Intervertebral Motion Research Articles

Investigator analytic repeatability of two new intervertebral motion biomarkers for chronic, nonspecific low back pain in a cohort of healthy controls

BackgroundUnderstanding the mechanisms underlying chronic, nonspecific low back pain (CNSLBP) is essential to advance personalized care and identify the most appropriate intervention. Recently, two intervertebral motion biomarkers termed “Motion Sharing Inequality” (MSI) and “Motion Sharing Variability” (MSV) have been identified for CNSLBP using quantitative fluoroscopy (QF). The aim of this study was to conduct intra- and inter-investigator analytic repeatability studies to determine the extent to which investigator error affects their measurement in clinical studies.MethodsA cross-sectional cohort study was conducted using the image sequences of 30 healthy controls who received QF screening during passive recumbent flexion motion. Two independent investigators analysed the image sequences for MSI and MSV from October to November 2018. Intra and inter- investigator repeatability studies were performed using intraclass correlations (ICC), standard errors of measurement (SEM) and minimal differences (MD).ResultsIntra-investigator ICCs were 0.90 (0.81,0.95) (SEM 0.029) and 0.78 (0.59,0.89) (SEM 0.020) for MSI and MSV, respectively. Inter-investigator ICCs 0.93 (0.86,0.97) (SEM 0.024) and 0.55 (0.24,0.75) (SEM 0.024). SEMs for MSI and MSV were approximately 10 and 30% of their group means respectively. The MDs for MSI for intra- and inter-investigator repeatability were 0.079 and 0.067, respectively and for MSV 0.055 and 0.067.ConclusionsMSI demonstrated substantial intra- and inter-investigator repeatability, suggesting that investigator input has a minimal influence on its measurement. MSV demonstrated moderate intra-investigator reliability and fair inter-investigator repeatability. Confirmation in patients with CNSLBP is now required.

Analysis of translation and angular motion in loaded and unloaded positions in the lumbar spine

Background ContextAbnormalities in intervertebral rotation and translation are important to diagnosis and treatment planning for common spinal disorders. Tests that do not sufficiently load the spine can result in mis-diagnosed motion abnormalities. Upright flexion and extension x-rays are commonly used despite known limitations. Additional evidence is needed in support of preliminary studies suggesting that the change from standing to supine may sufficiently stress the spine to diagnose motion abnormalities. PurposeCompare intervertebral translation between flexion and extension to translation between upright and supine positions in a representative clinical population. Study Design/SettingProspective analysis of images retrospectively collected from routine clinical practices. MethodsAfter obtaining IRB approval for analysis of previously obtained images, patients were identified via chart reviews where a neutral-lateral x-ray and an MRI or CT exam were obtained for diagnosis of a spinal disorder and where flexion-extension x-rays had been obtained to help diagnose abnormal intervertebral motion. The mid-sagittal slice from the MRI or CT exam was paired with the neutral-lateral radiograph. Intervertebral translation at the L4-L5 and L5-S1 levels between supine and standing and between flexion and extension were measured from the images using previously validated methods. The translations were classified as normal or abnormal with reference to a previously obtained database of intervertebral motion in radiographically normal and asymptomatic volunteers. ResultsAt the L5-S1 level in particular, there tended to be greater translation between the supine and standing than between upright flexion and extension. On average, translations were below that found in asymptomatic volunteers. No abnormal translations were detected from flexion-extension radiographs whereas approximately 7% of levels had abnormal translations between supine and upright positions. ConclusionsIntervertebral translations between supine and standing, measured using the mid-sagittal slice from a MRI or CT exam and a lateral x-ray with the patient standing can help to identify abnormal motion. This would be particularly valuable for patients with limited flexion and extension. This study thereby adds to the evidence in support of measuring intervertebral motion between the supine and upright positions to detect abnormal intervertebral motion.

Physical therapist attitude and opinion about cervical spine examination: A national Spanish survey

A correct examination is essential during a differential diagnosis of neck pain patients. Therefore, the objective of this study was to provide an update on the properties considered most important by physical therapists (PTs) when conducting accessory and physiological movement tests during the cervical spine physical examination. A total of 84 private physiotherapy centres participated in this online cross-sectional survey including 415 active physiotherapists and members of one autonomous Spanish Physiotherapists School. This survey included information about the characteristics of the respondents (eg, weekly patient care, highest qualification and specific training in osteopathy and manual therapy), their opinion about the accuracy and reliability of accessory and physiological movement tests, the frequency and importance of mobility and pain responses, and the most commonly reference used to make a judgement. Pain responses are most frequently used by physiotherapists at a rate of 79.8% and also rated as important by 42.65% respondents mobility aspects such as quality of end-feel (17.3%), quantity of translation (16.4%) and quality of resistance (13.3%) during passive accessory intervertebral movement tests. During passive and active physiological movement tests, the most frequent properties assessed were the quality of motion path (80.5% and 84.3%, respectively) and quantity of angle bending (81.7% and 77.6%, respectively). Pain responses are used as reference by 54.7% to make a clinical judgement during passive accessory intervertebral movement tests. Physical therapists face validity in relation to passive accessory intervertebral movement test for assessing spinal segmental motion aspects has been decreasing with more attention devoted to pain responses. The current scepticism regarding the motion properties assessed with these tests is associated with utility aspects such as validity, sensitivity, accuracy and specificity.

Efficacy of Integrating Cervical Posture Correction With Lumbar Stabilization Exercises for Mechanical Low Back Pain: A Randomized Blinded Clinical Trial.

Although current lumbar stabilization exercises are beneficial for chronic mechanical low back pain, further research is recommended focusing on global spinal alignment normalization. This randomized, controlled, blinded trial was conducted to determine the effects of adding cervical posture correction to lumber stabilization on chronic mechanical low back pain. Fifty adult patients (24 males) with chronic mechanical low back pain and forward head posture received 12 weeks treatment of either both programs (group A) or lumbar stabilization (group B). The primary outcome was back pain. The secondary outcomes included the craniovertebral angle, Oswestry Disability Index, C7-S1 sagittal vertical axis, and sagittal intervertebral movements. The multivariate analysis of variance indicated a significant group-by-time interaction (P = .001, partial η2 = .609). Pain, disability, C7-S1 sagittal vertical axis, and l2-l3 intervertebral rotation were reduced in group A more than B (P = .008, .001, .025, and .001). Craniovertebral angle was increased in A when compared to B (P = .001). However, there were no significant group-by-time interactions for other intervertebral movements. Within-group comparisons were significant for all outcomes except for craniovertebral angle within patients in the control group. Adding cervical posture correction with lumber stabilization for management of chronic low back pain seemed to have better effects than the application of a stabilization program only.

Lumbar lordosis obtained with and without intervertebral thoracic spine motions during rhythmic gymnastics movements: a preliminary study

Back pain and injuries are very prevalent in rhythmic gymnastics (Hutchinson 1999). The evaluation of the lumbar intervertebral stresses during the execution of rhythmic gymnastics movements could ...

A Comparison of Clinical Spinal Mobility Measures to Experimentally Derived Lumbar Spine Passive Stiffness.

Spinal stiffness and mobility assessments vary between clinical and research settings, potentially hindering the understanding and treatment of low back pain. A total of 71 healthy participants were evaluated using 2 clinical assessments (posteroanterior spring and passive intervertebral motion) and 2 quantitative measures: lumped mechanical stiffness of the lumbar spine and local tissue stiffness (lumbar erector spinae and supraspinous ligament) measured via myotonometry. The authors hypothesized that clinical, mechanical, and local tissue measures would be correlated, that clinical tests would not alter mechanical stiffness, and that males would demonstrate greater lumbar stiffness than females. Clinical, lumped mechanical, and tissue stiffness were not correlated; however, gradings from the posteroanterior spring and passive intervertebral motion tests were positively correlated with each other. Clinical assessments had no effect on lumped mechanical stiffness. The males had greater lumped mechanical and lumbar erector spinae stiffness compared with the females. The lack of correlation between clinical, tissue, and lumped mechanical measures of spinal stiffness indicates that the use of the term "stiffness" by clinicians may require reevaluation; clinicians should be confident that they are not altering mechanical stiffness of the spine through segmental mobility assessments; and greater resting lumbar erector stiffness in males suggests that sex should be considered in the assessment and treatment of the low back.

How are midfoot (i.e. Chopart and Lisfranc joint) kinematics altered in adolescents with CP with plano-valgus feet, compared to healthy subjects?

Detecting pseudarthrosis following spinal fusion is important for accurate diagnosis and treatment. Current diagnostic measures hold certain drawbacks. Radiostereometric analysis (RSA) is a radiographic technique with the capability to measure intervertebral segment changes and may be a novel way of assessing fusion.The purpose of this work was to measure the accuracy and precision of RSA in instrumented posterior cervical and lumbar spinal fusion for measuring intervertebral movement. Further, to gain surgical practice with RSA in spine and determine optimal bead placements.Artificial bone and cadaveric spine models were used to simulate a 3-level cervical (C3–C6) and a 2-level (L4–S1) lumbosacral posterior spinal fusion to analyze bead placements and to measure RSA accuracy and precision.Preliminary RSA bead placements were planned and measured in the artificial model. Secondary bead placements were adjusted slightly in the cadaveric model to consider additional fusion scenarios. Bead spread, detectability, and stability were measured to determine optimal placements. Translational and rotational precision of both models were measured. Accuracy was measured in the artificial spine model. Model-based RSA software was used for analysis.Optimal bead placements were found to be throughout the lateral mass of C3–C6 and in the spinous process, transverse process, and within the screw canal of L4–S1. Detectability was high among all segments. Spread was greater in L4–S1 than C3–C6 due to bead collinearity along the transverse axis of the cervical vertebrae. Translational and rotational RSA accuracy in cervical and lumbosacral regions ranged between 0.005 to 0.014 mm and 0.058 to 0.208°. Translational and rotational precision measured in the phantom models ranged 0.017 to 0.131 mm and 0.058 to 0.394° in C3–C6, and 0.086 to 0.191 mm and 0.200 to 0.369° in L4–S1. Translational and rotational precision measured in the cadaveric models ranged 0.054 to 0.548 mm and 0.148 to 1.386° in C3–C6, and 0.068 to 0.164 mm and 0.100 to 0.270° in L4–S1.RSA was found to be a feasible radiographic technique in C3–C6 and L4–S1 spinal fusion when measured in artificial and cadaveric models. Optimal bead placements were determined. Bead spread was shown to be better throughout the lumbar region than the cervical region due to anatomical size variations. RSA accuracy and precision were within acceptable RSA criteria.The results from this work contribute to the accuracy, precision, and bead placements for studying RSA in cervical and lumbar spinal fusions. This work may further support the development of clinical studies to assess spinal fusion by evaluating postoperative intervertebral movement using RSA.

Passive intervertebral motion characteristics in chronic mid to low back pain: A multivariate analysis

PurposeStudies comparing back pain patients and controls on continuous intervertebral kinematics have shown differences using univariate parameters. Hitherto, multivariate approaches have not been applied to this high dimensional data, risking clinically relevant features being undetected. A multivariate re-analysis was carried out to estimate main modes of variation, and explore group differences. Methods40 participants with mechanical back pain and 40 matched controls underwent passive recumbent quantitative videofluoroscopy. Intervertebral angles of L2/3 to L4/5 were obtained for right and left side-bending, extension, and flexion. Principal components analysis (PCA) was used to identify the main modes of variation, and to obtain a lower dimensional representation for comparing groups. Linear discriminant analysis (LDA) was used to identify how groups differed. ResultsPCA identified three main modes of variation, all relating to range of motion (ROM) and its distribution between joints. Significant differences were found for coronal plane motions only (right: p = 0.02, left: p = 0.03) . LDA identified a shift in ROM to more cranial joints in the back pain group. ConclusionThe results confirm altered motion sharing between intervertebral joints in back pain, and provides more details about this. Further work is required to establish how these findings lead to pain, and so strengthen the theoretical basis for treatment and management of this condition.

An in vivo study exploring correlations between early-to-moderate disc degeneration and flexion mobility in the lumbar spine

PurposeEarly disc degeneration (DD) has been thought to be associated with loss of spine stability. However, before this can be understood in relation to back pain, it is necessary to know the relationship between DD and intervertebral motion in people without pain. This study aimed to find out if early-to-moderate DD is associated with intervertebral motion in people without back pain.MethodsTen pain-free adults, aged 51–71, received recumbent and weight bearing MRI scans and quantitative fluoroscopy (QF) screenings during recumbent and upright lumbar flexion. Forty individual level and 10 composite (L2-S1) radiographic and MRI DD gradings were recorded and correlated with intervertebral flexion ROM, translation, laxity and motion sharing inequality and variability for both positions.ResultsKinematic values were similar to previous control studies. DD was evidenced up to moderate levels by both radiographic and MRI grading. Disc height loss correlated slightly, but negatively with flexion during weight bearing flexion (R = − 0.356, p = 0.0.025). Composite MRI DD and T2 signal loss evidenced similar relationships (R = − 0.305, R = − 0.267) but did not reach statistical significance (p = 0.056, p = 0.096). No significant relationships between any other kinematic variables and DD were found.ConclusionThis study found only small, indefinite associations between early-to-moderate DD and intervertebral motion in healthy controls. Motion sharing in the absence of pain was also not related to early DD, consistent with previous control studies. Further research is needed to investigate these relationships in patients.

Influence of creep deformation on sub-regional lumbar spine motion during manual lifting

Prolonged or repetitive spine flexion induces creep deformation of posterior spine tissues allowing for increased intervertebral motion beyond ‘normal’ limits, which may influence sub-regional (intersegmental) spine motion during subsequent manual lifting tasks. Using spine skin-surface kinematics, intersegmental lumbar spine motion was recorded over 20 minutes of prolonged static spine flexion and a subsequent manual lifting task (2 lifts every 3 minutes, 30 minutes total) in 14 participants. Results demonstrated that mid to lower lumbar intersegmental levels (i.e. L2/L3 to L4/L5) experienced the greatest overall creep deformation and range of motion during both prolonged flexion and manual lifting; however, overall range of motion during manual lifting was unaffected. Additionally, creep deformation did not completely recover within 30 minutes. Future work should continue to investigate the influence of this residual creep, as well as how overall creep deformation impacts spine neuromuscular control and stability, and ultimately the development of low back disorders. Practitioner summary: Mid to lower lumbar spine levels (i.e. L2/L3 to L4/L5) experienced the greatest creep deformation and range of motion during both prolonged flexion and manual lifting. Repeated lifting following prolonged flexion may limit creep recovery; however, overall lifting kinematic motion remained unchanged.

Comparison of lumbar segmental stabilization and general exercises on clinical and radiologic criteria in grade‐I spondylolisthesis patients: A double‐blind randomized controlled trial

The effects of different physiotherapy protocols on patients suffering from grade-I spondylolisthesis have been thus far examined in a limited number of clinical trials. Therefore, the main purpose of this study was to compare the effects of lumbar segmental stabilization and general exercises on clinical and radiologic criteria in grade-I spondylolisthesis patients. This study was a double-blind randomized controlled trial (RCT) with a test-retest design and parallel groups. A total of 26 patients with grade-I spondylolisthesis were thus randomly assigned to experimental group (13 patients, lumbar segmental stabilization exercises) and control group (13 patients, general exercises). Subsequently, pain, functional disability, kinesiophobia, translational motion, angular motion and slip percentage of the vertebra were investigated. Of the 120 people recruited in this study, only 26 patients were eligible. According to pre/post-intervention comparison, a statistically significant decrease was observed in the experimental group in terms of pain (p = 0.000), functional disability (p = 0.004), kinesiophobia (p = 0.002), translational motion (p = 0.043) and angular motion (p = 0.011), but not for slip percentage (p = 0.122). Considering the control group, a statistically significant decline was reported for pain (p = 0.043) and functional disability (p = 0.002). However, no significant differences were found for other variables in the control group. With regard to inter-group comparison, there was no statistically significant difference between the two groups regarding the given variables except for kinesiophobia (p = 0.040). Both lumbar segmental stabilization and general exercises led to reduction in pain and functional disability of patients with grade-I spondylolisthesis. Therefore, lumbar segmental stabilization exercises seemed to be better than general ones with reference to improving kinesiophobia and intervertebral movements.

A phantom and cadaveric study of radiostereometric analysis in posterior cervical and lumbar spinal fusion

BACKGROUND CONTEXTDetecting pseudarthrosis following spinal fusion is important for accurate diagnosis and treatment. Current diagnostic measures hold certain drawbacks. Radiostereometric analysis (RSA) is a radiographic technique with the capability to measure intervertebral segment changes and may be a novel way of assessing fusion. PURPOSEThe purpose of this work was to measure the accuracy and precision of RSA in instrumented posterior cervical and lumbar spinal fusion for measuring intervertebral movement. Further, to gain surgical practice with RSA in spine and determine optimal bead placements. STUDY DESIGNArtificial bone and cadaveric spine models were used to simulate a 3-level cervical (C3–C6) and a 2-level (L4–S1) lumbosacral posterior spinal fusion to analyze bead placements and to measure RSA accuracy and precision. METHODSPreliminary RSA bead placements were planned and measured in the artificial model. Secondary bead placements were adjusted slightly in the cadaveric model to consider additional fusion scenarios. Bead spread, detectability, and stability were measured to determine optimal placements. Translational and rotational precision of both models were measured. Accuracy was measured in the artificial spine model. Model-based RSA software was used for analysis. RESULTSOptimal bead placements were found to be throughout the lateral mass of C3–C6 and in the spinous process, transverse process, and within the screw canal of L4–S1. Detectability was high among all segments. Spread was greater in L4–S1 than C3–C6 due to bead collinearity along the transverse axis of the cervical vertebrae. Translational and rotational RSA accuracy in cervical and lumbosacral regions ranged between 0.005 to 0.014 mm and 0.058 to 0.208°. Translational and rotational precision measured in the phantom models ranged 0.017 to 0.131 mm and 0.058 to 0.394° in C3–C6, and 0.086 to 0.191 mm and 0.200 to 0.369° in L4–S1. Translational and rotational precision measured in the cadaveric models ranged 0.054 to 0.548 mm and 0.148 to 1.386° in C3–C6, and 0.068 to 0.164 mm and 0.100 to 0.270° in L4–S1. CONCLUSIONSRSA was found to be a feasible radiographic technique in C3–C6 and L4–S1 spinal fusion when measured in artificial and cadaveric models. Optimal bead placements were determined. Bead spread was shown to be better throughout the lumbar region than the cervical region due to anatomical size variations. RSA accuracy and precision were within acceptable RSA criteria. CLINICAL SIGNIFICANCEThe results from this work contribute to the accuracy, precision, and bead placements for studying RSA in cervical and lumbar spinal fusions. This work may further support the development of clinical studies to assess spinal fusion by evaluating postoperative intervertebral movement using RSA.

Paths of the cervical instantaneous axis of rotation during active movements-patterns and reliability.

The instantaneous helical axis (IHA) is a characteristic of neck movement that is very sensitive to changes in coordination and that has potential in the assessment of functional alterations. For its application in the clinical setting, normative patterns must be available, and its reliability must be established. The purpose of this work is to describe the continuous paths of the IHA during cyclic movements of flexion-extension (FE), lateral bending (LB), and axial rotation (AR) and to quantify their reliability. Fifteen healthy volunteers participated in the study; two repetitions were made on the same day (by different operators) and over an 8-day interval (by the same operator) to evaluate the inter-operator and inter-session reliability, respectively. The paths described by the IHA suggest a sequential movement of the vertebrae in the FE movement, with a large vertical displacement (mean, 10cm). The IHA displacement in LB and AR movements are smaller. The paths described by the IHAs have a very high reliability for FE movement, although it is somewhat lower for LB and RA movements. The standard error of measurement (SEM) is less than 0.5cm. These results show that the paths of the IHA are reliable enough to evaluate changes in the coordination of intervertebral movement. Graphical abstract A video photogrammetry system is used to record the cyclic movements of the neck, from which the continuous trajectories of the associated instantaneous helical axis (IHA) are calculated. We have analyzed the movements of flexion-extension (FE), lateral flexion (LB), and axial rotation (AR) for a sample of 15 healthy subjects. The measurements have been repeated with two different operators (in the same session) and in two separate sessions (same operator). IHA displacement patterns have been obtained in each movement, and the reliability of the measurement of such IHA trajectories has been estimated.

Influences of passive intervertebral range of motion on cervical vertebral form

The cervical spine is the junction between the head and trunk, and it therefore facilitates head mobility and stability. The goal of this study is to test several predictions regarding cervical morphology and intervertebral ranges of motion. Intervertebral ranges of motion for 12 primate species were collected via radiographs or taken from the literature. Morphometric data describing functionally relevant aspects of cervical vertebral morphology were obtained from museum specimens representing these species. We tested for correlations between intervertebral movement and vertebral form using phylogenetic generalized least-squares regression. Results demonstrate limited support for the hypothesis that range of motion (ROM) is influenced by cervical vertebral morphology. Few morphological variables correlate with ROM and no relationship is consistently significant across cervical joints. These results indicate that the relationship between vertebral morphology and joint ranges of motion is, at most, weak, providing little support the use of bony morphology to reconstruct axial mobility in fossil specimens. Future work should investigate the role of soft tissues in vertebral joint stability.

Anterior selective stabilization combined with laminoplasty for cervical myelopathy due to massive ossification of the posterior longitudinal ligament: report of early outcomes in 14 patients.

Surgical management of massive ossification of the posterior longitudinal ligament (OPLL) is challenging. To reduce surgical complications, the authors have performed anterior selective stabilization combined with laminoplasty (antSS+LP) for massive OPLL since 2012. This study aimed to elucidate the short-term outcome of the antSS+LP procedure. The authors' analysis was based on data from 14 patients who underwent antSS+LP for cervical myelopathy caused by massive OPLL and were followed up for at least 2 years after surgery (mean follow-up duration 3.3 years). Clinical outcome was evaluated preoperatively, at 6 months and 1 year postoperatively, and at the final follow-up using the Japanese Orthopaedic Association (JOA) scoring system for cervical myelopathy and the recovery rate of the JOA score. The following radiographic parameters were measured preoperatively, immediately after surgery, at 1 year after surgery, and at the final follow-up: the C2-7 angle, measured on lateral plain radiographs, and the segmental lordosis angle (SLA), measured on sagittal CT scans. The correlation between radiographic parameters and clinical outcomes was evaluated. The mean JOA score increased from 10.4 before surgery to 13.6 and 13.8 at 6 months and 1 year after surgery, respectively; at the final follow-up the mean score was 13.4. This postoperative recovery was significant (p = 0.004) and was maintained until the final follow-up. No patient required revision surgery due to postoperative neurological deterioration. However, the C2-7 angle gradually deteriorated postoperatively. Similarly, the SLA was significantly increased immediately after surgery, but the improvement was not maintained. The recovery rate at the final follow-up correlated positively with the change in C2-7 angle (r = 0.60, p = 0.03) and the change in SLA (r = 0.72, p < 0.01). AntSS+LP is safe and effective and may be an alternative to anterior decompression and fusion for the treatment of patients with massive OPLL. No postoperative neurological complications or significant postoperative exacerbation of neck pain were observed in our case series. Not only reducing intervertebral motion and decompressing the canal at the maximal compression level but also acquiring segmental lordosis at the maximal compression level are crucial factors for achieving successful outcomes of antSS+LP.

Lumbar Intervertebral Motion Analysis During Flexion and Extension Cinematographic Recordings in Healthy Male Participants: Protocol.

BackgroundPhysiological motion of the lumbar spine is a subject of interest for musculoskeletal health care professionals, as abnormal motion is believed to be related to lumbar conditions and complaints. Many researchers have described ranges of motion for the lumbar spine, but only a few have mentioned specific motion patterns of each individual segment during flexion and extension. These motion patterns mostly comprise the sequence of segmental initiation in sagittal rotation. However, an adequate definition of physiological motion of the lumbar spine is still lacking. The reason for this is the reporting of different ranges of motion and sequences of segmental initiation in previous studies. Furthermore, due to insufficient fields of view, none of these papers have reported on maximum flexion and extension motion patterns of L1 to S1. In the lower cervical spine, a consistent pattern of segmental contributions was recently described. In order to understand physiological motion of the lumbar spine, it is necessary to systematically study motion patterns, including the sequence of segmental contribution, of vertebrae L1 to S1 in healthy individuals during maximum flexion and extension.ObjectiveThis study aims to define the lumbar spines’ physiological motion pattern of vertebrae L1, L2, L3, L4, L5, and S1 by determining the sequence of segmental contribution and the sequence of segmental initiation of motion in sagittal rotation of each vertebra during maximum flexion and extension. The secondary endpoint will be exploring the possibility of analyzing the intervertebral horizontal and vertical translation of each vertebra during maximum flexion and extension.MethodsCinematographic recordings will be performed on 11 healthy male participants, aged 18-25 years, without a history of spine problems. Cinematographic flexion and extension recordings will be made at two time points with a minimum 2-week interval in between.ResultsThe study has been approved by the local institutional medical ethical committee (Medical Research Ethics Committee of Zuyderland and Zuyd University of Applied Sciences) on September 24, 2018. Inclusion of participants will be completed in 2020.ConclusionsIf successful, these physiological motion patterns can be compared with motion patterns of patients with lumbar conditions before or after surgery. Ultimately, researchers may be able to determine differences in biomechanics that can potentially be linked to physical complaints like low back pain.Trial RegistrationClinicalTrials.gov NCT03737227; https://clinicaltrials.gov/ct2/show/NCT03737227International Registered Report Identifier (IRRID)DERR1-10.2196/14741

Diagnostic Accuracy of Videofluoroscopy for Symptomatic Cervical Spine Injury Following Whiplash Trauma.

Background: Intervertebral instability is a relatively common finding among patients with chronic neck pain after whiplash trauma. Videofluoroscopy (VF) of the cervical spine is a potentially sensitive diagnostic tool for evaluating instability, as it offers the ability to examine relative intervertebral movement over time, and across the entire continuum of voluntary movement of the patient. At the present time, there are no studies of the diagnostic accuracy of VF for discriminating between injured and uninjured populations. Methods: Symptomatic (injured) study subjects were recruited from consecutive patients with chronic (>6 weeks) post-whiplash pain presenting to medical and chiropractic offices equipped with VF facilities. Asymptomatic (uninjured) volunteers were recruited from family and friends of patients. An ethical review and oversight were provided by the Spinal Injury Foundation, Broomfield, CO. Three statistical models were utilized to assess the sensitivity, specificity, positive and negative predictive values (PPV and NPV) of positive VF findings to correctly discriminate between injured and uninjured subjects. Results: A total of 196 subjects (119 injured, 77 uninjured) were included in the study. All three statistical models demonstrated high levels of sensitivity and specificity (i.e., receiver operating characteristic (ROC) values of 0.71 to 0.95), however, the model with the greatest practical clinical utility was based on the number of abnormal VF findings. For 2+ abnormal VF findings, the ROC was 0.88 (93% sensitivity, 79% specificity) and the PPV and NPV were both 88%. The highest PPV (1.0) was observed with 4+ abnormal findings. Conclusions: Videofluoroscopic examination of the cervical spine provides a high degree of diagnostic accuracy for the identification of vertebral instability in patients with chronic pain stemming from whiplash trauma.

Dynamic interactions between lumbar intervertebral motion segments during forward bending and return

Continuous dynamic multi-segmental studies of lumbar motion have added depth to our understanding of the biomechanics of back pain, but few have attempted to continuously measure the proportions of motion accepted by individual levels. This study attempted to compare the motion contributions of adjacent lumbar levels during an active weight bearing flexion and return protocol in chronic, non-specific low back pain (CNSLBP) patients and controls using quantitative fluoroscopy (QF).Eight CNSLBP patients received QF during guided standing lumbar flexion. Dynamic motion sharing of segments from L2 to S1 were calculated and analysed for interactions between levels. Eight asymptomatic controls were then matched to the 8 patients for age and sex and their motion sharing patterns compared.Share of intersegmental motion was found to be consistently highest at L2-L3 and L3-L4 and lowest at L5-S1 throughout the motion in both groups, with the exception of maximum flexion where L4-L5 received the greatest share.Change in motion sharing occurred throughout the flexion and return motion paths in both participant groups but tended to vary more at L4-L5 in patients (p < 0.05). In patients, L5-S1 provided less angular range (p < 0.05) and contributed less at maximum bend (p < 0.05), while L3-L4, on average over the bending sequence, provided a greater share of motion (p < 0.05).Intervertebral motion sharing inequality is therefore a normal feature during lumbar flexion. However, in patients, inequality was more pronounced, and variability of motion share at some levels increased. These effects may result from differences in muscular contraction or in the mechanical properties of the disc.

Subgrouping Factors Influencing Migraine Intensity in Women: A Semi-automatic Methodology Based on Machine Learning and Information Geometry.

Migraine is a heterogeneous condition with multiple clinical manifestations. Machine learning algorithms permit the identification of population groups, providing analytical advantages over other modeling techniques. The aim of this study was to analyze critical features that permit the differentiation of subgroups of patients with migraine according to the intensity and frequency of attacks by using machine learning algorithms. Sixty-seven women with migraine participated. Clinical features of migraine, related disability (Migraine Disability Assessment Scale), anxiety/depressive levels (Hospital Anxiety and Depression Scale), anxiety state/trait levels (State-Trait Anxiety Inventory), and pressure pain thresholds (PPTs) over the temporalis, neck, second metacarpal, and tibialis anterior were collected. Physical examination included the flexion-rotation test, cervical range of cervical motion, forward head position while sitting and standing, passive accessory intervertebral movements (PAIVMs) with headache reproduction, and joint positioning sense error. Subgrouping was based on machine learning algorithms by using the nearest neighbors algorithm, multisource variability assessment, and random forest model. For migraine intensity, group 2 (women with a regular migraine headache intensity score of 7 on an 11-point Numeric Pain Rating Scale [where 0 = no pain and 10 = maximum pain]) were younger and had lower joint positioning sense error in cervical rotation, greater cervical mobility in rotation and flexion, lower flexion-rotation test scores, positive PAIVMs reproducing migraine, normal PPTs over the tibialis anterior, shorter migraine history, and lower cranio-vertebral angles while standing than the remaining migraine intensity subgroups. The most discriminative variable was the flexion-rotation test score of the symptomatic side. For migraine frequency, no model was able to identify differences between groups (ie, patients with episodic or chronic migraine). A subgroup of women with migraine who had common migraine intensity was identified with machine learning algorithms.

Evidence and recommendations for the use of segmental motion testing for patients with LBP – A systematic review

BackgroundAssessment of low back pain (LBP) includes segmental motion tests. Although often used in clinical practice, the validity, inter- and intra-rater reliability of such tests in individuals with LBP are not universally accepted, making it difficult to interpret findings in clinical practice. ObjectiveThe purposes of this study were to determine the validity and reliability of segmental motion tests for patients with LBP and to give reasoned recommendations for their use in practice. DesignSystematic review. MethodsA systematic literature research was conducted of databases PubMed, LIVIVO and Cochrane library. The included studies were appraised for quality by using QUADAS-2 and an adapted version of QAREL tools. Results of studies were appraised to give reasoned recommendations taking quality criteria into account. ResultsThirteen studies were included covering passive accessory intervertebral motion testing (PAIVMs), passive physiological intervertebral motion testing (PPIVMs) and the prone instability test (PIT). The risk of bias of studies ranged from high to low. When used in isolation, specificity of PAIVMS and PPIVMs was generally high and sensitivity poor. Reliability was overwhelming poor for both. Reliability of the PIT was inconsistent. None of these assessments can be strongly recommended when used in isolation. ConclusionThe evidence regarding validity and reliability of segmental motion testing is poor and clinical use of stand-alone tests cannot be recommended. Superiority of the combination of tests as a test battery or with other clinical information needs further investigation.