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Intraoperator reliability of MRI-based area measurement of intervertebral foramina in the cervical spine
Abstracts / Manual Therapy 25 (2016) e57ee169
Newcastle-Ottawa Scale. Data was presented in tabulated form using qualitative meta-synthesis approach & grouped according to outcome, stage post injury and severity. Strength of the overall body of evidence was assessed using GRADE. Results: From searching 498 records were retrieved, with 14 studies (from case studies to large observational cohorts) being included in the evidence synthesis. Thoracic pathologies and dysfunction reported in WAD include thoracic disc pathology, long thoracic & spinal accessory nerve injury, alteration in trunk sway, trapezius myofascial-enthesal dysfunction, thoracic myofascial trigger points, alteration in activity of serratus anterior and several studies reporting thoracic outlet syndrome (n¼5). Most data related to chronic presentations and unclassified presentations, although some evidence exists for acute WAD and WADII. Quality of included studies range from poor to good, often a consequence of poor reporting. Conclusion: There is evidence, albeit low quality of TD in WAD involving structures including nerves, disc & muscles. Further research is required to fully describe TD in WAD, including the effect of injury on thoracic joints/ mobility; something that is a notable omission from the current evidence. Implications: Anatomical dysfunction post WAD is not exclusive to the cervical spine and evidence of TD should be a consideration for clinicians examining patients with WAD. Findings of this research support the need for further investigation of TD in WAD Funding Acknowledgements: Unfunded Ethics Approval: Not required Disclosure of Interest: None Declared Keywords: Systematic review, Thoracic dysfunction, Whiplash, New directions Advanced assessment/practice and managing complex patients PO3-CS-025 CRANIO-CERVICAL STABILITY OF CERVICAL FLEXOR MUSCLES IN HEALTHY ADULT MALES K. Hazaki*, N. Kawano, N. Ogushi. * Corresponding author.
Background: The longus colli (LC) is attached to the antero-external surface of the cervical vertebrae and it is thought to stabilize the cranio-cervical region. However, the effects of the LC on cranio-cervical stability have not been investigated in detail. Purpose: The present study aimed to determine the effect of the LC and sternocleidomastoideus (SCM) muscles on cranio-cervical stability by measuring muscle thickness while external force was applied to the head. Methods: The muscle thickness of the LC and SCM of 20 healthy males (mean age, 20.3 ± 0.9 y) was measured on the right side using ultrasonography (US) with a 10-MHz linear array probe placed parallel to the vertical axis running external to and 2 cm inferior from the thyroid cartilage and tilted 20 inward in the median sagittal plane. External force was applied horizontally to the rear, 2-3 cm above the smooth part of the forehead above and between the eyebrows, and 20 degrees inside the back of the right and left frontal eminence. The amount of applied external force strength measured using a hand dynamometer was none and 1, 2 and 3 kgw. The participants were seated in a neutral position, with their hips and knees bent 90 , with the arms lying along the sides of the body. The participants were asked to hold their cranio-cervical region against each external force for at least five seconds while US images of the LC and SCM were acquired. The thickness of the LC and SCM muscles was measured on US images using ImageJ image analysis software. All data were normalized as ratios of the baseline data without a load. Changes in normalized muscle thickness in the three directions at four grades of force strength were multiple comparison evaluated by two-way repeated ANOVA and Scheffe tests. Results: The normalized muscle thickness of the LC and SCM did not significantly differ in any direction at any force strength.The main effect of force strength significantly differed (p < 0.001), whereas main effect of direction did not. The thickness of the LC and SCM muscles significantly differed between 1 and 2, 1 and 3, and 2 and 3 kgw (all p < 0.001).
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Conclusion: The LC and SCM stabilized the cranio-cervical region because the LC and SCM muscles thickened with increasing external force strength. Furthermore, the right and left LC and SCM muscles seemed to contract to stabilize the cranio-cervical region because the direction of the external force did not alter stability. Implications: The LC and SCM do not have the relationship of the intrinsic muscles and the extrinsic muscles, and both muscles appear to synergistically contract to maintain cranio-cervical stability in healthy males. Funding Acknowledgements: Nothing Ethics Approval: This study is a part of the study that received the approval by the Ethical Committee about the study and the education for the organism in Osaka Electro-Communication University ( No.14-007). Disclosure of Interest: None Declared Keywords: Longus colli, Sternocleidomastoid, Ultrasonography Advanced assessment/practice and managing complex patients PO3-CS-026 INTRAOPERATOR RELIABILITY OF MRI-BASED AREA MEASUREMENT OF INTERVERTEBRAL FORAMINA IN THE CERVICAL SPINE H. Usa 1, *, H. Takei 2, M. Hata 2, 3, H. Kamio 1, N. Shida 1, A. Senoo 4. 1 Division of Physical Therapy, Faculty of Health Sciences, Japan; 2 Department of Physical Therapy, Graduate School of Human Health Sciences, Tokyo Metropolitan University, Japan; 3 Senkawa-Shinoda Orthopedic Clinic, Japan; 4 Department of Radiological Sciences, Graduate School of Human Health Sciences, Tokyo Metropolitan University, Tokyo, Japan * Corresponding author.
Background: Nerve roots exist in intervertebral foramina in the spine. Compression of nerve roots and spinal nerves due to narrowing of the foraminal space often causes various symptoms in spinal disease (e.g., a herniated disk and spondylosis deformans). Thus, it is important to measure the area of the intervertebral foramen and to assess its changes. Magnetic resonance imaging (MRI) is often used for accurate area measurement of intervertebral foramina. However, to the best of our knowledge, its reliability has not yet been tested in detail. Purpose: This study aimed to investigate the intraoperator reliability of MRI-based area measurement of intervertebral foramina in the cervical spine. Methods: Subjects were 11 young healthy adults without a past history of neck problems (mean age, 21.1 years; range, 19e26 years). The mean value and standard deviation (in brackets) for height was 162.9 (8.2) cm, and that for weight was 57.1 (7.9) kg. The operator was a physiotherapist with 12 years’ experience. An MRI scanner (Achieva 3.0T, Philips Electronics Japan) was used to acquire images of the neck in the supine position with the neck positioned in its neutral position. Areas of both the right and left intervertebral foramina from C2/3 to C7/T1 were measured using the 3D MPR function of the image analysis software OsiriX Lite 7.0. Statistical analysis software IBM SPSS Statistics Ver. 20 was used to calculate the intraoperator intraclass correlation coefficient (ICC) of the areas of each intervertebral foramen. The BlandeAltman analysis was performed to examine the types of intraoperator errors. A 95% confidence interval for the minimal detectable change (MDC95) was calculated to test limit values that represent “true change” in measurements of intervertebral foraminal areas. Results: The mean areas and standard deviations (in brackets) of the first and second measurements (in cm2) of both sides of intervertebral foraminal areas were as follows: 1.37 (0.18) and 1.40 (0.20) for the right, and 1.43 (0.19) and 1.43 (0.16) for the left at C2/3, respectively; 1.26 (0.19) and 1.29 (0.17) for the right, and 1.27 (0.12) and 1.26 (0.12) for the left at C3/ 4; 1.37 (0.20) and 1.31 (0.19) for the right, and 1.35 (0.20) and 1.40 (0.19) for the left at C4/5; 1.36 (0.27) and 1.33 (0.24) for the right, and 1.32 (0.22) and 1.26 (0.22) for the left at C5/6; 1.37 (0.25) and 1.36 (0.23) for the right, and 1.22 (0.24) and 1.17 (0.24) for the left at C6/7; 1.17 (0.15) and 1.16 (0.18) for the right, and 1.12 (0.20) and 1.13 (0.21) for the left at C7/T1, respectively. The ICCs (1, 1) were 0.84e0.91. The BlandeAltman analysis revealed that errors were of a random type. Respective MDC95 values (in cm2) for the
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Abstracts / Manual Therapy 25 (2016) e57ee169
right and left areas were: 0.17 and 0.20 at C2/3; 0.21 and 0.14 at C3/4; 0.16 and 0.17 at C4/5; 0.21 and 0.16 at C5/6; 0.21 and 0.23 at C6/7; 0.18 and 0.18 at C7/T1. Conclusion: The ICC, an index of relative reliability (agreement), was 0.8 or higher in the measurement of every intervertebral foramen, indicating that the method shown in this study is reliable and can be used in the analysis of intervertebral foraminal areas. Errors of this method belong to the random type. Thus, with respect to absolute reliability (accuracy), errors can be reduced by repeating the test under identical conditions, and by using the mean of test results as a representative value. Furthermore, MDC95 results indicated that differences 0.2 cm2 were likely to be measurement errors. Implications: The method measuring intervertebral foraminal areas, shown in this study, is highly reliable, and can be used in establishing scientific evidence for therapeutic effect of joint mobilization in cervical spinal disease resulting from nerve root compression. Funding Acknowledgements: This work was supported by Tokyo Metropolitan University. Ethics Approval: The Research Safety and Ethics Committee of the Tokyo Metropolitan University, Arakawa Campus (approval number 13041).
Implications: This is the first study investigating the relationship between the severity of fat infiltration in LMM and the severity of lumbar dysfunction. The presented findings could have implications for the treatment of LBP. There is evidence that exercise therapy is effective in treating chronic LBP. However, if patients with LBP and fat infiltration of LMM demonstrate decreased lumbar flexion, exercise strategies that stimulate co-contraction of large trunk muscles may enhance stiffness and therefore should perhaps not be chosen. Active and passive mobilisation of lumbar segmental stiffness and specific stabilizing exercises might be more efficient for this subgroup. Further research is necessary to provide evidence whether these strategies are effective for the treatment of LBP and for the prevention of progressive atrophy of LMM. Funding Acknowledgements: Unfunded but supported by Zurich University of Applied Sciences, Switzerland. Ethics Approval: Harmlessness of the study was approved by local ethic authorities.
Disclosure of Interest: None Declared
Advanced assessment/practice and managing complex patients PO3-LB-042 RED FLAGS ASSOCIATED WITH THE EARLY DETECTION OF METASTATIC BONE DISEASE AS A CAUSE OF BACK PAIN
Keywords: Cervical spine, Intervertebral foramina, MRI Advanced assessment/practice and managing complex patients PO3-LB-039 CORRELATION BETWEEN LUMBAR DYSFUNCTION AND FAT INFILTRATION IN LUMBAR MULTIFIDUS MUSCLES IN PATIENTS WITH LOW BACK PAIN M. Hildebrandt*, G. Fankhauser, A. Meichtry, H. Luomajoki. Institute of Physiotherapy, Zurich University of Applied Sciences, Winterthur, Switzerland * Corresponding author.
Background: Lumbar multifidus muscles (LMM) are important for spinal stability. Low back pain (LBP) is often associated with fat infiltration in LMM. Studies investigating the association between low back dysfunction and fat infiltration plus their implication for physical rehabilitation are still sparse. Purpose: The purpose of this study was to evaluate the relationship between the severity of lumbar dysfunction and the extent of fat infiltration of LMM and its implications for exercise strategies of lumbar muscles in patients suffering from LBP. We hypothezised that increased fat infiltration of LMM is correlated with impaired lumbar flexion (LF) and impaired movement and posture control. Methods: In a cross-sectional study, 42 individuals with acute or chronic LBP were recruited. Their MRI findings were visually rated and graded using three criteria for fat accumulation in LMM: Grade 0 (0-10% fat), Grade 1 (10-50% fat) and Grade 2 (>50% fat). Lumbar sagittal range of motion (Spinal Mouse®), dynamic posture control (Spinal Mouse®), sagittal movement control (movement control tests), body awareness (two-point discrimination tests) and selfassessed functional disability (Oswestry disability index) were measured to determine the subjects low back dysfunction. For each response a linear model was fitted to the data using fat, gender, age, duration of LBP and body mass index as covariates. Pairwise contrasts between the fat-grades were estimated. We were interested in the covariate-adjusted effect of fat on the outcomes. Results: The main result was that increased severity of fat infiltration in the lumbar multifidus muscles correlated with decreased range of motion of lumbar flexion (p¼0.032). Pairwise contrasts between the fat-grades indicated a significant difference between Grade 1 and Grade 2 (12.42 degrees, 95% CI 0.513, 24.3). None of the covariates (age, gender, body masss index and duration of LBP) were associated with impaired LF. No significant correlation was found between the severity of fat infiltration in LMM and impaired movement control, posture control, body awareness or functional disability. Conclusion: Fat infiltration of lumbar multifidus muscles correlates with reduced range of motion of lumbar flexion but not with impaired movement and posture control. Whether asymptomatic subjects with decreased LF also demonstrate increased fat infiltration of LMM is unknown and has to be investigated.
Disclosure of Interest: None Declared Keywords: Fat infiltration, Low back pain, Multifidus muscle
L. Finucane. Background: The incidence of serious pathology causing back pain is around 1 in 100 patients in clinical practice, with one of the commonest being metastatic bone disease (MBD). MBD is caused by a number of primary cancers but most commonly breast, prostate and lung cancers. The most commonly described symptom of MBD is back pain which has a prevalence of 80% in the general population, which makes it difficult to diagnose clinically. Identification of MBD is supported by a history of cancer, including the type of cancer and time since diagnosed, along with the presence of low back pain. Red flags which increase suspicion of serious pathology are typically late stage manifestations of the disease (weight loss, unremitting pain, fever) when outcome is poor. Currently there is limited evidence of the early signs of MBD. Purpose: To identify the red flags associated with the early signs of MBD in people presenting with back pain with a history of a primary diagnosis of breast, prostate and/or lung cancer. Methods: A literature review was carried out to investigate whether the clinical presentation could be used to identify the early signs and symptoms of MBD arising in breast, prostate and lung cancer. Results: The literature review did not find any evidence of a clinical presentation that would help identify MBD. No combination of factors could be used reliably or with sufficient sensitivity and specificity to be of value in identifying patients with MBD. Not all patients with a primary diagnosis of breast, prostate and lung cancer will go on to develop metastatic disease and there was no evidence to support investigating all patients with back pain and a previous history of cancer. The risk factors of developing MBD were identified as tumour size, nodal involvement, stage, and type of cancer at initial diagnosis. Conclusion: Identifying patients with serious pathology is challenging for clinicians. Current red flags do not help to identify early signs of MBD in those patients with a primary diagnosis of breast, prostate or lung cancer. Understanding how patients clinically present in the early stages could help in early diagnosis and improve outcome for patients. Further research into patients experience of MBD would be useful to improve our knowledge of signs and symptoms that may help in identifying MBD. Implications: Knowing the risk factors associated with MBD may help clinicians make early and appropriate clinical decisions for further investigation for patients presenting with low back pain and result in better patient outcomes. Funding Acknowledgements: this work was unfunded Ethics Approval: Ethis was not required Disclosure of Interest: None Declared
Newcastle-Ottawa Scale. Data was presented in tabulated form using qualitative meta-synthesis approach & grouped according to outcome, stage post injury and severity. Strength of the overall body of evidence was assessed using GRADE. Results: From searching 498 records were retrieved, with 14 studies (from case studies to large observational cohorts) being included in the evidence synthesis. Thoracic pathologies and dysfunction reported in WAD include thoracic disc pathology, long thoracic & spinal accessory nerve injury, alteration in trunk sway, trapezius myofascial-enthesal dysfunction, thoracic myofascial trigger points, alteration in activity of serratus anterior and several studies reporting thoracic outlet syndrome (n¼5). Most data related to chronic presentations and unclassified presentations, although some evidence exists for acute WAD and WADII. Quality of included studies range from poor to good, often a consequence of poor reporting. Conclusion: There is evidence, albeit low quality of TD in WAD involving structures including nerves, disc & muscles. Further research is required to fully describe TD in WAD, including the effect of injury on thoracic joints/ mobility; something that is a notable omission from the current evidence. Implications: Anatomical dysfunction post WAD is not exclusive to the cervical spine and evidence of TD should be a consideration for clinicians examining patients with WAD. Findings of this research support the need for further investigation of TD in WAD Funding Acknowledgements: Unfunded Ethics Approval: Not required Disclosure of Interest: None Declared Keywords: Systematic review, Thoracic dysfunction, Whiplash, New directions Advanced assessment/practice and managing complex patients PO3-CS-025 CRANIO-CERVICAL STABILITY OF CERVICAL FLEXOR MUSCLES IN HEALTHY ADULT MALES K. Hazaki*, N. Kawano, N. Ogushi. * Corresponding author.
Background: The longus colli (LC) is attached to the antero-external surface of the cervical vertebrae and it is thought to stabilize the cranio-cervical region. However, the effects of the LC on cranio-cervical stability have not been investigated in detail. Purpose: The present study aimed to determine the effect of the LC and sternocleidomastoideus (SCM) muscles on cranio-cervical stability by measuring muscle thickness while external force was applied to the head. Methods: The muscle thickness of the LC and SCM of 20 healthy males (mean age, 20.3 ± 0.9 y) was measured on the right side using ultrasonography (US) with a 10-MHz linear array probe placed parallel to the vertical axis running external to and 2 cm inferior from the thyroid cartilage and tilted 20 inward in the median sagittal plane. External force was applied horizontally to the rear, 2-3 cm above the smooth part of the forehead above and between the eyebrows, and 20 degrees inside the back of the right and left frontal eminence. The amount of applied external force strength measured using a hand dynamometer was none and 1, 2 and 3 kgw. The participants were seated in a neutral position, with their hips and knees bent 90 , with the arms lying along the sides of the body. The participants were asked to hold their cranio-cervical region against each external force for at least five seconds while US images of the LC and SCM were acquired. The thickness of the LC and SCM muscles was measured on US images using ImageJ image analysis software. All data were normalized as ratios of the baseline data without a load. Changes in normalized muscle thickness in the three directions at four grades of force strength were multiple comparison evaluated by two-way repeated ANOVA and Scheffe tests. Results: The normalized muscle thickness of the LC and SCM did not significantly differ in any direction at any force strength.The main effect of force strength significantly differed (p < 0.001), whereas main effect of direction did not. The thickness of the LC and SCM muscles significantly differed between 1 and 2, 1 and 3, and 2 and 3 kgw (all p < 0.001).
e91
Conclusion: The LC and SCM stabilized the cranio-cervical region because the LC and SCM muscles thickened with increasing external force strength. Furthermore, the right and left LC and SCM muscles seemed to contract to stabilize the cranio-cervical region because the direction of the external force did not alter stability. Implications: The LC and SCM do not have the relationship of the intrinsic muscles and the extrinsic muscles, and both muscles appear to synergistically contract to maintain cranio-cervical stability in healthy males. Funding Acknowledgements: Nothing Ethics Approval: This study is a part of the study that received the approval by the Ethical Committee about the study and the education for the organism in Osaka Electro-Communication University ( No.14-007). Disclosure of Interest: None Declared Keywords: Longus colli, Sternocleidomastoid, Ultrasonography Advanced assessment/practice and managing complex patients PO3-CS-026 INTRAOPERATOR RELIABILITY OF MRI-BASED AREA MEASUREMENT OF INTERVERTEBRAL FORAMINA IN THE CERVICAL SPINE H. Usa 1, *, H. Takei 2, M. Hata 2, 3, H. Kamio 1, N. Shida 1, A. Senoo 4. 1 Division of Physical Therapy, Faculty of Health Sciences, Japan; 2 Department of Physical Therapy, Graduate School of Human Health Sciences, Tokyo Metropolitan University, Japan; 3 Senkawa-Shinoda Orthopedic Clinic, Japan; 4 Department of Radiological Sciences, Graduate School of Human Health Sciences, Tokyo Metropolitan University, Tokyo, Japan * Corresponding author.
Background: Nerve roots exist in intervertebral foramina in the spine. Compression of nerve roots and spinal nerves due to narrowing of the foraminal space often causes various symptoms in spinal disease (e.g., a herniated disk and spondylosis deformans). Thus, it is important to measure the area of the intervertebral foramen and to assess its changes. Magnetic resonance imaging (MRI) is often used for accurate area measurement of intervertebral foramina. However, to the best of our knowledge, its reliability has not yet been tested in detail. Purpose: This study aimed to investigate the intraoperator reliability of MRI-based area measurement of intervertebral foramina in the cervical spine. Methods: Subjects were 11 young healthy adults without a past history of neck problems (mean age, 21.1 years; range, 19e26 years). The mean value and standard deviation (in brackets) for height was 162.9 (8.2) cm, and that for weight was 57.1 (7.9) kg. The operator was a physiotherapist with 12 years’ experience. An MRI scanner (Achieva 3.0T, Philips Electronics Japan) was used to acquire images of the neck in the supine position with the neck positioned in its neutral position. Areas of both the right and left intervertebral foramina from C2/3 to C7/T1 were measured using the 3D MPR function of the image analysis software OsiriX Lite 7.0. Statistical analysis software IBM SPSS Statistics Ver. 20 was used to calculate the intraoperator intraclass correlation coefficient (ICC) of the areas of each intervertebral foramen. The BlandeAltman analysis was performed to examine the types of intraoperator errors. A 95% confidence interval for the minimal detectable change (MDC95) was calculated to test limit values that represent “true change” in measurements of intervertebral foraminal areas. Results: The mean areas and standard deviations (in brackets) of the first and second measurements (in cm2) of both sides of intervertebral foraminal areas were as follows: 1.37 (0.18) and 1.40 (0.20) for the right, and 1.43 (0.19) and 1.43 (0.16) for the left at C2/3, respectively; 1.26 (0.19) and 1.29 (0.17) for the right, and 1.27 (0.12) and 1.26 (0.12) for the left at C3/ 4; 1.37 (0.20) and 1.31 (0.19) for the right, and 1.35 (0.20) and 1.40 (0.19) for the left at C4/5; 1.36 (0.27) and 1.33 (0.24) for the right, and 1.32 (0.22) and 1.26 (0.22) for the left at C5/6; 1.37 (0.25) and 1.36 (0.23) for the right, and 1.22 (0.24) and 1.17 (0.24) for the left at C6/7; 1.17 (0.15) and 1.16 (0.18) for the right, and 1.12 (0.20) and 1.13 (0.21) for the left at C7/T1, respectively. The ICCs (1, 1) were 0.84e0.91. The BlandeAltman analysis revealed that errors were of a random type. Respective MDC95 values (in cm2) for the
e92
Abstracts / Manual Therapy 25 (2016) e57ee169
right and left areas were: 0.17 and 0.20 at C2/3; 0.21 and 0.14 at C3/4; 0.16 and 0.17 at C4/5; 0.21 and 0.16 at C5/6; 0.21 and 0.23 at C6/7; 0.18 and 0.18 at C7/T1. Conclusion: The ICC, an index of relative reliability (agreement), was 0.8 or higher in the measurement of every intervertebral foramen, indicating that the method shown in this study is reliable and can be used in the analysis of intervertebral foraminal areas. Errors of this method belong to the random type. Thus, with respect to absolute reliability (accuracy), errors can be reduced by repeating the test under identical conditions, and by using the mean of test results as a representative value. Furthermore, MDC95 results indicated that differences 0.2 cm2 were likely to be measurement errors. Implications: The method measuring intervertebral foraminal areas, shown in this study, is highly reliable, and can be used in establishing scientific evidence for therapeutic effect of joint mobilization in cervical spinal disease resulting from nerve root compression. Funding Acknowledgements: This work was supported by Tokyo Metropolitan University. Ethics Approval: The Research Safety and Ethics Committee of the Tokyo Metropolitan University, Arakawa Campus (approval number 13041).
Implications: This is the first study investigating the relationship between the severity of fat infiltration in LMM and the severity of lumbar dysfunction. The presented findings could have implications for the treatment of LBP. There is evidence that exercise therapy is effective in treating chronic LBP. However, if patients with LBP and fat infiltration of LMM demonstrate decreased lumbar flexion, exercise strategies that stimulate co-contraction of large trunk muscles may enhance stiffness and therefore should perhaps not be chosen. Active and passive mobilisation of lumbar segmental stiffness and specific stabilizing exercises might be more efficient for this subgroup. Further research is necessary to provide evidence whether these strategies are effective for the treatment of LBP and for the prevention of progressive atrophy of LMM. Funding Acknowledgements: Unfunded but supported by Zurich University of Applied Sciences, Switzerland. Ethics Approval: Harmlessness of the study was approved by local ethic authorities.
Disclosure of Interest: None Declared
Advanced assessment/practice and managing complex patients PO3-LB-042 RED FLAGS ASSOCIATED WITH THE EARLY DETECTION OF METASTATIC BONE DISEASE AS A CAUSE OF BACK PAIN
Keywords: Cervical spine, Intervertebral foramina, MRI Advanced assessment/practice and managing complex patients PO3-LB-039 CORRELATION BETWEEN LUMBAR DYSFUNCTION AND FAT INFILTRATION IN LUMBAR MULTIFIDUS MUSCLES IN PATIENTS WITH LOW BACK PAIN M. Hildebrandt*, G. Fankhauser, A. Meichtry, H. Luomajoki. Institute of Physiotherapy, Zurich University of Applied Sciences, Winterthur, Switzerland * Corresponding author.
Background: Lumbar multifidus muscles (LMM) are important for spinal stability. Low back pain (LBP) is often associated with fat infiltration in LMM. Studies investigating the association between low back dysfunction and fat infiltration plus their implication for physical rehabilitation are still sparse. Purpose: The purpose of this study was to evaluate the relationship between the severity of lumbar dysfunction and the extent of fat infiltration of LMM and its implications for exercise strategies of lumbar muscles in patients suffering from LBP. We hypothezised that increased fat infiltration of LMM is correlated with impaired lumbar flexion (LF) and impaired movement and posture control. Methods: In a cross-sectional study, 42 individuals with acute or chronic LBP were recruited. Their MRI findings were visually rated and graded using three criteria for fat accumulation in LMM: Grade 0 (0-10% fat), Grade 1 (10-50% fat) and Grade 2 (>50% fat). Lumbar sagittal range of motion (Spinal Mouse®), dynamic posture control (Spinal Mouse®), sagittal movement control (movement control tests), body awareness (two-point discrimination tests) and selfassessed functional disability (Oswestry disability index) were measured to determine the subjects low back dysfunction. For each response a linear model was fitted to the data using fat, gender, age, duration of LBP and body mass index as covariates. Pairwise contrasts between the fat-grades were estimated. We were interested in the covariate-adjusted effect of fat on the outcomes. Results: The main result was that increased severity of fat infiltration in the lumbar multifidus muscles correlated with decreased range of motion of lumbar flexion (p¼0.032). Pairwise contrasts between the fat-grades indicated a significant difference between Grade 1 and Grade 2 (12.42 degrees, 95% CI 0.513, 24.3). None of the covariates (age, gender, body masss index and duration of LBP) were associated with impaired LF. No significant correlation was found between the severity of fat infiltration in LMM and impaired movement control, posture control, body awareness or functional disability. Conclusion: Fat infiltration of lumbar multifidus muscles correlates with reduced range of motion of lumbar flexion but not with impaired movement and posture control. Whether asymptomatic subjects with decreased LF also demonstrate increased fat infiltration of LMM is unknown and has to be investigated.
Disclosure of Interest: None Declared Keywords: Fat infiltration, Low back pain, Multifidus muscle
L. Finucane. Background: The incidence of serious pathology causing back pain is around 1 in 100 patients in clinical practice, with one of the commonest being metastatic bone disease (MBD). MBD is caused by a number of primary cancers but most commonly breast, prostate and lung cancers. The most commonly described symptom of MBD is back pain which has a prevalence of 80% in the general population, which makes it difficult to diagnose clinically. Identification of MBD is supported by a history of cancer, including the type of cancer and time since diagnosed, along with the presence of low back pain. Red flags which increase suspicion of serious pathology are typically late stage manifestations of the disease (weight loss, unremitting pain, fever) when outcome is poor. Currently there is limited evidence of the early signs of MBD. Purpose: To identify the red flags associated with the early signs of MBD in people presenting with back pain with a history of a primary diagnosis of breast, prostate and/or lung cancer. Methods: A literature review was carried out to investigate whether the clinical presentation could be used to identify the early signs and symptoms of MBD arising in breast, prostate and lung cancer. Results: The literature review did not find any evidence of a clinical presentation that would help identify MBD. No combination of factors could be used reliably or with sufficient sensitivity and specificity to be of value in identifying patients with MBD. Not all patients with a primary diagnosis of breast, prostate and lung cancer will go on to develop metastatic disease and there was no evidence to support investigating all patients with back pain and a previous history of cancer. The risk factors of developing MBD were identified as tumour size, nodal involvement, stage, and type of cancer at initial diagnosis. Conclusion: Identifying patients with serious pathology is challenging for clinicians. Current red flags do not help to identify early signs of MBD in those patients with a primary diagnosis of breast, prostate or lung cancer. Understanding how patients clinically present in the early stages could help in early diagnosis and improve outcome for patients. Further research into patients experience of MBD would be useful to improve our knowledge of signs and symptoms that may help in identifying MBD. Implications: Knowing the risk factors associated with MBD may help clinicians make early and appropriate clinical decisions for further investigation for patients presenting with low back pain and result in better patient outcomes. Funding Acknowledgements: this work was unfunded Ethics Approval: Ethis was not required Disclosure of Interest: None Declared