Archive for category Lumbar Spine

Abstract

Background:

Outcome measurements are used to validate chiropractic adjustments, and they have not always been compared to each other under the same treatment conditions and trials.

Methods:

Twenty-one participants were non-randomly assigned to a treatment or a control group. The Oswestry index questionnaire was completed, and lateral bending lumbar radiographs were collected. Treatment group participants received nine treatments in two weeks, the control group was untreated, and both groups were re-evaluated after two weeks.

Results:

The average number of segments manipulated per day went from 8.3 ± 1.0 (day 1) to 3.0 ± 2.6 (day 9), with a standardized effect size of 2.69. The Oswestry disability index for the treatment group was 29.8% ± 11.8% disability pre-treatment and 14.20% ± 11.5% disability post-treatment, with a standardized effect size of 1.34. In the radiograph analysis, the number of dysfunctional segments changed from 6.8 ± 2.3 pre-treatment to 1.8 ± 5.2 post-treatment, with a standardized effect size of 1.24.

Conclusion:

A significant correlation was found between pre- and post-treatment measurements of the Oswestry index and dynamic radiographs.


Spine Research. 2016 Vol. 2 No. 1: 12 (iMedPub Journals)

Author information: Roy RA, Bouchera JP, Comtois AS. University of Quebec in Montreal, Department of Kinanthropology, Montreal, Quebec, Canada.

ClinicalTrials.gov Identifier: NCT00739570


Full Text

 

Read More

Abstract

OBJECTIVE:

The objective of this case series was to investigate the feasibility and safety of a novel method for the management of chronic lower back pain. Injections of recombinant human growth hormone and testosterone to the painful and dysfunctional areas in individuals with chronic lower back pain were used. In addition, the participants received manual therapies and exercise addressing physical impairments such as motor control, strength, endurance, pain, and loss of movement. Pain ratings and self-rated functional outcomes were assessed.

STUDY DESIGN:

This is a case series involving consecutive patients with chronic lower back pain who received the intervention of injections of recombinant human growth hormone and testosterone, and attended chiropractic and/or physical therapy. Outcomes were measured at 12 months from the time of injection.

SETTING:

A community based hospital affiliated office, and a private practice block suite.

PARTICIPANTS:

A total of 60 consecutive patients attending a pain management practice for chronic lower back pain were recruited for the experimental treatment. Most participants were private pay.

INTERVENTIONS:

Participants who provided informed consent and were determined not to have radicular pain received diagnostic blocks. Those who responded favorably to the diagnostic blocks received injections of recombinant human growth hormone and testosterone in the areas treated with the blocks. Participants also received manipulation- and impairment-based exercises.

OUTCOME MEASURES:

Outcomes were assessed at 12 months through pain ratings with the Mankowski Pain Scale and the Oswestry Disability Index.

RESULTS:

Of the 60 patients recruited, 49 provided informed consent, and 39 completed all aspects of the study. Those patients receiving the intervention reported a significant decrease in pain ratings (P<0.01) and a significant improvement in self-rated Oswestry Disability Index scores (P<0.01). In addition, in the Oswestry Disability Index results, 41% of the patients demonstrated a 50% or greater change in their disability score. Of the subjects who withdrew from the study, one was due to the pain created by the injections and nine were for nonstudy factors.

CONCLUSION:

The intervention appeared to be safe and the results provide a reasonable expectation that the intervention would be beneficial for a population of individuals with chronic nonradicular lower back pain. Due to the design of the study, causality cannot be inferred, but the results do indicate that further study of the intervention may be warranted.


J Pain Res. 2015 Jun 23;8:295-302. [PMID:26203272]

Author information: Dubick MN, Ravin TH, Michel Y, Morrisette DC;  Charleston, SC, USA.


Full Text Article 

Read More

Abstract

BACKGROUND:

Assessments of posteroanterior (PA) spinal stiffness using mobilization apparatuses have demonstrated an increase in PA spine stiffness during voluntary contraction of the lumbar extensor muscles; yet, little work has been done to this degree in symptomatic subjects.

OBJECTIVE:

To use a previously validated dynamic mechanical impedance procedure to quantify changes in PA dynamic spinal stiffness at rest and during lumbar isotonic extension tasks in patients with low back pain (LBP).

METHODS:

Thirteen patients with LBP underwent a dynamic spinal stiffness assessment in the prone-resting position and again during lumbar extensor efforts. Stiffness assessments were obtained using a handheld impulsive mechanical device equipped with an impedance head (load cell and accelerometer). PA manipulative thrusts (approximately 150 N, <5 milliseconds) were delivered to skin overlying the L3 left and right transverse processes (TPs) and to the L3 spinous process (SP) in a predefined order (left TP, SP, right TP) while patients were at rest and again during prone-lying lumbar isotonic extension tasks. Dynamic spinal stiffness characteristics were determined from force and acceleration measurements using the apparent mass (peak force/peak acceleration, kg). Apparent mass measurements for the resting and active lumbar isotonic task trials of each patient were compared using a 2-tailed, paired t test.

RESULTS:

A significant increase in the PA dynamic spinal stiffness was noted for thrusts over the SP (apparent mass [17.0%], P=.0004) during isotonic trunk extension tasks compared with prone resting, but no statistically significant changes in apparent mass were noted for the same measures over the TPs.

CONCLUSIONS:

These findings add support to the significance of the trunk musculature and spinal posture in providing increased spinal stability.


J Manipulative Physiol Ther. 2004 May;27(4):229-37. [PMID:15148461]

Author information: Colloca CJ, Keller TS. Department of Kinesiology, Atizona State University, Tempe, AZ, USA.


Read More

Abstract

OBJECTIVE:

To simultaneously quantify vertebral motions and neuromuscular and spinal nerve root responses to mechanical force, manually assisted, short-lever spinal manipulative thrusts.

METHODS:

Four patients underwent lumbar laminarthrectomy to decompress the central spinal canal and neuroforamina, as clinically indicated. Prior to decompression, finely threaded, 1.8-mm diameter intraosseous pins were rigidly fixed to the lumbar spinous process (L1 or L3) using fluoroscopic guidance, and a high-frequency, low-noise, 10-g, triaxial accelerometer was mounted to the pin. Following decompression, 4 needle electromyographic (nEMG) electrodes were inserted into the multifidus musculature adjacent to the pin mount bilaterally, and 2 bipolar platinum electrodes were cradled around the left and right S1 spinal nerve roots. With the spine exposed, spinal manipulative thrusts were delivered internally to the lumbosacral spinous processes and facet joints and externally by contacting the skin overlying the respective spinal landmarks using 2 force settings ( approximately 30 N, < 5 milliseconds (ms); approximately 150 N, < 5 ms) and 2 force vectors (posteroanterior and superior; posteroanterior and inferior).

RESULTS:

Spinal manipulative thrusts resulted in positive electromyographic (EMG) and compound action potential (CAP) responses that were typically characterized by a single voltage potential change lasting several milliseconds in duration. However, multiple EMG and CAP discharges were observed in numerous cases. The temporal relationship between the initiation of the mechanical thrust and the neurophysiologic response to internal and external spinal manipulative therapy (SMT) thrusts ranged from 2.4 to 18.1 ms and 2.4 to 28.6 ms for EMG and CAP responses, respectively. Neurophysiologic responses varied substantially between patients.

CONCLUSIONS:

Vertebral motions and resulting spinal nerve root and neuromuscular reflex responses appear to be temporally related to the applied force during SMT. These findings suggest that intersegmental motions produced by spinal manipulation may play a prominent role in eliciting physiologic responses.


J Manipulative Physiol Ther. 2003 Nov-Dec;26(9):579-91. [PMID:14673407]

Author information: Colloca CJ, Keller TS, Gunzburg R. State of the Art Chiropractic Center, Pheonix, AZ, USA.

Read More

Abstract

OBJECTIVE:

To quantify in vivo spinal motions and coupling patterns occurring in human subjects in response to mechanical force, manually assisted, short-lever spinal manipulative thrusts (SMTs) applied to varying vertebral contact points and utilizing various excursion (force) settings.

METHODS:

Triaxial accelerometers were attached to intraosseous pins rigidly fixed to the L1, L3, or L4 lumbar spinous process of 4 patients (2 male, 2 female) undergoing lumbar decompressive surgery. Lumbar spine acceleration responses were recorded during the application of 14 externally applied posteroanterior (PA) impulsive SMTs (4 force settings and 3 contact points) in each of the 4 subjects. Displacement time responses in the PA, axial (AX), and medial-lateral (ML) axes were obtained, as were intervertebral (L3-4) motion responses in 1 subject. Statistical analysis of the effects of facet joint (FJ) contact point and force magnitude on peak-to-peak displacements was performed. Motion coupling between the 3 coordinate axes of the vertebrae was examined using a least squares linear regression.

RESULTS:

SMT forces ranged from 30 N (lowest setting) to 150 N (maximum setting). Peak-to-peak ML, PA, and AX vertebral displacements increased significantly with increasing applied force. For thrusts delivered over the FJs, pronounced coupling was observed between all axes (AX-ML, AX-PA, PA-ML) (linear regression, R(2) = 0.35-0.52, P <.001), whereas only the AX and PA axes showed a significant degree of coupling for thrusts delivered to the spinous processes (SPs) (linear regression, R(2) = 0.82, P <.001). The ML and PA motion responses were significantly (P <.05) greater than the AX response for all SMT force settings. PA vertebral displacements decreased significantly (P <.05) when the FJ contact point was caudal to the pin compared with FJ contact cranial to the pin. FJ contact at the level of the pin produced significantly greater ML vertebral displacements in comparison with contact above and below the pin. SMTs over the spinous processes produced significantly (P <.05) greater PA and AX displacements in comparison with ML displacements. The combined ML, PA, and AX peak-to-peak displacements for the 4 force settings and 2 contact points ranged from 0.15 to 0.66 mm, 0.15 to 0.81 mm, and 0.07 to 0.45 mm, respectively. Intervertebral motions were of similar amplitude as the vertebral motions.

CONCLUSIONS:

In vivo kinematic measurements of the lumbar spine during the application of SMTs over the FJs and SPs corroborate previous spinous process measurements in human subjects. Our findings demonstrate that PA, ML, and AX spinal motions are coupled and dependent on applied force and contact point.


J Manipulative Physiol Ther. 2003 Nov-Dec;26(9):567-78. [PMID:14673406]

Author information: Keller TS, Colloca CJ, Gunzburg R. Department of Mechanical Engineering, University of Vermont, Burlington, USA.

Read More

Abstract

OBJECTIVE:

To develop a mathematical model capable of describing the static and dynamic motion response of the lumbar spine to posteroanterior forces.

DESIGN:

Static, impulsive and oscillatory forces with varying thrust angles and offsets were applied to the model, and the resulting motion responses were compared to experimental data published for spinal mobilization and manipulation of prone-lying subjects.

BACKGROUND:

Methods are sought to improve understanding of the dynamic force-induced displacement response of the lumbar spine during spinal mobilization and manipulation treatment.

METHODS:

The thorax, pelvis and five lumbar vertebrae were represented as seven rigid structures and eight flexible joint structures. Flexible joint structures were modeled using spring and damper elements with three displacement degrees-of-freedom (posterior-anterior and axial displacement, and flexion-extension rotation). The resulting 21 degrees-of-freedom lumped parameter model was solved in modal space.

RESULTS:

The fundamental natural frequency of vibration was 5.24 Hz. Simulations performed using 100 N static and dynamic posteroanterior forces applied to the L3 vertebrae indicated that peak L3 segmental displacements were up to 2.40 mm (impulsive) and 8.23 mm (oscillatory at 2 Hz). Appreciable axial displacements (0.41 mm) and flexion-extension rotations (1.49 degrees ) were also observed for oscillatory forces at L3. The posteroanterior motion response of the lumbar vertebrae was relatively insensitive to both the thrust force angle and thrust force offset, but axial displacements and flexion-extension rotations showed a large change (2-fold or greater) for thrust angles greater than -5 degrees (caudal) in comparison to vertical thrusts. Intersegmental motion responses for static, impulsive and oscillatory loads were more comparable than their segmental counterparts.

CONCLUSIONS:

The model predicts lumbar segmental and inter-segmental motion responses to manipulative forces that are otherwise difficult to obtain experimentally.

RELEVANCE:

This study assists clinicians to understand the biomechanics of posteroanterior forces applied to the lumbar spine of prone-lying subjects. Of particular clinical relevance is the finding that greater spinal mobility is possible by targeting specific load-time histories.


Clin Biomech (Bristol, Avon). 2002 Mar;17(3):185-96. [PMID:11937256]

Author information: Keller TS, Colloca CJ, Béliveau JG. Department of Mechanical Engineering, University of Vermont, 119C Votey Building, Burlington VT 05405-0156, USA.

Read More

Abstract

Assessments of spinal stiffness are becoming more  popular in recent years as a objective biomechanical means to evaluate  the human frame. Studies investigating posteroanterior (PA) forces in  spinal stiffness assessment have shown relationships to spinal level,  body type, and lumbar extensor muscle activity. Such measures may be  important determinants to discriminate between patients with low back  pain and asymptomatic subjects. However, little objective evidence is  available discerning variations in PA stiffness and its clinical  significance. No study has investigated the relationships of invivo PA  spinal stiffness to radiographic images. L5-S1 disc to body height  ratios were calculated from digitized plane film lateral radiographs of  eighteen symptomatic LBP patients (8 females and 10 males, 15-69 years,  mean 44.3 SD 15.4 years). Posterior disc height ratio (PDR) and anterior  disc height ratio (ADR) were compared to the L5 posterior-anterior  dynamic effective stiffness determined using a validated in vivo  mechanical impedance assessment procedure [1]. Dynamic effective  stiffness (N/m) was calculated from the impedance-frequency response  spectrum as the dynamic mechanical impedance (Force/Velocity, Ns/m) x  circular frequency (rad/sec). Dynamic effective stiffness (minl) at the  first resonance frequency (fminl)is reported. No correlation was noted  between minl and ADR at L5. However, minl was positively correlated to  the PDR at L5 {minl=232 x PDR + 32 (R=0.76)}. Dynamic spinal stiffness  assessments may provide additional biomechanical data that may be prove  to be of use to clinicians in the diagnosis of lumbar spinal disorders.


Reference: Christopher J. Colloca,DC; Tony S. Keller,PhD; Terry  K. Peterson,DC; Daryn E. Seltzer,DC; Arlan W. Fuhr,DC. Proceedings of the International  Conference on Spinal Manipulation , Sept 21-23,2000.

Read More
Abstract BACKGROUND: Although the mechanisms of spinal manipulation are poorly understood, the clinical effects are thought to be related to mechanical, neurophysiologic, and reflexogenic processes. Animal studies have identified mechanosensitive afferents in animals, and clinical studies in human beings have measured neuromuscular responses to spinal manipulation. Few, if any, studies have identified the basic neurophysiologic […]

Fuhr Intraoperative

Abstract

BACKGROUND:

Although the mechanisms of spinal manipulation are poorly understood, the clinical effects are thought to be related to mechanical, neurophysiologic, and reflexogenic processes. Animal studies have identified mechanosensitive afferents in animals, and clinical studies in human beings have measured neuromuscular responses to spinal manipulation. Few, if any, studies have identified the basic neurophysiologic mechanisms of spinal manipulation in human beings or animals.

OBJECTIVES:

The purpose of this clinical investigation was to determine the feasibility of obtaining intraoperative neurophysiologic recordings and to quantify mixed-nerve root action potentials in response to lumbosacral spinal manipulation in a human subject undergoing lumbar spinal surgery.

METHODS:

An L4-L5 laminectomy was performed in a 62-year-old man. Short-duration (<0.1 ms) mechanical force, manually assisted spinal manipulative thrusts (150 N) were delivered to the lumbosacral spine with an Activator II Adjusting Instrument. With the spine exposed, spinal manipulative thrusts were delivered internally to the L5 mammillary process, L5-S1 joint, and the sacral base with various force vectors. This protocol was repeated by contacting the skin overlying respective anatomic landmarks. Mixed-nerve root recordings were obtained from gas-sterilized platinum bipolar hooked electrodes attached to the S1 nerve root at the level of the dorsal root ganglion during the spinal manipulative thrusts and during a 30-second baseline period during which no spinal manipulative thrusts were applied.

RESULTS:

During the active trials, mixed-nerve root action potentials were observed in response to both internal and external spinal manipulative thrusts. Differences in the amplitude and discharge frequency were noted in response to varying segmental contact points and force vectors, and similarities were noted for internally and externally applied spinal manipulative thrusts. Amplitudes of mixed-nerve root action potentials ranged from 200 to 2600 mV for internal thrusts and 800 to 3500 mV for external thrusts.

CONCLUSIONS:

Monitoring mixed-nerve root discharges in response to spinal manipulative thrusts in vivo in human subjects undergoing lumbar surgery is feasible. Neurophysiologic responses appeared sensitive to the contact point and applied force vector of the spinal manipulative thrust. Further study of the neurophysiologic mechanisms of spinal manipulation in humans and animals is needed to more precisely identify the mechanisms and neural pathways involved.


J Manipulative Physiol Ther. 2000 Sep;23(7):447-57. [PMID:11004648]

Author information: Colloca CJ, Keller TS, Gunzburg R, Vandeputte K, Fuhr AW. Postdoctoral and Related Professional Education Department Faculty, Logan College of Chiropractic, St. Louis, MO, USA.

 

Read More

Introduction:

A biomechanical analysis of the spine is  important for understanding its response to different loading  environments. Although substantial information exists on the dynamic  response of the spine in the axial direction, little is known about the  dynamic response to externally applied, posterior-anterior (PA) directed  forces Such as chiropractic manipulations, in this paper, a  5-degree-of-freedom (DOF), lumped equivalent model the lumbar spine is  developed. Model results are compared to quasi-static, oscillatory and  impulsive force measurements of vertebral motion associated with  mobilization [1], manual manipulation [2] and mechanical force,  manually-assisted (MFMA) adjustments [3].

 

Material and methods:

Five Degree-of Freedom Model A 5-DOF mass, massless-spring and damper model of the lumbar  spine is shown in Fig. 1. This model differs from that of a single-DOF  system in that it has 5 natural frequencies.

Modeling of this multi-DOF structure necessitates one governing  equation of motion for each DOF; in matrix form: [M]d2x/dt2+ [C]dx/dt +  [K]x = [F] (1) where [M] is the mass matrix, [C] is the damping matrix,  [K] is the stiffness matrix, [F] is the PA excitation force matrix, and  x = x(t) is the resulting displacement vector. Here we assume that the  system has zero mass coupling, in which case [M] is diagonal. [K] is  written in terms of the stiffness influence coefficients and is a band  matrix along the diagonal. The equations of motion are solved in modal  space using the eigensolution (i.e. the modal properties) of the  homogeneous equation of motion (free vibration without damping). The  eigenvectors (mode shapes) are then assembled into a mode shape matrix such that[M]= [I] and [K] =[frequencies 2], where {tr} denotes the transpose, [I] is the diagonal identity matrix. Given modal damping ratios for each mode shape i, the 5×5 damping

Using Matlab, the motion response of the spine was studied in  response to a 100 N static load, 100 N sinusoidal oscillation, and 100 N  impulsive force applied to each of the vertebral segments. The  following coefficients were used for the mass matrix (kg) and stiffness  (kN/m) matrix [3]: ml=m2=0.170, m3=m4=m5=0.114; kl=50, k2=40, k3=k4=30, k5=45; l,…5= 0.25 (25% of critical) resulting in damping coefficients CIJ ranging from 40-60 Ns/m.

Results:

The PA damped and undamped natural frequencies predicted by the model  were 44.6 Hz and 46. 1 Hz, respectively. Steady State Response The  steady state response to a PA sinusoidal oscillation, f= Foe is given by  the frequency response function; H(oo)=[K oo2M + iooC] (3)For PA  sinusoidal loading, the model-predicted natural frequency ranged from  39-47 Hz (Fig. 2). At resonance, segmental and inter-segmental P A  displacements were 7.1 mm and 1.7 mm, respectively, for PA thrusts on  L3. PA spine mobilization [1] and manual manipulation [2]  correspond to an oscillatory frequency of ~2 Hz. At 2 Hz segmental and  Inter-segmental displacements were predicted to be 4.0 mm (L3) and 1.5  mm (L3-L4), respectively.

 

Impulsive Force Response: The response to an initial displacement [X0] and velocity [V0] was derived by assuming a solution x = UeM for eq. (1): PA MFMA adjustments produce a damped sinusoidal-like  oscillation With a duration of ~5 ms (impulsive force). Hence, we used  the impulse-momentum principle to estimate V0 (1.84 m/s) for a damped  MFMA oscillation f=466e-1000sin(200(3.14)t). Model predicted L3 and  L3.L4 displacements were 1.25 mm and 0.89 mm, respectively, for PA  impulsive forces at L3.

 

Discussion and Conclusions:

The model predicted PA  oscillatory and impulsive resonant frequency of the lumbar spine Is  consistent with previous experimental findings [3]. Segmental  displacements were over 3-fold greater for manual and mobilization  therapies in comparison to MFMA therapy, but differences in  inter-segmental displacements were less remarkable for these three types  of spinal manipulation.

 


Reference: T.S. Keller and C. J. Colloca; Dynamic  Response of the Human Lumbar Spine: A 5 DOF Lumped Parameter Time and  Frequency Domain Model; Proceeding of the 2000 Meeting of the European Society of  Biomechanics, Dublin, Ireland, August 10-14.

References: [1] M. Lee and N.L. Svensson (1993) JMPT 16:  439-446. [2] I. Gal et al. (1997) JMPT 20: 30.40. [3] T.S. Keller, C.I.  Colloca, and A. W. Fuhr(1999) JMPT 22: 75-86.

Acknowledgements: National Institute of Chiropractic Research; Foundation for the Advancement of Chiropractic Education.

Read More

CLINICAL VIGNETTE:

A 36-year-old male suffered from  severe low back pain. His pain diagram indicated a localized region of  pain around his left lower lumbar region, sacroiliac joint and buttock.  He states that he occasionally feels a slight tingling sensation in his  left posterior thigh, but not distal to the knee. This tingling  sensation only occurs for a few moments once or twice a week. The lower  back pain is daily, and worse in the mornings upon rising from bed.  After he gets to work the pain subsides; but then worsens again by  mid-afternoon. The patient is employed as a car mechanic and must  frequently work bent over the hoods of cars in a flexed position, which  aggravates his pain. He says that occasionally he will get “stuck” in a  position where he is leaning forward and to the right, and that he must  slowly work out his back to be able to straighten up again. He does not  recall any specific low back injury that set off this particular episode  of acute pain, which began insidiously about 3 wks before his first  visit. How- ever, he has had such episodes about once or twice a year  for over 10 yr, and has previously seen chiropractors with fairly good  results.

Physical examination began with lumbar ranges of motion, which  were restricted into flexion at 25 degree, left lateral bending at 15  degree, and left rotation at 10 degree. He exhibited a mild antalgic  lean to the right. He does not walk with an obvious limp, but is  observed to avoid full weight-bearing on his left leg. Kemp’s maneuver  elicited sharp but localized left low back pain over the left L5/SI  facet and sacroiliac joint, with only mild left buttock pain. There was  no reproduction of any left thigh symptoms. Static palpation of the L5  and Sl spinous processes elicited sharp local pain, and motion palpation  P-A over- pressure on the left L5/Sl facet joint also caused sharp  local pain. Muscle palpation revealed some hyper tonicity of the left  erector spinae, quadratus lumborum, and gluteus medius / minimus muscle;  however, no true spasm was detected. Repeated extension in the standing  position elicited some increased pain over the left lumbar facets, but  repeated extension in the prone position afforded the patient some  relief of his low back pain.

Plain film radiographs of the lumbar spine demonstrates about  50% narrowing of the L5/Sl disc space, and a mild right lateral lean of  the lumbar spine. There is no apparent loss or accentuation of the  lumbar lordosis. There is slight rotation of the 15 spinous toward the  left, but no other gross malalignments were noted. He was scheduled for  an MRI by his primary care physician, but the insurance company denied  authorization for the test, citing “lack of compelling medical  necessity” to perform advanced diagnostic imaging tests. Tentative  diagnosis by his primary care physician was lumbar sprain, and he was  given a prescription for Ibuprofen 800 mg t.i.d.


Chiropr Technique Vol. 11, No. 1, February 1999

Author information: Michael J. Schnelder, D.C., James M. Cox,  D.C., Bradley S. Polkinghorn, D.C., Charles Blum, D.C., Harvey Getzoff,  D.C., and Stephan J. Troyanovich, D.C.

Read More