PROGRAM VJEŽBI ZA KRONIČNU KRIŽOBOLJU KOJI SE TEMELJI NA ZAJEDNIČKIM KLINIČKIM OBILJEŽJIMA BOLESNI

Vjekoslav Grgić

Ciljevi. 1. Odrediti koja su klinička obilježja zajednička bolesnicima s kroničnom križoboljom (KK). 2. Predstaviti program vježbi za KK sastavljen na temelju zajedničkih kliničkih obilježja bolesnika. Ispitanici i metode. U prospektivnu studiju uključili smo 420 bolesnika s nespecifičnom KK (skupina A), 420 bolesnika s KK-om (s radikularnom boli ili bez nje) i degenerativnim promjenama na lumbosakralnoj (LS) kralježnici (skupina B) te 80 bolesnika s KK-om nakon operacije hernije lumbalnog diska (skupina C). Klinička obilježja bolesnika, prije svega obilježja najvažnijih parametara za odabir vježbi, ocjenjivali smo s pomoću fizijatrijskog i manualnoga funkcijskog pregleda. Rezultati. Velika većina bolesnika imala je ova zajednička klinička obilježja: 1. hipertonične/skraćene lumbalne ekstenzore (A: 89,5%, B: 92%, C: 92,5%), 2. hipertonične/skraćene mišiće psoase (A: 83%, B: 90,5%, C: 92,5%), 3. ograničenu aktivnu (A: 71,4%, B: 89%, C: 94%) i pasivnu (segmentnu) pokretljivost (A: 86,4%, B: 92%, C: 95%) LS kralježnice, 4. bolne aktivne pokrete LS kralježnice (A: 44%, B: 88,6%, C: 95%), 5. skoliotično držanje (rjeđe skoliozu) obično u kombinaciji sa smanjenom/izravnanom lumbalnom lordozom (A: 87%, B: 89%, C: 90%), 6. hipotonične/slabe glutealne (A: 51,2%, B: 68%, C: 82,5%) i trbušne mišiće (A: 33,8%, B: 56,4%, C: 60%) i 7. skraćene mišiće stražnje lože natkoljenice (A: 70,7%; ispitivanje fleksibilnosti mišića stražnje lože natkoljenice u bolesnika iz skupine B i C nepouzdano je zbog često pozitivnog Lasegueova znaka). U 6,7% ispitanika iz skupine A, 4,8% ispitanika iz skupine B i 2,5% ispitanika iz skupine C našli smo hipermobilnost LS kralježnice. Naš program vježbi za KK sastavljen na temelju zajedničkih kliničkih obilježja bolesnika uključuje: 1. vježbe istezanja lumbalnih ekstenzora, 2. vježbe istezanja mišića psoasa, 3. vježbe istezanja mišića stražnje lože natkoljenice, 4. vježbe jačanja trbušnih mišića, 5. vježbe jačanja glutealnih mišića i 6. fleksijske vježbe za poboljšanje pokretljivosti LS kralježnice. Zaključak. Naš program vježbi za KK nameće se kao program prvog izbora za liječenje KK. Glavna prednost našeg programa pred standardnim programima ogleda se u ciljanom djelovanju na disfunkcionalne mišiće i hipomobilne fasetne zglobove. Prema rezultatima naše studije ekstenzijske vježbe za jačanje lumbalnih ekstenzora i hiperekstenzijske vježbe za poboljšanje pokretljivosti LS kralježnice nisu prikladne za većinu bolesnika s KK-om.

Aims. 1. To determine which clinical characteristics are common in patients with chronic low back pain (CLBP) and 2. To present an exercise program for CLBP composed on the basis of the common clinical characteristics of patients. The examinees and methods. In the prospective study, we have included 420 patients with nonspecific CLBP (group A), 420 patients with CLBP (with or without radicular pain) and degenerative changes of lumbosacral (LS) spine (group B) and 80 patients with CLBP after a lumbar disc herniation surgery (group C). The clinical characteristics of patients and especially the characteristics of the most important parameters for the selection of exercises have been evaluated by means of physiatric and manual functional examination. Results. The vast majority of patients had these common clinical characteristics:1. hypertonic/shortened lumbar extensors (A: 89,5%, B: 92%, C: 92,5%), 2. hypertonic/shortened psoas muscles (A: 83%, B: 90,5%, C: 92,5%), 3. restricted active (A: 71,4%, B: 89%, C: 94%) and passive (segmental) mobility (A: 86,4%, B: 92%, C: 95%) of LS spine, 4. painful active movements of LS spine (A: 44%, B: 88,6%, C: 95%), 5. scoliotic posture (more rarely scoliosis) usually in a combination with reduced/flattened lumbar lordosis (A: 87%, B: 89%, C: 90%), 6. hypotonic/weak gluteal (A: 51,2%, B: 68%, C: 82,5%) and abdominal muscles (A: 33,8%, B: 56,5%, C: 60%) and 7. shortened hamstrings (A: 70,7%; hamstrings flexibility testing in patients from groups B and C is unreliable because of a frequently positive Lasegue’s sign). In 6,7% of examinees from the group A, 4,8% examinees from the group B and 2,5% examinees from the group C, we have found LS spine hypermobility. Our exercise program for CLBP composed on the basis of the common clinical characteristics of the patients includes: 1. Stretching exercises for lumbar extensors, 2. Stretching exercises for psoas muscles, 3. Stretching exercises for hamstrings, 4. Strengthening exercises for abdominal muscles, 5. Strengthening exercises for gluteal muscles and 6. Flexion exercises for improvement of LS spine mobility. Conclusion. Our exercise program for CLBP comes unavoidably as a program of first choice in CLBP treatment. The main advantage of our program compared to standard programs is reflected in the targeted action on dysfunctional muscles and hypomobile facet joints. According to the results of our study, extension exercises for strengthening of lumbar extensors and hyperextension exercises for improvement of LS spine mobility are not appropriate for the majority of patients with CLBP.