Introduction
Back pain is a major cause of economic losses in manufacturing. The research, conducted in the U.S. indicate that the overall cost of diagnosis, treatment and disability compensation and disability are employed in connection with this pathology has increased from 4.6 billion in 1977 to 11.4 billion dollars in 1994, that allows to relate the disease to one of the most expensive [ 8]. Causes of back pain are very diverse, the most common myofascial, spondylogenic, vistserogennye, psychogenic disorders. Dorsalgia can be divided into two groups: spondylogenic and nespondilogennye [ 2 - 4, 9].
In recent years, researchers' attention was drawn to the primary myofascial pathology as one of the the main pathogenetic factors of pain of the locomotor system [ 1, 5]. However, despite the fairly large number of publications devoted to the diagnosis and treatment of myofascial pain syndrome in the practice of diagnosis and treatment of these disorders presents certain difficulties due to lack of clear distinctive features of the disease, the abundance of terms that describe it, making it difficult to understand the essence of the process, and how a consequence, lead to the appointment of inadequate therapy.
In the complex treatment of back pain is widely used manual therapy aimed at correcting the functional locomotor disturbances and securing the optimal motor stereotype. Of particular interest are opportunities for new soft techniques of manual therapy, which include indirect functional techniques and methods protivorastyazheniya. Indirect functional techniques based on biomechanical mechanisms of the system-level and neuro-muscular control. Indirect technique - a method of moving the lung or bone segments in a direction opposite from the direction of correction as long as the resistance of tissue restraints can be overcome and the tension bilaterally balanced, allowing a relaxed ligaments and muscles themselves to reach its normal position.
Indirect technology is characterized by: - minimal effort for the medical effects, the direction of therapeutic effects is carried out in the direction of maximum relaxation, which manifests a decrease in resistance to pressure monitor finger in dysfunctional segment, the direction of movement are combined and performed in 3 planes for further adjustment of relaxation in inhalation or exhalation phase connects the respiratory mechanism. After overcoming the resistance forces produce a return to the midline. Efficacy of treatment is estimated by a relaxation of segmental tissue restrictions and increase range of motion
[ 6].
The methodology protivorastyazheniya are neurophysiological properties of muscle and fascia to respond to stress relief with restoration of physiological balance - relaxation [ 7]. During the procedure is tender point - the zone with maximum tenderness. After this segment, or extremity with impaired derive motion in 3 planes to the maximum relaxation desired muscle or ligament, or the whole motor chain, which is accompanied by a decrease or complete disappearance of pain. Specially developed search algorithm of tender points and the sequence of movements. This is followed by stage holding a doctor of the patient's body, which lasts 90 seconds. In the course of treatment, the patient remains completely passive, which allows pinpoint location of tender points and eliminate the dysfunction within the physiological tissue barriers.
protivorastyazheniya Principles of the method: the restoration of normal movement patterns in the musculo-skeletal system ; decrease nociceptive input through the creation of long-term myofascial adaptation, and improvement of regional tissue blood supply.
purpose of this study was to investigate clinical features dorsalgia various origins based on the dynamics of integral indicators neuroorthopedic research into the treatment process.
Materials and methods
we examined 460 patients, men - 263 (57,2%) , women - 197 (42,8%) with pain in his lower back. Most patients were aged 30-60 years - 76,7%. To clarify the morphological condition of bone stasctures and the presence of root compression were carried out spondilography or computed tomography. For thermographic studies, we used a thermal imager, "Rubin-2" with the original video controller microprocessor IAC-16, which allows to obtain thermal image on the screen of the monitor with the division of the isotherms of colors (16 colors, with difference in temperature up to 0,1 ° C). We studied the thermal image back, split into 3 zones: cervical, thoracic and lumbar. Electroneuromyographic survey was conducted on 4-channel electromyograph "MBN". Based on analysis of aggregate capacity of motor units (MUP) in the affected muscles, the data obtained were evaluated according to the recommendations and BM Hecht (1990) 5 electromyographic stages denervatsionno-reinnervatsionnogo process. To assess the condition of blood circulation of lower extremities was performed reovasography flexible ribbon electrodes imposed on the proximal and distal parts of the study area. Record reovazogramm performed on 4-channel unit 4RG-2MTS. Along with the visual assessment (regularity, the shape of the curve, the presence and severity of additional waves), investigated the quantitative indicators: rheographic, diastolic and bisferious indices, skewness.
All patients with neuroorthopedic survey is conducted counting "integral pathobiomechanical index (IPBP), comprising the" backbone pathobiomechanical index (PBPP) and pathobiomechanical outcome measures (PBPK). Taken into account when assessing PBPP pain and fixation rates. Fixation rate is composed of dynamic and static components, which include indicators of restrictions of movements in the sagittal, frontal and horizontal planes (flexion, traction, lateroflexion and rotation), with the same name of motion were evaluated only in the direction of the maximum limit, and allow for improvements in the tone of paravertebral muscles in scores the degree of change in physiological lordosis at the lumbar level and degree of scoliosis. In the analysis determined the PBPK muscle tone in the limbs, the severity of peripheral autonomic manifestations, pathology of peripheral joints, severity of pain on palpation of trigger points, their duration and irradiation, and the degree of muscle wasting and the number of trigger points in the affected muscle.
Results and discussion
Patients with musculo-skeletal genesis dorsalgia complained of recurrent pain whining character, in their study of kinaesthetic determined by the active trigger points. At the same time reflected the pain arising from the activation of trigger points, had the area of distribution that does not coincide with the spine. When spondilograficheskom study significant morphological changes were absent or the clinical picture did not match the level of detected radiological signs of degenerative process of the lumbosacral spine, and the pain does not coincide with the zone of innervation of the dermatome, did not change the deep reflexes. In patients with lesions spondylogenic pain were shooting in nature, the spread of pain corresponded to a specific dermatitis, noted the change of deep reflection, X-ray and computed tomography examination was found corresponding changes in the intervertebral disc.
This allowed divide our patients into two groups: I group - 276 people. (60%) with musculoskeletal and II group - 184 people. (40%) with spondylogenic syndromes of the lumbosacral level. Distribution of individual syndromes in groups are presented in Table 1.
Table 1.
distribution of patients in groups syndromes
| Syndrome | I group | II Group | Total |
| lumbodynia | 180 (39,1%) | 74 (16,1%) | 254 (55,2%) |
| sciatica | 96 (20,9%) | 52 (11,3%) | 148 (32,2%) |
| spondylogenic | - | 58 (12,6%) | 58 (12,6%) |
| Total | 276 (60,0%) | 184 (40,0%) | 460 (100%) |
main complaint against a patient in both groups was pain, which is the degree of severity did not differ, but patients of the first group often noted pain whining character, and the second one - to shoot nature, which extends to dermatitis. In analyzing the data neuroorthopedic examination of patients with the syndrome lumbalgia found that patients of group 1 weremorefrequent flexion, and 2 groups - extension device limitations. Flattening the lumbar lordosis weremoreprevalent in group 2 patients, while the tone of paravertebral muscles was significantly higher in patients of Group 1.
patients with the syndrome of sciatica severity of clinical symptoms to a greater extent determined by the musculo- dystonic and muscle-degenerative changes that occur in muscles that undergo mioadaptivnye overload. Limit the amount of active movements in the lumbar spine-dimensional noted in patients of both groups in all directions, but was dominated by flexion and rotation constraints. Flattening the lumbar lordosis weremoreprevalent in group 2 patients. Segmental vegetative disorders in the lower extremities in the form of numbness, coldness, burning, pulse and swelling occurred 2 timesmoreoften in patients in group 2 (23.5% and 46.3%, respectively).
in patients with radicular syndromes revealed reduction or absence of knee-jerk - 34,9%, Achilles - 44,2%, plantar - 16,3% cases, hypoesthesia in the dermatomes L 4 - 11,6%, L 5 - 41,9%, S 1 - 46,5%; and reduced dorsiflexion of the big toe in 39,3% cases . Limit the amount of active movements in the lumbar spine was found in 94% of patients, dominated limit flexion and rotation. Flattening the lumbar lordosis in these patients revealed in 73,6% of cases. Noteworthy are significantly (p <0,01) higher integral pathobiomechanical indicators in patients with spondylogenic nature of the defeat than the musculo-skeletal - 22,29 ± 0,36 and 20,32 ± 0,41, respectively.
treatment results in the two groups are presented in Table 2. Efficacy of treatment was determined as follows:
(IPBP before treatment - after treatment IPBP): IPBP before treatment ' 100%
Table 2.
Dynamics neuroorthopedic indicators in treatment
| Indicators | PBPP (points) | PBPK (points) | IPBP (points) | |||
| Group | First | second | First | second | First | second |
| Pre-treatment | 9,66 ± 0,45 | 10,66 ± 0,35 | 10,72 ± 0,42 | 11,62 ± 0,32 | 20,32 ± 0,41 | 22,29 ± 0,36 |
| After treatment | 6,93 ± 0,35 | 5,39 ± 0,29 | 6,44 ± 0,29 | 7,65 ± 0,26 | 15,85 ± 0,32 | 13,24 ± 0,27 |
| p | <0,01 | <0,01 | <0,01 | <0,01 | <0,01 | <0,01 |
PBPP - pathobiomechanical figure spine,
PBPK - pathobiomechanical figure limbs,
IPBP - integral pathobiomechanical index
When calculating the effectiveness of treatment for patients of the first group the figure was 22,0%, while the second - 40,6%.
Patients 1 - the second group in the survey neuroorthopedic positive trend was due to lower degree of activity of trigger points is to reduce the duration of pain, degree of irradiation of trigger points on palpation, as well as in reducing the muscle tone of the limbs. These differences were confirmed by quantitative evaluation according to tenzoalgimetrii during treatment: at the entrance average was 21,17 ± 2,44 conv, then after the course of treatment were reported higher rates - 28,73 ± 2,32 conv (P <0,05). Patients in group 2 pathobiomechanical indicators spine weremoredynamic, a statistically significant increase in range of motion in the lumbar spine (p <0,01). Also there was a significant (p <0.01) decrease in tone of paravertebral muscles. More pronounced dynamic thermal patterns in the treatment process was observed in patients in group 2 in the projection of the lumbosacral spine. The smallest fluctuations in teplogramm observed in the projection of the joints of the lower extremities in patients in group 2 with dystrophic form of the disease. Repeated electromyographic study of muscles with myofascial trigger points showed that the mean duration of motor units tended to increase on average by 16,3%. Analysis of histograms of durations DE revealed the growth of AE with increasing duration. In the dynamic analysis rheovasography lower extremities in patients with lumbar pain syndromes after treatment was significantly (p <0,01) increased pulse blood filling of the femur and tibia, decreased vascular tone and the asymmetry of the hip, improved vascular reactivity. The most pronounced dynamics of EGR was observed in patients with spondylogenic radiculopathy and sciatica syndrome: a significant reduction of the asymmetry coefficient, accompanied by a decrease in peripheral vascular tone and the normalization of venous outflow on the affected side. Retesting of postural tests showed improvement in vascular reactivity - the majority of patients recorded positive results?? Ktsiya on trial. In general, patients with syndromes spondylogenic dynamics RVG wasmorepronounced.
Thus, despite the difficulty of differential diagnosis dorsalgia, it was found that spondylogenic pain syndromes are characterized by higher integral pathobiomechanical indicators than musculo-skeletal, mainly due tomoresevere restrictions on movement in the spine, vertebral deformities and frequent occurrence of segmental autonomic disorders. When spondylogenic radicular syndromes neuroorthopedic all indicators were significantly higher indicating amoresevere course dorsalgia and allows us to treat this pathology as a syndrome complicated by degenerative disc disease. Dynamics pathobiomechanical violations and indicators of instasmental methods ismorepronounced in patients with spondylogenic dorsalgia as discogenic pain is accompanied by changes in the muscular, articular and ligamentous stasctures. High occurrence dorsalgia and relatively high efficiency of correction pathobiomechanical violations, confirmed the dynamics of neuroorthopedic indicators in the treatment process, indicate the desirability of greater use of soft techniques of manual therapy.
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article was published in the journal vertebral neurology "Volume 8, ¹ 1-2, 2001 .