Simo Taimela

Scoring of patellofemoral disorders.

A new questionnaire was used to evaluate subjective symptoms and functional limitations in patellofemoral disorders. The questionnaire was completed independently by four groups of female subjects: controls (N = 17), and subjects with anterior knee pain (N = 16), patellar subluxation (N = 16), and patellar dislocation (N = 19). The questionnaire mean scores for the groups were 100, 83, 68, and 62 points, respectively (p < 0.0001). The items dealing with abnormal painful patellar movements (subluxations) (p < 0.0001), limp (p < 0.0001), pain (p < 0.0001), running (p < 0.0001), climbing stairs (p < 0.0001), and prolonged sitting with the knees flexed (p < 0.0001) differentiated the study groups most clearly. We recommend that these questions be asked when taking a standardized clinical history of an anterior knee pain patient. We also analyzed lateral patellar tilt and displacement by magnetic resonance imaging (MRI) in 28 subjects with patellar subluxation or dislocation. Low questionnaire sum score correlated best with increased lateral patellar tilt measured during quadriceps contraction in 0 degree knee flexion. It seems that a tendency to lateral patellar tilt during quadriceps contraction causes anterior knee pain and can be imaged in knee extension when the patella is not fully supported by femoral condyles.

A Randomized Clinical Trial of Three Active Therapies for Chronic Low Back Pain

Study Design.A randomized clinical trial.Objectives.To examine the relative efficacy of three active therapies for chronic low back pain.Summary of Background Data.There is much evidence documenting the efficacy of exercise in the conservative management of chronic low back pain, but many questions

The effect of lumbar fatigue on the ability to sense a change in lumbar position. A controlled study.

STUDY DESIGN A cross-sectional study in patients with recurrent/chronic low back trouble and healthy control subjects. OBJECTIVE To evaluate the effect of paraspinal muscle fatigue on the ability to sense a change in lumbar position. SUMMARY OF BACKGROUND DATA Protection against spinal injury requires proper anticipation of events, appropriate sensation of body position, and reasonable muscular responses. Lumbar fatigue is known to delay lumbar muscle responses to sudden loads. It is not known whether the delay is because of failure in the sensation of position, output of the response, or both. METHODS Altogether, 106 subjects (57 patients with low back trouble [27 men and 30 women] and 49 healthy control subjects [28 men and 21 women]) participated in the study. Their ability to sense a change in lumbar position while seated on a special trunk rotation unit was assessed. A motor rotated the seat with an angular velocity of 1 degree per second. The task in the test involved reacting to the perception of lumbar movement (rotation) by releasing a button with a finger movement. The test was performed twice, before and immediately after a fatiguing procedure. During the endurance task, the participants performed upper trunk repetitive extensions against a resistance, with a movement amplitude adjusted between 25 degrees flexion and 5 degrees extension, until exhaustion. RESULTS Patients with chronic low back trouble had significantly poorer ability than control subjects on the average to sense a change in lumbar position (P = 0.007), which was noticed before and after the fatiguing procedure. Lumbar fatigue induced significant impairment in the sensation of position change (P < 0.000001). CONCLUSIONS Lumbar fatigue impairs the ability to sense a change in lumbar position. This feature was found in patients and control subjects, but patients with low back trouble had poorer ability to sense a change in lumbar position than control subjects even when they were not fatigued. There seems to be a period after a fatiguing task during which the available information on lumbar position and its changes is inaccurate.

Back and hip extensor fatigability in chronic low back pain patients and controls

OBJECTIVE To compare the lumbar paraspinal and gluteus maximus muscle fatigability between chronic low back pain patients and healthy controls by using electromyographic (EMG) spectral analysis during a maximal isometric endurance task. DESIGN A cross-sectional comparative study between chronic low back pain patients and healthy control subjects. SETTING Physical medicine and rehabilitation clinic in Finland. SUBJECTS Twenty women with nonspecific chronic low back pain (longer than 3 months) and 15 healthy controls. INTERVENTION Subjects performed maximal voluntary isometric back extensions (MVC) at 30 degrees forward flexion in a specially designed measurement unit. A 50% MVC load was used in isometric endurance test. OUTCOME MEASURES Low back pain intensity was assessed by using the visual analogue scale and functional disability by the Oswestry disability index. Time to endurance was measured. Bipolar surface EMG recordings were made over the lumbar paraspinal muscles (L3-L4, L5-S1) and over the gluteus maximus muscles. Average EMG (aEMG%), and initial spectral median frequency (MFinit) and change over time (MFslope) were computed. RESULTS Pain intensity and functional disability were higher and MVC and time to endurance were lower in the chronic low back pain group (p < .05). Similar muscle activity levels (aEMG%) and MFinit indicated similar muscle loading in both groups at the beginning of the endurance test. EMG spectral decreases (MFslope) indicated that lumbar paraspinal muscle fatigability was similar in both groups. In the chronic low back pain group, the gluteus maximus fatigued faster than in the control group (greater MFslope, p < .05). However, the shorter endurance time indicated greater fatigability in the chronic low back pain group in general (p < .05). CONCLUSIONS The chronic low back pain patients were weaker and fatigued faster than the healthy controls. The EMG fatigue analysis results suggest that the gluteus maximus muscles are more fatigable in chronic low back pain patients than in healthy control subjects during a sustained back extension endurance test.

Active therapy for chronic low back pain part 3. factors influencing self-rated disability and its change following therapy

Design. Cross-sectional analysis of the factors influencing self-rated disability associated with chronic low back pain and prospective study of the relationship between changes in each of these factors and in disability following active therapy. Objectives. To examine the relative influences of pain, psychological factors, and physiological factors on self-rated disability. Summary of Background Data. In chronic LBP, the interrelationship between physical impairment, pain, and disability is particularly complicated, due to the influence of various psychological factors and the lack of unequivocal methods for assessing impairment. Investigations using new “belief” questionnaires and “sophisticated” performance tests, which have shown promise as discriminating measures of impairment, may assist in clarifying the situation. Previous studies have rarely investigated all these factors simultaneously. Methods. One hundred forty-eight patients with cLBP completed questionnaires and underwent tests of mobility, strength, muscle activation, and fatigability, and (in a subgroup) erector spinae size and fiber size/type distribution. All measures were repeated after 3 months active therapy. Relationships between each factor and self-rated disability (Roland and Morris questionnaire) at baseline, and between the changes in each factor and changes in disability following therapy, were examined. Results. Stepwise linear regression showed that the most significant predictors of disability at baseline were, in decreasing order of importance: pain; psychological distress; fear-avoidance beliefs; muscle activation levels; lumbar range of motion; gender. Only changes in pain, psychological distress, and fear-avoidance beliefs significantly accounted for the changes in disability following therapy. Conclusion. A combination of pain, psychological and physiological factors was best able to predict baseline disability, although its decrease following therapy was determined only by reductions in pain and psychological variables. The active therapy programm—in addition to improving physical function—appeared capable of modifying important psychological factors, possibly as a result of the positive experience of completing the prescribed exercises without undue harm.

Acute injuries in soccer, ice hockey, volleyball, basketball, judo, and karate: analysis of national registry data.

Abstract Objective: To determine the acute injury profile in each of six sports and compare the injury rates between the sports. Design: Analysis of national sports injury insurance registry data. Setting: Finland during 1987-91. Subjects: 621691 person years of exposure among participants in soccer, ice hockey, volleyball, basketball, judo, or karate. Main outcome measures: Acute sports injuries requiring medical treatment and reported to the insurance company on structured forms by the patients and their doctors. Results: 54186 sports injuries were recorded. Injury rates were low in athletes aged under 15, while 20-24 year olds had the highest rates. Differences in injury rates between the sports were minor in this adult age group. Overall injury rates were higher in sports entailing more frequent and powerful body contact. Each sport had a specific injury profile. Fractures and dental injuries were most common in ice hockey and karate and least frequent in volleyball. Knee injuries were the most common cause of permanent disability. Conclusions: Based on the defined injury profiles in the different sports it is recommended that sports specific preventive measures should be employed to decrease the number of violent contacts between athletes, including improved game rules supported by careful refereeing. To prevent dental injuries the wearing of mouth guards should be encouraged, especially in ice hockey, karate, and basketball.

Active treatment of chronic neck pain: a prospective randomized intervention.

Study Design. A randomized comparative study with single-blind outcome assessments. Objectives. To compare the efficacy of a multimodal treatment emphasizing proprioceptive training (ACTIVE) with activated home exercises (HOME) and recommendation of exercise (CONTROL) in patients with nonspecific chronic neck pain. Summary of Background Data. The efficacy of active exercises and passive physiotherapy for neck trouble has been somewhat disappointing in the previous few studies. Methods. Seventy-six patients (22 men, 54 women) with chronic, nonspecific neck pain participated. Sixty-two participated the 1-year follow-up. Subjective pain and disability, cervical ranges of motion, and pressure pain threshold in the shoulder region were measured at baseline, at 3 months, and at 12 months. The ACTIVE treatment consisted of 24 sessions of proprioceptive exercises, relaxation, and behavioral support. The HOME regimen included a neck lecture and two sessions of practical training for home exercises and instructions for maintaining a diary of progress. The CONTROL treatment included a lecture regarding care of the neck with a recommendation to exercise. Results. The average self-experienced total benefit was highest in the ACTIVE group, and the HOME group rated over the CONTROL group (P < 0.001). Differences between the groups in favor of the ACTIVE treatment were recorded in reduction of neck symptoms and improvements in general health and self-experienced working ability (P < 0.01–0.03). Changes in measures of mobility and pressure pain threshold were minor. Conclusions. Regarding self-experienced benefit, the multimodal treatment was more efficacious than activated home exercises that were clearly more efficacious than just advising. No major differences were noted in objective measurements of cervical function between the groups, but the content validity of these assessments in chronic neck trouble can be questioned.

Active therapy for chronic low back pain part 1. Effects on back muscle activation, fatigability, and strength.

Design. Randomized prospective study of the effects of three types of active therapy on back muscle function in chronic low back pain patients. Objectives. To quantify the effects of 3 months active therapy on strength, endurance, activation, and fatigability of the back entensor muscles. Summary of Background Data. Many studies have documented an association between chronic low back pain and diminished muscular performance capacity. Few studies have quantified the changes in these measures following interventions using objective measurement techniques or related them to changes in clinical outcome. Methods. A total of 148 individuals (57% women) with chronic low back pain (age, 45.0 ± 10.0 years; duration of low back pain, 10.9 ± 9.5 years) were randomized to a treatment that they attended for 3 months: active physiotherapy, muscle reconditioning on devices, or low-impact aerobics. Before and after therapy, assessments were made of the following: trunk muscle strength (in flexion, extension, lateral bending, and axial rotation), erector spinae activation (maximal, and during forward bending movements), back extensor endurance (Biering-S/orensen test), and erector spinae fatigability (determined from changes in the median frequency of the surface electromyographic signal) during isometric and dynamic tests. Results. A total of 132 of 148 patients (89%) completed the therapy. Isometric strength in each movement direction increased in all groups post-therapy (P < 0.0008), most notably in the devices group. Activation of the erector spinae during the extension tests also increased significantly in all groups and showed a weak, but significant, relationship with increased maximal strength (P = 0.01). Pretherapy 55% of the subjects showed no relaxation of the back muscles at L5 when in the fully flexed position; no changes were observed in any group post-therapy. Endurance time during the Biering-S/orensen test increased significantly post-therapy in all groups (P = 0.0001), but there were no significant changes in EMG-determined fatigability. Fatigability of the lumbar muscles at L5 (EMG median frequency changes) during the dynamic test increased post-therapy (P = 0.0001) without group differences. Conclusion. Significant changes in muscle performance were observed in all three active therapy groups post-therapy, which appeared to be mainly due to changes in neural activation of the lumbar muscles and psychological changes concerning, for example, motivation or pain tolerance.

One-footed and externally disturbed two-footed postural control in patients with chronic low back pain and healthy control subjects. A controlled study with follow-up.

Study Design. A study of postural control during one‐footed and externally disturbed two‐footed stance among healthy control subjects and patients with chronic low back pain at the beginning of a functional back restoration program and 6 months later at follow‐up examination. Objectives. To study postural control cross‐sectionally among control subjects and patients with low back pain, and to evaluate the effects of functional restoration on the postural control parameters in a follow‐up examination. Summary of Background Data. Deficits of motor skills and coordination have been reported in association with musculoskeletal disorders. It has been found that patients with chronic low back pain have impaired psychomotor control, but the impairment is reversible with successful low back rehabilitation. It is insufficiently known how functional activation and intensive physical training affect postural control. Methods. Sixty‐one healthy volunteers (32 men, 29 women) and altogether 99 patients with low back pain participated in the study. Sixty‐eight patients (33 men, 35 women) had moderate and 31 (18 men, 13 women) had severe low back pain. Postural stability was measured with a force platform. In two‐footed stance, vibration stimulation on calf and back muscles was used to disturb the balance. Center point of force‐velocity (cm/sec), average position shift in anteroposterior direction (cm), and maximal position shift in lateral direction (cm) were used as the parameters. Results. Reliability of all tests was acceptable. Center point of force‐velocity was the most sensitive parameter and the one‐footed measurement the most sensitivetest for evaluating postural stability. At the beginning, the patients with severe low back pain had poorer one‐footed postural control compared with the control subjects (P = 0.0003). The subgroup of patients with moderate low back pain participated in the restoration program. The outcome of the restoration program was considered good if the disability because of low back pain (Oswestry index) decreased during the restoration program and poor if the disability increased or did not change. The one‐footed postural stability remained primarily at the same level as the initial results in the control and good outcome groups, but became significantly poorer in the poor outcome group. The difference between poor outcome and control groups was statistically significant (P = 0.04). Conclusions. Impaired postural stability seems to be one factor in multidimensional symptomatology of patients with chronic low back trouble. Postural stability is easily disturbed in case of impairment in strength, coordination, or effective coupling of muscles in the lumbar and pelvic area. Patients with chronic low back pain seem to experience impairment in these functions, which should be taken into consideration when back rehabilitation programs are planned.

Modic changes in endplates of lumbar vertebral bodies: prevalence and association with low back and sciatic pain among middle-aged male workers.

Study Design. Cross-sectional comparison of self-reported low back pain (LBP) symptoms and Modic findings on magnetic resonance imaging (MRI). Objectives. To investigate associations of frequency and intensity of LBP and sciatic pain with Modic changes in a sample of middle-aged male workers with or without whole-body vibration exposure. Summary of Background Data. Vertebral endplate changes are bone marrow lesions visible on MRI and are assumed to be associated with degenerative intervertebral disc disease. Associations of these so-called Modic changes with clinical symptoms are controversial. Furthermore, most of these studies have been performed in selected series of patients. Methods. A total of 228 middle-aged male workers (159 train engineers and 69 sedentary controls) from northern Finland underwent sagittal T1 and T2-weighted MRI. Both endplates of 1140 lumbar interspaces were graded for type and extent of Modic changes. Logistic regression was used to analyze associations of pain variables with Modic changes. Results. Train engineers had on the average higher sciatic pain scores than the sedentary controls, but the prevalence of Modic changes was similar in both occupational groups. Altogether, 178 Modic changes in 128 subjects were recorded: 30% were type I, 66% type II, and 4% both types I and II. Eighty percent of changes occurred at L4–L5 or L5–S1. Modic changes at L5–S1 showed significant association with pain symptoms with increased frequency of LBP (odds ratio [OR] 2.28; 95% confidence interval [CI] 1.44–3.15) and sciatica episodes (OR 1.44; 95% CI 1.01–1.89), and with higher LBP visual analog scores during the past week (OR 1.36; 95% CI 1.06–1.70). Type I lesions and extensive lesions in particular were closely associated with pain. Conclusions. Modic changes at L5–S1 and Modic type I lesions are more likely to be associated with pain symptoms than other types of Modic changes or changes located at other lumbar levels.