Brugger Concept

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Original Editor - Anna Fuhrmann
Top Contributors - Anna Fuhrmann, Kim Jackson and Rishika Babburu

Introduction

The diagnostic and treatment of functional disorders of the locomotor system and the adjacent therapy concept "Brügger Therapy" was developed by Dr. med (MD) 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). These protective reactions adapt the movement patterns on a subcortical level. 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 or positions, 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.

Interference factor

According to Brügger's research, interference factors are factors that can provoce a functional symptomatics. Interference factors occur when there are potentially damaged or already damaged structures that cause an adaptation (protective reaction) in the body's movement pattern. Interference factors can include muscolusceletal, internal (organ-related) or neurological damages. Most interference factors are taken care of by the subcortical structures without us noticing. E.g. if a person was sitting for a long time in a slouched position and their body was generally in a healthy condition, the subcortical structures will at some point assume a different position, in which the strain on the structures is shifted and no overload on any tissue will be caused. Only if the summation of nociception, either through persistent interference factors or the combination of multiple interference factors, passes a certain threshold, the protective reaction and a pain sensation will occur.

Typical examples of interference factors are:

• Flexural stress
• Contract muscles
• Mechanical overload oedema (swelling in a muscle caused by excessive or unergonomic use)
• Scars (mostly when rigid or painful to touch)

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.

Brügger conceptualised the wholistic approach to upright posture by constructing the famouse cogwheel model.

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. An illustration is given below in the case example.

Typical case example of a patient with reflexive pain resulting from stooped posture

A patient comes in with acute pain in their right shoulder and a latent pain in their lower back, which has been a condition for a few months. The patient reports no trauma or injury that could be related to the pain. So far all treatment atempts of the shoulder and back have been fruitless. Range of motion (ROM) of the right shoulder is restricted to Flex/Ext 150/0/30 due to pain. The pain occurs delayed when they are sitting in comparison to standing. ROM of head rotation and lumbar extension are both limited as well. The patient history reveals that they had been working a lot of overtime from home in the last two weeks, where no ergonomic office equipment was available. Recreating their working position during therapy, a stooped position becomes apparent. Assuming that this was the predominant working position during working from home, a contraction of the abdominal muscles (and maybe other ventral structures) might be causal interference factors. In a thorough analysis, the insertion of the ventral abdominal muscles (pubic tubercle/ pubic crest through the inguinal ligament) is painful to palpation, indicating an irritation in the area. The therapist therefore targets the abdominal muscles as a key point of intervention. To monitor progress, three reported tests are noted, which are retaken after the intervention (see below). Decontraction techniques that target the contract abdominal muscles loosen the ventral traction and help reach a more erect position. This lowers the NSB which was triggered by the interfering factor (ventral traction and irritation of abdominal muscle incertion). The centrally organised protection programme (the NSB) which caused the shoulder pain and lower back pain is redundant since there is not more potentially damaged structure that needs to be guarded by thwarting extension of the ventral structures.

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	Decontraction of abdominal muscles	+	o	++
	Trigger point therapy of Trapezius muscle	(-)	+	o

This is a simplified example, please note that usually more interference factors play part in the NSB and pain development and a more wholistic approach to the analysis is needed to fully intercept the symptoms.

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 as often as possible 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
• Shoulder impingement syndrome
• Neck pain
• Headaches
• Runner's knee
• Whiplash injuries

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. Practising motion patterns that help reinstate physiological movements in daily life is key in training the patient to become self-effective in pain management and prevention. The therapist's key role is to determine the activities that attribute to the cause of pain in relation to the patient's activities of daily living (ADL). In collaboration with the patient, finding measures that counteract the interference factors sufficiently to cease the nociception which is causing the pain, and adopting strategies which help prohibit the known interference factors from being reactivated.