Brugger Concept

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Introduction

The diagnostic and treatment of functional disorders of the locomotor system and the adjacent therapy concept "Brügger Therapy" was developed by Dr. med Alois Brügger, a Swiss neurologist and neurophysiologist. It is mostly used in European and especially German-speaking countries and has been implemented as a standard functional analysis concept into many physiotherapy practices.Brügger conceived his reflexive pain concept after realizing that patients suffering from slip disk are not always freed of symptoms after surgery. He followed the notion that there need to be factors that cause pain similar to nerve root compression. His investigations found that motion patterns typical to modern sitting and akinetic lifestyles cause centrally organized protective reactions, which he called "arthro-tendo-myotic protective reactions". He described different states muscles could be forced into in order to block or encourage certain movements. These states are activated by a central neurological reaction to inhibit activity (hypotendomyosis) or to enhance activity (hypertendomyosis) in a muscle or group of muscles.

Pathoneurophysiology of functional disorders

The central aspect of Dr. Brügger's approach to diagnosis and treatment is the analysis of the posture, stance and motion patterns which the patient uses throughout their daily life. He found out that the protective measures which the body implements to spare damaged (or threatened) tissues are caused by the nociceptive somatomotor blockage effect (NSB). Brügger labelled the origin of the pain, which correlates to the damaged tissue, as Interference factor. The pain experienced by the patient triggers the NSB in order to allow for the affected areas to heal or at least not become more damaged. NSBs reprogramme the physiological patterns of stance, gait, posture, etc. using evasive movements which do not trigger the pain experience. By identifying the interference factors that cause evasive movements, the therapist can readjust the patient's behaviour back to the physiological origin. Since the interference factors are not necessarily located at the point where the patient experiences pain, this often requires an extensive analysis of the body's motion pattern. The concept calls for looking beyond the pain location and identifying reactive chains within the musculoskeletal system.

Locomotion patterns in upright and stooping postures

Under physiological circumstances the human body develops motion patters that work effectively, economically and protectively to the anatomical structures. Essential to this is the upright position of the body, in which all structures operate in the most ergonomic way. When assuming a stooping posture the structures leave their biomechanically optimal position. In the long-term this can cause damage to tissues which are under higher distress induced by the unphysiological positioning. Brügger saw the decrease in quality and quantity of movement through the modern lifestyle as the main cause of increasing pain-related diagnoses.

Functional analysis

Clinical diagnostic of patients with musculoskeletal pain within the Brügger concept includes the typical patient history, pain anamnesis and posture analysis but puts a special focus on involuntary movement patterns and the analysis of daily activities.

Main analysis tool: patient-specific reported test

To measure therapeutic effects in the short- and long-term, the therapist and patient try to find three to five reported tests, which are specific to the patient's problem. These can include the report of pain during a certain motion, a decreased range of motion, a movement or a daily activity that cannot be realized by the patient, etc. Before and after every measure, the test is executed and a short indication whether the reported impairment has increased, decreased or not changed is noted. Results are put on record in a matrix table, which can be continued with as many reported tests and measures as needed. It is recommended to reuse reported tests for as long as they bear witness to an impairment, and to keep track of progress by adding the session date in the interventions.

Example of reported test records

Key: "+" indicates improvement of impairment, "o" indicates no change of impairment, "-" indicates worsening of impairment; effect size is indicated by either putting the note in parentheses for little change "(+)" or by adding one sign "++" for a big change or two signs "+++" for a very big change.

• *NRS: Numeric reporting scale: pain reporting measurement tool on a scale from 1 to 10
• **ROM: range of motion

Patient XYZ		Reported tests
Date of session	Therapeutic intervention	Shoulder joint pain (NRS* 5) during shoulder elevation >90° Flex (while standing)	ROM** of head rotation: right < left (while standing)	Lumbar pain (NRS 3) in spinal extension (while standing)
01.01.2021	Deep abdominal breathing exercise	+	o	++
	Trigger point therapy of Trapezius muscle	(-)	+	o

Biomechanics behind the concept of upright and stooping position

The positioning of the body sections in daily activities and especially during heavy labour are key to functional analysis, according to Brügger. The physiological lordosis can be found in two of the spinal sections, the lumbar spine and the cervical section. Brügger saw the double-S shape of the spine as a combination of two main lordoses. The biomechanical importance of these physiological lordoses to force distribution along the spine was compared to one of a tension band, which counteracts the ventral weight load of the inner organs and arms. Therefore, the physiological shape of the spine is essential to the bipedal, upright posture of humans. When losing the double-S shape through an unhealthy adaption of the posture to a low-motion lifestyle, the load-bearing capacity of the muscles, tendons and bones, as well as all other involved tissues, decreases. When seated, the risk of stooped posture becomes a lot higher than in stance, since the act of standing needs far more muscle activity to keep the balance. Nevertheless, also in stance and gait stooping posture can persist when strength and activation of the erecting muscles are low. In Table 1 the typical joint positions of upright and stooped positions are listed. Similarly, the pattern of unphysiological upper body and arm positioning are flexion-adduction oriented. These (stooped) patterns however are tendencies of motion which are adapted in everyday life more frequent in comparison to their (upright) counterpart. It is not intended to label terminal upright position patterns as ideal positions for posture. Adapting middle range posture and varying positions is considered most effective from a biomechanical point of view.

Table 1. Motion patterns when seated without back-and armrest compared
Upright position	Stooped position
Pelvic extension Hip flexion Hip abduction Hip outward rotation Knee flexion Dorsal extension of talocrural joint Pronation of talotarsal joint Extension, abduction of toes	Pelvic flexion Hip extension Hip adduction Hip inward rotation Little knee flexion Plantar flexion of talocrural joint Supination of talotarsal joint Flexion, adduction of toes

Typical diagnoses

Brügger conceived his reflexive pain concept after realizing that patients with motion patterns typical to modern sitting and akinetic lifestyles often suffer from disharmony within the locomotive system. Typical diagnoses which can be treated effectively by the Brügger therapy concept are problems possibly related to posture/workload or problems which indicate a single cause to the pain, but prove to be resistant to treatment focused on the location of the pain.

Examples:

• Unspecific back pain
• Tennis elbow
• Impingement syndrome
• Neck pain
• Headaches
• Runner's knee

Therapeutical concept

Education and encouraging patient compliance is imperative to therapy outcome, as patients need to understand how their behaviour can influence the therapeutical effects.