Körperwahrnehmung bei Rückenschmerzen

Aktuelle Studien belegen Körperwahrnehmungsprobleme bei Phantomschmerzen, CRPS und beim Karpaltunnelsyndrom. Leiden Patienten mit Rückenschmerzen ebenfalls unter Störungen der Körperwahrnehmung? Wie kann man solche Symptome testen, und mit welchen Übungen diesem Phänomen begegnen? Der folgende Artikel bietet praxisnahe Antworten auf diese Fragen

Bewegungskontrolldysfunktion als Subgruppe von unspezifischen Rückenschmerzen

«Erworben im Rahmen der Schweizer Nationallizenzen (http://www.nationallizenzen.ch)»Schmerzen des untere Rückens sind meist unspezifisch, d. h. es gibt keinen spezifischen medizinischen Grund für die Schmerzen. Eine Subgruppierung unspezifischer Rückenschmerzen wurde deswegen als einer der wichtigsten Forschungsschwerpunkte genannt. Eine mögliche Subgruppe ist die Bewegungskontrolldysfunktion, bei der der Patient seine Bewegungen nicht bewusst kontrollieren kann. Eine Testbatterie wurde entwickelt und validiert, um diese Patientengruppe zu untersuchen und zu behandeln. Sie besteht aus 6 Bewegungstests und wurde als reliabel bewertet. Mit diesem Testverfahren können Personen mit Rückenschmerzen zuverlässig von gesunden Personen unterschieden werden. Ebenfalls untersucht wurde der Zusammenhang mit der Körperwahrnehmung. Dabei zeigte sich, dass Zweipunktdiskriminationsfähigkeit mit der verschlechterten Bewegungskontrolle des Rückens korreliert. Eine Fallserienstudie (n=38) ergab, dass diesen Patienten mit spezifischen Übungen gut geholfen werden kann. Da es in dieser Studie keine Kontrollgruppe gab, kann jedoch eine Kausalität nicht hergestellt werden. Low back pain (LBP) is in most cases non-specific, meaning that there is no clear medical cause for the problem. Subgrouping of these patients has been declared as one of main research areas of LBP. One possible subgroup of LBP is movement control dysfunction which means that patients cannot actively control movements of the lower back. A test battery consisting of six movement control tests was created to examine this dysfunction and was found to be reliable. The test battery can discriminate between patients with LBP and healthy controls. It was also shown that patients with movement control deficits have a distorted body image which can be measured with two-point discrimination tests. In a case series study (n = 38) patients with movement control dysfunction could be extensively improved in their disability, pain and function. However, as there was no control group in the study no causal conclusions can be drawn

Short-term effect on pain and function of neurophysiological education and sensorimotor retraining compared to usual physiotherapy in patients with chronic or recurrent non-specific low back pain, a pilot randomized controlled trial

Background: Non-specific chronic low back pain (NSCLBP) is a major health problem. Identification of subgroups and appropriate treatment regimen was proposed as a key priority by the Cochrane Back Review Group. We developed a multimodal treatment (MMT) for patients with moderate to severe disability and medium risk of poor outcome. MMT includes a) neurophysiological education on the perception of pain to decrease self-limitation due to catastrophizing believes about the nature of NSCLBP, b) sensory training of the lower trunk because these patients predominantly show poor sensory acuity of the trunk, and c) motor training to regain definite movement control of the trunk. A pilot study was conducted to investigate the feasibility of MMT, prior to a larger RCT, with focus on patients’ adherence and the evaluation of short-term effects on pain and disability of MMT when compared to usual physiotherapy. Method: We conducted a randomised controlled trial (RCT) in a primary care physiotherapy centre in Switzerland. Outcome assessment was 12 weeks after baseline. Patients with NSCLBP, considerable disability (five or more points on the Roland and Morris Disability Questionnaire (RMDQ) and medium or high risk of poor outcome on the Keele Start Back Tool (KSBT) were randomly allocated to either MMT or usual physiotherapy treatment (UPT) by an independent research assistant. Treatment included up to 16 sessions over 8 to 12 weeks. Both groups were given additional home training of 10 to 30 minutes to be performed five times per week. Adherence to treatment was evaluated in order to assess the feasibility of the treatment. Assessments were conducted by an independent blinded person. The primary outcome was pain (NRS 0-10) and the secondary outcome was disability (RMDQ). Between-group effects with Student’s t-test or the Mann-Whitney U test and the standardized mean difference of the primary outcome were calculated. Results: Twenty-eight patients (46% male, mean age 41.5 years (SD 10.6)) were randomized to MMT (n = 14) or UPT (n = 14). Patients’ adherence to treatment was >80% in both groups. Pain reduction (NRS; [95% CI]) was 2.14 [1.0 to 3.5] in the MMT and 0.69 [-2.0 to 2.5.] in the UPT. The between-group difference was 1.45 [0.0 to 4.0] (p = 0.03), representing a moderate effect size of 0.66 [-0.1 to 1.5]. Reduction in disability on the RMDQ was 6.71 [4.2 to 9.3] in MMT and 4.69 [1.9 to 7.4] in UPT, with a non-significant between-group difference of 2.02 [-1.5 to 5.6] (p = 0.25). The required sample size for a RCT with six months follow-up was estimated at 170 patients. Conclusions: MMT was found to be feasible and to significantly reduce pain in the short term when compared with UPT. A future RCT with a six-month follow-up would require approximately 170 patients

Correlation between lumbar dysfunction and fat infiltration in lumbar multifidus muscles in patients with low back pain

Background: Lumbar multifidus muscles (LMM) are important for spinal motion and stability. Low back pain (LBP) is often associated with fat infiltration in LMM. An increasing fat infiltration of LMM may lead to lumbar dysfunction. The purpose of this study was to investigate whether there is a correlation between the severity of lumbar dysfunction and the severity of fat infiltration of LMM. Methods: In a cross-sectional study, 42 patients with acute or chronic LBP were recruited. Their MRI findings were visually rated and graded using three criteria for fat accumulation in LMM: Grade 0 (0–10%), Grade 1 (10–50%) and Grade 2 (>50%). Lumbar sagittal range of motion, dynamic upright and seated posture control, sagittal movement control, body awareness and self-assessed functional disability were measured to determine the patients’ low back dysfunction. Results: The main result of this study was that increased severity of fat infiltration in the lumbar multifidus muscles correlated significantly with decreased range of motion of lumbar flexion (p = 0.032). No significant correlation was found between the severity of fat infiltration in LMM and impaired movement control, posture control, body awareness or self-assessed functional disability. Conclusion: This is the first study investigating the relationship between the severity of fat infiltration in LMM and the severity of lumbar dysfunction. The results of this study will contribute to the understanding of the mechanisms leading to fat infiltration of LMM and its relation to spinal function. Further studies should investigate whether specific treatment strategies are effective in reducing or preventing fat infiltration of LMM

Use of Rasch analysis to investigate structural validity of a set of movement control tests for the neck

In pressBackground: Movement control abilities are often reduced in persons with neck pain. In physiotherapeutic practice observational tests are frequently used to assess the impaired abilities. Several tests for movement control abilities are available, but no evidence exists on how to combine and interpret them. Objective: The aim was to investigate structural validity of a set of movement control tests with Rasch analysis. Design: Cross-sectional study Methods: Thirty persons with and thirty without neck pain were recruited for this study. All persons performed ten movement control tests. A partial credit model was applied to investigate item fit, ordering of the item response functions, dimensionality and hierarchy of the tests. Results: The majority of persons with neck pain had moderate disabilities and the mean value in the Neck disability index was 10.7. Functioning of the movement control tests to measure the construct “movement control abilities” was adequate for the majority of tests. Three movement control test showed considerable misfit. Possible explanations were a reactive movement control instead of an active control and a more challenging test position. Test difficulties and person abilities could be estimated for the complete sample. The most difficult test was “sitting rocking forward” (1.13 logits) and the least difficult test was “lifting the right arm” (-1.30 logits). The highest person ability estimate was 3.61 logits indicating that movement control tests are missing to evaluate persons with moderate neck disabilities. Conclusion: Modifying the existing set of tests is required to evaluate the complete spectrum of persons with neck pain

Reliability of movement control tests on the cervical spine

Background: Movement control impairment reduces active control of movement. Patients with this might form an important subgroup among patients with mechanical cervical pain. Diagnosis is based on the observation of active movement tests. Although widely used clinically, few studies have been performed to determine the reliability of a test battery. The aim of this study was to determine the inter-tester reliability of movement control impairment [MCI] tests on the cervical spine. Methods: Forty-five subjects (31 patients with neck pain, 14 healthy controls) were videotaped while performing a standardized test battery consisting of 13 tests of active movement control. Using observation, two experienced physiotherapists independently rated test performances as correct or incorrect. One of them was blinded to all other patient information and both to each other. Kappa coefficients and 95% confidence intervals [CI] for inter-tester results were calculated. Results: The kappa values for inter-tester reliability ranged in from 0.47-1.0 of the 13 tests, 2 demonstrated perfect reliability (k = 1.0), 4 excellent (k 0.81-0.99), 6 substantial (k 0.61-0.8) and 1 good (k 0.41-0.6). Conclusions: The physiotherapists were able reliably rate the majority the tests in this series of motor control tasks. There have been studies performed describing the assessment and treatment of movement control impairment problems and low back pain. However, no study has involved the assessment of the cervical dysfunction subgroup. This study presents a reliable test battery, for clinical use, to perform more specific examination of this subgroup

Intertester and intratester reliability of movement control tests on the hip for patients with hip osteoarthritis

Hip joint complaints are a problem associated with increasing age and impair the mobility of a large section of the elderly population. Reliable and valid tests are necessary for a thorough investigation of a joint. A fundamental function of the hip joint is movement control and a test of this function forms a part of the standard examination. Until now there have been few scientific studies which specifically investigate the reliability of measurement tests of movement control of the hip joint. The aim of this study was to examine the intratester and intertester reliability of the movement control tests of the hip joint which are in use in current clinical practice

The influence of electromyographic biofeedback therapy on knee extension following anterior cruciate ligament reconstruction : a randomized controlled trial

Background: Loss of knee extension and a deficit in quadriceps strength are frequently found following anterior cruciate ligament (ACL) reconstruction. The aim of this study was to investigate whether the addition of Eletromyographic Biofeedback (EMG BFB) therapy for the vastus medialis muscle to the in the early phase of the standard rehabilitation programme could improve the range of knee extension and strength after ACL reconstruction more than a standard rehabilitation programme. The correlation between EMG measurement and passive knee extension was also investigated. Method: Sixteen patients, all of whom underwent endoscopic ACL reconstruction using patellar tendon autograft, were randomly assigned to two groups: - Control group (8 patients): standard rehabilitation protocol; with full weight-bearing postoperative, knee brace (0° extension, 90° flexion), electrical stimulation, aquatics and proprioceptive training. - The EMG BFB group (8 patients): EMG BFB was added to the standard rehabilitation protocol within the first postoperative week and during each session for the next 6 weeks. Each patent attended a total of 16 outpatient physiotherapy sessions following surgery. High-Heel-Distance (HHD) Test, range of motion (ROM) and integrated EMG (iEMG) for vastus medialis were measured preoperatively, and at the 1, 2, 4 and 6-week follow ups. Additionally, knee function, swelling and pain were evaluated using standardized scoring scales. Results: At 6 weeks, passive knee extension (p  0.01) differences were found between the two groups for the assessment of knee function, swelling and pain. Conclusion: The results indicate that EMG BFB therapy, in the early phase of rehabilitation after ACL reconstruction, is useful in enhancing knee extension. Improved innervation of the vastus medialis can play a key role in the development of postoperative knee extension. EMG BFB therapy is a simple, inexpensive and valuable adjunct to conventional therapeutic modalities