The immediate reduction in low back pain intensity following lumbar joint mobilization and prone press-ups is associated with increased diffusion of water in the L5-S1 intervertebral disc

Manual therapy plus sexual advice compared with manual therapy or exercise therapy alone for lumbar radiculopathy: a randomized controlled trial

CONTEXT

The biopsychosocial approach to managing low back pain (LBP) has the potential to improve the quality of care for patients. However, LBP trials that have utilized the biopsychosocial approach to treatment have largely neglected sexual activity, which is an important social component of individuals with LBP.

OBJECTIVES

The objectives of the study are to determine the effects of manual therapy plus sexual advice (MT+SA) compared with manual therapy (MT) or exercise therapy (ET) alone in the management of individuals with lumbar disc herniation with radiculopathy (DHR) and to determine the best sexual positions for these individuals.

METHODS

This was a single-blind randomized controlled trial. Fifty-four participants diagnosed as having chronic DHR (>3 months) were randomly allocated into three groups with 18 participants each in the MT+SA, MT and ET groups. The participants in the MT+SA group received manual therapy (including Dowling's progressive inhibition of neuromuscular structures and Mulligan's spinal mobilization with leg movement) plus sexual advice, those in the MT group received manual therapy only and those in the ET group received exercise therapy only. Each group received treatment for 12 weeks and then followed up for additional 40 weeks. The primary outcomes were pain, activity limitation, sexual disability and kinesiophobia at 12 weeks post-randomization.

RESULTS

The MT+SA group improved significantly better than the MT or ET group in all outcomes (except for nerve function), and at all timelines (6, 12, 26, and 52 weeks post-randomization). These improvements were also clinically meaningful for back pain, leg pain, medication intake, and functional mobility at 6 and 12 weeks post-randomization and for sexual disability, activity limitation, pain catastrophizing, and kinesiophobia at 6, 12, 26, and 52 weeks post-randomization (p<0.05). On the other hand, many preferred sexual positions for individuals with DHR emerged, with "side-lying" being the most practiced sexual position and "standing" being the least practiced sexual position by females. While "lying supine" was the most practiced sexual position and "sitting on a chair" was the least practiced sexual position by males.

CONCLUSIONS

This study found that individuals with DHR demonstrated better improvements in all outcomes when treated with MT+SA than when treated with MT or ET alone. These improvements were also clinically meaningful for sexual disability, activity limitation, pain catastrophizing, and kinesiophobia at long-term follow-up. There is also no one-size-fits-all to sexual positioning for individuals with DHR.

Effects of spinal manipulation or mobilization as an adjunct to neurodynamic mobilization for lumbar disc herniation with radiculopathy: a randomized clinical trial

OBJECTIVES

To determine the long-term clinical effects of spinal manipulative therapy (SMT) or mobilization (MOB) as an adjunct to neurodynamic mobilization (NM) in the management of individuals with Lumbar Disc Herniation with Radiculopathy (DHR).

DESIGN

Parallel group, single-blind randomized clinical trial.

SETTING

The study was conducted in a governmental tertiary hospital.

PARTICIPANTS

Forty (40) participants diagnosed as having a chronic DHR (≥3 months) were randomly allocated into two groups with 20 participants each in the SMT and MOB groups.

INTERVENTIONS

Participants in the SMT group received high-velocity, low-amplitude manipulation, while those in the MOB group received Mulligans' spinal mobilization with leg movement. Each treatment group also received NM as a co-intervention, administered immediately after the SMT and MOB treatment sessions. Each group received treatment twice a week for 12 weeks.

OUTCOME MEASURES

The following outcomes were measured at baseline, 6, 12, 26, and 52 weeks post-randomization; back pain, leg pain, activity limitation, sciatica bothersomeness, sciatica frequency, functional mobility, quality of life, and global effect. The primary outcomes were pain and activity limitation at 12 weeks post-randomization.

RESULTS

The results indicate that the MOB group improved significantly better than the SMT group in all outcomes (p < 0.05), and at all timelines (6, 12, 26, and 52 weeks post-randomization), except for sensory deficit at 52 weeks, and reflex and motor deficits at 12 and 52 weeks. These improvements were also clinically meaningful for neurodynamic testing and sensory deficits at 12 weeks, back pain intensity at 6 weeks, and for activity limitation, functional mobility, and quality of life outcomes at 6, 12, 26, and 52 weeks of follow-ups. The risk of being improved at 12 weeks post-randomization was 40% lower (RR = 0.6, CI = 0.4 to 0.9, p = 0.007) in the SMT group compared to the MOB group.

CONCLUSION

This study found that individuals with DHR demonstrated better improvements when treated with MOB plus NM than when treated with SMT plus NM. These improvements were also clinically meaningful for activity limitation, functional mobility, and quality of life outcomes at long-term follow-up.

TRIAL REGISTRATION

Pan-African Clinical Trial Registry: PACTR201812840142310.

Myofascial and discogenic origins of lumbar pain: A critical review

The purpose of this three-part narrative review is to examine the anatomy of, and the research which supports, either the lumbar myofascia or intervertebral disc (IVD) as principal sources of our patient's low back pain. A comprehensive understanding of anatomical lumbar pain generators in combination with the current treatment-based classification system will further improve and enhance clinical decision-making skills. Section I reviews the anatomy of the spinal myofascia, myofascial sources of lumbar pain, and imaging of myofascial tissues. Part II reviews the anatomy of the IVD, examines the IVD as a potential lumbar pain generator, and includes detailed discussion on Nerve Growth Factor, Inflammatory Cytokines, Vertebral End Plates and Modic change, Annular tears, and Discogenic instability. Part III looks at the history of myofascial pain, lab-based research and myofascial pain, and various levels of discogenic pain provocation research including animal, laboratory and human subjects. Our review concludes with author recommendations on developing a comprehensive understanding of altered stress concentrations affecting the posterior annulus fibrosis, neo-innervation of the IVD, inflammatory cytokines, discogenic instability, and how this knowledge can complement use of the Treatment-Based Classification System.

Effects of the Addition of Hands-on Procedures to McKenzie Exercises on Pain, Functional Disability and Back Mobility in Patients with Low Back Pain: A Randomised Clinical Trial

Background

Low back pain (LBP) is a common musculoskeletal disorder that affects people of all ages. This study investigates the effects of the addition of hands-on procedures to McKenzie exercises on patients with LBP and derangement syndrome.

Methods

Forty-eight female patients were randomly assigned to either the experimental group or control group. All the patients in both groups underwent McKenzie exercises, transcutaneous electrical nerve stimulation (TENS) and education for 35 min/session-45 min/ session, with three sessions/week for 2 weeks. Hands-on procedures were added to the McKenzie extension exercises only for the patients in the experimental group. A visual analogue scale (VAS), the Oswestry disability index (ODI), back range of motion (BROM) and body diagrams were used to measure pain, functional disability, BROM and the centralisation of symptoms, respectively.

Results

The mean values of VAS, ODI and BROM significantly improved after the interventions in both groups (P < 0.05), whereas the results of repeated measures ANOVA and Mann-Whitney U tests showed statistically non-significant differences between the two groups (P > 0.05).

Conclusion

The addition of hands-on procedures to McKenzie exercises, TENS and education significantly alleviated back pain and functional disability and improved the back mobility and centralisation of symptoms in patients with LBP and derangement syndrome; however, these measures did not result in any significant additional benefits for such patients.

Effects of exercise therapy plus manual therapy on muscle activity, latency timing and SPADI score in shoulder impingement syndrome

PURPOSE

The study aimed to compare the effects of exercise therapy plus manual therapy (ET plus MT) and exercise therapy (ET) alone on muscle activity, muscle onset latency timing and shoulder pain and disability index-Hindi (SPADI-H) score in athletes with shoulder impingement syndrome (SIS).

MATERIALS AND METHOD

Overhead male athletes diagnosed with SIS were randomly allocated into ET plus MT group(n = 40) and ET group(n = 40). Muscle activity, muscle onset latency timings and SPADI-H score were assessed. Both the groups performed 8 weeks of intervention and were evaluated at baseline, 4th and 8th weeks.

RESULT

ET plus MT group was more effective in increasing muscle activity, optimising latency timings and decreasing SPADI score when compared to ET group alone(p < 0.05). After treatment muscle activity and SPADI-H improved in both groups (p < 0.05).

CONCLUSION

ET plus MT was superior for improving muscle activity, muscle onset latency timing and SPADI score compared to ET alone.

Assessing the contribution of lower limb mobilization, in the supine position, on shoulder-pelvis girdles dissociation

BACKGROUND

Several articular, muscular and neurological diseases generate mobility loss in the shoulder and pelvis girdles. Joint mobilization contributes to improving shoulder-pelvis girdles dissociation, but current mobilization techniques are not always successful and standardized. A robotic medical device, DPA Med®, by inducing trunk mobilization through lower limb oscillation has been developed for producing such a shoulder-pelvis girdles dissociation and is already used worldwide in rehabilitation hospitals.

RESEARCH QUESTION

To determine the optimal lower limb oscillation frequency that generated the best shoulder-pelvis girdles dissociation using the DPA Med® device.

METHODS

Thirty healthy adult volunteers (mean age: 38.6 [SD 15.2] years, mean height: 174 [SD 11.9] cm, mean body mass: 70.3 [SD 14.7] kg) participated in this prospective study. A kinematic analysis quantified pelvic and shoulder girdle mobility (rotation and lateral tilt) at different DPA Med® frequencies, from 0.5 Hz to 1 Hz. A visual analysis of the lower limb movement was also performed, using video sensors, to better understand the kinematics involved.

RESULTS

All DPA Med® frequencies have shown significant shoulder-pelvis girdles dissociation (p < 0.05). This study established an optimal oscillation frequency with the minimal interindividual variability at 0.808 Hz. It induced pelvic mobility similar to that of normal gait, in the transverse and frontal planes (10.3°, SD 2.9°, and 12.0°, SD 2.2°, respectively). This trunk mobility was achieved by producing a lemniscate-shaped motion in the lower limbs (an eight-shaped motion in the transverse plane).

SIGNIFICANCE

This study has shown that the DPA Med® device is able to induce shoulder-pelvis girdles dissociation similar to that of normal gait and allowed to establish the existence of an optimal DPA Med® oscillation frequency for lower limb mobility at 0.808 Hz. Further studies are required to evaluate its potentially benefits on gait disorders.

Two manual therapy techniques for management of lumbar radiculopathy: a randomized clinical trial

CONTEXT

Evidence has shown that spinal mobilization with leg movement (SMWLM) and progressive inhibition of neuromuscular structures (PINS) are individually effective in the management of lumbar radiculopathy. However, previous evidence reported data for only a short-term study period and did not investigate the effect of the combined manual therapy techniques.

OBJECTIVES

To compare the combined effects of two manual therapy techniques (SMWLM and PINS) with the individual techniques alone (SMWLM or PINS) in the management of individuals with lumbar radiculopathy.

METHODS

A total of 60 patients diagnosed with unilateral lumbar radiculopathy secondary to disc herniation were randomly allocated into three groups: 20 participants each in the SMWLM, PINS, and combined SMWLM + PINS groups. Each group attended two treatments per week for 30 min each, for three months. Participants were assessed at baseline, immediately posttreatment, and then at three, six, and nine months follow-up using the Visual Analog Scale (VAS), Rolland-Morris Disability Questionnaire (RMDQ), and Sciatica Bothersomeness Index (SBI).

RESULTS

Between-groups analyses using a two-way repeated-measures analysis of variance indicated significant interactions between groups and follow-up times for all outcomes (p=0.001). Participants receiving combined SMWLM + PINS treatment experienced greater improvement in leg pain, back pain, disability, and sciatica at all timelines (immediately posttreatment, and three, six, and nine months follow-up) than the participants receiving SMWLM or PINS alone (p<0.05). However, participants receiving SMWLM alone showed better improvement than the participants receiving PINS alone at all timelines (p<0.05).

CONCLUSIONS

A combined SMWLM + PINS treatment protocol showed greater improvement than the individual techniques alone in the management of individuals with LR in this study.

Could compression and traction loading improve the ability of magnetic resonance imaging to identify findings related to low back pain?

BACKGROUND

Diagnostic imaging is routinely used to depict structural abnormalities in people with low back pain (LBP), but most findings are prevalent in people with and without LBP. It has been suggested that LBP is related to changes induced in the spine due to loading. Therefore, new imaging measurements are needed to improve our ability to identify structures relating to LBP.

OBJECTIVES

To investigate the response of the lumbar spine to compression and traction in participants with and without chronic LBP using MRI T₂-mapping.

METHOD

Fifteen participants with chronic LBP were matched for age, weight, and gender with 15 healthy volunteers. All participants underwent MRI under three loading conditions maintained for 20 min each: resting supine, followed by compression and traction, both using 50% body weight. Participants were imaged in the last 5 min of each loading condition. Disc morphometric and fluid-based measurements from T₂-maps were obtained.

RESULTS

Traditional MRI measurements (i.e. disc height, width and mean signal intensity) were not able to capture any differences in the changes measured in response to loading between individuals with and without pain. The location of the T₂ weighted centroid (WC) was able to capture the difference between groups in response to compression in the horizontal (p < 0.01) and vertical direction (p < 0.01), and in response to traction in the vertical direction (p < 0.01). While the location of T₂WC moved anteriorly (Effect Size (ES): 0.44) and inferiorly with compression in those with pain (ES: 0.34), it moved posteriorly (ES: -0.14) and superiorly (ES: -0.05) in the group without pain. In response to traction, the vertical location of T₂WC moved superiorly in both groups but the change was larger in those with pain (ES _Pain = -0.52; ES _{No Pain}: -0.13).

CONCLUSION

The novel measurements of the location of the T₂WC in the intervertebral discs were the only measurements capturing differences in response to loading between those with and without low back pain.

The degenerative lumbar disc: not a disease, but still an important consideration for OMPT practice: a review of the history and science of discogenic instability

BACKGROUND

A recent AAOMPT position paper was published that opposed the use of the term 'degenerative disc disease' (DDD), in large part because it appears to be a common age-related finding. While common, there are significant physiologic and biomechanical changes that occur as a result of discogenic degeneration, which are relevant to consider during the practice of manual therapy.

METHODS

A narrative review provides an overview of these considerations, including a historical perspective of discogenic instability, the role of the disc as a pain generator, the basic science of a combined biomechanical and physiologic cycle of degeneration and subsequent discogenic instability, the influence of rotation on the degenerative segment, the implications of these factors for manual therapy practice, and a perspective on an evidence-based treatment approach to patients with concurrent low back pain and discogenic degeneration.

CONCLUSIONS

As we consider the role of imaging findings such as DDD, we pose the following question: Do our manual interventions reflect the scientifically proven biomechanical aspects of DDD, or have we chosen to ignore the helpful science as we discard the harmful diagnostic label?

Three-Dimensional Spinal Position With and Without Manual Distraction Load Increases Spinal Height

OBJECTIVE

The purpose of this study was to investigate if spinal height increases using 3-dimensional (3-D) spinal position with and without manual distraction load and to assess the correlation between spine height changes and degrees of trunk rotation.

METHODS

Fifty-six participants were randomly placed in one of two groups: (1) 3-D spinal position with manual distraction load, and (2) without manual distraction load. Spinal height was measured before and after the interventions using a stadiometer. For the statistical analysis, we used a 2 (Loading status: pre- versus post-intervention height) X 2 (3-D spinal position: with versus without manual distraction load) repeated measures Analysis of Variance (ANOVA) was used to identify significant interaction and main effects. Paired t-tests were used to calculate differences in spinal height changes between the two interventions. Pearson correlation coefficient was used to measure correlations between changes in spinal heights and degrees of trunk rotation.

RESULTS

Mean spinal height increase with 3-D spinal position with and without manual distraction load was 6.30 mm (±6.22) and 5.69 mm (±4.13), respectively. No significant interaction effect was present between loading status and 3-D spinal position but a significant main effect in loading status was. Paired t-tests revealed significant differences in spinal heights between pre-and post-3-D spinal position with and without manual distraction load. No significant correlation was measured between trunk rotation and spinal height changes.

CONCLUSION

3-D spinal position with or without distraction load increased spinal height. This suggests that 3-D spinal positioning without manual distraction could be used in home settings to help maintain intervertebral disc (IVD) health.

A randomized clinical trial comparing non-thrust manipulation with segmental and distal dry needling on pain, disability, and rate of recovery for patients with non-specific low back pain

Objective: The purpose of this study was to examine the within and between-group effects of segmental and distal dry needling (DN) without needle manipulation to a semi-standardized non-thrust manipulation (NTM) targeting the symptomatic spinal level for patients with non-specific low back pain (NSLBP). Methods: Sixty-five patients with NSLBP were randomized to receive either DN (n = 30) or NTM (n = 35) for six sessions over 3 weeks. Outcomes collected included the oswestry disability index (ODI), patient specific functional scale (PSFS), numeric pain rating scale (NPRS), and pain pressure thresholds (PPT). At discharge, patients perceived recovery was assessed. Results: A two-way mixed model ANOVA demonstrated that there was no group*time interaction for PSFS (p = 0.26), ODI (p = 0.57), NPRS (p = 0.69), and PPT (p = 0.51). There was significant within group effects for PSFS (3.1 [2.4, 3.8], p = 0.018), ODI (14.5% [10.0%, 19.0%], p = 0.015), NPRS (2.2 [1.5, 2.8], p = 0.009), but not for PPT (3.3 [0.5, 6.0], p = 0.20). Discussion: The between-group effects were neither clinically nor statistically significant. The within group effects were both significant and exceeded the reported minimum clinically important differences for the outcomes tools except the PPT. DN and NTM produced comparable outcomes in this sample of patients with NSLBP. Level of evidence: 1b.

Changes in Spinal Height After Manual Axial Traction or Side Lying: A Clinical Measure of Intervertebral Disc Hydration Using Stadiometry

OBJECTIVES

The purpose of this study was to determine the immediate effects of a manual therapy technique consisting of axial traction compared with side lying on increased spine height after sustained loading.

METHODS

Twenty-one asymptomatic participants were included. Participants either received manual therapy technique consisting of manual axial traction force for 2 consecutive rounds of 3 minutes or sustained side lying for 10 minutes. Spine height was measured using a commercially available stadiometer. Spinal height change was determined from measurements taken after loaded walking and measurements taken after manual therapy. A paired t test was performed to determine if a manual therapy technique consisting of axial traction increased spinal height after a period of spinal loading.

RESULTS

A significant increase in height was found after both manual therapy technique and sustained side lying (P < .0001). The mean height gain was 8.60 mm using 3-dimensional axial separation.

CONCLUSION

This study is an initial attempt at evaluating the biomechanical effects of manual therapy technique consisting of axial traction. Both manual axial traction force and sustained side-lying position were equally effective for short-term change in spine height after a loaded walking protocol among healthy asymptomatic individuals. This study protocol may help to inform future studies that evaluate spine height after loading.

Short-term increase in discs' apparent diffusion is associated with pain and mobility improvements after spinal mobilization for low back pain

Pain perception, trunk mobility and apparent diffusion coefficient (ADC) within all lumbar intervertebral discs (IVDs) were collected before and shortly after posterior-to-anterior (PA) mobilizations in 16 adults with acute low back pain. Using a pragmatic approach, a trained orthopaedic manual physical therapist applied PA mobilizations to the participants' spine, in accordance with his examination findings. ADC _all was computed from diffusion maps as the mean of anterior (ADC _ant ), middle (ADC _mid ), and posterior (ADC _post ) portions of the IVD. After mobilization, pain ratings and trunk mobility were significantly improved and a significant increase in ADC _all values was observed. The greatest ADC _all changes were observed at the L₃-L₄ and L₄-L₅ levels and were mainly explained by changes in ADC _ant and ADC _post , respectively. No significant changes in ADC were observed at L₅-S₁ level. The reduction in pain and largest changes in ADC observed at the periphery of the hyperintense IVD region suggest that increased peripheral random motion of water molecules is implicated in the IVD nociceptive response modulation. Additionally, ADC changes were observed at remote IVD anatomical levels that did not coincide with the PA spinal mobilization application level.

MRI evaluation of the effects of extension exercises on the disc fluid content and location of the centroid of the fluid distribution

BACKGROUND

McKenzie prone press-up exercises have been hypothesised to reduce intradiscal pressure, allowing fluid to be reabsorbed into the disc, which could improve the internal stability and local chemical milieu of the disc, potentially reducing symptoms.

OBJECTIVE

To investigate the immediate effects of prone press-up exercises on lumbar disc fluid content and movement.

DESIGN

Quantification of MRI changes before and after a single exercise session.

METHODS

The mid-sagittal T₂-weighted MR images of 22 volunteers with low back pain were obtained before and immediately after performing press-up exercises. The whole disc and nucleus regions of the L4-5 and L5-S1 discs were then segmented, and their mean signal intensity (MSI) and signal intensity weighted centroid (SIWC) were computed to estimate disc fluid content and displacement.

RESULTS

There were no significant differences between the MSI and the vertical position of the SIWC of the whole disc before and after extension at either disc level (effect size [ES]: -0.23 to 0.09). There was a significant anterior displacement (0.1 ± 5.4 mm) of the location of the SIWC of the disc after extension exercise at L4-5 (ES: 0.22), but not at L5-S1 (ES: 0.00) or at either level for the nucleus region (ES: -0.06; 0.16).

CONCLUSION

Little evidence was found supporting the hypothesis that press-up exercises affect disc fluid content and distribution. Novel parameters reflecting fluid distribution detected similar or larger effects of the extension than MSI. If such exercises are effective in reducing symptoms, it is likely through other mechanisms than by changing fluid content or distribution.

Increased spinal height using propped slouched sitting postures: Innovative ways to rehydrate intervertebral discs

BACKGROUND

Upright and slouched sitting are frequently adopted postures associated with increased intradiscal pressure, spinal height loss and intervertebral disc pathology.

OBJECTIVES

To examine the effects of two sustained propped slouched sitting (PSS) postures on spinal height after a period of trunk loading.

METHODS

Thirty-four participants without a history of low back pain (LBP) were recruited (age 24.4 ± 1.6 years). Subjects sat in (1) PSS without lumbar support and (2) PSS with lumbar support for 10 min, after a period of trunk loading. Spinal height was measured using a stadiometer.

RESULTS

Mean spinal height increase during PSS without lumbar support was 2.94 ± 3.63 mm and with lumbar support 4.74 ± 3.07 mm.

CONCLUSIONS

Both PSS with and without lumbar support significantly increased spinal height after a period of trunk loading (p < 0.001). Such PSS postures can provide a valuable alternative to upright sitting and may be recommended for recovering spinal height in the working environment following periods of loading.

Age-related differences in the response of the L5-S1 intervertebral disc to spinal traction

BACKGROUND

Lumbar traction is a common treatment for low back pain; however its mechanisms of action are poorly understood. It has been hypothesized that a key effect of lumbar traction is its capacity to influence fluid movement within the intervertebral disc (IVD).

OBJECTIVES

To determine differences in the apparent diffusion coefficient (ADC) obtained with lumbar diffusion-weighted imaging (DWI) of the L5-S1 IVD before, and during, the application of lumbar traction.

DESIGN

Case series, repeated measures.

METHODS

A static traction load of ∼50% of body-weight was applied to the low back using a novel "MRI-safe" apparatus. DWI of the lumbar spine was performed prior to, and during the application of the traction load.

RESULTS

Participants were currently asymptomatic and included a young adult group (n = 18) and a middle-aged group (n = 15). The young adult group had a non-significant 2.2% increase in ADC (mean change = 0.03 × 10^-3 mm²/s, SD = 0.24, 95% CI = -0.09, 0.15). The ADC for the middle-aged group significantly increased by 20% (mean change of 0.18 × 10^-3 mm²/s, SD = 0.19; 95% CI = 0.07, 0.28; p = 0.003; effect size = 0.95). There was an inverse relationship between the ADC obtained before traction and the percent increase in ADC that was measured during traction.

CONCLUSION

Static traction was associated with an increase in diffusion of water within the L5-S1 IVDs of middle-age individuals, but not in young adults, suggesting age-related differences in the diffusion response. Further study is needed to assess the relationship between these findings and the symptoms of back pain.

LEVEL OF EVIDENCE

4.

Physiological effects of physical therapy interventions on lumbar intervertebral discs: A systematic review

BACKGROUND CONTEXT

The use of physical therapy has been recommended in the treatment of low back pain based on primarily mechanical and neurophysiological effects. Recent studies have measured the physiological effects of physical therapy interventions, including manual therapy and traction, on the intervertebral discs (IVD), and these findings may have implications for the long-term management or even prevention of low back pain.

PURPOSE

The objective of this systematic review is to investigate the literature regarding possible physiological effects of physical therapy interventions on the intervertebral disc (IVD).

STUDY DESIGN

Systematic Review.

METHODS

A literature search of published articles through December 2014 resulted in the retrieval of 8 clinical studies assessing the influence of physical therapy interventions on the physiology of the IVD.

RESULTS

Three studies, including two using animal models, investigated the effects of 30-minute intermittent traction on disc height. One in vivo animal study and two studies using human subjects assessed changes of disc height associated with static traction. Three studies investigated the effects of lumbar spine manipulation and mobilization on changes in water diffusion within the IVD. All studies confirmed, either directly or indirectly, that their respective intervention influenced disc physiology primarily through water flow.

CONCLUSION

Physical therapy interventions may have an effect on the physiology of the IVD, primarily through water diffusion and molecular transport, which are important for the health of the IVD.

The Effectiveness of Thai Massage and Joint Mobilization

BACKGROUND

Non-specific low back pain (LBP) is a common health problem resulting from many risk factors and human behaviors. Some of these may interact synergistically and have been implicated in the cause of low back pain. Massage both traditional Thai massage and joint mobilization as a common practice has been shown to be effective for some subgroup of nonspecific LBP patients.

PURPOSE AND SETTING

The trial compared the effectiveness between traditional Thai massage and joint mobilization for treating nonspecific LBP. Some associated factors were included. The study was conducted at the orthopedic outpatient department, Lerdsin General Hospital, Bangkok, Thailand.

METHODS

Prospective, randomized study was developed without control group. The required sample size was estimated based on previous comparative studies for effectiveness between techniques. Two primary outcome measures were a 0 to 10 visual analog scale (VAS) of pain and Oswestry Disability Index (ODI). Secondary outcome measures were satisfaction of patients and adverse effects of the treatment. The "intention to treat" (ITT) and per protocol approach were used to compare the significance of the difference between treatment groups.

PARTICIPANTS

One hundred and twenty hospital outpatients, 20 (16.7%) male and 100 (83.3%) female, were randomized into traditional Thai massage and joint mobilization therapy. The average age of traditional Thai massage and joint mobilization was 50.7 years and 48.3 years, respectively. Both groups received each treatment for approximately 30 minutes twice per week over a four-week period. Total course did not exceed eight sessions.

RESULT

With ITT, the mean VAS of traditional Thai massage group before treatment was 5.3 (SD = 1.7) and ODI was 24.9 (SD = 14.7), while in joint mobilization groups, the mean VAS was 5.0 (SD = 1.6) and ODI was 24.6 (SD = 15). After treatment, the mean VAS and ODI were significantly reduced (VAS = 0.51 (SD = 0.89) and ODI = 8.1 (SD = 10.7) for traditional Thai massage, VAS = 0.86 (SD = 1.49) and ODI = 8.26 (SD = 12.97) for joint mobilization). Constipation was found in 34 patients (28.3%).

CONCLUSION

The traditional Thai massage and joint mobilization used in this study were equally effective for short-term reduction of pain and disability in patients with chronic nonspecific LBP. Both techniques were safe with short term effect in a chosen group of patients.

Factors in Patient Responsiveness to Directional Preference-Matched Treatment of Neck Pain With or Without Upper Extremity Radiation

PURPOSE

Patient-related predictive factors in responsiveness to directional preference therapy for neck pain with or without upper extremity radiation (NP/R) have not been reported. A directional preference is any neck movement that, when performed repeatedly to end range, results in centralization and/or alleviation of NP/R. It was hypothesized that patient compliance with a prescribed, directional preference-matched home exercise program would improve positive responsiveness to NP/R treatment.

METHODS

Patient-related factors thought to affect responsiveness to care were collected retrospectively from charts and de-identified for patients with NP/R who underwent chiropractic treatment at a multispecialty spine clinic from January 2014 through June 2015. Responsiveness was measured by calculating the percentage change in Neck Bournemouth Questionnaire (NBQ) scores over treatment time. Multiple linear regression was used to identify factors associated with positive responsiveness.

RESULTS

Mean percentage change in patient NBQ score from initial intake to discharge was 50% (standard deviation: 32%). Of 104 patients meeting study inclusion criteria, 86 (83%) reported experiencing improvement after the first treatment session. Bivariate analysis of patient characteristics by compliance with directional preference-matched exercise indicated that compliant patients (n=95, 91%) demonstrated significantly greater responsiveness to care than did noncompliant patients, at 55% versus 25% change in NBQ score, respectively (P=0.0041). Four factors were statistically significant predictors of patient responsiveness to directional preference therapy for NP/R: patient compliance with directional preference-matched exercise (P=0.0023), patient age (P=0.0029), condition chronicity (P<0.0001), and whether the patient reported improvement of symptoms following initial treatment session (P=0.0003).

CONCLUSIONS

The results of this study suggest that patient compliance with directional preference exercise is associated with patient responsiveness to conservative treatment of NP/R, as are age, chronicity and report of immediate symptom improvement.

Effect of interferential current therapy on pain perception and disability level in subjects with chronic low back pain: a randomized controlled trial

Objective:

To assess the short-term efficacy of transregional interferential current therapy on pain perception and disability level in chronic non-specific low back pain.

Design:

A randomized, single-blinded (the assessor collecting the outcome data was blinded), controlled trial.

Setting:

A private physiotherapy research clinic.

Subjects:

A total of 64 individuals, 20 men and 44 women, mean (SD) age was 51 years (11.93), with low back pain of more than three months, with or without pain radiating to the lower extremities above the knee, were distributed into a control ( n = 20) or an experimental group ( n = 44). A 2:1 randomization ratio was used in favour of the latter.

Interventions:

A transregional interferential current electrotherapy protocol was performed for participants in the experimental group, while the control group underwent a ‘usual care’ treatment (massage, mobilization and soft-tissue techniques). All subjects received up to 10 treatment sessions of 25 minutes over a two-week period, and completed the intervention and follow-up evaluations.

Outcome measures:

Self-perceived pain was assessed with a Visual Analogue Scale. Secondary measure included the Oswestry Low Back Disability Index. Evaluations were collected at baseline and after the intervention protocol.

Results:

Significant between-group differences were found for interferential current therapy on pain perception ( p = 0.032) and disability level ( p = 0.002). The observed differences in the between-group mean changes were of 11.34 mm (1.77/20.91) and 13.38 points (4.97/21.78), respectively.

Conclusions:

A two-week transregional interferential current treatment has shown significant short-term efficacy, when compared with a ‘usual care’ protocol, on self-perceived pain and functionality in subjects with chronic low back pain.

Diffusion-Weighted MRI Assessment of Adjacent Disc Degeneration After Thoracolumbar Vertebral Fractures

OBJECTIVE

The purpose of this study was to assess, by the mean apparent diffusion coefficient (ADC), if a relationship exists between disc ADC and MR findings of adjacent disc degeneration after thoracolumbar fractures treated by anatomic reduction using vertebral augmentation (VAP).

MATERIALS AND METHODS

Twenty non-consecutive patients (mean age 50.7 years; range 45-56) treated because of vertebral fractures, were included in this study. There were 10 A3.1 and 10 A1.2 fractures (AO classification). Surgical treatment using VAP was applied in 14 cases, and conservative in 6 patients. MRI T2-weighted images and mapping of apparent diffusion coefficient (ADC) of the intervertebral disc adjacent to the fractured segment were performed after a mean follow-up of 32 months. A total of 60 discs, 3 per patient, were analysed: infra-adjacent, supra-adjacent and a control disc one level above the supra-adjacent.

RESULTS

No differences between patients surgically treated and those following a conservative protocol regarding the average ADC values obtained in the 20 control discs analysed were found. Considering all discs, average ADC in the supra-adjacent level was lower than in the infra-adjacent (1.35 ± 0.12 vs. 1.53 ± 0.06; p < 0.001). Average ADC values of the discs used as a control were similar to those of the infra-adjacent level (1.54 ± 0.06). Compared to surgically treated patients, discs at the supra-adjacent fracture level showed statistically significant lower values in cases treated conservatively (p < 0.001). The variation in the delay of surgery had no influence on the average values of ADC at any of the measured levels.

CONCLUSIONS

ADC measurements of the supra-adjacent discs after a mean follow-up of 32 months following thoracolumbar fractures, showed that restoration of the vertebral collapse by minimally invasive VAP prevents posttraumatic disc degeneration.

Feasibility of MR elastography of the intervertebral disc

Low back pain (LBP) is a costly and widely prevalent health disorder in the U.S. One of the most common causes of LBP is degenerative disc disease (DDD). There are many imaging techniques to characterize disc degeneration; however, there is no way to directly assess the material properties of the intervertebral disc (IVD) within the intact spine. Magnetic resonance elastography (MRE) is an MRI-based technique for non-invasively mapping the mechanical properties of tissues in vivo. The purpose of this study was to investigate the feasibility of using MRE to detect shear wave propagation in and determine the shear stiffness of an axial cross-section of an ex vivo baboon IVD, and compare with shear displacements from a finite element model of an IVD motion segment in response to harmonic shear vibration. MRE was performed on two baboon lumbar spine motion segments (L3-L4) with the posterior elements removed at a range of frequencies (1000-1500Hz) using a standard clinical 1.5T MR scanner. Propagating waves were visualized in an axial cross-section of the baboon IVDs in all three motion-encoding directions, which resembled wave patterns predicted using finite element modeling. The baboon nucleus pulposus showed an average shear stiffness of 79±15kPa at 1000Hz. These results suggest that MRE is capable of visualizing shear wave propagation in the IVD, assessing the stiffness of the nucleus of the IVD, and can differentiate the nucleus and annulus regions.

Diffusion-weighted imaging in musculoskeletal radiology-clinical applications and future directions

Diffusion-weighted imaging (DWI) is an established diagnostic tool with regards to the central nervous system (CNS) and research into its application in the musculoskeletal system has been growing. It has been shown that DWI has utility in differentiating vertebral compression fractures from malignant ones, assessing partial and complete tears of the anterior cruciate ligament (ACL), monitoring tumor response to therapy, and characterization of soft-tissue and bone tumors. DWI is however less useful in differentiating malignant vs. infectious processes. As of yet, no definitive qualitative or quantitative properties have been established due to reasons ranging from variability in acquisition protocols to overlapping imaging characteristics. Even with these limitations, DWI can still provide clinically useful information, increasing diagnostic accuracy and improving patient management when magnetic resonance imaging (MRI) findings are inconclusive. The purpose of this article is to summarize recent research into DWI applications in the musculoskeletal system.

What effect can manual therapy have on a patient's pain experience?

Manual therapy (MT) is a passive, skilled movement applied by clinicians that directly or indirectly targets a variety of anatomical structures or systems, which is utilized with the intent to create beneficial changes in some aspect of the patient pain experience. Collectively, the process of MT is grounded on clinical reasoning to enhance patient management for musculoskeletal pain by influencing factors from a multidimensional perspective that have potential to positively impact clinical outcomes. The influence of biomechanical, neurophysiological, psychological and nonspecific patient factors as treatment mediators and/or moderators provides additional information related to the process and potential mechanisms by which MT may be effective. As healthcare delivery advances toward personalized approaches there is a crucial need to advance our understanding of the underlying mechanisms associated with MT effectiveness.

Do participants with low back pain who respond to spinal manipulative therapy differ biomechanically from nonresponders, untreated controls or asymptomatic controls?

STUDY DESIGN

Nonrandomized controlled study.

OBJECTIVE

To determine whether patients with low back pain (LBP) who respond to spinal manipulative therapy (SMT) differ biomechanically from nonresponders, untreated controls or asymptomatic controls.

SUMMARY OF BACKGROUND DATA

Some but not all patients with LBP report improvement in function after SMT. When compared with nonresponders, studies suggest that SMT responders demonstrate significant changes in spinal stiffness, muscle contraction, and disc diffusion. Unfortunately, the significance of these observations remains uncertain given methodological differences between studies including a lack of controls.

METHODS

Participants with LBP and asymptomatic controls attended 3 sessions for 7 days. On sessions 1 and 2, participants with LBP received SMT (+LBP/+SMT, n = 32) whereas asymptomatic controls did not (-LBP/-SMT, n = 57). In these sessions, spinal stiffness and multifidus thickness ratios were obtained before and after SMT and on day 7. Apparent diffusion coefficients from lumbar discs were obtained from +LBP/+SMT participants before and after SMT on session 1 and from an LBP control group that did not receive SMT (+LBP/-SMT, n = 16). +LBP/+SMT participants were dichotomized as responders/nonresponders on the basis of self-reported disability on day 7. A repeated measures analysis of covariance was used to compare apparent diffusion coefficients among responders, nonresponders, and +LBP/-SMT subjects, as well as spinal stiffness or multifidus thickness ratio among responders, nonresponders, and -LBP/-SMT subjects.

RESULTS

After the first SMT, SMT responders displayed statistically significant decreases in spinal stiffness and increases in multifidus thickness ratio sustained for more than 7 days; these findings were not observed in other groups. Similarly, only SMT responders displayed significant post-SMT improvement in apparent diffusion coefficients.

CONCLUSION

Those reporting post-SMT improvement in disability demonstrated simultaneous changes between self-reported and objective measures of spinal function. This coherence did not exist for asymptomatic controls or no-treatment controls. These data imply that SMT impacts biomechanical characteristics within SMT responders not present in all patients with LBP. This work provides a foundation to investigate the heterogeneous nature of LBP, mechanisms underlying differential therapeutic response, and the biomechanical and imaging characteristics defining responders at baseline.

LEVEL OF EVIDENCE

3.

Spinal height change in response to sustained and repetitive prone lumbar extension after a period of spinal unloading

OBJECTIVE

The purpose of this study was to investigate if differences in spinal height changes in healthy individuals were observed after a period of spinal unloading using repetitive as compared with sustained lumbar extension exercises.

METHODS

This study used a pretest, posttest, crossover design. Asymptomatic participants were recruited using convenience sampling. Thirty-two participants (15 male; 17 female) without back pain were included in the data analysis (mean, 24.4 years; range, 20-41 years). Participants performed sustained or repetitive prone lumbar extension exercises after 1 hour of sustained spinal unloading. Spinal height was measured using a stadiometer before and after the repetitive and sustained prone lumbar extension exercises.

RESULTS

Paired t tests revealed no significant difference in spine height after repetitive (P = .774) or sustained (P = .545) prone lumbar extension after a period of spinal unloading. No significant difference between spinal height changes occurred between sustained (mean [SD], -0.28 [2.59] mm) and repetitive (mean [SD], -0.12 [2.42] mm) lumbar extension (P = .756).

CONCLUSION

In this group of asymptomatic individuals, sustained and repetitive lumbar extension exercises did not appear to affect spinal height after a period of spinal unloading.

Short-term effect of spinal manipulation on pain perception, spinal mobility, and full height recovery in male subjects with degenerative disk disease: a randomized controlled trial

OBJECTIVE

To evaluate the short-term effect on spinal mobility, pain perception, neural mechanosensitivity, and full height recovery after high-velocity, low-amplitude (HVLA) spinal manipulation (SM) in the lumbosacral joint (L5-S1).

DESIGN

Randomized, double-blind, controlled clinical trial with evaluations at baseline and after intervention.

SETTING

University-based physical therapy research clinic.

PARTICIPANTS

Men (N=40; mean age ± SD, 38 ± 9.14 y) with diagnosed degenerative lumbar disease at L5-S1 were randomly divided into 2 groups: a treatment group (TG) (n=20; mean age ± SD, 39 ± 9.12 y) and a control group (CG) (n=20; mean age ± SD, 37 ± 9.31 y). All participants completed the intervention and follow-up evaluations.

INTERVENTIONS

A single L5-S1 SM technique (pull-move) was performed in the TG, whereas the CG received a single placebo intervention.

MAIN OUTCOME MEASURES

Measures included assessing the subject's height using a stadiometer. The secondary outcome measures included perceived low back pain, evaluated using a visual analog scale; neural mechanosensitivity, as assessed using the passive straight-leg raise (SLR) test; and amount of spinal mobility in flexion, as measured using the finger-to-floor distance (FFD) test.

RESULTS

The intragroup comparison indicated a significant improvement in all variables in the TG (P<.001). There were no changes in the CG, except for the FFD test (P=.008). In the between-group comparison of the mean differences from pre- to postintervention, there was statistical significance for all cases (P<.001).

CONCLUSIONS

An HVLA SM in the lumbosacral joint performed on men with degenerative disk disease immediately improves self-perceived pain, spinal mobility in flexion, hip flexion during the passive SLR test, and subjects' full height. Future studies should include women and should evaluate the long-term results.

The within-session change in low back pain intensity following spinal manipulative therapy is related to differences in diffusion of water in the intervertebral discs of the upper lumbar spine and L5-S1

STUDY DESIGN

Single-group, prospective, repeated-measures design with responder analysis.

OBJECTIVE

To determine differences in the changes in diffusion of water within the lumbar intervertebral discs between participants with low back pain who reported a within-session reduction in pain intensity following a single treatment of spinal manipulative therapy and those who did not.

BACKGROUND

There is a paucity of research that describes the physiologic events associated with analgesia following intervention for low back pain. Postintervention increases in the diffusion of water within various soft tissues of the spine may be one of many potential mechanisms linked to pain reduction.

METHODS

Nineteen adults between 20 and 45 years of age participated in this study. All participants reported low back pain of at least 2 on an 11-point (0-10) verbally administered numeric pain rating scale at the time of enrollment. Participants underwent T2- and diffusion-weighted lumbar magnetic resonance imaging scans immediately before and after receiving a single treatment of spinal manipulative therapy. Individuals who reported a decrease in current pain intensity of more than 2 following treatment were classified as "within-session responders," and the remainder were classified as "not-within-session responders." The apparent diffusion coefficient (ADC), representing the diffusion of water in the nucleus pulposus, was calculated from ADC maps derived from the midsagittal diffusion-weighted images.

RESULTS

Two-way, repeated-measures analyses of variance indicated significant group-by-time interactions. Participants in the within-session-responder group (n = 12) had a postintervention increase in ADC at L1-2 (P = .001), L2-3 (P = .002), and L5-S1 (P = .01) compared to those in the not-within-session-responder group (n = 7). Large effect sizes in ADC between responder groups were observed at L1-2 (d = 1.74), L2-3 (d = 1.83), and L5-S1 (d = 1.49). No significant group-by-time interactions were observed at the L3-4 and L4-5 levels.

CONCLUSION

Changes in the diffusion of water within the lumbar intervertebral discs at the L1-2, L2-3, and L5-S1 levels appear to be related to differences in within-session pain reports following a single treatment of spinal manipulative therapy.

Comparison of apparent diffusion coefficient and T2 relaxation time variation patterns in assessment of age and disc level related intervertebral disc changes

PURPOSE

To compare the variation patterns of ADC and T2 values in different age and intervertebral disc (IVD) levels, thus to identify their sensitivities in assessing age and disc level related IVDs changes.

MATERIALS AND METHODS

The T2 and ADC values were recorded from 345 IVDs of 69 volunteers. Kendall's correlation analysis was used to identify the relationship between age and T2/ADC mean values respectively. The one-way analysis of variance (ANOVA) with post hoc analysis was then applied to test the differences of T2 and ADC values among different IVD levels and age groups, followed by linear regression analysis between age (<45 and >45 years) and T2/ADC mean values. This study was approved by the Ethics Committee of the Chinese Academy of Medical Sciences and the Peking Union Medical College Hospital.

RESULTS

Significant negative correlation was observed between age and T2/ADC mean values. The T2 and ADC values showed significant differences among IVD levels and among age groups except for T2 values in age group 1 (25-34 years) and group 2 (35-44 years), and for ADC values at L1-2 level. Both T2 and ADC values showed significant differences between young (age<45 years) and elderly group (age>45 years) at each IVD level. A linear relationship was observed between age and T2/ADC mean values in the elderly group as well as in the young group for the ADC mean values, while no such tendency was identified in the young group for the T2 mean values.

CONCLUSIONS

ADC values may be a more sensitive parameter than T2 in assessing age and disc level related intervertebral disc changes.

A treatment-based classification approach to examination and intervention of lumbar disorders

CONTEXT

Low back injuries are a common occurrence in athletes and often result in missed competition and practice time. The examination of athletes with low back pain commonly involves diagnostic imaging, which rarely guides the clinician in selecting the appropriate interventions.

DATA ACQUISITION

All years of PubMed, CINAHL, PEDro, and SPORTDiscus were searched in December 2010. Keywords included treatment based classification and lumbar with the following terms: rehabilitation, treatment, athlete, low back pain, sports, and outcomes.

RESULTS

A treatment-based classification approach is preferred for the management of the athlete with low back pain. The treatment-based classification approach involves 3 steps. First is to screen the patient for potentially serious conditions that are not appropriate for conservative management. Second is staging the athlete (based on current disability ratings and ability to perform functional activities). Finally, treatment interventions are selected on the basis of the athlete's signs and symptoms.

CONCLUSION

The treatment-based classification scheme provides the clinician with a reliable algorithm for matching an athlete's symptom presentation to the optimal intervention, potentially reducing participation loss. Managing individuals with low back pain using a treatment-based classification approach significantly reduces disability and pain compared with current clinical practice guideline standards.

Subgrouping patients with low back pain: a treatment-based approach to classification

Context:

Low back pain (LBP) is a prevalent condition imposing a large socioeconomic burden. Despite intensive research aimed at the efficacy of various therapies for patients with LBP, most evidence has failed to identify a superior treatment approach. One proposed solution to this dilemma is to identify subgroups of patients with LBP and match them with targeted therapies. Among the subgrouping approaches, the system of treatment-based classification (TBC) is promoted as a means of increasing the effectiveness of conservative interventions for patients with LBP.

Evidence acquisition:

MEDLINE and PubMed databases were searched from 1985 through 2010, along with the references of selected articles.

Results:

TBC uses a standardized approach to categorize patients into 1 of 4 subgroups: spinal manipulation, stabilization exercise, end-range loading exercise, and traction. Although the TBC subgroups are in various stages of development, recent research lends support to the effectiveness of this approach.

Conclusions:

While additional research is required to better elucidate this method, the TBC approach enhances clinical decision making, as evidenced by the improved clinical outcomes experienced by patients with LBP.

Magnetic resonance imaging: fundamental safety issues

Medical practitioners have a variety of imaging modalities at their disposal. The exquisite soft tissue delineation available with magnetic resonance imaging (MRI) has resulted in the rising utilization of this particular modality. Increasingly, physical therapists around the world are actively involved in not only referring patients with musculoskeletal conditions for MRI but also in the acquisition of MRI data in both the clinical and research arenas. The MRI process involves the use of a very strong static magnetic field, time-varying (gradient) fields, and radiofrequency energy. To ensure the well-being of patients, staff, and visitors, an understanding of the primary hazards of this environment and the rigorous safety procedures that must be followed is imperative to the clinician. This paper describes the basic components of an MRI system, discusses various MRI safety issues, and presents the screening procedure necessary prior to using MRI. Primary hazards associated with the imaging process are also reviewed. J Orthop Sports Phys Ther 2011;41(11):820-828. doi:10.2519/jospt.2011.3906.

Magnetic resonance imaging: the underlying principles

The creation of a magnetic resonance image (MRI) and its inherent contrast are controlled by a variety of anatomical structure- and sequence-dependent parameters. While these may seem confusing to the uninitiated, they provide MRI with great flexibility and make it a powerful clinical tool. This article describes the principles of basic physics behind magnetic resonance spectroscopy (MRS) and imaging, including a basic description of the properties of magnetic resonance compatible nuclei, how a radiofrequency (RF) pulse produces a signal, and how this signal can be spatially encoded to produce an image. The relaxation properties of the MRI signal depend on biological tissue type and can provide information on tissue composition, environment, and pathological changes. The contrast properties within an image can be manipulated based on the relaxation properties of the anatomical sample and the nature of the imaging sequence. The benefits of T1- and T2-weighted images in musculoskeletal imaging and the common sequences used (including turbo spin echo [TSE], fat suppression sequences such as STIR, and rapid breath-hold sequences such as HASTE and FISP) are discussed. The principles behind contrast agents and diffusion-weighted imaging and how they can be applied in the body are considered.

Diffusion-weighted magnetic resonance imaging of the musculoskeletal system: an emerging technology with potential to impact clinical decision making

Diffusion-weighted imaging (DWI) is an application of magnetic resonance imaging that allows the measurement of water movement within and between tissues. Originally developed as a way of detecting early signs of stroke or brain disease, DWI is now being used to study physiologic events within the musculoskeletal system. The accurate measurement of water diffusion can provide important information regarding tissue responses associated with trauma and disease, as well as offer insight toward the mechanism by which physical therapy interventions affect tissues. The purpose of this paper is to discuss the rationale for DWI and its potential clinical and research applications for patients with musculoskeletal disorders. Specific examples of the use of DWI for patients with painful spinal disorders are used as illustrations.

The pearls and pitfalls of magnetic resonance imaging for the spine

Musculoskeletal imaging of the spine can be an invaluable tool to inform clinical decision making in patients with spinal pain. An understanding of the technology involved in producing and interpreting high-resolution images produced from magnetic resonance imaging (MRI) of the human spine is necessary to better appreciate which sequences can be used for, or tailored to, individual patients and their conditions. However, there is substantial variability in the clinical meaningfulness of some MRI findings of spinal tissues. For example, normal variants can often mimic significant musculoskeletal pathology, which could increase the risk of misinformed clinical decisions and, even worse, poor or adverse outcomes. This clinical commentary will highlight some of the pearls and pitfalls of MRI for the cervical, thoracic, and lumbar regions, and include cases to illustrate some of the common imaging artifacts and normal variants for MRI of the spine.

Discussion paper: what happened to the 'bio' in the bio-psycho-social model of low back pain?

PURPOSE

Over 20 years ago the term non-specific low back pain became popular to convey the limitations of our knowledge of the pathological source of most people's low back pain. Knowledge of underlying pathology has advanced little since then, despite limited improvements in outcomes for patients with low back pain.

METHODS

This paper discusses potential misunderstandings related to diagnostic studies in the field of low back pain and argues that future diagnostic studies should include and investigate pathological sources of low back pain.

RESULTS

Six potential misunderstandings are discussed. (1) Until diagnosis is shown to improve outcomes it is not worth investigating; (2) without a gold standard it is not possible to investigate diagnosis of low back pain; (3) the presence of pathology in some people without low back pain means it is not important; (4) dismissal of the ability to diagnose low back pain in clinical guidelines is supported by the same level of evidence as recommendations for therapy; (5) suggesting use of a diagnostic test in research is misinterpreted as endorsing its use in current clinical practice; (6) we seem to have forgotten the 'bio' in biopsychosocial low back pain.

CONCLUSIONS

We believe the misunderstandings presented in this paper partly explain the lack of investigation into pathology as an important component of the low back pain experience. A better understanding of the biological component of low back pain in relation, and in addition, to psychosocial factors is important for a more rational approach to management of low back pain.