A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction

The morphological and microscopical characteristics of posterior layer of human thoracolumbar fascia; A potential source of low back pain

BACKGROUND

Posterior layer of thoracolumbar fascia (PTLF) is the deep fascia of back of the trunk, which connects the trunk, upper limb and lower limb muscles. Very few cadaveric studies of posterior layer of thoracolumbar fascia (PTLF) are found in the literature, which mention the presence of nerve receptors in it but, quantification of the nerve receptors where not found. Providing the morphological and morphometrical data of PTLF may help the exercise physiologists, sports physicians, occupational health assistants and, physiotherapists to modify or invent new protocol of treatment to help the society.

METHODS

In this study, twenty formalin embalmed human cadavers were used and we have documented the orientation of the PTLF and quantified the number of peripheral nerve endings at the different vertebral levels.

RESULTS

Mean distance of PTLF from vertebral spines to the musculofascial junction was at thoracic region 3.38cm and 3.34cm; at lumbar region, it was 7.4cm and 7.36cm and at sacral region it was 2.98cm and 2.96cm on right and left side, respectively. The angulation of PTLF varies from 18-110 degrees at different vertebral levels. The microscopic data shows the thickness of PTLF and number of nerve endings in the sacral level is increased compared to that of thoracic vertebral levels.

CONCLUSIONS

We have contributed the novel morphological and microscopical details to the limited existing data on PTLF. We also have provided the quantitative data of nerve fibers, which are possible nociceptors of PTLF.

Effects of virtual reality-based neck-specific sensorimotor training in patients with chronic neck pain: A randomized controlled pilot trial

OBJECTIVE

To evaluate the effects of neck-specific sensorimotor training using a virtual reality device compared with 2 standard rehabilitation programmes: with, and without general sensorimotor training, in patients with non-traumatic chronic neck pain.

DESIGN

Pilot randomized control study.

PATIENTS AND METHODS

A total of 51 participants were randomly assigned to 1 of 3 groups: 1: control group; 2: sensorimotor group; 3: virtual reality group. All 3 groups received the clinic's standard rehabilitation programme. Group 2 also received "general sensori-motor training" in the form of group therapy, for a total of 120 min. Group 3 received additional virtual reality-based "neck-specific sensorimotor training" for a total of 120 min. Participants' neck pain, head-aches, active cervical range of motion, and Neck Disability Index were determined before and after 3 weeks of intervention.

RESULTS

Compared with the control group, the virtual reality group showed significant (p < 0.05) advantages in relief of headaches, and active cervical range of motion in flexion and extension. Com-pared with the sensorimotor group, the virtual reality group showed significant improvements in cervical extension.

CONCLUSION

Virtual reality-based sensorimotor training may increase the effects of a standard rehabilitation programme for patients with non-traumatic chronic neck pain, especially active cervical range of motion in extension.

The immediate effect of two lumbar stabilization methods on postural control parameters and their reliability during two balance tasks

Background: Lumbosacral orthosis (LSO) and/or the isolated contraction of the transversus abdominis muscle by the abdominal drawing-in maneuver (ADIM) can increase lumbar stiffness, consequently influencing postural control. The purpose of this study was to compare the effects of LSO and ADIM on postural control during two balance tasks and determine their reliability.Methods: Twenty participants (50% men) randomly performed three experimental conditions: 1) without lumbar stabilization, 2) with LSO), and 3) with ADIM. Each experimental condition was tested in two postural tasks: semi-tandem and one-legged stance on a force platform for 30 seconds, while the Center of pressure postural (COP) parameters were computed.Results: The two methods of lumbar stabilization were comparable and did not significantly reduce the COP values across time, even though a few individuals presented a change in their COP data above the levels of measurement errors. The reliability of these measurements was generally acceptable and sometimes excellent (≥ 0.90 and ≤10% error measurement).Conclusions: Both LSO and isolated contraction of the transversus abdominis muscle by ADIM do not change postural control in one-legged stance and in semi-tandem tasks. These results have implications for use or not these methods for postural control on a rehabilitation perspective.

Comparison of neck extensor muscle endurance and cervical proprioception between asymptomatic individuals and patients with chronic neck pain

INTRODUCTION

Neck extensor endurance (NEE) and cervical proprioception are vital for maintaining cervical spine function and defects in these processes have been associated with chronic neck pain (CNP). The objectives of the study are 1) To investigate the association between NEE and cervical joint position error (JPE) in subjects with CNP; 2) to compare the cervical extensor endurance and cervical JPE of CNP subjects with those of asymptomatic controls; and 3) to determine the relationship between Pain Catastrophizing Scale (PCS) scores, NEE, and cervical JPE in subjects with CNP.

METHOD

Sixty-four participants (32 asymptomatic, 32 with CNP) participated in this comparative cross-sectional study. Cervical proprioception was assessed by measuring the absolute JPE in the sagittal and transverse directions. NEE was assessed using a clinical extensor endurance test. NEE capacity and JPE were compared and correlated between asymptomatic and CNP subjects. Pain catastrophic behavior was assessed using the Pain Catastrophizing Scale (PCS) in CNP subjects.

RESULTS

CNP subjects showed lower NEE capacity (p < 0.001) and significantly larger JPEs (p < 0.001) than asymptomatic participants. NEE negatively correlated with JPEs in all directions (p < 0.001) in asymptomatic subjects and only neck extension errors showed a correlation in CNP subjects (r = -0.45, p = 0.009). PCS scores were negatively correlated with endurance capacity (r = -0.42, p = 0.017) and positively correlated with JPE (flexion: r = 0.57, p = 0.001).

CONCLUSION

CNP subjects showed impaired proprioception and lower endurance capacity compared to asymptomatic participants. Neck extension errors alone correlated with JPE in CNP subjects. PCS scores negatively correlated with NEE in subjects with CNP.

Passive stiffness characteristics and neutral zone quality of the scoliotic lumbar torso in the principle anatomical planes of motion

BACKGROUND

The 1-10% prevalence rate of adult scoliosis frequently requires expensive therapy and surgical treatments and demands further research into the disease, especially with an aging population. Most studies examining the mechanics of scoliosis have focused on in vitro testing or computer simulations. This study quantitatively defined the passive stiffness properties of the in vivo scoliotic spine in three principle anatomical motions and identified differences relative to healthy controls.

METHODS

Adult scoliosis (n = 14) and control (n = 17) participants with no history of spondylolisthesis, spinal fracture, or spinal surgery participated in three different tests (torso lateral side bending, torso axial rotation, and torso flexion/extension) that isolated mobility to the in vivo lumbar spine. The spinal stiffnesses and spinal neutral zone width were calculated. These parameters were statistically compared between factor of population and within factor of direction.

FINDINGS

Torque-rotational displacement data were fit using a double sigmoid function, resulting an in excellent overall fit (Avg. R² = 0.95). There was a significant interaction effect between populations when comparing axial twist neutral zone width vs. lateral bend neutral zone width and axial twist stiffness vs. lateral bend stiffness. The axial twist neutral zone width magnitude was significantly larger in scoliosis patients.

INTERPRETATION

The present study is the first investigation to quantify the whole trunk neutral zone of the scoliotic lumbar spine. Future research is needed to determine if lumbar spine mechanical characteristics can help explain progression of scoliosis and complement scoliosis classification systems.

Low-Back Pain and Knee Position-Related Differences on Postural Control Measures During a One-Legged Stance in Athletes

CONTEXT

Chronic low-back pain (CLBP) may be associated with changes in postural balance in athletes as poor postural control during sports practice.

OBJECTIVE

To compare the postural control of athletes with and without CLBP during 2 one-legged stance tasks and identify the center of pressure (COP) cutoff values to determine the main differences. Designed: A cross-sectional study.

SETTING

Laboratory of functional evaluation and human motor performance.

PARTICIPANTS

A total of 56 male athletes, 28 with and 28 without CLBP (mean age = 26 y).

INTERVENTION

The one-legged stance with knee extension and with the knee at 30° flexion tasks were measured and analyzed on a force platform. The participants completed three 30-second trials (30 s of rest between each trial).

MAIN OUTCOME MEASURES

The COP parameters: the area of COP, mean COP sway velocity in both the anteroposterior and mediolateral directions, and total COP displacement were computed, and a receiver operating characteristics curve analysis was applied to determine the group differences.

RESULTS

Athletes with CLBP had poorer postural control (P < .01) in both tasks. The 30° knee flexion reported more postural instability than the knee extension for all COP parameters (a large effect size d = 0.80).The knee extension cutoffs identified were >7.1 cm2 for the COP area, >2.6 cm/s for the COP sway velocity in the anterior-posterior direction, and >3.2 cm/s for the mediolateral direction. Whereas, the 30° knee flexion cutoffs were >10.9 cm2 for the COP area, >2.9 cm/s for the COP sway velocity in the anterior-posterior direction, and >4.1 cm/s for the mediolateral direction. Both measures showed enough sensitivity and specificity (ie, area under the curve = 0.88 in and 0.80, respectively) to discriminate both groups.

CONCLUSIONS

The athletes with CLBP had poorer postural control than the healthy athletes and obtained specific cutoff scores from the COP values.

The Potential Role of Hepatocyte Growth Factor in Degenerative Disorders of the Synovial Joint and Spine

This paper aims to provide a comprehensive review of the changing role of hepatocyte growth factor (HGF) signaling in the healthy and diseased synovial joint and spine. HGF is a multifunctional growth factor that, like its specific receptor c-Met, is widely expressed in several bone and joint tissues. HGF has profound effects on cell survival and proliferation, matrix metabolism, inflammatory response, and neurotrophic action. HGF plays an important role in normal bone and cartilage turnover. Changes in HGF/c-Met have also been linked to pathophysiological changes in degenerative joint diseases, such as osteoarthritis (OA) and intervertebral disc degeneration (IDD). A therapeutic role of HGF has been proposed in the regeneration of osteoarticular tissues. HGF also influences bone remodeling and peripheral nerve activity. Studies aimed at elucidating the changing role of HGF/c-Met signaling in OA and IDD at different pathophysiological stages, and their specific molecular mechanisms are needed. Such studies will contribute to safe and effective HGF/c-Met signaling-based treatments for OA and IDD.

Pain Catastrophizing Is Related to Static Postural Control Impairment in Patients with Nonspecific Chronic Low Back Pain: A Cross-Sectional Study

Purpose

Pain catastrophizing may contribute to the altered trunk muscle activity in patients with nonspecific chronic low back pain (NSCLBP). It is unclear if pain catastrophizing influences static postural control in patients with NSCLBP. This study aimed to investigate the relationship between pain catastrophizing and static postural control in NSCLBP patients.

Methods

Sixty-eight participants with NSCLBP and 40 healthy participants were recruited. Postural control was assessed by the sway area and the sway length of the center of pressure (COP) during balance tests. Pain catastrophizing in participants with NSCLBP was assessed by the Pain Catastrophizing Scale (PCS). Bilateral transversus abdominis (TrA) activation was evaluated by ultrasound imaging-measured percent change in muscle thickness. Associations between COP parameter and PCS/subscales of PCS were examined by multiple linear regression (MLR).

Results

Our results observed a larger COP sway area in NSCLBP group under eyes-closed condition (p < 0.001) and a lower level of voluntary activation of the bilateral TrA (p < 0.001), compared with the healthy control group. The MLR analyses revealed that the COP area sway under eyes-closed condition was significantly associated with the PCS score/helplessness score of PCS, voluntary activation of the left TrA, and age in participants with NSCLBP (β = 0.222/0.236, 0.341/0.344, and 0.328/0.325; p=0.045/0.033, 0.002, and 0.004, resp.).

Conclusions

Static postural control was associated with pain catastrophizing, voluntary activation of TrA, and age in participants with NSCLBP. This indicated that pain catastrophizing may affect postural control and should be considered when interpreting balance test results and managing NSCLBP.

Comparison between high-velocity low-amplitude manipulation and muscle energy technique on pain and trunk neuromuscular postural control in male workers with chronic low back pain: A randomised crossover trial

BACKGROUND

A therapeutic recommendation for restoring function in individuals with chronic low back pain (CLBP) is manual therapy through manipulative spinal or muscle energy techniques.

OBJECTIVES

To compare the effectiveness of two osteopathic manipulative techniques on clinical low back symptoms and trunk neuromuscular postural control in male workers with CLBP.

METHOD

Ten male workers with CLBP were randomly allocated to two groups: high-velocity low-amplitude (HVLA) manipulation or muscle energy techniques (MET). Each group received one therapy per week for both techniques during 7 weeks of treatment. Pain and function were measured by using the Numeric Pain-Rating Scale, the McGill Pain Questionnaire and the Roland Morris Disability Questionnaire. The lumbar flexibility was assessed by Modified Schober Test. Electromyography (EMG) and force platform measurements were used for evaluation of trunk muscular activation and postural balance, respectively at three different times: baseline, post intervention, and 15 days later.

RESULTS

Both techniques were effective (p < 0.01) in reducing pain with large clinical differences (-1.8 to -2.8) across immediate and after 15 days. However, no significant effect between groups and times was found for other variables, namely neuromuscular activation and postural balance measures.

CONCLUSION

Both techniques (HVLA thrust manipulation and MET) were effective in reducing back pain immediately and 15 days later. Neither technique changed the trunk neuromuscular activation patterns nor postural balance in male workers with LBP.

CLINICAL IMPLICATIONS

These results may facilitate clinical decision-making for CLBP management in physiotherapy programs.

Elasticity standard values of the thoracolumbar fascia assessed with acoustic radiation force impulse elastography on healthy volunteers: A cross section study

INTRODUCTION

Determining the normal values for acoustic radiation force impulse (ARFI) shear wave elastography of the thoracolumbar fascia (TLF) and define possible factors of influence.

METHODS

We measured the shear wave velocity (SWV) in m/s and the diameter (anterior-posterior) in mm of the TLF bilateral in 267 healthy participants with the Acuson S3000™ (Siemens) using the virtual touch image quantification mode (VTIQ). The parameters were tested for correlations with the anthropometric data of the participants, between different age groups and the genders, as well as information obtained from the history, such as smoking and sporting activities.

RESULTS

We determined a mean SWV of 3.28 ± 0.55 m/s for the left thoracolumbar fascia and 3.44 ± 0.55 m/s for the right. The diameter on the right was 2.7 ± 0.8 mm. On the left, it was 2.7 ± 0.9 mm. Neither body mass index (BMI) nor gender had a significant effect on either of the measured parameters (p > 0.05). The same goes for regular medication, sporting activity or the consumption of alcohol (p > 0.05). The results concerning the effect of smoking and age were inconclusive as they only had a significant influence to either the right or the left side of the TLF but not on the other side.

CONCLUSIONS

We collected the normal value for ARFI shear wave elastography of the TLF in 267 healthy participants. Furthermore, neither gender, BMI, sports activity nor the consumption of alcohol affected the elasticity or the diameter of the thoracolumbar fascia.

Systematic reviews evaluating the effectiveness of motor control exercises in patients with non-specific low back pain do not consider its principles - A review

BACKGROUND

Motor control exercise (MCEs), spinal stabilization or core stability exercises were developed with the aim of restoring the coordination, control, and capacity of the trunk muscles and systematic reviews (SR) evaluating their effectiveness has shown conflicting results. This we hypothesized was due to the non-consideration of principles of neuroplasticity. The objective of this review was to review the operating definitions used in these reviews for these exercises and evaluate if these reviews have considered and satisfied the principles of these exercises in persons with NSLBP, both acute and chronic.

METHODS

The available evidence to address the research question was sought in the reviews published in English between January 2006 and April 2019 using the population, intervention, comparison, and outcome format. Data were extracted against the following factors: satisfy the principles of specific inclusion criteria; interventions; experience-dependent plasticity; and measure any one of the concepts of motor control. The quality of the evidence obtained was graded using the National Institute for Health and Care Excellence protocol and the quality of SRs evaluated using the R-AMSTAR.

RESULTS

Eleven reviews on core stability/spinal stabilization exercises and four reviews on MCE were considered in this review. The results showed that most of the studies considered by the reviews did not adhere to the principles of these exercises.

CONCLUSION

There is wide heterogeneity in the understanding, administration, and progression of exercises. The exercises were implemented without considering the potential for neuroplasticity of the nervous system and the principles of motor learning.

Center of rotation locations during lumbar spine movements: a scoping review protocol

OBJECTIVE

The objective of this review is to identify and map current literature describing the center of rotation locations and migration paths during lumbar spine movements.

INTRODUCTION

Altered lumber spine kinematics has been associated with pain and injury. Intervertebral segments' center of rotations, the point around which spinal segments rotate, are important for determining the features of lumbar spine kinematics and the potential for increased injury risk during movements. Although many studies have investigated the center of rotations of humans' lumbar spine, no review has summarized and organized the state of the science related to center of rotation locations and migration paths of the lumbar spine during lumbar spine movements.

INCLUSION CRITERIA

This review will consider studies that include human lumbar spines of any age and condition (e.g. heathy, pathological) during lumbar spine movements. Quantitative study designs, including clinical, observational, laboratory biomechanical experimental studies, mathematical and computer modeling studies will be considered. Only studies published in English will be included, and there will be no limit on dates of publication.

METHODS

PubMed, MEDLINE, Embase, the Cochrane Library Controlled Register of Trials, CINAHL, ACM Digital Library, Compendex, Inspec, Web of Science, Scopus, Google Scholar, and dissertation and theses repositories will be searched. After title and abstract screening of identified references, two independent reviewers will screen the full-text of identified studies and extract data. Data will be summarized and categorized, and a comprehensive narrative summary will be presented with the respective results.

Impairments of Postural Balance in Surgically Treated Lumbar Disc Herniation Patients

Reports on body sway control following microdiscectomy lack reports on side-specific balance deficits as well as the effects of trunk balance control deficits on body sway during upright stances. About 3 weeks post microdiscectomy, the body sway of 27 patients and 25 controls was measured while standing in an upright quiet stance with feet positioned parallel on an unstable support surface, a tandem stance with the involved leg positioned in front or at the back, a single-leg stance with both legs, and sitting on an unstable surface. Velocity, average amplitude, and frequency-direction-specific parameters were analyzed from the center of pressure movement, measured by the force plate. Statistically significant differences between the 2 groups were observed for the medial-lateral body sway frequency in parallel stance on a stable and unstable support surface and for the sitting balance task in medial-lateral body sway parameters. Medium to high correlations were observed between body sway during sitting and the parallel stance, as well as between the tandem and single-legged stances. Following microdiscectomy, deficits in postural balance were side specific, as expected by the nature of the pathology. In addition, the results of this study confirmed the connection between proximal balance control deficits and balance during upright quiet balance tasks.

Measurement and Analysis of Biomechanical Outcomes of Chiropractic Adjustment Performance in Chiropractic Education and Practice

OBJECTIVE

The purpose of this study was to compare biomechanical measures of chiropractic adjustment performance of the McTimoney toggle-torque-recoil (MTTR) technique among students and chiropractors.

METHODS

Fifty-three participants (15 year-3 [Y3] and 16 year-5 chiropractic students and 22 McTimoney chiropractors [DCs]) participated in this study. Each applied 10 MTTR thrusts to a dynamic load cell, 5 each with their left and right hands. Biomechanical variables including preload force, peak force, time to peak force, thrust duration, and total thrust time were computed from each of the force-time histories and compared within groups using a series of 2-way analysis of variance to evaluate the effects of sex and handedness, and between groups to determine the effect of experience using a series of 3-way analysis of variance. The Games-Howell post hoc test was used to further assess pairwise comparisons.

RESULTS

Mean time to peak force was more than 3 × shorter for DCs (69.96 ms) compared with Y3 students (230.36 ms) (P = .030). Likewise, mean thrust duration was also found to be nearly 2.5-fold significantly shorter for DCs (117.77 ms) compared with Y3 students (283.84 ms) (P = .030). The DCs took significantly less total thrust time (mean = 1.27 seconds) in administering MTTR thrusts than Y3 students (1.89 seconds) (P = .006). No significant differences were found among any of the 3 clinician groups for peak force or in time to peak force or thrust duration for comparisons of all 10 MTTR thrusts among year-5 students and DCs. Higher peak forces were observed for thrusts delivered with clinicians' dominant hands (P = .001), and the fastest thrusts were found for the dominant hands of DCs (P = .001). Sex had no significant effect on biomechanical variables. The Y3 students had significant greater variability in thrust times for each hand and for analyses of both hands combined (P = .001).

CONCLUSION

Training and experience were found to result in shorter MTTR thrust times and other biomechanical variables that have been identified as important factors in the mechanisms of chiropractic adjustments. Identification of such biomechanical markers as performance outcomes may be of assistance in providing feedback for training in chiropractic education and technique application.

Injectable Biologics for the Treatment of Degenerative Disc Disease

Purpose of Review

Spinal pain and associated disability is a leading cause of morbidity worldwide that has a strong association with degenerative disc disease (DDD). Biologically based therapies to treat DDD face significant challenges posed by the unique milieu of the environment within the intervertebral disc, and many promising therapies are in the early stages of development. Patient selection, reasonable therapeutic goals, approach, and timing will need to be discerned to successfully translate potential therapeutics. This review provides a brief overview of the status of intradiscal biologic therapies.

Recent Findings

Proposed systemic delivery of therapeutic agents has not progressed very much in large part due to the risk of adverse events in remote tissues plus the very limited vascular supply and therefore questionable delivery to the intervertebral disc nucleus pulposus. Intradiscal delivery of therapeutic proteins shows good potential for clinical trials and translation with encouraging results from large animal pre-clinical studies plus an enhanced understanding of the biology of DDD. There are a few cell-based therapies currently under pre-clinical and clinical trial investigation; however, these attempts continue to be hampered by unknown if any, mechanism of action, no downstream detection of transplanted cells, mixed results concerning efficacy, small sample numbers, and a lack of objective evidence of pain mediation.

Summary

Treatment of DDD using biologically based therapeutics is a widely sought-after goal; however, potential therapies need to address pain and disability in larger, well-controlled studies.

Judokas with low back pain have lower flexibility of the hip-spine complex: A case-control study

OBJECTIVE

Study whether male adult judokas with and without low back pain (LBP) have different hip-spine flexibility.

DESIGN

Cross-sectional.

SETTING

Judo training centres.

PARTICIPANTS

Judokas with (n = 29) and without (n = 33) LBP.

MAIN OUTCOME MEASURES

Range of motion (ROM) (passive and active rotations) of hips, lumbar spine (flexion-extension) and fingertip-to-floor distance (FTFD).

RESULTS

The non-dominant hips of judokas with LBP had 6.8 ± 1.2° (ES:1.45, p < 0.001) lower passive and 8.0 ± 1.3° (ES:1.55, p < 0.001) lower active internal rotation. Dominant hips of judokas with LBP had 5.1 ± 1.6° (ES: 0.81, p = 0.002) lower active internal rotation and 8.8 ± 2.9° (ES:0.79, p = 0.003) lower active total rotation. The LBP group showed 8.0 ± 2.8° (ES: 0.73, p = 0.006) lower flexion and 6.0 ± 2.2° (ES: 0.69, p = 0.009) lower extension of the lumbar spine. The FTFD in the LBP group was 7.3 ± 2.6 cm (ES: 0.72, p = 0.007) lower. The multi-level regression analyses showed passive (OR 1.54, 95%CI 1.18-2.00, p = 0.001) and active (OR 1.47, 95%CI 1.16-1.87, p = 0.001) hip internal rotation of the non-dominant leg and lumbar spinal flexion (OR 1.11, 95%CI 1.03-1.20, p = 0.006) and extension (OR 1.16, 95%CI 1.01-1.33, p = 0.035) were related to LBP.

CONCLUSION

Lower hip internal rotation of the non-dominant leg (passive and active) and lower lumbar flexibility are significantly related to LBP in male adult judokas.

Balance Control in Patients with Subacute Non-Specific Low Back Pain, with and without Lumbar Instability: A Cross-Sectional Study

BACKGROUND

Patients with low back pain (LBP) have poorly coordinated neuromuscular control, which may alter the normal postural stability of the spine. Altered movement control may occur at any stage of LBP.

PURPOSE

(1) To identify differences in balance control and proprioceptive sense between subacute non-specific LBP (NSLBP) patients with and without lumbar instability (LI) and healthy subjects and (2) to investigate the correlation between factors of motor control deficits and balance.

PATIENTS AND METHODS

Thirty-six participants matched by gender, age, and body mass index (BMI) were allocated into three groups of 12: subacute NSLBP patients with LI, subacute NSLBP patients without LI, and healthy subjects. Balance, proprioceptive sense, pain, functional disability, and fear of movement were evaluated.

RESULTS

Subacute NSLBP patients with LI exhibited greater impairments in balance control, proprioceptive sense, and functional ability than patients without LI (p<0.05). Subacute NSLBP patients showed more impairments in balance control, proprioceptive sense, and fear of movement than healthy subjects (p<0.001), with the following effect sizes (partial η2) for static balance on stable and unstable surface: 0.597 and 0.560, anticipatory balance: 0.417, and dynamic balance: 0.536; proprioceptive sense: 0.676; and fear of movement: 0.379. Significant fair correlations were found between (1) static balance and proprioceptive sense, functional disability, and fear of movement; (2) functional reach test (FRT) and pain; and (3) the five times sit to stand test (FTSTS) and functional disability.

CONCLUSION

Subacute NSLBP patients with LI showed greater impairment in balance control than patients without LI. Reduced proprioceptive sense, increased pain, functional disability, and fear of movement were fairly related to impaired balance.

Meta-Analysis of Integrated Therapeutic Methods in Noninvasive Lower Back Pain Therapy (LBP): The Role of Interdisciplinary Functional Diagnostics

Introduction. Lower back pain (LBP) is almost a problem of civilizations. Quite often, it is a consequence of many years of disturbed distribution of tension within the human body caused by local conditions (injuries, hernias, stenoses, spondylolisthesis, cancer, etc.), global factors (postural defects, structural integration disorders, lifestyle, type of activity, etc.), or systemic diseases (connective tissue, inflammation, tumours, abdominal aneurysm, and kidney diseases, including urolithiasis, endometriosis, and prostatitis). Therefore, LBP rehabilitation requires the use of integrated therapeutic methods, combining the competences of interdisciplinary teams, both in the process of diagnosis and treatment. Aim of the Study. Given the above, the authors of the article conducted meta-analysis of the literature in terms of integrated therapeutic methods, indicating the techniques focused on a holistic approach to the patient. The aim of the article is to provide the reader with comprehensive knowledge about treating LBP using noninterventional methods. Material and Methods. An extensive search for the materials was conducted online using PubMed, the Cochrane database, and Embase. The most common noninterventional methods have been described, as well as the most relevantly updated and previously referenced treatment of LBP. The authors also proposed noninvasive (measurable) diagnostic procedures for the functional assessment of the musculoskeletal system, including initial, systematic, and cross-sectional control. All figures and images have been prepared by the authors and are their property.

Results

This review article goes beyond combining a detailed description of each procedure with full references, as well as a comprehensive discussion of this very complex and troublesome problem.

Conclusions

Lower back pain is a serious health problem, and this review article will help educate physicians and physiotherapists dealing with LBP in the options of evidence-based treatment. Ultimately, the article introduces and postulates the need to systematize therapeutic procedures in LBP therapy, with a long-term perspective.

Effectiveness of an Eye-Cervical Re-Education Program in Chronic Neck Pain: A Randomized Clinical Trial

Objectives

Proprioceptive training is popularly applied as a therapeutic exercise method in physiotherapy. Its effects on pain and range of motion are only poorly evaluated. Therefore, this study assesses the effectiveness of proprioceptive training with an Eye-Cervical Re-education Program to decrease pain and increase the joint range in chronic neck pain patients. Material and Methods.

Design

A randomized, no-blinded, controlled clinical trial. Setting. Physiotherapy consultation. Participants. 44 people were divided into two groups. Interventions. All patients were treated with a multimodal physiotherapy intervention. The experimental group was supplemented with an exercise program that included eye-cervical proprioception. Outcomes. The primary outcomes included pain pressure thresholds (upper trapezius, levator scapulae, and splenius capitis) and cervical range of motion. The secondary outcomes included pain measured by the Visual Analogical Scale and the McGillSpv Questionnaire.

Results

The proprioception treatment was effective in reducing the pain pressure threshold in the right upper trapezius (p=0.001), left upper trapezius (p=0.001), left upper trapezius (p=0.001), left upper trapezius (p=0.001), left upper trapezius (p=0.001), left upper trapezius (

Conclusions

The Eye-Cervical Re-education Program is effective at relieving pain pressure thresholds in the upper trapezius, right levator scapula, and left splenius capitis and especially effective for increasing the cervical range of motion. This trial is registered with NCT03197285 (retrospective registration).

Influence of Sarcopenia on the Effect of Exercise Therapy for Elderly Patients with Chronic Low Back Pain

Introduction

Sarcopenia, a condition characterized by decreased skeletal muscle mass, has increasingly been attracting attention in Japan, which has an aged society. The association between chronic low back pain (CLBP) and muscle mass is important. This study aimed to investigate the effect of exercise therapy for CLBP with or without sarcopenia.

Methods

This study was a prospective cohort study. Patients who were aged >65 years during 2017-2018 and had CLBP, with pain lasting >12 weeks and pain intensity being ≥3, were included in the study. The patients were divided into two groups: sarcopenia (S) and nonsarcopenia (NS) groups. The numerical rating scale (NRS) for pain intensity, Roland-Morris Disability Questionnaire (RMDQ), Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), Hospital Anxiety and Depression Scale (HADS), trunk muscle strength, a European Quality of Life instrument, and an NRS of treatment satisfaction were assessed. All patients underwent a high-intensity exercise therapy during 2 weeks of hospitalization and were followed up for 1 and 3 months.

Results

Twenty-eight patients with CLBP were included. The prevalence rate of sarcopenia was 42.9%. The NRS and RMDQ scores and gait function were clinically improved at the end points in all patients with or without sarcopenia. Moreover, high treatment satisfaction was achieved. The quality of life, treatment satisfaction, psychological disorder subscale score of the JOABPEQ, and HADS score tended to be lower in the S group than in the NS group.

Conclusions

Our short-term exercise therapy was effective for low back pain, disability, and gait disturbance in elderly patients with CLBP with or without sarcopenia. However, the prevalence of sarcopenia was high in elderly patients with CLBP. Although low back pain and disability in patients in the S group were improved by exercise therapy, their quality of life and treatment satisfaction might be lower than those of patients without sarcopenia.

Comparison of intra subject repeatability of quantitative fluoroscopy and static radiography in the measurement of lumbar intervertebral flexion translation

Low back pain patients are sometimes offered fusion surgery if intervertebral translation, measured from static, end of range radiographs exceeds 3 mm. However, it is essential to know the measurement error of such methods, if selection for back surgery is going to be informed by them. Fifty-five healthy male (34) and female (21) pain free participants aged 21-80 years received quantitative fluoroscopic (QF) imaging both actively during standing and passively in the lateral decubitus position. The following five imaging protocols were extracted from 2 motion examinations, which were repeated 6 weeks apart: 1. Static during upright free bending. 2. Maximum during controlled upright bending, 3. At the end of controlled upright bending, 4. Maximum during controlled recumbent bending, 5. At the end of controlled recumbent bending. Intervertebral flexion translations from L2-S1 were determined for each protocol and their measurement errors (intra subject repeatability) calculated. Estimations using static, free bending radiographic images gave measurement errors of up to 4 mm, which was approximately twice that of the QF protocols. Significantly higher ranges at L4-5 and L5-S1 were obtained from the static protocol compared with the QF protocols. Weight bearing ranges at these levels were also significantly higher in males regardless of the protocol. Clinical decisions based on sagittal translations of less than 4 mm would therefore require QF imaging.

Baropodometric evaluation of foot load distribution during gait in the group of professionally active nurses

OBJECTIVES

Nurses are extremely exposed to musculoskeletal overloads. Prolonged standing postural balance distributions, functional deficits and pain may affect the symmetry of the load on the feet. The study aimed to assess the distribution of foot load during gait among nurses.

METHODS

The sample of this prospective and observational study consisted of 37 female nurses with mean age of 39 years. The Nordic Musculoskeletal Questionnaire (NMQ) was used to evaluate musculoskeletal disturbances and baropodometric gait analysis (BGA) was performed to register distribution of foot load during gait.

RESULTS

We showed that 68% of nurses declare that they know the principles of workplace ergonomics, but only 14% comply with them. NMQ results indicate that as many as 73% of the respondents feel ailments in the "lower back" area. An asymmetry was observed in the load of IV-V of the metatarsal head between the left and right foot (P = .000) and in the load of the left and right lateral part of the heel (P = .028) in the BGA test. Correlations between ailments occurring in the neck area and loading of the lateral arch of the right foot (P = .032) were found. Moreover, the load in this area correlated positively with the occurrence of "lower back" pain (P = .045).

CONCLUSIONS

Nurses have asymmetric distribution of foot load during gait, which results in a discrepancy between the loads on the three main support points of the foot and which may affect nurses' work productivity.

Individuals With and Without Low Back Pain Use Different Motor Control Strategies to Achieve Spinal Stiffness During the Prone Instability Test

BACKGROUND

The prone instability test is used to identify individuals with low back pain (LBP) who would benefit from trunk stabilization exercises. Although activity from muscles during the leg-raising portion of the prone instability test theoretically enhances spinal stiffness and reduces pain, evidence for this is lacking.

OBJECTIVES

To compare and contrast (1) pain and stiffness changes between prone instability testing positions, and (2) muscle activation patterns during the prone instability test leg raise in individuals with and without LBP.

METHODS

Participants with (n = 10) and without (n = 10) LBP participated in this laboratory case-control study. Spinal stiffness was measured using a beam-bending model and 3-D kinematic data. Stiffness changes were compared across the test positions and between groups. Surface electromyographic data were collected on trunk and limb musculature. Principal-component analysis was used to extract muscle synergies.

RESULTS

Spinal stiffness increased across testing positions in all participants (P<.05). Participants with LBP experienced reduced pain during the test (P<.001). No between-group difference was found in spinal stiffness during leg raising during the test (P>.05). Participants without LBP used 3 muscle synergies during the leg raise and participants with LBP used 2 muscle synergies.

CONCLUSION

Spinal stiffness increased in all participants; however, participants without LBP demonstrated a muscle synergy pattern where each synergy was associated with a distinct function of the prone instability test. Participants with LBP used a more global stabilization pattern, which may reflect a maladaptive method of enhancing spinal stability. J Orthop Sports Phys Ther 2019;49(12):899-907. Epub 3 Aug 2019. doi:10.2519/jospt.2019.8577.

Exploring the role of cervical spine endurance as a predictor of concussion risk and recovery following sports related concussion

BACKGROUND

Concussions have become a significant public health concern with rising incidence rates. Concussions have been shown to occur concurrently with neck injuries, such as whiplash-associated-disorder, therefore, understanding the role of the neck in concussions is important.

OBJECTIVES

To determine if there is a relationship between cervical muscle endurance and either concussion incidence, or concussion recovery in university athletes. Specifically, the primary aim was to investigate a relationship between pre-season deep neck flexor endurance test (DNFET) time in those who sustained an in-season injury versus those who did not. The secondary aim is to determine correlation in DNFET times and concussion recovery.

DESIGN

Longitudinal observational study.

METHODS

Pre-season DNFET was performed on university athletes. In the event of a concussion, cervical endurance and neuromuscular adaptation was re-assessed with the DNFET. Rehabilitative exercises were prescribed, as required, and DNFET was measured at subsequent treatments.

RESULTS

There was no significant difference between pre-season DNFET times and concussion incidence (p = 0.55). However, there was a moderate correlation between DNFET times and concussion recovery (R = 0.47, p = 0.001) whereby DNFET times improved predictively throughout rehabilitation.

CONCLUSIONS

While no statistically significant relationship was found between DNFET and concussion incidence, a significant clinical relationship was present with recovery. The validity of the DNFET test as a means for assessing risk or measuring recovery requires additional research.

Impact of Lifting of Two Types of Barrels on Postural Control, Trunk Muscle Recruitment, and Kinematic Measures in Manual Workers

The aim of this study was to evaluate the impact of 2 types of beer barrels on postural control, trunk activation, and kinematic measures in adult workers. Twelve (12) males randomly performed 4 tasks on a force platform for 20 s: (1) hold an empty recyclable barrel, (2) hold a full recyclable barrel (30 L), (3) hold an empty steel barrel, and (4) hold a full steel barrel (30 L). Trunk muscular activation, force platform and kinematic measures at the trunk, hip, and knee joints were computed. The full steel barrel produced greater postural oscillation than other conditions. Higher trunk activity was also reported during the full steel barrel task. Significant kinematic changes only in the trunk were observed between the empty steel barrel and the full recyclable barrel tasks. In conclusion, the full steel barrel produced a negative impact on postural control, increasing trunk activity and changing trunk flexion angle in adult workers.

Can Biomechanics Research Lead to More Effective Treatment of Low Back Pain? A Point-Counterpoint Debate

SYNOPSIS

Although biomechanics plays a role in the development and perhaps the persistent or recurrent nature of low back pain (LBP), whether biomechanics alone can provide the basis for intervention is debated. Biomechanics, which refers to the mechanics of the body, including its neuromuscular control, has been studied extensively in LBP. But, can gains be made in understanding LBP by research focused on this component of biology in the multifactorial biopsychosocial problem of LBP? This commentary considers whether biomechanics research has the potential to advance treatment of LBP, and how likely it is that this research will lead to better treatment strategies. A point-counterpoint format is taken to present both sides of the argument. First, the challenges faced by an approach that considers biomechanics in isolation are presented. Next, we describe 3 models that place substantial emphasis on biomechanical factors. Finally, reactions to each point are presented as a foundation for further research and clinical practice to progress understanding of the place for biomechanics in guiding treatment of LBP. J Orthop Sports Phys Ther 2019;49(6):425-436. Epub 15 May 2019. doi:10.2519/jospt.2019.8825.

Motor Control Changes in Low Back Pain: Divergence in Presentations and Mechanisms

Compared to healthy individuals, patients with low back pain demonstrate differences in all aspects of trunk motor control that are most often studied as differences in muscle activity and kinematics. However, differences in these aspects of motor control are largely inconsistent. We propose that this may reflect the existence of 2 phenotypes or possibly the ends of a spectrum, with "tight control" over trunk movement at one end and "loose control" at the other. Both may have beneficial effects, with tight control protecting against large tissue strains from uncontrolled movement and loose control protecting against high muscle forces and resulting spinal compression. Both may also have long-term negative consequences. For example, whereas tight control may cause high compressive loading on the spine and sustained muscle activity, loose control may cause excessive tensile strains of tissues. Moreover, both phenotypes could be the result of either an adaptation process aimed at protecting the low back or direct interference of low back pain and related changes with trunk motor control. The existence of such phenotypes would suggest different motor control exercise interventions. Although some promising data supporting these phenotypes have been reported, it remains to be shown whether these phenotypes are valid, how treatment can be targeted to these phenotypes, and whether this targeting yields superior clinical outcomes. J Orthop Sports Phys Ther 2019;49(6):370-379. Epub 12 Jun 2018. doi:10.2519/jospt.2019.7917.

Fascia Is Able to Actively Contract and May Thereby Influence Musculoskeletal Dynamics: A Histochemical and Mechanographic Investigation

Fascial tissues form a ubiquitous network throughout the whole body, which is usually regarded as a passive contributor to biomechanical behavior. We aimed to answer the question, whether fascia may possess the capacity for cellular contraction which, in turn, could play an active role in musculoskeletal mechanics. Human and rat fascial specimens from different body sites were investigated for the presence of myofibroblasts using immunohistochemical staining for α-smooth muscle actin (n = 31 donors, n = 20 animals). In addition, mechanographic force registrations were performed on isolated rat fascial tissues (n = 8 to n = 18), which had been exposed to pharmacological stimulants. The density of myofibroblasts was increased in the human lumbar fascia in comparison to fasciae from the two other regions examined in this study: fascia lata and plantar fascia [H(2) = 14.0, p < 0.01]. Mechanographic force measurements revealed contractions in response to stimulation by fetal bovine serum, the thromboxane A2 analog U46619, TGF-β1, and mepyramine, while challenge by botulinum toxin type C3–used as a Rho kinase inhibitor– provoked relaxation (p < 0.05). In contrast, fascial tissues were insensitive to angiotensin II and caffeine (p < 0.05). A positive correlation between myofibroblast density and contractile response was found (r_s = 0.83, p < 0.001). The hypothetical application of the registered forces to human lumbar tissues predicts a potential impact below the threshold for mechanical spinal stability but strong enough to possibly alter motoneuronal coordination in the lumbar region. It is concluded that tension of myofascial tissue is actively regulated by myofibroblasts with the potential to impact active musculoskeletal dynamics.

Postural cueing increases multifidus activation during stabilization exercise in participants with chronic and recurrent low back pain: An electromyographic study

Persons with low back pain (LBP) have demonstrated altered morphology and function of the deep multifidus (DM). This study examined the effects of postural cueing for increased lumbar lordosis on DM and longissimus thoracis (LT) activation during lumbar stabilization exercises (LSE) performed by persons with LBP. Nine adults with a history of chronic or recurrent LBP were recruited. Fine-wire EMG data was collected while participants performed 10 LSE's in neutral posture and with postural cueing. Percent maximum voluntary isometric contraction of L5 DM and T12 LT, and ratios of activation (DM/LT) were analyzed. There was a significant main effect for posture on DM activation (p < 0.001), indicating greater activation levels during exercises performed with postural cueing vs. neutral posture. LT activation did not increase significantly with postural cueing. Following a significant 1-way repeated measures ANOVA (p = 0.034) for the postural cueing condition, pairwise comparisons demonstrated significantly higher DM/LT activation ratios for prone leg lift, variable-angle Roman chair at 15°, bridging, and bilateral arm and leg lift. These results suggest postural cueing can be used across a range of LSE intensities to increase DM activation without a significant increase in LT activation in patients with chronic or recurrent LBP.

The role of the facet capsular ligament in providing spinal stability

Low back pain (LBP) is the most common type of pain in America, and spinal instability is a primary cause. The facet capsular ligament (FCL) encloses the articulating joints of the spine and is of particular interest due to its high innervation - as instability ensues, high stretch values likely are a cause of this pain. Therefore, this work investigated the FCL's role in providing stability to the lumbar spine. A previously validated finite element model of the L4-L5 spinal motion segment was used to simulate pure moment bending in multiple planes. FCL failure was simulated and the following outcome measures were calculated: helical axes of motion, range of motion (ROM), bending stiffness, facet joint space, and FCL stretch. ROM increased, bending stiffness decreased, and altered helical axis patterns were observed with the removal of the FCL. Additionally, a large increase in FCL stretch was measured with diminished FCL mechanical competency, providing support that the FCL plays an important role in spinal stability.

Quantifying Range of Motion and Stress Patterns at the Transitional Lumbosacral Junction: Pilot Study Using a Computational Model for Load-Bearing at Accessory L5-S1 Articulation

Background

Symptomatic or asymptomatic transitional anomalies at the lumbosacral junction are common occurrences in the population. Lumbosacral (L5-S1) accessory articulations are the most common presentations of transitional anomalies at this region. Such anatomical alterations are believed to be associated with biomechanical changes of load-bearing and movement restrictions leading to low back pain. This study attempts to use computational models of a normal and a lumbosacral transitional vertebrae (LSTV) accessory articulation to analyze and compare the range of motion and loading patterns at the lumbosacral articulations.

Methods

Three-dimensional Finite Element computational models of normal and accessory L5-S1 articulated sacrum were created. These models were tested for range of motion and stress patterns generated at the lumbosacral articulations using similar loading and motion simulation to elicit different moments/excursions at the lumbosacral junctions.

Results

Compared to the normal variant, the transitional model exhibited different range of motion and divergent patterns of stress generation at the lumbosacral and accessory articulations with equal and physiological magnitudes of loading applied to both the models.

Conclusions

The finite element modeling approach can be used for biomechanical investigations in LSTV variants. However, larger sample studies with different LSTV models may be required to statistically compare movement and loading patterns at LSTV-affected lumbosacral and sacroiliac junctions, and to recommend definitive treatment strategies in these situations.

Lumbar stabilisation exercises versus back endurance-resistance exercise training in athletes with chronic low back pain: protocol of a randomised controlled trial

Background

Chronic low back pain (CLBP) is an important disorder in athletes that may negatively affect their performance in competitions. The literature usually recommends physiotherapy based on exercises for back pain management in athletes. Recent evidence suggests that interventions based on lumbar muscle stabilisation exercises (LMSE) and back endurance-resistance exercises (BERE) may improve back pain and function performance. However, it is still unclear which type of exercise is more effective for the treatment of CLBP in athletes.

Objective

To compare the efficacy of LMSE versus BERE in athletes with CLBP.

Design

The study is a 2-arm, prospectively registered, randomised controlled trial.

Setting

The physical therapy clinical and biomechanics laboratory of the UNOPAR University.

Participants

32 male athletes with CLBP, age between 18 and 40 years old, recruited from the local community.

Intervention

An 8-week intervention programme will be carried out with LMSE s versus BERE.

Measurements

Trunk neuromuscular patterns during balance tasks (unipodal and over a ball) using electromyography and force platform parameters, pain, disability, fear and avoidance will be assessed by a blinded assessor at baseline and at follow-up after 8 weeks of intervention period.

Limitations

The absence of blinding intervention and the exclusion of female athletes, seated sports and swimmers will affect the internal and external validity of the study.

Conclusions

The results of this study will elucidate which of these two interventions promote better results in trunk neuromuscular pattern, back pain and function in male athletes with CLBP.

Multiscale modelling of the human lumbar facet capsular ligament: analysing spinal motion from the joint to the neurons

Due to its high level of innervation, the lumbar facet capsular ligament (FCL) is suspected to play a role in low back pain (LBP). The nociceptors in the lumbar FCL may experience excessive deformation and generate pain signals. As such, understanding the mechanical behaviour of the FCL, as well as that of its underlying nerves, is critical if one hopes to understand its role in LBP. In this work, we constructed a multiscale structure-based finite-element (FE) model of a lumbar FCL on a spinal motion segment undergoing physiological motions of flexion, extension, ipsilateral and contralateral bending, and ipsilateral axial rotation. Our FE model was created for a generic FCL geometry by morphing a previously imaged FCL anatomy onto an existing generic motion segment model. The fibre organization of the FCL in our models was subject-specific based on previous analysis of six dissected specimens. The fibre structures from those specimens were mapped onto the FCL geometry on the motion segment. A motion segment model was used to determine vertebral kinematics under specified spinal loading conditions, providing boundary conditions for the FCL-only multiscale FE model. The solution of the FE model then provided detailed stress and strain fields within the tissue. Lastly, we used this computed strain field and our previous studies of deformation of nerves embedded in fibrous networks during simple deformations (e.g. uniaxial stretch, shear) to estimate the nerve deformation based on the local tissue strain and fibre alignment. Our results show that extension and ipsilateral bending result in largest strains of the lumbar FCL, while contralateral bending and flexion experience lowest strain values. Similar to strain trends, we calculated that the stretch of the microtubules of the nerves, as well as the forces exerted on the nerves' membrane are maximal for extension and ipsilateral bending, but the location within the FCL of peak microtubule stretch differed from that of peak membrane force.

Ultrastructure of tendon rupture depends on strain rate and tendon type

Previous research has shown that both the mechanics and elongation mechanisms of tendon and ligament vary with strain rate during tensile loading. In this study, we sought to determine if the ultrastructural damage created during tendon rupture also varies with strain rate. A bovine forelimb model was used, allowing two anatomically proximate but physiologically distinct tendons to be studies: the positional common digital extensor tendon, and the energy storing superficial digital flexor tendon. Samples from the two tendon types were ruptured at rates of either 1%/s or 10%/s. Relative to unruptured control samples, changes to collagen fibril structure were assessed using scanning electron microscopy (SEM), and changes to collagen molecule packing were studied using differential scanning calorimetry (DSC). Rupture at 1%/s caused discrete plasticity damage that extended along the length of collagen fibrils in both the extensor and flexor tendons. Consistent with this, DSC showed molecular packing disruption relative to control samples. Both SEM and DSC showed that extensor tendon fibrils sustained more severe damage than the more highly crosslinked flexor tendon fibrils. Increasing strain rate during rupture decreased the level of longitudinal disruption experienced by the collagen fibrils of both tendon types. Disruption to D-banding was no longer seen in the extensor tendon fibrils, and discrete plasticity damage was completely eliminated in the flexor tendon fibrils, indicating a transition to localized point failure. Ultrastructural damage resulting from tendon rupture depends on both strain rate and tendon type. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2842-2850, 2018.

Aberrant intervertebral motion in patients with treatment-resistant nonspecific low back pain: a retrospective cohort study and control comparison

PURPOSE

Intervertebral kinematic assessments have been used to investigate mechanical causes when back pain is resistant to treatment, and recent studies have identified intervertebral motion markers that discriminate patients from controls. However, such patients are a heterogeneous group, some of whom have structural disruption, but the effects of this on intervertebral kinematics are unknown.

METHODS

Thirty-seven patients with treatment-resistant back pain referred for quantitative fluoroscopy were matched to an equal number of pain-free controls for age and sex. All received passive recumbent flexion assessments for intervertebral motion sharing inequality (MSI), variability (MSV), laxity and translation. Comparisons were made between patient subgroups, between patients and controls and against normative levels from a separate group of controls.

RESULTS

Eleven patients had had surgical or interventional procedures, and ten had spondylolisthesis or pars defects. Sixteen had no disruption. Patients had significantly higher median MSI values (0.30) than controls (0.27, p = 0.010), but not MSV (patients 0.08 vs controls 0.08, p = 0.791). Patients who received invasive procedures had higher median MSI values (0.37) than those with bony defects (0.30, p = 0.018) or no disruption (0.28, p = 0.0007). Laxity and translation above reference limits were not more prevalent in patients.

CONCLUSION

Patients with treatment-resistant nonspecific back pain have greater MSI values than controls, especially if the former have received spinal surgery. However, excessive laxity, translation and MSV are not more prevalent in these patients. Thus, MSI should be investigated as a pain mechanism and for its possible value as a prognostic factor and/or target for treatment in larger patient populations. These slides can be retrieved under Electronic Supplementary Material.

Outcome of Percutaneous Transforaminal Endoscopic Lumbar Surgery in >60-Year-Old Patients with Low Back Pain

Study Design

Retrospective study.

Purpose

To evaluate the outcome of percutaneous transforaminal endoscopic lumbar surgery (PTELS) and to evaluate the efficacy of this technique in the treatment of lumbar disc herniation (LDH) and lumbar spine stenosis (LSS) in >60-year-old patients.

Overview of Literature

There has been number of studies done in aspect of PTELS. All those studies focused on overall clinical aspect with no any age specific analysis. This articles deals with the patient >60 years old with low back pain (LBP) treated with the PTELS. This study provides the details of clinical outcome after the surgery in those age group.

Methods

We retrospectively studied 77 patients aged >60 years; out of these, 45 patients presented with LDH and 22 patients with lumbar spinal stenosis who underwent PTELS.

Results

The mean age of the patients who underwent the surgery was 68.33±6.97 years and the mean duration of the surgery and the postoperative duration of hospitalization were 87.31±24.746 minutes and 79±2.711 days, respectively. The pre- and postoperative Oswestry Disability Index were 52.8022±11.98299 and 16.3513±12.97398 (p <0.05), respectively, indicating statistical significance. The pre- and postoperative visual analogue scale scores of the leg and back were 6.27±1.213 and 4.79±1.162 (p <0.05) and 1.40±1.688 and 1.30±1.436, respectively (p <0.05), which showed a significant difference. Based on the MacNab criteria, 76.1%, 10%, and 6% of the patients showed excellent or good, fair, and poor outcomes, respectively. Incomplete removal of content and reherniation were observed in 3% and 7.5% of the patients. No significant difference was found between the clinical outcomes of PTELS between LDH and LSS.

Conclusions

PTELS can be a good technique in spine surgery to relieve symptoms for LBP with satisfactory outcome, short duration of hospitalization, and advantages such as elimination of general anesthesia in elderly patients.

Do Older Adults and Those Recovered from Low Back Injury Share Common Muscle Activation Adaptations?

Theoretical models suggest trunk muscle activation compensates for spinal systems impairments. The purpose of this study was to determine if two populations (older adults and those recovered from a lower back injury (rLBI)) with spinal system impairments have similar muscle activation patterns to each other, but differ from controls. Trunk electromyograms collected from 12 older adults, 16 rLBI, and 19 controls during two dynamic tasks showed that older adults and rLBI had higher activation amplitudes, sustained temporal and more synergistic activation relative to controls. However, differences found between older adults and rLBI suggest that spinal system impairments differed between groups or that recent pain (rLBI) uniquely influenced muscle activation. This sheds light on our understanding of the relationship between spinal system impairments and muscle activation.

Dynamic multi-segmental postural control in patients with chronic non-specific low back pain compared to pain-free controls: A cross-sectional study

Reduced postural control is thought to contribute to the development and persistence of chronic non-specific low back pain (CNLBP). It is therefore frequently assessed in affected patients and commonly reported as the average amount of postural sway while standing upright under a variety of sensory conditions. These averaged linear outcomes, such as mean centre of pressure (CP) displacement or mean CP surface areas, may not reflect the true postural status. Adding nonlinear outcomes and multi-segmental kinematic analysis has been reported to better reflect the complexity of postural control and may detect subtler postural differences. In this cross-sectional study, a combination of linear and nonlinear postural parameters were assessed in patients with CNLBP (n = 24, 24-75 years, 9 females) and compared to symptom-free controls (CG, n = 34, 22-67 years, 11 females). Primary outcome was postural control measured by variance of joint configurations (uncontrolled manifold index, UI), confidence ellipse surface areas (CEA) and approximate entropy (ApEn) of CP dispersion during the response phase of a perturbed postural control task on a swaying platform. Secondary outcomes were segment excursions and clinical outcome correlates for pain and function. Non-parametric tests for group comparison with P-adjustment for multiple comparisons were conducted. Principal component analysis was applied to identify patterns of segmental contribution in both groups. CNLBP and CG performed similarly with respect to the primary outcomes. Comparison of joint kinematics revealed significant differences of hip (P < .001) and neck (P < .025) angular excursion, representing medium to large group effects (r′s = .36 − .51). Significant (P′s < .05), but moderate correlations of ApEn (r = -.42) and UI (r = -.46) with the health-related outcomes were observed. These findings lend further support to the notion that averaged linear outcomes do not suffice to describe subtle postural differences in CNLBP patients with low to moderate pain status.

Morphology of the lumbar multifidus muscle in lumbar disc herniation at different durations and at different ages

The aim of the present study was to evaluate the relative functional volume of bilateral lumbar multifidus (LM) muscles across different stages and ages of patients with lumbar disc herniation (LDH). The relative functional volumes of LM muscles in both non-affected and affected sides in the L4-L5 and L5-S1 segmental level were measured in a resting prone position, and visual analogue score (VAS) for pain and Japanese Orthopedic Association (JOA) scores were recorded. The correlation between changes in the relative net volume of LM muscles and times of onset, ages, VAS and JOA scores were analyzed. A total of 327 cases were selected. The affected sides of LM muscles could present a certain degree of atrophy in stages >3 weeks. During the duration of the course, all cases presented different degrees of LM muscle atrophy. In addition, the degree of LM muscle atrophy was positively correlated with its duration. Age could influence the degree of LM muscle atrophy. Patients with unilateral LDH had <10% asymmetry on relative functional volume in the youth group. At the L4-L5 segments, patients with unilateral LDH had >10% asymmetry within the course of 3 months in the elderly group. The reduced rate of the relative functional net LM muscle volume was positively correlated with VAS scores, age, duration and JOA scores. In conclusion, the reduced rate of relative functional net LM muscle volume was positively correlated with age, duration, VAS scores and JOA scores. Although these findings are unreliable markers of lumbar pathology in an individual level for use in clinical or research settings, there is a notable importance of early intervention in LM muscle atrophy.

Is standing balance altered in individuals with chronic low back pain? A systematic review

PURPOSE

To examine the static standing balance of individuals with chronic low back pain when compared to a healthy control group.

METHODS

A search of available literature was done using PubMed, SPORTDiscus, CINAHL, and Scopus databases. Studies were included if they contained the following: (1) individuals with chronic low back pain 3 months or longer; (2) healthy control group; (3) quantified pain measurement; and (4) center of pressure measurement using a force plate. Two authors independently reviewed articles for inclusion, and assessed for quality using the Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross Sectional Studies. Cohen's d effect size was calculated to demonstrate the magnitude of differences between groups.

RESULTS

Nine articles were included in this review. Quality scores ranged from 5/8 to 8/8. Although center of pressure measures were nonhomogeneous, subjects with chronic low back pain had poorer performance overall compared to healthy controls. Despite inconsistencies in statistical significance, effect sizes were frequently large, indicating a lack of sufficient power in the included studies. Data were insufficiently reported among certain studies, limiting the ability of direct study comparison.

CONCLUSIONS

Results suggest that balance is impaired in individuals with chronic low back pain when compared to healthy individuals. Implications for rehabilitation Static balance is affected in individuals with chronic low back pain. Balance assessments should be completed for individuals with chronic low back pain. Results from balance assessments should be used to indicate areas of improvement and help guide the course of treatment, as well as reassess as treatment progresses.

Relationship Between Proprioception and Endurance Functionality of the Cervical Flexor Muscles in Chronic Neck Pain and Asymptomatic Participants

OBJECTIVE

The purpose of this study was to compare the relationship between flexion endurance capacity and joint position error in participants with or without chronic neck pain (CNP).

METHODS

Sixty-one CNP and 60 asymptomatic volunteers participated in this cross-sectional, case-control, and correlational analysis study. The measured variables included absolute and constant joint repositioning errors in the sagittal and horizontal directions, clinical flexor endurance test score, pain intensity, and neck disability index.

RESULTS

The groups did not statistically differ in flexion endurance (P > .05). The CNP group had a smaller absolute error on the right (P < .01) and left (P = .01) rotation and an overshooting error pattern in the flexion direction (P < .05). But the asymptomatic group did not exhibit any over-/undershooting pattern tendency (P > .05). Although flexion endurance was not correlated with any of the joint repositioning error components in either group, pain and disability scores were significantly correlated with left rotation absolute error (r = -0.34 and ρ = -0.37, respectively).

CONCLUSION

The clinical cervical flexor endurance test, ignoring the relative contribution of the deep and superficial groups of muscles, may not efficiently characterize CNP patients.

Muscle Control and Non-specific Chronic Low Back Pain

Objectives

Chronic low back pain (CLBP) is the most prevalent of the painful musculoskeletal conditions. CLBP is a heterogeneous condition with many causes and diagnoses, but there are few established therapies with strong evidence of effectiveness (or cost effectiveness). CLBP for which it is not possible to identify any specific cause is often referred to as non‐specific chronic LBP (NSCLBP). One type of NSCLBP is continuing and recurrent primarily nociceptive CLBP due to vertebral joint overload subsequent to functional instability of the lumbar spine. This condition may occur due to disruption of the motor control system to the key stabilizing muscles in the lumbar spine, particularly the lumbar multifidus muscle (MF).

Methods

This review presents the evidence for MF involvement in CLBP, mechanisms of action of disruption of control of the MF, and options for restoring control of the MF as a treatment for NSCLBP.

Results

Imaging assessment of motor control dysfunction of the MF in individual patients is fraught with difficulty. MRI or ultrasound imaging techniques, while reliable, have limited diagnostic or predictive utility. For some patients, restoration of motor control to the MF with specific exercises can be effective, but population results are not persuasive since most patients are unable to voluntarily contract the MF and may be inhibited from doing so due to arthrogenic muscle inhibition.

Conclusions

Targeting MF control with restorative neurostimulation promises a new treatment option.