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

A diagnostic model of nerve root compression localization in lower lumbar disc herniation based on random forest algorithm and surface electromyography

Objective

This study aimed to investigate the muscle activation of patients with lumbar disc herniation (LDH) during walking by surface electromyography (SEMG) and establish a diagnostic model based on SEMG parameters using random forest (RF) algorithm for localization diagnosis of compressed nerve root in LDH patients.

Methods

Fifty-eight patients with LDH and thirty healthy subjects were recruited. The SEMG of tibialis anterior (TA) and lateral gastrocnemius (LG) were collected bilaterally during walking. The peak root mean square (RMS-peak), RMS-peak time, mean power frequency (MPF), and median frequency (MF) were analyzed. A diagnostic model based on SEMG parameters using RF algorithm was established to locate compressed nerve root, and repeated reservation experiments were conducted for verification. The study evaluated the diagnostic efficiency of the model using accuracy, precision, recall rate, F1-score, Kappa value, and area under the receiver operating characteristic (ROC) curve.

Results

The results showed that delayed activation of TA and decreased activation of LG were observed in the L5 group, while decreased activation of LG and earlier activation of LG were observed in the S1 group. The RF model based on eight SEMG parameters showed an average accuracy of 84%, with an area under the ROC curve of 0.93. The RMS peak time of TA was identified as the most important SEMG parameter.

Conclusion

These findings suggest that the RF model can assist in the localization diagnosis of compressed nerve roots in LDH patients, and the SEMG parameters can provide further references for optimizing the diagnosis model in the future.

Electromyography activities in patients with lower lumbar disc herniation

BACKGROUND

Lumbar disc herniation (LDH) can affect lower limb muscle function resulting in an abnormal gait. This study aims to use surface electromyography (SEMG) to evaluate patients with L4/L5 and L5/S1 LDH throughout muscle movement.

METHODS

Twenty L4/L5 LDH patients (L5 Group), twenty L5/S1 LDH patients (S1 Group), and twenty healthy controls (Healthy) were recruited for the study. SEMG of bilateral tibialis anterior (TA) and lateral gastrocnemius (LG) muscles of patients were recorded using the DELSYS Wireless EMG System (TrignoTM Wireless Systems, Delsys Inc., USA). Root-mean-square (RMS), mean power frequency (MPF), and median frequency (MF) were compared between bilateral limbs in each participant.

RESULTS

Reduced MPF and MF was found in TA measurements of the L5 Group and LG measurements of the S1 Group. The MPF and MF of the TA of symptomatic limbs of the L5 Group were reduced when compared to asymptomatic limbs (p= 0.006, p= 0.012, p< 0.05), and there were no significant differences in LG measurements (p> 0.05). The LG MPF and MF of the S1 Group in symptomatic limbs were reduced when compared to asymptomatic limbs (p= 0.006, p= 0.017, p< 0.05), and there were no significant differences in TA measurements (p> 0.05). Although there were no significant differences in RMS between bilateral limbs of the L5 and S1 Groups, we found some changes in RMS curves. First, compared to asymptomatic limbs of L4/L5LDH patients, β-peaks in the TA of symptomatic limbs appeared earlier. Second, two peaks in the LG of symptomatic limbs were found in L5/S1 LDH patients.

CONCLUSION

TA is affected in patients with LDH of L4/L5, and LG is affected in patients with LDH of L5/S1. As demonstrated, SEMG can identify LDH-related muscle dysfunction.

Diastasis recti abdominis in adult women based on abdominal computed tomography imaging: Prevalence, risk factors and its impact on life

AIMS AND OBJECTIVES

This study aimed to obtain the incidence of diastasis recti abdominis (DRA) and analyse possible risk factors in adult females. Moreover, the relationships between DRA and lower back pain, pelvic floor function and quality of life were also analysed.

BACKGROUND

Diastasis recti abdominis is a separation of the abdominal muscles at the linea alba. Currently, studies on the prevalence rates, risk factors and consequences of DRA are varied. In particular, reports on DRA among adult women are lacking.

DESIGN

A one-sample questionnaire study design is used following the STROBE checklist.

METHODS

The inter-rectus distance was measured by computed tomography in 644 women. Custom questionnaires, the Oswestry Disability Index, The International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form and the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) were used to investigate personal information, the subjects' back pain, pelvic floor function and quality of life, respectively.

RESULTS

The incidence of DRA was 28.4%. Age, the number of pregnancies, BMI and diabetes were influencing factors for DRA. After age stratification, pregnancy and diabetes were found to be risk factors for DRA in young women, and obesity and diabetes were risk factors for DRA in older women. This study showed that the association between DRA and low back pain was highly significant.

CONCLUSIONS

Diastasis recti abdominis is common in adult women. Avoiding multiple pregnancies, preventing diabetes and controlling weight may prevent DRA, which may be beneficial for decreasing low back pain in women.

RELEVANCE TO CLINICAL PRACTICE

The findings have important implications for the health of adult women which can provide the basis for appropriate nursing implementation for DRA patients. The application of specific prevention and intervention measures for the risk factors may reduce the severity of low back pain.

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.

Early Impact of Postoperative Bracing on Pain and Quality of Life After Posterior Instrumented Fusion for Lumbar Degenerative Conditions: A Randomized Trial

STUDY DESIGN

A randomized controlled trial.

OBJECTIVE

To investigate whether bracing after posterior spinal instrumented fusion (PSIF) can improve pain relief and quality of life (QoL) 6 weeks and 3 months postoperatively.

SUMMARY OF BACKGROUND DATA

Braces are commonly prescribed after PSIF in patients with lumbar degenerative conditions with the aim of improving pain relief and QoL. However, there is a lack of evidence on the indication for postoperative bracing, as surgeons use braces mainly based on their experience and training.

METHODS

A randomized blinded and controlled trial of 43 patients with PSIF for lumbar degenerative conditions were recruited. The caregivers were blinded but not the orthotist in the present study. There were 25 patients in the brace group and 18 patients in the control group with similar baseline characteristics. All patients completed the Oswestry Disability Index (ODI), the short form (SF)-12v2 General Health Survey and Visual Analog Scale (VAS) for back pain preoperatively, at 6 weeks and 3 months follow-up. Wilcoxon-Mann-Whitney test and a level of significance of 0.05 were used for statistical analyses.

RESULTS

Both groups had comparable demographic characteristics, and preoperative SF-12v2, ODI, and VAS scores. The ODI, SF-12v2, and VAS for back pain were improved in comparison to preoperative scores. The improvement was significant at 3 months follow-up regarding ODI and VAS for both groups and significant only for the control group regarding SF-12v2 scores. The improvement in ODI, SF-12v2, and VAS was significantly greater for control group at 3 months postoperatively. Moreover, larger proportion of patients in the control group reached minimum clinically important difference as compared to brace group at 6 weeks and 3 months.

CONCLUSION

Postoperative bracing did not result in better improvement in QoL or pain relief up to 3 months after PSIF in patients with lumbar degenerative conditions.

LEVEL OF EVIDENCE

1.

Patients with sciatica still experience pain and disability 5 years after surgery: A systematic review with meta-analysis of cohort studies

BACKGROUND AND OBJECTIVE

The clinical course of patients with sciatica is believed to be favourable, but there is conflicting evidence on the postoperative course of this condition. We aimed to investigate the clinical course of sciatica following surgery.

DATABASES AND DATA TREATMENT

An electronic search was conducted on MEDLINE, EMBASE and CINAHL from inception to April 2015. We screened for prospective cohort studies investigating pain or disability outcomes for patients with sciatica treated surgically. Fractional polynomial regression analysis was used to generate pooled means and 95% confidence intervals (CI) of pain and disability up to 5 years after surgery. Estimates of pain and disability (converted to a 0-100 scale) were plotted over time, from inception to last available follow-up time.

RESULTS

Forty records (39 cohort studies) were included with a total of 13,883 patients with sciatica. Before surgery, the pooled mean leg pain score was 75.2 (95% CI 68.1-82.4) which reduced to 15.3 (95% CI 8.5-22.1) at 3 months. Patients were never fully recovered in the long-term and pain increased to 21.0 (95% CI 12.5-29.5) at 5 years. The pooled mean disability score before surgery was 55.1 (95% CI 52.3-58.0) and this decreased to 15.5 (95% CI 13.3-17.6) at 3 months, and further reduced to 13.1 (95% CI 10.6-15.5) at 5 years.

CONCLUSIONS

Although surgery is followed by a rapid decrease in pain and disability by 3 months, patients still experience mild to moderate pain and disability 5 years after surgery. WHAT DOES THIS REVIEW ADD?: This review provides a quantitative summary of the postoperative course of patients with sciatica. Patients with sciatica experienced a rapid reduction in pain and disability in the first 3 months, but still had mild to moderate symptoms 5 years after surgery. Although no significant differences were found, microdiscectomy showed larger improvements compared to other surgical techniques.

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.

Physiotherapy Post Lumbar Discectomy: Prospective Feasibility and Pilot Randomised Controlled Trial

OBJECTIVES

To evaluate: acceptability and feasibility of trial procedures; distribution of scores on the Roland Morris Disability Questionnaire (RMDQ, planned primary outcome); and efficient working of trial components.

DESIGN AND SETTING

A feasibility and external pilot randomised controlled trial (ISRCTN33808269, assigned 10/12/2012) was conducted across 2 UK secondary care outpatient physiotherapy departments associated with regional spinal surgery centres.

PARTICIPANTS

Consecutive consenting patients aged >18 years; post primary, single level, lumbar discectomy.

INTERVENTIONS

Participants were randomised to either 1:1 physiotherapy outpatient management including patient leaflet, or patient leaflet alone.

MAIN OUTCOME MEASURES

Blinded assessments were made at 4 weeks post surgery (baseline) and 12 weeks post baseline (proposed primary end point). Secondary outcomes included: Global Perceived Effect, back/leg pain, straight leg raise, return to work/function, quality of life, fear avoidance, range of movement, medication, re-operation.

RESULTS

At discharge, 110 (44%) eligible patients gave consent to be contacted. 59 (54%) patients were recruited. Loss to follow up was 39% at 12 weeks, with one site contributing 83% losses. Mean (SD) RMDQ was 10.07 (5.58) leaflet and 10.52 (5.94) physiotherapy/leaflet at baseline; and 5.37 (4.91) leaflet and 5.53 (4.49) physiotherapy/leaflet at 12 weeks. 5.1% zero scores at 12 weeks illustrated no floor effect. Sensitivity to change was assessed at 12 weeks with mean (SD) change -4.53 (6.41), 95%CI -7.61 to -1.44 for leaflet; and -6.18 (5.59), 95%CI -9.01 to -3.30 for physiotherapy/leaflet. RMDQ mean difference (95%CI) between change from baseline to twelve weeks was 1.65(-2.46 to 5.75). Mean difference (95%CI) between groups at 12 weeks was -0.16 (-3.36 to 3.04). Participant adherence with treatment was good. No adverse events were reported.

CONCLUSIONS

Both interventions were acceptable, and it is promising that they both demonstrated a trend in reducing disability in this population. A randomised controlled trial, using a different trial design, is needed to ascertain the effectiveness of combining the interventions into a stepped care intervention and comparing to a no intervention arm. Findings will guide design changes for an adequately powered randomised controlled trial, using RMDQ as the primary outcome.

TRIAL REGISTRATION

ISRCTN registry 33808269.

Driving reaction time before and after surgery for lumbar disc herniation in patients with radiculopathy

PURPOSE

Although patients scheduled to undergo lumbar disc surgery often ask when they are allowed to drive a motor vehicle again, there are no published recommendations on this subject.

METHODS

We conducted a prospective study in 46 consecutive patients (mean age 48.9 years) to determine driving reaction time (DRT) before and after surgery in patients with lumbar disc herniation. Of the patients 23 had left-side radiculopathy and 23 right-side radiculopathy. Driving reaction time as well as back and leg pain were evaluated preoperatively, on the day of discharge from hospital and at the 5-week follow-up examination (FU). 31 healthy subjects were tested as controls.

RESULTS

Significant improvement in DRT was seen for both patient samples (p < 0.05). For patients with a right-side radiculopathy preoperative DRT was 664 ms (median, IQR: 241), which was reduced to 605 ms (median, IQR: 189) immediately postoperatively and to 593 ms (median, IQR: 115) at FU. For patients with a left-side radiculopathy DRT was 675 ms (median, IQR: 247) preoperatively, 638 ms (median, IQR: 242) postoperatively and 619 ms (median, IQR: 162) at FU. Pain was moderately correlated to DRT. Control subjects had a driving reaction time of 487 (median, IQR: 116), which differed significantly from patients at all three testing times (p < 0.001).

CONCLUSION

Our data indicate a positive effect of the surgery on driving ability. Therefore, we would suggest that for both patient samples it is safe to continue driving after hospital discharge. However, patients have to be informed about increased DRT caused by radiculopathy already before surgery.