Back extensor muscle fatigue in patients with lumbar disc herniation. Pre-operative and post-operative analysis of electromyography, endurance time and subjective factors

The effects of Pilates on pain, functionality, quality of life, flexibility and endurance in lumbar disc herniation

Aim: To assess the effects of clinical Pilates exercises (CPE) on the level of pain, functional status, flexibility, static and dynamic endurance of the trunk muscles and quality of life (QoL) in patients with lumbar disc herniation. Materials & methods: Individuals were divided into two groups: the CPE (6 weeks, three-times a week) group (n = 27) and the control group (n = 27). The clinical outcome measures were the visual analog scale for the evaluation of the pain intensity, Oswestry disability index for functional disability, short form-36 for health related QoL, sit and reach and hand finger floor distance test for the flexibility, side-bridge and sit-ups test for the static and dynamic endurance. Results: At the end of the 6 weeks the amount of decrease in the level of pain and Oswestry disability index, amount of increase in sit-reach test and hand-finger-to-floor distance, duration of the lateral bridge and sits-ups test and most of the short form-36 sub parameters was significantly higher (p < 0.05) in the CPE group. Conclusion: CPE was an effective and safe method for symptomatic patients with lumbar disc herniation in reducing the pain level and functional disability and improving flexibility, static and dynamic endurance and partially their QoL. Clinical Trial Registration: NCT03198273 (ClinicalTrials.gov).

Effects of Complex Rehabilitation Program on Reducing Pain and Disability in Patients with Lumbar Disc Protrusion—Is Early Intervention the Best Recommendation?

(1) Background: Due to its frequency and possible complications, low back pain (LBP) has a high social impact, it is a common problem of the active population and the second reason for visiting a physician. In patients with lumbar disc protrusion (LDP), one of the most common causes of LBP, the nucleus pulposus bulges against the disc and then protrudes into the spinal cord, but the annulus fibrosus remains intact; (2) Objectives: The primary objective of this study was to determine the efficacy of a rehabilitation treatment (RT) comprising electrotherapy (ET), hydrotherapy (HT) and individualized physical therapy (PT) versus ET alone in patients with LDP. The second objective was to investigate whether there is a correlation between early RT and the symptomatology of patients with LDP; (3) Methods: The research was conducted between July 2021 and January 2022 at the Ceres Hotel Treatment Centre from Baile 1 Mai, Romania, and all the study subjects signed an informed consent form. For this study, the block randomization method was used to randomize subjects into groups that resulted in equal sample size, in order to maintain a reasonably good balance among groups. Therefore, the two groups had the same number of subjects (30 subjects) and the randomization was made taking into account the patient’s motivation or the subject’s willingness to receive not only electrotherapy treatment, but also the physical exercises and hydrotherapy. The eligibility criteria were: low back pain for more than three months, an MRI confirmed diagnosis of LDP (without dural compression), and ability to perform a PT program. The control group received only a classical ET program. In addition, the patients in the experimental group received a complex individualized PT program associated with HT and ET. To achieve these objectives, the study subjects were monitored for spinal mobility (lateral lumbar flexion—LLF, index fingers-ground—IFG, lumbar Schober tests for flexion—LS, Inverted Schober test for extension—ILS), trunk flexor and extensor muscle strength (LF strength, LE strength), level of pain (Short Form McGill Pain Questionnaire—SF-MPQ, Visual Analogue Scale—VAS), and the degree of limitation in activities of daily living (Oswestry Disability Index—ODI); (4) Results: Comparing the evolution of the subjects, using the One-Way ANOVA between groups, we observed a significant improvement in all variables [SF-MPQ (95% CI, 7.996/11.671), VAS (95% CI, 1.965/3.169), mobility FTF (95% CI, −7.687/−3.940), LS (95% CI, 2.272/2.963), LE strength (95% CI, −5.676/−3.324), LF strength (95% CI, −5.970/−3.630), disability (95% CI, 8.026/10.441) after six months of treatment for the experimental group subjects. A clear correlation was found, using the Bravis–Pearson test, between the earliest possible initiation of RT and improvement of patients’ symptoms; (5) Conclusion: The current study proves the importance of combining ET with HT and PT. The earlier the RT is implemented, the lower the pain perception and level of disability associated with the lumbar disease.

Gender differences in multifidus fatty infiltration, sarcopenia and association with preoperative pain and functional disability in patients with lumbar spinal stenosis

BACKGROUND

In patients with lumbar spinal stenosis, female gender has been associated with higher pain and functional disability. Sarcopenia and multifidus atrophy have also been associated with symptomatic severity.

PURPOSE

The purpose of this study was to determine if gender differences in sarcopenia and multifidus atrophy are associated with gender disparities in disease symptomatology.

STUDY DESIGN

Prospectively collected medical records and imaging studies were retrospectively reviewed.

PATIENT SAMPLE

We retrospectively reviewed medical records and imaging studies for 63 patients with clinically and radiologically defined lumbar spinal stenosis at L3/4 or L4/5 who underwent minimally invasive decompression.

OUTCOME MEASURES

Pain and functional disability were measured using the Oswestry Disability Index (ODI) and visual analogue scores for back pain (VASB) and leg pain (VASL).

METHODS

Multifidus total cross sectional area (tCSA), multifidus functional cross sectional area (fnCSA), multifidus fatty infiltration (FI), psoas tCSA, and psoas relative cross sectional area (rCSA) were evaluated by univariable and multivariable regression to identify gender linked and gender independent predictors of higher ODI, VASB, and VASL.

RESULTS

Female gender was significantly associated with lower multifidus fnCSA (p < .001), higher multifidus FI (p < .001), lower psoas tCSA (p < .001), lower psoas rCSA (p = .002), and higher preoperative ODI (p = .008). Lower psoas rCSA (p = .044) and psoas tCSA in the lowest sex specific quartile (p = .034) were significantly associated with higher preoperative VASB and psoas rCSA less than the sex specific median (p = .050) was significantly associated with higher preoperative VASL after controlling for age and gender. Multifidus FI was significantly associated with preoperative ODI after adjusting for age (p = .048) but not after controlling additionally for gender (p = .651).

CONCLUSIONS

Female patients with lumbar spinal stenosis may develop more severe and functionally significant multifidus atrophy, resulting in a more severe clinical course with higher functional disability. Sarcopenia was significantly associated with higher preoperative back pain and leg pain in both male and female patients with lumbar spinal stenosis.

Dysfunctional muscle activities and co-contraction in the lower-limb of lumbar disc herniation patients during walking

This study aimed to investigate lower-limb muscle activities in gait phases and co-contraction of one gait cycle in patients with lumbar disc herniation (LDH). This study enrolled 17 LDH patients and 17 sex- and age-matched healthy individuals. Bilateral muscle activities of the rectus femoris (RF), biceps femoris long head (BL), tibialis anterior (TA), and lateral gastrocnemius (LG) during walking were recorded. The gait cycle was divided into four phases by the heel strike and top off according to the kinematics tracks. Root mean square (RMS), mean frequency (MF), and co-contraction of surface electromyography signals were calculated. The LDH patients showed enhanced BL RMS during the single support phase (SS), second double support phase, and swing phase (SW) as well as decreased MF of RF during SS and of TA and LG during SW (p < 0.05). The co-contraction of the TA-LG was increased in LDH patients than in the control group (p < 0.05). Positive correlations were observed between TA-LG co-contraction (affected side, r = 0.557, p = 0.020; contralateral side, r = 0.627, p = 0.007) and the Oswestry disability index scores in LDH patients. LDH patients have increased BL firing rate and insufficient motor unit recruitment in specific phases in the lower limbs during walking. Dysfunction in LDH patients was associated with immoderate intermuscular co-contraction of the TA-LG during walking.

The Relevance of Dual Tasking for Improving Trunk Muscle Endurance After Back Surgery

OBJECTIVE

To determine the effect of dual tasking on trunk muscle endurance in patients after lumbar diskectomy.

DESIGN

Cross-sectional study.

SETTING

Rehabilitation hospital setting.

PARTICIPANTS

Individuals (N=14) undergoing primary lumbar diskectomy.

INTERVENTION

Using a randomized design on 2 separate days, muscle endurance was evaluated during prone bridging and Biering-Sorensen tests. Each test was randomly performed under 2 cognitive conditions: single task without cognitive condition and self-regulated dual task (ie, mathematical task).

MAIN OUTCOME MEASURES

The primary outcomes were time to failure and pain assessed by the visual analog scale from 0 to 100 mm. The secondary outcomes were kinesiophobia assessed by the Tampa Scale and disability assessed by the Oswestry Disability Index. Associations were tested using a repeated measures analysis of variance with relevant interaction test.

RESULTS

A significant interaction between condition, endurance tests, and kinesiophobia (P=.005) was found. The post hoc comparison showed positive effects between cognitive conditions in both endurance tests (prone bridging test: mean difference, 15.7s; 95% confidence interval [CI], 7.5-24s; P=.001; Biering-Sorensen test: mean difference, 7.9s; 95% CI, 1.9-14s; P=.014). The linear regression analysis between the Tampa Scale for Kinesiophobia and the difference of time to failure between cognitive conditions showed a positive correlation only during the Biering-Sorensen test (r=0.80; P=.001).

CONCLUSIONS

A self-regulated dual task increases trunk muscle endurance in patients after lumbar diskectomy. The results suggest that the difference observed in time to failure between the single task and dual task is associated with fear avoidance, especially during back extension. This strategy seems especially relevant for patients with high levels of fear avoidance and may be used to improve trunk muscle endurance.

Gender differences in the surgical management of lumbar degenerative disease: a scoping review

OBJECTIVE

Despite efforts toward achieving gender equality in clinical trial enrollment, females are often underrepresented, and gender-specific data analysis is often unavailable. Identifying and reducing gender bias in medical decision-making and outcome reporting may facilitate equitable healthcare delivery. Gender disparity in the utilization of surgical therapy has been exemplified in the orthopedic literature through studies of total joint arthroplasty. A paucity of literature is available to guide the management of lumbar degenerative disease, which stratifies on the basis of demographic factors. The objective of this study was to systematically map and synthesize the adult surgical literature regarding gender differences in pre- and postoperative patient-reported clinical assessment scores for patients with lumbar degenerative disease (disc degeneration, disc herniation, spondylolisthesis, and spinal canal stenosis).

METHODS

A systematic scoping review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. MEDLINE, Embase, and the Cochrane Registry of Controlled Trials were searched from inception to September 2018. Study characteristics including patient demographics, diagnoses, procedures, and pre- and postoperative clinical assessment scores (pain, disability, and health-related quality of life [HRQoL]) were collected.

RESULTS

Thirty articles were identified, accounting for 32,951 patients. Six studies accounted for 84% of patients; 5 of the 6 studies were published by European groups. The most common lumbar degenerative conditions were disc herniation (59.0%), disc degeneration (20.3%), and spinal canal stenosis (15.9%). The majority of studies reported worse preoperative pain (93.3%), disability (81.3%), and HRQoL (75%) among females. The remainder reported equivalent preoperative scores between males and females. The majority of studies (63.3%) did not report preoperative duration of symptoms, and this represents a limitation of the data. Eighty percent of studies found that females had worse absolute postoperative scores in at least one outcome category (pain, disability, or HRQoL). The remainder reported equivalent absolute postoperative scores between males and females. Seventy-three percent of studies reported either an equivalent or greater interval change for females.

CONCLUSIONS

Female patients undergoing surgery for lumbar degenerative disease (disc degeneration, disc herniation, spondylolisthesis, and spinal canal stenosis) have worse absolute preoperative pain, disability, and HRQoL. Following surgery, females have worse absolute pain, disability, and HRQoL, but demonstrate an equal or greater interval change compared to males. Further studies should examine gender differences in preoperative workup and clinical course.

Neuromuscular morphometric characteristics in low back pain with unilateral radiculopathy caused by disc herniation: An ultrasound imaging evaluation

BACKGROUND

Little is known about the neuromuscular morphometric characteristics in patients with sciatica.

OBJECTIVE

To evaluate the possible changes of nerve and muscle structures in patients with low back pain with unilateral radiculopathy due to lumbar disc herniation by ultrasound imaging.

DESIGN

A case-control observational study.

METHODS

Forty individuals were divided into case (n = 20; low back pain with unilateral radiculopathy due to disc herniation), and healthy control groups (n = 20). The thickness of lumbar multifidus at L5 level, and of lower limb muscles (i.e., biceps femoris, medial gastrocnemius, and soleus) was measured during both rest and full contraction to calculate the rest/contraction ratio of these muscles. Additionally, the sciatic nerve cross-sectional area and the echogenicity of the nerve and muscles were measured based on ultrasound imaging. The association between severity of low back pain radiculopathy (i.e., pain and patients' perceived disability) and rest/contraction ratio was assessed.

RESULTS

Patients with sciatica showed sciatic nerve enlargement, and different contraction ratios for multifidus (at L5)/ankle plantar flexors compared to the controls. The rest/contraction ratio for biceps femoris was similar between the two groups.

CONCLUSION

According to these findings, ultrasound imaging can be considered a useful tool to detect changes in the sciatic nerve and muscles due to disc herniation. Furthermore, regarding the observation of significant changes in muscle rest/contraction ratio in the multifidus and gastrosoleus, one might attribute these changes to the nerve root compression.

Lumbar Spine Paraspinal Muscle and Intervertebral Disc Height Changes in Astronauts After Long-Duration Spaceflight on the International Space Station

STUDY DESIGN

Prospective case series.

OBJECTIVE

Evaluate lumbar paraspinal muscle (PSM) cross-sectional area and intervertebral disc (IVD) height changes induced by a 6-month space mission on the International Space Station. The long-term objective of this project is to promote spine health and prevent spinal injury during space missions and here on Earth.

SUMMARY OF BACKGROUND DATA

National Aeronautics and Space Administration (NASA) crewmembers have a 4.3 times higher risk of herniated IVDs, compared with the general and military aviator populations. The highest risk occurs during the first year after a mission. Microgravity exposure during long-duration spaceflights results in approximately 5 cm lengthening of body height, spinal pain, and skeletal deconditioning. How the PSMs and IVDs respond during spaceflight is not well described.

METHODS

Six NASA crewmembers were imaged supine with a 3 Tesla magnetic resonance imaging. Imaging was conducted preflight, immediately postflight, and then 33 to 67 days after landing. Functional cross-sectional area (FCSA) measurements of the PSMs were performed at the L3-4 level. FCSA was measured by grayscale thresholding within the posterior lumbar extensors to isolate lean muscle on T2-weighted scans. IVD heights were measured at the anterior, middle, and posterior sections of all lumbar levels. Repeated measures analysis of variance was used to determine significance at P < 0.05, followed by post-hoc testing.

RESULTS

Paraspinal lean muscle mass, as indicated by the FCSA, decreased from 86% of the total PSM cross-sectional area down to 72%, immediately after the mission. Recovery of 68% of the postflight loss occurred during the next 6 weeks, still leaving a significantly lower lean muscle fractional content compared with preflight values. In contrast, lumbar IVD heights were not appreciably different at any time point.

CONCLUSION

The data reveal lumbar spine PSM atrophy after long-duration spaceflight. Some FCSA recovery was seen with 46 days postflight in a terrestrial environment, but it remained incomplete compared with preflight levels.

LEVEL OF EVIDENCE

4.

Effects of Volitional Spine Stabilization and Lower Extremity Fatigue on Trunk Control During Landing in Individuals With Recurrent Low Back Pain

STUDY DESIGN

Controlled laboratory study.

BACKGROUND

Recurrent low back pain (LBP) and neuromuscular fatigue are independently thought to increase the risk of spine injury. Volitional preemptive abdominal contraction (VPAC) is thought to improve lumbar spine and pelvis control in individuals with recurrent LBP. The effects of VPAC on fatigued landing performance in individuals with recurrent LBP are unknown.

OBJECTIVES

To determine the effects of VPAC and lower extremity fatigue on trunk control during landing in a population of individuals with recurrent LBP.

METHODS

Thirty-two recurrent LBP (mean ± SD age, 21.2 ± 2.7 years) and 33 healthy (age, 20.9 ± 2.3 years) subjects performed 0.30-m drop-jump landings with and without VPAC and fatigue. Trunk, pelvis, and hip biomechanical and electromyographic variables were obtained using 3-D motion capture. Hypotheses were tested using analysis of variance.

RESULTS

Volitional preemptive abdominal contraction resulted in significantly earlier muscle onsets across all muscles, with and without fatigue, in both groups (mean ± SD, 0.058 ± 0.019 seconds earlier; P≤.001) and altered lumbar lateral flexion (1.4° ± 14.8° greater right lateral flexion; P = .002). Fatigue significantly delayed muscle onsets (0.040 ± 0.014 seconds later; P≤.001) and altered pelvic obliquity (1.4° ± 11.0° greater; P≤.001) and trunk side flexion (2.0° ± 14.8° less; P≤.001). The recurrent LBP group exhibited delayed muscle onsets (0.039 ± 0.031 seconds later; P≤.004) and 4.2° less hip abduction at initial contact (P≤.008) in comparison to healthy controls.

CONCLUSION

Volitional preemptive abdominal contraction decreases some of the detrimental effects of fatigue on landing biomechanics and thus may reduce spine injury risk in individuals with recurrent LBP.

Are lumbar multifidus fatigue and transversus abdominis activation similar in patients with lumbar disc herniation and healthy controls? A case control study

PURPOSE

The aims of this study were to assess lumbar multifidus fatigue (LM) and transversus abdominis activation (TrA) in individuals with lumbar disc herniation associated with low back pain.

METHODS

Sixty individuals were divided into the lumbar herniation (LHG, n = 30) and control groups (CG, n = 30). Fatigue of the LM was assessed using surface electromyography during the Sorensen effort test, and activation of the TrA with a pressure biofeedback unit. Pain intensity was determined using a visual analog scale and the McGill pain questionnaire. The Oswestry disability questionnaire and the Borg scale for self-evaluating exertion were used to assess functional disability.

RESULTS

Fatigue was significantly more intense and the TrA activation was insufficient (p < 0.01) in individuals with disc herniation relative to the control group. The LHG had mild functional disability and moderate pain. There were differences in the initial exertion self-evaluation between groups, which were not observed in the final exertion evaluation.

CONCLUSION

Individuals with lumbar disc herniation associated with low back pain have increased fatigue of the LM and decreased activation of the TrA, when compared to the control group.

Intensive, progressive exercise improves quality of life following lumbar microdiskectomy: a randomized controlled trial

Objective:

The purpose of the study was to examine changes in quality of life measures in patients who have undergone an intensive exercise program following a single level microdiskectomy.

Design:

Randomized controlled trial with blinded examiners.

Setting:

The study was conducted in outpatient physical therapy clinics.

Subjects:

Ninety-eight participants (53 male, 45 female) who had undergone a single-level lumbar microdiskectomy allocated to receive exercise and education or education only.

Interventions:

A 12-week periodized exercise program of lumbar extensor strength and endurance training, and mat and upright therapeutic exercises was administered.

Outcome measures:

Quality of life was tested with the Short Form 36 (SF-36). Measurements were taken 4–6 weeks postsurgery and following completion of the 12-week intervention program. Since some participants selected physical therapy apart from the study, analyses were performed for both an as-randomized (two-group) design and an as-treated (three-group) design.

Results:

In the two-group analyses, exercise and education resulted in a greater increase in SF-36 scales, role physical (17.8 vs. 12.1) and bodily pain (13.4 vs. 8.4), and the physical component summary (13.2 vs. 8.9). In the three-group analyses, post-hoc comparisons showed exercise and education resulted in a greater increase in the SF-36 scales, physical function (10.4 vs. 5.6) and bodily pain (13.7 vs. 8.2), and the physical component summary (13.7 vs. 8.9) when compared with usual physical therapy.

Conclusions:

An intensive, progressive exercise program combined with education increases quality of life in patients who have recently undergone lumbar microdiskectomy.

Effect of centers of rotation on spinal loads and muscle forces in total disk replacement of lumbar spine

The placement of artificial disks can alter the center of rotation and kinematic pattern; therefore, forces in the spine during the motion will be affected as a result. The relationship between the location of joint center of artificial disks and forces in the spinal components is not investigated. A musculoskeletal model of the spine was developed, and three location cases of center of rotation were investigated varying 5 mm anteriorly and posteriorly from the default center. Resultant joint forces, ligament forces, facet forces, and muscle forces for each case were predicted during sagittal motion. No considerable difference was observed for joint force (maximum 14%). Anterior shift of center of rotation induced the most ligament forces (200 N) and facet forces (130 N) among the three cases. Posterior and anterior shifts of centers of rotation from the default location caused considerable changes in muscle forces, respectively: 108% and 70% of increase in multifidi muscle and 157% and 187% of increase in short segmental muscle. This study showed that the centers of rotation due to the design and the surgical placement of artificial disk can affect the kinetic results in the spine.

Lumbar muscle fatigue and subjective health measurements in patients with lumbar disc herniation 2 years after surgery

INTRODUCTION

In this prospective study the purpose was to evaluate patients with lumbar-disc herniation regarding changes in back-muscle fatigue and subjective health measurements 2 years after surgery.

METHODS

Endurance time, EMG median frequency and ratings of lumbar-muscle fatigue and pain were measured before surgery, 4 weeks after and 2 years after surgery in 26 patients (19 men and 7 women) with lumbar-disc herniation. A modified Sørensen test was performed with concurrent recordings of electromyography from the lumbar muscles at four recording sites. The questionnaires Oswestry disability index, Roland-Morris disability questionnaire, Self-efficacy scale, SF-36, Back beliefs questionnaire, Odom and a 6-grade physical activity scale were used.

RESULTS

Two years after surgery the patients had longer endurance times (increase from 178 s to 231 s, p < 0.001), a non-significant tendency for flatter L5 slopes (decrease from -0.20 to -0.16 Hz/s, p < 0.066), higher initial median frequency (L1 increase from 58 to 64 Hz p < 0.001, L5 increase from 76 to 84 Hz p = 0.001) and improved questionnaire scores. The questionnaires Oswestry, Roland-Morris and SF-36 physical functioning correlated with the endurance time 0.69-0.93 and with L5 slope 0.01-0.93 and the highest correlations were found in women.

CONCLUSION

Both EMG and endurance time measurements are needed for evaluating fatigue in lumbar-disc herniation.

Reliability of measurements of endurance time, electromyographic fatigue and recovery, and associations to activity limitations, in patients with lumbar disc herniation

BACKGROUND

Electromyographic (EMG) spectral parameters and endurance tests for back muscles have long been used to estimate low-back muscle fatigue.

PURPOSE

The present purpose was to evaluate the test-retest reliability of a fatigue-testing protocol and to investigate associations between activity limitations and fatigue in patients with lumbar disc herniation.

METHODS

To evaluate the reliability, endurance time, EMG spectral parameters and ratings of lumbar muscle fatigue and back pain were measured three times in 15 patients with lumbar disc herniation. The patients performed a modified Sørensen test with concurrent recordings of electromyography from the lumbar muscles at four recording sites. Ratings of their perceived fatigue and pain on a Borg scale were collected simultaneously. Recovery over five minutes was recorded. Questionnaires about activity, participation, self-efficacy and health were also used.

RESULTS

Endurance time had an ICC of 0.85 indicating good reliability. Initial, end and median frequency recovery had intraclass correlation coefficients (ICCs) over 0.6 that is acceptable but with large standard errors of measurement. The median frequency slopes for the four recording sites had ICCs of 0.19-0.48. Agreement coefficients for the Borg ratings ranged between 0.78 and 0.97. Moderate correlation was found between activity limitations and endurance time.

CONCLUSIONS

Endurance time measurement and Borg ratings may be recommended for evaluating intervention both with groups of patients, i.e. for research purposes, and for individuals. The median frequency parameters may be recommended for groups only. The study shows the importance of establishing the reliability of the patient category if the results are to be used to evaluate intervention.

Evaluation of change in muscle activity as a result of posterior lumbar spine surgery using a dynamic modeling system

STUDY DESIGN

A commercially available musculoskeletal model of the lumbar spine was modified to study the change in muscle activation as a result of posterior lumbar surgery at the L3-L4 and L4-L5 segments.

OBJECTIVE

To evaluate how graded resection of the lumbar paraspinal muscles as a result of posterior lumbar surgery affects muscle activity for a variety of movement tasks.

SUMMARY OF BACKGROUND DATA

Several in vivo studies compare the change in functional outcome of the paraspinal muscles following surgery. However, due to limitations that exist with current in vivo methods no study to date has been able to quantitatively examine how the function of individual muscles in the lumbar spine change in response to different levels of injury.

METHODS

A multibody dynamic musculoskeletal model of the lumbar spine was modified to measure muscle activity using a parametric examination of change in the cross-sectional area of muscles affected by posterior lumbar surgery.

RESULTS

This study shows that the reduction in muscle cross-sectional area as a result of posterior lumbar surgery at L3-L4 and L4-L5 results in a change in trunk muscle activity where the greatest change occurs during axial rotation and lateral bending. The results suggest that preservation of the posterior paraspinal musculature results in greater preservation of the normal muscle activity than traditional open techniques.

CONCLUSION

Preservation of the paraspinal musculature associated with minimally invasive surgical approaches to the lumbar better preserve postoperative muscle activity. This study suggests that there is a positive correlation between the reduction of paraspinal muscle cross-sectional area following posterior lumbar spine surgery and the alteration in trunk muscle activity.

Time courses of adaptation in lumbar extensor performance of patients with a single-level microdiscectomy during a physical therapy exercise program

STUDY DESIGN

Longitudinal single-cohort study.

OBJECTIVE

To characterize the time course of performance adaptations during a postsurgical exercise intervention following a single-level microdiscectomy.

BACKGROUND

Patients with a recent history of lumbar microdiscectomy are functionally limited, weak, have compromised paraspinal musculature, and benefit from an exercise program.

METHODS

Patients (n = 48) with a single-level microdiscectomy participated in a 12-week (36 sessions) comprehensive strength and endurance exercise program starting 4 to 6 weeks postsurgery. Lumbar extensor strength was quantified as the degree from horizontal on a modified Sorensen test procedure. Patients unable to assume the horizontal position were assumed to have strength deficits. Lumbar muscular endurance performance was quantified by the amount of time patients could hold the Sorensen test position at the horizontal. The time rate of lumbar muscular endurance adaptations were analyzed using longitudinal growth curve modeling.

RESULTS

The adherence rate of this program was low (67%). Twenty percent of the patients were identified as having strength deficits. These deficits were corrected in all patients within 3 to 9 weeks. Linear mixed-model results suggest an improvement of 5.6 seconds in hold time per week of exercise. Both the initial level of endurance and the rates of improvements were highly individualized.

CONCLUSION

The time course of musculoskeletal performance adaptations in persons with a history of lumbar surgery is highly individualized. When compared to normative endurance times, the results of this study indicate that the number of sessions and duration of therapy needed to generate meaningful adaptations of the paraspinal musculature is longer than what is typically provided in the clinic postsurgery.

LEVEL OF EVIDENCE

Therapy, level 4.J Orthop Sports Phys Ther 2010;40(6):336-344, Epub 13 May 2010. doi:10.2519/jospt.2010.3141.

An intensive, progressive exercise program reduces disability and improves functional performance in patients after single-level lumbar microdiskectomy

BACKGROUND

Restoration of physical function following lumbar microdiskectomy may be influenced by the postoperative care provided.

OBJECTIVE

The purpose of this study was to examine the effectiveness of a new interventional protocol to improve functional performance in patients who have undergone a single-level lumbar microdiskectomy.

SETTING

The study was conducted in physical therapy outpatient clinics.

DESIGN AND PARTICIPANTS

Ninety-eight participants (53 male, 45 female) who had undergone a single-level lumbar microdiskectomy were randomly allocated to receive education only or exercise and education.

INTERVENTION AND MEASUREMENTS

The exercise intervention consisted of a 12-week periodized program of back extensor strength (force-generating capacity) and endurance training and mat and upright therapeutic exercises. The Oswestry Disability Index (ODI) and physical measures of functional performance were tested 4 to 6 weeks postsurgery and 12 weeks later, following completion of the intervention program. Because some participants sought physical therapy outside of the study, postintervention scores were analyzed for both an as-randomized (2-group) design and an as-treated (3-group) design.

RESULTS

In the 2-group analyses, exercise and education resulted in a greater reduction in ODI scores and a greater improvement in distance walked. In the 3-group analyses, post hoc comparisons showed a significantly greater reduction in ODI scores following exercise and education compared with the education-only and usual physical therapy groups.

LIMITATIONS

The limitations of this study include a lack of adherence to group assignment, disproportionate therapist contact time among treatment groups, and multiple use of univariate analyses.

CONCLUSIONS

An intensive, progressive exercise program combined with education reduces disability and improves function in patients who have undergone a single-level lumbar microdiskectomy.

Assessing musculoskeletal performance of the back extensors following a single-level microdiscectomy

STUDY DESIGN

A descriptive and exploratory investigation of lumbar extensor performance in persons with a recent history of single-level microdiscectomy.

OBJECTIVE

To provide a justification for and outline the procedure of assessing lumbar extensor musculature performance.

BACKGROUND

The time of holding an unsupported trunk horizontally, also called the Sorensen test (ST), is often used to test the lumbar extensor endurance of healthy and patient populations, but may need to be modified for some patients.

METHODS AND MEASURES

Sixty-eight participants completed a modified ST procedure, along with several questionnaires and performance measures, approximately 4 to 6 weeks after a single-level microdiscectomy. Participants were classified as either able to complete or unable to complete the final position of the modified ST procedure (trunk horizontal).

RESULTS

Fifty-one point five percent of the participants could not attain the final position of the modified ST procedure due to either pain or perceived exertion. Those who could not attain the final position of the modified ST procedure had significantly lower scores (compared to those who could) on most measures. A majority (78.8%) of the participants in this study who were unable to complete the ST were correctly classified using the Fear-Avoidance Belief Questionnaire Work Subscale and a 24-hour activity questionnaire.

CONCLUSION

The ability to attain the final position of the modified ST procedure was closely associated with fear-avoidance beliefs and physical activity level, suggesting that this test may be too intense (either real or perceived) for many patients within 4 to 6 weeks following a single-level microdiscectomy.

Low levels of physical activity in back pain patients are associated with high levels of fear-avoidance beliefs and pain catastrophizing

BACKGROUND AND PURPOSE

Fear-avoidance beliefs are important determinants for disability in patients with non-specific low-back pain (LBP). The association with self-reported level of physical activity is less known. The aim of the present study was to describe the level of physical activity in patients with chronic non-specific LBP and its relation to fear-avoidance beliefs and pain catastrophizing.

METHOD

A cross-sectional study on 64 patients with chronic non-specific LBP in primary healthcare. The variables measured and the questionnaires used were: level of physical activity (six-graded scale); activity limitations (Roland Morris Disability Questionnare (RDQ)); fear-avoidance beliefs (Tampa Scale of Kinesiophobia (TSK) 13-item and sub-scales 'activity avoidance' and 'somatic focus'); and pain catastrophizing (Pain Catastrophizing Scale (PCS)). The level of physical activity was dichotomised into low and high physical activity. Individual median scores on the TSKandPCSscales were used to group the patients into different levels offear-avoidance beliefs and pain catastrophizing. Univariate logistic regressions were used to calculate odds ratios for having low physical activity.

RESULTS

Patients with low physical activity had significantly higher scores in fear-avoidance beliefs and pain catastrophizing (p < 0.05). Odds ratios for low level of physical activity were between 4 and 8 (p < 0.05) for patients with high fear-avoidance beliefs or medium/high pain catastrophizing.

CONCLUSIONS

This study indicates that it seems important for physiotherapists in primary care to measure levels of fear-avoidance beliefs or pain catastrophizing. In particular, the two subscales of the TSK could be of real value for clinicians when making treatment decisions concerning physical exercise therapy for patients with chronic LBP.

Changes in the total Oswestry Index and its ten items in females and males pre- and post-surgery for lumbar disc herniation: a 1-year follow-up

To study the characteristics and changes in the total Oswestry Disability Index (ODI) and in its ten component items in female and male patients pre- and post-surgery for lumbar disc herniation. Ninety-eight patients [mean (SD) age 43 (13), 61% males] undergoing lumbar disc herniation surgery were selected for this clinical 12-month follow-up. Subjective disability and back and leg pain were assessed by ODI version 1.0 and the visual analog scale. Pre-operatively females had a significantly higher mean (SD) total ODI [59(3)] than males [51(2)] (P = 0.030). Females were more disabled in the walking, sex life, social life and travelling items of the ODI compared to males. The total Oswestry decreased by 38 (95% CI - 44 to - 31) in females and by 34 (- 39 to - 30) in males at the 1-year follow-up. Most of the improvement (88% in females and 80% in males) occurred during the first 6 weeks; thereafter the changes were minor. In males the changes were greatest in pain, social life and travelling and in females in walking, social life and travelling. Internal consistency value of ODI was 0.88 (95% CI 0.82-0.91). Item analysis of the ODI showed that all the items except pain had high corrected item correlation. As recovery following lumbar disc surgery occurred to a great extent during the first 6 weeks, the early post-operative outcome appears to be quite a reliable indicator of the overall post-operative outcome over the 1-year follow-up. The ODI proved to capture a wide range of disability in these lumbar disc surgery patients, thereby supporting the future use of the index. The "pain intensity" component, which collects data on the use of painkillers in version 1.0 of the ODI did not support the item structure of the index in this study. The use of ODI version 2.0 might remove this problem.