Background: The use of intraoperative neurophysiological monitoring, including direct nerve stimulation (especially the facial nerve), acoustic evoked potentials (AEP) and somatosensory evoked potentials (SSEP), is a helpful tool in the microsurgery of vestibular schwannoma to prevent nerve injury. Patient characteristics and intraoperative and postoperative variables might also influence the postoperative facial nerve function. The study was performed to investigate these variables and the intraoperative neurophysiological monitoring values. Methods: Seventy-nine patients with vestibular schwannoma were included consecutively into this study. Intraoperative neurophysiological monitoring, including SSEP, AEP, and direct nerve stimulation for facial and trigeminal nerve electromyography, was performed utilizing digital data storage in all cases. The intensity (in volts) of the direct stimulation and the latency (in ms) for the orbicularis oculi and the orbicularis oris muscle and the amplitude (in mV) was measured. Univariate and multivariate statistical analyses concerning the different parameters was performed directly after the operation and in the subsequent follow-ups 3 and 6 months after the operation. Results: The mean intensity was 0.79 V (SD.29). The latency and amplitude for the oris muscle was 5.2ms (SD 2.07) and 0.68mV (SD.57), respectively. The mean latency for the occuli muscle was 5.58ms (SD 2.2) and the amplitude was 0.58mV (SD 1.04). The univariate and multivariate statistical analyses showed significance concerning the postoperative facial nerve function and the amplitude of the direct stimulation of the facial nerve in the orbicularis oris muscle (p = 0.03), so repeated direct nerve stimulation might show FN function deterioration. The mean diameter of the tumors was 24mm (range 10–57mm). Cross total resection and near total was achieved in 76 patients (96%) and subtotal in three patients (4%). The preoperative House–Brakeman score (HBS) 1 was constant in 65 (82%) cases. The mortality in our series was 0%; the overall morbidity was 10%. The HBS was not influenced concerning the extent of resection. The mean follow-up was 28 months (range 6 to 60 months). The limitations of the study might be a low number of patients and the retrospective character of the study. Conclusion: Intraoperative neurophysiological monitoring is crucial in vestibular schwannoma surgery. Repeated direct nerve stimulation and a detected decreased amplitude might show facial nerve function deterioration.

The study proposes an ecosystemic approach as an intervention for attentional difficulties and heightened motor activity, traditionally known as AD/HD. A literature study of AD/HD is presented first as a psycho-educational frame of reference. The focus then shifts to the symtoms of AD/DH to move closer to the possible underlying causes of these symptoms. In doing so, the focus changes from AD/HD as a diagnosis to attentional difficulties and heightened motor activity as presenting symptoms. Attention and motor activity as constructs are investigated in terms of their neuro-anatomical, neuro-chemical and neuro-physiological aspects. Furthermore, neurodevelopment, physiological stress, neurodevelopmental delay, information processing systems, sensory-motor subsystems and integration as constructs are investigated to understand their role in attention and modulation of motor activity. The study of attention and motor activity and their associated neurological factors motivates an alternative, ecosystemic method of intervention. The proposed approach includes an investigation into internal and external biochemical ecosystems such as environmental pollutants, deficiencies of essential nutrients and genetic deficiencies of the immune system. Other aspects such as time, maturation and neurodevelopment are also considered as well as the gentle interplay between these aspects. The therapeutic intervention includes sound therapy, neurodevelopmental movement activities, EEG neurofeedback and nutrition. Experimental research with a sample population of 12 diagnosed grade 4 and 5 AD/HD learners over a 11 week period was conducted. Statistically significant improvements in aspects of attention were noted using 2 standardised instruments and verification through parent interviews in the first and second experimental groups. Statistically significant improvements were noted in aspects of motor activity (a decline in hyperactive behaviour) in the second experimental group with verification from teacher interviews. Additionally, children in the first experimental group improved significantly more than children in the control group with regards to mathematic skills. The second experimental group showed significant improvement with large effect sizes on reading, mathematic skills and spelling. In conclusion, the statistically significant results obtained with the proposed approach motivates implementation, with improvements in attention, motor activity control and academic performance as a prospect. / Psychology of Education / D. Ed.(Psychology of Education)

Much has been researched and written on the concept of intelligence in the last century and while much of it has been applied in educational settings and commercial organisations, little has been investigated and applied within a sports context. Early research in the 1970s identified sport intelligence as comprising primarily of reaction time and recall and it was only in 2002, some 30 years later, that it again appeared in the literature with sport intelligence being considered a psychological characteristic of Olympic champions. The research of Gould, Diffenbach and Moffet (2002) into sport intelligence hypothesised that sport intelligence included having “the ability to analyse, being innovative, being a student of the sport, making good decisions, understanding the nature of elite sport, and being a quick learner” (p. 5). Later research by Blue (2009) proposed a comprehensive model of sport intelligence as it applied to golf wherein he posited that sport intelligence – albeit in a golfing context – comprised a ‘competition’ and ‘developmental’ intelligence. Other than the thematic assessment of Gould et al. (2002) and the golf-specific study of Blue (2009) no literature, data or research was available internationally, on the African continent nor in South Africa. The researcher responded to the call for further research and decided to complete a qualitative, exploratory study in South Africa. The research commenced by covering what was available on sport intelligence literature and to build on it by reviewing and considering general intelligence theories. Both orthodox and unorthodox approaches were considered and the review suggested that sport intelligence would conceptually and theoretically consist of a number of dimensions and constructs including a series of cognitive processes like memory, reasoning, problem solving, decision making and other rational processes. The third source of literature was a review of sport psychology and it emphasised the importance and significance of emotional, motivational and other psychological factors in addition to the influences of personality. The literature review led to the researcher identifying 14 hypotheses which were explored with 15 credible sport participants, whereafter a thorough content analysis of the 14 hypotheses was performed. 13 of the 14 initial hypotheses were accepted with one included as a theme within another. The thematic assessment resulted in the identification and development of a systems model of sport intelligence comprising six components as follows:  A neurophysiological component;  A cognitive/rational component;  An emotional/affective component;  A team/group component;  A societal/ecological component; and  A metaphysical component. The investigation and analyses furthermore indicated that the components do not exist in isolation of one another and each dimension seems of equal significance. The data suggested a parallel process and dynamic interplay between these components and this led to a systemic perspective being adopted when synthesising the model into a logical and coherent framework. Each of the components were critically evaluated from a cognitive and systemic perspective. The systemic perspective proposed challenges the view that performance is not only an individual endeavour but also a systemic endeavour. / Psychology / D. Litt. et Phil. (Consulting Psychology)

Much has been researched and written on the concept of intelligence in the last century and while much of it has been applied in educational settings and commercial organisations, little has been investigated and applied within a sports context. Early research in the 1970s identified sport intelligence as comprising primarily of reaction time and recall and it was only in 2002, some 30 years later, that it again appeared in the literature with sport intelligence being considered a psychological characteristic of Olympic champions. The research of Gould, Diffenbach and Moffet (2002) into sport intelligence hypothesised that sport intelligence included having “the ability to analyse, being innovative, being a student of the sport, making good decisions, understanding the nature of elite sport, and being a quick learner” (p. 5). Later research by Blue (2009) proposed a comprehensive model of sport intelligence as it applied to golf wherein he posited that sport intelligence – albeit in a golfing context – comprised a ‘competition’ and ‘developmental’ intelligence. Other than the thematic assessment of Gould et al. (2002) and the golf-specific study of Blue (2009) no literature, data or research was available internationally, on the African continent nor in South Africa. The researcher responded to the call for further research and decided to complete a qualitative, exploratory study in South Africa. The research commenced by covering what was available on sport intelligence literature and to build on it by reviewing and considering general intelligence theories. Both orthodox and unorthodox approaches were considered and the review suggested that sport intelligence would conceptually and theoretically consist of a number of dimensions and constructs including a series of cognitive processes like memory, reasoning, problem solving, decision making and other rational processes. The third source of literature was a review of sport psychology and it emphasised the importance and significance of emotional, motivational and other psychological factors in addition to the influences of personality. The literature review led to the researcher identifying 14 hypotheses which were explored with 15 credible sport participants, whereafter a thorough content analysis of the 14 hypotheses was performed. 13 of the 14 initial hypotheses were accepted with one included as a theme within another. The thematic assessment resulted in the identification and development of a systems model of sport intelligence comprising six components as follows:  A neurophysiological component;  A cognitive/rational component;  An emotional/affective component;  A team/group component;  A societal/ecological component; and  A metaphysical component. The investigation and analyses furthermore indicated that the components do not exist in isolation of one another and each dimension seems of equal significance. The data suggested a parallel process and dynamic interplay between these components and this led to a systemic perspective being adopted when synthesising the model into a logical and coherent framework. Each of the components were critically evaluated from a cognitive and systemic perspective. The systemic perspective proposed challenges the view that performance is not only an individual endeavour but also a systemic endeavour. / Psychology / D. Litt. et Phil. (Consulting Psychology)

The study proposes an ecosystemic approach as an intervention for attentional difficulties and heightened motor activity, traditionally known as AD/HD. A literature study of AD/HD is presented first as a psycho-educational frame of reference. The focus then shifts to the symtoms of AD/DH to move closer to the possible underlying causes of these symptoms. In doing so, the focus changes from AD/HD as a diagnosis to attentional difficulties and heightened motor activity as presenting symptoms. Attention and motor activity as constructs are investigated in terms of their neuro-anatomical, neuro-chemical and neuro-physiological aspects. Furthermore, neurodevelopment, physiological stress, neurodevelopmental delay, information processing systems, sensory-motor subsystems and integration as constructs are investigated to understand their role in attention and modulation of motor activity. The study of attention and motor activity and their associated neurological factors motivates an alternative, ecosystemic method of intervention. The proposed approach includes an investigation into internal and external biochemical ecosystems such as environmental pollutants, deficiencies of essential nutrients and genetic deficiencies of the immune system. Other aspects such as time, maturation and neurodevelopment are also considered as well as the gentle interplay between these aspects. The therapeutic intervention includes sound therapy, neurodevelopmental movement activities, EEG neurofeedback and nutrition. Experimental research with a sample population of 12 diagnosed grade 4 and 5 AD/HD learners over a 11 week period was conducted. Statistically significant improvements in aspects of attention were noted using 2 standardised instruments and verification through parent interviews in the first and second experimental groups. Statistically significant improvements were noted in aspects of motor activity (a decline in hyperactive behaviour) in the second experimental group with verification from teacher interviews. Additionally, children in the first experimental group improved significantly more than children in the control group with regards to mathematic skills. The second experimental group showed significant improvement with large effect sizes on reading, mathematic skills and spelling. In conclusion, the statistically significant results obtained with the proposed approach motivates implementation, with improvements in attention, motor activity control and academic performance as a prospect. / Psychology of Education / D. Ed.(Psychology of Education)

Les Interfaces Cerveau-Ordinateur basées sur l’Imagerie Mentale (IM-ICO) permettent auxutilisateurs d’interagir uniquement via leur activité cérébrale, grâce à la réalisation de tâchesd’imagerie mentale. Cette thèse se veut contribuer à l’amélioration des IM-ICO dans le but deles rendre plus utilisables. Les IM-ICO sont extrêmement prometteuses dans de nombreuxdomaines allant de la rééducation post-AVC aux jeux-vidéo. Malheureusement, leurdéveloppement est freiné par le fait que 15 à 30% des utilisateurs seraient incapables de lescontrôler. Nombre de travaux se sont focalisés sur l’amélioration des algorithmes de traitementdu signal. Par contre, l’impact de l’entraînement des utilisateurs sur leur performance estsouvent négligé. Contrôler une IM-ICO nécessite l’acquisition de compétences et donc unentraînement approprié. Or, malgré le fait qu’il ait été suggéré que les protocolesd’entraînement actuels sont théoriquement inappropriés, peu d’efforts sont mis en oeuvre pourles améliorer. Notre principal objectif est de comprendre et améliorer l’apprentissage des IMICO.Ainsi, nous cherchons d’abord à acquérir une meilleure compréhension des processussous-tendant cet apprentissage avant de proposer une amélioration des protocolesd’entraînement afin qu’ils prennent en compte les facteurs cognitifs et psychologiquespertinents et qu’ils respectent les principes issus de l’ingénierie pédagogique. Nous avonsainsi défini 3 axes de recherche visant à investiguer l’impact (1) de facteurs cognitifs, (2) de lapersonnalité et (3) du feedback sur la performance. Pour chacun de ces axes, nous décrivonsd’abord les études nous ayant permis de déterminer les facteurs impactant la performance ;nous présentons ensuite le design et la validation de nouvelles approches d’entraînementavant de proposer des perspectives de travaux futurs. Enfin, nous proposons une solution quipermettrait d’étudier l’apprentissage de manière mutli-factorielle et dynamique : un systèmetutoriel intelligent. / Mental-imagery based brain-computer interfaces (MI-BCIs) enable users to interact with theirenvironment using their brain-activity alone, by performing mental-imagery tasks. This thesisaims to contribute to the improvement of MI-BCIs in order to render them more usable. MIBCIsare bringing innovative prospects in many fields, ranging from stroke rehabilitation tovideo games. Unfortunately, most of the promising MI-BCI based applications are not yetavailable on the public market since an estimated 15 to 30% of users seem unable to controlthem. A lot of research has focused on the improvement of signal processing algorithms.However, the potential role of user training in MI-BCI performance seems to be mostlyneglected. Controlling an MI-BCI requires the acquisition of specific skills, and thus anappropriate training procedure. Yet, although current training protocols have been shown tobe theoretically inappropriate, very little research is done towards their improvement. Our mainobject is to understand and improve MI-BCI user-training. Thus, first we aim to acquire a betterunderstanding of the processes underlying MI-BCI user-training. Next, based on thisunderstanding, we aim at improving MI-BCI user-training so that it takes into account therelevant psychological and cognitive factors and complies with the principles of instructionaldesign. Therefore, we defined 3 research axes which consisted in investigating the impact of(1) cognitive factors, (2) personality and (3) feedback on MI-BCI performance. For each axis,we first describe the studies that enabled us to determine which factors impact MI-BCIperformance; second, we describe the design and validation of new training approaches; thethird part is dedicated to future work. Finally, we propose a solution that could enable theinvestigation of MI-BCI user-training using a multifactorial and dynamic approach: an IntelligentTutoring System.

<p>Degenerativne bolesti kičme nastaju kao posledica promena na dinamičkim segmentima kičmenog stuba. Klinički ove promene se mogu manifestovati u vidu radikulopatije, mijelopatije i radikulomijelopatije. Najče&scaron;će primenjivana metoda operativnog lečenja kod ovih pacijenata je prednja cervikalna diskektomija sa fuzijom koja omogućava adekvatnu anatomsku i funkcionalnu restituciju degenerativno promenjene cervikalne kičme. Imajući u vidu da su već kompromitovane nervne strukture u riziku od dodatnih o&scaron;tećenja u različitim fazama operativnog zahvata primena intraoperativnog neurofiziolo&scaron;kog monitoringa je dobila svoje mesto i u hirur&scaron;kim tretmanima degenerativnih oboljenja kičme. Svrha primene neuromonitoringa je da obezbedi povratnu informaciju hirurgu o promenama u funkciji nervnih struktura pre nego &scaron;to dođe do ireverzibilnih o&scaron;tećenja. Na ovaj način moguće je prevenirati nastanak novog ili pogor&scaron;anje postojećeg deficita. Takođe intraoperativni nalazi neurofiziolo&scaron;kih parametara mogu da ukažu na težinu postojećeg oboljenja i da budu prediktori ishoda lečenja. Ciljevi ove doktorske disertacije bili su utvrđivanje faza operativnog zahvata u kojima najče&scaron;će dolazi do promena u neurofiziolo&scaron;kim parametrima, kao i postojanje korelacije nalaza intraoperativnog neurofiziolo&scaron;kog monitoringa sa preoperativnim kliničkim nalazom pacijenta kao i rezultatima procene ishoda nakon prednje cervikalne diskektomije se fuzijom. Ova studija je obuhvatila 30 pacijenata kod kojih je indikovano operativno lečenje degenerativnih promena u vratnom segmentu kičmenog stuba prednjom mikrodiskektomijom sa fuzijom. Preoperativno je izvođen klinički pregled pacijenata i kori&scaron;teni su Numerička skala bola i Upitnik za pacijente sa bolom u vratnoj kičmi, koji su takođe popunjavani na otpustu i mesec dana nakon operacije. U toku hirur&scaron;ke procedure upotrebom intraoperativnog neurofiziolo&scaron;kog monitoringa registrovani su somatosenzorni (SSEP) i motorni evocirani potencijali (MEP), kao i spontana elektromiografija. Kod svih SSEP do&scaron;lo je do statistički značajnog povećanja amplitude (p&lt;0,05), dok je kod desnog n. medianusa zabeleženo i statistički značajno skraćenje latence (p&lt;0,05). Značajne promene se beleže između početka i kraja operativnog zahvata, kao i u fazi uklanjanja intervertebralnog diska kada dolazi do dekompresije. U vrednostima pražne struje potrebne za dobijanje MEP nije bilo statistički značajnih promena izuzev kod m. triceps brachii obostrano. Kod pacijenata sa radikulopatijom vrednost pražne struje za dobijanje mi&scaron;ićnog odgovora je statistčki značajno niža u odnosu na pacijente sa mijelopatijom (p&lt;0,05). SSEP koreliraju sa poremećajem senzibiliteta, refleksnim odgovorom i bolom. MEP koreliraju takođe sa refleksnim odgovorom, dok negativna korelacija sa manuelnim mi&scaron;ićnim testom pokazuje da klinički očuvana gruba mi&scaron;ićna snaga ne mora biti pokazatelj pravog stanja motornog sistema. Preoperativne vrednosti NDI su se statistički značajno smanjile mesec dana nakon operacije (p&lt;0,05). U vrednostima bola postoji statistčki značajna razlika između svih merenje (p&lt;0,008), izuzev između bola na otpustu i mesec dana nakon operacije (p&gt;0,008). Latenca desnog n.medianusa pokazuje negativnu, a amplituda pozitivnu korelaciju sa vrednostima bola mesec dana postoperativno (p&lt;0,05). Povećanje amplitude i skraćenje latence SSEP ukazuje na značajan stepen dekompresije. Stabilnost MEP ukazuje na intraoperativnu očuvanost motornih puteva i da nije do&scaron;lo do novog motornog deficita niti produbljivanja postojećeg. SSEP i MEP koreliraju sa kliničkim nalazom, dok su vrednosti bola i NDI statistički značajno manje nakon operacije. Ovi rezultati ukazuju da klinički nalaz pacijenta korelira sa neurofiziolo&scaron;kim nalazom, kao i da introperativne promene neurofiziolo&scaron;kih parametara mogu biti prediktivni faktor ishoda operativnog lečenja.</p> / <p>Degenerative spinal diseases are consequence of spondylotic changes on dynamic segments of spinal column. These changes can result in different clinical appearances such as radiculopathy, myelopathy and radiculomyelopathy. The most common surgical procedure used in treatment of this group of patients is anterior cervical discectomy and fusion (ACDF) which can provide adequate anatomical and functional restitution of degenerative cervical spine. Considering the fact that already compromised neural structure can be additionally damaged in different stages of surgical procedure, use of intraoperative neurophysiological monitoring (IONM) has role in surgical treatment of degenerative spinal diseases. The aim of use of IONM is to provide real time feedback for surgeon regarding changes in function of neural structures before irreversible damage occurs. This is the way to prevent new neurological deficit from occurring or to prevent worsening of preexisting deficit. Results of intraoperative monitoring can additionally emphasize severity of disease and help in outcome assessment. The aim of this doctoral thesis was to determine phases of surgical procedure in which changes in neurophysiological parameters occurs most commonly. Another aim was to determine correlation between findings of intraoperative neurophysiological monitoring and clinical assessment and outcome prediction in patients treated with anterior cervical discectomy with fusion. Thirty patients who met inclusion criteria were enrolled in this study. All of them were treated surgically due to degenerative changes of cervical spine and ACDF were performed in all cases. Patients were thoroughly examined before surgery. Detailed neurological examination were performed together with Numeric pain rating scale (NPRS) and Neck Disability index (NDI) questionnaire. NPRS and NDI were applied on discharge from the hospital and one month after surgery. During surgery we registered somatosensory evoked potentials (SSEP), motor evoked potentials (MEP) and spontaneous elektromiography. In all SSEP there were statistically significant increase in amplitude (p&lt;0.05), while in the case of right n. medianus statistically significant shortening of the latency (p&lt;0.05) was recorded. Significant changes are recorded between beginning and the end of the surgical procedure, as well as in the phase of removing of the intervertebral disc when decompression occurs. In the threshold intensity needed to elicit the MEP there were no statistically significant changes except for m. triceps brachii bilaterally. In patients with radiculopathy, the value of the stimulus intensity needed for obtaining muscular response was statistically significantly lower in comparison with patients with myelopathy (p&lt;0.05). SSEP showed the best correlation with sensory disorder, tendon reflexes and pain. MEPs also correlate with tendon reflexes, while a negative correlation with a manual muscle strength testing results shows that clinically preserved muscle strength does not have to be reliable indicator of the motor system condition. Preoperative NDI values were statistically significantly reduced a month after surgery (p&lt;0.05). In pain values there is a statistically significant difference between all measurements (p&lt;0.008), except between pain on release and a month after surgery (p&gt;0.008). The right n.medianus latency shows a negative, and the amplitude shows positive correlation with pain values one month postoperatively (p&lt;0.05). Increasing amplitude and shortening latency of the SSEP indicates a significant degree of decompression. The stability of the MEP indicates the intraoperative preservation of motor pathways and absence of both new motor deficiency or worsening of the existing one. SSEP and MEP correlate with clinical findings, while pain and NDI values are statistically significantly less after surgery. These results indicate that clinical findings in the patients correlate with the neurophysiological findings. Results also points out that the intraoperative changes in neurophysiological parameters can be a predictive factor for the outcome of surgical treatment.</p>

La chiropratique est une profession de la santé qui s’intéresse au diagnostic, au traitement, et à la prévention des troubles musculosquelettiques. L’intervention la plus communément utilisée en chiropratique est la manipulation vertébrale (dite « ajustement chiropratique »). D’ailleurs, les consultations en chiropratique sont principalement pour des douleurs vertébrales, particulièrement dans la région lombaire. La lombalgie est la principale cause d'incapacité à travers le monde. Elle engendre des coûts considérables pour la société et les individus atteints. Chez environ un tiers des individus, la lombalgie persiste et devient chronique, entraînant une incapacité et une diminution de la qualité de vie. Chez ces individus, aucun processus pathologique affectant les tissus vertébraux ne peut être mis en évidence. En effet, cette douleur, dite nociplastique, serait plutôt causée par des mécanismes pathologiques du système nociceptif. La lombalgie chronique, dite primaire chez ces individus, est ainsi considérée comme le diagnostic en soi, et non un symptôme secondaire à une pathologie sous-jacente. Chez certains individus, les manipulations vertébrales peuvent soulager la lombalgie chronique primaire. Cependant, leur efficacité comme intervention de première ligne et leurs mécanismes hypoalgésiques restent à démontrer. L'objectif général de cette thèse est d’examiner les mécanismes hypoalgésiques des manipulations vertébrales. Le premier objectif spécifique est d’examiner les mécanismes hypoalgésiques d’une manipulation vertébrale à l’aide d’un modèle expérimental de douleur persistante chez des individus en santé. Le deuxième objectif spécifique est d’examiner les mécanismes du soulagement de la douleur lombaire chronique primaire par une intervention chiropratique de quatre semaines, qui comprend douze séances de manipulations vertébrales. La thèse comprend deux études empiriques, soit une étude expérimentale et une étude clinique, qui sont précédées d’une revue de littérature ciblée. Le premier article est une revue narrative explorant les mécanismes neurophysiologiques de la manipulation vertébrale pour soulager la douleur vertébrale. Le deuxième article décrit les résultats d’une étude expérimentale chez des individus en santé. Dans cette étude, nous avons examiné les mécanismes d'inhibition de la douleur en réponse à une manipulation vertébrale ciblant un segment vertébral dont la peau a été sensibilisée par une application topique de capsaïcine. Le troisième article est une revue narrative examinant l'efficacité des manipulations vertébrales pour le traitement des douleurs vertébrales. Le quatrième article décrit les résultats d’un essai contrôlé randomisé avec groupe placebo chez des individus atteints de lombalgie chronique primaire. Dans cette étude, nous avons examiné si le soulagement de la lombalgie chronique primaire par une intervention chiropratique s’accompagne d’une atténuation de processus pathologiques contribuant à la douleur nociplastique. Les résultats indiquent qu’une manipulation vertébrale peut atténuer l’hyperalgésie mécanique secondaire observée avec le modèle expérimental de douleur persistante. Ceci suggère qu’une manipulation vertébrale pourrait agir sur des processus pathologiques qui mènent à la douleur chronique. Ces résultats sont cohérents avec la réduction de la douleur observée chez les patients atteints de lombalgie chronique primaire recevant des manipulations vertébrales. De plus, la réduction de la lombalgie chronique était accompagnée d’une réduction de l’hyperalgésie mécanique lombaire et de la dramatisation de la douleur. Dans l’ensemble, ces résultats suggèrent qu’une intervention chiropratique comprenant des manipulations vertébrales est efficace pour réduire la lombalgie chronique primaire, et que cet effet pourrait découler en partie d’une réduction de processus contribuant à la douleur nociplastique. Ceci renforce les recommandations cliniques sur l’utilisation de la chiropratique pour le soulagement de la lombalgie chronique primaire. D’autres études seront nécessaires pour clarifier les mécanismes neurophysiologiques et anti-inflammatoires des manipulations vertébrales. / Chiropractic is a health profession focused on the diagnosis, treatment, and prevention of musculoskeletal disorders, mainly through spinal manipulation (also known as "chiropractic adjustment"). The majority of patients consult a chiropractor seeking spine pain relief, primarily in the lower back. Low back pain is the leading cause of global disability, generating considerable costs for society and affected individuals. At least one third of people with low back pain experience persistent pain, leading to chronic disability and a decrease in quality of life. In affected individuals, no pathological process affecting the spinal tissues can be identified. Instead, this pain, called nociplastic, is presumed to be caused by pathological mechanisms within the nociceptive system. Thus, in these individuals, low back pain is considered as chronic primary pain, and not the symptom of an underlying disease. In some individuals, spinal manipulations can relieve chronic primary low back pain. However, their effectiveness as a first-line intervention and their hypoalgesic mechanisms remain to be demonstrated. The overarching aim of this thesis is to examine the hypoalgesic mechanisms of chiropractic spinal manipulations. The first specific objective is to investigate the hypoalgesic mechanisms of a spinal manipulation using an experimental model of persistent back pain in healthy individuals. The second specific objective is to investigate the mechanisms of relief of chronic primary low back pain by a four-week chiropractic intervention, including twelve sessions of spinal manipulations. The thesis includes two empirical studies: an experimental study and a clinical study, both preceded by a targeted literature review. The first study is a narrative review exploring the neurophysiological mechanisms of spinal manipulation to relieve spine pain. The second article describes the results of an experimental trial on healthy individuals, where we examined the mechanisms of pain inhibition following a spinal manipulation targeting a spinal segment sensitized by the topical application of capsaicin The third article is a narrative review examining the effectiveness of spinal manipulation for the treatment of spine pain. The fourth article describes the results of a randomized placebo-controlled trial with individuals suffering from chronic primary low back pain. In this study, we examined whether the relief of chronic primary low back pain by a chiropractic intervention is accompanied by an attenuation of pathological processes contributing to nociplastic pain. The results indicate that a single spinal manipulation can mitigate segmental mechanical hyperalgesia observed with the experimental model of persistent pain. This suggests that spinal manipulations could act on pathological processes that lead to chronic pain. These results are consistent with the pain reduction observed in patients with chronic primary low back pain receiving spinal manipulations. Furthermore, low back pain relief was accompanied by a reduction in mechanical hyperalgesia and in pain catastrophizing. Overall, these results indicate that a chiropractic intervention including spinal manipulations is efficacious in reducing chronic primary low back pain, and that this effect could in part stem from a reduction in processes contributing to nociplastic pain. This reinforces clinical recommendations on the use of chiropractic for the relief of chronic primary low back pain. Further studies will be needed to clarify the neurophysiological and anti-inflammatory mechanisms of spinal manipulations.

<p>Трауматско оштећење мозга (ТОМ) настаје услед дејства спољашње мехничке силе на кранијум и ендокранијални садржај, које се карактерише привременим или трајним неуролошким оштећењем, функционалном онеспособљеношћу или психосоцијалном неприлагођеношћу. Најчешће коришћени предиктори исхода су године повређеног, иницијални Гласгов кома скор (ГКС), статус зеница на пријему, време протекло од момента повређивања до неурохируршког збрињавања, удружене повреде, хипоксија, хипертензија и налаз компјутерско-томографског снимања. Основни циљ истраживања је израда алгоритма ургентног лечења трауматског можданог оштећења и дизајн скале за рану предикцију исхода ТОМ уз додатну анализу појединих фактора на пријему (ГКС, неуролошки налаз, радиолошки налаз, клинички симптоми). Спроведено је ретроспективно и проспективно истраживање којим је обухваћено 568 испитаника који су у периоду од 1.6.2018. до 31.05.2019. лечени унутар Клиничког центра Војводине у Новом Саду због трауматске озледе мозга. Узорак је чинило 34,3% жена и 65,7 % мушкараца. Старосна структура узорка је од 18-96 године (М=56,56; SD=20,17). Свим пацијентима је по пријему начињена радиолошка дијагностика компјутеризованом томографијом (ЦТ), начињен је детаљан физикални и неуролошки преглед, те је детаљно узета анамнеза. Нотирани су следећи подаци: витални параметри (артеријски крвни притисак, сатурација крви кисеоником), статус и повреде других система органа, знаци повређивања главе и врата. За неуролошки преглед је коришћена ГКС скала. За ЦТ преглед је нотирано присуство интракранијалних трауматских лезија и прелома лобање. Резултати овог истраживања указали су на неопходност пажљивог разматрања бројних фактора (радиолошких и клиничких) који се могу испољити већ на самом пријему. Иако ЦТ има висок појединачни допринос предвиђању исхода у моделу са више варијабли није се издвојио као значајан. Пацијенти који су имали дужи период између времена протеклог од момента повређивања до неурохируршког збрињавања имали су бољи исход лечења. Предпоставља се да су пацијенти који су стизали раније у здравствену установу имали тежа трауматска оштећења мозга и самим тим исход је био лошији, док су пацијенти са благим оштећењима долазили касније управо из разлога што манифестације проблема нису биле хитне. Ротердам скала се издвојила добром дискриминативном способношћу када се користи као изолован инструмент. Као најјачи предиктори издвојили су се следећи предиктори: нису показане цистерне на ЦТ-у, присутан САХ, померање више од 5 mm, присутан мали субдурални хематом, присутна велика контузија, примена антиагрегациона тераpија. Успешност предвиђања на основу новог модела је 96%. Резултати студије се могу искористити за боље разумевање ТОМ у смислу лакшег решавања дијагностичких дилема и терапијских, креирање ефикаснијих дијагностичких протокола и прецизније процене исхода након повређивања. Предикција исхода лечења је од великог значаја како би се благовермено направио алгоритам лечења и праћења ових пацијената.</p> / <p>Traumatsko oštećenje mozga (TOM) nastaje usled dejstva spoljašnje mehničke sile na kranijum i endokranijalni sadržaj, koje se karakteriše privremenim ili trajnim neurološkim oštećenjem, funkcionalnom onesposobljenošću ili psihosocijalnom neprilagođenošću. Najčešće korišćeni prediktori ishoda su godine povređenog, inicijalni Glasgov koma skor (GKS), status zenica na prijemu, vreme proteklo od momenta povređivanja do neurohirurškog zbrinjavanja, udružene povrede, hipoksija, hipertenzija i nalaz kompjutersko-tomografskog snimanja. Osnovni cilj istraživanja je izrada algoritma urgentnog lečenja traumatskog moždanog oštećenja i dizajn skale za ranu predikciju ishoda TOM uz dodatnu analizu pojedinih faktora na prijemu (GKS, neurološki nalaz, radiološki nalaz, klinički simptomi). Sprovedeno je retrospektivno i prospektivno istraživanje kojim je obuhvaćeno 568 ispitanika koji su u periodu od 1.6.2018. do 31.05.2019. lečeni unutar Kliničkog centra Vojvodine u Novom Sadu zbog traumatske ozlede mozga. Uzorak je činilo 34,3% žena i 65,7 % muškaraca. Starosna struktura uzorka je od 18-96 godine (M=56,56; SD=20,17). Svim pacijentima je po prijemu načinjena radiološka dijagnostika kompjuterizovanom tomografijom (CT), načinjen je detaljan fizikalni i neurološki pregled, te je detaljno uzeta anamneza. Notirani su sledeći podaci: vitalni parametri (arterijski krvni pritisak, saturacija krvi kiseonikom), status i povrede drugih sistema organa, znaci povređivanja glave i vrata. Za neurološki pregled je korišćena GKS skala. Za CT pregled je notirano prisustvo intrakranijalnih traumatskih lezija i preloma lobanje. Rezultati ovog istraživanja ukazali su na neophodnost pažljivog razmatranja brojnih faktora (radioloških i kliničkih) koji se mogu ispoljiti već na samom prijemu. Iako CT ima visok pojedinačni doprinos predviđanju ishoda u modelu sa više varijabli nije se izdvojio kao značajan. Pacijenti koji su imali duži period između vremena proteklog od momenta povređivanja do neurohirurškog zbrinjavanja imali su bolji ishod lečenja. Predpostavlja se da su pacijenti koji su stizali ranije u zdravstvenu ustanovu imali teža traumatska oštećenja mozga i samim tim ishod je bio lošiji, dok su pacijenti sa blagim oštećenjima dolazili kasnije upravo iz razloga što manifestacije problema nisu bile hitne. Roterdam skala se izdvojila dobrom diskriminativnom sposobnošću kada se koristi kao izolovan instrument. Kao najjači prediktori izdvojili su se sledeći prediktori: nisu pokazane cisterne na CT-u, prisutan SAH, pomeranje više od 5 mm, prisutan mali subduralni hematom, prisutna velika kontuzija, primena antiagregaciona terapija. Uspešnost predviđanja na osnovu novog modela je 96%. Rezultati studije se mogu iskoristiti za bolje razumevanje TOM u smislu lakšeg rešavanja dijagnostičkih dilema i terapijskih, kreiranje efikasnijih dijagnostičkih protokola i preciznije procene ishoda nakon povređivanja. Predikcija ishoda lečenja je od velikog značaja kako bi se blagovermeno napravio algoritam lečenja i praćenja ovih pacijenata.</p> / <p>Traumatic brain injury (TBI) Is defined as temporary or permanent neurological damage, functional disability or psychosocial inadaptability occurring due to effects of external mechanical force to brain and cranium. Mostly used predictors are age, Glasgow coma scale score, pupillary reactivity, time from injury to neurosurgical intervention, combined injuries, hypoxia, hypertension and computed tomography (CT) findings. Basic goal of this research was to analyse TBI and design early outcome prediction scale together with the analysis of individual factors on admission (GCS, neurological status, radiological findings). This research was both retro and prospective and included 568 patients treated for TBI at Clinical centre of Vojvodina in Novi Sad from 01.06.2018. to 31.05.2019. Sample was made out of 34,3% females and 65,7 % males aged from 18 to 96 years ( M=56,56; SD=20,17). All patients had CT diagnostics preformed upon admission, had undergone detailed general and neurological examination and patient&rsquo;s history was taken. Physical examination included: vitals (arterial blood pressure, blood oxygenation), status and injuries of other organs, signs of injury to head and neck. GCS scale was used for neurological examination Computed tomography (CT) included presence of intracranial lesions and skull fractures. Results of this research showed importance of careful observation of multiple factors (radiological and clinical) that can be present at the time of admission. Despite CT having high individual predictive power for outcome, in multiple variable model it was not significant. Patients with longer time elapsed to treatment had better outcome. It is assumed that patients who arrived shortly after injury had severe TBI thus having worse outcome, while patients suffering from mild TBI arrived later and thus had better outcome right because their symptoms of TBI were not very symptomatic. Rotterdam scale showed good disciminative power. The strongest predictors were: CT absence of cisterns, present subarachnoid haemorrhage, midline shift over 5mm, presence of small subdural haematoma, presence of large contusion, presence of antiaggregational therapy. Predictive power based on primary model was 96%. Results of this study can be used for better understanding of TBI in order to solve some diagnostic dilemma, create more efficient diagnostic protocols and facilitate more precise outcome assessment after TBI. Prediction of treatment outcome is very important in order to timely design treatment algorithm of treatment and follow up of TBI patients.</p>