Motorisk kontrol set i sammenhæng med bevægeapparatsbesvær

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Sigrid Lauridsen
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1 Vidensbaseret undersøgelse af motorisk kontrol i fysioterapi - symposium fagkongres 2015 Motorisk kontrol set i sammenhæng med bevægeapparatsbesvær Martin B. Josefsen Muskuloskeletal Fysioterapeut Dansk Selskab for Fysioterapi, formand Dansk Selskab for Muskuloskeletal Fysioterapi, underviser, formand Klinik for Ryg og Nakke Fysioterapi Master Class Course: Cervicogenic Headache and Dizziness

2 Motorisk kontrol et vidensfelt i komplekse sammenhænge Motorisk kontrol er et vidensfelt blandt mange andre vidensfelter i fysioterapi. Motorisk kontrol er ofte afhængig af patientpræsentation. Der er forskel på "raske" og "syge", samt arten af "sygdom". Ved bevægeapparatsbesvær er der ofte tæt sammenhæng med bl.a. "dysfunktion", smertemekanismer, biomekanik og vedligeholdende faktorer.

3 Muskuloskeletale smerter Du finder hvad du leder efter? Koncepter er opstået og haft fokus på forskellige elementer. I see Bones and Joints Kaltenborn, Maitland, McKenzie, Mulligan I see muscles and motor control and movement patterns! Sahrmann, Kinetic Control I see pain when there shouldn t be any Waddell etc. Oooops we ve got a brain: Central Sensitization! Modern pain gurus Clinical reasoning: Look at it all and make things fit! Jones, Rivett etc.

5 Hovedpine patienten og motorisk kontrol - spørgsmål i forskning og i praksis Er der ændret motorisk kontrol? Hvilken type ændret kontrol? Hvorfor er der ændret motorisk kontrol? Hos hvilken type hovedpine patient? Hvad har det af betydning for behandlingen?

6 Musculoskeletal Headache? CgH Z-joints Ass. Mm. TMJ-HA TMJ Ass. Mm. TTH TrPs? Centr Sens? TTH TrPs? TTH CS? Whiplash and HA? Neck? (TMJ?) CNS? Centr Sens? Migr Brain Neuro-Vasc Post Commotio? MTBI? CNS? Brain/CNS Mixed HA types? Other HA types? Cx syndromer 2B

7 Aethiology Cervicogenic Headache Pain referred from C0-3 Nociceptive afferents Facet joints (capsules) Discs (outer rims) Ligaments Muscles (joint near structures) Neural tissues Osseus Mediation through trigeminocervical nucleus Interneural convergence with pericranial and cervical nerve supplies Central sensitization spreading mechanism likely (Chua et al 2011) Bogduk 1995, 2005, Bartsch 2005, Silverman 2002, Jull 2002, Chua et al 2011 MBJ - Cervicogenic Headache 7

8 Aethiology Cervicogenic Headache (Classified CgH subjects) Pathoanatomic studies: Diagnostic Blocks C0/1, C1/2, C2/3, (3/4) Bogduk 1995, Aprill 2002 Aprill et al 2002: Diagnostic Blocks 34 subjects C1/2 block = total pain reduction in 21 of 34 classified CgH subjects. Clinical studies indicating C0-4 involvement: Manual joint P/E (validity, reliability) Jull et al 1988, 1994, 1997, Zito et al 2006, Hall et al 2010 C 0/1 C 1/2 C 2/3 8 MBJ - Cervicogenic Headache 8

9 Neck Pain and Muscle dysfunction Muscular changes Muscle imbalance Weaknes Deep Cx Flexors Overly active superficial neck muscles (e.g. SCM) Falla, Jull, Zito, Watson & Trott MBJ - Cervicogenic Headache 9

10 CgH Musculoskeletal Characteristics Single headache types - CgH vs TTH & Migr n = 73 of 196 HA sufferers Migr 22 - TTH 33 - CgH 18 Significant CgH Physical findings (p=0.001) ROM Cx reduced / painful (rotation/extension). Manual P/E segmental UCx (C0-3). Cx flexor and extensor strength reduced. DCF Deep Cervical Flexor mm. Dysfunction (CCF-T). DCE - reduced CSA at C2 mm. (US-Imaging). Non-significant: Kinaesthetic Sense Cx Jull et al 2007 MBJ - Cervicogenic Headache 10

11 Cervicogenic Headache - Dx Criteria Cluster of P/E findings 1. Reduced AROM Especially Rotation and Extension (Migraine and TTH rarely have reduced ROM) 2. Dysfunctional / painful UCx segments - Manual P/E (Migraine and TTH rarely have dysfunctional UCx Joints) 3. Altered Muscle Function CCFT (24-26 mmhg +SCM) (Migraine and TTH rarely have altered Muscle Function) 3 Pos. Criteria: 100% sensitivity, 94% specificity non-mixed headache types Jull et al 2007 (Part 1, Cephalalgia) Mixed headache Types: Sensitivity and specificity lower Amiri et al 2007 (Part 2, Cephalalgia) Clinical messages Cluster of positive P/E findings strengthens CgH Dx/DDx Symptomatic classification & C/O also important (DDx) MBJ - Cervicogenic Headache 11

12 Hypothesis categories Function / Participation (ICF) Patient Perspective Patient understandi ng / expectation Painmechanisms Nociceptive -Local -Referred Structures / syndrome Contributing / predisposing factors Biomechanical Contraindications / Red Flags Handling Treatment Prognosis Neurogenic -Peripheral -Central -SMP Diff-Diagn. Consideratio ns Central Sensitization Psycho- Social - Yellow Flags MBJ - Cervicogenic Headache 12

13 Control (n=14): Existing guidelines Rest, graded exposure / activites, stretching Treatment (n=15): Existing guidelines + individualized components based on assessment; Cervical mobilisation Motor control exercises Vestibular rehab Cervico-ocular exercises. Treatment group: 73% medically cleared after 8 weeks Control group: 7% medically cleared after 8 weeks

14 A nice example that post commotio / concussion patients might suffer from different (or multiple) conditions. Despite of similar symptoms such as - Headache - Dizziness Assessment results (diagnosis) and targeted treatment strategies - Symptomatic neck (cervicogenic)? - Associated neck muscle dysfunction? - Inner ear / vestibular disorder (BPPV)? - Brain (MTBI)? - Etc. Differential diagnosis is the key to succes

15 Muskuloskeletal smerte På nogle afgrænsede felter er der vidensmæssigt lovende grundlag for at bekræfte teoretiske hypoteser Hvor kommer smerten fra (patoanatomi) Hvilke muskulære dysfunktioner er associeret med smerten. Hvilke anamnestiske fund er brugbare i diagnosen Hvilke kliniske fund er brugbare i diagnosen Hvilke behandlingsmuligheder er relevante og evt. evidente Ændret motorisk kontrol / muskelfunktion er ofte associeret med den samlede muskuloskeletale dysfunktion

16 There might be multiple reasons for altered motor control / movement patterns

17 Don t just look at motor control or movement patterns Praksis: Differentialdiagnostik er vejen til succesfuld behandling. Forskning: Inddrag specialviden og eksisterende evidens i studiet og om de patienter der undersøges / behandles. In- og eksklusion skærpes? Incorporate minimal differential diagnosis in the inand exclusion criteria. Multiple undersøgelseskriterier? Subgrupper? Flere interventionsgrupper? Multimodal behandling? Pragmatiske RCTs?

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