Scientific Conference Committee
  • Prof. Jacob Patijn, MD, PhD, University Maastricht, Netherlands (Science Director IAMMM)
  • Prof. Olavi Airaksinen, MD, PhD, University East Finland, Finland (Chairman IAMMM)
  • Prof. Omega Erika Huber PhD, Zurich University for Applied Sciences, Winterthur, Switzerland (invited member)
  • Prof. Hannu Luomajoki PhD, Zurich University for Applied Sciences, Winterthur, Switzerland (invited member)
  • Prof. Schiottz- Christensen Berit MD PhD, Aarhus University, Department of Rheumatology,

Infantile Postural and Movement Asymmetries – Development of a Symmetry Score and First Results of a Pilot Trial with a Single Manual Medical Treatment
M. Ammermann, R.Sacher
Background: An objective measuring instrument is required for conducting evidence- based studies for follow-up of infantile postural and movement asymmetries, also known as kinematic imbalance due to sub-occipital strain (KISS). The purpose of our study is to develop a quantifiable symmetry score and to verify it. Furthermore the Symmetry Score shall be used in a pilot study to investigate the manual medical treatment for children with postural or movement asymmetries.
Methods: Three studies were conducted. Due to reliability, six test items examining postural and movement asymmetries which came under consideration, were investigated in 24 infants with postural abnormality (range: 14-24 weeks). The inter-rater reliability was chosen as primary endpoint. Furthermore, intra-rater reliability and test-retest reliability were determined. Analysis and weighting of the items were performed by calculating the intra-class correlation coefficient (ICC). The validity was reviewed by expert opinion as well as through a study with 26 infants (range: 12-28 weeks) of a cross section population. The pilot study involved 38 babies, aged 14-24 weeks, which were examined video based, their autonomic symptoms were recorded and subsequently they were treated once manual medically. Moreover the parents were instructed to a daily home-program focusing on “tummy-time”.
Results: The reliability tests led to a 4-Item Symmetry Score with a point value between 4 points (very symmetrical) and 17 points (very asymmetrical). The chosen items achieved an ICC > 0,8 respectively Cohens ́s Kappa > 0,6. The experts opinions matched mainly to a majority agreement (>50%). Furthermore a comparison between the outcome of a clinical testing versus the Symmetry Score applied to 26 children without diagnosed abnormalities, displayed an agreement of 84,6%. The pilot study showed, besides autonomic improvements, a good reduction of the postural and movement abnormalities because 63% of the manual medically treated children were assessed symmetric afterwards.
Discussion: The Symmetry Score is designed for usage in clinical studies for it is not pragmatic in daily routine. However, evidence-based Manual Medicine requires an objective measuring instrument.
Conclusion: The reliable and valid 4-Item Symmetry Score served for the diagnosis, evaluation and follow-up of infants aged 3-6 months with infantile postural and movement asymmetries. The results of a pilot study showed the positive effect of a single manual medical treatment session going along with home-program focusing on “tummy-time”.
Keywords: Infant, Child Development, Asymmetry, Symmetry Score, Manual Medicine

Differences between posture and force controlled activity of abdominal muscles seem to be evolutionary determined: lessons from an eight weeks’ abdominal sit-up training

Christoph Anders, Franz Ludwig
Universitätsklinikum Jena, Klinik für Unfall- Hand und Wiederherstellungschirurgie FB Motorik, Pathophysiologie und Biomechanik, Jena, Germany
Purpose: This study sought to evaluate if the known difference between posture and force controlled stress levels of abdominal muscles might be caused by a generally de-conditioned abdominal muscle status.
Methods: Therefore 21 healthy untrained young males underwent an eight weeks specific training of their abdominal muscles specifically considering a posture-related task as was sit-ups. Subjects were investigated two times in an identical manner. They had to accomplish isometric flexion and extension tasks in two different modes: with imposed (force controlled) and applied (posture controlled) portions of their upper body weight. The respective task sequence was individually randomized. All tasks were performed in upright posture. Surface EMG (SEMG) of five main trunk muscles was obtained during the isometric test situations and compared between test modes and times. The abdominal muscle training consisted of an individually determined daily sit-up training with increasing intensity, starting at 50% of a max sit-up test at first visit.
Results: The maximum number of sit-ups increased from 69± 40 at first visit to 172± 125 at second visit. In contrast, maximum isometric flexion and extension forces were not systematically different between visits (Flexion T1: 502 ± 124 N, T2: 525 ± 122 N; Extension T1: 720 ± 92 N, T2: 727 ± 100 N). In the ANOVA all muscles showed a tendency or even significantly reduced amplitudes at T2, but the differences between control modes for the abdominal muscles remained virtually unchanged, still showing similarly elevated amplitudes for the posture controlled tasks vs. force control. In the back muscles differences between control modes at T1 were negligible but developed larger amplitudes for the posture controlled tasks at T2.
Conclusions: The applied training was unable to alter the known amplitude differences between posture and force controlled tasks for the abdominal muscles. These results add another partial result that argues for an evolutionary determined difference between the two control modes.

Manual Therapy in Mechanical Neck Pain

Bakhtadze M A, Kuzmininov K O, Bolotov D A
NI Pirogov’s Russian National Research Medical University, Dept. Neurology, Neurosurgery and Medical Genetics, Moscow, Russia
Objective: To investigate the effectiveness of manual therapy (MT) in patients with nonspecific neck pain (NPP).
Material and Methods: Ninety-two patients with NNP, aged from 18 to 60 years (41.1 ± 10.2 years) 64 (69.6%) female, 28 (30.4%) male, were examined. Treatment duration was 3 weeks with 6 sessions (2 sessions per week). The effectiveness was evaluated by measuring the decrease op pain intensity, improvement of daily activity, and patient-related recovery measured with the 11-point Numerical Rating Scale (NRS), the Neck Disability Scale Index (NDI) and the 7-point Global Perceived Effect scale (GPE). Size effect was assessed using Cohen’s d .
Results: In the end of treatment, pain was reduced by 3.4 ± 2.3 points (from 4.5 ± 2.5 to 1.1 ± 1.0 points; Cohen’s d 1.98); disability was improved by 9.5 ± 5.0 points (from 15.0 ± 5.6 to 5.8 ± 4.0 points; Cohen’s d 1.97); patients assessed mean global improvements as »improved» and »much improved» (the improvement by 2-3 points on GPE scale).
Conclusion: Manual Therapy in NNP is effective method that decreases pain syndrome, improves daily activity and is positively assessed by the patients

Relational Pathophysiology - mechanisms of somatic dysfunction

L. Beyer; K. Niemier
Summary: Dysfunctions of the locomotor system (LMS) are among the most frequent clinical findings in patients with musculoskeletal pain. LMS dysfunction does not always depend on structural changes; together with restrictions in activities of daily living and pain, these entities may be defined as “functional diseases”. We analyse physiological principles in the periphery of the LMS that influence the quality of the resulting movement. We use a cybernetic consideration centerd around the velocity of processes in elementary cycles of excitation in nerve and muscle.
According to the concept of relational pathology (Ricker 1923) we use the functional system of movement and show, that all the different functional components and parts of regulation and control, important to assure the correct movement, as are afference, efference divergence, convergence motivation, memory and adaptation are linked together, in relation to each other. We postulate that the LMS and processes occurring within it require a high functional “reagibility” to adequately compensate for/adapt to changing external and internal conditions. If we apply our consideration to intermodal parallel processes, we can make a second hypothesis, namely that a failure in one function (system) has to be compensated by the other involved systems. In this manner, elementary dysfunctions are causally involved in the development of LMS dysfunctions, their chronification, and development of pain.

Manual medicine in German healthcare

Beyer L., Loudovici-Krug D.
Summary: The additional qualification “manual medicine” is one of the mostly chosen qualification according to a survey of the German medical association, with rising tendency. Little is known about the quantity of application of MM in daily healthcare practice.
The two German academies of the German society of MM – ÄMM and DGMSM – used an internal developed questionnaire to learn more about use of MM by different medical specialists: number of patients treated, prescriptions, recommendations. About 500 members of both societies from 2475 have sent back the completed questionnaire, 444 of them working in there medical practice, the others in clinics. Medical specialists applying MM are mostly orthopedists (221), general practitioners (179) and doctors in rehabilitation medicine (65). They are also specialized in pain therapy (255) and acupuncture (221).
MM is primarily applied in the movement system, but also in the digestive system and others. MM diagnostics are provided in 30% – 40% of patients. Prescriptions of manual therapy and physical therapy as well as prevention offers in form of motion exercises, sports or diet instructions are also analysed.
The results are related to the different groups of medical specialists.
The results show the great importance of MM for general practitioners. The questionnaire needs further development. More details about manual diagnosed and treated symptoms and dysfunctions have to be gathered.

Reliability and Validity of Lumbopelvic Kinematics Related to Nonspecific Low Back Pain

Christoph Bauer, PT, MSc
Zurich University of Applied Sciences, Institute of Physiotherapy, Winterthur, Switzerland
Introduction: Low back pain (LBP) poses substantial challenges for clinical management. In 80-90% of all LBP patients, symptoms are attributed as nonspecific LBP (NSLBP). Attempts to identify effective interventions for people with NSLBP have often been unsuccessful. Past studies often treated NSLBP as a homogenous entity, although many clinicians notice distinguishable subgroups in daily practice. Valid classification systems are needed and are priority for primary care of LBP patients. A basic component of many contemporary LBP classification systems is the examination of lumbar-pelvic and postural kinematics. This examination is problematic because simple measurement systems such as visual observation or goniometers lack accuracy, reliability, validity, comprehensiveness, and practicality. To overcome these limitations this doctoral thesis introduces a novel, wireless movement-analysis system based on inertial measurement units (IMUs). In using the novel IMU system, the aims of the studies conducted in this thesis were to assess: The concurrent validity of lumbar-pelvic kinematics (Study I), the reliability of lumbar-pelvic kinematics (Study II), the associations between NSLBP intensity and lumbar-pelvic kinematics (Study III), the associations between fatigue and NSLBP with non-linear lumbar-pelvic kinematics (Study IV), and the effect of exercise therapy on non-linear lumbar-pelvic kinematics (Study V).
Methods: Studies I-IV were conducted at a movement laboratory. Asymptomatic controls and subjects with nonspecific LBP performed a series of lumbar movement tests, from which indices of lumbar-pelvic kinematics (e.g. range of motion, movement variability and complexity) were calculated. The concurrent validity of the IMU-system was tested against an optoelectronic system. The reliability of lumbar-pelvic kinematics was analysed by comparing repeated measures over two days. To analyse the association between NSLBP intensity and lumbar=pelvic kinematics participants with
different levels of NSLBP intensity performed movement tests. To investigate the effect of fatigue and NSLBP participants performed a movement test prior and after fatiguing of the lumbar musculature. The effect of exercise therapy was investigated in a randomized controlled trial in study V: After randomization, the intervention group was treated twice a week for six months while the control group only attended the measurement sessions. Follow-up measurements were taken at post treatment and at twelve months’ follow-up.
Results: The IMU system is concurrently valid to measure lumbar-pelvic kinematics in the primary movement direction. However, the system appears less valid for assessing movements in non-primary directions. On average, measures of lumbar range of motion, movement variability and complexity are more reliable compared to measures of movement control impairments and reposition error. NSLBP intensity affects lumbar-pelvic kinematics, so that participants with higher intensity NSLBP showed more variable and less predictable lumbar movement. Fatigue affects lumbar-pelvic kinematics, and this effect depends on the presence of NSLBP. The pain free participants showed more complex and less predictable lumbar movement after an isometric endurance test than participants suffering from LBP. Pain free people might adjust to fatigue by reducing load on fatigued tissues while preserving task performance. Exercise therapy affects lumbar-pelvic kinematics, and when compared to no intervention it may reverse or reduce deterioration of lumbar movement control, by increasing or preserving the degree of movement variability.
Conclusion: As a conclusion, this thesis identified concurrently valid and reliable indices of lumbopelvic kinematics related to nonspecific NSLBP. The association between 1) lumbopelvic kinematics and 2) NSLBP intensity, fatigue, and exercise therapy appears to be bidirectional: Pain free subjects show less variable lumbar movement than people with NSLBP, but they exhibit more complex and variable movement as a response to fatigue. Six months exercise therapy resulted in preserved, more variable and complex movement strategy. Therefore, a nonlinear or U-shaped relationship between movement complexity and variability with disease was identified. Future research should address questions such as improvements of the IMU system’s
validity and define the optimal lumbar movement strategy that would be predictive for low back health in prevention and also in follow up of active physical rehabilitation.

The inter-tester reliability of a manual rotation test of the knee: a reproducibility study

Ruud Brouwer MD MSc, Ben de Bot MD MSc, Paul Cuppen MD MSc, Prof. Dr. Peter Van Roy, PhD
Faculty for Medicine and Farmacy, Vrij Universiteit Brussel, Begium
Background: Determining the reliability of a manual knee rotation test is important to strengthen the clinical relevance of this test in daily practice. If it appears to be a reliable test, it can be used in future studies like evaluating its relation to knee complaints and its ability to determine differences before and after treatment.
Methods: Internal and external rotation of the knees of 48 subjects were manually tested by two observers to determine the inter-observer agreement. Kappa values were calculated. The knee rotation of the subjects was also measured with a new developed laser rotation meter. The findings of the manual test were compared to the measurements with the laser rotation meter.
Results: The inter-observer agreement for the manual knee rotation test was high (92%), the kappa value was substantial (0,75). The kappa value was (negatively) influenced by a very low prevalence of a restricted external rotation (0,04). Comparison of the results of the manual test with the results obtained with the laser rotation meter could not be made for the external rotation because of the low prevalence of restricted external rotation. For the internal rotation a significant difference of the measurements with the rotation meter was found between the groups with restricted internal rotation and the group with non-restricted internal rotation (as judged by the observers), but this was only the case for left knees. For right knees no significant difference between the groups was found though a trend to significance was noticed.
Conclusion: The manual rotation test of the knee is a reliable test. In a sample with a prevalence of the index condition of around 50% the highest kappa value for the achieved degree of agreement will be achieved. Though a restricted internal rotation (as judged by the observers) seems to be measurable in degrees, still the question remains to what extent judging the end feel is reflected in the measurements with the laser rotation meter.
Keywords: knee rotation, tibial rotation, manual examination, reliability, measuring device, kappa calculation

The cooperation with maxillofacial colleagues: Work in progress.
Heiner Biedermann, MD PhD Privat Praxis, Köln, Germany
Summary: In our research of the long-term effects of manipulations of new born we found that the occurrence of maxillo- facial problems decreased markedly - years later.
This is just one item showing us how much work still has to be done finding and explaining the effects of early manual therapy in new-born.
Case histories are presented and nosological models which might help to explain this interaction between functional disturbances early on and later problems in the dental region.
As there is no animal model available, we have to find other ways to shed light on this hugely interesting (and efficient) treatment.
This presentation cannot be conclusive, but is a call for co-ordinated further work.

The rotation of the lower leg in a healthy population

Paul Cuppen MD MSc MM, Ben de Bot MD MSc MM, Ruud Brouwer MD MSc MM, Prof. Dr. Peter Van Roy PhD.
Faculty for Medicine and Farmacy, Vrij Universiteit Brussel, Begium
Background: The aim of this study was to investigate the reliability of a manual rotation test of the knee.
Methods: A new knee rotation device using laser technology was developed. The rotational movements of the knee were examined in healthy subjects. In a test-retest procedure twenty subjects were tested twice with a one week interval. Subsequently one hundred subjects were tested with the laser rotation meter. Internal-, external rotation and total ROM were recorded. The difference between left and right, and the effects of age and gender were analyzed. Two laser pointers placed proximally and distally on the tibia, projected their beams on a protractor scale with a range of 900 and provided with a scale of half degrees.
Results: In the test – retest procedure high to excellent ICC-values (0,708 - 0,938) were calculated for the distal measurements. ICC’s between 0,104 and 0,521 were calculated for the measurements with the proximal laser. Therefore the proximal laser was not used in the subsequent study of 100 subjects.
In this sample of 100 subjects the female subjects had a significantly greater left (P=0,000) and right (P=0,012) total range of motion and a greater left external rotation (P=0,000) than the male subjects. The right external rotation and left and right internal rotation were not significantly different. Left knees showed a greater total ROM (P=0,004) and external rotation (P=0,001) than right knees, but for the internal rotation no difference was found. In age groups (<25, 26-40, 41+) the left total ROM was significantly larger in the 41+ group (P=0,009). In the younger groups, the total ROM revealed no difference. The external rotation showed significant difference in the groups <25 (P=0,016) and 41+( P=0,003), with more left than right rotation. In the group 26-40 no left-right differences were found.
Conclusion: The developed laser rotation meter revealed to be a reliable measuring instrument when using the distal laser pointer. The left knee showed a larger total range of motion, probably because of a larger external rotation, but not in all age groups. Woman showed a larger total range of motion for both sides, but only the left external rotation was larger. The internal rotation revealed no difference between the sexes and age groups.
Keywords: knee rotation, tibial rotation, tibio-femoral rotation, measuring device, reliability

Observations from Osteopathic Manipulative Treatment in the Prenatal and Peripartum Period

David M. Escobar, D.O. Skagit Regional Health, Mt. Vernon, WA, U.S.A.
INTRODUCTION: The role of manual medicine in treating women during pregnancy, labor and delivery represents a nascent field of research. In osteopathic philosophy and practice the role of spinal and pelvic manipulation can be indicated in a number of situations, including treating low-back pain associated with pregnancy; it is also possible to reduce labor and delivery complications with osteopathic manipulative treatment (OMT). There are several instances in the literature in both animal and human models supporting the concept of visceral-somatic interactions between the lumbar spine and the uterus. One study from 1918 suggested the duration of labor could be reduced by the use of OMT. Two more recent studies have demonstrated reduced incidence of meconium-stained amniotic fluid and other complications with use of OMT in pregnancy.
AIM: This case series examines pregnant patients treated with OMT both antenatally and during labor and delivery under the care of this author. The main objective is to determine if the findings in the literature can be observed in a single physician’s practice of perinatal OMT in a non-academic medical center. A secondary objective is to determine the mean duration of Stage II of labor of primiparous and multiparous mothers receiving OMT. Observations are made as to rate of meconium-stained amniotic fluid, Apgar scores, presence of a Grade II laceration or greater, and duration of Stage II of labor. The overall duration of labor was not examined, as several mothers in this case series required labor induction due to pregnancy-induced hypertension, pre-eclampsia, and intrahepatic cholestasis of pregnancy.
MATERIALS AND METHODS:A retrospective chart review is conducted of this author’s patients to whom OMT, prenatal care, and labor and delivery services were provided. All deliveries were by spontaneous vaginal delivery at the same birth center. A total of 9 patient charts are reviewed; the only exclusion criterion is if a patient did not receive OMT by this author. Descriptive statistics and Student t-test for stage II of labor duration are generated using Microsoft Excel 2016TM.
RESULTS:Of the 9 patient charts evaluated, only one instance demonstrated meconium-stained amniotic fluid (a rate of 0.11). There is no equivalence in mean duration of stage II of labor between primiparous and multiparous mothers in this small cohort (55.5 minutes vs. 40 minutes: p=0.373, 95%CI: -23.04 – 54.04). Only two mothers experienced clinically significant Stage 2 vaginal or perineal lacerations (rate of 0.22). The median Apgar scores at 1-minute and at 5-minutes are 8 and 9 respectively.
CONCLUSION: This small, limited case series demonstrates several findings consistent with that found in the broader literature; providing OMT to pregnant women can minimize occurrences of meconium-stained amniotic fluid, may reduce the rate of
vaginal or perineal lacerations, and may potentially reduce the duration of labor. More robust, randomized cohort studies are needed to further elucidate these observations at our birth center.

Hormone receptor expression in human fascial tissue and modulation of the extracellular matrix according to the hormone levels

C. Fede1*, R. De Caro1, C. Stecco1 1 Department of Neuroscience, Institute of Human Anatomy, University of Padova, Italy
BACKGROUND: Many clinical and experimental findings point to sex differences in myofascial pain, demonstrating that adult women tend to have different myofascial problems with respect to men [1]. It is possible that sex hormones can play a role in extracellular matrix and collagen remodeling and thus contribute to functions of myofascial tissue, causing a sensitization of fascial nociceptors.
METHODS: This study was approved by the Institutional Ethics Review Board according to ethical regulations regarding research conducted on human tissues. Immunohistochemical and molecular investigations of relaxin receptor 1 (RXFP1) and estrogen receptor-alpha (ERα) were carried out on samples of human fascia collected from female volunteers patients during orthopedic surgery (age between 42 and 70 yrs, divided into pre- and post-menopausal groups), and in fibroblast cells isolated from deep fascia. Furthermore, an in vitro stimulation was performed with levels of beta-estradiol equal to the follicular phase or to the periovulatory phase, and the matrix was analyzed after Sirius Red staining, and by immunohistochemical staining of collagen I-III-IV, fibrillin, and elastin.
RESULTS: RXFP1 and ERα are expressed in all the human fascial districts examined and in fascial fibroblasts culture cells, to a lesser degree in the post-menopausal with respect to the pre-menopausal women. Furthermore, different levels of beta-estradiol modulate the extracellular matrix: collagen III and fibrillin increase when the hormone levels rise up to the periovulatory concentration (~400 pg/mL).
CONCLUSIONS: Our results demonstrated that the fibroblasts located within different districts of the muscular fasciae express sex hormone receptors and can modulate the extracellular matrix according to the hormone levels, influencing the tissue hydration and the lubrication of sliding surfaces. These results can help to explain the link between hormonal factors and myofascial pain: hormones play a key role in extracellular matrix remodeling by inhibiting fibrosis and inflammatory activities, both important factors affecting fascial stiffness and sensitization of fascial nociceptors [2].
REFERENCES: 1. Rollman GB, Lautenbacher S. Sex differences in musculoskeletal pain. Clin J Pain, 17:20-4, 2001. 2. Fede C, Albertin G, Petrelli L, Sfriso MM, Biz C, De Caro R, Stecco C. Hormone receptor expression in human fascial tissue. Eur J Histochem, 60(4):2710, 2016.

The change in the paradigm of sciatica with the advent of CT: From somatic referred pain to herniated disc and radiculopathy.

Simon Vulfsons1,2, Gili Martonovits2, Amir Minerbi3,2, Aharon S Finestone4,5
1Institute for Pain Medicine, Rambam Health Care Campus, Haifa, Israel. 2Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel. 3Department of Family Medicine, Clalit Health Services, Haifa and Western Galilee District. 4Department of Orthopaedics, Assaf Harofeh Medical Center, Zeriffin, Israel. 5Sackler Faculty of Medicine, Tel Aviv University, Israel.
Back pain accompanied by lower limb pain, often called "sciatica" is a common complaint. The mechanism of this phenomenon, and particularly the leg pain is not clear and several explanations have been proposed. Two main hypotheses are somatic referred pain (i.e. that somatic tissue - muscle, fascia bone, ligaments, etc., refer pain down the leg) and radicular pain (i.e. pain of neurogenic origin usually arising from an intervertebral disc herniation, causing a local inflammatory process and pressing on the dorsal roots as they emerge between the lumbar vertebrae. From reviewing the literature, it seems that reference to somatic referred pain was more prevalent in the early 20th century, while radiculopathy was prevalent more recently. The purpose of this work is to examine the relative frequency of articles published associated with each of the mechanisms, and test if there were changes in the trends over the years. We hypothesize that there was a statistically significant change the relative frequency of publications relating to the 2 mechanisms and that this change is temporally associated with the advent of advanced imaging (CT and later MRI). Such a finding could represent a change in paradigm.
Data and methods
Review of medical text books published between 1880 and 2018, in disciplines dealing with back and lower limb pain. Identifying relevant keywords in each text book. Classification of each keyword as related to one of the two mechanisms (somatic referred or radicular), or neutral.
Computerized review of articles, in 3 conventional databases (Web of science, Embase, Pubmed), and description of the related keyword frequencies, as a function of time (corrected for the number of article published each year) in blocks of 5 years, and avoiding duplicate articles. Multivariate analysis in order to examine the trends and changes in trends.
We collected key words from 81 textbooks (15 orthopedic books, 5 pain, 9 surgery, 20 general medicine, 20 neurology, 12 internal medicine) between 1880 and 2018. The keywords matched 5 groups according to primary mechanisms (somatic, radicular, neurological-mechanical, neurological-metabolic, unclear mechanism).
In total, 5,984 articles were found with references to "sciatica". In the neurological- metabolic group 422, in the neurological-mechanical group 1429, in the radicular group 2097, in the somatic group 1137 and in the unclear mechanism group 899.
In 1950 the dominant mechanism was neurological-metabolic (80% of all etiology) followed by somatic (50%). This situation was maintained until 1970, after which a significant change was observed in the dominant mechanisms, with a rise in radicular and neurological-mechanical conditions and a decrease in metabolic and somatic causes. The crossover was in 1980, when the radicular mechanism reached 50%. This mechanism continued rising till 2000 and then plateaued out.
We found that during the years 1970-1990, there was a significant change in the key words used in articles referring to sciatica. This change occurred following the advent of advanced imaging. This change likely represents a paradigm change. While previously, it was conceivable that pain in one area of the body could be related to processes in other areas, once we were able to visualize the body anatomy, we needed visual proof of the mechanism. Only mechanisms that could be visualized survived. Whether one of the paradigms represents reality better than another is a question that can be approached only after we recognize there has been a paradigm change. The lack of correlation between imaging and clinical presentation and the limited success of spine surgery might damper the enthusiasm for the radicular paradigm. The paradigm that is thought and taught will dominate the way young doctors begin their medical career. Once they think according to a paradigm, changing is very hard. The most important thing with paradigms is recognizing them so they can be challenged.

Title: Evaluation of mitochondrial function in chronic myofascial trigger points - A prospective, cohort pilot study using high-resolution respirometry.

Michael J. Fischer MD, PhD; Dominik Pesta PhD.
Institution: Vamed Rehabilitation Center Kitzbühel, Austria
Background: Myofascial trigger points (MTrPs), a common phenomenon possibly caused by chronic overload, overstretching, or direct trauma of the affected muscle, can result in pain and hypoxic areas within the muscle. This pilot study established a minimally invasive biopsy technique to obtain high- quality MTrP tissue samples in sufficient amount to evaluate mitochondrial function via high-resolution respirometry.
Secondary objectives included the feasibility and safety of the biopsy procedure.
Methods: Twenty healthy males participated in this study. Percutaneous biopsy sampling optimized with a suction-enhancement technique was used to obtain biopsies of the musculus (m.) trapezius MTrP (TTP group) from 10 individuals or the m. gluteus medius MTrP (GTP group) from 10 individuals, as well as the m. vastus lateralis from all participants to serve as the control muscle. Measurements of oxygen consumption were carried out at 37°C using high-resolution respirometry. Oxygen concentration (μM= nmol/ml) and oxygen flux ( were recorded.
Results: Mitochondrial respiration was highest in the GTP group compared to the TTP group and the control muscle whereas no differences were observed between the GTP and the control muscle. When normalizing respiration to an internal reference state, there were no differences between groups. None of the groups had hematomas or reported surgical complications. Patient-reported pain was minimal for all 3 groups. All participants reported a low procedural burden.
Conclusions: This pilot study used a safe and minimally invasive technique for obtaining biopsies of MTrPs suitable for high-resolution respirometry analysis of mitochondrial function in MTrPs. The results suggest that there are no qualitative differences in biopsies of MTrPs of the trapezius and gluteus medius muscles compared to control biopsies of the vastus lateralis muscle, implying that mitochondria do not appear to have a role in the development of MTrPs.

“What’s in the tin, when
holism is written on the package?”
Jens Foell, MD Imperial college London
Summary: This talk outlines historical and political aspects of the term holism and argues for a contextually sensitive approach to musculoskeletal matters. Holism appears as term in various contexts in opposition to reductionism. In the context of musculoskeletal medicine it invites an appreciation of the interconnectedness of influences on the locomotor system, a “system of systems”. The term holism itself is used almost ubiquitously and includes virtue signaling and hopes of salvation that ultimately can lead to totalitarian ambitions. In the narrower biological context of the locomotor system holism stands for looking at musculoskeletal phenomena in functional chains. In the wider context of disability the conceptual lens is widened to include sociological aspects. Methods of complexity reduction are essential to categorise musculoskeletal concepts in research and administration and have been used extensively as part of reproducibility studies in this community of practice.”


Hildebrandt M.1, Fankhauser G.1, Meichtry A.2, Luomajoki H.2 1 Physio Hildebrandt, Sickingerstrasse 4, 3014 Bern, Switzerland 2 Zurich University of Applied Sciences, Institute of Physiotherapy, Winterthur, Switzerland
Background: Lumbar multifidus muscles (LMM) are important for spinal motion and stability. Low back pain (LBP) is often associated with fat infiltration in LMM. An increasing fat infiltration of LMM may lead to lumbar dysfunction. The purpose of this study was to investigate whether there is a correlation between the severity of lumbar dysfunction and the severity of fat infiltration of LMM.
Methods: In a cross-sectional study, 42 patients with acute or chronic LBP were recruited. Their MRI findings were visually rated and graded using three criteria for fat accumulation in LMM: Grade 0 (0-10%), Grade 1 (10-50%) and Grade 2 (>50%). Lumbar sagittal range of motion, dynamic upright and seated posture control, sagittal movement control, body awareness and self-assessed functional disability were measured to determine the patients' low back dysfunction.
Results: The main result of this study was that increased severity of fat infiltration in the lumbar multifidus muscles correlated significantly with decreased range of motion of lumbar flexion (p = 0.032). No significant correlation was found between the severity of fat infiltration in LMM and impaired movement control, posture control, body awareness or self-assessed functional disability.
Conclusion: This is the first study investigating the relationship between the severity of fat infiltration in LMM and the severity of lumbar dysfunction. An increasing fat infiltration of LMM changes visco-elastic properties of the lumbar spine but has no effect on lumbar sensory-motor abilities. The results of this study will contribute to the understanding of the mechanisms leading to fat infiltration of LMM and its relation to spinal function. Further studies should investigate whether specific treatment strategies are effective in reducing or preventing fat infiltration of LMM.

Knee OA : What are the best exercises and what are the important measures?

Professor Omega E. Huber, PT, PhD Zurich University of Applied Sciences, Institute of Physiotherapy, Winterthur, Switzerland
Background: Knee OA is ranked as the 11th highest contributor to global disability and more than half of all persons with symptomatic knee OA are younger than 65 years of age. In the setting of other chronic conditions (non-communicable diseases (NCD)), OA is largely underdiagnosed and undertreated. Care received by individuals with OA in primary care settings is variable and often inconsistent with clinical practice guidelines.
Physical activity (PA): Given the evidence for effectiveness, feasibility and safety, PA should be an integral part of standard care for people with knee OA. Health care providers should plan and deliver PA interventions that include the behavioral change techniques self-monitoring, goal-setting, action planning, feedback and problem solving.
Exercise: Recommendations for exercise are aerobic activity, muscle strength and movement/stretching. However, in the last 5 years, literature reported a new type of exercise: Neuromuscular exercise. The effectiveness of neuromuscular exercise is confirmed in knee injury prevention and knee injury treatment and is now under evaluation in OA prevention/treatment.
Measures: The most important constructs behind the chosen measures are pain, physical function/activity and quality of life. It is highly recommended to use patient- reported outcome measures (PROMs) as well as performance-based measures.

“The future of Manual Medicine – is it better for the lights to go out or to stay on?”

Dr Michael Hutson
Summary: This presentation analyses the disturbing trends in musculoskeletal health and associated attitudes of UK citizens, suggesting that the most important factors in the development of MSK pain are poor awareness of and/or self-management of risk factors, including co-morbidity (particularly obesity and psychological problems), and lack of exercise.
In the UK, a basic question is how to maintain or nurture the spirit of MSK medicine in a medical environment that is dominated by managed care and (often unhelpful) technology. Managed clinical care for back pain incorporates the standard algorithm of advice, analgesics, physiotherapy, rest, sick notes, referral to NHS MSK (medical and physiotherapy) services when available, radiological investigation, referral for orthopaedic surgical opinion and/or pain management.
In 2016, The UK Chief Medical Officer’s Guidelines for MSK conditions included “Start active, Stay Active”, with assistance from self-management websites. Recently, paymasters have decided not to fund “inappropriate” treatments. I discuss how Manual Medicine practitioners might survive recent decisions.

Effect of spinal cord stimulation on early disability pension in 198 failed back surgery syndrome patients: case-control study.

Short title: Early disability pension predicts failure of spinal cord stimulation in failed back surgery syndrome patients.
Hanna Kaijankoski, MD; Mette Nissen, MD; Tiina-Mari Ikäheimo RN; Mikael von und zu Fraunberg, MD, PhD; Olavi Airaksinen, MD, PhD; Jukka Huttunen, MD, PhD
Departments of Physical and Rehabilitation Medicine (H.K., O.A.) and Neurosurgery (M.N., T-M.I., M.F, J.H) of Kuopio University Hospital (KUH), and Faculty oh Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.
Background: Spinal cord stimulation (SCS) has proven to be a cost-effective treatment for failed back surgery syndrome (FBSS). However, the effect on patients’ working capability remains unclear.
Objective: Our aim is to evaluate the impact of SCS on working capability and to identify the factors behind permanent disability in FBSS patients.
Methods: The study group consisted of 198 working-age patients with SCS trialed or implanted for FBSS in a single center between 1996 and 2014. For each patient, three living controls, matched by age, gender, and birthplace, were otherwise randomly selected by the Population Register Center. The data on working ability were obtained from the Social Insurance Institution. Patients were divided into three groups: SCS trial only, SCS implanted permanently, and SCS implanted but later explanted.
Results: A rehabilitation subsidy was given to 68 patients and 8 controls for a mean of 5.2 (CI95% 2.4–8.2) and 0.2 (CI95% 0.05–0.6) days per month (p<0.05). At the end of follow-up, 16 (37%), 13 (33%), 25 (22%), and 27 (5%) subjects were on disability pension (DP) in the SCS trial, SCS explanted, SCS permanent, and control groups. Patients in the SCS trial-only group were significantly more often on DP than were patients with permanent SCS (OR 2.6; CI95% 1.2–5.9; p=.02).
Conclusion: For a selected group of FBSS patients, SCS can reduce the need for sick leave and DP. The outcome of SCS treatment can possibly be predicted by finding out whether the patient is on a DP or rehabilitation

Movement control impairments: current developments

Prof. Dr. Hannu Luomajoki, PT OMT, PhD Zurich University of Applied Sciences, Institute of Physiotherapy, Winterthur, Switzerland
Background: Movement control impairment means that the patient can not actively control her or his active movements and may because of this may create pain in the musculoskeletal system. Tests and treatment regimens have been developed to assess and treat this dysfunction. This talk will review the main studies in this field in the last few years.
Methods: Reliability studies on low back, neck and lower extremity have been conducted by our research group and by others. Also effectivity studies, mainly on low back pain have been carried out. A systematic review and meta-analysis was published this year by our group of Zürich University of Applied Sciences (ZHAW).
Results: Reliability of the test batteries for low back, neck and lower extremity have been found to be of good to very good level. Effectivity of the treatment, mainly by low back pain, has been shown to be good. Our meta-analyses revealed that specific exercises for movement control of the back are more effective than other kind of exercises by low back pain.
Conclusions: Movement control impairments are a subgroup of patients with musculoskeletal problems. Tests have been developed and they have been shown to be reliable to assess this dysfunction. Also the effectivity of specific exercises has been shown in a few of RCTs, and finally a meta-analyses showed these exercises being more effective than other exercises by low back pain. Further effectivity studies are needed to proof the effects on other body parts.

Pathomorphological influences on functional diseases

Kay Niemier
Summary: Concerning muscular-skeletal diseases, pathomorphological findings are the main diagnostic and therapeutic target of modern medicine.
Scientifically the evidence for the influence of pathomorphological findings on chronic muscular-skeletal pain is small. On the other hand, muscular skeletal dysfunctions are thought to be one factor for pain development and chronification. Function including the function of the muscular skeletal system is bound to structure. Therefore it seems reasonable to assume, that degenerative changes of the loco-motor system might have an influence on its function, hence play a role in its dysfunction and diseases.
In order to have an systematic approach for the assessment of pathomorphological findings of the loco-motor system an classification system for its influence is suggested:
  • Pathomorphological findings without influence
  • Pathomorphological findings as cause of pain (e.g. inflammation)
  • Pathomorphological findings causing/influencing secondary dysfunction (e.g.
    muscular dysbalance secondary to joint degeneration)
  • Pathomorphological findings causing/influencing primary functional findings (e.g.
    Polyneuropathy causing disturbance of coordination)
    In this presentation we will discuss the reasoning behind this approach and further steps for its evaluation.

From the somatic dysfunction to the functional disease - what it takes to become a disease?

Kay Niemier, Germany
Introduction: Manual Medicine is well accepted by therapists and patients. There is evidence that it has positive effects in the treatment of diseases of the loco motor system. Despite these facts, manual medicine is not established in academic medicine. The reason might be a lack of a defined therapeutic target. No other medical field is defined by the treatment of clinical findings (somatic dysfunction) but by diseases or syndromes.
In this presentation we will discuss somatic dysfunction, the development of functional diseases and its chronification.
  • -  Expert panel
  • -  Literature search
    Results: Diagnostic and therapeutic target of manual medicine is the functional disease and the underlying primary and secondary somatic dysfunction.
    Somatic dysfunction and functional disease are defined as follows:
    Functional diseases of the loco motor system are marked by the following lead symptoms: pain and deficits in function, participation and activities. Underlying are disturbances of neurophysiological processes in one or more systems responsible for movement and posture; degenerative and psychosocial factors might influence functional diseases. Somatic dysfunctions are result of a discrepancy between burden and endurance of the structure and/or tissues. Somatic dysfunctions are primary to functional diseases. The somatic dysfunction is defined as discrepancy between the present neurophysiological state and the physiological target parameter.

    Other factors may influence functional diseases and lead to chronification.
    Discussion: In order to establish manual medicine in academic medicine, an accepted definition of functional diseases as diagnostic and therapeutic target is essential. Specific primary and secondary somatic dysfunctions are the cause for functional diseases and ought to be diagnosed and treated. Other factors influencing functional diseases and can lead to chronification. For chronic functional diseases a multimodal interdisciplinary diagnostic is the base for the therapeutic strategy.

A Protocol Proposal for Kappa Study on Straight Leg Raising
Janne Pesonen
Kuopio University Hospital, Department of Physical and Rehabilitation Medicine, Kuopio, Finland
Summary: Low back pain is recognized to be a common cause of disability in Western industrialized countries. In patients who report symptoms that also radiate into the lower limb, clinicians evaluate the possible causes of radiculopathy both through history and physical examination. Physical tests for nerve root tension signs have been designed to aid the diagnosis of intervertebral disc herniation causing lumbar radiculopathy. Of those, the straight leg raise (SLR) test is the most widely used and accepted.
The straight leg raise (SLR) is performed by lifting the patient’s foot with a knee extended until 90 degrees of hip flexion while the patient lies in a supine position, or stopped once first symptoms are provoked. What is regarded as a positive test result has a lot of variability in the literature regarding the location and type of reproduced symptoms and a hip flexion degree at which the symptoms are provoked. SLR has also its limitations: When employed on its own it shows pooled high sensitivity but low specificity for detection of lumbar intervertebral disc herniation (LIDH).
Instead, according to recent studies, the SLR evaluates the movement and mechanical sensitivity of the lumbosacral neural structures and their distal extensions, and a possible impairment in neural movement for whatever reason, not specifically due to LIDH.
One of the reasons for this physical provocation test showing high sensitivity and low specificity may lie in the description of execution of the SLR test being ambiguous. Moreover, no articles assessing the repeatability of this widely used test are to be found in the literature.
The rationale underpinning this experiment states that variability in reference standard may partly explain the inconsistency in the diagnostic accuracy findings. By extension, if the execution of this test is better described along with its interpretation, it will have a positive impact on its specificity and sensitivity, as well as better clinical outcomes for both patients and clinical practitioners using the test.
In our study we will perform SLR to 2 patient groups (n=20 subjects per each group): The SLR positive group and control group. Exclusion criteria are range of movement (ROM) restriction in hip or knee, known malignant tumour or disease of spine, metabolic bone disease, lumbar spinal stenosis, age over 65 or under 20 years, or painful ROM of hip or knee. The Kappa study protocol is planned in accordance with the IAMMM guidelines.

Treatment of Acute Lumbar Radiculopathy Due to Disc Herniation with Non-invasive Position-Induced Transient 'Opening' of the Intervertebral Foramen: A Randomized Controlled Trial.

Marinko Rade, PhD
1 Department of Physical and Rehabilitation Medicine, Kuopio University Hospital, Kuopio, Finland. 2
Background: Lumbar radiculopathy is a problem for which there is a need for new and effective conservative treatments. Here we studied a new approach that reduces pressure on the nerve root through self-management strategies that open the intervertebral foramen transiently and repeatedly.
Objective: Investigate the effect of sustained lumbar positions that transiently open the intervertebral foramen in patients with acute lumbar radiculopathy.
Design: Acute (mean 8 days), randomised controlled trial, gold standard diagnosis (MRI, electrophysiology).
Setting: University hospital, controlled inpatient medical environment. Patient Selection: Patients with LBP and sciatica, single level lumbar disc herniation
and radiculopathy.
Interventions: Patients with acute LBP and sciatica were randomly assigned to control and treatment groups. Control group patients received dexamethasone and tramadol, remained active by walking and flexing as much as tolerated and did not extend their spine. Intervention group patients received the same and a protocol that reduces intra-foraminal pressure transiently by positioning their lumbar spine in flexion and contralateral lateral flexion.
Outcome Measures: Determined prior to commencement: low back pain (VAS), leg pain (VAS), straight leg raise, disability (EQ5D5L, Oswestry/ODI).
Results: Treatment group exhibited significantly greater improvements than control group in LBP (VAS 70.7%, p≤.006), leg pain (VAS 65.7%, p≤.012), SLR (74.6%, p≤.003) and disability (EQ5D5L 194.1 %, p≤.001; Oswestry 53.7%, p≤.001) at 8 days.
Conclusions: Greater benefits in LBP, leg pain and disability were associated with a protocol of transient positional foramen opener manoeuvres that was added to medication and walking in patients with acute lumbar radiculopathy.

Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Orthopaedic and Rehabilitation
Hospital “Prim. dr.Martin Horvat”, Rovinj, Croatia
More study of this approach is required, particularly since the protocol is simple, safe, inexpensive and can be performed ad hoc at home by patients themselves for pain relief.

A biomechanical explanation of orthomanual treatment.

Wouter Schuller 1,2, Jos Noordzij 3, Kasper Huetink 2, Piet Hoogland 4
1 VU University Medical Center, Department of Epidemiology & Biostatistics and the EMGO+ Institute for Health and Care Research, van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands. 2 Spineclinic, Mahoniehout 10-12, 1507 ED, Zaandam, The Netherlands. 3 BovenIJ hospital, dept. of radiology, Statenjachtstraat 1, 1034 CS, Amsterdam, 4 VU University Medical Center, dept. of anatomy & neuroscience, van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
Background: In orthomanual medicine bony prominences are palpated to determine the 3-D position of the pelvis. Asymmetries of these structures are thought to be related to alterations in the position of pelvic and spinal joints. These altered joint positions are corrected in a strict sequence of mobilizing techniques. Correction of pelvic unleveling has a major role in the orthomanual treatment of low back pain.
Objective: Our aim was to develop a theoretical biomechanical model explaining the empirical findings on the relationship between the position of the pelvic bones and the L4 and L5 lumbar vertebrae, and to explore possible methods for further anatomical study.
Theoretical model: In our hypothetical model the spine and the pelvic girdle are viewed as a construction composed of structural bony elements and tensile ligamenteous structures. In an unlevel pelvis the iliac bones rotate around a transverse axis in a ventro-cranial direction on the higher side and a dorso-caudal direction on the lower side. Due to the rotation of the iliac bones, the sacrum rotates around a sagittal axis. Due to the anatomical shape of the sacro-iliac joints, the sacrum shifts laterally from the ventro-cranially rotated ilium, combined with an anterior rotation on the lower side (nutation). Due to stretching forces of the iliolumbar ligaments, L4 and L5 show a similar rotation around the AP axis towards the lower side.
Methods for further study: We tested whether the clinical observations concerning the 3-D positions of the pelvic bones were visible in anatomical specimen and in 3-D CT imaging, and whether this could be reproduced in a pelvic model.
Findings: Rotation of the pelvic bones around a transverse axis could be reproduced in a pelvic model, is visible in 3-D CT imaging and in anatomical specimen. Co-rotation of
the sacrum is clearly shown. Co-rotation of the L4 and L5 lumbar vertebrae is visible in the pelvic model and in anatomical specimen.
Conclusion: Our biomechanical model could explain empirical findings on which orthomanual treatment is based. Pelvic models, 3-D CT imaging and anatomical studies are suitable for further study.

Patients with neck pain improving after MSK treatment

Wouter Schuller 1,2, Raymond W.J.G. Ostelo 1,3, Daphne Rohrich 1, Henrica C.W. de Vet 1
1 VU University Medical Center, Department of Epidemiology & Biostatistics and the EMGO+ Institute for Health and Care Research, van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands,2 Spineclinic, Mahoniehout 10-12 1507 ED, Zaandam, The Netherlands, 3 Department of Health Science of the faculty of earth and life sciences and the EMGO+ Institute for Health and Care Research, VU University, Amsterdam, The Netherlands
Study design: prospective observational cohort study
Objectives: We aimed to describe the baseline characteristics of neck pain patients consulting musculoskeletal (MSK) physicians in The Netherlands, to describe the clinical course after MSK treatment and to find possible predictors of a favorable course.
Methods: We conducted a prospective, observational cohort study. MSK physicians recorded data about baseline characteristics, the number of treatment session and the type of treatment administered in a web-based registry. Registered patients were recruited to fill in web-based questionnaires at baseline, and at several intervals during a follow-up period of six months. Patient baseline data consisted of a variety of possible predictor variables. At baseline and at follow-up Patient Reported Outcome Measures (PROMs) were used, measuring the level of pain, functional status, and global perceived effect. At three months follow up this was supplemented with a questionnaire recording the occurrence of side effects.
Patients were classified into different groups according to their pain trajectories with Latent Class Growth Analysis (LCGA). Baseline variables were evaluated as predictors of a favorable outcome using logistic regression analyses.
Results: Preliminary analyses are presented. In a period of two years 434 patients answered to the baseline questionnaire and at least one follow-up measurement. LCGA identified three groups of patients with distinct pain trajectories. One group (N=148, 34%) started with high pain levels and showed no improvement. A second
group (N=102, 24%) started with moderate pain levels and showed mild improvement. A third group (N=184, 42%) started with high pain levels and showed strong improvement. The group of patients showing strong improvement was compared with the group of patients showing no improvement. In the univariate analyses patients with sciatica (OR 1.22), patients who had visited a medical specialist (OR 1.56), patients with work (OR 1.72), patients with a high educational level (OR 1.18), and patients treated with the OMM technique (1.17) had a higher chance to end up in the group of improved patients. Patients with concomitant headache (OR 0.66), patients with radiating pins and needles (OR 0.87), patients treated previously elsewhere (OR`s PT 0.46, MT 0.78, Chiropractor 0.65, other 0.76), and patients reporting side effects after treatment (OR 0.78) had a lower chance to end up in the group of improved patients. It was not possible to construct and validate a properly fitting prediction model.
Conclusion: MSK physicians in The Netherlands were consulted by patients with, on average, long standing pain with moderate disability. A first group of patients presented with high pain scores and showed strong improvement, a second group of patients presented with moderate pain scores and showed only mild improvement, and a third group of patients showed no improvement in the six months after treatment. A prediction model could not be validated.

Patients with low back pain not improving after MSK treatment

Wouter Schuller 1,2, Raymond W.J.G. Ostelo 1,3, Daphne Rohrich 1, Henrica C.W. de Vet 1
1 VU University Medical Center, Department of Epidemiology & Biostatistics and the EMGO+ Institute for Health and Care Research, van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands, 2 Spineclinic, Mahoniehout 10-12 1507 ED, Zaandam, The Netherlands, 3 Department of Health Science of the faculty of earth and life sciences and the EMGO+ Institute for Health and Care Research, VU University, Amsterdam, The Netherlands
Study design: prospective observational cohort study
Objectives: We aimed to describe the baseline characteristics of Low Back Pain patients consulting musculoskeletal (MSK) physicians in The Netherlands, to describe the clinical course after MSK treatment and to find possible predictors of a non- favorable course.
Methods: We conducted a prospective, observational cohort study. MSK physicians recorded data about baseline characteristics and about the number of treatment session and the type of treatment used in a web-based registry. Registered patients were recruited to fill in web-based questionnaires at baseline, and at several intervals during a follow-up period of six months. Patient baseline data consisted of a variety of possible predictor variables. At baseline and at follow-up Patient Reported Outcome Measures (PROMs) were used, measuring the level of pain, functional status, and global perceived effect. At three months follow up this was supplemented with a questionnaire recording the occurrence of side effects.
Patients were classified into different groups according to their pain trajectories with Latent Class Growth Analysis (LCGA). Baseline variables were evaluated as predictors of a non-favorable outcome using logistic regression analyses.
Results: Preliminary analyses are presented. In a period of two years 1117 patients answered to the baseline questionnaire and at least one follow-up measurement. LCGA identified three groups of patients with distinct pain trajectories. One group (N=226, 20%) started with high pain levels and showed no improvement. A second group (N=313, 28%) started with moderate pain levels and showed mild improvement.
A third group (N=578, 52%) started with high pain levels and showed strong improvement. The group of patients not improving after treatment was compared with the two groups of improved patients. Male gender (OR 0.57) and time since first episode (OR 0.84) were negative predictors of a non-favorable outcome. Duration of the current episode (OR 1.71) , baseline NRS score (2.30), and the use of the OMM treatment (OR 1.35) were positive predictors of a non-favorable outcome. The prediction model showed a reasonable area under the curve (0.74), but a low explained variance (R2 0.15).
Conclusion: Musculoskeletal physicians in The Netherlands were consulted by patients with, on average, long-standing pain of moderate disability. A first group of patient presented with high pain scores and showed strong improvement, a second group of patients presented with moderate pain scores and showed mild improvement, and a third group of patients showed no improvement in the six months after treatment. A prediction model for a non-favorable outcome is presented.

Development and Evaluation of the JESS-Score (Jenaer-Stand-Stability- Score)

Smolenski, UC, MD, Best, N, MD Faculty of Medicine, Jena University Hospital, Institute of Physiotherapy, Germany
Background: Stand Stability is an important stereotype next to movement and breathing. Furthermore it is an active process and not a passive condition. With incorrect performance comes uneconomic posture and further impairments at the motor system. The JESS-Score should record all entities, which effect a stable standing position, summarize and analyze them.
Methods: The JESS- Score summarize dynamic, static, active and passive trials. It includes provocational posturography, the Bregma-Test as well as kinesthetic differentiation ability via goal orientated step test, the Ito and McGill trials and Jandas movement stereotypes (trunk alignment in dorsal position and hyperextension hip joint). All participants filled in the SF 12. Furthermore there were specific assessments for different groups of patients.
The Tests were evaluated and presented via spider chart to immediately visualize the outcomes. The Bregma-Test is new part of the JESS-Score. This is the topic of the presentation. Test variables like test/retest (Interrater, Intrarater, Life- versus-Video) and interrater testing have a decisive role. The test variables from each part are necessary for the conclusion of the whole system.
Results and Conclusion: Test persons, who are active and inactive peoples, were assessed and analyzed. Paramount is to prove the test/retest- reliability of the Bregma-Test. Overall there is a high test/retest- reliability even with the different levels of difficulty. As a result the classification of the stand stability with the JESS Score is verified.
The goal is, after complete evaluation, to simplify and reduce the quantity of the assessments of the JESS Score. In conclusion we may see, that stand stability and movement stereotypes show higher accuracy then the McGill and Ito trials.

Role of fasciae around the median nerve in pathogenesis of carpal tunnel syndrome: microscopic and ultrasound study

Carla Stecco1*, Chenglei Fan1, Federico Giordani2
1Department of Neuroscience, Institute of Human Anatomy, University of Padova, Italy, 2Department of Surgery, Oncology and Gastroenterology DiSCOG, Orthopedic Clinic, University of Padova, Italy
BACKGROUND Carpal Tunnel Syndrome (CTS) is the most common problem in hand affecting 1-3% of the population [1], while recurrence of CTS following surgery is reported to be between 7-20% [2]. The relationship, if any, between the fasciae around the median nerve (MN) and pathogenesis is unknown, although some hypothesises have been proposed to explain those abnormalities.
The aim of this study was to investigate the connection between myofascial structure and epineural sheath of MN under macroscopic and microscopic point of view to evaluate a possible role of fascia in the pathogenesis of CTS.
METHODS Anatomic study (approved by the local ethical committee) was carried out on 9 unembalmed upper limbs managed by the ‘Body Donation Program’ at the Institute of Anatomy, University of Padova. 4 samples of MN and surrounding tissue were excised from arm at 4 different levels for microscopic analysis (Figure 1). Ultrasound images of MN were analyzed in 11 healthy subjects and 8 CTS patients to evaluate the MN transversal displacement during the 3th finger and all fingers motion at the Carpal tunnel (CT) and forearm levels.
RESULTS Anatomical continuity between the epimysium and epineural sheath was found and the reduction of paraneural fat tissue from proximal to distal was demonstrated in all samples. The MN displacement in both levels were significantly different between healthy and CTS subjects, while it was significantly decreased in CTS subjects (p<0.001).
CONCLUSION This study has clearly demonstrated the link between MN sheath and myofascial structure. Therefore, it is possible to argue that an unbalance condition of the epimysial fasciae has to be considered in the pathogenesis of CTS. The CT segment will be more sensitive to pressure since the reduced fat component which reveals a decreased ability in cushioning to protect the nerve. Ultrasound study has confirmed the previous studies about reduction of displacement in CT, but has also shown the reduction of displacement in the forearm for the first time. The present study suggests that the CTS is not only a nerve compression in the CT, but also has a global problem that can affect the nerve movements along all the upper limb.
Figure 1: * , median nerve; $, paraneural fat tissue (not show the lacertus fibrosus and half forearm levels).
[1] Atroshi, I., Gummesson, C., Johnsson, R., Ornstein, E., Ranstam, J., Rosén, I. Prevalence of carpal tunnel syndrome in a general population. JAMA 282, 153,1999.
[2] Jones N., Ahn H. and Eo S.. Revision Surgery for Persistent and Recurrent Carpal Tunnel Syndrome and for Failed Carpal Tunnel Release. Plastic and Reconst
Misdiagnosis leading to unfortunate sequelae: A Case History
Oving Clinic, Church Lane, Oving, West Sussex, United Kingdom
Summary: An elderly woman presents with injuries from a fall. She later had a hospital admission due to an electrolyte abnormality. She is under treatment for chest pain from a cardiologist. She is also grieving for the loss of her son and developed chest pain during this period. She was found to have signs of thoracic dysfunction and was treated successfully for this.
The link between all these apparent loosely connected events will be explained in the presentation.
An outline of the prevalence and type of somatic thoracic pain presentations then follows. A description of a clinical thoracic pain syndrome not described in the literature but encountered by the author at least half a dozen times in his clinical career will hopefully invite lively audience discussion and our shared experience will hopefully infrom future management of such cases.

Predictors for better surgical outcome in lumbar spinal stenosis: a 5 and 10 years follow-up study

Tuomainen Iina MD1,2, Aalto Timo MD, PhD 3, Kröger Heikki MD, PhD4, Airaksinen Olavi MD, PhD 1
1. Department of Rehabilitation, Kuopio University Hospital, Finland 2. Department of Surgery (incl. Physiatry), Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland 3. Medical Center Ikioma, Mikkeli, Finland4. Department of Orthopaedics and Traumatology, Kuopio University Hospital and Kuopio Musculoskeletal Research Unit, University of Eastern Finland
Introduction: Lumbar spinal stenosis (LSS) is a leading cause for low back surgery in patients older than 65 years. Due to aging of the population, the prevalence is likely to increase. Conservative treatment is usually the first line choice especially in mild to moderate cases. If the conservative treatment fails after three to six months, surgical treatment is suggested to be more beneficial than continuous conservative treatment. However, the benefits of surgery seem to decline after 4 years when compared to conservative treatment. Limited data is available about predictors for better long-term surgical outcome in patients with LSS. In this prospective study, we aim to analyze preoperative predictors for surgical outcome in LSS in a 10-year follow-up.
Material and Methods: This is a prospective observational study, where 102 study patients with LSS underwent a decompressive surgery between 2001 and 2004. Study patients fulfilled detailed questionnaires preoperatively and 3 months, 6 months, 1 year, 2 years, 5 years and 10 years postoperatively. The surgical outcome were Oswestry Disability Index (ODI) and Visual analogue scale (VAS). Longitudinal associations were analyzed using a linear mixed model, which was adjusted for preoperative age, gender, marital status and time.
Results: Seventy-two of the original study patients were available for the evaluation at the 10-year follow-up. The mean age was 69 years (9,6) and 62,5% (n=45) were women. The mean ODI-score was 29,37 (20,9) and the mean VAS-score was 32,78 (28,2).
The predictors for better ODI scores at the 10-year follow-up were no previous lumbar operation (estimate -7,11 (SD 3,3); p<0,05; 95%CI -13,4;-0,8), better self-rated health (- 9,44 (2,5); p<0,001; 95%CI -14,4;-4,5), non-smoking (-9,20 (3,0); p<0,005; 95%CI -15,2;- 3,2) and use of regular painkillers less than 6 months (-9,39 (2,6); p<0,001; 95% CI - 15,2;-3,2).
The predictors for lower VAS scores were no previous lumbar operation (-15,42 (4,2); p<0,001; 95%CI -23,7;-7,1), better self-rated health (-8,54 (3,3); p<0,05, 95%CI -15,1;- 2,0), non-smoking (-9,40 (3,9); p<0,05; 95%CI -17,1;-1,7) and use of regular painkillers
less than 6 months (-8,30 (3,3); p<0,05; 95%CI -14,9;-1,7). Body Mass Index nor the number of comorbidities were not associated with the better ODI- and VAS-scores.
Conclusion: The preliminary results show that preoperative better self-rated health, not having a previous lumbar operation, non-smoking and use of regular pain killers less than 6 months predicted better postoperative disability and lesser pain during the 10-year follow-up in patients with LSS.

Setting up a multi-centre randomised controlled trial of an enhanced rehabilitation programme following proximal femoral fracture: lessons from a process evaluation.

Professor Nefyn H Williams, MD PhD Professor in Primary Care, Department of Health Services Research, University of Liverpool, Background: A study funded by the HTA programme completed the first two phases of
the MRC framework for complex interventions. The first phase developed an enhanced community-based rehabilitation intervention following surgical repair of proximal femoral fracture. The second phase was a randomised feasibility study, which assessed the feasibility of trial methods including a process evaluation to inform the definitive phase III RCT.
Methods: Mixed methods process evaluation in a randomised feasibility study of 61 patient and 31 carer participants. Process evaluation components: recruitment of sites and rehabilitation teams, response of rehabilitation teams, recruitment and reach in patient and carer participants, intervention delivery, delivery to individuals, response of individual patients to the enhanced intervention or usual rehabilitation, response of carer participants, unintended consequences, testing intervention theory and context.
Results: Usual rehabilitation care was very variable. The enhanced rehabilitation group received a mean of five additional therapy sessions. All of the returned goal-setting diaries had inputs from the therapy team, and half had written comments by the patients and carers. Focus group themes: variation of usual care and its impact on delivering the intervention; the importance of goal setting; the role of the therapist in providing reassurance about safe physical activities; acceptability of the extra therapy sessions.
Discussion: Lessons learnt for the phase III definitive RCT include how to enhance recruitment, and improve training materials, the workbook, delivery of the extra therapy sessions and recording of usual rehabilitation care. The phase III RCT is now being set up with 10 sites in Merseyside, North Wales, South Wales, Nottingham, London and East Anglia. The sample size will be 446 patient participants.