Conference Science Committee
1st Science Director Prof Jacob Patijn MD PhD, Maastricht The Netherlands,
Chairman IAMMM and 2nd Science Director Prof Olavi Airaksinen MD PhD, Kuopio Finland
Special Scientific Members
  • Prof Raffaele DeCaro, MD PhD, Padua Italy
  • Prof Carla Stecco, MD PhD, Padua Italy



EXPRESSION OF THE ENDOCANNABINOID RECEPTORS IN HUMAN FASCIAL TISSUE


G. Albertin, C. Fede, M.M. Sfriso, L. Petrelli


Department of Anatomy and Movement Sciences, Department of Molecular Medicine, University of Padua, Italy


Background: Endocannabinoids are endogenous lipid mediators with wide range of biological effects similar to those of marijuana. They exert their biological effects via two main G-protein-coupled cannabinoid receptors, the CB1 (cannabinoid receptor 1) and CB2 (cannabinoid receptor 2). Cannabinoid receptors have been localized in the central and peripheral nervous system as well as on cells of the immune system, but recent studies gave evidence for the presence of cannabinoid receptors in different types of tissues.1,2 Their presence was supposed in myofascial tissue, suggesting that the endocannabinoid system may help resolve myofascial trigger points, suppressing pro-inflammatory cytokines such as IL-1beta, TNF-alpha and increasing anti-inflammatory cytokines.3, 4
However, until now the expression of CB1 and CB2 in fasciae and in fascial fibroblasts has not yet been established.

Material and Methods:
In this work small samples of fascia were collected from volunteers’ patients: for each sample were done a fibroblast cell isolation, immunohistochemical investigation (CB1 and CB2 antibodies) and real time RT-PCR to detect the expression of CB1 and CB2.

Results:
The immunostaining results demonstrate the expression of CB2 and CB1 on fascial fibroblasts and fascial tissue. In the tissue not all the fibroblasts are positive, whereas the isolated and expanded cells are homogeneous. These results are confirmed by the real time PCR where the specificity of the reaction on fibroblasts and fascial tissue is the same, but the amount of expression in the tissue is lower, for both CB1 and CB2.

Conclusion: This is the first demonstration that the fibroblasts of the muscular fasciae express CB1 and CB2. These results could represent a new target for drugs to care fascial fibrosis and inflammation. The presence of the endocannabinoid system in the fascial fibroblasts can also explain the efficacy of cannabis to care myofascial pain and the possible stimulation during manipulative treatments and exercises (5).
More studies about the interactions between fibroblasts, extracellular matrix and CB1 and CB2 receptors could help to understand the role of these receptors on myofascial pain
.

References
[1].Van Sickle MD, Duncan M, Kingsley PJ, Mouihate A, Urbani P, Mackie K et al. Identification and functional characterization of brainstem cannabinoid CB2 receptors. Science 2005;310:329–332.
[2]. Pacher P, Gao B. Endocannabinoid effects on immune cells: implications for inflammatory liver diseases. Am J Physiol Gastrointest Liver Physiol 2008;294:G850–G854.
[3].Pavan PG, Stecco A, Stern R, Stecco C. Painful connections: densification versus fibrosis of fascia. Curr Pain Headache Rep 2014;18(8):441.
[4].Fiz J, Durán M, Capellà D, Carbonell J, Farré M. Cannabis use in patients with fibromyalgia: effect on symptoms relief and health-related quality of life. PLoS One 2011;6(4).
[5].Russo EB. Clinical endocannabinoid deficiency (CECD): can this concept explain therapeutic benefits of cannabis in migraine, fibromyalgia, irritable bowel syndrome and other treatment-resistant conditions? Neuro Endocrinol Lett 2004;25(1-2):31-9.

Walkway vs. treadmill walking: are both conditions interchangeable without any qualification? Lessons from gluteal muscles.


Ch. Anders, S. Patenge, R.W. Kinne

Universitätsklinikum Jena, Klinik für Unfall- Hand und Wiederherstellungschirurgie FB Motorik, Pathophysiologie und Biomechanik, Jena, Deutschland
Corresponding author: Ch. Anders;
CHRISTOPH.Anders@med.uni-jena.de.

Purpose: This study sought systematic differences between functional characteristics of the gluteal region during walkway and treadmill walking.

Material and
Methods: "Silver-aged" healthy subjects of both sexes (n = 54) walked on a walkway at their self-selected slow, normal, and fast walking speeds and with matched speeds of 3, 5, and 6 km/h on a treadmill (SLOW; NORMAL; FAST). The gluteal region was explored by Surface EMG using two pre-fabricated electrode strips of eight electrodes on each side, horizontally aligned at mid-distance between greater trochanter and iliac crest, and allowing analysis of eight vertically oriented electrode pairs per side (P1 to P8; ventral to dorsal). Grand averaged amplitude curves and extracted time independent variables (mean amplitude and cumulative muscle activity per distance (CMAPD) were used to compare walkway vs. treadmill.

Results
: Treadmill walking evoked significantly elevated muscular activation (mean amplitude; CMAPD) in the gluteal region, with a focus on P1 to P4, and disproportionately elevated values at SLOW. Grand averaged curves revealed significantly elevated amplitudes for treadmill walking during load acceptance (SLOW; NORMAL), mid-stance (all speeds), and late swing phase (SLOW; all P1 to P8), with generally decreased frequencies of significant differences from SLOW to FAST.

Conclusions
: Treadmill walking requires elevated effort of gluteal muscles, in particular at SLOW, with potential implications for (pre-operative) diagnosis and muscular training for rehabilitation, neurological dysfunction, and/or elderly people.


Abdominal trunk muscles should be considered according their identifiable functional subunits.

Ch. Anders, L. Gotthardt, R. Reimann

Universitätsklinikum Jena, Klinik für Unfall- Hand und Wiederherstellungschirurgie FB Motorik, Pathophysiologie und Biomechanik, Jena, Deutschland. Corresponding author: Ch. Anders;
CHRISTOPH.Anders@med.uni-jena.de.


Purpose: The study aimed at the identification of possible localization related differences of trunk muscle activation characteristics during static load situations

Material and Methods: Healthy middle aged subjects of both sexes (n=53, 19 to 57 years) were exposed to static trunk load situations. Surface EMG was obtained at isometric load levels of 25%, 50%, 75%, and 100% of the subjects' upper body weight (UBW) in sagittal and frontal plane. The SEMG was obtained from both oblique and the straight abdominal muscles. SEMG amplitude levels were quantified as root mean square (rms). For all muscles the electrodes were placed at the recommended, but also at caudally (for external oblique (OE) and straight abdominal (RA) muscles) and cranially (internal oblique (OI) abdominal muscle) shifted positions.

Results: The applied static load situations for the shifted positions provoked elevated amplitudes for OI and OE, but mainly reduced amplitudes for RA. The magnitude of the amplitude differences was influenced by load situation. Main force directions between positions did not differ for RA, but were deviated towards more lateral directions for OI and OE with respect to the shifted positions. Load level did not systematically influence these deviations of the main force directions.

Conclusions: Abdominal trunk muscles have to be regarded as multifunctional muscles, containing sub-units that interact differently with externally applied load situations. This has to be considered for functional evaluation tests and has also possible implications in therapeutic interventions.



" Muscle, muscle function and myoskeletal disorder - a personal history"

Professor Lothar Beyer, MD, PhD

Berlin, ÄMM e.V.,

Manual Medicine (MM) has a high potential to be a personalized treatment in individual accordance with the anatomical and physiological prepositions, the daily requirements in professional and leisure activities and the symptoms and complaints of the patient.
In MM one aim is to relieve pain. There is also the duty to take care in prevention of the pain development in the MSS. Therefore we shout know more about the
ethiopathogenesis of myoskeletal dysbalaces and pain.

The concept of Functional Mobility:There rises the question: Is it the pain what causes the dysfunction or may it be that the dysfunction is a preposition of pain. – the hen and egg principle. As the definition of pain is: Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, we may ask “What means potential tissue damage”? May be there is the key for prevention of dysfunction and also pain.

Forty years ago, sportsphysiology was searching for possibilities to control and to guide individually the process of preparation for a competition.
Sportsphysiology shows an unlimited diversity of voluntary movements, which are influenced by physical and psychical factors, voluntarily and involuntarily influenced by the subject and by the environment.
There is
a plurality of partial processes in adaptation and perfecting:
All this processes, all the different functions in the different systems have to be coordinated for daily live and occupational activities, that’s a
coordination of coordination.

Hypothesis: If in a cooperation of different functions, common ensuring the same performance, one partial function slows down, e.g. one function drops back behind the others, all the other functions need a functional flexibility to compensate / to adapt.

Definition: Functional mobility (Fiziologicheskaia labil’nost’) in physiology the speed of flow of elementary cycles of excitation in nerve and muscle tissues. Vvedenskii 1886 (1852 – 1922)
Performance (disuse, overuse, inadequate use), Functional Flexibility (inhibition, inter- and intramuscular coordination, fatigue) and motor pattern (stereotype, asymmetry, hypomobility) build the three corners of a triangle of functional balance.

Hypothesis Decline of the FF may be an important source in ethiopathogenesis of myoskeletal dysbalances and pain.

Behind the FF may be the activation of the CNS itself, as was postulated by the
Yerkes and Dodson principle, displaying the relation between central activation and performance, which is optimal only after good preparation of performance and during limited time.
In MM we investigate changes in muscle tonus, asymmetric posture and stereotyped movements, which may be the symptoms of imbalanced relationship between centre and periphery.

Some results from my early period of living physiology in sports medicine are demonstrated.
To restore the optimal functional relationship between different but linked functional motor circuits may be the aim and the result of manual intervention.
Reliability and evidence of the manual and functional tests in MM can be better achieved by comparing manual outcome with additional physiological parameters of muscle and nervous activity.

Conclusions:
There are subjectve and objective signs of motor control dysfunction (MCD)
Reliability and evidence in MM may be better achieved comparing manual outcome with physiological parameters of muscle and nervous activity.
Lets develop a Model on the base of Functional Mobility to prove the Ethiopatogenetic hypotheses Myoskeletal functional impairment (motor control dysfunction) exists (mostly) bevor the pain develops
Early signs of MCD may be used for prediction and prevention and individualised treatment
Screening test should be elaborated


Reflux in babies - the mm- approach. A katamnestic study of 200 cases.

Heiner Biedermann, MD PhD

Privat Praxis, Köln, Germany


BACKGROUND: In the last decade 'reflux' sky-rocketed to paediatric attention (4 times more search queries, especially Anglophone countries and the BeNeLux), whereas the interest in 'Colic' decreased markedly.
In our consultation we see 1.000 - 1.500 babies (1 -12 months old) every year.

MATERIAL AND METHODS: Of a random sample of 250 cases we tried to reconstitute the case history, either by re- examination or telephone interview a year later.
Of these, 207 cases yielded sufficient data.
As the anatomy of toddlers is incompatible with a reflux sensu strictu we interpret the complaints of the parents as a mixture of over- acidification of the stomach and excessive vomiting in these children.

RESULTS: Our comparison of the success of the previous treatments and the one manipulation at our place shows the marked improvement due to the re-establishment of normal cervical function and its positive influence on the symptoms.

CONCLUSION: Whereas the influence of the lack of H. pylori in these families is beyond the scope  of this study we think we can prove the influence  of manual medicine on the functional pathology of the oesophagus and thus on 'reflux'.

Fascial Manipulation Associated with Standard Care Compared to Only Standard Postsurgical Care for Total Hip Arthroplasty: A Randomized Controlled Trial

Massimo Busato, Cristian Quagliati, Lara Magri, Mirco Branchini
Hospital Bolognini di Seriate, Bergamo, Italy

Background: Postsurgical physiotherapy programs after total hip arthroplasty (THA) show important differences between types and numbers of treatment sessions. To increase functional recovery in postsurgical patients, manual therapy can be added to traditional physiotherapy programs. Fascial Manipulation (FM) has been demonstrated to be effective in decreasing pain and increasing muscular capacity.

Objective: Randomized controlled trial to compare the effectiveness of FM when added to a standard protocol of care.

Material and Methods:
A total of 51 patients were recruited after total hip arthroplasty. Inclusion criteria were first THA surgery, posterior lateral access, and onset of pain within a maximum 2 years. Patients were randomized into 2 groups; both followed a standard protocol based on 2 daily sessions of active exercises for 45 minutes. In the study group, 2 sessions were replaced by FM.
Main Outcome Measures: Functional outcome measures were collected before and after treatment and at the end of the
rehabilitation program. The measures included the Harris Hip Score; Timed Up-and-Go test; articular range of motion in
abduction, flexion, extension, and bilateral external rotation with heels together; and verbal numerical scale.

Results:
Statistically significant differences were observed in degrees of flexion between the study and control group with
25.4 (_11.3) and 18.7 (_9.5), respectively (P ¼ .04); for abduction with 16.8 (_7.0) and 11.1 (_6.1), respectively (P ¼ .005); for extension with 16.2 (_4.9) and 9.3 (_3.8), respectively (P ¼ .001); for bilateral external rotation with heels together with 8.3 (_4.3) and 5.5 (_4.6), respectively (P ¼.04); for the Harris Hip Score 23.3 (_8.9) and 14.5 (_8.5), respectively (P ¼.002); and for verbal numerical scale score 1.1 (_2.1) and 0.5 (_1.1), respectively.

Conclusions:
This study demonstrates that 2 FM sessions are able to significantly improve several functional outcomes in patients compared to usual treatment after THA.


A reproducibility study of a lumbar test according to the Marsman method in a small medical centre.

Alain Coiffard MD, Rodolphe Gadrat MD, Vivien Duchesne MD

St. Phane Brunet, Medical Centre, Aix en Provence, France

Objectives: We expect that scientific studies can only be realized in university based structures. We realized a reproducibility study of a rotation test in standing position.

Material and Methods: Two examiners, blinded for each other results, tested 40 subjects
after a study phase to obtain an 80% overall agreement. The subjects, visiting a medical
centre, were tested for their rotation mobility of their lumbar spine and lower extremities.
1 The study was performed according the IAMMM protocol for reproducibility
studies
2

Results:
After three trials, in the formation phase, to obtain overall agreement of 80%, the study phase showed an overall agreement of 70% and Kappa value of 0.38.3

Conclusion: Our study proved at first that a reproducibility MSK‐study can be realised in a small medical structure. Besides, we will show in our presentation the complete structure of
our study, our pitfalls and recommendations as we will use in our next study.


References
1. Jacob Patijn, (2012) Reproducibility and Validity: Protocols for diagnostic procedures in musculoskeletal medicine (French version), IAMMM
2. Sjef Rutte (2007), Examination course lumbar spine (French version), Marsman method, p 33, Marsman Foundation Harlem, Netherlands
3. Jacob Cohen (1960). A coefficient of agreement for nominal scales, Educational and Psychological Measurement 20 (1): 37–46.



Evaluation of Fascial Manipulation (Stecco Method) efficiency in the deep fascia structure modification through ultrasound scanning and elastography.
Copetti L, Biscosi M, Tomat S.
Department of Anatomy and Movement Science at the Padova University, Italy
Objectives: the aim of this study is the observation through ultrasound scan and elastographic analysis of the condition of the deep fascia on determined knots corresponding to the coordination centres (CC) or fusion centres (CF) of the Manipolazione Fasciale method, previously considered as densified through the palpation. It will also be observed whether the deep fascia structure modifies after the treatment.
Material and Methods: 10 individuals have been submitted to ultrasound and elastographic examinations in order to verify the condition of the deep fascia of the involved knots and of the contralateral knots considered healthy. After the diagnostic procedures the CC and CF considered as densified through palpation have been manipulated through the practice of the Fascial Manipulation and thereafter a second ultrasound scan and a second elastography have been carried out to verify whether the manipulation had changed the considered fascia.
Conclusions: the observations suggest that the tissue knots detected through palpation and described as densifications are attributable to a deep fascia alteration and the Fascial Manipulation appears to be efficient as far as the recovery of the correct physiology of the deep fascia. Wherever a densification is detected through palpation, during the elastography the deep fascia appears to be between the most rigid tissue of the region. It cannot be stated that a tight link exists between the local treatment and an increase in the elasticity of the deep fascia of the above mentioned knot.

The reliability and the inter-observer agreement of a diagnostic knee rotation test
P. Cuppen, MD,1 R. Brouwer MD,1 B de Bot, MD,2
1Cheiron Medical Centre, Waalre, The Netherlands, 2Medisch Orthomanueel Centrum Maasbracht, The Netherlands

Introduction:
As part of our MSc-study at the Free University of Brussels we examined the rotation of the knee in a fixed position using a manual test.
Aim:
Because there is no uniform agreement about the outcome of the rotational movements of the knee, we tried to find out what is normal.
Material and Methods:
Therefore, we developed a “rotational-device” in cooperation with the Technical University of Eindhoven.
To our knowledge there is no “golden standard” to objectivize the rotational movements of the knee.
Step 1: Validation; Is the newly developed measuring instrument a reliable device to measure the rotational movements of the knee?
Step 2: Measuring the manual test in comparison to the “rotatometer”. Is the manual test reliable to assess the rotational movements of the knee?
Step 3: Study of the “inter-observer reliability”
Discussion: The protocols formats will be discussed in detail.

EXPRESSION OF HORMONE RECEPTORS IN HUMAN FASCIAL TISSUE


C. Fede, G. Albertin, L. Petrelli
.


Department of Anatomy and Movement Sciences, Department of Molecular Medicine, University of Padua, Italy


Background: Fascia is a tissue that interact with different structure in a very precise manner. It creates a structural continuity that give form and function to every tissue and organ. It plays a significant role in mechanical tension, transmitting force, correct motor coordination so altered structure of specific components layers could generate a clinical problem. Recent studies have shown the possible role of the fascial nociceptors to mechanical and chemical stimuli may contribute to myofascial or musculoskeletal pain (1). Many epidemiologic, clinical, and experimental evidence points to sex differences in myofascial pain, and generally adult women more often have myofascial problems than do men (2). It is possible that one of the stimuli to sensitization of fascial nociceptors could come from hormonal factors such as oestrogen and relaxing that are involved in extracellular matrix and collagen remodelling (3). Relaxin-2 (RLX-2) is recognized as anti-fibrotic factor that is the ligand for RXFP1. Oestrogens and in particular 17β-estradiol (E2) regulate a widespread of physiological functions and the actions are mediated by two oestrogen receptor isoforms, ERα and ERβ. We hypothesized that E2 and relaxin contribute on metabolism and function of myofascial tissue.

Material and Methods:
Immuno-histochemical and molecular investigation (real-time PCR analysis) for RXFP1 and ERα localization were carried out in human fascia of different districts (peroneal, abdomen rectum, hip and low back fascia) and in fibroblasts isolated from the same districts, with the aim of describing both protein and RNA expression.

Results: ERα and RXFP1 are expressed on fibroblasts of human fascial tissues and RXFP1 expression was particular intense on vessels and nerves. These results are confirmed in isolated fibroblasts derived from the same fascial districts. Not all the cells have the same reactivity but the positive reaction was evident in the cytoplasm of cells for RXFP1 and with more intensity on nuclei of cells for ERα.

Conclusion: Our results are the first demonstration that the fibroblasts of different districts of the muscular fasciae express sex hormone receptors. These findings could represent a new target for the care of myofascial pain and the possible stimulation during manipulative treatments and exercises. More studies about the interactions between fibroblasts, extracellular matrix and hormone receptors (oestrogen, progesterone, relaxin) could help to understand the role of these receptors on myofascial pain.

Reference:
[1].Pavan PG, Stecco A, Stern R, Stecco C. Painful connections: densification versus fibrosis of fascia. Curr Pain Headache Rep 2014;18(8):441

[2].Rollman GB, Lautenbacher S.Sex differences in musculoskeletal pain.Clin J Pain. 2001 Mar;17(1):20-4
[3].Dehghan F, Yusof A, Muniandy S, Salleh N. Estrogen receptor (ER)-α, β and
progesterone receptor (PR) mediates changes in relaxin receptor (RXFP1 and RXFP2) expression and passive range of motion of rats' knee. Environ Toxicol Pharmacol. 2015; 40(3):785-91.



Study on reliability and validity of sacroiliac joint diagnosis (-study)
Dr. Wolfgang von Heymann, MD, Dr. Horst Moll, MD
Physicians’ seminar for Manual Therapy of spine and extremities, Isny, Germany (MWE), Institute for medical biometrics and computer science, University of Heidelberg, Germany, Corresponding author: Geraldine Rauch, PhD, University of Heidelberg, Germany
INTRODUCTION: There is hitherto no “golden standard” for the diagnosis of sacroiliac joint (SIJ) dysfunction. Even fluoroscopic guided injections could not give sufficient proof of the origin of pain in the pelvic girdle. Several functional and pain-provocation tests are described. It was suggested that a combination of five pain-provocation tests, of which three should give a positive answer, would be classified to be reliable (Laslett, 2008).
AIM: MWE teaches the diagnosis of SIJ by a combination of functional and pain-provocation tests that were not included in the Laslett-study. The reliability and reproducibility of these tests shall be checked in comparison to the already evaluated tests.
MATERIALS AND METHODS: 150 subjects (75 with pelvic girdle pain, 75 asymptomatic controls) are examined by two raters proceeding immediately from one to the other by a set of tests, consisting of the already evaluated tests and in addition of the diagnostic procedure of the MWE. This procedure consists of three steps: check of mobility, check of articular induced muscular irritation (body protection) and pain-provocation to check for more or less painful reactions of the irritation during functional testing. Each rater sees 50% of the subjects in first place, and then they immediately change to the other. After collecting all data, there will be an evaluation of the reliability and validity of the testing results according to Cohen’s Kappa (respecting the prevalence factor).
RESULTS: The collection of data is not yet finished. There are no results that can be published today. Until the presentation, approximately 100 of 150 subjects will be investigated. A preliminary survey of the data seems to show a good reliability and validity of the newly investigated diagnostic procedures, comparable to those already evaluated. Final evaluation will be published after reaching the defined number of investigated subjects.
CONCLUSIONS: A set of SIJ-tests consisting out of checks for mobility, articular related muscular irritation and pain-provocation for a more or less painful direction of functional mobility is compared with already evaluated pain-provocation tests for the SIJ. Preliminary results show that this set of tests is equivalent to the evaluated tests. We will propose this set of SIJ-tests, as they are reliable, reproducible, and safe for the patient as well as easily to teach also to beginners in manual medicine.
Manual Medicine treatment of headache in older children: preliminary data of a cohort study

B. Küsgen MD, PhD, H. Biedermann, MD, PhD

Privat Praxis, Köln, Germany

Background: Prevalence of headache in school children constantly rises over the last years. Figures differ between 40 - 60 % of children and adolescents all over the world. In children tension type headache (up to 25%) is the most common cause of primary headache, followed by migraine (ca. 8 %). It can have a large impact on school (absence days, learning / concentration deficits) and other aspects of daily life, and often affects the children's and their families' overall quality of life to a big extent. Headache at children's age often results in extensive diagnostic measures resulting in little effective therapeutic solutions. Treatment options are nonpharmacological (e.g. relaxation/behavioural techniques/biopsychological approaches) or based on medication. Many children do not improve via the offered treatments and have a long standing history of their problem. Often their condition is experienced into adulthood which shows the need for effective intervention for paediatric headache.
Nearly 3/4 of all the patients at school children's age (6-16) who come to our Manual Medicine Practice report headache as a problem. For nearly half of the patients their headache problem is one of the main or even exclusive reason for an appointment with us. We find dysfunction of the occipitocervical junction (often in combination with dysfunction of other spinal segments/ SI joints / postural imbalances) as the underlying cause of headache in many of those children. Treating those patients - if positively identified to have such dysfunctions - with Manual Medicine techniques can mean a prompt, relevant treatment option. Albeit, Manual Medicine as a possible tool to help those children is not yet recognized widely if not rejected by the clinicians involved.

Matreial and Methods: In a prospective cohort study on children we identified 95 patients with headache as their major complaint who had segmental dysfunction of their cervical spine as a possible cause for their condition. Those patients were treated according to their clinical findings with Manual Medicine techniques by the three specialist doctors of our Manual Medicine Practice. Of those we were able (so far, July 2016) to follow up 83 children after treating them (mostly by telephone interviews and/or follow up appointments 6, 12 and 18 months after treatment). Age ranged from 6 to 16 years. Recruiting time was January – December 2014. In 76 % of the children headache was a longstanding problem (6 months – 8 yrs) affecting life 'severely' in nearly 80 % of the cases. (Almost) all children had gone through the 'standard' diagnostic procedures (specialised clinics= 'Kopfschmerzambulanzen', MRI, internal/ paediatric/ENT/neurological/psychological assessment, etc.) and had been treated variously prior to coming to us with little or no effect – the reason for their appointment with us.

Results:
We used a German school type rating system (marks 1-6) to evaluate the effect. After one single visit / treatment in our Practice headache was no longer present in 48% of the children (mark 1). They did not need any further intervention and after 18 months there was no recurrence. Of the remaining 52 % we had to treat 2/3 again for relapse with satisfying longterm results afterwards (marks 1-3). 1/3 remained free from dysfunction with the condition having improved remarkably (marks 1-3). Only 4% (i.e. 3 children) of the 83 treated did not respond to our treatment (marks 4-5) and continued with their headache in an unchanged way.


Conclusions:
Although we present preliminary figures the data we collected shows undoubtedly how often children's headache is related to segmental spinal dysfunction. Applying Manual Medicine is accordingly a highly effective, time and cost saving treatment for a sometimes devastating condition. It can be safely applied and – as we could show – in many cases promptly relieve children's headache relevantly. Awareness for this possible somatic condition underlying the often labelled 'primary headache' should be raised and brought into interdisciplinary discussion.

FASCIAL MANIPULATION IN THE REHABILITATION OF UPPER EXTREMITY REPETITIVE STRAIN INJURY

Tiina Lahtinen-Suopanki PT, BSc

Rehabilitation Centre Orton,Tenholantie 10, 00280 Helsinki, Finland. Corresponding author:
tiina.lahtinen-suopanki@orton.fi

BACKGROUND: Playing an instrument means countless amounts of repetitions and a high load for the performing hands. The repetitive movement overloading can result in various symptoms including deficits in motor control, loss of strength and pain.

MATERIAL AND METHODS: The study group consisted of eight symptomatic violinists aged 25.8 (±4.0) years who had been playing the same instrument for 19.3 (±4.9) years and had had their upper extremity symptoms for 3.5 (±3.1) years. The five control group musicians were age matched women who had been playing the violin for 17.0 (±1.8) years.
The disability in connection was measured by VAS- scale 0-10 at the baseline and at the end of the study. Three grips were measured and their average value was compared between the two groups at the baseline and at the end of the study. The study group musicians were evaluated and treated by three interventions with Fascial Manipulation (FM) method within two months.
All the musicians who participated in the study were voluntary and gave their written approval for the use of the data.

RESULTS: The baseline disability was 8.50 (±1.31) and at the end of the study 4.25 (±1.83), p = 0.011. The baseline grip force difference between the symptomatic side of the study group and corresponding side of the control group showed statistically significant difference (p = 0.012). A notable improvement (p = 0.019) of grip strength of the symptomatic hand was at the end of the study.

CONCLUSION: The fascial dysfunction seems to play a role in the peripheral mechanical sensitisation and disability in cumulative stress disorders. Treatment aiming to restore fascial function had a favourable effect on the force and mechanosensitivity.



THE EFFECT OF FASCIAL MANIPULATION IN PELVIC MOVEMENT CONTROL
Tiina Lahtinen-Suopanki, PT, BSc

Rehabilitation Centre Orton, Helsinki, Finland, Corresponding author: tiina.lahtinen-suopanki@orton.fi

INTRODUCTION: Muscle contraction tensions the fascia which is one of the key elements in pelvic force closure. Impaired movement control has been associated with posterior pelvic pain and turns up as an increased pelvic lateral shift (PLS) during single leg stance.
Measurement of PLS during one leg stance before and after Fascial Manipulation (FM) was carried out with patients having dysfunction in lumbar-pelvis and/or lower extremity.

MATERIAL AND METHODS: The study group consisted of 14 female and 6 male patients whose mean age was 45,2 years (18-69). The dysfunctional or/and painful body areas lumbar (12), pelvis(2), hip (4), knee (2) and ankle (4). They were tested with single leg stance test and found to have asymmetry in the PLS. The patients were evaluated and treated by the Fascial Manipulation method.
RESULTS: There was no statistically significant difference between females and males in the PLS on the healthy side, so they were analysed together as one study group (N=20). The baseline mean PLS of the asymptomatic side was 42,85 mm and 62,60mm on the symptomatic. After FM there was a mean change of 15,2mm of PLS on the symptomatic side (p = 0.013) and on the asymptomatic side the change was 2,7mm (p=0.095).
DISCUSSION: The measurements of the PLS during single leg stance that were done before and after show a change towards movement symmetricity which means a change in the muscle recruitment and synergistic function. Restoring the normal functioning of the fascia may help to prevent further stress and strain and pain of the pelvic structures.


Three years after successful intervention for low back pain – how are the patients now?
Vesa Lehtola, PT
Department of Physical and Rehabilitation Medicine, Kuopio University Hospital, Kuopio, Finland
Background: Only 15% of patients with low back pain (LBP) will get a specific diagnosis, and the majority of cases are categorized as non-specific LBP. Despite the recommendations of clinical guidelines, only a few studies have been published on subgroups of patients with LBP. Movement control impairment (MCI) is one potential subgroup, and clinical tests have been developed to identify it. Exercise is recommended in clinical guidelines, as it seems to be an effective treatment for chronic LBP, but little is known about the management of subacute LBP.
Material and Methods
: The effect of general exercises versus specific movement control exercises (SMCEs) was compared in a randomized controlled trial in a population with recurrent subacute LBP. Patients in both groups had five treatment sessions of either specific or general exercises, including short application of manual therapy. The primary outcome measure was the Roland-Morris Disability Questionnaire (RMDQ) evaluated at baseline, after 3 months of intervention, and at the 12-month follow-up. The trial included 70 eligible patients. The 12-month follow-up was completed by 61 patients (n= 30 SMCE and n=31 general exercise, drop-out rate 12.9%, SMCE 14.3% and general exercise 11.4%). Patients in both groups significantly improved as a result of the therapeutic interventions. SMCE was superior according to the mean change in the RMDQ between baseline and the 12-month follow-up (-1.7 points; 95% CI -3.9 to -0.5). However, the difference was below the clinically significant three points and the Oswestry Disability Index (ODI) did not differ between the groups. Combined SMCEs and manual therapy was slightly superior to general exercises combined with manual therapy for patients with non-specific recurrent subacute LBP and MCI. Disability was alleviated and function tended to improve more at the 12-month follow-up with the specific exercises.
Results: In Sept 2016 the research group has started to conduct an extra three-year follow-up for the patients of this study.
The preliminary results of the RMDQ, the Patient-Specific Functional Scale (PSFS), need for pain medication, amount of sick leave, need for treatment modalities and adherence towards exercises will be presented.

The European Training Requirements for “Additional Competence Manual Medicine” for Physician Specialists within the Union Europeenne des Medecins Specialistes (UEMS). History and actual tasks of the European Scientific Society of Manual Medicine, (ESSOMM).
Dr. Hermann Locher,
Introduction:
The European Scientific Society Of Manual Medicine (ESSOMM) (President Dr. Hermann Locher) was founded 2008 with the agreement of the national MM-societies of Belgium, Bulgaria, Denmark, Germany, Estonia, Finland, France, Italy, Netherlands, Poland Slovak Republic, Spain, Switzerland, Czech Republic and Hungary. Actually the ESSOMM has 13 Member societies. The Societies are exclusively for physicians and represent 12 000 Physicians in Europe. In UEMS (Union Europeenne Medecins Specialistes) was founded a so called Multidisciplinary joint committee in 2013 that acts on the level of a European specialist section. Manual medicine is therefore an accepted physician specialist discipline in Europe. It is a so called “additional competence”.
On the UEMS Council in Warsaw 2015 were accepted the European Training Requirements (ETR MM) for manual medicine that represent the internationally accepted standards for education for this additional competence.
Schedule of Education and Training in MM: 300 hours of contact teaching in theory (33%) and practice (67%) of core Manual Medicine training is recommended, representing at least 30 ECTS credit points
(European Credit Transfer System).
Aims of further ESSOMM work: Introduction of translational research in explanation of effects of Manual Medicine United Presentation of MM (WHO-paper). Unification of nomenclature and definitions in Europe (FIMM- Glossary). Definition of curriculum MM (UEMS, CAS according to Bologna process). Selection of proved and reliable tests for physical examination under functional aspects. Scientific underlying of techniques of Manual Medicine in Europe and validity of checking assessments with good prediction (e.g. SIJ- Diagnosis).
Distinction from other disciplines whose procedures are not scientifically proved (e.g. Osteopathy by non-physicians).
To give scientifically proved procedures to Politics, health care systems and assurances.  
Radiological Anatomy of the superficial and deep fascia

Professor Veronica Macchi, Anatomy and Movement Sciences, Department of Molecular Medicine, University of Padova, Italy


In the last ten years we have studied the radiological appearance of the superficial and deep fasciae, in normal population, basing on imaging techniques, such as computed tomography (CT), magnetic resonance (MR) and ultrasound (US). From the methodological point of view, the study is based by the comparison between topographical relationship of the different structures observed with dissection and histological macro-section and the corresponding radiological images. At CT examination H value of the fascia is – 80 HU, appearing slightly hyperdense: the superficial fascia appears as a relatively hyperdense tortuous line between hypodense superficial adipose tissue and hypodense deep adipose tissue; the deep fascia appears as a hyperdense line of connective tissue recognisable at intervals when it covers the muscles, where adipose tissue is localised between the fascia and the fibre muscle. At MR examination in the T1- and T2-weighted sequences the superficial fascia appears as a low signal intensity tortuous line of connective tissue. In the T1-weighted sequences the deep fascia appears as a low signal intensity tortuous line of connective tissue recognizable at intervals when it covers the muscles, where adipose tissue is localized between the fascia and the fibre muscle. At US both the superficial and deep fascia appear as hyperecogenic lines. In our experience each technique has advantages and disadvantages:  CT images are finely detailed and allows a very accurate analysis of the fascia but CT examination presents the major disadvantage of using X-ray and so it is considered invasive method. MR produce good image, with lowest resolution with respect to CT and US. It allows to study the fascia and is currently used for the pathology of the fascia, as well as the US. Finally, US allows to analyse sliding of the different layers of the tissues and is non-invasive and not expensive, but is heavily operator-dependent. Thus we suggest an integration of the three methods to study in a comprehensive way the radiological appearance of the fasciae.



Forward head posture associated with neck pain. Is it reversible?

Jean-Yves Maigne, MD PhD

Hôtel-Dieu hospital, Paris, France

Background: It is acknowledged that chronic forward head posture (or anterior head translation) leading to a loss of cervical lordosis may accelerate cervical disc degeneration by increasing stresses on the cervical spine and is associated with rather negative clinical outcomes. On the opposite, little is known about transient, reversible forward head posture associated with neck pain.

Material and Methods: 19 patients, with neck pain and a forward head posture on a lateral X-ray were X-rayed after recovery of their neck pain (usually after a manual treatment) to document the evolution of their cervical spine posture. They were 11 males and 8 females, mean age 39. The trouble involved in all cases the upper and mid-cervical spine, starting at C4-5 in 10 cases and C5-6 in 9.

Results: In 6 cases, the anterior translation was completely reversible, having disappeared on the follow up film. In 5 cases, there was a slight improvement of the trouble. In 5 other cases, the posture was identical and in the last 3 cases, it was more marked, despite the clear clinical improvement.

Conclusion: The causes of forward head posture associated with neck pain are not known. Theoretically, it could be attributed to either hypertonia (hyperactivity) of the neck flexors, or hypotonia of the neck extensors, or separation of the posterior endplates (due to a disc herniation) or approximation of the anterior endplates (due to disc degeneration) at C4-5 or C5-6.


Fracture in the Elderly Multidisciplinary Rehabilitation (FEMuR): a phase II randomised feasibility study of a multidisciplinary rehabilitation package following hip fracture
Nefyn H Williams, Jessica L Roberts, Nafees Ud Din, Nicola Totton, Joanna M Charles, Claire A Hawkes, Val Morrison, Zoe Hoare, Michelle Williams, Aaron W Pritchard, Swapna Alexander, Andrew Lemmey, Robert T Woods, Catherine Sackley, Pip Logan, Rhiannon T Edwards, Clare Wilkinson.
North Wales Centre for Primary Care Research, School of Healthcare Sciences, Bangor University, Gwynedd, UK. Corresponding author: e-mail: nefyn.williams@bangor.ac.uk
Background: Hip fracture is a common, major health problem in elderly people, associated with high mortality rates, loss of independence and a large cost burden on society amounting to ~£2.3 billion annually in the UK. A programme of multidisciplinary rehabilitation is recommended to optimise recovery from hip fracture, but there is insufficient evidence of overall effectiveness or cost-effectiveness for such programmes.
Objective: To conduct a feasibility study for a future definitive randomised controlled trial (RCT) of an enhanced rehabilitation package for hip fracture.
Material and Methods: Older adults (aged ≥65) who received surgical treatment for hip fracture, lived independently prior to fracture, had mental capacity and received rehabilitation in North Wales were recruited to usual care (control) or usual care + enhanced rehabilitation package (intervention). Intervention included six additional home-based therapy sessions delivered by a physiotherapy team and supported by a patient-held information workbook and goal-setting diary. Outcome measures including Barthel Activities of Daily Living (BADL, primary measure) were assessed at baseline and three-month follow up.
Results: Sixty-two participants were recruited, 61 randomised (control 32; intervention 29) and 49 (79%) completed three-month follow up. Minimal differences occurred between the two groups for most outcomes, including BADL which showed a ceiling effect. The intervention group showed a medium sized improvement in the Nottingham Extended Activities of Daily Living (NEADL) relative to the control group, with an adjusted mean difference between groups of 3.0 (Cohen’s d 0.63). the mean cost of delivering the intervention was £231 per patient.
Conclusion: Trial methods were feasible in terms of eligibility, recruitment and retention. NEADL was a more appropriate primary measure and should be used in a definitive RCT.
Development of a complex intervention for improving outcomes in elderly hip fracture patients: a realist approach.
Nefyn H Williams, Jessica L Roberts, Nafees Ud Din, Michelle Williams, Claire A Hawkes, Joanna M Charles, Zoe Hoare, Val Morrison, Swapna Alexander, Andrew Lemmey, Catherine Sackley, Pip Logan, Clare Wilkinson, Jo Rycroft-Malone.
North Wales Centre for Primary Care Research, School of Healthcare Sciences, Bangor University, Gwynedd, UK. Corresponding author: nefyn.williams@bangor.ac.uk
Background: Hip fracture is a major problem in an ageing population, leading to loss of independence and significant financial and societal burden. Development of a complex intervention to improve outcomes for hip fracture patients requires identification of the evidence base and subsequent development of theory relating to which intervention components work best and in what circumstances.
Material and Methods: Realist review of the rehabilitation literature to determine the mechanisms behind multidisciplinary rehabilitation and to establish the effective components for specific patient groups and circumstances. Survey of current rehabilitation practice in the UK sent to therapy managers, physiotherapists and occupational therapists in a variety of settings. Focus groups conducted with multidisciplinary teams, hip fracture patients, and their carers. Synthesis of resultant data informed the design of the intervention.
Results: Three programme theories were developed relating to important components of hip fracture rehabilitation interventions: improving patient engagement by tailoring the intervention to individual needs; reducing fear of falling and improving self-efficacy to exercise and perform activities of daily living; and co-ordination of rehabilitation delivery. An intervention to enhance usual rehabilitation was developed to target these theory areas comprising: a physical component consisting of additional therapy sessions; and a psychological component consisting of a workbook to enhance self-efficacy and a patient held goal-setting diary for self-monitoring.
Conclusions: A realist approach has advantages in the development of evidence-based interventions and can be used in conjunction with other established methods. A complex rehabilitation intervention was developed which has been tested to assess the feasibility of trial methods for a future definitive randomised controlled trial.

Outcomes of a stationary multimodal complex treatment of the musculoskeletal system. Results of the ANOA study.

Jenny Nisser
1, Matthias Psczolla2, Kay Niemier3, Wolfram Seidel4, Anke Steinmetz2, Steffen Derlien1
Background Context: The evidence-based treatment of chronic back pain comes into focus of current research. Treatment modalities of pain patients are discussed diversely. Single standing therapeutic measures are considered less efficient and with less impact than multimodal approaches. A positive scientific evidence exists for cognitive behavioral multimodal complex programs. It is still unclear whether certain subgroups of patients with chronic back pain benefit from other forms of therapy, such as functional multimodal therapy concepts.

Purpose:
Is a stationary interdisciplinary multimodal-nonsurgical complex treatment of the musculoskeletal system (ANOA concept) effective for a subgroup of patients with complex (multifactorial) vertebral pain syndromes?

Study Design / Setting:
In the prospective multicenter cohort study a functional diagnostic and treatment concept with a subgroup of patients was employed.

Patient Sample:
249 patients (42.6% men, 57.4% women) with vertebral pain syndrome were included.

Outcome Measures:
The outcome measure for this study is the change in pain intensity, were collected with the assessment for pain graduation (von Korff). From this assessment in the present study two items were used: average pain (AP), v. Korff- mean pain intensity (MPI).

Methods:
As part of the multimodal interdisciplinary diagnostic, patients with chronic back pain on the basis of complex disorders of the musculoskeletal system were selected for the functional multimodal treatment concept. After the treatment, the changes in pain perception were recorded. The data were collected at the following measuring time points (MTP): T1 (before the intervention / baseline), T2 (end of intervention), T3 (6 months after the end of the intervention) and T4 (12 months after the end of the intervention). The statistical analysis was performed independently from the clinics. After testing for normal distribution the t-test for dependent samples or the Wilcoxon test was used. The statistical subgroup analysis based on selected personal parameters (degree of pain chronicity (MPSS), gender, age) was performed with the process “linear mixed models".

Results:
For both parameters, a significant reduction in the perceived pain intensity was detected over all MTP. With the parameter AP, a reduction by 1.83 points (6.02, T4: T1 4.19) was found, while the AP intensity was reduced by 18.43 points (T1: 65.42, T4: 46.99). Furthermore, with the statistical subgroup analysis we were able to define the efficacy of the treatment concept within the subgroups (chronicity degree (MPSS), gender, age).

Conclusions:
By the multimodal interdisciplinary diagnostic and treatment concept a subgroup of patients with chronic back pain was selected and treated successfully. A differentiated approach to the diagnostics and treatment of chronic pain syndromes of the musculoskeletal system is a possible approach to find a way out of the dilemma of chronic back pain.

Non-specific low back pain – an attempt to develop subgroups

Kay Niemier


90% of low back pain patients get classified unspecific. Treatment results in Germany of patients classified of having chronic unspecific low back pain are poor. Only ¼ of patients profit from the treatment provided, while ¾ either get worse or have no benefit.
So far there is no comprehensive diagnostic system to divide patients according to the clinical presentation, clinical and para clinical findings. Since a sound diagnosis is necessary to provide treatment, the poor treatment results are not surprising. In order to overcome the problem multimodal, interdisciplinary treatment programs were developed. In these programs one subgroup of patients with dysfunctional beliefs and coping strategies are treated successfully. The ANOA group evaluated a treatment program for patients with muscular skeletal dysfunction as the main cause for the chronic unspecific low back pain.
Unspecific low back pain (LBP) is usually caused by a combination of different individual and clinical factors. There are morphological as well as psychosocial factors and muscular skeletal dysfunction. In addition neurophysiological pain chronification plays a role in the development of LBP.
In order to plan the treatment for each individual patient it is necessary to evaluate the different influencing factors.
In this presentation a attempt to classify the patients into subgroups will be discussed.

FASCIAL INNERVATION

Andrea Porzionato
Department of Anatomy and Movement Sciences, Department of Molecular Medicine, University of Padova, Italy


Aim of the Study: The aim of the study was to analyze innervation of the fascial structures of hand.

Material and Methods: Samples of fascia were taken from 16 upper limbs of unembalmed cadavers and from 5 patients with Dupuytren’s disease. A quantitative and qualitative histological study was then conducted, with histochemical and immunohistochemical techniques, analyzing density, type and localization of the receptors.

Results: The study confirmed the presence of free nerve endings, Pacinian corpuscles and Golgi-Mazzoni corpuscles. The midpalmar fascia showed the higher density of Pacinian corpuscles (density 2.18±1.63 cm2) and Golgi-Mazzoni corpuscles (density 1.50±1.18) and showed a density of free nerve endings similar to that of the other analyzed 4 fasciae (density 22.35±6.24); the thenar fascia didn’t show any encapsulated receptor and showed the lower density of free nerve endings (density 10.40±2.41). The presence of non-myelinated receptors was confirmed by the study with anti-tubulin antibodies. The comparison between unaffected and affected fascia found a statistically significant higher density of free nerve endings in Dupuytren’s disease (density 38.71±7.11).

Conclusion: The fascial structures of the hand are richly innervated. The central role in the proprioception of the hand is confirmed by the presence of numerous mechanoreceptors and by the strategically convenient position assumed by Pacinian corpuscles able to perceive variations of fascial tension in every direction. The nociceptive function is confirmed by the increment of the free nerve endings in the affected fascia, suggesting a role in the pathogenesis of Dupuytren’s disease and particularly in the genesis of the pain.


Impairment of neural movement with the straight leg raise test in patients with lumbar intervertebral disc herniation.

Rade M.1,2 *, Pesonen J.1*, Könönen M.3 , Marttila J.3, Shacklock M.4, Vanninen R.3 , Kankaanpää M.5, Airaksinen O.1
1. Kuopio University Hospital, Department of Physical and Rehabilitation Medicine, Kuopio, Finland
2. Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Orthopaedic and Rehabilitation Hospital “Prim. dr.Martin Horvat”, Rovinj, Croatia.
3. Kuopio University Hospital, Department of Radiology, Kuopio, Finland.
4. Neurodynamic Solutions, Adelaide, Australia.
5. Tampere University Hospital, Department of Physical and Rehabilitation Medicine, Tampere, Finland.
* Shared authorship

Corresponding author: Marinko Rade, M.Sc. Orth Med, PhD, Department of Physical and Rehabilitation Medicine, Kuopio University Hospital, P.O.Box  1607, 70211 Kuopio, Finland. E-mail: marinko.rade@kuh.fi; marinko.rade@gmail.com

BACKGROUND: Straight leg raise (SLR) test is a widely used clinical test to evaluate neural tightness and mechanosensitivity in patients with low back pain and sciatic symptoms or radiculopathy. Earlier studies by Rade et al. have shown that during the SLR test in asymptomatic volunteers tensile forces are transmitted throughout the system and the spinal cord in the thoracolumbar region slides distally in response to the clinically applied SLR test.
PURPOSE: Test if the excursion of the cord is altered in patients with lumbar intervertebral disc herniation (LIDH), a situation in which lumbar nerve root excursion has been shown to be impaired.
METHODS: in this controlled radiological study we studied 15 voluntary patients with sciatic symptoms due to subacute LIDH with a 1.5T magnetic resonance (MR) scanner (Siemens Aera, Erlangen, Germany). First a spine specialist diagnosed the LIDH with conventional MR scanning sequences. Following this the subjects were scanned with the same 1.5T MR scanner using different scanning sequences for planning and for measurement purposes as part of the experimental protocol. Planning: T2 weighted turbo spin echo sequence (TR 3530ms, TE 96ms, 17 slices, slice thickness 3mm, FOV 300mm, in plane resolution 0.8x0.8mm, flip angle 150 degrees). Sagittal slices were aligned with the spinal cord to allow better identification of the medullar cone.
Measurement: T2 weighted spc 3D-sequence (TR 1800ms, TE 128ms, slice thickness 1mm, sagittal scan, FOV 300mm, phase encoding direction proximal to caudal, in plane resolution 0.6x0.6mm, flip angle 160 degrees).
Coronal, axial and sagittal slices (slice thickness 1mm, approximately 70 slices in each plane) were reconstructed from the native 3D sagittal scans using the MPR program available in Sectra PACS program (Sectra Workstation IDS7, version 15.1.8.5-2013 – Sectra AB, Sweden).
The displacement of the medullar cone relative to the upper intervertebral surface of the adjacent vertebra during the unilateral passive symptomatic, asymptomatic and bilateral SLR was quantified and compared with the position of the medullar cone in the neutral (anatomic) position. Each movement was performed twice for evaluation of reproducibility.
RESULTS: The number of subjects required to produce statistically significant results (p<.05) was five for both symptomatic SLR, asymptomatic SLR and for bilateral SLR. The conus medullaris displaced caudally with the asymptomatic SLR by 2.28 ± 1 mm (Mean±SD) (p≤.001) 95% CI (-2.81, -1.75). However, the excursion produced by the symptomatic SLR was only 0.76 ± 0.34 mm (p≤.001) 95% CI (-0.95, -0.58), a reduction of 66.6 %. Alternatively, the symptomatic produced only 33.3 % of cord excursion produced by the asymptomatic SLR. The bilateral SLR produced 3.40 ± 1.68 mm of cord excursion (p≤.001) 95% CI (-3.63, -2.98).
Pearson correlations proved higher than 0.99 for inter-observer reliability as well as results reproducibility for each tested manoeuvre. Observed power was 1 for each tested manoeuvre.
CONLUSION: The data suggests that in patients with LIDH the neural displacement during SLR on the symptomatic side is significantly impaired by the compressing IVD herniation.
With these results, the authors expect that the sliding of neural structures in the vertebral canal may indeed represent a protective mechanism which preserves the spinal cord and neural roots from excessive strain and that limitation of neural adaptive movements can be associated with production of symptoms in clinical settings. Hence the preservation of free sliding of the neural structures in the vertebral canal, along with the associated meninges, might indeed be an essential condition for maintaining an asymptomatic spine. To our knowledge, these are the first non-invasive data to objectively support the limitation of neural movements into the vertebral canal with LIDH in in-vivo and structurally intact human subjects.
These findings clarify the mechanism of why the SLR test is considered a useful tool to assess neuromechanical impairment with sciatic patients.

Normative Data of Multidirectional Spinal Cord Displacement with Unilateral and Bilateral Straight Leg Raise Tests in Asymptomatic Subjects

Rade M.1,2, Könönen M.3, Marttila J.3, Shacklock M.1,4 , Vanninen R.3, Kankaanpää M.5, Airaksinen O.1

1. Kuopio University Hospital, Department of Physical Medicine and Rehabilitation, Kuopio, Finland; 2. Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Orthopaedic and Rehabilitation Hospital “Prim. dr.Martin Horvat”, Rovinj, Croatia; 3. Kuopio University Hospital, Department of Radiology, Kuopio, Finland; 4. Neurodynamic Solutions, Adelaide, Australia; 5. Tampere University Hospital, Department of Physical Medicine and Rehabilitation, Tampere, Finland.
Corresponding author: marinko.rade@kuh.fi; marinko.rade@gmail.com

INTRODUCTION: Normal vertical displacement of the conus medullaris with unilateral and bilateral SLR has been quantified and the "principle of linear dependence" has been described and supported at different angles of hip flexion and with different magnetic resonance (MR) scanning method.
AIM: Provide a full set of normative data of conus medullaris displacement within the vertebral canal in all three planes with unilateral and bilateral SLR tests to allow for clinical comparison with patients with IVD herniation.
MATERIALS AND METHODS: In this controlled radiologic study 10 asymptomatic volunteers were scanned with 1.5T magnetic resonance scanner (Siemens Magnetom Aera, Erlangen, Germany) using different scanning sequences for planning and for measurement purposes as in earlier experiments. Conus displacement in both antero-posterior direction (sagittal slices) and latero-lateral direction (axial slices) was quantified within the vertebral canal during unilateral passive left, right SLR and bilateral SLR and compared with the position of the conus in the neutral (anatomic) position. Each movement was performed twice for evaluation of reproducibility. The measurements were repeated by two observers. Three practitioners performed the manoeuvres in a random sequence in order to avoid possible series effects.
RESULTS: Lateral displacement: the conus displaced toward the right into the spinal canal by 0.52±0.23 mm (mean ± SD) with unilateral right SLR (p≤.001), toward the left by 0.05±0.28 mm with a left SLR (p≤.634), and toward the right by 0.37±0.34 mm with a bilateral SLR (p≤.008). Anteroposterior displacement: the conus displaced anteriorly into the spinal canal by 0.55±0.34 mm with unilateral right SLR (p≤.001), by 0.73±0.36 mm with a left SLR (p≤.001), and again anteriorly by 0.82±0.38 mm with a bilateral SLR (p≤.001). Pearson’s correlations were higher than 0.95 for both intra- and inter-observer reliability and the observed power was higher than 0.99 for all the variables tested.
CONCLUSIONS: Lateral and antero-posterior displacement of conus medullaris into the vertebral canal occurs consistently with unilateral and bilateral SLRs following directions predicted by tension vectors, but that due to their low magnitude they may be clinically irrelevant. From the summative information collected in this line of research it emerges that the i) conus medullaris moves consistently in a caudal direction in response to SLR ii) this displacement is primarily due to direct transmission of forces through the lumbosacral nerve roots and the adjacent dura to the spinal cord, iii) when tensile forces are transmitted through the neural system as in the clinical SLR, the magnitude of conus medullaris displacement prevails over the amount of bone adjustment iv) that the conus medullaris displacement with unilateral SLR is doubled by the bilateral SLR (principle of linear dependence), v) that more displacement occurs with higher degrees of hip flexion, vi) that some lateral and antero-posterior displacement occurs consistently with unilateral and bilateral SLRs but that due to their low magnitude they may be clinically irrelevant. We believe we have presented the first conclusive and complete full set of normative data on non-invasive, in vivo, normative measurement of spinal cord displacement with the SLR ever presented.


In Vivo MRI Measurement of Spinal Cord Displacement in the Thoracolumbar Region of Asymptomatic Subjects with Unilateral and Sham Straight Leg Raise Tests

Rade M.1,2, Könönen M.3, Marttila J.3, Shacklock M.1,4 , Vanninen R.3 , Kankaanpää M.5, Airaksinen O.1

1. Kuopio University Hospital, Department of Physical Medicine and Rehabilitation, Kuopio, Finland;2. Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Orthopaedic and Rehabilitation Hospital “Prim. dr.Martin Horvat”, Rovinj, Croatia; 3. Kuopio University Hospital, Department of Radiology, Kuopio, Finland; 4. Neurodynamic Solutions, Adelaide, Australia; 5. Tampere University Hospital, Department of Physical Medicine and Rehabilitation, Tampere, Finland.

Corresponding author: Marinko Rade, M.Sc. Orth Med, PhD, Department of Physical Medicine and Rehabilitation, Kuopio University Hospital, P.O.Box  1607, 70211 Kuopio, Finland. E-mail: marinko.rade@kuh.fi; marinko.rade@gmail.com


INTRODUCTION: Normal displacement of the conus medullaris with unilateral and bilateral SLR has been quantified and the "principle of linear dependence" has been described and supported at different angles of hip flexion and with different magnetic resonance (MR) scanning methods.
AIM: Investigate whether previously recorded movements of conus medullaris with the unilateral and bilateral SLR are primarily due to transmission of tensile forces transmitted through the neural tissues during SLR, ii) adjustment of the vertebral canal around the conus, or iii) the result of reciprocal movements between vertebrae and nerves.
MATERIALS AND METHODS: In this controlled radiologic study, a cadaver experiment done by Alf Breig in 1978 was replicated and implemented with the use of non-invasive modern scanning techniques in in-vivo and structurally intact human subjects. Ten asymptomatic volunteers were scanned with 1.5T magnetic resonance (MR) scanner (Siemens Magnetom Aera, Erlangen, Germany) using different scanning sequences for planning and for measurement purposes. Planning: T2 weighted turbo spin echo sequence. Measurement: T2 weighted spc 3D-sequence. Coronal, axial and sagittal slices (slice thickness 1mm, approximately 70 slices in each plane) were reconstructed from the native 3D sagittal scans using the MPR program available in Sectra PACS program (Sectra Workstation IDS7, version 15.1.8.5-2013 – Sectra AB, Sweden). The displacement of the medullar cone relative to the upper intervertebral surface of the adjacent vertebra during the unilateral passive right, left and sham SLR was quantified and compared with the position of the conus in the neutral (anatomic) position. Each movement was performed twice for evaluation of reproducibility. The measurements were repeated by two observers. Three practitioners performed the manoeuvres in a random sequence in order to avoid possible series effects. All the metric values were rounded to the next lowest decimal integer (2.55=2.5) to provide more conservative and reliable data.
RESULTS: The conus displaced caudally in the spinal canal by 3.54±0.87 mm (µ±SD) with unilateral (p≤.001) and proximally by 0.29±1.83 mm with sham SLR (p≤.542). Pearson’s correlations were higher than 0.99 for both intra- and inter-observer reliability and the observed power was 1 for unilateral SLRs and 0.052 and 0.149 for left and right sham SLR respectively.
CONCLUSIONS: While conus movements with SLR are relevant and predictable, magnitude and direction of conus movements during the Sham SLR seem to be consistent within subjects, but not between subjects and cannot be predicted. Three relevant points emerge from the presented data: i) reciprocal movements between the spinal cord and the surrounding vertebrae are likely to occur during SLR in asymptomatic subjects, ii) conus medullaris displacement in the vertebral canal with SLR is primarily due to transmission of tensile forces through the neural tissues, iii) when tensile forces are transmitted through the neural system as in the clinical SLR, the magnitude of conus medullaris displacement prevails over the amount of bone adjustment.

The prevalence of myofascial trigger points in patients suffering from anterior knee pain compared with healthy subjects.
Evgeni Rozenfeld1,2, Aharon S Finestone3,2, Leonid Kalichman2
1Israel Defense Forces Medical Corps. 2Dept. Physical Therapy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Israel. 3Orthopaedic surgery, Assaf HaRofeh MC, Zeriffin, affiliated to Sackler Faculty of Medicine Tel-Aviv University, Israel, email: asff@inter.net.il.


Introduction:
Anterior knee pain (AKP) is a very common problem among adolescents, young athletes and soldiers. There are many theories attempting to explain the etiology of AKP but there is little reference to myofascial trigger points (MTrPs) as a possible cause of AKP.

Objective:
To evaluate the association between prevalence of active and latent MTrPs in hip and thigh muscles in soldiers with symptoms of AKP.


Design:
Observational exploratory - case control study.

Setting
: Physical Therapy Department, Military outpatient clinic, Beer-Sheva, Israel.

Subjects:
65 soldiers and officers (42 men and 23 women) that were referred to physical therapy due to various medical conditions. Half of the subjects (N=33) were referred to physical therapy with a diagnosis of AKP and the other half (N=32) were referred with upper limb complaints.

Methods
: Each subject underwent a physical evaluation by an examiner blinded to the patient's main complaint. The evaluation was performed on rectus femoris (proximal), vastus medialis (middle and distal), vastus lateralis (middle and distal) and gluteus medius (anterior, posterior and distal). Dichotomous findings included a palpable taut band, tenderness, pain radiation, and relevance of referred pain to patient’s complaint. Based on these, diagnosis of latent MTrP or active MTrP was established.

Results:
In six out of eight areas, the cases had higher prevalence of total active and latent MTrPs than the controls. The strongest difference was in mid VMO and distal VL, 11 of the cases (33.3%) had MTrP's vs. 0 in controls (p=0.0001, χ2). When summarizing MTrP's by muscles, cases have significantly more MTrP's than controls in all evaluated muscles. 78.8% of cases had at least one MTrP in the evaluated limb whereas only 6.3% of controls had any MTrP in the evaluated limb.

Conclusions:
Subjects with AKP have greater prevalence of MTrPs in their thigh and hip muscles than controls. This indicates a connection between MTrPs and myofascial pain syndrome to AKP. Further study is necessary to determine whether MTrPs are the cause or the consequence.

Sport Injury Prevention in individuals with Chronic Ankle Instability: Fascial Manipulation vs control group randomized controlled trial
Antonio Santagata, Simone Brandolini, Giacomo Lugaresi, Aurelie Marchand

Background: Chronic ankle instability (CAI) is one of the most common disorder in sports patients with high rates of recurrences following an initial ankle sprain. Sprains are often correlated with recurrent sprains, loss of range of motion (ROM), and deficits in proprioception and postural control. However, international guidelines do not currently recognize a therapeutic gold standard.

Objective:
To evaluate the effectiveness of Fascial Manipulation® (FM) as a preventative measure in semi-professional athletes presenting with CAI. To monitor equilibrium, ROM of the ankle and patient symptoms through a questionnaire.

Study Design:
Single-blind randomized controlled trial.

Setting:
Rehabilitation department of a medical center.

Participants:
Semi-professional footballers (soccer) with CAI.

Methods
: 29 male subjects were recruited, 9 were assigned to a baseline group, 20 were randomized into two groups: study and control. The baseline group provided baseline data on health status. The three groups followed a specific training program of 20 workouts over 4 weeks. The study group underwent an additional 3 FM treatment sessions.

Main outcome measures:
Outcomes of equilibrium, ROM, and symptomatology were measure at baseline, before each treatment, and at follow-up at 1, 3, and 6 months.

Results:
Two severe traumas and one mild trauma were reported in the control group during the trial period. The outcomes in the study group showed improvements reaching statistical significance.

Conclusion:
FM was effective in improving equilibrium, ROM, and symptomatology in footballers with CAI. FM intervention was found to be effective in preventing injury in the study sample.


ICF to be used among low back pain patients with and without radiculopathy

Prof. Berit Schiøttz-Christensen, MD. PhD

University Southern Denmark,
Institute of Regional Health Research, Denmark

Introduction: The World Health Organization (WHO) has developed the International Classification of Functioning, Disability and Health (ICF) to provide a common language and framework for addressing the impact of a given health condition on human functioning. To enhance the applicability of the ICF in clinical practice, a Comprehensive and a Brief ICF Core Set for patients with LBP has been developed.

Purpose: of this study was to evaluate the extent to which certain PROMs used in clinical practice (RMDQ, SF-36 and pain scores) cover and match the categories in the Brief ICF Core Set for patients with LBP. The specific aims were: (i) to link the items in the PROMs to the detailed classification in the
ICF and examine the extent to which the identified categories in the PROMs covered the Brief ICF Core Set for LBP, and (
ii) to examine to what extent a clinician’s view on patients’ problems according to the Brief ICF Core Set correlates with the scores of matching items from the PROMs.

Material and Methods: The PROMs were linked to the Brief ICF Core Set for low back pain. Secondly, a cross-sectional study was conducted including 70 patients with low back pain. The patients completed the PROMs, and the Brief ICF Core Set for low back pain was assessed by a clinician using qualifiers.

Results: The items in the PROMs were successfully linked to the ICF. Twelve of the 38 unique ICF categories derived from the PROMs were covered by the Brief ICF Core Set (34%). A weak correlation was found between the patients’ responses and the clinician’s assessment.

Conclusion: The selected PROMs do not cover the prototypical spectrum of problems encountered in patients with low back pain as defined by the Brief ICF Core Set. The clinical assessment of patients’ problems according to the Brief ICF Core Set does not correlate with the scores of matching items from the PROMs.

Future studies: If ICF is chosen to be used in daily clinic the scoring process has to be facilitated by patient reported information.
We now introduce a new questionnaire including PROMIS questions supported with subjects missing. This questionnaire will be validated.

Measuring change after treatment by M/M Medicine physicians in The Netherlands, preliminary results of a large cohort study with a one-year follow-up

Wouter Schuller, MD

Free University Medical Centre, Institute for Health and Care Research EMGO+, Epidemiology & Biostatistics, Amsterdam, The Netherlands.

Objective: Measuring change in patients in the first year after the start of Musculoskeletal (MSK) treatment

Methods:
A large observational cohort study was carried out in a number of MSK practices in The Netherlands. Patients were asked to fill in questionnaires at baseline and after a follow-up period of 6, 12, 18,24,32 and 52 weeks. Baseline data included type, duration and severity of complaints. Follow-up questionnaires included a Numerical Rating Scale (NRS), Global Perceived Recovery (GPE) and the Oswestry Disability Index (ODI) for low back pain patients and the Neck Disability Index (NDI) for patients with neck pain. The treating physician would register the main complaint and the type and number of treatments used.

Results:
Preliminary results are presented of 599 patients. Patients presented with main complaints of low back pain radiating into the legs (27.5%), low back pain without radiation (22.6%), neck pain radiating into the arms (10.4%), neck pain without radiation (10.4%) or different (29.1%). The complaints had frequently lasted for more than one year (61.4%). Most patients increasingly reported strong improvement through the first half year after the start of treatment (72% at 6 months), with a change in the NDI score of up to 8 points (33% improvement), and 7 points in the ODI (33% improvement). NRS improved from 5.8 to 2.9 at 32 weeks (50% improvement). This improvement is generally sustained during the rest of the follow-up.
Spinal Manipulative Treatment (SMT) was the type of treatment predominantly used (orthomanual treatment 72.6%, manual/musculoskeletal treatment 16.7%). Other treatment options mentioned were McKenzie (14.4%), and injections (1.5%). The number of treatments used varied from 0 to 12. Most patients were treated within 5 sessions.

Conclusion:
In the first half year after the start of MSK treatment most patients report increasing improvement, which is reflected in various outcome measures used. This improvement is sustained during the remainder of a one-year follow-up.

Side effects after treatment by M/M Medicine physicians in The Netherlands, preliminary results of a large cohort study

Wouter Schuller, MD

Free University Medical Centre, Institute for Health and Care Research EMGO+, Epidemiology & Biostatistics, Amsterdam, The Netherlands
.

Objective: Measuring adverse effects after MSK treatment in patients with low back pain and neck pain.

Methods:
A large observational cohort study (n = 599) was carried out in a number of MSK practices in The Netherlands. Patients were asked to fill in questionnaires at baseline and after a follow-up period of 6,12,18,32 and 52 weeks. At 12-weeks follow-up a questionnaire was added asking whether patients had experienced adverse reactions after any of the treatments.

Results:
Some adverse reactions were reported by 25.9% of the total population. Patients with a main complaint of neck pain reported adverse effects more frequently (45.9%). Most frequent reported adverse effects were tiredness (6.5%%), general malaise (2,8%), new neck pain (2.7%), radiating pain in the legs (2.5%) and a new headache (2.3%). Most adverse effects resolved within a month, but a very small number of patients reported that these complaints were not resolved yet. A minority of patients visited their General Practitioner due to these adverse effects (1.0%), or had to call in sick from work (2.3%).

Conclusions:
Minor adverse reactions are occur frequently after MSK treatment. Most resolve within a month, but some patients report lasting complaints or have to visit their GP or call in sick due to adverse effects.

Shoulder pain and coxarthrosis – correlation of parietal and visceral findings within pilot studies

Prof. U C Smolenski, T Quaiser, R Otto

University Clinic Jena, Institute of Physiotherapy 07749 Jena, Am Klinikum 1, Germany


Background:
Joint malfunctions are concerning the beginning and the progression depending on multifactorial and unknown dimensions of influence.
In this context functional connections are often described between the joints and the internal organs. These connections seem primarily to be fascial and neurological pathways. An interaction takes place between the parietal and visceral system which is substantial for the medical examination and finally for the treatment.

Objective:
In the present study, in 2 model regions of the shoulder and the pelvic girdle a linkage between the appearance of visceral and fascial diagnosing in the upper thorax aperture or the pelvis is examined. This investigation focuses on their frequency and manifestations in correlation of changes in the joint.

Methodology: In 2 trials, carried out with 35 resp. 45 patients suffering from shoulder pain or coxarthrosis, a defined manual visceral examination was conducted. At the same time the parietal investigation of the respective joint region was implemented. As a secondary parameter the quality of life was recorded. Both studies were approved by the ethical review committee of the Friedrich-Schiller-University.
Results:
The coxarthrosis correlates on the affected side with more visceral findings than on the not affected side. Moreover, there is a significant interrelationship between frequency and manifestation. 77% of the involved patients with shoulder pain showed visceral findings, again significantly more on the affected body side. Overall, in both studies, no correlation could be ascertained by organ findings and everyday activity.
Conclusion:
As a result, in both studies appears dysfunctions of the joint going along with visceral and fascial findings. In conclusion, a standardized medical examination of the visceral structures is recommended for diagnostics as well as for treatment.


Human Recombinant Hyaluronidase Injections for Upper Limb Muscle Stiffness in Individuals with Cerebral Injury: A Case Series Antonio Stecco, Preeti Raghavan, Ying Lub, Mona Mirchandani
NYU Langone Medical Center, New York City
, USA Introduction: Spasticity, muscle stiffness and contracture cause severe disability after central nervous system injury. However, current treatment options for spasticity produce muscle weakness which can impede movement, and do not directly address muscle stiffness. Here we propose that the accumulation of hyaluronan within muscles promotes the development of muscle stiffness, and report that treatment with the enzyme hyaluronidase increases upper limb movement and reduces muscle stiffness without producing weakness.
Material and Methods: 20 patients with unilateral upper limb spasticity received multiple intramuscular injections of human recombinant hyaluronidase with saline at a single visit. The safety and efficacy of the injections, passive and active movement, and muscle stiffness at eight upper limb joints were assessed at four time points: pre-injection (T0), within 2 weeks (T1), within 4–6 weeks (T2), and within 3–5 months post-injection (T3).
Results: There were no clinically significant adverse effects from the injections. Passive movement at all joints, and active movement at most joints increased at T1, and persisted at T2 and T3 for most joints. The modified Ashworth scores also declined significantly over time post-injection.
Conclusion: Hyaluronidase injections offer a safe and potentially efficacious treatment for muscle stiffness in neurologically impaired individuals. These results warrant confirmation in placebo-controlled clinical trials. KEYNOTE LECTURE: ROLE OF FASCIA IN PROPRIOCEPTION AND PAIN
Carla Stecco, Professor of Anatomy and Movement Sciences, Department of Molecular Medicine, University of Padova, Italy

The role of the fasciae has traditionally been relegated to the job of deftly holding ‘parts’ together, but recently different researches have demonstrate that it has a specific organization. This presentation will illustrate new studies of the gross and histological (fibre content, structural conformation, and innervation) anatomy of the human fasciae, and debate their role in proprioception and pain perception.

The relationships among deep fasciae and muscles will be analysed, evidencing as this organization could guarantee a perceptive and directional continuity, acting somewhat like a transmission belt between two adjacent joints and also between synergic muscle groups.
Different levels of innervations could be recognizable inside the various fasciae, according with their different roles in movements coordination and perception.

The precise anatomy of the fasciae could be altered by trauma, surgery, overuse syndromes, etc.

This presentation could contribute to clinician’s understanding of the biomechanical behaviour of the fasciae, their role in acute and chronic myofascial pain syndromes and of the real effectiveness of different therapies.

Treating the Fascial System: A Pragmatic Study for those with Back Pain

1Larry Steinbeck, PT, MS, CMTPT, 2Brent Harper, PT, PhD, DSc, DPT, OCS, FAAOMPT, 2Adrian Aron, MS, PhD

1.Fascial Manipulation Association,
2. Radford University, Roanoke, Virginia, USA,
Corresponding author: larry.steinbeck@gmail.com


Purpose
: Fascial Manipulation (FM) method addresses the movement system based on regional interdependence within a biomechanical model based on anatomical spatial plane vectors. Our study compared FM to standard physical therapy (SPT) for LBP outcomes.

Methods: A pragmatic experimental time series at sessions one, three, six, and discharge. LBP subjects were randomized into SPT (n=49) and FM (n=53). Both received thermal and/or electrical modality and general exercises. SPT received general STM, mobilization, manipulation, and/or traction. FM received FM. Outcomes: Numeric Pain Rating Scale (NPRS) and a 15-point Likert Global Rating of Change (GRC).

Results: Gender, age and chronicity were similar (p>0.05) and did not influence outcomes. FM had fewer visits (7.5±3.5) than SPT (10.1±6, p=0.01). At discharge, 92% FM had ≥5 GRC versus 44.7% SPT (p=0.0001), 72% FM had GRC scores ≥6 versus 19.1% SPT (p=0.0001), and 94% FM decreased NPRS by ≥2 points versus 57.4% of SPT (p=0.0001). 58% of FM decreased NPRS by ≥4 points NPRS versus 17% SPT (p=0.0001). NPRS and GRC changes occurred at SPT third visit with no further statistical changes; FM had immediate changes in both, which continued through discharge. GRC differences retained statistical significance when analyzed by ANCOVA for number of visits (p=0.01).

Conclusion: Varied LBP diagnoses patients receiving FM had fewer visits resulting in greater improvement in pain and positive perceived benefit. FM provides a systematic method to assess the fascia system complementing clinical paradigms involving arthrology, myology, and neurodynamics.


Trigger Points and Deep Muscle Stabilizing System

Prof. Vlasta Tosnerova, MD, PhD., Aneta Maresova, MD

Department of Rehabilitaton, Medical Faculty in Hradec Kralove, Charles University in Prague, Czech Republic


Objective:
First aim of study was to define trigger points (TrPs) in muscles according to scheme in patients with low back pain (LBP) and neck pain (NP). Next we tested ability to activate deep muscle stabilizing system (DMSS) by diaphragm test (DT). After functional diagnostics we used physiotherapy to activate DMSS by using exercises of muscles in sagittal plane that is the most responsible for posture (exercises from developmental kinesiology). After therapy we checked number of TrPs if there are the same or if changed and if patients were able to activate DMSS and how patients improved or unimproved concerning pain.

Material and
Methods:
We investigated patients (n=10) with LBP and NP. Pain was asked using Visual Analogical Scale (VAS). We palpated TrPs according to defined protocol. We tested diaphragm test (DT), we were interested if patient are able to activate it or not. We compared pain before physiotherapy (activation of DMSS - 5 courses) and after. We tested the same method control group (n=5) without LBP or NP. Three independent investigators performed all investigations. We evaluate findings by Kappa method.


Results: 10 patients (100%) with LBP a NP at the beginning were not able to activated DMSS and DT was positive. After physiotherapy (5 courses) by activation of DMSS 5 patients (50%) were able to activate DMSS and DT was negative. Compared control group was able to activate DMSS (100%) from the beginning, DT was negative and TrPS were latent and no spontaneous pain. Concerning TrPs in patients with LBP and NP, TrPs were in very similar number in defined muscles as people from control group. After physiotherapy patients with LBP and NP improved evaluated by VAS, their manifested TrPs changed to latent once. Spontaneous pain diminished. Concerning localization of TrPs the most of them were in upper part of m. trapezius, mm. sternocleidomastoids, m. erector spine in thoracolumbar region and in diaphragm. Kappa was on good statistical level.

Conclusion, Implications and Impact on Rehabilitation:
Results suggest that activation of DMSS positively influents LBP and NP caused by dysfunction of motor system. Activation of DMSS could be very important



Comparison of radiofrequency treatment of the cervical facet joints plus local anaesthetics versus cervical facet joint local anaesthetic block alone in patients with cervical facet joint pain: Preliminary results of a prospective double blind randomised trial

Maarten van Eerd2, Jacob Patijn1.2, Maarten van Kleef2
1Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, The Netherlands.
2Maastricht University Medical Centre (UPCM), Dept. Anaesthesiology and Pain Management, Maastricht University, The Netherlands

Background: Although radiofrequency (RF) treatment for cervical facet joint related neck pain is frequently applied in interventional pain medicine, no randomized controlled trials are available in patients with chronic degenerative neck pain that prove its efficacy in this patient population.


Objective: The objective of this study was to evaluate and compare the effectiveness of RF treatment of the cervical facet joint combined with a long acting local anaesthetic versus long acting local anaesthetics alone in patients with degenerative cervical facet joint pain


Study Design: Double-blind prospective randomized controlled trial. Details of the design and study protocol were registered in the ClinicalTrials.gov Identifier (NCT01743326).

Material and Methods
: A total of 240 patients were screened of whom 85 were eligible for the study. 9 patients declined to participate. The remaining 76 patients were included and randomly assigned to receive a local anaesthetic (bupivacaine) plus a radiofrequency denervation (n= 37) or a local anaesthetic (bupivacaine) alone (n= 39).

Main outcome measures:
Outcome measures, covering important domains of chronic pain were: a. 11-point Numeric Rating Scale (NRS) 30% and 50% improvement, b. Patient global Impression of Change on a 7 point Likert Scale (PGIC), c. consumption of pain medication (MQS), d. Patient Specific Functional Scale, Quality of life scale (RAND 36), and e. Neck Disability Index (NDI, Dutch version)at follow-ups of 6 weeks, 3 and 6 months and 1 year.


Results: At 6 months, clinical success on the NRS30 (30 % improvement) or GPE was 64.9% (n=24) in the Bupivacaine + RF group and 56.4%(n=22) in the Bupivacaine group. There was no significant between group difference. The results of the NRS50 (50 % improvement of NRS). Both groups had improvement as compared with the baseline score in the NDI, RAND36 (PHS +MHS), and MQS. The domain bodily pain out of the RAND36 was statistically significant better in the Bupivacaine + RF group.
Conclusion: RF treatment of the facet joints in patients with chronic neck pain is equally effective as an injection with bupivacaine alone. Some results indicate a better result with RF treatment.

Evaluation of the validity of a manual preferential mobility diagnostic procedure: the passive thoracic lateral bending test.”

Menno van Hogezand, Sjef Rutte , Aldo Scafoglieri, ,Peter van Roy, Eric Cattrysse

Department of Anatomy and Manual Therapy Vrije Universiteit Brussels Belgium

Background: In manual/musculoskeletal medicine, no reliable lateral bending tests for the thoracic spine are known to differentiate left-right mobility.

Aim: Evaluation of the inter-observer reproducibility and validity of a lateral bending test of the thoracic spine using an electromagnetic tracker device (ETD). Exploring the mutual relation between the function of sweeping with hand dominance and the measurements outcome of the lateral bending test.
  
Material and Methods: 24 healthy students were examined by 4 blinded observers; 2 for the laterality and sweeping test and 2 for the manually performed passive lateral bending test in relation to the electromagnetic trackers. For the inter-observer agreements to estimate Kappa values, the IAMMM protocol was used.

Results: The intraclass correlations (ICC) of the measurements of the lateral bending of 2 observers ranged from -.98 to .981. 
The Kappa of the function sweeping was P
c (Kappa): 1.0 (95% CI 1.00 - 1.00) with a Po 1.00 and Pindex .83 and of the lateral bending test .47 (95% CI: -0.13-1.00) the Po .92 and Pindex .92 in between 2 observers. The inter-observer agreement for the function sweeping and handedness had a Kappa of .86 and .86 (95% CI .60 - 1.00 ) Po .96 Pindex .80, the lateral bending test and handedness -. Poc18 Po .92 Pindex .92 and .07 . The function sweeping and measurement lateral bending Observer A: Pc .22 (95% CI -.16 - .70) with a Po .97 and Pindex .84
Observer B: P
c -.07 (95% CI -.20 - -.05) with a Po .75 and Pindex .83
The average lateral bending performed with the ETD, was left larger than to the right.

Conclusions:  We didn’t reach the estimate number of subjects (50). Measurements of lateral bending test with the electromagnetic tracker device were unreliable to quantify left right differences of the thoracic spine. The function sweeping and handedness seems related. Long-term impact of ankle sprains on postural control and fascial densification
Kobi Weiss BPT, Hila Lachman BPT, Naama Freilich BPT, Leonid Kalichman PT, PhD
Physical Therapy Department, Recanati School for Community Health Professions, Faculty of Health Sciences at Ben-Gurion University of the Negev, Beer Sheva, Israel.
Background: Ankle sprain (AS) is very common in the general population and especially among sportsmen. Long-term effects of significant AS on postural control and fascial changes are unknown.
Aims: to evaluate the effect of an AS in the past on postural control and fascial changes in the adjacent body segment.
Methods: Case-control study included 20 young, apparently healthy subjects with a history (≥ 6 months) of significant (Grades 2, 3) AS and 20 control subjects without AS. Demographic data were collected and all subjects undergo Star excursion balance test (SEBT ) and evaluation of fascial densification in calf and upper foot areas according to the Stecco method. Study was performed in accord with international and local ethical policies and approved by IRB.
Results: Comparison of the SEBT results in the research group significant differences were found between the leg with and without AS with lower results for a sprained foot: anterior (p = 0.009), posterior (P = 0.048), antero-medial (p = 0.043), postero-medial (p = 0.011). In the control group no difference in SEBT parameters was found between right and left legs. In the comparison of SEBT results (leg with AS in the study group vs. right leg in the control group) significant differences were found (lower scores in the AS controls) in following directions: anterior (p <0.001), antero-latrell (p <0.001), posterior (P = 0.028 ), postero-medial (P = 0.001), medial (P = 0.001), antero-medial (p <0.001).
In the study group, the leg with AS significantly high prevalence of fascial densification was found in following points: talus internal rotation (p = 0.020), talus retro (p = 0.034), talus external rotation (p = 0.046) and pes external rotation (p = 0.008). No difference between the legs was found in a control group. A comparison between the leg with AS in the study group and the right leg in a control group showed significantly high prevalence of of fascial densification in following points: talus internal rotation (p = 0.014), talus retro (p = 0.001), talus lateral (p = 0.040) and pes external rotation (p = 0.060).
Conclusions: Our results show that there are long term effects of an AS on postural control and on the sensitivity and motility of fascia in calf and foot. More observational and interventional studies are needed to understand the causal relationships between fascial condition and postural control and to suggest possible ways of treatment.
A First Step Towards Structurally Influencing the Peripheral Component of Spasticity Using Botulinum Injections.”

Geerie Winnubst, MD, Ed Weterings, MD

Maastricht University Medical Centre, Department for Rehabilitation and Physical Medicine, Maastricht, The Netherlands

Spasticity is a condition in which certain muscles are continuously contracted. This contraction causes stiffness or tightness of the muscles and can interfere with normal movement, speech, and gait. Spasticity is usually caused by damage to the portion of the brain or spinal cord that controls voluntary movement. The damage causes a disruption in the balance of signals between the nervous system and the muscles. This imbalance leads to increased activity of the muscles. Spasticity negatively affects muscles and joints of the extremities and is particularly harmful to growing children (AANS November 2006).
Our research assesses the potential consequences of a continuous hypertonia of trunk and girdle muscles to arm and leg movement. More specifically, we assess the consequences of continuous hypertonia to bi-articular and multi-articular muscles of the sensorimotor joints as well as changes in the movement selectivity caused within the arthrokinetic chain. We outline the ways in which, in cases of spasticity, those trunk and girdle muscles that have a stabilizing function for the ability to perform movement – such as the m. latissimus dorsi, the m. biceps brachii caput med, and the m.biceps femoris caput longum – have the ability to affect the peripheral joints in combination with their, mostly paretic, conductive bi-articular or multi-articular muscles.

Insufficient moments of force during deliberate target movement (grabbing an object or walking) cause change in the sensorimotor joints followed by hypertonia of mostly the paretic peripheral muscles. The purpose of the research is to prove that detonization of trunk and girdle muscles, possibly followed by detonization of peripheral bi-articular or multi-articular muscles, causes normalization of performing deliberate target movements as well as the appearance of movement selectivity. Apart from reducing spasticity and increasing movement selectivity, the second purpose of this research is to assess whether the improvement of the functioning of a patient by detonization using botulinum injections is predictable. One of the measurements we will use for this research will be 3D recordings of the CAREN system to capturing motions before and after injections of botulinum.


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In cooperation with
the Department of Anatomy, Faculty of Medicine, University of Padua