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1
MUSCLE DYSFUNCTION IN
CERVICAL PAIN AND THE
IMPLICATIONS FOR
TRAINING
Deborah Falla
CENTER FOR ANESTHESIOLOGY, EMERGENCY...
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Contemporary theory proposes that the
motor adaptation:
(i) involves a diversity of changes from subtle changes in
the d...
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Contemporary theory proposes that the
motor adaptation:
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the d...
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Subtle changes in the distribution of activity -
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In people with neck pain but no back pain -
those with poor ability to perform a voluntary
activation of the lower abdo...
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Forward Slide 10˚ Backward Tilt10˚ Forward TiltBackward Slide
Boudreau & Falla. Exp Brain Res. 2014
Onset (ms)
Delayed ...
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Is training effective
for restoration of
motor function?
Design of Study
Patients with chronic neck pain
Randomized int...
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Training
15 N contraction , 0-360°
Relative muscle specificity to direction, RSD (%)
Act as usual
15 N contraction , 0-...
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Numerous clinical trials have demonstrated
the efficacy of interventions that target
rehabilitation of sensorimotor con...
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Presentatie Dr. Deborah Falla

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Tijdens NVMT symposium 2015

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Presentatie Dr. Deborah Falla

  1. 1. 1 MUSCLE DYSFUNCTION IN CERVICAL PAIN AND THE IMPLICATIONS FOR TRAINING Deborah Falla CENTER FOR ANESTHESIOLOGY, EMERGENCY AND INTENSIVE CARE MEDICINE, UNIVERSITY HOSPITAL GÖTTINGEN, GERMANY DEPARTMENT OF NEUROREHABILITATION ENGINEERING BERNSTEIN CENTER FOR COMPUTATIONAL NEUROSCIENCE UNIVERSITY MEDICAL CENTER GÖTTINGEN, GERMANY Changes in sensorimotor control are an almost obligatory feature of musculoskeletal conditions Evidence for modification of motor and/or sensory functions has been reported for a broad array of conditions, and these changes have become common targets for rehabilitation It has been assumed that sensorimotor changes are relevant for the development, perpetuation or recurrence of pain and/or injury Reflect on these assumptions in relation to neck pain Models of motor adaptation to pain Muscle pain Group III & IV excitation Increased muscle activity Muscle ischemia Vicious cycle theory Johansson & Sojka. 1991 Muscle pain Group III & IV excitation Decreased agonistic muscle activity Increased antagonistic muscle activity Inhibition of α-motoneurons Excitation α-motoneurons This pathway is facilitated in case of agonistic muscle activity This pathway is facilitated in case of antagonistic muscle activity Pain adaptation theory Lund. Can J Physiol Pharmacol. 1991
  2. 2. 2 Contemporary theory proposes that the motor adaptation: (i) involves a diversity of changes from subtle changes in the distribution of activity within and between muscles to complete/relative avoidance of movement; (ii) is specific to the individual; (iii) has a general aim (at least in the short term) to protect the painful/threatened body part from real or anticipated further pain/injury; (iv) may precede or follow the onset of pain/injury; (v) has potential long term consequences if it is maintained, excessive or inappropriate Hodges and Falla. GMMPT. 2015 Contemporary theory proposes that the motor adaptation: (i) involves a diversity of changes from subtle changes in the distribution of activity within and between muscles to complete/relative avoidance of movement; (ii) is specific to the individual; (iii) has a general aim (at least in the short term) to protect the painful/threatened body part from real or anticipated further pain/injury; (iv) may precede or follow the onset of pain/injury; (v) has potential long term consequences if it is maintained, excessive or inappropriate Hodges and Falla. GMMPT. 2015 Contemporary theory proposes that the motor adaptation: (i) involves a diversity of changes from subtle changes in the distribution of activity within and between muscles to complete/relative avoidance of movement; (ii) is specific to the individual; (iii) has a general aim (at least in the short term) to protect the painful/threatened body part from real or anticipated further pain/injury; (iv) may precede or follow the onset of pain/injury; (v) has potential long term consequences if it is maintained, excessive or inappropriate Hodges and Falla. GMMPT. 2015
  3. 3. 3 100 200 300 mV0 10 20 30 40 • 200 400 600 800 1000 1200 Subtle changes in the distribution of activity - High density surface EMG LateralMedial Cranial Caudal y-axis x-axis No redistribution of upper trapezius muscle activity during sustained contractions in patients with trapezius myalgia Control Cranial Caudal x-axis y-axis Medial Lateral 0 – 5 s 55 – 60 s 140 120 100 80 60 40 20 0 µV Trapezius Myalgia 0 – 5 s 55 – 60 s Falla et al. J Electromyogr Kinesiol. 2009 140 120 100 80 60 40 20 0 µV acromion C7 Shift in the distribution of activity across the trapezius muscle with experimental neck pain Barbero, et al. 2015 Baseline Isotonic Hypertonic Recovery 10 20 30 40 50 60 70 80 90 100 95 100 105 110 115 120 125 130 Percentage of Cycle (%) Y-axiscentroid(%) * * * * * * * * * Caudal Cranial *
  4. 4. 4 Contemporary theory proposes that the motor adaptation: (i) involves a diversity of changes from subtle changes in the distribution of activity within and between muscles to complete/relative avoidance of movement; (ii) is specific to the individual; (iii) has a general aim (at least in the short term) to protect the painful/threatened body part from real or anticipated further pain/injury; (iv) may precede or follow the onset of pain/injury; (v) has potential long term consequences if it is maintained, excessive or inappropriate Hodges and Falla. GMMPT. 2015 Persistence of the motor adaptation could also underpin reduced “confidence” in the injured /painful region, thus promoting disuse or modified use of the body part, that is, the adapted motor behaviour could interact with psychosocial issues Contemporary theory proposes that the motor adaptation: (i) involves a diversity of changes from subtle changes in the distribution of activity within and between muscles to complete/relative avoidance of movement; (ii) is specific to the individual; (iii) has a general aim (at least in the short term) to protect the painful/threatened body part from real or anticipated further pain/injury; (iv) may precede or follow the onset of pain/injury; (v) has potential long term consequences if it is maintained, excessive or inappropriate Hodges and Falla. GMMPT. 2015
  5. 5. 5 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 EMGamplitudenormalisedtobaseline S1 S2 S3 S4 S5 S6 S7 S8 RHYO RSTER RSCA RUTR RLTR LHYO LSTER LSCA LSPL LUTR LLTR Gizzi et al. 2015 Individual changes in response to experimentally induced neck muscle pain Decreased Unchanged Increased Contemporary theory proposes that the motor adaptation: (i) involves a diversity of changes from subtle changes in the distribution of activity within and between muscles to complete/relative avoidance of movement; (ii) is specific to the individual; (iii) has a general aim (at least in the short term) to protect the painful/threatened body part from real or anticipated further pain/injury; (iv) may precede or follow the onset of pain/injury; (v) has potential long term consequences if it is maintained, excessive or inappropriate Hodges and Falla. GMMPT. 2015 Despite the diversity of adaptation in muscle activation in pain, the net effect of the adaptation appears to have the general aim to protect the painful/threatened body part from real or anticipated further pain or injury
  6. 6. 6 60 240 30 210 0 180 330 150 300 120 270 90 60 240 30 210 0 180 330 150 300 120 270 90 Left Sternocleidomastoid Right Sternocleidomastoid Left Splenius Capitis Right Splenius Capitis 60 240 30 210 0 180 330 150 300 120 270 90 60 240 30 210 0 180 330 150 300 120 270 90 ° ° ° ° mean resultant vector (preferred direction) Falla et al. Clin Neurophysiol. 2010 EMG Tuning Curves Left Sternocleidomastoid Right Sternocleidomastoid Left Splenius Capitis Right Splenius Capitis 60 240 30 210 180 330 150 300 120 270 90 60 240 30 210 180 330 150 300 120 270 90 0 0° ° 60 240 30 210 180 330 150 300 120 270 90 60 240 30 210 180 330 150 300 120 270 90 0 0° ° mean resultant vector (preferred direction) Falla et al. Clin Neurophysiol. 2010 EMG Tuning Curves 60 240 30 210 0 180 330 150 300 120 270 90 ° Directional specificity of muscle activity is reduced in persons with neck pain 15 N contraction , 0-360° Relative muscle specificity to direction Neck Pain Controls Left SCM Right SCM Left SCap Right SCap Falla et al. Clin Neurophysiol. 2010
  7. 7. 7 Average amplitude of neck muscle activity is increased 0 10 20 30 40 50 60 70 80 Right SCM Left SCM Right SCap Left SCap Neck Pain Controls EMGamplitude(µV) Falla et al. Clin Neurophysiol. 2010 * * * * Assessment of trunk rotations during gait with and without the head turned Falla et al. 2015 Pelvis 0 10 20 30 40 50 60 70 80 90 100-10 0 10 % gait cycle Angle(°) Thorax-Pelvis -10 0 10 Thorax -10 0 10 Neck Pain Controls Hiprangeofmotion(°)Kneerangeofmotion(°)Anklerangeofmotion(°) 3 km/h Self-selected 5 km/h Neutral (L) Rot (R) Rot Neutral (L) Rot (R) Rot Neutral (L) Rot (R) Rot L R L R L R L R L R L R L R L R L R Falla et al. 2015 HipKneeAnkle
  8. 8. 8 0 2 4 6 8 10 12 14 16 18 0 2 4 6 8 10 12 14 16 18 0 2 4 6 8 10 12 14 16 18 Trunkrotation(°) Neutral (L) Rot (R) Rot Neutral (L) Rot (R) Rot Neutral (L) Rot (R) Rot 3 km/h Self-selected 5 km/h Neck Pain Controls Falla et al. 2015 Reduced trunk rotations in neck pain during gait with the head turned * * * * * * Reduced trunk rotations in neck pain during gait with the head turned Differencetrunkrotation: Neutral-headrotation(°) Neck Pain Controls 3 km/h Self-selected 5 km/h L R L R L R -3.5 -3 -2.5 -2 -1.5 -1 -0.5 0 * * * * * * Falla et al. 2015 Contemporary theory proposes that the motor adaptation: (i) involves a diversity of changes from subtle changes in the distribution of activity within and between muscles to complete/relative avoidance of movement; (ii) is specific to the individual; (iii) has a general aim (at least in the short term) to protect the painful/threatened body part from real or anticipated further pain/injury; (iv) may precede or follow the onset of pain/injury; (v) has potential long term consequences if it is maintained, excessive or inappropriate Hodges and Falla. GMMPT. 2015
  9. 9. 3 100 200 300 mV0 10 20 30 40 • 200 400 600 800 1000 1200 Subtle changes in the distribution of activity - High density surface EMG LateralMedial Cranial Caudal y-axis x-axis No redistribution of upper trapezius muscle activity during sustained contractions in patients with trapezius myalgia Control Cranial Caudal x-axis y-axis Medial Lateral 0 – 5 s 55 – 60 s 140 120 100 80 60 40 20 0 µV Trapezius Myalgia 0 – 5 s 55 – 60 s Falla et al. J Electromyogr Kinesiol. 2009 140 120 100 80 60 40 20 0 µV acromion C7 Shift in the distribution of activity across the trapezius muscle with experimental neck pain Barbero, et al. 2015 Baseline Isotonic Hypertonic Recovery 10 20 30 40 50 60 70 80 90 100 95 100 105 110 115 120 125 130 Percentage of Cycle (%) Y-axiscentroid(%) * * * * * * * * * Caudal Cranial *
  10. 10. 10 In people with neck pain but no back pain - those with poor ability to perform a voluntary activation of the lower abdominal muscles, were 3–6 times more likely to develop persistent or recurrent LBP in the following two years than those who performed well on this task Moseley 2004 Development of pain may be mediated by suboptimal tissue loading related to the “new” movement pattern adopted after the initial exposure to nociceptive input/pain e.g. development of back pain secondary to modified gait in low limb injury Nadler et al., 2000 Reduced motor control may lead to pain Contemporary theory proposes that the motor adaptation: (i) involves a diversity of changes from subtle changes in the distribution of activity within and between muscles to complete/relative avoidance of movement; (ii) is specific to the individual; (iii) has a general aim (at least in the short term) to protect the painful/threatened body part from real or anticipated further pain/injury; (iv) may precede or follow the onset of pain/injury; (v) has potential long term consequences if it is maintained, excessive or inappropriate Hodges and Falla. GMMPT. 2014 Boudreau & Falla, Exp Brain Res 2014 Onset of neck muscle activation in response to full body perturbations 0 100 200 300 400 500 Time (ms) Control R SCM L SCM R SCap L SCap 600 Neck Pain 0 100 200 300 400 500 Time (ms) 600 Forward Slide 10˚ Backward Tilt10˚ Forward TiltBackward Slide
  11. 11. 11 Forward Slide 10˚ Backward Tilt10˚ Forward TiltBackward Slide Boudreau & Falla. Exp Brain Res. 2014 Onset (ms) Delayed neck muscle activity in response to full body perturbations Controls Neck pain 50 70 90 110 FT FS BS BT 50 70 90 110 FT FS BS BT Onset (ms) Sternocleidomastoid Splenius Capitis * * * * * * * * Elliott et al., PLoS ONE, 2011 Control Whiplash patients with moderate to severe pain Increased muscle fatty infiltrate in patients with severe pain by 3 months after onset of pain/injury 0 0.1 0.2 0.3 0.4 1 3 Time Post Injury (Months) TotalMFI Fatty infiltration of muscle tissue occurs soon following neck trauma but not immediately * Changed motor output/ mechanical behavior: Change - stiffness, force direction, load distribution, variability, force & movement amplitude Long term consequences: Increase potential for injury &/or nociceptor provocation injured tissues & other body segments - load, invariable load, shock absorption, deconditioning Load exceeds tissue tolerance Discrete excessive load Accumulated load (Posture, function, etc.) Short term benefit: Protection of the injured/painful region – muscle activity/stress, movement, potential for error Psychosocial features Fear/attitudes/beliefs Mismatch between motor output - sensory input Subtle Redistributed activity within & between muscles Sensitized nervous system Mechanism: changes in sensorimotor system Motor cortex excitability/ organisation, sensory cortex, cognitive- emotional, sensory integration, sensorimotor mismatch, brain stem, spinal cord (e.g. inhibition/ excitation), receptor injury etc) Major Avoidance of movement Changes in motor behavior Real or threatened nociceptive input/pain/injury Hodges and Falla. GMMPT. 2015
  12. 12. 12 Is training effective for restoration of motor function? Design of Study Patients with chronic neck pain Randomized into 1 of 2 groups motor relearning program of specific exercise control: act as usual 8 week exercise intervention Measures baseline and week 9 Outcome assessment: Directional specificity of neck muscle activity Falla, et al. Eur J Pain. 2013 60 240 30 210 0° 180 330 150 300 120 270 90 60 240 30 210 0° 180 330 150 300 120 270 90 60 240 30 210 0° 180 330 150 300 120 270 90 60 240 30 210 0° 180 330 150 300 120 270 90 60 240 30 210 0° 180 330 150 300 120 270 90 60 240 30 210 0° 180 330 150 300 120 270 90 60 240 30 210 0° 180 330 150 300 120 270 90 Pre Post Pre Post 60 240 30 210 0° 180 330 150 300 120 270 90 60 240 30 210 0° 180 330 150 300 120 270 90 60 240 30 210 0° 180 330 150 300 120 270 90 60 240 30 210 0° 180 330 150 300 120 270 90 60 240 30 210 0° 180 330 150 300 120 270 90 60 240 30 210 0° 180 330 150 300 120 270 90 60 240 30 210 0° 180 330 150 300 120 270 90 60 240 30 210 0° 180 330 150 300 120 270 90 Training Actasusual (R) SCM(L) SCM (R) SCap(L) SCap (R) SCM(L) SCM (R) SCap(L) SCap (R) SCM(L) SCM (R) SCap(L) SCap (R) SCM(L) SCM (R) SCap(L) SCap 60 240 30 210 0° 180 330 150 300 120 270 90 Falla, et al. Eur J Pain. 2013
  13. 13. 13 Training 15 N contraction , 0-360° Relative muscle specificity to direction, RSD (%) Act as usual 15 N contraction , 0-360° Relative muscle specificity to direction, RSD (%) 60 240 30 210 0 180 330 150 300 120 270 90 ° 60 240 30 210 0 180 330 150 300 120 270 90 ° Pre Post Left SCM Right SCM Left SCap Right SCap Falla, et al. Eur J Pain. 2013 Enhanced directional specificity of muscle activity following training Is training effective for relief of pain? Symptomatic relief following motor control training in neck pain Falla et al. Clin Neurophysiol. 2006 MILD IDIOPATHIC Falla, et al. Eur J Pain. 2013 Jull et al. Pain. 2007 0 10 20 30 40 50 60 70 80 90 %ReductioninNeckPain Resistance 47% %ReductioninNeckPain 25% MODERATE SEVERE IDIOPATHIC COLD HYPERALGESIA WHIPLASH 16% %ReductioninNeckPain 0 10 20 30 40 50 60 70 80 90
  14. 14. 14 Numerous clinical trials have demonstrated the efficacy of interventions that target rehabilitation of sensorimotor control for the management of neck pain These interventions are more effective when targeted to findings of a detailed assessment and that people with features consistent with nociceptive pain (e.g. features of pain that imply a proportional and predictable relationship to mechanical loading) are more likely to respond favorably The relative involvement of sensorimotor, psychosocial, and other biological mechanisms in a patient’s presentation will vary between individuals and it is not possible to completely separate these mechanisms A goal is to identify individuals who will benefit most from rehabilitation targeted at restoration/rehabilitation of sensorimotor changes and the best methods to address the underlying mechanisms in those for whom it is relevant
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    Apr. 19, 2015

Tijdens NVMT symposium 2015

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