www.stabiliteitstrainingscentrum.nl

Ademhaling

Michelle D Smith, Anne Russell and Paul W Hodges

Disorders of breathing and continence have a stronger

association with back pain than obesity and physical

activity Australian Journal of Physiotherapy 2006 Vol. 52 – © Australian Physiotherapy Association

2006

Key words: Back Pain, Urinary Incontinence, Respiration Disorders, Epidemiology

Although obesity and physical activity have been argued to predict back pain, these factors

are also related to incontinence and breathing difficulties. Breathing and continence

mechanisms may interfere with the physiology of spinal control, and may provide a link to

back pain. The aim of this study was to establish the association between back pain and

disorders of continence and respiration in women. We conducted a cross-sectional analysis of

self-report, postal survey data from the Australian Longitudinal Study on Women’s Health.

We used multinomial logistic regression to model four levels of back pain in relation to both

the traditional risk factors of body mass index and activity level, and the potential risk factors

of incontinence, breathing difficulties, and allergy. A total of 38 050 women were included

from three age-cohorts. When incontinence and breathing difficulties were considered,

obesity and physical activity were not consistently associated with back pain. In contrast, odds

ratios (OR) for often having back pain were higher for women often having incontinence

compared to women without incontinence (OR were 2.5, 2.3 and 2.3 for young, mid-age and

older women, respectively). Similarly, mid-aged and older women had higher odds of having

back pain often when they experienced breathing difficulties often compared to women with

no brerathing problems (OR of 2.0 and 1.9, respectively). Unlike obesity and physical

activity, disorders of continence and respiration were strongly related to frequent back pain.

This relationship may be explained by physiological limitations of co-ordination of postural,

respiratory and continence functions of trunk muscles.

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Marshall Hagins, PhD,* Markus Pietrek, MD,† Ali Sheikhzadeh, PhD,† Margareta Nordin,

Dr. Sci.,† and Kenneth Axen, PhD‡

The effects of breath control on intra-abdominal pressure

during lifting tasks SPINE Volume 29, Number 4, pp 464–469 ©2004, Lippincott Williams & Wilkins, Inc.

Key words: intra-abdominal pressure, breath control, low back pain, lifting

Study Design. This was a repeated measures study examining 11 asymptomatic subjects

while performing dynamic lifting using various postures, loads, and breath control methods.

Objectives. To examine the effects of breath control on magnitude and timing of intra-

abdominal pressure during dynamic lifting.

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Summary of Background Data. Intra-abdominal pressure has been shown to increase

consistently during static and dynamic lifting tasks. The relationship between breath control

and intra-abdominal pressure during lifting is not clear.

Methods. Eleven healthy subjects were tested using lifting trials consisting of two levels of

posture and load and four levels of breath control (natural breathing, inhalation- hold,

exhalation-hold, inhalation-exhalation). Intraabdominal pressure was measured using a

microtip pressure transducer placed within the stomach through the nose. Timing of intra-

abdominal pressure was determined relative to lift-off of the weights. Repeated measures

analysis of variance was used to determine the effect of breath control, posture, and load on

intra-abdominal pressure magnitude and timing.

Results. There was a significant effect of breath control (P _ 0.018) and load (P _ 0.002), but

not of posture (P _ 0.434), on intra-abdominal pressure magnitude. The inhalation- hold form

of breath control produced significantly greater peak intra-abdominal pressure than all other

forms of breath control (P _ 0.000 for all comparisons). No other comparisons among levels

of breath were significantly different. No significant main effects of breath control were found

relative to intra-abdominal pressure timing.

Conclusions. Breath control is a significant factor in the generation of intra-abdominal

pressure magnitude during lifting tasks. The effects of respiration should be controlled in

studies analyzing intra-abdominal pressure during lifting.

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P.W. Hodges,* R. Sapsford, and L.H.M. Pengel

Division of Physiotherapy, the University of Queensland, Brisbane, Queensland, Australia

Postural and respiratory functions of the pelvic floor

muscles Neurourology and Urodynamics 26:362–371 (2007)

Key words: pelvic floor electromyography; postural control; respiration

Aims: Due to their contribution to modulation of intra-abdominal pressure (IAP) and stiffness

of the sacroiliac joints, the pelvic floor muscles (PFM) have been argued to provide a

contribution to control of the lumbar spine and pelvis. Furthermore, as IAP is modulated

during respiration this is likely to be accompanied by changes in PFM activity.

Methods: In order to evaluate the postural and respiratory function of the PFM, recordings of

anal and vaginal electromyographic activity (EMG) were made with surface electrodes during

single and repetitive arm movements that challenge the stability of the spine. EMG recordings

were also made during respiratory tasks: quiet breathing and breathing with increased dead-

space to induce hypercapnoea.

Results: EMG activity of the PFM was increased in advance of deltoid muscle activity as a

component of the pre-programmed anticipatory postural activity. This activity was

independent of the direction of arm movement. During repetitive movements, PFM EMG was

tonic with phasic bursts at the frequency of arm movement. This activity was related to the

peak acceleration of the arm, and therefore the amplitude of the reactive forces imposed on

the spine. Respiratory activity was observed for the anal and vaginal EMG and was primarily

expiratory. When subjects moved the arm repetitively while breathing, PFM EMG was

primarily modulated in association with arm movement with little respiratory modulation.

Conclusions: This study provides evidence that the PFM contribute to both postural and

respiratory functions.

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www.stabiliteitstrainingscentrum.nl

Lee DG, Lee LJ, McLaughlin L.

Diane Lee & Associates, BC, Canada. dianelee@dianelee.ca

Stability, continence and breathing: the role of fascia

following pregnancy and delivery. J Bodyw Mov Ther. 2008 Oct;12(4):333-48. Epub 2008 Jul 1

Pregnancy-related pelvic girdle pain (PRPGP) has a prevalence of approximately 45% during

pregnancy and 20-25% in the early postpartum period. Most women become pain free in the

first 12 weeks after delivery, however, 5-7% do not. In a large postpartum study of prevalence

for urinary incontinence (UI) [Wilson, P.D., Herbison, P., Glazener, C., McGee, M.,

MacArthur, C., 2002. Obstetric practice and urinary incontinence 5-7 years after delivery. ICS

Proceedings of the Neurourology and Urodynamics, vol. 21(4), pp. 284-300] found that 45%

of women experienced UI at 7 years postpartum and that 27% who were initially incontinent

in the early postpartum period regained continence, while 31% who were continent became

incontinent. It is apparent that for some women, something happens during pregnancy and

delivery that impacts the function of the abdominal canister either immediately, or over time.

Current evidence suggests that the muscles and fascia of the lumbopelvic region play a

significant role in musculoskeletal function as well as continence and respiration. The

combined prevalence of lumbopelvic pain, incontinence and breathing disorders is slowly

being understood. It is also clear that synergistic function of all trunk muscles is required for

loads to be transferred effectively through the lumbopelvic region during multiple tasks of

varying load, predictability and perceived threat. Optimal strategies for transferring loads will

balance control of movement while maintaining optimal joint axes, maintain sufficient intra-

abdominal pressure without compromising the organs (preserve continence, prevent prolapse

or herniation) and support efficient respiration. Non-optimal strategies for posture, movement

and/or breathing create failed load transfer which can lead to pain, incontinence and/or

breathing disorders. Individual or combined impairments in multiple systems including the

articular, neural, myofascial and/or visceral can lead to non-optimal strategies during single or

multiple tasks. Biomechanical aspects of the myofascial piece of the clinical puzzle as it

pertains to the abdominal canister during pregnancy and delivery, in particular trauma to the

linea alba and endopelvic fascia and/or the consequence of postpartum non-optimal strategies

for load transfer, is the focus of the first two parts of this paper. A possible physiological

explanation for fascial changes secondary to altered breathing behaviour during pregnancy is

presented in the third part. A case study will be presented at the end of this paper to illustrate

the clinical reasoning necessary to discern whether conservative treatment or surgery is

necessary for restoration of function of the abdominal canister in a woman with postpartum

diastasis rectus abdominis (DRA).

McGill SM, Karpowicz A.

Department of Kinesiology, Spine Biomechanics Laboratory, University of Waterloo,

Waterloo, ON, Canada. mcgill@healthy.uwaterloo.ca

Exercises for spine stabilization: motion/motor patterns,

stability progressions, and clinical technique. Arch Phys Med Rehabil. 2009 Jan;90(1):118-26

www.stabiliteitstrainingscentrum.nl

OBJECTIVE: To quantify several forms of the curl-up, side-bridge, and birddog exercises

(muscle activity and 3-dimensional [3D] spine position) including some corrective techniques

to assist clinical decision-making.

DESIGN: A basic science study of a convenience sample with a retest of expert intervention.

SETTING: Spine Biomechanics Laboratory/Research Clinic.

PARTICIPANTS: Healthy men (N=8) performed the exercises, and 5 subjects repeated the

exercises as an expert applied corrective techniques.

INTERVENTIONS: Not applicable.

MAIN OUTCOME MEASURES: Surface electromyography of selected trunk and hip

muscles together with video analysis and 3D spine posture were collected.

RESULTS: Comparison of muscle activation levels showed there were justifiable

progressions in each exercise form. In general, bracing of the abdominal wall enhanced

activation of the obliques, but different techniques caused migration of muscle activity to

other muscles. Examples of specific findings include the following. Movement during these

traditionally isometric exercises such as drawing squares with the hand/foot while in the

birddog posture enhances activation of many muscle groups. Breathing while holding the

isometric exercises had differing effects on muscle activation which was exercise dependent.

Some corrective exercise techniques, such as fascial raking, substantially changed relative

activation between muscles in the abdominal wall.

CONCLUSIONS: The data presented in this study may be used to guide the clinical decision

process when choosing a specific exercise form together with selecting the correct starting

level, a logical progression, suitable dosage, and possible corrective technique to enhance

tolerance of a patient.

Balogh A.

Pilates and pregnancy RCM Midwives. 2005 May;8(5):220-2.

Swiss Cottage Pilates Studio, London. adi@swisspilates.com

Pregnancy is associated with a number of musculoskeletal problems. It is important to educate

all mothers, as well as those involved in ante- and postnatal care with advice on bras and

exercises that are safe in pregnancy (in particular pelvic floor exercises). There is not much

that can be done to alter the inevitable physiological and hormonal changes of pregnancy.

However, by strengthening the core stabilising muscles around the pelvis and spine, and

improving the breathing pattern, it is hoped that one can optimise the body for the challenges

it may face. Pilates is based on the principle that a central core is developed and then

movements are introduced to challenge this core stability. This philosophy is clearly

applicable in pregnancy--a significant test both mentally and physically on the mother's body.

By maximising the mother's core stability before and during pregnancy, it should be possible

to limit any potential harm. Returning to exercise soon after the birth is important for the

mother's physical and mental wellbeing--she looks after her baby's body for nine months, who

cares for hers?

Hart N, Laffont I, de la Sota AP, Lejaille M, Macadou G, Polkey MI, Denys P, Lofaso F

Service de Physiologie-Explorations Fonctionnelles, Rééducation Fonctionnelle et Centre

d'Innovation technologique Hôpital Raymond Poincaré, Garches, France.

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Respiratory effects of combined truncal and abdominal support in patients with spinal

cord injury.

Arch Phys Med Rehabil. 2005 Jul;86(7):1447-51.

OBJECTIVE: To determine whether a custom girdle, designed to provide truncal stability

and abdominal support, will improve pulmonary function, enhance inspiratory muscle

activity, and reduce the sensation of respiratory effort in patients with spinal cord injury

(SCI).

DESIGN: Pulmonary function, transdiaphragmatic pressure time product (PTP di ), twitch

(Tw Pdi) and maximal transdiaphragmatic pressures (Pdi), and perception of respiratory effort

(Borg Rating of Perceived Exertion score) were measured with and without an abdominal

girdle in a seated position.

SETTING: Rehabilitation hospital.

PARTICIPANTS: Ten patients with posttrauma SCI (injury level, C5-T6).

INTERVENTION: Application of the abdominal girdle.

MAIN OUTCOME MEASURES: Borg score and measures of lung volumes, dynamic

abdominal compliance, and Tw Pdi and maximal Pdi.

RESULTS: Wearing of the girdle was associated with a lower Borg score (P = .002) and

reduced functional residual capacity (P = .006) but increased inspiratory capacity (P = .02)

and forced vital capacity (P = .02). Although there was a decrease in dynamic abdominal

compliance (P < .001) and an increase in PTP di (P = .02), this was accompanied by an

increase in both Tw Pdi (P = .02) and maximal Pdi (P = .03).

CONCLUSIONS The custom girdle reduced the sensation of respiratory effort in patients

with SCI by optimizing the operating lung volumes and decreasing abdominal compliance,

which enhanced diaphragm performance.

O'Sullivan PB, Beales DJ, Beetham JA, Cripps J, Graf F, Lin IB, Tucker B, Avery A.

School of Physiotherapy, Curtin University of Technology, Shenton Park, Western Australia,

Australia. tosulliv@cc.curtin.edu.au

Altered motor control strategies in subjects with sacroiliac

joint pain during the active straight-leg-raise test. Spine. 2002 Jan 1;27(1):E1-8

STUDY DESIGN: An experimental study of respiratory function and kinematics of the

diaphragm and pelvic floor in subjects with a clinical diagnosis of sacroiliac joint pain and in

a comparable pain-free subject group was conducted.

OBJECTIVE: To gain insight into the motor control strategies of subjects with sacroiliac

joint pain and the resultant effect on breathing pattern.

SUMMARY OF BACKGROUND DATA: The active straight-leg-raise test has been

proposed as a clinical test for the assessment of load transfer through the pelvis. Clinical

observations show that patients with sacroiliac joint pain have suboptimal motor control

strategies and alterations in respiratory function when performing low-load tasks such as an

active straight leg raise.

METHODS: In this study, 13 participants with a clinical diagnosis of sacroiliac joint pain

and 13 matched control subjects in the supine resting position were tested with the active

straight leg raise and the active straight leg raise with manual compression through the ilia.

Respiratory patterns were recorded using spirometry, and minute ventilation was calculated.

Diaphragmatic excursion and pelvic floor descent were measured using ultrasonography.

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RESULTS: The participants with sacroiliac joint pain exhibited increased minute ventilation,

decreased diaphragmatic excursion, and increased pelvic floor descent, as compared with

pain-free subjects. Considerable variation was observed in respiratory patterns. Enhancement

of pelvis stability via manual compression through the ilia reversed these differences.

CONCLUSIONS: The study findings formally identified altered motor control strategies and

alterations of respiratory function in subjects with sacroiliac joint pain. The changes observed

appear to represent a compensatory strategy of the neuromuscular system to enhance force

closure of the pelvis where stability has been compromised by injury.

Hodges PW, Heijnen I, Gandevia SC.

Department of Physiology, Prince of Wales Medical Research Institute and University of New

South Wales, Sydney, Australia. p.hodges@shrs.uq.edu.au

Postural activity of the diaphragm is reduced in humans

when respiratory demand increases. J Physiol. 2001 Dec 15;537(Pt 3):999-1008.

1. Respiratory activity of the diaphragm and other respiratory muscles is normally co-

ordinated with their other functions, such as for postural control of the trunk when the limbs

move. The integration may occur by summation of two inputs at the respiratory motoneurons.

The present study investigated whether postural activity of the diaphragm changed when

respiratory drive increased with hypercapnoea.

2. Electromyographic (EMG) recordings of the diaphragm and other trunk muscles were made

with intramuscular electrodes in 13 healthy volunteers. Under control conditions and while

breathing through increased dead-space, subjects made rapid repetitive arm movements to

disturb the stability of the spine for four periods each lasting 10 s, separated by 50 s.

3. End-tidal CO(2) and ventilation increased for the first 60-120 s of the trial then reached a

plateau. During rapid arm movement at the start of dead-space breathing, diaphragm EMG

became tonic with superimposed modulation at the frequencies of respiration and arm

movement. However, when the arm was moved after 60 s of hypercapnoea, the tonic

diaphragm EMG during expiration and the phasic activity with arm movement were reduced

or absent. Similar changes occurred for the expiratory muscle transversus abdominis, but not

for the erector spinae. The mean amplitude of intra-abdominal pressure and the phasic

changes with arm movement were reduced after 60 s of hypercapnoea.

4. The present data suggest that increased central respiratory drive may attenuate the postural

commands reaching motoneurons. This attenuation can affect the key inspiratory and

expiratory muscles and is likely to be co-ordinated at a pre-motoneuronal site.

Hodges PW, Gandevia SC.

Prince of Wales Medical Research Institute, University of New South Wales, Sydney, New

South Wales 2031, Australia. p.hodges@unsw.edu.au

Changes in intra-abdominal pressure during postural and

respiratory activation of the human diaphragm J Appl Physiol. 2000 Sep;89(3):967-76.

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In humans, when the stability of the trunk is challenged in a controlled manner by repetitive

movement of a limb, activity of the diaphragm becomes tonic but is also modulated at the

frequency of limb movement. In addition, the tonic activity is modulated by respiration. This

study investigated the mechanical output of these components of diaphragm activity.

Recordings were made of costal diaphragm, abdominal, and erector spinae muscle

electromyographic activity; intra-abdominal, intrathoracic, and transdiaphragmatic pressures;

and motion of the rib cage, abdomen, and arm. During limb movement the diaphragm and

transversus abdominis were tonically active with added phasic modulation at the frequencies

of both respiration and limb movement. Activity of the other trunk muscles was not

modulated by respiration. Intra-abdominal pressure was increased during the period of limb

movement in proportion to the reactive forces from the movement. These results show that

coactivation of the diaphragm and abdominal muscles causes a sustained increase in intra-

abdominal pressure, whereas inspiration and expiration are controlled by opposing activity of

the diaphragm and abdominal muscles to vary the shape of the pressurized abdominal cavity.

Hodges PW, Butler JE, McKenzie DK, Gandevia SC.

Prince of Wales Medical Research Institute, Sydney, Australia.

Contraction of the human diaphragm during rapid

postural adjustments. J Physiol. 1997 Dec 1;505 ( Pt 2):539-48.

1. The response of the diaphragm to the postural perturbation produced by rapid flexion of the

shoulder to a visual stimulus was evaluated in standing subjects. Gastric, oesophageal and

transdiaphragmatic pressures were measured together with intramuscular and oesophageal

recordings of electromyographic activity (EMG) in the diaphragm. To assess the mechanics of

contraction of the diaphragm, dynamic changes in the length of the diaphragm were measured

with ultrasonography.

2. With rapid flexion of the shoulder in response to a visual stimulus, EMG activity in the

costal and crural diaphragm occurred about 20 ms prior to the onset of deltoid EMG. This

anticipatory contraction occurred irrespective of the phase of respiration in which arm

movement began. The onset of diaphragm EMG coincided with that of transversus abdominis.

3. Gastric and transdiaphragmatic pressures increased in association with the rapid arm

flexion by 13.8 +/- 1.9 (mean +/- S.E.M.) and 13.5 +/- 1.8 cmH2O, respectively. The

increases occurred 49 +/- 4 ms after the onset of diaphragm EMG, but preceded the onset of

movement of the limb by 63 +/- 7 ms.

4. Ultrasonographic measurements revealed that the costal diaphragm shortened and then

lengthened progressively during the increase in transdiaphragmatic pressure.

5. This study provides definitive evidence that the human diaphragm is involved in the control

of postural stability during sudden voluntary movement of the limbs.

Shirley D, Hodges PW, Eriksson AE, Gandevia SC.

Spinal stiffness changes throughout the respiratory cycle. J Appl Physiol. 2003 Oct;95(4):1467-75.

Source

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School of Physiotherapy, Faculty of Health Sciences, Univ. of Sydney, P.O. Box 170,

Lidcombe, Sydney NSW 1825, Australia. D.Shirley@fhs.usyd.edu.au

Abstract

Posteroanterior stiffness of the lumbar spine is influenced by factors, including trunk muscle

activity and intra-abdominal pressure (IAP). Because these factors vary with breathing, this

study investigated whether stiffness is modulated in a cyclical manner with respiration. A

further aim was to investigate the relationship between stiffness and IAP or abdominal and

paraspinal muscle activity. Stiffness was measured from force-displacement responses of a

posteroanterior force applied over the spinous process of L2 and L4. Recordings were made

of IAP and electromyographic activity from L4/L2 erector spinae, abdominal muscles, and

chest wall. Stiffness was measured with the lung volume held at the extremes of tidal volume

and at greater and lesser volumes. Stiffness at L4 and L2 increased above base-level values at

functional residual capacity (L2 14.9 N/mm and L4 15.3 N/mm) with both inspiratory and

expiratory efforts. The increase was related to the respiratory effort and was greatest during

maximum expiration (L2 24.9 N/mm and L4 23.9 N/mm). The results indicate that changes in

trunk muscle activity and IAP with respiratory efforts modulate spinal stiffness. In addition,

the diaphragm may augment spinal stiffness via attachment of its crural fibers to the lumbar

vertebrae.

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Houding en emotie

Emoties binnen een fysiotherapeutische setting FysioPraxis, 3, 34-

37; Burken, P. van. (2002), dit artikel is voorzien van een bruikbare literatuurlijst die dieper

op deze stof ingaat.

Artikel in de map hoofdcursus

De deeelnemers vinden deze tekst op de site van Psychfysio.

http://www.psychfysio.nl/Publicaties/Burken2002a.asp

www.stabiliteitstrainingscentrum.nl

Claudine JC Lamoth*1, John F Stins1, Menno Pont2, Frederick Kerckhoff2 and Peter J Beek1

Address: 1Research Institute MOVE, Faculty of Human Movement Sciences, VU University

Amsterdam, van der Boechorststraat 9, 1081 BT, Amsterdam, the Netherlands and

2Rehabilitation Center Amsterdam, Department of Health and Behavior, Overtoom 283, 1054

HW, Amsterdam, the Netherlands

Email: Claudine JC Lamoth* - C.Lamoth@fbw.vu.nl; John F Stins - j.stins@fbw.vu.nl;

Menno Pont - m.Pont@rcamsterdam.nl;

Frederick Kerckhoff - f.kerckhoff@rcamsterdam.nl; Peter J Beek - p.beek@fbw.vu.nl

* Corresponding author

Effects of attention on the control of locomotion in

individuals with chronic low back pain Journal of NeuroEngineering and Rehabilitation 2008, 5:13 doi:10.1186/1743-0003-5-13

Abstract

Background: People who suffer from low back pain (LBP) exhibit an abnormal gait pattern,

characterized by shorter stride length, greater step width, and an impaired thorax-pelvis

coordination which may undermine functional walking. As a result, gait in LBP may require

stronger cognitive regulation compared to pain free subjects thereby affecting the degree of

automaticity of gait control. Conversely, because chronic pain has a strong attentional

component, diverting attention away from the pain might facilitate a more efficient walking

pattern.

Methods: Twelve individuals with LBP and fourteen controls participated. Subjects walked

on a treadmill at comfortable speed, under varying conditions of attentional load: (a) no

secondary task, (b) naming the colors of squares on a screen, (c) naming the colors of color

words ("color Stroop task"), and (d) naming the colors of words depicting motor activities.

Markers were attached to the thorax, pelvis and feet. Motion was recorded using a three-

camera SIMI system with a sample frequency of 100 Hz. To examine the effects of health

status and attention on gait, mean and variability of stride parameters were calculated. The

coordination between thoracic and pelvic rotations was quantified through the mean and

variability of the relative phase between those oscillations.

Results: LBP sufferers had a lower walking speed, and consequently a smaller stride length

and lower mean thorax-pelvis relative phase. Stride length variability was significantly lower

in the LBP group but no significant effect of attention was observed. In both groups gait

adaptations were found under performance of an attention demanding task, but significantly

more so in individuals with LBP as indicated by an interaction effect on relative phase

variability.

Conclusion: Gait in LBP sufferers was characterized by less variable upper body movements.

The diminished flexibility in trunk coordination was aggravated under the influence of an

attention demanding task. This provides further evidence that individuals with LBP tighten

their gait control, and this suggests a stronger cognitive regulation of gait coordination in

LBP. These changes in gait coordination reduce the capability to deal with unexpected

perturbations, and are therefore maladaptive.

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Exp Brain Res (2011) 212:603–611 DOI 10.1007/s00221-011-2767-z

www.stabiliteitstrainingscentrum.nl

Walk to me when I smile, step back when I’m angry:

emotional faces modulate whole-body approach–avoidance

behaviors John F. Stins • Karin Roelofs • Jody Villan • Karen Kooijman • Muriel A. Hagenaars •

Peter J. Beek

Keywords Emotional facial expression Postural control Emotion Reaction time Step initiation

Approach–avoidance

Abstract Facial expressions are potent social cues that can induce behavioral dispositions,

such as approach– avoidance tendencies. We studied these tendencies by asking participants

to make whole-body forward (approach) or backward (avoidance) steps on a force plate in

response to the valence of social cues (happy or angry faces) under affect-congruent and

incongruent mappings. Posturographic parameters of the steps related to automatic stimulus

evaluation, step initiation (reaction time), and step execution were determined and analyzed as

a function of stimulus valence and stimulus–response mapping. The main result was that

participants needed more time to initiate a forward step towards an angry face than towards a

smiling face (which is evidence of a congruency effect), but with backward steps, this

difference failed to reach significance. We also found a reduction in spontaneous body sway

prior to the step with the incongruent mapping. The results provide a crucial empirical link

between theories of socially induced action tendencies and theories of postural control and

suggest a motoric basis for socially guided motivated behavior.

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John F Stins*, Annick Ledebt, Claudia Emck, Elisabeth H van Dokkum and

Peter J Beek

Address: Research Institute MOVE, Faculty of Human Movement Sciences, VU University

Amsterdam, van der Boechorststraat 9, 1081 BT,

Amsterdam, The Netherlands

Email: John F Stins* - j.stins@fbw.vu.nl; Annick Ledebt - a_ledebt@fbw.vu.nl; Claudia

Emck - c.emck@fbw.vu.nl; Elisabeth H van

Dokkum - liesjetvandokkum@gmail.com; Peter J Beek - p.beek@fbw.vu.nl

* Corresponding author

Patterns of postural sway in high anxious children Behavioral and Brain Functions 2009, 5:42 doi:10.1186/1744-9081-5-42

Abstract

Background: Current research suggests that elevated levels of anxiety have a negative impact

on the regulation of balance. However, most studies to date examined only global balance

performance, with little attention to the way body posture is organized in space and time. The

aim of this study is to examine whether posturographic measures can reveal (sub)clinical

balance deficits in children with high levels of anxiety.

Methods: We examined the spatio-temporal structure of the centre-of-pressure (COP)

fluctuations in children with elevated levels of anxiety and a group of typically developing

children while maintaining quiet stance on a force plate in various balance challenging

conditions. Balance was challenged by adopting sensory manipulations (standing with eyes

closed and/or standing on a foam surface) and using a cognitive manipulation (dual-tasking).

www.stabiliteitstrainingscentrum.nl

Results: Across groups, postural performance was strongly influenced by the sensory

manipulations, and hardly by the cognitive manipulation. We also found that children with

anxiety had overall more postural sway, and that their postural sway was overall less complex

than sway of typically developing children. The postural differences between groups were

present even in the simple baseline condition, and the group differences became larger with

increasing task difficulty.

Conclusion: The pattern of postural sway suggests that balance is overall less stable and more

attention demanding in children with anxiety than typically developing children. The findings

provide further evidence for a neuro-behavioral link between psychopathology and the

effectiveness of postural control.

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Stins JF, Roerdink M, Beek PJ.

To freeze or not to freeze? Affective and cognitive

perturbations have markedly different effects on postural

control. SourceResearch Institute MOVE, Faculty of Human Movement Sciences, VU University

Amsterdam, van der Boechorststraat 9, 1081 BT Amsterdam, The Netherlands.

j.stins@fbw.vu.nl

Abstract

Similar effects have been reported for diverting attention from postural control and increased

anxiety on the characteristics of center-of-pressure (COP) time series (decreased excursions

and elevated mean power frequency). These effects have also received similar interpretations

in terms of increased postural stiffness, suggesting that cognitive and affective manipulations

have similar influences on postural control. The present experiment tested this hypothesis by

comparing postural conditions involving manipulations of attention (diverting attention from

posture using cognitive and motor dual tasks) and anxiety (standing at a height), and by

complementing posturography with electromyographic analyses to directly examine

neuromuscular stiffness control. Affective and cognitive manipulations had markedly

different effects. Unlike the height condition, diverting attention from balance induced smaller

COP amplitudes and higher sway frequencies. In addition, more regular COP trajectories

(lower sample entropy) were found in the height condition than the dual-task conditions,

suggesting elevated attentional investment in posture under the affective manipulation.

Finally, based on an analysis of the cross-correlation function between anterior-posterior COP

time series and enveloped calf muscle activity, indications of tighter anticipatory

neuromuscular control of posture were found for the height condition only. Our data suggest

that affective and cognitive perturbations have qualitatively different effects on postural

control, and thus are likely to be associated with different control processes, as evidenced by

differences in neuromuscular regulation and attentional investment in posture.

Roelofs K, Hagenaars MA, Stins J.

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Facing freeze: social threat induces bodily freeze in

humans. Source Department of Clinical, Health and Neuropsychology, Leiden University Institute for

Psychological Research, Leiden, The Netherlands. roelofs@fsw.leidenuniv.nl

Abstract

Freezing is a common defensive response in animals threatened by predators. It is

characterized by reduced body motion and decreased heart rate (bradycardia). However,

despite the relevance of animal defense models in human stress research, studies have not

shown whether social threat cues elicit similar freeze-like responses in humans. We

investigated body sway and heart rate in 50 female participants while they were standing on a

stabilometric force platform and viewing cues that were socially threatening, socially neutral,

and socially affiliative (angry, neutral, and happy faces, respectively). Posturographic

analyses showed that angry faces (compared with neutral faces and happy faces) induced

significant reductions in body sway. In addition, the reduced body sway for angry faces was

accompanied by bradycardia and correlated significantly with subjective anxiety. Together,

these findings indicate that spontaneous body responses to social threat cues involve freeze-

like behavior in humans that mimics animal freeze responses. These findings open avenues

for studying human freeze responses in relation to various sociobiological markers and social-

affective disorders.

www.stabiliteitstrainingscentrum.nl

Motor control algemeen

Manohar M. Panjabi

Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New

Haven, Connecticw U.S.A.

The Stabilizing System of the Spine. Part I. Function,

Dysfunction, Adaptation, and Enhancement JOURNAL OF SPINAL DISORDERS & TECHNIQUES Vol.5 No.4 August 1992

Summary: Presented here is the conceptual basis for the assertion that the spinal stabilizing

system consists ofthree subsystems. The vertebrae, discs, and ligaments constitute the passive

subsystem. All muscles and tendons surrounding the spinal column that can apply forces to

the spinal column constitute the active subsystem. The nerves and central nervous system

comprise the neural subsystem, which determines the requirements for spinal stability by

monitoring the various transducer signals, and directs the active subsystem to provide the

needed stability. A dysfunction of a component of any one of the subsystems may lead to one

or more of the following three possibilities: (a) an immediate response from other subsystems

to successfully compensate, (b) a long-term adaptation response of one or more subsystems,

and (c) an injury to one or more components of any subsystem. It is conceptualized that the

first response results in normal function, the second results in normal function but with an

altered spinal stabilizing system, and the third leads to overall system dysfunction, producing,

for example, low back pain. In situations where additional loads or complex postures are

anticipated, the neural control unit may alter the muscle recruitment strategy, with the

temporary goal of enhancing the spine stability beyond the normal requirements. Key Words:

Spine stabilizing system-Spinal instability-Lumbar spine-Muscle function-Low back pain.

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Manohar M. Panjabi

Departmmt of Orthopaedics and Rehabilitation, Yale University School of Medicine, New

Haven, Connecticut, U.S.A

The Stabilizing System of the Spine. Part II. Neutral Zone

and Instability Hypothesis JOURNAL OF SPINAL DISORDERS & TECHNIQUES Vol.5 No.4 August 1992

Summary: The neutral zone is a region of intervertebral motion around the neutral posture

where little resistance is offered by the passive spinal column. Several studies-in vitro

cadaveric, in vivo animal, and mathematical simulations-have shown that the neutral zone is a

parameter that correlates well with other parameters indicative of instability ofthe spinal

system. It has been found to increase with injury, and possibly with degeneration, to decrease

with muscle force increase across the spanned level, and also to decrease with instrumented

spinal fixation. In most of these studies, the change in the neutral zone was found to be more

sensitive than the change in the corresponding range of motion. The neutral zone appears to

be a clinically important measure of spinal stability function. It may increase with injury to

the spinal column or with weakness of the muscles, which in turn may result in spinal

instability or a low-back problem. It may decrease, and may be brought within the

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physiological limits, by osteophyte formation, surgical fixation/fusion, and muscle

strengthening. The spinal stabilizing system adjusts so that the neutral zone remains within

certain physiological thresholds to avoid clinical instability. Key Words: Spine stabilizing

system-Spinal instability- Neutral zone-Muscle function-Low-back pain.

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J. Hoffman, P. Gabel

Expanding Panjabi’s stability model to express movement: A

theoretical model Abstract

Novel theoretical models of movement have historically inspired the creation of new methods

for the application of human movement. The landmark theoretical model of spinal stability by

Panjabi in 1992 led to the creation of an exercise approach to spinal stability. This approach

however was later challenged, most significantly due to a lack of favourable clinical effect.

The concepts explored in this paper address and consider the deficiencies of Panjabi’s model

then propose an evolution and expansion from a special model of stability to a general one of

movement. It is proposed that two body-wide symbiotic elements are present within all

movement systems, stability and mobility. The justification for this is derived from the

observable clinical environment. It is clinically recognised that these two elements are present

and identifiable throughout the body in different joints and muscles, and the neural

conduction system. In order to generalise the Panjabi model of stability to include and

illustrate movement, a matching parallel mobility system with the same subsystems was

conceptually created. In this expanded theoretical model, the new mobility system is placed

beside the existing stability system and subsystems.

The ability of both stability and mobility systems to work in harmony will subsequently

determine the quality of movement. Conversely, malfunction of either system, or their

subsystems, will deleteriously affect all other subsystems and consequently overall movement

quality. For this reason, in the rehabilitation exercise environment, focus should be placed on

the simultaneous involvement of both the stability and mobility systems. It is suggested that

the individual’s relevant functional harmonious movements should be challenged at the

highest possible level without pain or discomfort. It is anticipated that this conceptual

expansion of the theoretical model of stability to one with the symbiotic inclusion of mobility,

will provide new understandings on human movement. The use of this model may provide a

Universal system for body movement analysis and understanding musculoskeletal disorders.

In turn, this may lead to a simple categorisation system alluding to the functional face-value

of a wide range of commonly used passive, active or combined musculoskeletal interventions.

Further research is required to investigate the mechanisms that enable or interfere with

harmonious body movements. Such work may then potentially lead to new and evolved

evidence based interventions.

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Tsao H, Danneels L, Hodges PW.

Source; Centre for Clinical Research Excellence in Spinal Pain, Injury and Health, School of

Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia.

Individual fascicles of the paraspinal muscles are activated

by discrete cortical networks in humans.

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Clin Neurophysiol. 2011 Aug;122(8):1580-7. doi: 10.1016/j.clinph.2011.01.048. Epub 2011

Mar 5.

Abstract

OBJECTIVE: To investigate whether functional specificity in different fascicles of the

paraspinal muscles is associated with discrete organisation within the motor cortex.

METHODS: In 11 healthy volunteers, electromyographic (EMG) activity was recorded

bilaterally using fine-wire intramuscular electrodes from the short and deep fibres of

multifidus (DM) at L4, and the longer and more superficial fibres of longissimus erector

spinae (LES) at L4 and L1. Surface electrodes were also placed over the right LES at L4 and

L1. Organisation at the motor cortex associated with motor excitation was investigated using

transcranial magnetic stimulation (TMS).

RESULTS: The results showed that motor cortical representation for DM was located

posteriorly to that for LES. TMS maps from surface recordings of LES showed two optimal

sites, which were located in proximity to the sites for DM and LES from intramuscular

recordings.

CONCLUSION: Different fascicles of the paraspinal muscles are organised and thus could

be controlled by discrete neuronal networks within the motor cortex. Further, TMS mapping

from surface recordings of paraspinal muscles may be confounded by cross-talk from multiple

underlying fascicles.

SIGNIFICANCE: Discrete organisation at the motor cortex appears consistent with

differential activation of different fascicles of the paraspinal muscles with function.

Benedict Martin Wand a, Luke Parkitny b, Neil Edward O’Connell c, Hannu Luomajoki d,

James Henry McAuley b, Michael Thacker e, G. Lorimer Moseley b,*

a School of Health Sciences, The University of Notre Dame Australia, Fremantle, WA,

Australia

b Neuroscience Research Australia & The University of New South Wales, Barker Street,

Randwick, Sydney, NSW 2031, Australia

c Centre for Research in Rehabilitation, School of Health Sciences and Social Care, Brunel

University, Uxbridge, UK

d Zürich University of Applied Sciences, Institute of Physiotherapy, Department of Health,

Winterthur, Switzerland

e CHAPS & Centre for Neuroimaging Sciences, IoP King’s College London, London, UK

3rd International conference on movement dysfunction 2009

Cortical changes in chronic low back pain: Current state

of the art and implications for clinical practice Manual Therapy 16 (2011) 15e20

Keywords: Low back pain Cortical reorganisation Physical therapy

Abstract

There is increasing evidence that chronic pain problems are characterised by alterations in

brain structure and function. Chronic back pain is no exception. There is a growing sentiment,

with accompanying theory, that these brain changes contribute to chronic back pain, although

empirical support is lacking. This paper reviews the structural and functional changes of the

brain that have been observed in people with chronic back pain. We cast light on the clinical

implications of these changes and the possibilities for new treatments but we also advise

caution against concluding their efficacy in the absence of solid evidence to this effect.

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Paul W. Hodges ⇑

Pain and motor control: From the laboratory to

rehabilitation Journal of Electromyography and Kinesiology 21 (2011) 220–228

Review The University of Queensland, Centre for Clinical Research Excellence in Spinal

Pain, Injury and Health, School of Health and Rehabilitation Sciences, Brisbane, Qld 4072,

Australia

Keywords: Motor control Pain Musculoskeletal pain Rehabilitation

Abstract

Movement is changed in pain and is the target of clinical interventions. Yet the understanding

of thephysiological basis for movement adaptation in pain remains limited. Contemporary

theories are relatively simplistic and fall short of providing an explanation for the variety of

permutations of changes in movement control identified in clinical and experimental contexts.

The link between current theories and rehabilitation is weak at best. New theories are required

that both account for the breadth of changes in motor control in pain and provide direction for

development and refinement of clinical interventions. This paper describes an expanded

theory of the motor adaptation to pain to address these two issues. The new theory, based on

clinical and experimental data argues that: activity is redistributed within and between

muscles rather than stereotypical inhibition or excitation of muscles; modifies the mechanical

behaviour in a variable manner with the objective to ‘‘protect’’ the tissues from further pain

or injury, or threatened pain or injury; involves changes at multiple levels of the motor system

that may be complementary, additive or competitive; and has short-term benefit, but with

potential long-term consequences due to factors such as increased load, decreased movement,

and decreased variability. This expanded theory provides guidance for rehabilitation directed

at alleviating a mechanical contribution to the recurrence and persistence of pain that must be

balanced with other aspects of a multifaceted intervention that includes management of

psychosocial aspects of the pain experience.

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H. Tsao,1 M. P.Galea2 and P.W. Hodges1

Reorganization of the motor cortex is associated with

postural control deficits in recurrent low back pain Brain (2008), 131, 2161-2171

Keywords: motor cortex; postural control; transcranial magnetic stimulation; abdominal

muscles

ABSTRACT Many people with recurrent low back pain (LBP) have deficits in postural control of the trunk

muscles and this may contribute to the recurrence of pain episodes. However, the neural

changes that underlie these motor deficits remain unclear. As the motor cortex contributes to

control of postural adjustments, the current study investigated the excitability and

organization of the motor cortical inputs to the trunk muscles in 11 individuals with and

without recurrent LBP. EMG activity of the deep abdominal muscle, transversus abdominis

(TrA), was recorded bilaterally using intramuscular fine-wire electrodes. Postural control was

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assessed as onset of TrA EMG during single rapid arm flexion and extension tasks. Motor

thresholds (MTs) for transcranial magnetic stimulation (TMS) were determined for responses

contralateral and ipsilateral to the stimulated cortex. In addition, responses of TrAtoTMS over

the contralateral cortex were mapped during voluntary contractions at 10% ofmaximum.MTs

andmap parameters [centre of gravity (CoG) and volume] were compared between healthy

and LBP groups.The CoG of themotor corticalmap of TrA in the healthy group was »2

cmanterior and lateral to the vertex, but wasmore posterior and lateral in the LBP group.The

location of the CoG and themap volume were correlated with onset of TrA EMG during rapid

armmovements. Furthermore, the MT needed to evoke ipsilateral responses was lower in the

LBP group, but only on the less excitable hemisphere.These findings provide preliminary

evidence of reorganization of trunk muscle representation at the motor cortex in individuals

with recurrent LBP, and suggest this reorganization is associated with deficits in postural

control.

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G.A. Jull a,*, D. Falla b, B. Vicenzino a, P.W. Hodges a

a Centre of Clinical Research Excellence in Spinal Pain, Injury and Health, Division of

Physiotherapy, School of Health and Rehabilitation Sciences,

The University of Queensland, Brisbane, QLD 4072, Australia

b Centre for Sensory-Motor Interaction (SMI), Department of Health Science and

Technology, Aalborg University, Denmark

The effect of therapeutic exercise on activation of the deep

cervical flexor muscles in people with chronic neck pain Manual Therapy 14 (2009) 696–701

Keywords: Neck pain; Electromyography; Motor training; Feedforward control

ABSTRACT

Deep cervical flexor muscle (DCF) activation is impaired with neck pain. This study

investigated the effects of low load cranio-cervical flexion (C-CF) and neck flexor

strengthening exercises on spatial and temporal characteristics of DCF activation during a

neck movement task and a task challenging the neck’s postural stability. Forty-six chronic

neck pain subjects were randomly assigned to an exercise group and undertook a 6-week

training program. Electromyographic (EMG) activity was recorded from the DCF,

sternocleidomastoid (SCM) and anterior scalene (AS) muscles pre and post intervention

during the cranio-cervical flexion test (CCFT) and during perturbations induced by rapid,

unilateral shoulder flexion and extension. C-CF training increased DCF EMG amplitude and

decreased SCM and AS EMG amplitude across all stages of the CCFT (all P< 0.05). No

change occurred in DCF EMG amplitude following strength training. There was no

significant between group difference in pre-post intervention change in relative latency of

DCF but a greater proportion of the C-CF group shortened the relative latency between the

activation of the deltoid and the DCF during rapid arm movement compared to the strength

group (P< 0.05). Specific low load C-CF exercise changes spatial and temporal characteristics

of DCF activation which may partially explain its efficacy in rehabilitation.

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Britt Stugea,_, Inger Holma,b, Nina Vøllestada

www.stabiliteitstrainingscentrum.nl

aSection for Health Science, University of Oslo, P.O. Box 1153, Blindern, N-0316 Oslo,

Norway

bPhysical Department, Rikshospitalet University Hospital, Oslo, Norway

Professional Issue

To treat or not to treat postpartum pelvic girdle pain with

stabilizing exercises? Manual Therapy Received 3 June 2004; received in revised form 2 June 2005; accepted 26

July 2005

Keywords: Postpartum pelvic girdle pain; Stabilizing exercises; Evidence-based practice

Abstract

Women with pelvic girdle pain (PGP) often consult physical therapists for help and are

treated with different therapies without firm evidence for the effectiveness. Two randomized

controlled trials have investigated the effect of stabilizing exercises for PGP. The most recent

study demonstrated significant positive results in favour of exercises (Stuge et al. The efficacy

of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after

pregnancy.

A randomized controlled trial. Spine 2004a;29(10):351–9), the other did not (Mens et al.

Diagonal trunk muscle exercises in peripartum pelvic pain: a randomized clinical trial. Phys.

Ther. 2000;80(12):1164–73). Consequently, the two studies provide contradictory advice for

treatment of PGP.

The question is thus, whether stabilizing exercises should be recommended as treatment for

PGP. Both the studies are of high methodological quality and are comparable with regard to

subjects studied. However, there are several differences in the interventions and these are

explored and discussed for better understanding of the conflicting results. Exercises that

focused on only global muscles showed no effect. However, these exercises were not

individualized and they were instructed by videotape. In the more recent study, exercises that

initially focused on local muscles, and then gradually added global muscles showed a

significant, positive effect. Exercises in that study were supervised, corrected, individualized

concerning choice of exercises, order and dosage, and pain was avoided. This comparison

indicates that effective treatment of postpartum PGP may be achieved when exercises for the

entire spinal musculature are included, individually guided and adapted to each individual.

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Stuge B, Lærum E, Kirkesola G, Vøllestad N. The Efficacy of a Treatment Program Focusing

on Specific Stabilizing

Exercises for Pelvic Girdle Pain After Pregnancy. A

Randomized Controlled Trial. SPINE 2004;29(4);351-9

Stuge B, Veierød M B, Lærum E, Vøllestad N.

The Efficacy of a Treatment Program Focusing on Specific

Stabilizing Exercises for Pelvic Girdle Pain After

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Pregnancy. A Two-Year Follow-up of a Randomized

Clinical Trial. SPINE 2004;29(10):E197-203

Eyal Lederman*

CPDO Ltd., 15 Harberton Road, London N19 3JS, UK

CRITICAL REVIEW The myth of core stability Received 26 October 2008; received in revised form 3 May 2009; accepted 4 August 2009

KEYWORDS Core stability; Spinal stabilisation; Transversus abdominis; Chronic lower back

and neuromuscular rehabilitation

Summary The principle of core stability has gained wide acceptance in training for the

prevention of injury and as a treatment modality for rehabilitation of various musculoskeletal

conditions in particular of the lower back. There has been surprisingly little criticism of this

approach up to date. This article re-examines the original findings and the principles of core

stability/spinal stabilisation approaches and how well they fare within the wider knowledge of

motor control, prevention of injury and rehabilitation of neuromuscular and musculoskeletal

systems following injury.

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Stuart M. McGill a, Sylvain Grenier a, Natasa Kavcic a, Jacek Cholewicki b

a Faculty of Applied Health Sciences, University of Waterloo, Waterloo, ON N2L 3G1,

Canada

b Yale University School of Medicine, New Haven, CT, USA

Coordination of muscle activity to assure stability of the

lumbar spine Journal of Electromyography and Kinesiology 13 (2003) 353–359

Keywords: Stability; Lumbar; Muscle; Motor control

Abstract

The intention of this paper is to introduce some of the issues surrounding the role of muscles

to ensure spine stability for discussion—it is not intended to provide an exhaustive review and

integration of the relevant literature. The collection of works synthesized here point to the

notion that stability results from highly coordinated muscle activation patterns involving

many muscles, and that the recruitment patterns must continually change, depending on the

task. This has implications on both the prevention of instability and clinical interventions with

patients susceptible to sustaining unstable events.

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Barr KP, Griggs M, Cadby T:

Lumbar Stabilization Core Concepts and Current

Literature, Part 1 Am J Phys Med Rehabil 2005;84:473–480.

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Key Words: Low Back Pain, Spine, Exercise, Rehabilitation

ABSTRACT

The factors that affect lumbar stability have been an area of extensive research. The clinical

application of this research in the form of lumbar stabilization exercise programs has become

a common treatment of low back pain and is also increasingly used by athletes to improve

performance and by the general public for health and the prevention of injury. This article

includes a review of the key concepts behind lumbar stabilization. The literature regarding

how those with low back pain differ in their ability to stabilize the spine from those without

low back pain is discussed, and an overview of current research that assesses the benefits of a

lumbar stabilization program to treat low back pain is provided.

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Peter B. O’Sullivan, PhD,* Wim Dankaerts, PhD,*† Angus F. Burnett, PhD,*

Garreth T. Farrell, M Manip Ther,* Evonne Jefford, M Manip Ther,*

Clare S. Naylor, M Manip Ther,* and Kieran J. O’Sullivan, M Manip Ther*

Effect of Different Upright Sitting Postures on Spinal-

Pelvic Curvature and Trunk Muscle Activation in a Pain-

Free Population SPINE Volume 31, Number 19, pp E707–E712

Conclusions. Different upright sitting postures resulted in altered trunk muscle activation.

Thoracic when compared to lumbo-pelvic upright sitting involved less coactivation of the

local spinal muscles, with greater coactivation of the global muscles. These results highlight

the importance of postural training specificity when the aim is to activate the lumbo-pelvic

stabilizing muscles in subjects with back pain.

Betekenis voor de cursus: houding in zit en het aansturen van de lage rugspiertraining. Ook is

deze studie van belang voor het duidelijk maken van de lagerugbeweging bij bepaalde

brugoefeningen met de Swissbal (psoaskiep).

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Michael P. Reiman, P. Cody Weisbach, and Paul E. Glynn

The Hip’s Influence on Low Back Pain: A Distal Link to a

Proximal Problem Journal of Sport Rehabilitation, 2009, 18, 24-32

Keywords: strength, rehabilitation

Abstract: Low back pain (LBP) is a multifactorial dysfunction, with one of the potential

contributing factors being the hip joint. Currently, research investigating the examination and

conservative treatment of LBP has focused primarily on the lumbar spine. The objective of

this clinical commentary is to discuss the potential link between hip impairments and LBP

using current best evidence and the concept of regional interdependence as tools to guide

decision making and offer ideas for future research.

Conclusion

Best current evidence supports the link between impairments at the hip and LBP. Research

suggests that decreased hip ROM, hip-extensor strength, and hip-adductor or -flexor

endurance might contribute to pain in the lumbar area. Because of this emerging relationship,

we suggest that hip-joint ROM, muscle performance, anatomical alignment, and mobility be

considered during examination of patients with LBP. Identifying hip impairments would lead

to an impairment-based approach to treatment because current evidence has not identified the

subgroup of LBP patients who would specifically benefit from treatment aimed at the hip.

Because of the lack of high-quality research to help guide decision making, clinicians are left

to intervene with impairment-level treatments. Interventions should focus on restoring hip

ROM through both thrust and nonthrust mobilizations aimed at the areas of restriction.

Treatments might also include both strength and endurance training of the identified impaired

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hip musculature. Future research should further test the theoretical basis of treating the hip for

LBP. Case studies or case series investigating the effects of hip mobilization or specific hip

strengthening in LBP and HSS populations would be helpful in describing how clinicians use

these techniques to treat this population. CPRs to identify subgroups of LBP and HSS patients

who will benefit from specific interventions aimed at the hip could help clinicians decide

when it is most appropriate to use these techniques. Most important to substantiate this

relationship would be randomized controlled trials to determine whether treating the hip adds

benefit to treatment of lumbar-spine impairments, which would also be necessary to validate

the CPR. Until such research is has been done to better direct treatment, it is recommended

that clinicians consider taking a regional approach to the examination and treatment of LBP.

Attention should be paid to the hip joint and its surrounding soft tissue, and interventions

should be applied based on the impairments identified.

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Claudine JC Lamoth*1, John F Stins1, Menno Pont2, Frederick Kerckhoff2 and Peter J Beek1

Address: 1Research Institute MOVE, Faculty of Human Movement Sciences, VU University

Amsterdam, van der Boechorststraat 9, 1081 BT,

Amsterdam, the Netherlands and 2Rehabilitation Center Amsterdam, Department of Health

and Behavior, Overtoom 283, 1054 HW, Amsterdam, the Netherlands

Email: Claudine JC Lamoth* - C.Lamoth@fbw.vu.nl; John F Stins - j.stins@fbw.vu.nl;

Menno Pont - m.Pont@rcamsterdam.nl;

Frederick Kerckhoff - f.kerckhoff@rcamsterdam.nl; Peter J Beek - p.beek@fbw.vu.nl

* Corresponding author

Research Effects of attention on the control of locomotion

in individuals with chronic low back pain Journal of NeuroEngineering and Rehabilitation

Abstract

Background: People who suffer from low back pain (LBP) exhibit an abnormal gait pattern,

characterized by shorter stride length, greater step width, and an impaired thorax-pelvis

coordination which may undermine functional walking. As a result, gait in LBP may require

stronger cognitive regulation compared to pain free subjects thereby affecting the degree of

automaticity of gait control. Conversely, because chronic pain has a strong attentional

component, diverting attention away from the pain might facilitate a more efficient walking

pattern.

Methods: Twelve individuals with LBP and fourteen controls participated. Subjects walked

on a treadmill at comfortable speed, under varying conditions of attentional load: (a) no

secondary task, (b) naming the colors of squares on a screen, (c) naming the colors of color

words ("color Stroop task"), and (d) naming the colors of words depicting motor activities.

Markers were attached to the thorax, pelvis and feet. Motion was recorded using a three-

camera SIMI system with a sample frequency of 100 Hz. To examine the effects of health

status and attention on gait, mean and variability of stride parameters were calculated. The

coordination between thoracic and pelvic rotations was quantified through the mean and

variability of the relative phase between those oscillations.

Results: LBP sufferers had a lower walking speed, and consequently a smaller stride length

and lower mean thorax-pelvis relative phase. Stride length variability was significantly lower

in the LBP group but no significant effect of attention was observed. In both groups gait

adaptations were found under performance of an attention demanding task, but significantly

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more so in individuals with LBP as indicated by an interaction effect on relative phase

variability.

Conclusion: Gait in LBP sufferers was characterized by less variable upper body movements.

The diminished flexibility in trunk coordination was aggravated under the influence of an

attention demanding task. This provides further evidence that individuals with LBP tighten

their gait control, and this suggests a stronger cognitive regulation of gait coordination in

LBP. These changes in gait coordination reduce the capability to deal with unexpected

perturbations, and are therefore maladaptive.

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Angus F. Burnetta,_, Mary W. Corneliusa, Wim Dankaertsb,c, Peter B. O’Sullivanb

aSchool of Biomedical and Sports Science, Edith Cowan University, 100 Joondalup Drive,

Joondalup, 6027 Western Australia, Australia

bSchool of Physiotherapy, Curtin University of Technology, Western Australia, Australia

cDepartment of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent,

Belgium

Spinal kinematics and trunk muscle activity in cyclists: a

comparison between healthy controls and non-specific

chronic low back pain subjects—a pilot investigation Manual Therapy 9 (2004) 211–219

Abstract

The aim of this pilot study was to examine whether differences existed in spinal kinematics

and trunk muscle activity in cyclists with and without non-specific chronic low back pain

(NSCLBP). Cyclists are known tobe vulnerable tolo w back pain (LBP) however, the

aetiology of this problem has not been adequately researched. Causative factors are thought to

be prolonged forward flexion, flexion–relaxation or overactivation of the erector spinae,

mechanical creep and generation of high mechanical loads while being in a flexed and rotated

position. Nine asymptomatic cyclists and nine cyclists with NSCLBP with a flexion pattern

disorder primarily related tocy cling were tested. Spinal kinematics were measured by an

electromagnetic tracking system and EMG was recorded bilaterally from selected trunk

muscles. Data were collected every five minutes until back pain occurred or general

discomfort prevented further cycling. Cyclists in the pain group showed a trend towards

increased lower lumbar flexion and rotation with an associated loss of co-contraction of the

lower lumbar multifidus. This muscle is known to be a key stabiliser of the lumbar spine. The

findings suggest altered motor control and kinematics of the lower lumbar spine are

associated with the development of LBP in cyclists.

Conclusions The findings of this pilot study lend further credibility to the idea that clinical

presentation of individuals suffering NSCLBP should be considered. During clinical

evaluation, all subjects in this study reported that their LBP was precipitated by flexion

related activities, in particular, during cycling. Cyclists in the pain group showed a trend

towards increased lower lumbar rotation and flexion with associated loss of cocontraction of

the muscles whose primary role is to control these movements (LM). Although these results

should be viewed with caution due to the small sample size in this study, they do lend support

to the presence of an underlying motor control disorder that predisposes the cyclists to

flexion/rotation strain of the low lumbar spine. Further research intothis group with a larger

sample size is required and rehabilitation strategies to manage LBP in cyclists needs tobe

formerly assessed.

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Buikdruk

Pijn en stijfheid in de bekkengordel hebben een relatie met buikdruk. Bij het uitvoeren van

oefenstof zal de therapeut rekening houden met het mogelijk bestaan of ontstaan van

inadequate buikdruk, alsmede de wijze van ademen.

Ian A.F. Stokes a,, Mack G. Gardner-Morse a, Sharon M. Henry b

a Department of Orthopaedics and Rehabilitation, University of Vermont, Burlington, VT

05405, USA

b Department of Rehabilitation and Movement Science, University of Vermont, Burlington,

VT 05405, USA

Abdominal muscle activation increases lumbar spinal

stability: Analysis of contributions of different muscle

groups Clinical Biomechanics xxx (2011) xxx–xxx

Keywords: Abdominal muscles; Biomechanics; Stability; Rehabilitation

Abstract

Background: Antagonistic activation of abdominal muscles and increased intra-abdominal

pressure are associated with both spinal unloading and spinal stabilization. Rehabilitation

regimens have been proposed to improve spinal stability via selective recruitment of certain

trunk muscle groups. This biomechanical analytical study addressed whether lumbar spinal

stability is increased by such selective activation.

Methods: The biomechanical model included anatomically realistic three-layers of curved

abdominal musculature, rectus abdominis and 77 symmetrical pairs of dorsal muscles. The

muscle activations were calculated with the model loaded with either flexion, extension,

lateral bending or axial rotation moments up to 60 Nm, along with intra-abdominal pressure

up to 5 or 10 kPa (37.5 or 75 mm Hg) and partial bodyweight. After solving for muscle

forces, a buckling analysis quantified spinal stability. Subsequently, different patterns of

muscle activation were studied by forcing activation of selected abdominal muscles to at least

10% or 20% of maximum.

Findings: Spinal stability increased by an average factor of 1.8 with doubling of intra-

abdominal pressure. Forcing at least 10% activation of obliques or transversus abdominis

muscles increased stability slightly for efforts other than flexion, but forcing at least 20%

activation generally did not produce further increase in stability. Forced activation of rectus

abdominis did not increase stability.

Interpretation: Based on analytical predictions, the degree of stability was not substantially

influenced by selective forcing of muscle activation. This casts doubt on the supposed

mechanism of action of specific abdominal muscle exercise regimens that have been proposed

for low back pain rehabilitation

Artikel in map hoofdcursus

Ian A.F. Stokes a,⁎, Mack G. Gardner-Morse a, Sharon M. Henry b

a Department of Orthopaedics and Rehabilitation, University of Vermont, Burlington, VT

05405, USA

www.stabiliteitstrainingscentrum.nl

b Department of Rehabilitation and Movement Science University of Vermont, Burlington,

VT 05405, USA

Intra-abdominal pressure and abdominal wall muscular

function: Spinal unloading mechanism Clinical Biomechanics 25 (2010) 859–866

Keywords: Abdominal muscles; Spinal loading; Biomechanics

Background: The roles of antagonistic activation of abdominal muscles and of intra-

abdominal pressurization remain enigmatic, but are thought to be associated with both spinal

unloading and spinal stabilization in activities such as lifting. Biomechanical analyses are

needed to understand the function of intra-abdominal pressurization because of the anatomical

and physiological complexity, but prior analyses have been oversimplified.

Methods: To test whether increased intra-abdominal pressure was associated with reduced

spinal compression forces for efforts that generated moments about each of the principal axis

directions, a previously published biomechanical model of the spine and its musculature was

modified by the addition of anatomically realistic three-layers of curved abdominal

musculature connected by fascia to the spine. Published values of muscle cross-sectional areas

and the active and passive stiffness properties were assigned. The muscle activations were

calculated assuming minimized muscle stress and stretch for the model loaded with flexion,

extension, lateral bending and axial rotation moments of up to 60 Nm, along with intra-

abdominal pressurization of 5 or 10 kPa (37.5 or 75 mm Hg) and partial bodyweight (340 N).

Findings: The analysis predicted a reduction in spinal compressive force with increase in

intra-abdominal pressurization from 5 to 10 kPa. This reduction at 60 Nm external effort was

21% for extension effort, 18% for flexion effort, 29% for lateral bending and 31% for axial

rotation.

Interpretation: This analysis predicts that intra-abdominal pressure produces spinal

unloading, and shows likely muscle activation patterns that achieve this.

Zit in map hoofdcursus

Jan Mens_, Gilbert Hoek van Dijke, Annelies Pool-Goudzwaard, Victor van der Hulst, Henk

Stam

Department of Rehabilitation Medicine, Erasmus Medical Centre, Dr. Molewaterplein 40,

3015 Rotterdam, GD, The Netherlands

Possible harmful effects of high intra-abdominal pressure

on the pelvic girdle Journal of Biomechanics 39 (2006) 627–635

Keywords: Low back pain; Intra-abdominal pressure; Biomechanics; Pelvic bones

Abstract

The present study explores the hypothesis that a high intra-abdominal pressure (IAP) loads the

ligaments of the pelvic girdle to such an extent that frequent periods of high IAP might cause

pain and/or interfere with recovery of patients with pelvic girdle pain (PGP). In a theoretical

model the size of the load of IAP on the pelvic girdle was computed. The diameters of

abdomen and pelvis needed for the calculations were measured on MRI scans; the IAP values

during activities were gained from literature. In slim, healthy subjects the calculated load on

the pelvic ring during activities of daily living was 26.0–52.0N with peaks to 135 N. During

www.stabiliteitstrainingscentrum.nl

straining, vigorous work or heavy exercises the load could increase to values ranging from

104 to 520 N. The load is higher in subjects with pain or fatigue, or in case of a distended

abdomen. When the load on the pelvic ring induced by IAP is larger than 100 N, the force

exceeds the force at which a pelvic belt relieves complaints in PGP; at 90 N, the force is

larger than the force at which isometric hip adduction provokes pain in PGP. We conclude

that the size of the load induced by IAP on the pelvic girdle seems to be sufficient to cause

pain in patients with PGP and might interfere with recovery. It seems worthwhile to give

patients with PGP instructions to reduce IAP as much as possible during activities.

Zit in map hoofdcursus

Paul W Hodges a,b,c,_, A.E. Martin Erikssond, Debra Shirleye, Simon C Gandeviab,c

aDepartment of Physiotherapy, The University of Queensland, Brisbane, Qld. 4072, Australia

bPrince of Wales Medical Research Institute, Sydney, Australia

cUniversity of New South Wales, Sydney, Australia

dDepartment of Community Medicine and Rehabilitation, Physiotherapy, University of

Umea°, Umea°, Sweden

eDepartment of Physiotherapy, University of Sydney, Sydney, Australia

Intra-abdominal pressure increases stiffness of the lumbar

spine Journal of Biomechanics 38 (2005) 1873–1880

Keywords: Intra-abdominal pressure; Spinal stiffness; Diaphragm; Trunk control

Abstract

Intra-abdominal pressure (IAP) increases during many tasks and has been argued to increase

stability and stiffness of the spine. Although several studies have shown a relationship

between the IAPincrease and spinal stability, it has been impossible to determine whether this

augmentation of mechanical support for the spine is due to the increase in IAPor the

abdominal muscle activity which contributes to it. The present study determined whether

spinal stiffness increased when IAPincreased without concurrent activity of the abdominal

and back extensor muscles. A sustained increase in IAPwas evoked by tetanic stimulation of

the phrenic nerves either unilaterally or bilaterally at 20 Hz (for 5 s) via percutaneous

electrodes in three subjects. Spinal stiffness was measured as the force required to displace an

indentor over the L4 or L2 spinous process with the subjects lying prone. Stiffness was

measured as the slope of the regression line fitted to the linear region of the force–

displacement curve. Tetanic stimulation of the diaphragm increased IAPby 27–61% of a

maximal voluntary pressure increase and increased the stiffness of the spine by 8–31% of

resting levels. The increase in spinal stiffness was positively correlated with the size of the

IAPincrease. IAPincreased stiffness at L2 and L4 level. The results of this study provide

evidence that the stiffness of the lumbar spine is increased when IAPis elevated.

Zit in map hoofdcursusus

www.stabiliteitstrainingscentrum.nl

Lichaamsbewust en aandacht

Aandacht en lichaamsbewustwording worden als belangrijke voorwaarde gezien voor het

optimaal uitvoeren van oefentherapie. Bij de aangeboden oefentherapeutische interventies ter

beïnvloeding van spanning en pijn in het bekkengebied zal de nadruk gelegd worden op het

aandachtig meemaken van die oefenstof en de reacties in het lichaam. Dit op basis van

onderstaande literatuur.

Robert Schütze a,*, Clare Rees a, Minette Preece b, Mark Schütze b

a School of Psychology, Curtin University of Technology, Perth, Australia

b Department of Pain Management, Sir Charles Gairdner Hospital, Perth, Australia

Low mindfulness predicts pain catastrophizing in a fear-

avoidance model of chronic Pain PAIN_ 148 (2010) 120–127

Abstract

The relationship between persistent pain and self-directed, non-reactive awareness of present-

moment experience (i.e., mindfulness) was explored in one of the dominant psychological

theories of chronic pain - the fear-avoidance model[53]. A heterogeneous sample of 104

chronic pain outpatients at a multidisciplinary pain clinic in Australia completed

psychometrically sound self-report measures of major variables in this model: Pain intensity,

negative affect, pain catastrophizing, pain-related fear, pain hypervigilance, and functional

disability. Two measures of mindfulness were also used, the Mindful Attention Awareness

Scale [4] and the Five-Factor Mindfulness Questionnaire [1]. Results showed that

mindfulness significantly negatively predicts each of these variables, accounting for 17-41%

of their variance. Hierarchical multiple regression analysis showed that mindfulness uniquely

predicts pain catastrophizing when other variables are controlled, and moderates the

relationship between pain intensity and pain catastrophizing. This is the first clear evidence

substantiating the strong link between mindfulness and pain catastrophizing, and suggests

mindfulness might be added to the fear-avoidance model. Implications for the clinical use of

mindfulness in screening and intervention are discussed.

Door P. van Burken: Hoe minder mindfull de patiënt is des te sterker spelen de factoren van

het fear-avoidance model.

Volgens de auteurs van dit artikel leidt catastroferen over pijn tot (bewegings)angst en

vermijding. Catastroferen over pijn bepaalt voor 7-31% de variatie in pijn intensiteit. Een

manier om catastroferen te beïnvloeden is via cognitief-gedragsmatige interventies. Een

recente ontwikkeling is de inzet van mindfulness. Het gaat er daarbij niet om de innerlijke

ervaring van pijn te veranderen maar om deze te accepteren.

Mindfulness is een aandachttoestand die min of meer tegengesteld is aan de aandacht die bij

catastroferen optreedt.

Catastroferen

Aandacht gericht op interpretaties en (abstracte) concepten.

Beoordelend

Automatisch (vaak)

www.stabiliteitstrainingscentrum.nl

Mindfulness

De aandacht gericht op de concrete actuele ervaring in het huidige moment

Niet-beoordelend (accepterend)

Intentioneel / opzettelijk

Er zijn onderzoeken die aannemelijk maken dat mindfulness gunstige effecten heeft op

stemming en pijn bij chronische pijnpatiënten. In de huidige studie willen de auteurs

onderzoeken of mindfulness negatief correleert met de herstelbelemmerende factoren uit het

bekende fear-avoidance model van chronische pijn, te weten: pijn intensiteit, catastroferen,

angst voor pijn, pijn hypervigilantie, en functionele beperkingen. Ze verwachten de sterkste

negatieve correlatie tussen mindfulness en catastroferen. Meer specifiek veronderstellen de

auteurs dat de mate van mindfulness de relatie die tussen catastroferen en pijn bestaat,

afzwakt.

Methode

De onderzoekspopulatie bestond uit een heterogene groep van 104 volwassen chronische

pijnpatiënten (outpatient) die op een afspraak wachten van hun pijnspecialist in het

ziekenhuis. De volgende variabelen werden via vragenlijsten gemeten:

•Duur en locatie van de pijn

•Mindfulness:

◦Five-Factor Mindfulness Questionnaire (FFMQ) Dit om een aantal factoren van mindfulness

te meten.

◦Mindful Attention Awareness Scale (MAAS) Dit om een totaal score te krijgen. (De FFMQ

geeft geen totaal score).

•Pijn intensiteit: subschaal uit de Brief Pain Inventory (BPI)

•Functionele beperkingen: subschaal uit de Brief Pain Inventory (BPI)

•Negatieve stemming: subschaal uit de I-PANAS-SF.

•Pijn catastroferen: Pain catastrophizing Scale (PCS).

•Pijn gerelateerde angst: Tampa Scale for Kinesiophobia (TSK).

•Pijn hypervigilantie: Pain Vigilance and Awareness Questionnaire (PVAQ).

Resultaten

De chronische pijnpatiënten bleken op de MAAS niet minder mindfull dan een steekproef uit

de algemene bevolking. Mindfulness gemeten via de MAAS correleerde negatief met elk van

de gemeten variabelen uit het fear-avoidance model. In een regressie analyse werd het aandeel

van mindfulness nader onderzocht. Dit maal met de vijf factoren van FFMQ. De vijf factoren

gezamenlijk verklaren 17%-41% van de factoren van het fear-avoidance model

(pijncatastroferen 41% verklaarde variantie). Na statistische controle op een aantal relevante

achtergrond variabelen, kwam de ‘uniek’ verklaarde variantie van mindfulness op 5% te

liggen. Mindfulness blijkt dus inderdaad onafhankelijk te modereren tussen pijnintensiteit en

catastroferen, maar zwak. Hoe lager de patiënt op mindfulness scoort des te sterker was de

relatie tussen pijn intensiteit en catastroferen. Deze uitkomst lijkt erop te wijzen dat de mate

waarop iemand mindfull in het huidige moment kan blijven het piekeren en catastroferen over

pijn vermindert.

Een suggestie van de auteurs is patiënten met pijn te screenen met de MAAS op de mate van

mindfulness en als die laag is daar een interventie voor aan te bieden. Mogelijk dat

www.stabiliteitstrainingscentrum.nl

chroniciteit daardoor beter voorkomen kan worden, en ook de ervaren pijn en disfunctioneren

wat vermindert. Hoewel diverse kleine trails hoopgevend zijn wat betreft de invloed van

mindfulness op chronische pijn, moet een grote trail nog uitgevoerd worden.

drs. P. van Burken

www.PsychFysio.nl

Jensen, M. P. (2010).

A Neuropsychological Model of Pain: Research and

Clinical Implications. The Journal of Pain, 11(1), 2-12.

De neuropsychologie van pijn en pijn-interventies

Jensen geeft een neuropsychologisch overzicht van hersenen en pijn. Vier regio’s blijken

daarbij erg belangrijk: prefrontale cortex, anterior cingulate cortex, sensorische cortex en de

insula.

Prefrontale cortex (PFC)

De prefrontaal cortex encodeert de cognitieve aspecten van acute en chronische pijn: de

betekenis van pijn en beslissingen rond coping met pijn. De PFC heeft in het algemeen een

inhiberende functie. Hoe sterker de activatie PFC des te minder pijn. Vanuit PFC kan top-

down pijndemping ontstaan door invloed op het periaqueductale grijs in de hersenstam.

Anterior Cingulate Cortex (ACC)

Activiteit van de ACC is betrokken bij zowel de affectie/emotionele dimensie van pijn

(=lijden) als de motivationeel/motorische dimensie (voorbereiden en initiëren van

gedragsmatige coping met pijn). Ze speelt een belangrijke rol bij het creëren van angstige

herinneringen in relatie tot pijn.

Primaire en secundaire sensorische cortex (S1 en S2)

Zowel de S1 als S2 is betrokken bij het spatieel encoderen van de nociceptie. S2 ontvangt als

eerste in de cortex de nociceptieve input. Waarschijnlijk encodeert S2 sterker de intensiteit en

kwaliteit van de pijn dan S1.

Insula

De insula is de sensorische component van het limbische systeem. Het encodeert hoe iemand

zich voelt op een groot aantal domeinen die gerelateerd zijn aan motivatie (de mate waarin

iemand dorst, honger, pijn, jeuk heeft versus verzadigd en fysiek tevreden zijn). Vooral bij

zuurstofgebrek, laag bloedsuiker niveau en pijn wordt ze actief.

Het pijn netwerk en plasticiteit

Er is geen pijncentrum in het brein. Pijn is het gevolg van het activeren van een netwerk van

verschillende regionen.

Langdurige perifere nociceptieve input sensitiseert bepaalde hersenregionen die de

verwerking van toekomstige nociceptieve input beïnvloeden. Patiënten met fibromyalgie en

chronische lage rugpijn hebben een verhoogde activatie in bepaalde regionen. Ook de

organisatie en structuur van de hersenen kan bij pijn veranderen. Regio S1 mond kan

bijvoorbeeld in de richting van S1 regio van het geamputeerde ledemaat verschuiven. Bij

www.stabiliteitstrainingscentrum.nl

fibromyalgie en chronische lage rugpijn is de grijze stof in PFC afgenomen, waardoor de

pijninhibitie ook afgenomen is. Per chronische pijn aandoening kan er een ander

activatiepatroon in de hersenen zijn.

Interventies gericht op cognities

Cognitieve herstructurering of cognitieve therapie

Het gaat hierbij om het achterhalen en corrigeren van disfunctionele automatische opvattingen

over pijn. Voorbeelden daarvan zijn catastroferen over pijn, vrees gerelateerde opvattingen

en/of een lage eigen effectiviteit verwachting. Cognitieve interventies zal primair effect

hebben op de PFC en via deze regio ook op de ACC. Immers cognitie (minder catastroferen:

PFC) geeft minder pijnlijden (ACC). Via deze emotionele pijnregio zal indirect ook minder

S1/S2 activatie optreden. Deze hypothesen moeten nog bevestigd worden, maar er zijn al

aanwijzingen.

Acceptatie gerichte therapie

Hierbij wordt de patiënt aangemoedigd/aangeleerd om het vechten tegen de pijn te stoppen en

de inspanningen te verleggen richting het behalen van andere gewaardeerde levensdoelen.

Cognitieve therapie zal de inhoud van de cognities willen veranderen, acceptatie gerichte

benaderingen willen daarentegen meer de focus verleggen. Beide benaderingen zullen een

primair effect hebben op de activiteit van de PFC. Omdat acceptatie gerichte benaderingen

ook aanmoedigen de aandacht te verleggen van pijn naar andere levensdoelen, zal deze

aandachtsverschuiving ook impact kunnen hebben op de sensorische component van de

pijnwaarneming (S1/S2). Er zijn aanwijzingen dat acceptatie gerichte therapie een sterker

effect heeft op de pijn intensiteit dan cognitieve therapie.

Interventies gericht op gedrag

Operante benadering

Deze benadering vertrekt vanuit de visie dat pijn gedrag/communicatie sterk beïnvloed wordt

door de omgeving (negeren, belonen, straffen). Het gaat daarbij niet alleen om de activiteiten

te verhogen, maar ook om duidelijk te maken dat pijn niet perse schade betekent, en dat

bewegen juist herstel veroorzaakt. Ook de operante benadering verschuift de aandacht weg

van de pijn in de richting van activiteiten. De betekenis van de pijn (PFC), het pijnlijden

(ACC) en de pijnsensatie (S1/S2) kan afnemen.

Motivational interviewing (MI)

Het centrale idee is dat de patiënt niet zozeer nieuwe vaardigheden moet aanleren, maar de

motivatie moet krijgen om de vaardigheden die hij al heeft te gaan inzetten. De patiënt wordt

aangemoedigd persoonlijke relevante redenen voor veranderingen te verzinnen en zichzelf te

overtuigen dat deze door hem haalbaar zijn. Dit vanuit intrinsieke motivatie. Waarschijnlijk

activeert MI sterker de anterior cortex (PFC) dan de posterior cortex (S1/S2 en insula).

Interventies gericht op vermogen relaxatie en comfort te ervaren

Relaxatie training

Relaxatie training kan de pijn verminderen maar dit correleert niet met een actuele spiertonus

vermindering perifeer, maar juist wel met de perceptie van afname van spierspanning en

www.stabiliteitstrainingscentrum.nl

toegenomen self efficacy. Dus het (centrale) corticale effect is belangrijker. Relaxatie training

richt zich op het ervaren van fysieke sensaties van ontspanning (S1/S2) maar dit ook in

combinatie met mentale rust (Insula/ACC). De verhoogde self efficacy zal waarschijnlijk met

verhoogde PFC activiteit correleren.

Hypnose

Hypnose bevat vaak een introductie die lijkt op relaxatie, gevolgd door suggesties gericht op

emoties of pijnsensaties/beleving. Hypnotische suggesties gericht op het reduceren van

pijnongemak in plaats van pijn intensiteit vermindert wel de activiteit in ACC, maar niet in de

sensorisch cortex. Andersom blijkt dat suggesties gericht op de pijn intensiteit maar niet op

pijnongemak de activiteit in S1 (en deels in S2) vermindert, maar niet in ACC. Men mag

verwachten dat suggesties gericht op self efficacy de PFC activeert, en dat suggesties gericht

op tevredenheid de insula zal activeren, maar dit moet nog worden onderzocht.

Placebo interventies

Placebo interventies hebben waarschijnlijk het sterkste effect via verwachtingen (PFC) en

motivatie (limbische systemen bijv ACC en Insula). Inderdaad blijkt bij een review dat PFC

activiteit toeneemt en ACC af.

Klinische implicatie

Kennis van deze relaties tussen de pijndimensies en neuropsychologie kan helpen bij de keuze

van interventies. Het leert de therapeut te luisteren naar welke elementen in de

pijnrapportage/beleving/gedrag het sterkst aanwezig zijn (sensorisch, cognitief affectief,

motivationeel) om vervolgens te speculeren dat een bepaald hersendeel daarbij betrokken is,

en men zich met interventies hier relatief specifiek op kan richten.

Bron: Jensen, M. P. (2010). A Neuropsychological Model of Pain: Research and Clinical

Implications. The Journal of Pain, 11(1), 2-12.

www.PsychFysio.nl

drs. P. van Burken

Jeanet J.A. Landsman-Dijkstra a,b,∗, Ruud van Wijck b,

Johan W. Groothoff c, Piet Rispens b

a Lifestyle Training Center, Dalfsen, The Netherlands

b Institute of Human Movement Sciences, University of Groningen, P.O. Box 196, 9700 AD

Groningen, The Netherlands

c Department of Social Medicine, University of Groningen, Groningen, The Netherlands

The short-term effects of a body awareness program:

better self-management of health problems for individuals

with chronic a-specific psychosomatic symptoms Patient Education and Counseling 55 (2004) 155–167

Keywords: Chronic A-specific Psychosomatic Symptoms; Stress; Self-management; Body

awareness

www.stabiliteitstrainingscentrum.nl

Abstract

A three-day residential Body Awareness Program (BAP) was developed to teach people with

Chronic A-specific Psychosomatic Symptoms (CAPS) to react adequately to disturbances of

the balance between a daily workload and the capacity to deal with it. The short-term effects

of the program for people withCAPSare presented in this study. The design is a non-control

group design with pre- and post-measures (2 months after the program). The sample for this

paper was formed by 187 participants. The mean age is 42.3 (S.D. = 8.9), and 57% is female.

The results showed decreased stress-related symptoms, increased quality of life, increased

self-efficacy, less depressive attribution style, more expression of emotions, and a positive

change of lifestyle. Most of these measured changes can be interpreted as clinically relevant

outcomes with medium-to-large effect sizes. Personal pre-training goals were attained by 85%

of the participants. Spouses also confirmed the found effects. Evaluation of the BAP gives

enough evidence to conclude that this program leads to positive effects in CAPS. Participants

react more adequately to disturbances between daily workload and the capacity to deal with

this load. They are more capable of self-management in coping with stress and psychosomatic

symptoms. Conclusions are drawn about the prevention by early interventions for patients

with a-specific physical symptoms.

Zit in map hoofdcursus

Naranjo, J. R., & Schmidt, S. (2012).

Is it me or not me? Modulation of perceptual-motor

awareness and visuomotor performance by mindfulness

meditation. BMC Neurosci, 13(1), 88. doi: 10.1186/1471-2202-13-88

Samenvatting door drs. P. van Burken (www.psychfysio.nl)

Mindfulness training helpt om tijdens bewegen minder fouten te maken

Het vermogen om jezelf als de oorzaak van je handelingen te ervaren is een essentieel element

in het ervaren van een zelf. Onder normale omstandigheden zijn we ons slechts beperkt

bewust van onze motorische handelingen. Vaak ontstaat motorisch bewustzijn pas als er een

conflict is tussen de voorspelde en de actuele sensorische consequenties.

Bij mindfulness training leert men om continu gewaar te zijn van de sensaties en ervaringen in

het huidige moment. Het bewustzijn van bewegen in het dagelijks leven valt hier ook onder.

Mindfulness training kan het motorisch bewustzijn versterken. Toch is hier nog maar weinig

onderzoek naar gedaan.

De auteurs onderzochten daarom of mindfulness meditatie een gunstig effect heeft op

motorisch bewustzijn, motorische nauwkeurigheid en bewegingsduur tijdens een

visuomotorische taak. Daarbij werd in verschillende mate verkeerde bewegingsfeedback

gegeven.

Methode

De onderzoekers bestudeerden twee groepen. Een groep betrof deelnemers aan een

mindfulness training van 8 sessies (MBSR) (N=11). De meting werd aan het begin van de

training en na acht weken gedaan. De controlegroep bestond uit mensen die geen mindfulness

training kregen (N=11). De tweede groep deelnemers bestond uit mensen die al lange tijd

ervaring hadden met mindfulness meditatie (N=9),. Deze proefpersonen werden vergeleken

met mensen zonder deze ervaring (N=11).

www.stabiliteitstrainingscentrum.nl

Taak

De proefpersonen moesten een digitale pen verplaatsen van punt A naar punt B. Ze konden

daarbij de verplaatsing van hun hand niet zien omdat er een solide projectieblad overheen

geplaatst was. Op dat projectieblad zag men een lichtpunt als zijnde het startpunt en een

lichtpunt als zijnde het eindpunt. Een zich daartussen verplaatsend lichtpunt gaf visuele

feedback over het afgelegde traject. De proefpersonen moesten een aantal rechtlijnige

trajecten afleggen. De feedback kon gemanipuleerd worden. Ze varieerde van gelijk zijnde

aan de actuele beweging van de arm onder het projectblad tot sterk afwijkend van de actuele

beweging. De valse feedback werd gemanipuleerd in een range van -27graden en + 27 graden.

De opdracht was om rustig en bewust een rechte lijn van het startpunt na het eindpunt te

trekken.

Bij foute feedback moesten de proefpersonen dus direct een bijstelling doen in hun

oorspronkelijke motorische preparatie. Na elke trail moesten de proefpersonen aangeven op

een schaal van 0-5 in welke mate zij de beweging volledig aan zichzelf toeschreven en geen

perceptueel motorconflict ervoeren. 0= geen conflict, 5 is sterk conflict.

Resultaten De resultaten laten zien dat mindfulness training geassocieerd is met het maken van minder

motorische fouten en trager bewegen. De drempel om een perceptueel-motorisch conflict op

te merken is in de mindfulness groep verlaagd. Dit gold voor de mindfulness trainingsgroep

maar niet voor de langdurig mediterenden. Het effect van minder fouten en trager bewegen

trad het sterkst op in trails waarbij perceptuele-motor incongruentie werd ervaren. Het lijkt

erop dat men zich dan meer motorisch bewust wordt van de afwijking in bewegingsfeedback

en overschakelt op meer mindful en trager bewegen. Daardoor kon beter correctie op het

bewegingstraject plaatsvinden.

Opmerking samenvatter

Zoals we al eerder schreven is bewustzijn van bewegen niet altijd gunstig. Toch zijn er

diverse methoden, zoals Feldenkrais, waarbij bewust bewegen centraal staat. Dit onderzoek

laat zien dat motorisch bewustzijn gunstig kan uitpakken in motorische situaties waar men

geconfronteerd wordt met onjuiste feedback. Bovendien bleek dit trainbaar via mindfulness

training.

Misschien mag men dit vertalen naar bewegingen die sterk intentioneel zijn. Misschien is het

ook zo dat mindfulness training het motorische bewustzijn versterkt en dat daardoor meer

informatie beschikbaar komt die aangewend kan worden voor correcte uitvoering van de

beweging. Bij mikken op een doel is primaire gerichtheid op het doel essentieel en

bijvoorbeeld niet een gerichtheid op de schouder. Overmatige gerichtheid op je eigen

lichaamsbeweging kan hier hinderen. Het huidige onderzoek laat echter zien dat mindful

bewegen weldegelijk ingezet kan worden om beter te ‘mikken’. Althans bij een rustige

bewegingstaak. Een correcte uitvoering van krachtraining kan hier ook onder vallen. Mogelijk

speelt voorgrond-achtergrond hier. Op de voorgrond houdt men de gerichtheid op het doel,

maar op de achtergrond is nu meer mindful informatie over het bewegingsverloop aanwezig

en kunnen correctieve strategieën ingezet worden terwijl men primair gericht blijft op het

doel. Kortom: mindful bewegen kan een vruchtbaar onderzoeksveld zijn binnen de

fysiotherapie. De vraag blijft dan bij welke typen van beweging een verhoogd motorisch

zelfbewustzijn gunstig is en bij welke vormen van bewegen juist niet.

Dit artikel in deze samenvatting laten lezen, samen met andere artikele op wwwpsychfysio.nl

Jeanet J.A. Landsman-Dijkstraa,*,1, Ruud van Wijckb,1,

Johan W. Groothoffc,1

www.stabiliteitstrainingscentrum.nl

aLifestyle Training Centre, Dalfsen, The Netherlands

bInstitute of Human Movement Sciences, University of Groningen, The Netherlands

cDepartment of Social Medicine, University of Groningen, The Netherlands

The long-term lasting effectiveness on self-efficacy,

attribution style, expression of emotions and quality of life

of a body awareness program for chronic a-specific

psychosomatic symptoms Patient Education and Counseling 60 (2006) 66–79

Keywords: Chronic a-specific psychosomatic symptoms; Stress; Self-management; Body

awareness

Abstract

Objective: A 3-day residential body awareness program (BAP) was developed to teach

people with chronic a-specific psychosomatic symptoms (CAPS) to react adequately to

disturbances of the balance between a daily workload and the capacity to deal with it. The

long-term effects of the program on body awareness, psychological factors, psychosomatic

symptoms and quality of life for people with CAPS are presented in this study.

Methods: A pre–post design is used with post-measures 2 and 12 months after the program,

without controls (n = 122). Mean age is 42.5 (S.D. = 9.0) and 60% is female.

Results: The results showed an increase of body awareness, self-efficacy, expression of

emotions and quality of life. Stress-related symptoms decreased and the attribution style was

found to be less depressive. Participants achieved significantly higher levels of functioning at

2 months which increased significantly more at 12 months. The majority of the measured

changes can be interpreted as clinically relevant outcomes with medium-to-large effect sizes.

Spouses of the participants also confirm the found effects.

Discussion and conclusion: Evaluation of the BAP gives evidence to conclude that this

program leads to the theoretically expected long-term effects in CAPS. Participants react

more adequately to disturbances between daily workload and the capacity to deal with this

load. Two and 12 months after the 3-day program, they are more capable of self-management

in coping with stress and psychosomatic symptoms.

Practice implications: This article sheds new light on the difficulties that individuals with

psychosomatic symptoms and their professional interventionists encounter when attempting to

manage the chronicity of the problems. By paying more attention to learning self-management

by increasing body awareness and self-efficacy, patient educators may be able to increase

their effectiveness.

Zit in map hoofdcursus

Jeanet J.A. Landsman-Dijkstraa,1,*, Ruud van Wijckb,1, Johan W. Groothoff c,1

aLifestyle Training Centre, Dalfsen, The Netherlands

bInstitute of Human Movement Sciences, University of Groningen, The Netherlands

cDepartment of Social Medicine, University of Groningen, The Netherlands

Improvement of balance between work stress and recovery

after a body awareness program for chronic aspecific

psychosomatic symptoms Patient Education and Counseling 60 (2006) 125–135

www.stabiliteitstrainingscentrum.nl

Keywords: Chronic aspecific psychosomatic symptoms; Stress; Self-management; Quality of

life

Abstract

Objective: A 3-day residential body awareness program (BAP) was developed to teach

people with chronic aspecific psychosomatic symptoms (CAPS) to react adequately to

disturbances of the balance between a daily workload and the capacity to deal with it. The

long-term effects of the program in improving the balance between work stress and recovery

are presented in this study. The intervening effect of ‘improved balance’ on quality of life is

also analysed.

Methods: A pre–post design is used with post-measures at 2 and 12 months after the

program, without controls (n = 122). Mean age is 42.5 years (S.D. = 9.0) and 60% of

participants are female.

Results: The results show participants become more active physically and socially, and at the

same time take the opportunity to recover. There was a difference measured in changing

balance for participants who are fully employed and participants who are not working or are

working part-time due to health problems: the second group reintegrated into work, the first

group spent more time socialising inside the family. Personal goals are realised by 85% of the

participants. Realising personal goals and becoming more active is a mediating factor for

increasing quality of life. The majority of the measured changes can be interpreted as

clinically relevant outcomes with medium-to-large effect sizes. Spouses of the participants

also confirm these effects.

Discussion and conclusion: Evaluation of the BAP gives evidence to conclude that this

program leads to long-term effects in CAPS. Participants react more adequately to

disturbances between daily workload and the capacity to deal with this load. Two and 12

months after the 3-day program, they changed their behaviour to a more active lifestyle and

increased self-management in coping with stress and psychosomatic symptoms.

Practice implications: By paying more attention to the balance between work stress and

recovery, patient educators may be able to increase their effectiveness. Personal goal

realization can be effective in guiding people by getting them out of the negative spiral.

Nederlands abstract van ditzelfde artikel door EVIDENCE BASED PRACTICE

ATTENDERING SPANNING, ONTSPANNING EN PSYCHOSOMATIEK

NEDERLANDS PARAMEDISCH INSTITUUT 1 NR. 4 - 14 SEPTEMBER 2006

Spanning, Ontspanning en Psychosomatiek

Lichaamsbewustwordingstraining geeft betere balans tussen werkstress en herstel :

persoonlijke trainingsdoelen realiseren helpt mensen uit een negatieve spiraal

Landsman JJA, van Wijck R, Groothoff JW. Improvement of balance between work

stress and recovery after a body awareness program for chronic aspecific

psychosomatic symptoms. Patient Education and Counseling 2006; 60(2): 125-135.

In Dalfsen is een driedaagse interne leefstijltraining ontwikkeld. Hierin wordt mensen met

chronische aspecifieke lichamelijke klachten (CALK) geleerd om adequaat te reageren op

verstoringen van de balans tussen lichamelijke en psychische belasting en belastbaarheid.

Technieken uit bio-energetica, ademtherapie en haptonomie worden toegepast om

lichaamsbewustwording te vergroten. In dit artikel zijn de lange termijn effecten beschreven

ten aanzien van de balans tussen werkstress en herstel. Er is een pre-post design gebruikt met

nametingen op twee en twaalf maanden na de driedaagse interventie, zonder controlegroep (n

=122). De gemiddelde leeftijd is 42,5 jaar (SD 9.0) en 60% is vrouw. De vier meest

genoemde symptomen zijn vermoeidheid, zich gespannen voelen, slaapproblemen en

hoofdpijn.

www.stabiliteitstrainingscentrum.nl

Meetinstrumenten/uitkomstmaten Evenwicht tussen werkstress en herstel: 1 week in

dagboek tijdregistratie voor activiteiten (werk, vrijetijdsbesteding, sport, sociale activiteiten,

etc.)

Realiseren van doelen: Goal Attainment Scale

Kwaliteit van Leven: World Health Quality of Life scale en de Nederlandse

versie van de Hopkins SCL-90

Resultaten

De deelnemers worden actiever op zowel fysiek als sociaal gebied en maken tegelijkertijd

meer en effectiever gebruik van hun mogelijkheden om te herstellen na inspanning. Er is meer

flexibiliteit, de deelnemers hebben meer gedragsalternatieven en passen deze toe bij het

hanteren van dagelijkse stress. Zowel het langdurig als kortdurend ziekteverzuim is gedaald.

Persoonlijke trainingsdoelen (zoals eigen grenzen leren kennen, leren ontspannen, omgaan

met stress op het werk, etc.) werden door 85% van de deelnemers gerealiseerd. De

meerderheid van de gemeten veranderingen zijn klinisch relevant met gemiddelde tot grote

effectmaten.

Conclusie

Twaalf maanden na de lichaamsbewustwordingstraining is er een gedragsverandering.

Deelnemers hebben een actievere levensstijl en kunnen beter omgaan met stress en

psychosomatische symptomen. [SH]

Zit in map hoofdcursus

Jeanet J.A. Landsman-Dijkstra a,b,∗, Ruud van Wijck b,

Johan W. Groothoff c, Piet Rispens b

a Lifestyle Training Center, Dalfsen, The Netherlands

b Institute of Human Movement Sciences, University of Groningen, P.O. Box 196, 9700 AD

Groningen, The Netherlands

c Department of Social Medicine, University of Groningen, Groningen, The Netherlands

Patient Education and Counseling 55 (2004) 155–167

The short-term effects of a body awareness program:

better self-management of health problems for individuals

with chronic a-specific psychosomatic symptoms_ Keywords: Chronic A-specific Psychosomatic Symptoms; Stress; Self-management; Body

awareness

Abstract

A three-day residential Body Awareness Program (BAP) was developed to teach people with

Chronic A-specific Psychosomatic Symptoms (CAPS) to react adequately to disturbances of

the balance between a daily workload and the capacity to deal with it. The short-term effects

of the program for people with CAPS are presented in this study. The design is a non-control

group design with pre- and post-measures (2 months after the program). The sample for this

paper was formed by 187 participants. The mean age is 42.3 (S.D. = 8.9), and 57% is female.

The results showed decreased stress-related symptoms, increased quality of life, increased

self-efficacy, less depressive attribution style, more expression of emotions, and a positive

change of lifestyle. Most of these measured changes can be interpreted as clinically relevant

outcomes with medium-to-large effect sizes. Personal pre-training goals were attained by 85%

of the participants. Spouses also confirmed the found effects. Evaluation of the BAP gives

www.stabiliteitstrainingscentrum.nl

enough evidence to conclude that this program leads to positive effects in CAPS. Participants

react more adequately to disturbances between daily workload and the capacity to deal with

this load. They are more capable of self-management in coping with stress and psychosomatic

symptoms. Conclusions are drawn about the prevention by early interventions for patients

with a-specific physical symptoms.

Zit in map hoofdcursus

Claudine JC Lamoth*1, John F Stins1, Menno Pont2, Frederick Kerckhoff2 and Peter J Beek1

Address: 1Research Institute MOVE, Faculty of Human Movement Sciences, VU University

Amsterdam, van der Boechorststraat 9, 1081 BT, Amsterdam, the Netherlands and

2Rehabilitation Center Amsterdam, Department of Health and Behavior, Overtoom 283, 1054

HW, Amsterdam, the Netherlands

Email: Claudine JC Lamoth* - C.Lamoth@fbw.vu.nl; John F Stins - j.stins@fbw.vu.nl;

Menno Pont - m.Pont@rcamsterdam.nl; Frederick Kerckhoff - f.kerckhoff@rcamsterdam.nl;

Peter J Beek - p.beek@fbw.vu.nl * Corresponding author

Effects of attention on the control of locomotion in

individuals with chronic low back pain Journal of NeuroEngineering and Rehabilitation

Abstract

Background: People who suffer from low back pain (LBP) exhibit an abnormal gait pattern,

characterized by shorter stride length, greater step width, and an impaired thorax-pelvis

coordination which may undermine functional walking. As a result, gait in LBP may require

stronger cognitive regulation compared to pain free subjects thereby affecting the degree of

automaticity of gait control. Conversely, because chronic pain has a strong attentional

component, diverting attention away from the pain might facilitate a more efficient walking

pattern.

Methods: Twelve individuals with LBP and fourteen controls participated. Subjects walked

on a treadmill at comfortable speed, under varying conditions of attentional load: (a) no

secondary task, (b) naming the colors of squares on a screen, (c) naming the colors of color

words ("color Stroop task"), and (d) naming the colors of words depicting motor activities.

Markers were attached to the thorax, pelvis and feet. Motion was recorded using a three-

camera SIMI system with a sample frequency of 100 Hz. To examine the effects of health

status and attention on gait, mean and variability of stride parameters were calculated. The

coordination between thoracic and pelvic rotations was quantified through the mean and

variability of the relative phase between those oscillations.

Results: LBP sufferers had a lower walking speed, and consequently a smaller stride length

and lower mean thorax-pelvis relative phase. Stride length variability was significantly lower

in the LBP group but no significant effect of attention was observed. In both groups gait

adaptations were found under performance of an attention demanding task, but significantly

more so in individuals with LBP as indicated by an interaction effect on relative phase

variability.

Conclusion: Gait in LBP sufferers was characterized by less variable upper body movements.

The diminished flexibility in trunk coordination was aggravated under the influence of an

attention demanding task. This provides further evidence that individuals with LBP tighten

their gait control, and this suggests a stronger cognitive regulation of gait coordination in

LBP. These changes in gait coordination reduce the capability to deal with unexpected

perturbations, and are therefore maladaptive.

www.stabiliteitstrainingscentrum.nl

Fascia

R. Schleip *, W. Klingler, F. Lehmann-Horn

Department of Applied Physiology, Ulm University, Albert-Einstein-Allee 11, 89069 Ulm,

Germany

Active fascial contractility: Fascia may be able to contract

in a smooth muscle-like manner and thereby influence

musculoskeletal dynamics

Summary Dense connective tissue sheets, commonly known as fascia, play an important role

as force transmitters in human posture and movement regulation. Fascia is usually seen as

having a passive role, transmitting mechanical tension which is generated by muscle activity

or external forces. However, there is some evidence to suggest that fascia may be able to

actively contract in a smooth muscle-like manner and consequently influence musculoskeletal

dynamics. General support for this hypothesis came with the discovery of contractile cells in

fascia, from theoretical reflections on the biological advantages of such a capacity, and from

the existence of pathological fascial contractures. Further evidence to support this hypothesis

is offered by in vitro studies with fascia which have been reported in the literature: the

biomechanical demonstration of an autonomous contraction of the human lumbar fascia, and

the pharmacological induction of temporary contractions in normal fascia from rats. If

verified by future research, the existence of an active fascial contractility could have

interesting implications for the understanding of musculoskeletal pathologies with an

increased or decreased myofascial tonus. It may also offer new insights and a deeper

understanding of treatments directed at fascia, such as manual myofascial release therapies or

acupuncture. Further research to test this hypothesis is suggested.

Conclusions These results suggest, that fascia is a contractile organ, due to the presence of

myofibroblasts. This ability is expressed on the one hand in chronic tissue contractures which

include tissue remodeling; and on the other hand in smooth muscle-like cellular contractions

over a time frame of minutes to hours, which can be strong enough to influence low back

stability and other aspects of human biomechanics. This offers future implications for the

understanding and clinical management of pathologies which go along with increased or

decreased myofascial stiffness (such as low back pain, tension headache, spinal instability, or

fibromyalgia). It also offers new insights for treatments directed at fascia, such as osteopathy,

the Rolfing method of myofascial release, or acupuncture. Further research on fascial

contractility is indicated and promising.

Artikel in map hoofdcursus.

www.stabiliteitstrainingscentrum.nl

Extremiteiten

L Öhberg1, R Lorentzon2, H Alfredson2

1Department of Radiation Sciences, Diagnostic Radiology, Umeå University, Umeå, Sweden

2Department of Surgical and Perioperative Science, Sports Medicine and National Institute

for Working Life, University of Umeå

Correspondence to: Dr Öhberg Department of Radiology, University Hospital of Umeå,

901 85 Umeå, Sweden; lars.ohberg.us@vll.se

Eccentric training in patients with chronic Achilles

tendinosis: normalised tendon structure and decreased

thickness at follow up Br J Sports Med2004;38:8-11 doi:10.1136/bjsm.2001.000284

Abstract

Objective: To prospectively investigate tendon thickness and tendon structure by

ultrasonography in patients treated with eccentric calf muscle training for painful chronic

Achilles tendinosis located at the 2–6 cm level in the tendon.

Methods: The patients were examined with grey scale ultrasonography before and 3.8 years

(mean) after the 12 week eccentric training regimen. At follow up, a questionnaire assessed

present activity level and satisfaction with treatment.

Results: Twenty six tendons in twenty five patients (19 men and six women) with a mean age

of 50 years were followed for a mean of 3.8 years (range 1.6–7.75). All patients had a long

duration of painful symptoms (mean 17.1 months) from chronic Achilles tendinosis before

treatment. At follow up, 22 of 25 patients were satisfied with treatment and active in Achilles

tendon loading activities at the desired level. Ultrasonography showed that tendon thickness

(at the widest part) had decreased significantly (p<0.005) after treatment (7.6 (2.3) v 8.8 (3)

mm; mean (SD)). In untreated normal tendons, there was no significant difference in

thickness after treatment (5.3 (1.3) mm before and 5.9 (0.8) mm after). All tendons with

tendinosis had structural abnormalities (hypoechoic areas and irregular structure) before the

start of treatment. After treatment, the structure was normal in 19 of the 26 tendons. Six of the

seven patients with remaining structural abnormalities experienced pain in the tendon during

loading.

Conclusions: Ultrasonographic follow up of patients with mid-portion painful chronic

Achilles tendinosis treated with eccentric calf muscle training showed a localised decrease in

tendon thickness and a normalised tendon structure in most patients. Remaining structural

tendon abnormalities seemed to be associated with residual pain in the tendon.

Bernhardsson S, Klintberg IH, Wendt GK.

Evaluation of an exercise concept focusing on eccentric

strength training of the rotator cuff for patients with

subacromial impingement syndrome. Clin Rehabil. 2011 Jan;25(1):69-78. doi: 10.1177/0269215510376005. Epub 2010 Aug 16.

www.stabiliteitstrainingscentrum.nl

Journal of Clinical Rehabilitation 25 (2011):69-78)

Abstract

OBJECTIVE: To evaluate the effect on pain intensity and function of an exercise concept

focusing on specific eccentric strength training of the rotator cuff in patients with subacromial

impingement syndrome.

DESIGN: Single-subject research design with baseline and treatment phases (AB design).

SETTING: Home-based training programme supervised and supported by visits to

physiotherapy clinic.

SUBJECTS: Ten patients, mean (SD) age 54 (8.6) years, symptom duration 12 (9.1) months.

INTERVENTION: Daily eccentric strengthening exercises of the rotator cuff during 12

weeks.

MAIN MEASURES: Primary outcome measures: Pain intensity, assessed with a visual

analogue scale, and function, using the Patient-Specific Functional Scale. Secondary outcome

measures: Shoulder function evaluated with the Constant score, and shoulder-related quality

of life evaluated with the Western Ontario Rotator Cuff Index.

RESULTS: Pain intensity decreased significantly in eight of the ten subjects. Function

improved significantly in all ten subjects. Constant score increased in nine subjects and

Western Ontario Rotator Cuff Index increased in seven subjects. Mean Constant score for the

whole group increased significantly from 44 to 69 points (P = 0.008). Mean Western Ontario

Rotator Cuff Index increased from 51 to 71% (P = 0.021).

CONCLUSION: A 12-week eccentric strengthening programme targeting the rotator cuff and

incorporating scapular control and correct movement pattern can be effective in decreasing

pain and increasing function in patients with subacromial impingement syndrome. A

randomized controlled trial is necessary to provide stronger evidence of the method.

Boling MC, Bolgla LA, Mattacola CG, Uhl TL, Hosey RG.

Outcomes of a weight-bearing rehabilitation program for

patients diagnosed with patellofemoral pain syndrome. Archives of Physical Medicine and Rehabilitation 2006; 87(11):

1428-1435.

Bespreking door NPI, S. van de Heuvel.

Het patellofemorale pijnsyndroom (PFP) is in de Verenigde Staten een veel voorkomende

oorzaak van kniepijn. Een van de meest algemeen geaccepteerde ontstaanswijze is het

abnormaal sporen van de patella, mogelijk door een vertraagde aanspanning van de vastus

medialis ten opzichte van de vastus lateralis. EMG onderzoek hiernaar is gaande, maar

er is (nog) geen consensus bereikt, omdat de resultaten elkaar tegenspreken. Ook is er sprake

van verzwakte heupmusculatuur, wat een rol zou kunnen spelen bij PFP. De auteurs van dit

artikel hebben in een laboratoriumsetting middels EMG registratie van de m quadriceps en de

m gluteus medius het effect van 6 weken revalidatie bij mensen met PFP onderzocht.

Onderzoek De onderzoeksgroep bestond uit 14 studenten (9 vrouwen en 5 mannen) van de

universiteitskliniek van Kentucky met het patellofemoraal pijnsyndroom. Zij kregen een

revalidatieprogramma. De controlegroep bestond uit 14 studenten (9 vrouwen en 5 mannen)

zonder knieklachten. Er is een voormeting en een nameting uitgevoerd. Tevens is de

intrawaarnemer betrouwbaarheid van EMG metingen onderzocht.

www.stabiliteitstrainingscentrum.nl

Interventie Revalidatie van 6 weken met het accent op belaste spierversterkende oefeningen

(uitstappen, traplopen, hurkzit, met en zonder gewichten) voor de m quadriceps femoris en de

heupabductoren, met vooraf rekken van de hamstrings, quadriceps en kuitspieren. Drie sessies

per week, een keer met supervisie en 2 keer thuis (bijgehouden met een trainingslogboek). De

oefeningen, met behulp van een Airax evenwichtskussen en Thera-band, moesten pijnvrij

worden uitgevoerd en werden indien mogelijk iedere week zwaarder (programma

uitvoerig beschreven in het artikel). De deelnemers aan het revalidatieprogramma kregen een

instructievideo mee en een voorlichtingsbrochure.

Meetinstrumenten

- EMG (begin van contractie (timing) en contractieduur) van vastus medialis, vastus lateralis

en gluteus medius bij traplopen (omhoog en omlaag);

- VAS: ergste pijn in de afgelopen week (10 cm);

- Functional Index Questionnaire (FIQ) 16 puntsvragenlijst.

Resultaten Het EMG van de vastus medialis en vastus lateralis, de VAS en de FIQ scores

verbeterden significant bij de studenten met PFP na de revalidatie. Bij de voormeting

verschilde de timing van de vastus medialis en vastus lateralis van de PFP groep significant

ten opzichte van de controlegroep, maar na de interventie niet meer. Er zijn geen verschillen

gevonden in de timing en contractieduur van de m. gluteus medius. De therapietrouw

gebaseerd op het trainingslogboek was hoog (98,3%).

Discussie Nadelen van het onderzoek zijn de kleine omvang van de studiepopulatie en het

ontbreken van een controlegroep met klachten, waardoor er niet gerandomiseerd kon worden.

Ook de matige intrawaarnemer betrouwbaarheid van de EMG metingen is een beperking.

Conclusie Dit onderzoek geeft bewijs dat een belast revalidatieprogramma voor patiënten met

het patellofemoraal pijnsyndroom een verandering geeft van de timing van contractie van de

vastus lateralis en medialis van de m quadriceps femoris. Ook is aangetoond dat een

gesuperviseerd thuisoefenprogramma voor studenten met patellofemoraal pijnsyndroom de

pijn vermindert en de functionele toestand verbetert. [S.P. van den Heuvel; NPi]

Zampagni ML, Corazza I, Molgora AP, Marcacci M.

Biomechanics Laboratory-Rizzoli Orthopaedics Institute, Bologna, Italy; Center of

Bioengineering and Motor Sciences, Trento University, Italy.

Can ankle imbalance be a risk factor for tensor fascia lata muscle weakness?

J Electromyogr Kinesiol. 2008 May 1

Risk factors that can determine knee and ankle injuries have been investigated and causes are

probably multifactorial. A possible explanation could be related by the temporary inhibition

of muscular control following an alteration of proprioceptive regulation due to the ankle

imbalance pathology. The purpose of our study was to validate a new experimental set up to

quantify two kinesiologic procedures (Shock Absorber Test (SAT) and Kendall and Kendall's

Procedure (KKP)) to verify if a subtalus stimulus in an ankle with imbalance can induce a

non-appropriate response of controlateral tensor fascia lata muscle (TFL). Fifteen male soccer

players with ankle imbalance (AIG) and 14 healthy (CG) were tested after (TEST) before

(NO-TEST) a manual percussion in subtalus joint (SAT). A new tailor-made device equipped

with a load cell was used to quantify TFL's strength activation in standardized positions. Two

trials for each subject were performed, separated by at least one 4-min resting interval. In NO-

TEST conditions both AIG and CG showed a progressive adaptation of the subject to the

force imposed by operator. No reduction in mean force, mean peak force, and muscle force

duration (p>0.5). AIG presented significant differences (mean difference 0.92+/-0.46s;

p=0.000) in muscle force duration in TEST conditions. Our results indicated that "wrong"

www.stabiliteitstrainingscentrum.nl

proprioceptive stimuli coming from the subtalus joint in AIG might induce inhibition in terms

of duration of TFL muscle altering the knee stability. This kinesiological evaluation might be

useful to prevent ankle and knee injuries.

Gregory R Waryasz*1,2 and Ann Y McDermott1,3

Address: 1Tufts University School of Medicine, Boston, MA, USA, 2Department of

Nutrition, Brigham and Women's Hospital, Boston, MA, USA and 3Kinesiology Department,

California Polytechnic State University, San Luis Obispo, CA, USA

Email: Gregory R Waryasz* -gregory.waryasz@tufts.edu; Ann Y McDermott -

ann.mcdermott@tufts.edu

* Corresponding author

Patellofemoral pain syndrome (PFPS): a systematic review

of anatomy and potential risk factors Dynamic Medicine 2008, 7:9

Abstract

Background: Patellofemoral Pain Syndrome (PFPS), a common cause of anterior knee pain, is successfully

treated in over 2/3 of patients through rehabilitation protocols designed to reduce pain and

return function to the individual. Applying preventive medicine strategies, the majority of

cases of PFPS may be avoided if a pre-diagnosis can be made by clinician or certified athletic

trainer testing the current researched potential risk factors during a Preparticipation Screening

Evaluation (PPSE). We provide a detailed and comprehensive review of the soft tissue,

arterial system, and innervation to the patellofemoral joint in order to supply the clinician with

the knowledge required to assess the anatomy and make recommendations to patients

identified as potentially at risk. The purpose of this article is to review knee anatomy and the

literature regarding potential risk factors associated with patellofemoral pain syndrome and

prehabilitation strategies. A comprehensive review of knee anatomy will present the

relationships of arterial collateralization, innervations, and soft tissue alignment to the

possible multifactoral mechanism involved in PFPS, while attempting to advocate future use

of different treatments aimed at non-soft tissue causes of PFPS.

Methods: A systematic database search of English language PubMed, SportDiscus, Ovid

MEDLINE, Web of Science, LexisNexis, and EBM reviews, plus hand searching the

reference lists of these retrieved articles was performed to determine possible risk factors for

patellofemoral pain syndrome.

Results: Positive potential risk factors identified included: weakness in functional testing;

gastrocnemius, hamstring, quadriceps or iliotibial band tightness; generalized ligamentous

laxity; deficient hamstring or quadriceps strength; hip musculature weakness; an excessive

quadriceps (Q) angle; patellar compression or tilting; and an abnormal VMO/VL reflex

timing. An evidence-based medicine model was utilized to report evaluation criteria to

determine the at-risk individuals, then a defined prehabilitation program was proposed that

begins with a dynamic warm-up followed by stretches, power and multi-joint exercises, and

culminates with isolation exercises. The prehabilitation program is performed at lower

intensity level ranges and can be conducted 3 days per week in conjunction with general

strength training. Based on an objective one repetition maximum (1RM) test which

determines the amount an individual can lift in good form through a full range of motion,

prehabilitation exercises are performed at 50–60% intensity.

Conclusion: To reduce the likelihood of developing PFPS, any individual, especially those

with positive potential risk factors, can perform the proposed prehabilitation program.

www.stabiliteitstrainingscentrum.nl

Zit in map hoofdcursuss

MICHAEL M. REINOLD, Rafael Escamila, Kevin E. Wilk

Current Concepts in the Scientific and Clinical Rationale

Behind Exercises for Glenohumeral and Scapulothoracic

Musculature Level of evidence Level 5. J Orthop Sports Phys Ther 2009; 39(2):105-117. doi:10.2519/

jospt.2009.2835

Key words electromyography, infraspinatus, serratus anterior, supraspinatus, trapezius

Synopsis The biomechanical analysis of rehabilitation exercises has led to more scientifically

based rehabilitation programs. Several investigators have sought to quantify the biomechanics

and electromyographic data of common rehabilitation exercises in an attempt to fully

understand their clinical indications and usefulness. Furthermore, the effect of pathology on

normal shoulder biomechanics has been documented. It is important to consider the

anatomical, biomechanical, and clinical implications when designing exercise programs. The

purpose of this paper is to provide the clinician with a thorough overview of the available

literature relevant to develop safe, effective, and appropriate exercise programs for injury

rehabilitation and prevention of the glenohumeral and scapulothoracic joints.

www.stabiliteitstrainingscentrum.nl

Swissbal

Rafael F. Escamilla, PT, PhD, CSCS, FACSM1 • Clare Lewis, PT, PsyD, MPH, MTC,

FAAOMPT2 • Duncan Bell, MPT3Gwen Bramblet, MPT3 • Jason Daffron, MPT3 • Steve

Lambert, MPT3 • Amanda Pecson, MPT3Rodney Imamura, PhD4 • Lonnie Paulos, MD5 •

James R. Andrews, MD6

Core Muscle Activation During Swiss Ball and Traditional

Abdominal Exercises J Orthop Sports Phys Ther 2010;40(5):265-276. doi:10.2519/jospt.2010.3073

KEY WORDS: crunch, EMG, low back pain, lumbar spine, rectus abdominis, sit-up

STUDY DESIGN: Controlled laboratory study using a repeated-measures, counterbalanced

design.

OBJECTIVES: To test the ability of 8 Swiss ball exercises (roll-out, pike, knee-up, skier, hip

extension right, hip extension left, decline push-up, and sitting march right) and 2 traditional

abdominal exercises (crunch and bent-knee sit-up) on activating core (lumbopelvic hip

complex) musculature.

BACKGROUND: Numerous Swiss ball abdominal exercises are employed for core muscle

strengthening during training and rehabilitation, but there are minimal data to substantiate the

ability of these exercises to recruit core muscles. It is also unknown how core muscle

recruitment in many of these Swiss ball exercises compares to core muscle recruitment in

traditional abdominal exercises such as the crunch and bent-knee sit-up.

METHODS: A convenience sample of 18 subjects performed 5 repetitions for each exercise.

Electromyographic (EMG) data were recorded on the right side for upper and lower rectus

abdominis,

external and internal oblique, latissimus dorsi, lumbar paraspinals, and rectus femoris, and

then normalized using maximum voluntary isometric contractions (MVICs).

RESULTS: EMG signals during the roll-out and pike exercises for the upper rectus

abdominis (63% and 46% MVIC, respectively), lower rectus abdominis (53% and 55%

MVIC, respectively), external oblique (46% and 84% MVIC, respectively), and internal

oblique (46% and 56% MVIC, respectively) were significantly greater compared to most

other exercises, where EMG signals ranged between 7% to 53% MVIC for the upper rectus

abdominis, 7% to 44% MVIC for the lower rectus abdominis, 14% to 73% MVIC for the

external oblique, and 16% to 47% MVIC for the internal oblique. The lowest EMG signals

were consistently found in the sitting march right exercise. Latissimus dorsi EMG signals

were greatest in the pike, knee-up, skier, hip extension right and left, and decline push-up

(17%-25% MVIC), and least with the sitting march right, crunch, and bent-knee sit-up

exercises (7%-8% MVIC). Rectus femoris EMG signal was greatest with the hip extension

left exercise (35% MVIC), and least with the crunch, roll-out, hip extension right, and decline

push-up exercises (6%-10% MVIC). Lumbar paraspinal EMG signal was relative low (less

than 10% MVIC) for all exercises.

CONCLUSIONS: The roll-out and pike were the most effective exercises in activating upper

and lower rectus abdominis, external and internal obliques, and latissimus dorsi muscles,

while minimizing lumbar paraspinals and rectus femoris activity.

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www.stabiliteitstrainingscentrum.nl

Gregory J Lehman*1, Brandon MacMillan2, Ian MacIntyre1, Michael Chivers1

and Mark Fluter2

Address: 1Department of Graduate Studies, Canadian Memorial Chiropractic College,

Toronto, ON, Canada and 2Undergraduate Department,

Canadian Memorial Chiropractic College, Toronto, ON, Canada

Email: Gregory J Lehman* - glehman@cmcc.ca; Brandon MacMillan -

bmacmillan@cmcc.ca; Ian MacIntyre - imacIntyre@cmcc.ca;

Michael Chivers - mchivers@cmcc.ca; Mark Fluter - mfluter@cmcc.ca

* Corresponding author

Shoulder muscle EMG activity during push up variations

on and off a Swiss ball Dynamic Medicine 2006, 5:7 doi:10.1186/1476-5918-5-7

Abstract

Background: Surface instability is a common addition to traditional rehabilitation and

strength exercises with the aim of increasing muscle activity, increasing exercise difficulty

and improving joint proprioception. The aim of the current study was to determine if

performing upper body closed kinetic chain exercises on a labile surface (Swiss ball)

influences myoelectric amplitude when compared with a stable surface. Methods: Thirteen

males were recruited from a convenience sample of college students. Surface

electromyograms were recorded from the triceps, pectoralis major, latissimus dorsi, rectus

abdominis and external oblique while performing push up exercises with the feet or hands

placed on a bench and separately on a Swiss ball. A push up plus exercise was also evaluated

with hands on the support surface.

Results and discussion: Not all muscles responded with an increase in muscle activity. The

pectoralis major muscle was not influenced by surface stability. The triceps and rectus

abdominis muscles showed increases in muscle activity only when the hands were on the

unstable surface. The external oblique muscle was only influenced by surface stability during

the performance of the push up plus exercise. No muscle showed a change in activation level

when the legs were supported by the Swiss ball instead of the bench.

Conclusion: Muscle activity can be influenced by the addition of surface instability however

an increase in muscle activity does not influence all muscles in all conditions. The

relationship between the participant's center of mass, the location of the unstable surface and

the body part contacting the Swiss ball may be important factors in determining the muscle

activation changes following changes in surface stability.

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Gregory J Lehman*1, Trish Gordon2, Jo Langley2, Patricia Pemrose2 and

Sara Tregaskis2

Address: 1Department of Graduate Studies, Canadian Memorial Chiropractic College,

Toronto, ON, Canada and 2Undergraduate Department,

Canadian Memorial Chiropractic College, Toronto, ON, Canada

Email: Gregory J Lehman* - glehman@cmcc.ca; Trish Gordon - tgordon@cmcc.ca; Jo

Langley - jlangley@cmcc.ca;

Patricia Pemrose - ppemrose@cmcc.ca; Sara Tregaskis - stregaskis@cmcc.ca

* Corresponding author

www.stabiliteitstrainingscentrum.nl

Replacing a Swiss ball for an exercise bench causes

variable changes in trunk muscle activity during upper

limb strength exercises Keywords: EMG; exercise; spine; stability; swissballs; rehabilitation; low back pain

Abstract

Background: The addition of Swiss balls to conventional exercise programs has recently

been adopted. Swiss balls are an unstable surface which may result in an increased need for

force output from trunk muscles to provide adequate spinal stability or balance. The aim of

the study was to determine whether the addition of a Swiss ball to upper body strength

exercises results in consistent increases in trunk muscle activation levels.

Methods: The myoelectric activity of four trunk muscles was quantified during the

performance of upper body resistance exercises while seated on both a stable (exercise bench)

and labile (swiss ball) surface. Participants performed the supine chest press, shoulder press,

lateral raise, biceps curl and overhead triceps extension. A repeated measures ANOVA with

post-hoc Tukey test was used to determine the influence of seated surface type on muscle

activity for each muscle.

Results & Discussion: There was no statistically significant (p < .05) difference in muscle

activity between surface conditions. However, there was large degree of variability across

subjects suggesting that some individuals respond differently to surface stability. These

findings suggest that the incorporation of swiss balls instead of an exercise bench into upper

body strength training regimes may not be justified based only on the belief that an increase

spinal stabilizing musculature activity is inherent. Biomechanically justified ground based

exercises have been researched and should form the basis for spinal stability training as

preventative and therapeutic exercise training regimes.

Conclusion: Selected trunk muscle activity during certain upper limb strength training

exercises is not consistently influenced by the replacement of an exercise bench with a swiss

ball.

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Diane E. Gregory, Nadine M. Dunk, and Jack P. Callaghan, University of Waterloo,

Waterloo, Ontario, Canada

Stability Ball Versus Office Chair:m Comparison of Muscle

Activation and Lumbar Spine Posture During Prolonged

Sitting CONCLUSION

There does not appear to be any advantage to using a stability ball as an office chair. No

postural or muscular activation differences were observed between the ball and the chair, with

the exception of reduced pelvic tilt while sitting on the ball. However, the increased reported

discomfort and potential safety issues associated with sitting on an unstable surface question

the use of a stability ball as an office chair.

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