Korelacija kliničkog i funkcionalnog sa ultrazvučnim nalazom mišića dubokih stabilizatora lumbosakralnog segmenta kičmenog stuba kod ispitanika sa lumbalnim sindromom

Abstract

Uvod i cilj rada: Lumbalni bol (LB) je veoma učestali i etiološki nehomogen klinički sindrom . U literaturi se, klasično navodi da akutna forma bola u ledjima ne predstavlja veći terapijski problem, ali da oko 10% slučajeva zadobije hroničnu formu. Novija istraživanja ukazuju da čak kod 82% pacijenata sa recidivantim tegobama, bolove osećaju i nakon godinu hronične forme, recidiv i pojava hroniciteta nisu zanemarljivi fenomeni. Nameće se pretpostavka da bi , medju razlozima za to, mogli da budu i nedostaci u proceni i lečenju pacijenata u akutnoj fazi LB. Sa druge strane, sudeći po statistikama dužine lečenja i povratka na posao, hronična forma LB se nedovoljno uspešno tretira. Terapijske preporuke za hronični LB su relativno nekonzistentne i nedovoljno utemeljene na dokazima. Na žalost, evolucija u hroničan lumbalni bol je nedovoljno proučena. Hroničan LB je udružen sa mišićnom slabošću I funkcionalnom onesposobljenoscu. Jedan od često navodjenih faktora hroniciteta je slabost dubokih stabilizatora LS segmenta kicmenog stuba, pre svega m.transversus abdominis (TrA) i m.multifidus lumborum (LM). Dostupni klinicki testovi nam ne daju pun uvid u njihovu funkciju i ne koreliraju sa strukturnim i funkcionalnim promenama koje su zabeležena metodama vizuelizacije i funkcionalnim ispitivanjima. Zlatni standard ispitivanja mišićne aktivacie, iglena EMG, nije idelana metoda za duboke mišiće trupa, posebno za tanak, blizu peritonealne membrane postavljen m.transversus abdominis. Tako, do sada u rutinskom kliničkom radu i istraživackim potrebama za ispitivanje veceg uzorka ispitanika, nije bilo lako objektivno proceniti ni strukturne ni funkcionalne osobine ove muskulature, čija je slabost vezana za hroničan lumbalni bol. Mi ne znamo kakva je priroda te veze izmedju slabosti dubokih stabilizatora lumbalnog segmenta kičmenog stuba i hroničnog bola u ledjima; ne znamo da li je bol uzrokovan tom slabošću ili je njihova slabost deo (mal)adaptacije na bol, ili oba ova fenomena imaju drugu zajedničku podlogu. Ne znamo ni da li postoji bilo kakva veza izmedju najvaznijih kliničkih fenomena u LB koje rutinski ispitujemo i kojima se rukovodimo u krojenju terapijskog koncepta i proceni oporavka pacijenta, kao što su stepen onesposobljenosti, jačina bola, radikulopatski fenomeni (bol, mišićna slabost, senzitivni fenomeni) sa strukturalnim I funkcionalnim promenama dubokih mišića trupa...

Background and aim: Low back pain (LBP) is a highly prevalent clinical syndrome with a heterogenous etiological background. It is usually stated that the acute low back pain has a good natural history and that approximately 10% of these subject develop a chronic form of LBP (cLBP). Recent studies suggest that 82% of non recent-onset patients suffer pain one year later. Even if the prevalence remained within the less pessimistic ranges, recurrent and chronic LB would still represent significant phenomenon with significant socio-economic impact and disease burden which tends to increase in future. The incidence of cLBP could be influenced by the initial evaluation and treatment in the acute phase of LBP. Judging by the estimation of activity limitation and work absence due to cLPB, we have not fully mastered the treatment of the cLBP. The recommendation for therapy are relatively inconsistent and not sufficiently evidence-based. Unfortunately, the evolution from acute to chronic LBP is not completely clarified. CLBP is associated with muscle weakness and disability in the activity of daily living and activities. One of the factors associated with the occurrence of cLBP is incompetent motor control of the muscles that act as deep stabilizers of the lumbar spine, especially transversal abdominal (TrA) and lumbar multifidi (LM) muscle. Structural and functional changes have been identified in these muscles in subjects with cLBP. Unfortunately, routine clinical tests can not give us the full insight into their function. Fine needle electromyography, which is the gold standard in estimation the level of muscle function, is not suitable for deep trunk muscles. So far, the objective assessment of these muscles structure and function in routine clinical practise and research designs which require a larger sample of subjects was not easily feasible. Apart from the described insufficient motor control of the muscles that act as key lumbar stabilizers and cLBP, we do not know whether their morphological and functional deficits, are primary event or adaptive behavior regarding to pain occurrence. We are also not aware if there is any relationship between the most significant clinical phenomenons which we examine in routine clinical practice and by which are we guided while tailoring therapy strategies in subject with LBP, and structural and functional changes in TrA and LM. Attempting to clarify this relationship, the primary aim of this study was to examine the relationship between the clinical parameters, electromyography and measures of transversal abdominal and lumbar multifidi muscle activation acquired by ultrasound...