[Orthopedic aspects in interdisciplinary multimodal therapy of chronic back pain]. / Orthopädische Aspekte in der multimodalen Therapie chronischer Rückenschmerzen.

The effect of interdisciplinary multimodal therapy of chronic back pain is well documented. With elapsing time changing diagnostic focuses, therapeutic strategies and objectives have to be considered. The chronicity leads to a modification of the relevance of structure-related diagnosis and therapy and changes the significance of the classic orthopedic instruments. The requirement of a rational causal therapy in chronic back pain still remains but the focal points shift to the consideration of somatic, psychological and social disposing and supporting factors.The aim of this paper is to reflect the necessary orthopedic expertise in the context of the pathomechanics of chronic back pain and the interdisciplinary teamwork.

[Exercise therapy in the treatment of chronic back pain. An integral part of interdisciplinary therapy]. / Medizinische Trainingstherapie beim chronischen Rückenschmerz. Ein integraler Bestandteil der interdisziplinären Therapie.

Chronic low back pain requires interdisciplinary and biopsychosocial treatment. Apart from the medical, psychological, and physiotherapeutic aspects of therapy, exercise therapy is an important component. Together with"work hardening," it represents the elements for reconditioning. The isolated effect is scientifically difficult to specify with the available data, but in most analytical studies, exercise therapy is an important component in an interdisciplinary setting. A nonspecific, diversified training program is superior to exercise solely of the trunk muscles. The primary tasks are to recover load capacity and diminish pain-avoidance behaviors, with consideration of the principles of"functional restoration." Thorough information and cooperation with the patient, continuous motivation, ratio control, a systematic increase in load, and permanent feedback are necessary. Close communication within the team makes immediate accompanying interventions of other specialized groups possible.

["Work hardening" for chonic back pain. An integral component of multimodal therapy programs]. / "Work hardening" bei chronischen Rückenschmerzen. Ein integraler Bestandteil multimodaler Therapieprogramme.

Work hardening is aimed at a reestablishment of the potentials needed in occupational everyday life. Fundamental motor abilities, such as strength, stability, flexibility and persistence, are restored and merged into the everyday life so that psychological contents, such as fear avoidance behavior will be positively affected. The design of work hardening is interdisciplinary in the sense of a holistic approach to back pain. Handling the pain under load requires sophisticated treatment and the training demands a high degree of individual design. A trusting and mutual agreement between therapist and patient is essential. Work hardening represents an important part of the therapy of chronic back pain and greatly supports regaining confidence in the physical efficiency and the ability to control the body.

[Orthopedic specialists in an interdisciplinary setting. Multimodal therapy for chronic back pain]. / Der Orthopäde im interdisziplinären Setting. Multimodale Therapie beim chronischen Rückenschmerz.

Chronic back pain compels a new therapeutic strategy. A therapeutic team setting and consequent consideration of proven treatments are required. The orthopedic specialist should manage a cooperating team with a psychologist and a physiotherapist, and information should be continuously exchanged according to the criteria for interdisciplinary multimodal pain therapy. The team's therapeutic tasks should be determined and distributed according to the individual patient's problems. Questionably relevant - in particular, somatic-oriented - diagnostic and therapeutic measures should be avoided. The team setting facilitates optimal task sharing and simultaneous professional application of the most effective therapy for chronic back pain: pharmaceutical therapy, including peridural infiltrations by the medical doctor; systematic and controlled increased load by the physiotherapist; and psychosocial assistance from the psychologist.

[Multimodal integrated assessment and treatment of patients with back pain. Pain related results and ability to work]. / Integrationsversorgung von Patienten mit Rückenschmerzen. Schmerzbezogene Ergebnisse und Arbeitsfähigkeit.

INTRODUCTION: The results of conventional chronic back pain therapy are unsatisfactory. Deconditioning, psychosocial disorders and prolonged disability are common sequelae. MATERIAL AND METHODS: The health insurance fund Deutsche Angestellten Krankenkasse (DAK) offers an interdisciplinary assessment by the Berlin-Brandenburg back pain network (BBR) to its members with ongoing work disability on account of back pain. After medical, physiotherapeutic and psychological exploration one of the following four options is suggested: further diagnostics, outpatient monomodal treatment, day-care pain management program of two intensities or inpatient pain treatment. The data of 394 patients with the leading diagnostic group of back pain (M54, ICD 10, 65.7%) and disability for 92.7 days (mean) are presented. RESULTS: The patients were severely impaired in physical and psychosocial aspects. The chronification was moderate (stage II-III of Mainz Staging System, MPSS). The success of treatment was evaluated 6 months after the initial assessment. All groups showed a significant reduction of pain, anxiety and depression whereas the wellbeing and daily activities improved, but best in the day-care pain management groups. CONCLUSION: Patient selection by a health fund, interdisciplinary assessment and severity adapted treatment resulted in significant reduction in pain and functional improvement in disabled back pain patients.

[Non-operative treatment of chronic low back pain: specific back muscular strength training versus improvement of physical fitness]. / Konservative Therapie des chronischen Rückenschmerzes: spezifisches Krafttraining der Rückenmuskulatur oder Steigerung der allgemeinen körperlichen Fitness.

AIM: A systematic review was performed to evaluate the clinical effects of specific back muscle and non-specific physical fitness training in chronic low back pain. METHOD: A computer-aided Medline research (19861999) of randomised clinical trials concerning both rehabilitation concepts was conducted. A rating system was used to assess the methodological score of each study. The results were analysed and a final statement for evidence according to three main parameters (back pain, physical capacity, and patients comfort) was postulated. RESULTS: Twelve randomised clinical trials were identified. Nine studies were determined as high-quality trials. For chronic low back pain specific back muscle exercises as well as non-specific fitness training were able to improve the patients' conditions sufficiently. In comparison with passive treatment or no treatment there is strong evidence for pain and physical capacity in both groups, but only a positive influence for patient' comfort in fitness groups. Nevertheless, a confrontation of both concepts in two studies did not reveal any notable differences in all three parameters. CONCLUSION: Principally, a specific strength training for back rnuscles as well as a non-specific fitness training are comparably effective to rehabilitate chronic low back pain.

Instability of the Contact Line between Three Fluid Phases during Mass Transfer Processes.

The movable contact line between two liquids and a gas phase sensitively reacts to small disturbances in the force equilibrium. The shape of the contact line and the adjoining interfaces is determined by the interface and surface tensions, the contact angles, the density differences (hydrostatic pressure), and the Laplace capillary pressure. When these change, the three-phase contact line can deform and even become unstable. Interface and surface tension depend on the concentration and temperature. During mass transport processes (concentration changes) various forms of the instability of the contact line can be observed: -Oscillations of a circular contact line (regular expansion and reduction); -Single deformations (bulges) which quickly disappear again; -Deformations (bulges) which run along the boundary line; -Periodically generated and damped deformations with different modes. The behavior of the three-phase contact line is of practical importance for coalescence processes and for spontaneous emulsification on liquid surfaces. Copyright 2000 Academic Press.

Marangoni-Stress-Driven "Solitonic" (Periodic) Wave Trains Rotating in an Annular Container during Heat Transfer

Periodic wave trains can be induced at the surface of liquid layers when the liquid is heated from above. These wave trains are an oscillatory regime of the Marangoni-instability. They are studied in a circular annular container, in which a wave synchronization is possible. Two counter-rotating (periodic) wave trains can be observed at a moderate level of supercritical Marangoni-number values. During the head-on collisions of the waves a negative phase shift occurs. This is evidence of the nonlinear interaction of the waves and their "solitonic" properties.

Tissue tightness disposes to disc hernia.

It seems likely that the tightness of tissue influences a patient's disposition to disc hernia. The aim of this study was to compare the mechanical behaviour of tissue from disc hernia patients with that of controls. A computerized finger hyperextensometer was constructed, which allowed the measurement of the viscoelastic properties of the capsule and ligaments at the metacarpophalangeal (MCP) joint. The disc group showed a reduced maximal extension angle of MCP joint II (P < 0.01), reduced tissue recovery value (P < 0.05), reduced relative subsecant area (P < 0.01) and relative integral of the regression curve (P < 0.01). The results indicate that an anulus fibrosus with reduced extension properties, reduced capacity of energy absorption and retarded shape recovery disposes to rupture.

[Prolapsed disk and constitutional disk flexibility]. / Diskusprolaps und konstitutionelle Bandfestigkeit.

The mechanical behaviour of anulus fibrosus is dependent on collagen fibers and influences the prolapse disposition. The aim of study was the comparison of constitutional mechanical tissue properties between a group of patients with disk herniation and normal. A computerized finger hyperextensiometer was developed which was able to analyse the viscoelastic tissue properties. In the disc herniation group the hyperextension angle of the metacarpophalangeal joint was smaller (p < 0.001), the relative integral area of the force/angle regression was larger (p < 0.001), the relative area under the secant of the curve (p < 0.01) and the recover value were smaller (p < 0.01). The results suggest that a anulus fibrosus with constitutional reduced extensibility, stress absorption capacity and recovery is disposed to herniation.

[Functional Independence Measure as a predictor of expected rehabilitation outcome in patients with total endoprosthesis replacement and after apoplectic infarct]. / Functional Independence Measure als Prädiktor des zu erwartenden Rehabilitationsergebnisses bei Patienten nach totalendoprothetischer Versorgung und nach apoplektischem Insult.

Functional Independence Measure (FIM) is a method for uniformly recording functional status in rehabilitation patients. It has been under development in the USA since 1985. In this study, the prognostic value of function tests by FIM on admission to the rehabilitation clinic was investigated in two groups (45 patients in all). Thirty-three patients were admitted for rehabilitation following apoplectic shock, the remaining 12 following treatment of fractures of the femoral neck by total hip replacement. A highly significant correlation was found between the total FIM score on admission and the patient's status on discharge. Of the individual functions studied, the activities "dressing and undressing" and "walking/riding in wheelchair" were found have the highest predictive value.

[Effect of constitutional ligament laxity and physical stress on development of patellar tip syndrome]. / Der Einfluss der konstitutionellen Bandlaxität und der körperlichen Belastung auf die Entstehung des Patellaspitzensyndroms.

Studies were performed in order to obtain information on the pathogenesis of patellar tip syndrome (PTS). Using a finger hyperextensiometer, ligamental laxity tests were performed on athletes, non-athletes and controls. Ninety-eight PTS patients who did not indulge regularly in sports, 39 patients from the German federal volleyball league, and 400 healthy controls were examined. No difference in the extensibility of ligaments was found between the patients from the group of competitive athletes and the controls. However, a significantly increased extensibility of the finger joints was found in all age and sex groups with "spontaneous" PTS. The authors conclude that 1) constitutional laxity of the ligaments is a key predisposing factor for PTS, and 2) PTS is triggered by physical stress. Susceptibility to microtrauma at the insertion of the patellar ligament is a function of the constitutional strength of the ligaments.

[Functional analysis of the cervical spine in healthy persons]. / Funktionsanalysen der Halswirbelsäule bei Gesunden.

Radiograms were taken of subjects with no symptoms of cervical spine problems; the cervical spine was evaluated in the spontaneous posture and at maximal flexion and extension. The position and movement of the vertebra, intervertebral height and gliding were calculated. The results showed that (1) lordosis in women occurred less pronounced than in men, and that there was an increase with age; (2) C 2-3 was the least flexible segment and motility increased in the caudal direction; mobility decreased with age and the segments of the lower cervical spine with the highest mobility decreased the most; (3) all posterior and ventral intervertebral heights showed a decrease with age at C 5-6 and C 6-7; (4) vertebral gliding decreased with age.

[Sudden hearing loss and the cranio-cervical junction]. / La hipoacusia brusca y la unión craneocervical.

Morphological alterations of the craniocervical junction as basilar impressions, a ponticulus posterior, an atlas assimilation, an intervertebral narrowing and spondylosis deformans, were found radiologically in patients with sudden hearing loss. There were no radiological differences to a healthy population. No relationship could be established between static morphological changes of the craniocervical junction of the upper cervical spine and the sudden hearing loss. However, there was a statistically significant reduction of the mobility in the upper cervical spine in patients suffering from sudden hearing loss. Very high standard deviations in the atlanto-occipital and the atlanto-odontoid joints are interpreted as hyper- as well as hypomobile joints. These results indicate a possible correlation between sudden hearing loss and a functional pathology of the craniocervical junction.

[Rotator syndrome of the shoulder and mobility of the cervical spine]. / Rotatorensyndrom der Schulter und Beweglichkeit der Halswirbelsäule.

"Painful shoulder" results from different pathogenetic disorders. There is a coincidence of cervical spine and shoulder syndromes. However, a deficit exists of reproducible proof correlation. In this study the motility of cervical spine in patients with painful shoulder syndromes is biometrically measured and compared with control persons. 41 patients and 94 healthy persons had been investigated. Radiograms of the cervical spine had been taken in spontaneous position, in maximal flexion and extension positions. The radiograms had been digitalized according to the technique of Arlen. In addition, vertebral gliding had been analyzed. There was no difference in spontaneous posture of the cervical spine. In patients the total motility was reduced. Regarding the single segments there was less motility in C4/5, C5/6, and C6/7. The physiologic vertebral gliding was diminished in C2/3 and C5/6. The correlation between reduced motility of cervical spine and shoulder pain can be explained by the following ways: 1. Interactions by posture 2. Disorders of muscular balance by nerve root lesions 3. Disturbance of muscle coordination by reflectoric afferences from cervical or shoulder regions. These results demonstrate the complexity of apparently local disorders of the shoulder.

[Sudden deafness and the craniocervical transition]. / Hörsturz und kraniozervikaler Ubergang.

Morphological alterations of the cranio-cervical junction as a basilar impression, a ponticulus posterior, an atlas assimilation, an intervertebral narrowing, and spondylosis deformans were found radiologically. There was no difference to a healthy population. This means there are no correlations between static morphological changes of the craniocervical junction and sudden deafness. However, there was a statistically significant reduced mobility in the upper cervical spine in patients suffering from sudden deafness. Especially very high standard deviations in the atlanto-occipital and the atlanto-dental joint are interpreted as hypermobile as well hypomobile atlas joints. These results indicate a correlation between sudden deafness and functional pathology of the craniocervical junction.

[Polymyography recording in epicondylopathia humeri radialis]. / Polymyographische Ableitungen bei der Epicondylopathia humeri radialis.

The innervation pattern of arm muscles in tennis elbow during defined movement of the wrist was analysed by polymyography. 30 patients with tennis elbow and 40 control persons had been investigated. Dorsal and palmar movements of the wrist joint lifting 5 kg had been performed. The electromyogram of 8 muscles had been registered. There was no abnormality in palmar flexion. The height and integrals of amplitudes in extensor muscles during extension had been considerably smaller. It is suggested that in tennis elbow the dorsal extension is exerted by a smaller number of fibers. This might be the cause of enthesiopathy.