Dysfunktion der Bewegungskontrolle als eine Subgruppe von nonspezifischen Rückenschmerzen

Gesundheit Institut für Physiotherapie Prof. Dr. phil. Hannu Luomajoki, PT OMT Dysfunktion der Bewegungskontrolle als eine Subgruppe von nonspezifischen Rückenschmerzen Movement control impairment as a sub-group of non specific Low Back Pain

Content Background of Low Back Pain (LBP) and movement control impairment (MCI) Can we examine MCI reliably? Is changed MCI a feature of CLBP? Does it correlate to distorted body image in the brain? Can we treat it?

Low Back Pain (LBP) Up to 80% of people have it at least once in life 1-year prevalence up to 50% Structures explain only a part of the pain Acute LBP cures by itself within 4 weeks no matter what you do However, up to 70% of these persons get LBP again within a year Chronic LBP is the second most costly sickness for the western societies (after depression) What to do?

Example of structural findings: Intervertebral disc and its role on LBP Disc lesions are hypothesised to be a major structure causing back pain and suffering (Videman and Nurminen, 2004). The diagnoses of changes in the intervertebral disc are mostly done by magnetic resonance imaging (MRI). However, the MRI findings have to be regarded with caution, as it has also been shown that up to 50% of asymptomatic subjects have pathological findings, such as signal hypointensity, anular tears, disc protrusions and endplate changes (Kjaer et al., 2005). A Finnish cross-sectional study found in a sample of 558 twenty-one year-old subjects about a 50% prevalence of disc degeneration (Takatalo et al., 2009). Earlier studies in the 1990 s (Boos et al., 1995, Jensen et al., 1994) have already raised the question of how useful MRI is in the diagnostics of LBP as even asymptomatic subjects have frequently abnormal imaging findings.

90% of LBP is non-specific Really?. Need to sub classify And this has been declared to be the most important issue for LBP Research (Airaksinen et al 2006 European Guidelines LBP)

Classification of LBP (O Sullivan 2005) 6

Background Movement control is an important part of motor control Some keywords (synonyms?): Relative flexibility (Sahrmann 2002); Functional stability (Comerford & Motram 2000); Maladaptive movement and motor control impairment (O sullivan 2000, 2005); Clinical instability (Panjabi 1992) But Let s name it by its own name

A popular hypothesis for «Instability»: Transversus Abdominis. Reliability & Validity of examination Hodges 1996: difference in recruitment pattern (EMG) (n=40) Gubler, Mannion et al 2010: no difference (Ultrasound) (n=96) Pulkovski et al 2010: No difference in thickness between patients with LBP and healthy persons whether in rest or contraction. No difference in holding contraction capability (n=100) Costa et al 2006: A Kappa of 0.52 was obtained for the palpation test while an ICC (2,1) of 0.58 was obtained for the PBU test. Mannion / Pulkovski et al 2008. Measurement of TrA function by US: The TrA preferential activation ratio is too imprecise to be of clinical use. The improvement of TA Activity does not correlate with improvement in disablity (Mannion et al 2012)

Evidence is that Training and exercises are beneficial (Airaksinen et al 2006 European Guidelines for LBP) However; what kind of exercises, does not seem to play a role! Even so called «specific Stabilisation» is not better than any other physiotherapy program Kriese et al 2010; Results: 17 trials were included. Conclusion: For LBP, SSE is more effective than a minimal intervention, but it is not more effective than other physiotherapy interventions Costa, Hodges et al 2009: Specific stabilisation sign. better than placebo ultrasound fo Pain reduction after 12 months, but the difference not clinically meaningful (0.8 points by NRS) (n=174)

Movement control:that difficult?

Can we assess movement control? Cook 2005; Delphi study; 188 OMT therapists estimated the main features of clinical instability. 88 % regarded findings in the active movement cotrol as a main finding Tests have been developed (Sahrmann 2002; O Sullivan 2000; Comerford & Motram 2001) Dankaerts & O Sullivan 2005; Reliability for whole subj. And phys. Assessment (k=0.95; N=35) Van Dillen 1998; 28 items, 4 Specialists, N= 138 (k= 0.5 0.8) White & Thomas 2002 (N=40) kappa = 0.2 0.6 Murphy et al 2006 N=40; vain PKB k=0.74

THE INTRA- AND INTERTESTER RELIABILITY OF MOVEMENT CONTROL TESTS OF THE LUMBAR SPINE Luomajoki et al 2007; Reliability of movement control tests in the lumbar spine. BMC Musculoskeletal Disorders 2007, 8:90 40 Patients with and without LBP were videod performining a set of 10 movemnet control tests 4 blinded Physios rated the tests Kappa values were calculated for inter- and intrarater reliability 6 of the tests were valued as reliable Conclusion: Physiotherapists can reliably rate the movement control test battery of six tests (K>0.6)

H. Luomajoki PhysioSwiss Genf 2012

Flexion Control impairment

Extension Control Impairment

Rotation Control Impairment

TEST RETEST RELIABILITY OF ACTIVE MOVEMENT CONTROL TESTS OF THE LUMBAR SPINE Luomajoki 2010 41 Patients were measured on two different days in their ability to control their movements of the back Analysis: Intraclass Correlation Coefficients (ICC 1.1) of test retest measures; point values, means and confidence intervals of lumbar movements for test retest results were calculated. Bland Altman plots for limits of agreement between mean values and mean differences between days were calculated as well. ICC > 0.70 were considered satisfactory.

Results & Conclusions: Within the SDD boundaries of this study, 93% of the subjects performed the same on both days in SKE and 90% in PKB. There were no significant differences between patients with LBP and healthy controls in the day to day reproducibility of the movement control tests. These two tests seem to have an acceptable level of stability and can therefore be recommended for clinical use to test the movement control ability in the low back.

. Movement control tests of the low back; evaluation of the difference between patients with low back pain and healthy controls Luomajoki et al: BMC Musculoskeletal Disorders 2008, 9:170 A cross sectional study including 210 persons with (108) and without (102) Low Back Pain

Results Mean scores positive tests ( Max 6) LBP Healthy controls 2.21 (SD 1.44) 0.75 (SD 1.03) Difference of the mean scores 1.46 Mean SD 1.24 Effect Size (ES) Effect Size (ES) <0.2 Small 0.5 Moderate > 0.8 Large 1.18 Odds ratio (OR) By cut off 3/6 Pos. Tests = 7.5 By cut off 2/6 = 6.5

Discussion There is a high significant difference in the active movement control performance between patients with LBP and those without LBP The results do not explain causality

Tactile acuity and lumbopelvic motor control in patients with back pain and healthy controls Br. J. Sports Med. 2011 Hannu Luomajoki and G. Lorimer Moseley Case controls study N=90 (LBP= 44; healthy N=46) Two Point Discrimination (TPD) Low Back Pain (LBP) and Movement Control Tests (MCT)

An easy way to measure brain s ability to map a body part: Two Point Discrimination test (TPD)

Results

Can we treat movement control dysfunction? Improvement in low back movement control, decreased pain and disability, resulting from specific exercise intervention Journal of Sport Medicin, Arthroscopy, Rehabilitation, Training and Technology SMARTT 2010 Hannu Luomajoki, Jan Kool, Eling D. de Bruin, Olavi Airaksinen

Exercises for Flexion control

Flexion control; Strengthening

Flexion control; Streching / Lenghtening

Extension control

Extension control

Extension control

Extension; Strenghthening

Extension; Streching / Lenghthening

Rotation Control

Rotation; Strengthening

Rotation; Streching / Lengthening

Key Message Movement control dysfunction is a clear sub group of LBP The inter-tester and intra-tester reliability of the active movement control tests of the low back is substantial. There is a clear and significant difference between patients with LBP compared to healthy controls in their movement control. Persons that have an increased TPD also have an impaired movement control of the low back. Distortion of the body scheme might explain why patients cannot control active movement of their back. Improvement of movement control through exercises leads to a decrease of LBP and improves functional disability due to back pain. However, as no control groups were included, no direct conclusions on the efficacy can be drawn.

Vielen Dank für die Aufmerksamkeit!

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