Muskel&Skjelett 2/2003

Transcription

Muskel&Skjelett 2/2003
muskel
skjelett

Nummer 4/2011 26. årgang
Utgiver: Manuellterapeutenes Servicekontor
Møter, kurs og seminarer
se side 3
➥ Ny kursrekke
i ultralyddiagnostikk
Side 7
Kritisk blikk på
manuellterapi
Hva er myter
og hva er
dokumentert
kunnskap?
➥ Manuellterapi mot
migrene er effektivt
Side 29
Side 8-23
Ekspert på
muskel og skjelett
Gå direkte til
manuellterapeut
• Akuttimer
• Diagnostisering
• Rekvisisjon av røntgen/MR
• Henvisning til legespesialist og fysioterapeut
• Sykemelding
Finn manuellterapeut på
www.manuellterapi.no
Manuellterapeutenes
Servicekontor
Idrettsskader
Hodepine
Hofte- og
lyskesmerter
Nakke- skulderog armsmerter
Brystsmerter
Ryggsmerter
Bekkenløsning
Svimmelhet
Nummenhet
i bein og armer
Kiss-kidd
Kolikk
Isjias
➥ Nyttig informasjonsmateriell
Side 6
Program for
Servicekontorets
fagseminar
23.-25. mars
Autorisasjon
av manuellterapeuter
utredes
Side 22-23
Side 30
Redcord Workstation
Professional
®
Redcord Workstation Professional gir deg muligheten til å kunne benytte alle posisjoner for
Neurac® slyngebehandling. Tre traverser gir mulighet for oppheng av hele kroppen.
Den ENESTE løsningen for Neurac® slyngebehandling
Sikre og behagelige opphengsmuligheter for
effektiv smertebehandling
Stødig konstruksjon tilpasset bruk av
vibrasjon og Redcord Stimula
Mykere bevegelser for enklere flytting av
traverser
Utfør detaljerte tester for å avdekke
svakheter i både dyp stabiliserings- og
ytre bevegelsesmuskulatur
Justeringmuligheter for alle typer pasienter
Forbedret design
Redcord AS
PB 55 , 4920 Staubø
Neurac slyngebehandling gjenoppretter normal muskelfunksjon og
Tlf: 37 05 97 70
reduserer smerte gjennom neuromuskulær stimulering og aktivering.
[email protected]
KURS, MØTER OG KONFERANSER
Januar
20.-21. Oslo. Diagnostisk ultralyd, muskel og skjelett. Kurs
1. Arr. Manuellterapeutenes Servicekontor. For info og påmelding, se www.manuellterapi.no > Kurs og seminarer.
28.-29. Lørenskog/A-hus. Kollegaveiledningsgruppe for
manuellterapeuter. Arr.: Norsk Manuellterapeutforening.
Info/påmelding, se www.manuellterapeutene.org/kurs
27.-29. Oslo. Kurs i diagnostikk og behandling av muskulære triggerpunkter, dry needeling/IMS. Trinn I. Arr.:
Ullernklinikken. For info og påmelding, se www.manuellterapi.no > Kurs og seminarer.
Diagnostisk ultralyd, muskel og skjelett
Oslo 20.-21. januar 2012
4 Det kreves ikke forkunnskaper om ultralyd for
å kunne delta.
4 Rabattert deltakeravgift for medlemmer.
4 Info og påmelding:
www.manuellterapi.no > kurs og seminarer
Manuellterapeutenes
Servicekontor
Februar
10. Oslo. Førstehjelp av spedbarn og barn. Arr. Interessegruppen for barnemanuellterapi i Norsk Manuellterapeutforening. For info og påmelding, se www.manuellterapeutene.org/kurs
Mars
22. Oslo. Kollegabasert veiledningsseminar for manuellterapeuter. Tema: Inkluderende arbeidsliv. Mer info og
påmelding, se www.manuellterapi.no > Kurs og seminarer
Arr.: Manuellterapeutenes Servicekontor
23.-25. Oslo. Tverrfaglig seminar for manuellterapeuter,
fysioterapeuter, leger, kiropraktorer og annet helsepersonell. Mer info og påmelding, se www.manuellterapi.no >
Kurs og seminarer. Arr. Manuellterapeutenes Servicekontor.
April
26.-28 Adelaide, Australia. NOI Neurodynamics and
the Neuromatrix conference. Arr.: Neuro Orthopaedic
Institute. Mer info og påmelding, se www.noi2012.com
Agenda
Oversikten over arrangementer er ikke fullstendig. Tips oss om aktuelle kurs,
kongresser og seminarer, slik at oversikten blir mest mulig komplett.
Kontakt redaksjonen, [email protected]. Tlf.: 913 00 403.
muskel&skjelett nr. nr. 4, desember 2011 3
– totalleverandør av fysikalsk utstyr!
Wobblesmart balansebrett
Trinnløs justerbar vanskelighetsgrad. Justering gjøres ved å vri på kula,
noe som gir større/mindre overflate å stå på. På undersiden er det seks
markeringer for å måle forbedring. Kula er av gummi og er dermed skli­
sikker. Overflaten av brettet er dekket med gripetape.
Brettet brukes til stabilisering og styrke av ankel, kne, hofte, rygg
og nakke, både forebyggende og i rehabilitering.
20%
ATT
Introduksjonstilbud:
Art.nr. 70089
Veil pris 428,­ eks mva
RAB
Nå 342,40,- eks mva
Treningsmatter
og balanseputer
Treningsmattene fra Airex er myke, og kan brukes til
behandling, massasje, trening og lek.
• Maksimal støtabsorbering
• Sklisikre
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Balanseputene er spesielt egnet til forebygging og rehabilitering.
Brukes til balanse­, koordinasjon­, reaksjons­ og mobilitetstrening,
stående stabilitetstrening, funksjonell trening av muskler i nedre eks­
tremiteter og motorisk trening.
Art.nr.
Veil pris
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Beskrivelse
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inkl mva
Art.nr.
Beskrivelse
20%
R
ABATT
Veil pris
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Tilbudene varer f.o.m. 1. november t.o.m. 31. desember 2011
www.medinor.no
Innhold
muskel
skjelett

Kunnskap i medisin
og manuellterapi
Servicekontorets tverrfaglige seminar 2012 setter et nødvendig
kritisk søkelys på eget fag.
Moderne manuellterapi bygger på evidensbasert kunnskap.
Forskning er imidlertid ofte beheftet med feil, og den har heller
ikke alltid gyldighet for den enkelte pasient.
Feil i forskning kan oppstå av
mange grunner. Det er ikke bare
direkte forskningsfusk som føre
til gale resultater og forkjære
tolkninger. Dersom vi ikke hele
tiden spørsmålstegn ved dem,
kan myter om behandlingsmetoder og -effekter oppstå og leve et
godt liv.
Forskning innen medisin og
manuellterapi i all hovedsak er
gruppestudier. Slike studier sier
noe om gjennomsnittseffekter,
men det kan være pasienter og/
eller subgrupper som oppnår
resultater som avviker mye fra
gjennomsnittet. Identifisering av
subgrupper og enkeltindivider
som kan ha nytte av en behandlingsmetode er derfor viktig.
Kryss av i kalenderen allerede
nå. Det ser ut til å bli et innholdsrikt og spennende seminar i Oslo
i mars!
Tidsskriftet
MuskelkSkjelett
Ansvarlig redaktør
Espen Mathisen
Nabbetorpveien 138
1636 Gml Fredrikstad
[email protected]
tlf.: 913 00 403
Utgiver
Manuellterapeutenes Servicekontor
Boks 797 , 8510 Narvik
3
5
6
7
8
10
22
24
26
28
29
30
Kalender med oversikt over
kurs og møter
Innhold
Leder
Nye brosjyrer og plakater
Manuellterapi mot skuldersmerter
Ny kursrekke i diagnostisk
muskel- og skjelettultralyd
7
Seminar i mars: Kritisk blikk på
muskel- og skjelettbehandling
Eyal Lederman:
The Myth of Core Stability
Fagprogram for seminaret
«Manuellterapi – kunnskap og myter»
Søk på Muskel&Skjelett Prisen
og Studentprisen 2012 8
Nytt fra
forskningsfronten
Referat fra
Nasjonal IA-konferanse
Manuell behandling av migrene
like effektivt som medikamenter
Manuellterapiautorisasjon
vurderes av direktoratet
Redaksjonskomite
Gro Camilla Riis
[email protected]
tlf.: 907 45 055
Bjørn Runar Dahl
[email protected]
tlf.: 922 59 017
Harald Markussen
[email protected]
tlf.: 915 94 788
30
Annonser
Åsmund Andersen, tlf.: 920 30 529
[email protected]
Trykk
Møklegaards Trykkeri
ISSN 1503 6588
Abonnement
Tidsskriftet sendes ut fire
ganger i året til medlemmer av
Manuellterapeutenes Servicekontor. Medlemmer av Unge
Fysioterapeuters Fellesskap
får bladet gratis tilsendt i 2011.
Andre kan tegne årsabonnement
for 175 kroner.
Opplag
1.200 eksemplarer
Neste nummer
Ca. 15.2.2012. Manusfrist: 7.1.2012
Internett
Les flere saker om muskel og skjelett
på www.manuellterapi.no
Informasjonsmateriell
AKTUELT
Kostbart muskel
og skjelettfravær
Nye brosjyrer og plakater
Sykefravær som skyldes
muskel og skjelettsykdommer
koster norske bedriftene over
27 milliarder kroner i året.
Det skriver Formidlingsenheten for muskel- og skjelettlidelser
(FORMI) etter å ha gjennomgått
tall fra SINTEF og NAV. o
(Kilde: www.formi.no)
Leger skal læres opp
i sykmeldingsarbeid
Servicekontoret har
trykket opp nye brosjyrer
og plakater med informasjon om manuellterapi.
Medlemmer kan bestille
materiell kostnadsfritt.
Gå direkte til
manuellterapeut
Arbeidsdepartementet foreslår at
det innføres obligatorisk opplæring
i sykmeldingsopplæring for leger.
Manuellterapeuter har hatt slik opplæring siden 2006.
En stor gruppe leger har ingen
formell opplæring i sykmeldingsarbeid. Dette skal det nå bli en
slutt på, ifølge departementet. o
Brukerveiledning
for elektronisk
samhandling
Ekspert på
muskel og skjelett
• Akuttimer
• Diagnostisering
• Rekvisisjon av røntgen/MR
• Henvisning til legespesialist og fysioterapeut
• Sykemelding
Finn manuellterapeut på
www.manuellterapi.no
Manuellterapeutenes
Servicekontor
n Til tross for at manuellterapeuter er
portvoktere i helsetjenesten, fins det
knapt opplysninger på kommunenes
hjemmesider om at det er direkte adgang til manuellterapi eller hvem som
er manuellterapeut i kommunen. Noen
kommuner skiller heller ikke mellom
fysioterapeuter og manuellterapeuter.
Pasientene mister dermed muligheten til
å oppsøke manuellterapeut direkte, da
Idrettsskader
Hodepine
Hofte- og
lyskesmerter
Nakke- skulderog armsmerter
Brystsmerter
Ryggsmerter
Bekkenløsning
Svimmelhet
Nummenhet
i bein og armer
Kiss-kidd
Kolikk
Isjias
de tror de må henvisning. Det er derfor
er en stor utfordring å informere befolkningen om tilbudet som fins. For en stor
del må manuellterapeuter selv informere
om tilbud. Servicekontoret sender informasjonsmateriell til medlemmene kostnadsfritt. Nå er det utarbeidet brosjyre
og plakat med nytt design som det går
an å bestille. Bestilling skjer ved å sende
en e-post til [email protected].
Manuellterapi effektivt mot skuldersmerter
Servicekontoret har utarbeidet en
veileder for elektronisk samhandling
for manuellterapeuter. Veiledningen
er sendt medlemmene i november.
Ikke mottatt? Ta kontakt med
[email protected]. o
6 muskel&skjelett nr. 4, des. 2011
n Det er rimelig god dokumentasjon for at manuell behandling i kombinasjon
med multimodal eller øvelsesterapi er effektiv i behandlingen av vanlige skulderlidelser. En systematisk oversiktsartikkel har gjennomgått 35 vitenskapelige
artikler som har undersøkt manuell- og manipulasjonsterapi for rotator cuffog skulderlidelser, adhesiv capsulitis og bløtdelslidelser i skulderen. Forskerne
fant at det er rimelig god dokumentasjon (nivå B, «fair evidence») for at manuelle teknikker i kombinasjon med multimodal eller øvelsesterapi er effektivt.
Brantingham et al..: Manipulative therapy for shoulder pain and disorders: expansion
of a systematic review. J Manipulative Physiol Ther. 2011 Jun;34(5):314-46.
Ultralyddiagnostikk
AKTUELT
Ny kursrekke i muskel- og skjelettultralyd
For en rekke
muskel- og
skjelettilstander,
for eksempel
skuldersmerter,
er ultralyd å foretrekke fremfor
røntgen og MR.
Manuellterapeutenes Servicekontor arrangerer neste år en kursrekke
i ultralyddiagnostikk for manuellterapeuter. For medlemmer er dette
et svært prisgunstig alternativ.
n Ultralyddiagnostikk er på full fart inn i muskelog skjelettbehandlingen. For en rekke tilstander
er ultralyd å foretrekke fremfor røntgen og MR.
Det gjelder spesielt der problemene har sin årsak
i bløtvevet rundt leddene. En ultralydundersøkelse
er rask, smertefri, uten strålebelastning og svært
pasientvennlig. En erfaren undersøker får i svært
mange tilfeller tilstrekkelig informasjon for videre
kliniske beslutninger på kort tid til en forholdsvis
rimelig kostnad.
Servicekontoret samarbeider med Ultralyd Trøndelag om tre to-dagerskurs i 2012:
- Kurs 1 avholdes fredag 20.-lørdag 21. januar
2012.
- Kurs 2 avholdes 20.-21 april 2012
- Kurs 3 21.-22. september 2012
Det er full anledning til å ta enkeltkurs, man behøver ikke å følge hele kursrekken.
Forkunnskaper om ultralyd er ikke nødvendig
for å kunne delta. Interesserte vil ved påmelding få
informasjon om nettressurser mv. for frivillig forberedelse.
For påmelding, gå til www.manuellterapi.no >
Kurs og seminarer.
muskel&skjelett nr. nr. 4, desember 2011 7
AKTUELT
Seminar 2012
Seminar i Oslo i mars: Kritisk blikk på muskel-
Myter står for fall når manuellterapeutene inviterer til årlig tverrfaglig
seminar 2012. Arrangementet går av stabelen 23.-25. mars i Oslo.
Manuellterapeut Øyvind
Segtnan er fagansvarlig i
komiteen som arrangerer
seminaret «Manuellterapi
– kunnskap og myter».
meret (se side 10 og utover)
som kan leses som en forberedelse til seminaret.
– Det skal bli spennende
å høre Ledermans vurderinger, og hans syn på hvorvidt dette er et sentralt område i ryggbehandlingen.
For å utfylle bildet er
manuellterapeut og forsker
Kjartan Fersum fra Bergen
invitert til å presentere sine
funn. Fersum har forsket
på subgruppering av behandling av vonde rygger.
– Han har samarbeidet
tett med den anerkjente
australske ryggforskeren
Peter O’Sullivan. Deres
forskning viser at ulike
subgrupper profiterer på
ulike behandlingstiltak.
En annen utlandsk gjest
på seminaret er Adrian
Louw som vil presentere
en kritisk oversikt over
effekten av kognitiv behandling og kirurgi. Det
planlegges også norske foredragsholdere over temaet
indikasjoner for kirurgi.
Ryggbehandling
– Seminarkomiteen ønsket
å foreta en kritisk gjennomgang av de modalitetene som ofte brukes
innen muskel- og skjelettbehandling. Er de behandlingsformene vi bruker
godt nok dokumentert?
Prinsippet om trening
av kjernemuskulatur for
å behandle muskel- og
skjelettilstander, spesielt
korsryggsmerter, dukket
opp i siste halvdel av 90-tallet. Treningsformer som
bygger på dette prinsippet, for eksempel Pilates,
er blitt svært populært.
– En del av oss mente
at betydningen av trening
av «core stability» som det
heter på engelsk, er overvurdert i forhold til andre
adekvate
Tverrfaglig seminar
behandlingsManuellterapiseminar 2012. Går av stabeBlokader, elektroterapi
23.-25. mars, se mer på tiltak. Da
len på Radisson Blu Scandinavia Hotel i Oslo
den
engelske
– Stadig flere manuwww.manuellterapi.no
23.-25. mars.
osteopaten og
ellterapeuter interesmanuellteraserer seg for diagnospeuten Eyal Lederman kom med en oversiktsartiske og terapeutiske blokader. Vi setter derfor
tikkel som stilte spørsmålstegn ved betydningen
blokader opp som et eget tema. Blant annet
av prinsippet, bestemte vi oss for å invitere han.
spør Tor Inge Andersen hvilken verdi slike
Ledermans foredrag har fått tittelen «The
blokader har, og det vil bli workshop der memyth of core stability». Muskel&Skjelett tryktoden blir demonstrert, forteller Segtnan.
ker en artikkel om samme emne i dette numProfessor Jan Magnus Bjordal, som har forsket på effekt av elektroterapi, og fysioterapeut/
8 muskel&skjelett nr. 4, desember 2011
Seminar 2012
AKTUELT
og skjelettbehandling
Subgruppering og behandling av kroniske ryggpasienter
forsker Kjersti Storheim
setter søkelyset på ulike
elektroterapeutiske modaliteter, mens professor
dr. med. Leiv Arne Rosseland redegjør for hva
slags legemidler som synes å gjøre hvilken nytte
ved ulike typer smerter.
– Work-shopene vi
har satt opp er med på
å utdype temaene. Det
Manuellterapeut Øyskjer i mindre grupper
vind Segtnan er faglig
hvor det blir rom for mer
ansvarlig i seminardebatt og refleksjon. Skal
manuellterapeuter sette
komiteen
ultralydveiledede injeksjoner? Funker Pilates,
og eventuelt på hvem?
Manuellterapeuter både behandler selv
og henviser til spesialiserte undersøkelser,
kirurgi og avansert smertebehandling.
– Vi må derfor være orientert om hva som er
myter, sikker og usikker kunnskap innen muskel- og skjelettbehandling. Avslutningsvis vil
vi presentere tankemodeller og vyer for veien
videre for alle oss som er opptatt av muskel- og
skjelett. Og som alltid blir det spennende å se
og høre hvem som vinner årets studentpris og
årets Muskel&Skjelett Pris, sier Segtnan og ønsker velkommen til vinterbyen Oslo i mars. o
Kollegaseminar om IA
n Det avholdes kollegabasert veiledningsseminar dagen før Servicekontorets fagseminar. Tema på kollegasamlingen torsdag
22. mars er sykmeldingspraksis og Inkluderende arbeidsliv (IA)-avtalens betydning for
manuellterapeuter som sykmeldere.
n Manuellterapeut Kjartan Vibe Fersum fra
Bergen disputerte i år for Ph.d.-graden med
avhandlingen «Classification and targeted
treatment of patients with non-specific chronic low back pain». Vibe Fersum har i flere år
samarbeidet med australske Peter O’Sullivan.
Han har utarbeidet et klassifiseringssystem
for denne pasientgruppen som tar utgangspunkt i både biologiske, psykologiske og sosiale faktorer.
Vibe Fersums avhandling var tredelt.
Den første delen var en litteraturstudie som
viste at klassifikasjonsbasert behandling for
kroniske ryggplager benyttes svært lite.
Andre del dokumenterte god enighet mellom ulike testere i klassifisering og støtter systemet til O’Sullivan.
Siste del bestod i å teste dette systemet på
kroniske ryggpasienter opp mot tradisjonell
manuellterapi og øvelser i en randomisert
kontrollert studie. Klassifikasjonsbasert behandling resulterte i betydelig mindre smerte,
bedre funksjon, færre tilbakefall og mindre
sykefravær, både på kort og lang sikt.
På seminaret holder han foredrag om hvilke
behandlingsstrategier som hjelper. Han deltar
også i debatten om core stability-trening.
muskel&skjelett nr. nr. 4, desember 2011 9
FORSKNING
Seminar 2012 – ryggbehandling
The Myth of Core Stability
Professor Eyal Lederman, CPDO Ltd., 15 Harberton Road, London N19 3JS, UK
E-mail: [email protected], tel: 0044 207 263 8551
Abstract
The principle of core stability has gained wide acceptance in training for prevention of injury and as a treatment modality for rehabilitation of various musculoskeletal conditions in particular the lower back. There
has been surprising little criticism of this approach up to date. This article will re-examine the original findings and the principles of core stability and how well they fare within the wider knowledge of motor control,
prevention of injury and rehabilitation of neuromuscular and musculoskeletal systems following injury.
Key words: Core stability, transverses abdominis, chronic lower back and neuromuscular rehabilitation
Introduction
Core stability (CS) arrived in the latter part of the
1990’s. It was largely derived from studies that
demonstrated a change in onset timing of the trunk
muscles in back injury and chronic lower back pain
(CLBP) patients [1, 2]. The research in trunk control
has been an important contribution to the understanding of neuromuscular reorganisation in back
pain and injury. As long as four decades ago it was
shown that motor strategies change in injury and
pain [3]. The CS studies confirmed that such changes take place in the trunk muscles of patients who
suffer from back injury and pain.
However, these findings combined with general
beliefs about the importance of abdominal muscles
for a strong back and influences from Pilates have promoted several assumptions prevalent in CS training:
1. That certain muscles are more important for stabilisation of the spine, in particular transverses
abdominis (TrA).
2. That weak abdominal muscles lead to back pain.
3. That strengthening abdominal or trunk muscles
can reduce back pain.
4. That there is a unique group of «core» muscles
working independently of other trunk muscles
5. That a strong core will prevent injury.
6. That there is a relationship between stability and
back pain.
10 muskel&skjelett nr. nr. 4, desember 2011
As a consequence of these assumptions, a whole
industry grew out of these studies with gyms and
clinics worldwide teaching the «tummy tuck» and
trunk bracing exercise to athletes for prevention of
injury and to patients as a cure for lower back pain
[4, 5]. At that point core stability became a cult and
TrA its mantra.
In this article some of these basic assumption
will be re-examined. In particular, it will examine:
1. The role of TrA as a stabiliser and relation to back
pain: is TrA that important for stabilisation?
2. The TrA timing issue: what are the timing differences between asymptomatic individuals and
patients with LBP? Can timing change by CS exercise?
3. Abdominal muscle strength: what is the normal
strength needed for daily activity? Can CS exercise affect strength?
4. Single muscle activation: can single muscle be
selected? Does it have any functional meaning
during movement?
Assumptions about stability and the role of
TrA muscle
In essence the passive human spine is an unstable structure and therefore further stabilisation is
provided by co-contraction of trunk muscles. Erroneously, these muscles are often referred to in
CS approach as the «core» muscles, assuming that
Seminar 2012 – ryggbehandling
there is a distinct group, with an anatomical and
functional characteristics specifically designed
to provide for the stability. One of the muscles in
this group to have received much focus is TrA. It
is widely believed that this muscle is the main anterior component of trunk stabilisation. It is now
accepted that many different muscles of the trunk
contribute to stability and that their stabilasing action may change according to varying tasks (see
further discussion below).
The TrA has several functions in the upright
posture. Indeed stability, but this function is in
synergy with every other muscle that makes up the
abdominals wall and beyond [6-8]. It acts in controlling pressure in the abdominal cavity for vocalization, respiration, defecation, vomiting etc. [9]. TrA
forms the posterior wall inguinal canal and where
its valve-like function prevents the viscera from
popping out through the canal [10].
How essential is TrA for spinal stabilisation?
One way to asses this is to look at situations where
the muscle is damaged or put under abnormal mechanical stress. Would this predispose the individual to lower back pain?
According to Gray’s Anatomy (36th edition 1980,
page 555) TrA is absent or fused to the internal
oblique muscle as a normal variation in some individuals. It would be interesting to see how these
individuals stabilise their trunk and whether they
suffer more back pain.
Pregnancy is another state that raises some
important questions about the role of TrA or any
abdominal muscle in spinal stabilisation. During
pregnancy the abdominal wall muscles undergo
dramatic elongation, associated with force losses
and inability to stabilise the pelvis against resistance [11, 12]. Indeed, in a study of pregnant women
(n=318) they were shown to have lost the ability to
perform sit-ups due to this extensive elongation
and subsequent force losses [12]. Whereas all nonpregnant women could perform a sit-up, 16.6% of
pregnant women could not perform a single sit-up.
However, there was no correlation between the situp performance and backache, i.e. the strength of
abdominal muscle was not related to backache. Despite
this, CS exercises are often prescribed as a method
for retraining the abdominal muscles and ultimately as a treatment for LBP during pregnancy. There
is little evidence that localized musculoskeletal
mechanical issues, including spinal stability play a
role in the development of LBP during pregnancy.
Often sited predisposing factors are, for example,
body mass index, a history of hypermobility and
amenorrhea [13], low socioeconomic class, existence
FORSKNING
of previous LBP [14], posterior/fundal location of
the placenta and a significant correlation between
fetal weight and LBP with pain radiation [14]. It is
surprising that such dramatic postural, mechanical and functional changes to the trunk and lumbar
spine seem to have an insignificant role in the development of back pain during pregnancy.
Another interesting period for us concerning
stabilisation is immediately after delivery. Postpartum, it would take the abdominal muscle about 4-6
weeks to reverse the length changes and undergo
re-shortening. Rectus abdominus takes about 4
weeks postpartum to re-shorten, and it takes about
8 weeks for pelvic stability to normalize [11]. It
would be expected that during this period there
would be minimal spinal support/stabilisation
from the slack abdominal muscles and their fascia.
Would this increase the likelihood for back pain?
In a recent study, the effects of a cognitive-behavioural approach were compared with standard
physiotherapy on pelvic and lower back pain immediately after delivery [15]. An interesting aspect
of this research was that out 869 pregnant women
who were recruited for the study, 635 were excluded because of their spontaneous unaided recovery
within a week of delivery. This would have been
during a period, well before the abdominal muscles
had time to return to their pre-pregnancy length,
strength or control [11]. Yet, this was a period when
back pain was dramatically reduced. How can it
be that back and pelvic pain is improving during a
period of profound abdominal muscle inefficiency?
Why does the spine not collapse? Has the relationship between abdominal muscles and spinal stability been over-emphasised?
Another potential source of information on the
relationship between altered abdominal muscle
function and back pain is the literature on obesity.
One would expect, as in pregnancy, the distention
of the abdomen to disrupt the normal mechanics
and control of the trunk muscle, including TrA.
According to CS model this should result in an increased incidence of back pain among this group.
Yet, epidemiological studies demonstrate weight
gains and obesity are only weakly associated with
lower back pain [16]. According to the CS model we
should be seeing an epidemic of back pain in overweight individuals.
Another area that can shed light on control of
stability and abdominal muscles is the study of abdominal muscles that have been damaged by surgery. Would such damage affect spinal stability or
contribute to back pain? In breast reconstruction after mastectomy, one side of the rectus abdominis is
muskel&skjelett nr. nr. 4, desember 2011 11
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used for reconstruction of the breast. Consequently,
the patient is left with only one sided rectus abdominis and weakness of abdominal muscles. Such
alteration in trunk biomechanics would also be expected to result in profound motor control changes.
Despite all these changes there seems to be no relationship to back pain or impairment to the patient’s
functional / movement activities, measured up to
several years after the operation [17, 18].
One area for further study would be that of subjects who have had inguinal hernia repair. In this
operation the TrA is known to be affected by the
surgical procedure [19, 20]. Up to date there is no
known epidemiological study linking such surgery
and back pain (perhaps because it doesn’t exist?).
We can conclude from the above that healthy
abdominal musculature can demonstrate dramatic
physiological changes, such as during pregnancy,
post-partum and obesity, with no detriment to spinal health. Similarly, damage to abdominal musculature does not seem to impair normal movement
or contribute to LBP.
The timing issue
In one of the early studies it was demonstrated that
during rapid arm/leg movement, the TrA in CLBP
patients had delayed onset timing when compared
with asymptomatic subjects [1, 2]. It was consequently assumed that the TrA, by means of its connection to the lumber fascia, is dominant in controlling spinal stability [8]. Therefore any weakness or
lack of control of this muscle would spell trouble
for the back.
This assumption is a dramatic leap of faith.
Firstly, in our body all structures are profoundly
connected in many different dimensions, including
anatomically and biomechanicaly. You need a knife
to separate them from each other. It is not difficult
to emphasise a connection that would fit the theory,
i.e. that the TrA is the main anterior muscle to controls spinal stability. In normal human movement
postural reflexes are organised well ahead in anticipation of movement or perturbation to balance. TrA
is one of the many trunk muscles that takes part
in this anticipatory organisation [21]. Just because
in healthy subjects it kicks off before all other anterior muscles, does not mean it is more important in
any way. It just means it is the first in a sequence of
events [22]. Indeed, it has been recently suggested
that earlier activity of TrA may be a compensation
for its long elastic anterior fascias [23].
It can be equally valid to assume that a delay in
onset timing in subjects with LBP may be an advantageous protection strategy for the back rather than
12 muskel&skjelett nr. nr. 4, desember 2011
a dysfunctional activation pattern. Furthermore,
it could be that during the fast movement of the
outstretched arm the subject performed a reflexive
pain evasion action that involved delayed activation of TrA, an action unrelated to stabilisation [24,
25]. An analogy would be the reflex pulling of the
hand from a hot surface. One could imagine that a
patient with a shoulder injury would use a different
arm withdrawal pattern from a normal individual.
This movement pattern would be unrelated to the
control of shoulder stability but would be intended
to produce the least painful path of movement, even
if the movement is not painful at the time. A similar
phenomenon has been demonstrated in trunk control where just the perception of a threat of pain to
the back resulted in altered postural strategies [26].
In the original studies of CS onset time differences between asymptomatic individuals and patients with CLBP were about 20 Ms, i.e. one fiftieth of
a second difference [27]. It should be noted that these
were not strength but timing differences. Such timings are well beyond the patient’s conscious control
and the clinical capabilities of the therapist to test
or alter.
Often, in CS exercise there is an emphasis on
strength training for the TrA or low velocity exercise performed laying or kneeling on all fours
[28]. It is believed that such exercise would help
normalise motor control which would include timing dysfunction. This kind of training is unlikely
to help reset timing differences. It is like aspiring
to play the piano faster by exercising with finger
weights or doing slow push ups. The reason why
this ineffective is related to a contradiction which
CS training creates in relation to motor learning
principles (similarity/transfer principle) and training principles (specificity principle, see further
discussion below). In essence these principles state
that our bodies, including the neuromuscular and
musculoskeletal systems, will adapt specifically to
particular motor events. What is learned in one particular situation may not necessarily transfer to a
different physical event, i.e. if strength is required –
lift weights, if speed is needed – increase the speed
of movement during training and along these lines
if you need to control onset timing switch your
movement between synergists at a fast rate, and
hope that the system will reset itself [29].
To overcome the timing problem the proponents
of CS came up with a solution – teach everyone to
continuously contract the TrA or to tense/brace the
core muscle [4, 30]. By continuously contracting it
would overcome the need to worry about onset
timing. What is proposed here is to impose an ab-
Seminar 2012 – ryggbehandling
normal, non-functional pattern of control to overcome a functional organisation of the neuromuscular system to injury: a protective control strategy
that is as old as human evolution.
We now know that following injury, one motor
strategy is to co-contract the muscles around the
joint (amongst many other complex strategies). This
injury response has also been shown to occur in
CLBP patients [31-34], who tend to co-contract their
trunk flexors and extensors during movement [35].
This strategy is subconscious, and very complex. It
requires intricate interactions between the relative
timing, duration, force, muscle lengths and velocities of contraction of immediate synergist [27, 36].
Further complexity would arise from the fact that
these patterns would change on a moment-to-moment basis and different movement/postural tasks
[37-39]. Whichever muscle activity is observed in
standing with the arm out-stretched will change
in bending forward, twisting or even the arm in a
different position. Indeed, in the original studies
of the onset timing of TrA delay in onset timing
were observed during fast but not during slow arm
movements [1]. Even during a simple trunk rotation or exercise the activity in TrA is not uniform
throughout the muscle [40, 41].
These studies demonstrate the complexity that a
patient re-learning trunk control may have to face.
How would a person know which part of the abdomen to contract during a particular posture or
movement? How would they know when to switch
between synergists during movement? How would
they know what is their optimal co-contraction
force? If CLBP patients already use a co-contraction
strategy why increase it? It is naïve to assume that
by continuously contracting the TrA it will somehow override or facilitate these patterns. No study
to date has demonstrated that core stability exercise
will reset onset timing in CLBP patients.
The strength issue
There is more confusion about the issue of trunk
strength and its relation to back pain and injury
prevention. What we do know is that trunk muscle control including force losses can be present as
a consequence of back pain/injury. However, from
here several assumptions are often made:
- That loss of core muscle strength could lead to
back injury,
- That increasing core strength can alleviate back
pain.
To what force level do the trunk muscles need to
co-contract in order to stabilise the spine? It seems
FAG
that the answer is – not very much. During standing and walking the trunk muscles are minimally
activated [42]. In standing the deep erector spinal,
psoas and quadratus lumborum are virtually silent! In some subjects there is no detectable EMG
activity in these muscles. During walking rectus
abdominis has a average activity of 2% maximal
voluntary contraction (MVC) and external oblique
5% MVC [43]. During standing «active» stabilisation is achieved by very low levels of co-contraction
of trunk flexors and extensor, estimated at less than
1% MVC rising up to 3% MVC when a 32 Kg weight
is added to the torso. With a back injury it is estimated to raise these values by only 2.5% MVC for
the unloaded and loaded models [44]. During bending and lifting a weight of about 15 kg co-contraction increases by only 1.5% MVC [45].
These low levels of activation raise the question
of why strength exercises are prescribed when such
low levels of co-contraction forces are needed for
functional movement. Such low co-contraction levels suggest the strength losses are unlikely ever to
be an issue for spinal stabilisation. A person would
have to loose substantial trunk muscle mass before
it will destabilise the spine!
The low levels of trunk muscle co-contraction
also have important clinical implications. It means
that most individuals would find it impossible to
control such low levels of activity or even be aware
of it. If they are aware of it they are probably cocontracting well above the normal levels needed
for stabilisation. This would come at a cost of increasing the compression of the lumbar spine and
reducing the economy of movement (see discussion
below).
Is there a relationship between weak abdominals
(e.g. TrA) and back pain? A common belief amongst
therapists and trainers who use CS is that trunk
strength will improve existing back pain. It has
been shown that a muscle such as multifidus [46]
can undergo atrophy in acute and CLBP (although
this is still inconclusive). However, strengthening
these muscles does not seem to improve the pain
level or disability in CLBP patients [47]. Improvement appeared to be mainly due to changes in neural activation of the lumbar muscles and psychological changes concerning, for example, motivation or
pain tolerance [48]. Similarly, it is well established
that the motor strategy changes in the recruitment
of the abdominal muscles in patients with CLBP
[31, 49, 50], with some studies demonstrating weakness of abdominal muscles [36, 51, 52]. No studies
to date have shown atrophy of abdominal muscles
and no studies have shown that strengthening the
muskel&skjelett nr. nr. 4, desember 2011 13
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core muscles, in particular the abdominal muscles
and TrA, would reduce back pain (see discussion
below).
There are also examples where abdominal muscle activity is no different between asymptomatic
and CLBP subjects. For instance, in studies of elite
golfers, abdominal muscle activity and muscle fatigue characteristics were similar between asymptomatic and CLBP subjects after repetitive golf
swings [53]. Yet, this is the type of sportsperson
who would often receive CS exercise.
Doubts have been also raised concerning the
effectiveness of many of CS exercise in helping to
increase the strength of core muscles. It has been
shown that during CS exercise, the maximal voluntary contraction (MVC) of the «core muscles» is
well below the level required for muscle hypertrophy and is therefore unlikely to provide strength
gains [54-56]. Furthermore, in a study of fatigue in
CLBP, four weeks of stabilisation exercise failed to
show any significant improvement in muscle endurance [57]. A recent study has demonstrated that
as much as 70% MVC is needed to promote strength
gains in abdominal muscle [58]. It is unlikely that
during CS exercise abdominal muscle would reach
this force level [59].
The single / core muscle activation problem
One of the principles of CS is to teach the individuals how to isolate their TrA from the rest of the
abdominal muscles or to isolate the «core muscle»
from «global» muscles.
It is doubtful that there exists a «core» group of
trunk muscle that operated independently of all
other trunk muscles during daily or sport activities
[37, 60]. Such classification is anatomical but has
no functional meaning. The motor output and the
recruitment of muscles is extensive [61, 62], effecting the whole body. To specifically activate the core
muscles during functional movement the individual would have to override natural patterns of trunk
muscle activation. This would be impractical, next
to impossible and potentially dangerous – «Individuals in an externally loaded state appear to select a
natural muscular activation pattern appropriate to
maintain spine stability sufficiently. Conscious adjustments in individual muscles around this natural level may actually decrease the stability margin
of safety»[63].
Training on single muscle is even more difficult.
Muscle-by-muscle activation does not exist [64]. If
you bring your hand to your mouth the nervous
system «thinks» hand to mouth rather than flex the
biceps, than the pectoral etc. Single muscle control
14 muskel&skjelett nr. nr. 4, desember 2011
is relegated in the hierarchy of motor processes to
spinal motor centers – a process that would be distant from conscious control (interestingly even the
motor neurons of particular muscles are intermingled rather than being distinct anatomical groups
in the spinal cord [65]). Indeed, it has demonstrated
that when tapping the tendons of rectus abdominis,
external oblique and internal oblique the evoked
stretch reflex responses can be observed not only in
muscle tapped, but it spreads equally to muscles on
the ipsilateral and contralateral sides of the abdomen [66]. This suggests sensory feedback and reflex
control of the abdominal muscles is functionally
related and would therefore be difficult to separate
by conscious effort.
This simple principles in motor control poses
two problems to CS training. First, it is doubtful that following injury only one group or single
muscles would be affected. Indeed, the more EMG
electrodes applied the more complex the picture
becomes [67]. It is well documented that other muscle are involved – multifidus [68], psoas [69], diaphragm [8], pelvic floor muscles [70], gluteals [71]
etc. Basically in CLBP we see a complex and wide
reorganisation of motor control in response to damage.
The second problem for CS is that it would be
next to impossible to contract a single muscle or
specific group. Even with extensive training this
would be a major problem [72]. Indeed, there is no
support from research that TrA can be singularly
activated [62]. The novice patient is more likely to
contract wide groups of abdominal muscles [6, 41,
73]. So why focus on TrA or any other specific muscle or muscle group?
CS and training in relation to motor learning
and training issues
Further challenges for the CS model arise from motor learning and training principles.
CS training seems to clash with three important
principles:
1. The similarity (transfer) principle in motor learning and specificity principle in training
2. Internal-external focus principles
3. Economy of movement
Similarity/specificity principles – when we
train for an activity we become skilled at performing it. So if we practice playing the piano we become a good pianist, hence a similarity principle.
We can’t learn to play the piano by practicing the
banjo. This adaptation to the activity is not only re-
Seminar 2012 – ryggbehandling
served to learning processes, it has profound physical manifestations – hence the specificity principle in
training [74]. For that reason a weight trainer looks
physically different to a marathon runner.
If a subject is trained to contract their TrA or any
anterior abdominal muscle while lying on their
back [75], there is no guarantee that this would
transfer to control and physical adaptation during standing, running, bending, lifting, sitting etc.
Such control would have to be practiced in some of
these activities. Anyone who is giving CS exercise
to improve sports performance should re-familiarise themselves with this basic principle.
It seems that such basic principles can escape
many of the proponents of CS. This is reflected in
one study which assessed the effect of training on a
Swiss ball on core stability muscles and the economy
of running [76]! In this study it was rediscovered that
practicing the banjo does not help to play the piano.
The subjects got very good at using their muscles
for sitting on a large inflatable rubber ball but it had
no effect on their running performance.
Trunk control will change according to the specific activity the subject is practicing. Throwing a
ball would require trunk control, which is different
to running. Trunk control in running will be different in climbing and so on. There is no one universal exercise for trunk control that would account
for the specific needs of all activities. Is it possible
to train the trunk control to specific activity? Yes,
and it is simple – just train in that activity and don’t
worry about the trunk. The beauty of it all is that no
matter what activity is carried out the trunk muscles are always specifically exercised.
Internal and external focus in training – CS
has evolved over time in response to many of the
model’s limitations described above. Currently, the
control of TrA is attempted in different standing
and moving patterns [30]. Speed of movement, balance and coordination has been introduced to the
very basic early elements of CS. The new models
encourage the subjects to «think about their core»
during functional activities. One wonders if David
Beckham thinks about the «core» before a free kick
or Michael Jordan when he slam-dunks or for that
matter our patient who is running after a bus, cooking or any other daily activities. How long can they
maintain that thought while multitasking in complex functional activities?
Maybe thinking about the core is not such a
good idea for sports training. When learning movement a person can be instructed to focus on their
technique (called internal focus) or on the movement goal (called external focus). When a novice
FAG
learns a novel movement focusing on technique
(internal focus) could help their learning [77]. For
a skilled person, performance improves if training
focuses on tasks outside the body (external-focus)
but it reduces when the focus is on internal processes within the body [78, 79]. For example, there
is greater accuracy in tennis serves and football
shots when the subjects use external-focus rather
than internal-focus strategies [80, 81]. This principle
strongly suggests that internal focus on TrA or any
other muscle group will reduce skilled athletic performance. (Tensing the trunk muscle has even been
shown to degrade postural control! [82])
What about movement rehabilitation for a CLBP
patients, would internal focus on specific muscles
improve functional use of trunk muscles? Lets imagine two scenarios where we are teaching a patient to lift a weight from the floor using a squat
position. In the first scenario, we can give simple
internal focus advice such bend your knees, and
bring the weight close to your body, etc [83, 84]. This
type of instruction contains a mixture of external
focusing (e.g. keep the object close to your body and
between your knees) and internal focus about the
body position during lifting. In the second scenario
which is akin to CS training approach, the patient
is given the following instructions: focus on cocontracting the hamstrings and the quads, gently
release the gluteals, let the calf muscles elongate,
while simultaneously shorten the tibialis anterior
etc. Such complex internal focusing is the essence
of CS training, but applied to the trunk muscles. It
would be next to impossible for a person to learn
simple tasks using such complicated internal focus
approach.
Economy of movement – The advice given to CS
trainees is to continuously tighten their abdominal
and back muscles could reduce the efficiency of
movement during daily and sports activities. Our
bodies are designed for optimal expenditure of energy during movement. It is well established that
when a novice learns a new motor skill they tend to
use a co-contraction strategy until they learn to refine their movement [85]. Co-contraction is known
to be an «energy waster» in initial motor learning
situations. To introduce it to skilled movement will
have a similar «wasteful» effect on the economy of
movement. Minetti states: «to improve locomotion
(and motion), mechanical work should be limited to just
the indispensable type and the muscle efficiency be kept
close to its maximum. Thus it is important to avoid: ….
using co-contraction (or useless isometric force)» [86].
Such energy wastage is likely to occur during
excessive use of trunk muscles as taught in CS.
muskel&skjelett nr. nr. 4, desember 2011 15
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In sporting activity this would have a detrimental effect on performance. Anderson in a study on
the economy of running states: «At higher levels of
competition, it is likely that ‘natural selection’ tends to
eliminate athletes who failed to either inherit or develop
characteristics which favour economy» [87].
CS in prevention of injury and therapeutic value
Therapist and trainers have been exalting the virtues of CS as an approach for improving sports performance [88], preventing injury and as the solution
to lower back. No matter what the underlying cause
for the complaint CS was going to save the day.
However, these claims are not supported by clinical studies:
Abdominal / stability exercise as prevention
of back pain
In one study, asymptomatic subjects (n=402) were
given back education or back education + abdominal strengthening exercise [89]. They were monitored for lower back pain for one year and number
of back pain episode were recorded. No significant
differences were found between the two groups.
There was a curious aspect to this study, which is
important to the strength issue in CS. This study
was carried out on asymptomatic subjects who
were identified as having weak abdominal muscles. Four hundred individuals with weak abdominal muscles and no back pain!
Description
Another large-scale study examined the influence of a core-strengthening program on low back
pain (LBP) in collegiate athletes (n=257). In this
study too, there were no significant advantage of
core strengthening in reducing LBP occurrence [90].
CS a treatment for recurrent LBP and CLBP
At first glance, studies of CS exercise for the treatment of recurrent LBP look promising – significant
improvements can be demonstrated when compared to other forms of therapy [91-94].
However an interesting trend emerges when CS
exercise are compared to general exercise (Table 1).
Both exercise approaches are demonstrated to be equally
effective [82, 95-101]. Systematic reviews repeat this
message [102].
These studies strongly suggest that improvements are due to the positive effects that physical
exercise may have on the patient rather than on
improvements in spinal stability (it is known that
general exercise can also improve CLBP [95, 96]).
So why give the patient complex exercise regimes that will both be expensive and difficult to
maintain? Indeed it is now recommended that patients should be encouraged to maintain their own
preferred exercise regime or given exercise that
they are more likely to enjoy. This of course could
include CS exercise. But the patient should be informed that it is only as effective as any other exercise.
CS compared to
Result
O’Sullivan et al., 1997
CLBP
(spondylolysis/spondylolisthesis)
General practitioner care
CS better
Hides et al. 2001
Recurrence after first
episode LBP
General practitioner care +
medication
CS better
Niemisto et al 2005
LBP
CS + manips + physician
care compared to just
physician care
Same
Goldby et al. 2006
CLBP
Control and MT
CS > MT> control
Stuge et al., 2004
LBP in pregnancy
Physical therapy
CS better
Bastiaenen et al., 2006
LBP post partum
Cognitive behavioural
therapy (CBT)
CBT better
Nilsson-Wikmar et al., 2005
LBP in pregnancy
General exercise
Same
Franke et al., 2000
CLBP
General exercise
Same
Koumantakis et al., 2005
CLBP
General exercise
Same
Rasmussen-Barr
2003;
CLBP
General exercise
Same
Recurrent LBP
Exercise + MT
Same
et
al.,
Cairnes et al 2006
Table 1: CS studies, description of study, CS compared to other therapeutic modalities and outcome.
16 muskel&skjelett nr. nr. 4, desember 2011
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CS in relation to etiology of back pain
Why has CS not performed better than any other
exercise? In part, due to all the issues that have been
discusses above. More importantly, in the last decade our understanding of the etiology of back pain
has dramatically changed. Psychological and psychosocial factors have become important risk and
prognostic factors for the onset of acute back pain
and the transition of acute to chronic pain states
[103]. Genetic factors [104] and behavioural/«use of
body» are also known to be contributing factors.
Localised, minor asymmetries of the spine, which
would include stability issues, have been reduced
in their importance as contributing factors to back
pain.
It is difficult to imagine how improving biomechanical factor such as spinal stabilisation can play
a role in reducing back pain when there are such
evident psychological factors associated with this
condition. Even in the behavioural/biomechanical
spheres of spinal pain it is difficult to imagine how
CS can act as prevention or cure. This can be clarified by grouping potential causes for back injury
into two broad categories:
1. Behavioural group: individuals who use their
back in ways that exert excessive loads on their
spine, such as bending to lift [105] or repetitive
sports activities [106-108].
2. Bad luck group: individuals who had suffered
a back injury from sudden unexpected events,
such as falls or sporting injuries [107].
In the behavioural group, bending and lifting is
associated with a low level increase in abdominal
muscle activity, which contributes to further spinal
compression [109]. In patients with CLBP lifting is
associated with higher levels of trunk co-contraction and spinal loading [33]. Any further tensing of
the abdominal muscle may lead to additional spinal compression. Since the spinal compression in
lifting approach the margins of safety of the spine,
these seemingly small differences are not irrelevant
[110]. It is therefore difficult to imagine how CS can
offer any additional protection to the lumbar spine
during these activities.
Often in CS advice is given to patients to brace
their core muscle while sitting to reduce or prevent
back pain. Although sitting is not regarded as a predisposing factor for LBP, some patient with existing
back pain find that standing relieves the back pain
of sitting [111]. This phenomenon has been shown
in CLBP patients who during sitting exhibit marked
anterior loss of disc space in flexion or segmental
FAG
instability [111]. Sitting, however, is associated with
increased activity of abdominal muscle (when compared to standing) [112] as well as increased stress
on the lumbar discs (compared to standing) [113].
Increasing the co-contraction activity of the anterior and back muscles is unlikely to offer any further protection in the patients with disc narrowing/
pathology, and may even result in greater spinal
compression. It is unknown whether core tensing
can impede the movement of the unstable segments. This seems unlikely because even in healthy
individual creep deformation of spinal structures
will eventually take place during sitting [114]. The
creep response is likely to be increased by further
co-contraction of trunk muscles.
In the bad luck group, CS will have very little
influence on the outcome of sudden unexpected
trauma. Most injuries occur within a fraction of a
second, before the nervous system manages to organise itself to protect the back. Often injuries are
associated with factors such as fatigue [115] and
over training [116]. These factors when combined
with sudden, unexpected high velocity movement
are often the cause of injury [107]. It is difficult to
see the benefit of strong TrA, abs or maintaining a
constant contraction in these muscles in injury prevention.
Potential damage with CS?
Continuous and abnormal patterns of use of the trunk
muscles could also be a source of potential damage for
spinal or pelvic pain conditions. It is known that when
trunk muscles contract they exert a compressive force on
the lumbar spine [45] and that CLBP patients tend to increase their co-contraction force during movement [44].
This results in further increases of spinal compression.
The advice in CS for patients to increase their co-contraction is likely to come at a cost of increasing compression on the already sensitised spinal joints and discs [33,
63]. Another recent study examined the effects of abdominal stabilization maneuvers on the control of spine
motion and stability against sudden trunk perturbations
[117]. The abdominal stabilization maneuvers were - abdominal hollowing, abdominal bracing and a «natural»
strategy. Abdominal hollowing was the most ineffective
and did not increase stability. Abdominal bracing did
improve stability but came at a cost of increasing spinal
compression. The natural strategy group seems to employ the best strategy – ideal stability without excessive
spinal compression.
An increase in intra-abdominal pressure could
be a further complication of tensing the trunk muscles [118]. It has been estimated that in patients with
pelvic girdle pain, increased intra-abdominal presmuskel&skjelett nr. nr. 4, desember 2011 17
FAG
Seminar
2012 – ryggbehandling
sure could exert potentially damaging forces on
various pelvic ligaments [119]. This study for example recommends teaching the patients to reduce
their intra-abdominal pressure, i.e. no CS.
Maybe our patients should be encouraged to relax their trunk muscle rather than hold them rigid? In a study of the effects of psychological stress
during lifting it was found that mental processing/
stress had a large impact on the spine. It resulted in
a dramatic increase in spinal compression associated with increases in trunk muscle co-contraction
and less controlled movements [120].
Psychological factors such as catastrophising and
somatisation are often observed in patients suffering from CLBP. One wonders if CS training colludes
with these factors, encouraging excessive focusing
on back pain and re-enforcing the patient’s notion
that there is something seriously wrong with their
back. Perhaps we should be shifting the patient’s
focus away from their back. (I often stop patients
doing specific back exercise).
Furthermore, CS training may shift the therapeutic focus away from the real issues that maintain the patient in their chronic state. It offers a
simplistic solution to a condition that may have
complex biopsychosocial factors. The issues that
underline the patient’s condition may be neglected,
with the patient remaining uninformed about the
real causes of their condition. Under such circumstance CS training may promote chronicity.
Conclusion
Weak trunk muscles, weak abdominals and imbalances between trunk muscles groups are not
pathological, just a normal variation. The division
of the trunk into core and global muscle system is a
reductionist fantasy, which serves only to promote
CS.
Weak or dysfunctional abdominal muscles will
not lead to back pain.
Tensing the trunk muscles is unlikely to provide
any protection against back pain or reduce the recurrence of back pain.
Core stability exercises are no more effective
than, and will not prevent injury more than, any
other forms of exercise. Core stability exercises are
no better than other forms of exercise in reducing
chronic lower back pain. Any therapeutic influence
is related to the exercise effects rather than CS issues.
There may be potential danger of damaging the
spine with continuous tensing of the trunk muscles
during daily and sports activities. Patients who
have been trained to use complex abdominal hol-
18 muskel&skjelett nr. nr. 4, desember 2011
lowing and bracing maneuvers should be discouraged from using them.
Epilogue
Many of the issue raised in this article were known
well before the emergence of CS training. It is surprising that the researchers and proponents of this
method ignored such important issues. Despite a
decade of extensive research in this area, it is difficult to see what contribution CS had to the understanding and care of patients suffering from back
pain.
Acknowledgement
I would like to thank Jaap H van Dieen, Ian Stevens and
Tom Hewetson for their help in preparing this article.
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Program tverrfaglig seminar 23.-25. mars 2012
Manuellterapi – kunnskap og myter
Fredag 23. mars 2012
10.00-10.20
10.20-11.10
Eyal Lederman
11.10-11.50
KAFFE
11.50-12.30
Eyal Lederman
12.30-13.30
LUNCH
13.30-14.15
Kjartan Vibe Fersum
14.15-15.00
Adrian Louw
15.00-1530
15.30-16.15
16.15-16.45
KAFFE
Adrian Louw
Moderator: Tor Inge
Andersen
16.45-17.30
17.30
19.30
Åpning, kulturelt innslag
The Myth of core stability 1
Besøk utstillere
The Myth of core stability 2
Subakutt og langvarige ryggplager, Hvilke behandlingsstrategier hjelper?
The efficacy of cognitive therapy on lumbar pain, a
critical review
Besøk utstillere
The efficacy of lumbar surgery?
Paneldebatt: is core stability a myth?
Bidrag til muskel og skjelettprisen
Felles vorspiel
Vi møtes på Sosialen!
Lørdag 24. mars 2012
09.00-09.15
Tor Inge Andersen
09.15-09.30
Tor Inge Andersen
09.30-10.00
Christian Hellum
10.00-10.30
Rainer Knobloch
Cervikal fasettleddsmerte, er klinisk diagnostikk
mulig
Diagnostiske og terapeutiske blokader, hvilken verdi har disse?
Er rygg-/nakkesmerter operasjonsindikasjon? Protesekirurgi – hvor står vi.
Iliosacralledd /coxyodynia, indikasjon for kirurgi.
10.30-11.10
KAFFE
Besøke utstillere
22 muskel&skjelett nr. nr. 4, desember 2011
Seminar 2012
11.10-11.40
Agnar Tegnander
11.40-12.10
Jan Bjordal
12.10-12.30
Kjersti Storheim
12.30-13.00
Moderator:
Øyvind Segtnan
LUNCH
Lars-Lennart Nielsen
Leiv Arne Rosseland
13.00-14.00
14.00-14.10
14.10-14.30
14.30-14.50
14.50-15.30
15.30-16.15
Leiv Arne Rosseland
KAFFE
Work-shop
1.Eyal Ledermann
2. Adrian Louw
FAG
Patofysiologi ved tendinopatier. Skleroserende
injeksjoner, eksentrisk trening.
Laser og div elektroterapeutiske modaliteter
som behandlings-alternativ
Trykkbølge – dokumentasjon
Spørsmål /diskusjon
Utdeling av Muskel&Skjelett Prisen
Medikamentell behandling av nevropatisk smerte
og sentral sensitivisering
Ryggsmerter hos den gravide
Besøk utstillere
1. Epicondylalgia – diagnose og behandling
2. New pre-op neuroscience education program aimed at decreasing fear and anxiety prior to surgery
3. Åse Torunn Bergum Odland
3. Pilates: Funker det?
4. Ultralyd skulder med injeksjonsteknikk
16.15-17.00
4. Kjetil Nord-Varhaug
og Øyvind Kvinge
Work-shop x 2
19.30
Festmiddag
Søndag 25. mars 2012
09.30-10-15
Åpningsforedrag
10.20-11.00
Eyal Ledermann
11.00-11.20
Kaffe, utsjekking
11.20-11.50
Eyal Ledermann
Forts.
11.50-12.10
Adrian Louw
12.10-12.30
Audun Lorentsen
Future practice for manual therapists, considering
the need for evidence based therapy and treatment
effect. How should we strive to have best possible
practice?
Manuellterapiens plass i behandling av muskelskjelettplager
12.30
Avslutning
Process Approach: A science based clinical
model for manual therapy
Det tas forbehold om endringer i programmet. Oppdatert program fins på manuellterapi.no. Her kan man også melde
seg på og reservere rom på seminarhotellet.
muskel&skjelett nr. nr. 4, desember 2011 23
AKTUELT
Seminar 2012 - Priser
Søk på Muskel&Skjelett Prisen 2012
Muskel&Skjelett Prisen er norsk manuellterapis
forskningspris og deles ut på manuellterapeutenes
tverrfaglige seminar hvert år.
Bidrag 2012 sendes [email protected]
innen 15. januar 2012.
Utdrag fra pris-statuttene, se rammen til høyre.
Søk på Studentprisen 2012
Manuellterapeutenes studentpris deles ut på
Servicekontorets årlige seminarer. Prisen er på
10.000 kroner. De som er manuellterapistudenter eller som var manuellterapistudenter i 2011
kan delta med presentasjon av oppgaver levert i
forbindelse med sine manuellterapistudier. Det
er en forutsetning at deltaker er medlem av Manuellterapeutenes Servicekontor.
Statutter for Studentprisen
A. Hvem som kan delta og hva bidraget skal bestå av
Nåværende manuellterapistudenter eller de som
var manuellterapistudenter foregående år, kan
delta.
Deltakere må være medlem av Manuellterapeutenes Servicekontor.
Deltakerne leverer et sammendrag av en
skriftlig oppgaver levert i forbindelse med manuellterapistudiet. Sammendraget må kunne
publiseres.
Deltaker må dokumentere at vedkommende
har bidratt i arbeidet som oppgaven bygger på.
Hver deltaker kan kun levere 1 bidrag
Sammendraget skal redegjøre for
- valg av problemstilling,
- materiale og metode
- resultater
- fortolkning/konklusjon
B. Hva juryen legger vekt på
I bedømmelsen av bidragene legges det vekt på
om tema er relevant for manuellterapeutenes
fag og yrkesrolle klarhet i fremstillingen
C. Kåring
Styret i Servicekontoret oppnevner en komite
som gjennomgår bidragene og kårer en vinner.
Vinnerens navn kunngjøres på Servicekontorets årlige fagseminarer. Bidrag kan sendes inn til
[email protected] innen 15. februar 2012.
24 muskel&skjelett nr. 4, desember 2011
Utdrag fra statuttene til
Muskel&Skjelett Prisen
1. Prisens størrelse
Prisen er på kr. 20 000, eventuelt kan
prisene deles på to søkere à kr 10 000.
Prisen deles ut på Manuellterapeutenes
Servicekontors årsmøteseminar.
2. Aktuelle typer design
• Studie med bakgrunn i kvalitativ metode.
• Studie med bakgrunn i kvantitativ metode.
• Utviklingsarbeid med bakgrunn i
litteraturstudie som metode.
3. Vurderingsgrunnlag av hvert enkelt bidrag
a) Problemstilling, klarhet og aktualitet.
b) Arbeidets materialdel og metodedel, inkludert
datainnsamling og dataanalyse.
c) Diskusjon av de oppnådde resultater, validitet
og relasjon til den foreliggende viten på dette
området.
d) Arbeidets relevans for manuellterapi.
e) Foredragets fremstilling med hensyn til
oppbygging, språk, tabeller og figurer.
Foredraget skal være på ca 20 minutter.
f) Sammendragets innhold og form.
Gradering av de enkelte punkter over:
Uopplyst (0 poeng)
Mindre god (1 poeng)
God (2 poeng)
Utmerket (3 poeng)
Dette gir en sumscore. Totalsummen avgjør
rekkefølge. Ved evt. samme pengsum blir
prisen delt.
4. Sammendrag
Alle søkerne sender inn et sammendrag og
en projektbeskrivelse på forhånd, innen en
annonsert tidsfrist. Sammendraget skal være på
maksimum 300 ord og være skrevet på norsk.
Under NKK kongress kan sammendraget og foredraget være skrevet på engelsk. Eventuelle videofremstillinger skal også leveres inn på forhånd.
5. Priskomitè
En priskomitè bestående av tre personer
oppnevnt at Servicekontorets styre vil
foreta vurdering, gradering og endelig
utvelgelse av de aktuelle vinnere av prisen.
.
6. Hvem kan søke på prisen?
Alle manuellterapeuter, leger, kiropraktorer og fysioterapeuter i Norge kan søke.
7. Finansiering
Forskningsprisen finansieres gjennom støtte fra
vare faste sponsorer, som også sponser tidsskriftet Muskel&Skjelett og våre årsmøteseminarer.
Dersom støtte fra sponsorene opphører vil
dette føre til at prisene ikke kan deles ut.
Nyhet: Integrasjon Melin Medical
Kjære behandler
Spar tid, penger og ressurser med selvbetjent
betalingsautomat fra Melin Medical og PVF.
Nå leverer vi løsningen som er fullintegrert i Kasse
Resepsjonssystemet til ProMed. Ingen nye rutiner for deg.
Du slipper masse arbeid med kø for betaling,
kasseoppgjør og har full oversikt over alle betalinger. Vi
har allerede 150000 feilfrie betalinger gjennom systemet
og mange fornøyde behandlere. Ta kontakt for to mnd.
uforpliktende gratis bruk.
Du kommer ikke til å angre!
Tlf 40322260 - [email protected] - www.melinmedical.no
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Med SMS påminnelse til pasienten kommer flere pasienter til avtalt tid.
Hvor lang tid tar det å varsle pasienter om at du ikke er på jobb en dag?
Med SMS tjenesten vår kan du varsle alle pasienter på ønsket dato på
under 1 minutt!
Kontakt oss for kostnadsfri oppkobling, du betaler kun 0,80 pr SMS.
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Visste du at ProMed:
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Kurseksempler:
Bokføring, Oppgjør til HELFO, Sykemelding/Henvisning
Vi ønsker alle nye og etablerte manuellterapeuter
lykke til i 2012
Tlf: 22 62 72 40 - www.pfv.no
FAG
Sammendrag
av internasjonal forskning
Nytt fra forskningsfronten
Sammendrag av forskningsartikler fra internasjonale peer-reviewed publikasjoner.
Husk også at norsk helsepersonell har gratis adgang til en rekke internasjonale
tidsskrifter via Helsebiblioteket, helsebiblioteket.no.
På manuellterapi.no > For medlemmer > Fag > Forskningsartikler finner du
også artikler som er relevante for manuellterapeuter.
Validity and reliability of using
photography for measuring knee range of motion: a methodological study
Justine M Naylor, Victoria Ko, Sam Adie, Clive Gaskin
Richard Walker, Ian A Harris, Rajat Mittal
BMC Musculoskeletal Disorders 2011, 12:77
Background
The clinimetric properties of knee goniometry are
essential to appreciate in light of its extensive use
in the orthopaedic and rehabilitative communities.
Intra-observer reliability is thought to be satisfactory, but the validity and inter-rater reliability of
knee goniometry often demonstrate unacceptable
levels of variation. This study tests the validity and
reliability of measuring knee range of motion using
goniometry and photographic records.
Methods
Design: Methodology study assessing the validity
and reliability of one method (’Marker Method’)
which uses a skin marker over the greater trochanter and another method (’Line of Femur Method’)
which requires estimation of the line of femur. Setting: Radiology and orthopaedic departments of
two teaching hospitals. Participants: 31 volunteers
(13 arthritic and 18 healthy subjects). Knee range of
motion was measured radiographically and photographically using a goniometer. Three assessors
were assessed for reliability and validity. Main outcomes: Agreement between methods and within
raters was assessed using concordance correlation
coefficient (CCCs). Agreement between raters was
assessed using intra-class correlation coefficients
(ICCs). 95% limits of agreement for the mean difference for all paired comparisons were computed.
26 muskel&skjelett nr. nr. 4, desember 2011
Results
Validity (referenced to radiographs): Each method
for all 3 raters yielded very high CCCs for flexion
(0.975 to 0.988), and moderate to substantial CCCs
for extension angles (0.478 to 0.678). The mean differences and 95% limits of agreement were narrower for flexion than they were for extension. Intrarater reliability: For flexion and extension, very
high CCCs were attained for all 3 raters for both
methods with slightly greater CCCs seen for flexion (CCCs varied from 0.981 to 0.998). Inter-rater
reliability: For both methods, very high ICCs (min
to max: 0.891 to 0.995) were obtained for flexion and
extension. Slightly higher coefficients were obtained for flexion compared to extension, and with the
Marker compared to the Line of Femur Method. For
intra- and inter-rater reliability, the mean differences (within 2 degrees) and 95% limits of agreement
(within 5 degrees) were generally clinically acceptable for both methods.
Conclusion
Photography potentially offers a superior method
of measurement over standard goniometry as visualising the centre of the knee is simplified in a twodimensional plane and the permanent record provides greater assessor transparency as well as opportunity to confer. The Marker and Line of Femur
Methods have moderate to substantial validity, but
the inter- and intra-rater repeatability for trained
observers are excellent with both methods yielding
small mean differences with narrow limits of agreement. The Line of Femur Method offers the added
advantage that it does not rely on inter-clinician
consistency in identifying the greater trochanter.
Sammendrag av internasjonal forskning
Low bone mineral density is a
significant risk factor for low-energy
distal radius fractures in middle-aged
and elderly men: A case-control study
Jannike Øyen, Gudrun Rohde, Marc Hochberg , Villy
Johnsen , Glenn Haugeberg.
BMC Musculoskeletal Disorders 2011, 12:67
Background
In general there is a lack of data on osteoporosis
and fracture in men; this also includes low-energy
distal radius fractures. The objectives of this study
were to examine BMD and identify factors associated with distal radius fractures in male patients
compared with controls recruited from the background population.
Methods
In a 2-year period, 44 men 50 years or older were
diagnosed with low-energy distal radius fractures,
all recruited from one hospital. The 31 men who attended for osteoporosis assessment were age-matched with 35 controls. Demographic and clinical
data were collected and BMD at femoral neck, total
hip and spine L2-4 was assessed by dual energy Xray absorptiometry.
Results
Apart from weight and living alone, no significant
differences were found between patient and controls for demographic variables (e.g. height, smoking) and clinical variables (e.g. co-morbidity, use
of glucocorticoids, osteoporosis treatment, falls and
previous history of fracture). However, BMD expressed as T-score was significant lower in patients
than in controls at all measurement sites (femoral
neck: -2.24 vs. -1.15, p < 0.001; Total hip: -1.65 vs.
-0.64, p < 0.001; Spine L2-4: -1.26 vs. 0.25, p = 0.002).
Among the potential risk factors for fracture evaluated, only reduced BMD was found to be significantly associated with increased risk for low-energy distal radius fractures in men.
Conclusion
The results from our study indicate that reduced
BMD is an important risk factor for low-energy distal radius fracture in men. This suggests that improvement of BMD by both pharmacological and
non-pharmacological initiatives may be a strategy
to reduce fracture risk in men.
FAG
A comparison of ultrasound and
clinical examination in the detection
of flexor tenosynovitis in early arthritis
Ihsane Hmamouchi et al.
BMC Musculoskeletal Disorders 2011, 12:91
Background
Tenosynovitis is widely accepted to be common in
rheumatoid arthritis (RA) and postulated to be the
first manifestation of RA, but its true prevalence
in early disease and in particular the hand has not
been firmly established. The aims of this study
were first to investigate the frequency and distribution of finger flexor tenosynovitis using ultrasound
in early arthritis, second to compare clinical examination with ultrasound (US) using the latter as the
gold standard.
Methods
33 consecutive patients who had who were initially
diagnosed with polyarthritis and suspected of polyarthritis and clinical suspicion of inflammatory
arthritis of the hands and wrists were assessed
during consecutive, routine presentations to the
rheumatology outpatient clinic. We scanned a total
of 165 finger tendons and subsequent comparisons
were made using clinical examination.
Results
Flexor tenosynovitis was found in 17 patients
(51.5%) on ultrasound compared with 16 (48.4%)
of all patients on clinical examination. Most commonly damaged joint involved on US was the second finger followed by the third, fifth, and fourth.
Both modalities demonstrated more pathology on
the second and third metacarpophalangeal (MCP)
compared with the fourth and fifth MCP. A jointby-joint comparison of US and clinical examination
demonstrated that although the sensitivity, specificities and positive predictive values of clinical examination were relatively high, negative predictive
value of clinical examination was low (0.23).
Conclusions
Our study suggest that clinical examination can be
a valuable tool for detecting flexor disease in view
of its high specificity and positive predictive values,
but a negative clinical examination does not exclude inflammation and an US should be considered.
Further work is recommended to standardize definitions and image acquisition for peritendinous
inflammation for ultrasound.
muskel&skjelett nr. nr. 4, desember 2011 27
FAG
Sykmeldingsarbeid og IA
Nasjonal konferanse om inkluderende arbeidsliv (IA) ble avholdt 3. november
på Lillestrøm. Arrangør var Arbeidsdepartementet og partene i arbeidslivet.
Kjersti Gundersen refererer fra konferansen.
Nasjonal IA-konferanse 2011
Manuellterapeut
Kjersti Gundersen
er styremedlem
i Servicekontoret.
Manuellterapeutene ble invitert til å delta på årets
konferanse, i og med at NMF er nye medlemmer av
LO. Representanter som møtte: Oddvar Knudsen
og Kjersti Gundersen.
Konferansen arrangeres årlig, den er kjent for å
være innholdsrik med hensyn til siste fakta vedrørende Inkluderende Arbeidsliv-avtalen og forskning vedrørende arbeidslivet som har som mål å
finne årsaker til fravær eller tilstedeværelse, til inkludering, til god personalpolitikk i sin helhet og
ikke minst god seniorpolitikk.
Konferansen var omfattende, noe de i alt 570
påmeldte og fremmøtte satte stor pris på. Marit
Christensen var ordstyrer. Hun bandt konferansen
mesterlig sammen, etter at den ble åpnet av arbeidsminister Hanne Bjurstrøm. I sin åpningstale snakket hun om «den nye IA-avtalen» inngått i februar
2010, gjeldende for perioden 1.3.2010 til 31.12.2013
med sine tre hovedmål:
• Reduksjon av sykefraværet med 20% i forhold til
nivået i 2. kvartal 2001; det vil si at det ikke skal
overstige 5,6%.
• Økt sysselsetting av personer med redusert
funksjonsevne.
• Yrkesaktivitet etter fylte 50 år forlenges med seks
måneder. Det vil si en målsetting om at arbeidsdyktige skal stå i jobb lengre enn de gjør i dag.
Resultatene har ikke kommet som ønsket; det
var en nedgang i sykefraværet i løpet av 2010, men
i løpet av 2011 er det en liten økning igjen. Arbeidsministeren av sluttet derfor sin innledning med
spørsmålet: Hva gjør vi nå?
Videre foredrag var delt inn i tre «avdelinger» i
henhold til IA-avtalens hovedmål.
I den første bolken ble det presentert forskningsresultater – og også informasjon om forskningsprosjekter som pågår – om hvilke faktorer i yrkes- og
familielivet, som medfører økt fravær, hva som
virker for å redusere fravær og så videre. Samtlige
foredragsholdere påpekte viktigheten av en god,
tilstedeværende og tydelig ledelse på arbeidsplassen, viktigheten av «å bli sett» som arbeidstager,
og ha et balansert arbeidsforhold med utfordrende
arbeidsoppgaver. Balanse mellom arbeidsliv og familieliv ble også poengtert som vesentlig.
28 muskel&skjelett nr. nr. 4, desember 2011
I den andre bolken holdt Hanne Bjurstrøm et
engasjert foredrag om regjeringens jobbstrategi for
unge med nedsatt funksjonsevne. Det gjenstår mye
arbeid for at dette skal fungere bra generelt, både
med hensyn til holdninger blant ledere og arbeidstagere generelt, og at det er et svært viktig arbeid!
Alle statistikker og all forskning tilsier at Norge
ikke har råd til å gå glipp av alle ressursene mennesker med redusert funksjonsevne «sitter inne
med». Både før og etter arbeidsministerens foredrag, ble viktigheten av tilrettelegging, mulighetene for tilrettelegging og hvilke virkemidler som
IA-avtalen innehar, påpekt.
Den tredje bolken var viet «det å stå lengre i
jobb». Fornyings-, administrasjons- og kirkeminister Rigmor Aasrud var en av foredragsholderne.
Hun fortalte at andelen i arbeidslivet som ønsker å
jobbe etter man får rett til pensjon, har steget jevnt
og trutt de siste årene. Fra 34% i 2004 til 54% i dag.
66% av arbeidstakere over 60 år ønsker å fortsette i
jobb etter at man får rett til pensjon. Hun konkluderte – som flere av foredragsholderne var inne på
– med at det handler om å bli sett, ha spennende og
verdige arbeidsoppgaver og å føle mestring. Livsfasepolitikk må sterkere inn i arbeidslivet, ikke bare
blant yngre arbeidstagere, men også blant de eldre.
Avslutningsvis delte hun ut «Seniorprisen» som ble
tildelt den bedriften i Norge som hadde utmerket
seg med en god, intern seniorpolitikk. Prisen gikk
til St. Olavs Hospital v/ organisasjonsdirektør Heidi
Magnussen. Hun presenterte sykehusets tiltak for
seniorer i etterkant av prisutdelingen.
Avslutningsvis holdt LOs Roar Flåten et foredrag om viktigheten av å stå sammen om IA-avtalens hovedmål. Han oppfordret både arbeidsgivere, NAV og tillitsvalgte/arbeidstagere til «å stå på
sjøl!». Lars Haukaas fra Spekter rundet av det hele
med å oppfordre til å stå på videre, det var mye å
jobbe for, bl.a. trygge jobber, ikke vikariater, samt
retten til deltids- og retten til heltidsjobber.
I det store og hele, var det en meget interessant
dag, sammen med en mengde engasjerte tilhørere
og dyktige, engasjerende foredragsholdere!
Kjersti Gundersen, referent
Aktuelt
FAG
Manuell behandling av migrene like
effektivt som medikamenter
Manuelle behandlingsformer, blant annet spinal manipulasjon,
kan være like effektivt som propranolol og topiramate i
behandlingen av migrene, ifølge litteraturstudie.
15 prosent av befolkningen opplever migreneanfall i løpet av
livet. Vanligvis behandles dette
med medikamenter.
Den nye studien som kiropraktor Aleksander Chaibi ved
Akershus universtitetssykehus
og medarbeidere har gjennomført har undersøkt om manuelle
behandlingsformer kan benyttes. Alle randomiserte studier
(RCT) publisert på engelsk som
har undersøkt manuellterapi i
behandling av migrene ble gjennomgått. Det ble gjort et litteratursøk i de store medisinskvitenskapelige databasene på søkeordene migrene,
manipulasjon, spinal mobilisering, kiropraktikk,
fysioterapi, osteopati og massasjeterapi.
7 RCTer ble identifisert. Resultatene viser at de manuelle
behandlingsformene kan være
like effektivt som medikamentene propranolol og topiramate
i profylaktisk behandling av migrene. Konklusjonen kan imidlertid ikke trekkes for bastant,
da antallet RCTer med god metodologisk kvalitet er lite.
Kilde: Chaibi A et al.: Manual
therapies for migraine: a systematic review. J Headache
Pain
Tilbakemelding på sykmeldingspraksis
Manuellterapeuter har nå fått tilgang til en ny
nettløsning med fakta om egen sykmeldingspraksis.
Oddvar Knutsen har representert Norsk Manuellterapeutforening i arbeidet med tilbakemeldingssystemet. Han forteller at portalen gir
kunnskap om den enkeltes sykmeldingspraksis.
– Etter å ha logget inn, kan man få statistikk
over sykmeldinger og sykefraværstilfeller fordelt på kjønn, alders, diagnoser, næring, varighet, gradering og utvikling over tid. Du kan også
sammenligne sykmeldingstall med kommune-,
fylkes og landsgjennomsnittet for manuellterapeuter.
Knutsen opplyser at hensikten med statistikken er å gi økt innsikt i hvordan man sykmelder,
slik at en får bedre grunnlag for refleksjon og utvikling av egen praksis på området. I tråd med
prinsippene i IA-avtalen skal det legges vekt på
arbeidsevne og aktivitet, og det er lagt opp til at
en i større grad skal ta i bruk gradert sykemelding. Informasjonen som ligger i tilbakemeldingen kan benyttes som utgangspunkt for gjennomgang og vurdering på egenhånd, men den
kan også være egnet som tema i kollegagrupper.
NAV vil benytte statistikken i dialog med
sykmelderne. Den skal imidlertid ikke benyttes
til kontroll av eller som grunnlag for sanksjoner
overfor sykmelderne.
NAV skal ha sendt ut informasjon til sykmelderne om statistikkløsningen i uke 47. Innlogging skjer ved hjelp av buypass-kort (for priser
på kortleser mv., se Brukerveiledning for elektronisk samhandling for manuellterapeuter, side
14-15). NAV gir også brukerstøtte når det gjelder
innlogging og funksjoner i løsningen som for eksempel utskrift, endre sammenligningsområde,
endre periode osv. på telefon og via e-post. n
muskel&skjelett nr. nr. 4, desember 2011 29
AKTUELT
Manuellterapeutautorisasjon vurderes
Helse- og omsorgsdepartementet har gitt Helsedirektoratet i oppdrag å
vurdere om manuellterapeuter bør gis autorisasjon i henhold til helsepersonelloven. LO og NMF er glade for at en slik vurdering endelig blir gjort.
LOs nestleder
Gerd Kristiansen
og NMF-leder
Peter Chr. Lehne.
Arkivfoto.
n Norsk Manuellterapeutforenings (NMF) nettsted
melder at departementet har bedt om det foretas en
pro- et contra vurdering av autorisasjon av manuellterapeuter.
– Vi glade for at direktoratet på et faglig grunnlag
ser behovet for en autorisasjonsvurdering og at departementet nå åpner for at det skal foretas en pro- et
contravurdering, sier LOs nestleder Gerd Kristiansen.
Leder Peter Chr. Lehne i NMF har tillit til at det
blir en god prosess, og er optimistisk med hensyn til
utfallet. Han peker på at autorisasjon av manuellterapeuter vil skape sammenheng mellom autorisasjonsbetegnelsen på den ene siden og manuellterapeutenes
faktiske kompetanse og plassering i helsevesenet på
den andre.
– Dette vil markant styrke pasientsikkerheten og
forebygge eksisterende misforståelser rundt manuellterapeuters yrkesrolle, noe som har vært et problem
både fra et pasientståsted og fra ståstedet til annet helsepersonell.
I første halvdel av 2011 vurderte LO disse argumentene svært grundig og konkluderte med at autorisasjon av manuellterapeuter er den mest hensiktsmessige offentlige godkjenningsformen.
– Denne vurderingen ble foretatt på et fritt faglig
grunnlag, før Norsk Manuellterapeutforening søkte
medlemskap i LO. En slik vurdering fra en av de vik-
30 muskel&skjelett nr. 4, desember 2011
tigste samfunnsaktørene gir trygghet for at vår argumentasjon holder faglig mål, sier Lehne.
NMF har sagt seg villig til å gi fra seg fysioterapeutautorisasjonen slik at problemstillingen med dobbelt
autorisasjon ikke oppstår. Forutsetningen er at manuellterapien fortsatt skal være en del av den offentlige
helsetjenesten.
Departementet har gitt direktoratet frist til 1. februar med å ferdigstille vurderingen.
NFFs faggruppe: – Vi er ikke
forskjellige fra fysioterapeuter
n Norsk Fysioterapeutforbunds (NFF) faggruppe for manuellterapi ønsker ikke autorisasjon av manuellterapeuter. På sin nettside
skriver gruppen at manuellterapeuters nye
rolle ikke gjør manuellterapeuter vesentlig forskjellig fra fysioterapeuter.
Faggruppen skriver videre at den er en del
av et fellesskap på 9.500 fysioterapeuter i NFF.
– Vi er opptatt av at befolkningens interesser blir ivaretatt gjennom en helsetjeneste der
også alle spesialitetene innen fysioterapi skal
bli kjent.
Nyhet! Gunstige medlemsfordeler!
Norsk Manuellterapeutforening og If har inngått en avtale som sikrer medlemmene ekstra
gunstige gruppelivs- og sykelønnsforsikringer.
Høres dette interessant ut?
Da tar du kontakt med Siv Olsen på telefon 63 91 20 94 eller e-post [email protected].
Hun kjenner bransjen og kan gi deg mer informasjon og utarbeide et tilbud tilpasset dine behov.
Vi anbefaler minimum 13 cm lengde pga lange adresser
Retur: Muskel&Skjelett. Nabbetorpveien 138, 1636 Gml Fredrikstad
minst 6 cm avstand
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