) patients (Lauche et al., 2012a;Mibu et al., 2015;Moreira et al., 2017). All studies reported distortions in BID in a variable percentage of patients: Moseley (2008) found that five out of six patients with CLBP reported difficulties in drawing their trunk along all the entire extension. ...
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