Thoracic kyphosis affects spinal loads and trunk muscle force

Comparing two corrective exercise approaches for body image and upper-quadrant posture in schoolgirls with hyperkyphosis

Proper posture is essential for healthy living. Maintaining an ideal upright posture is one of the most critical indicators of the health of the musculoskeletal and movement systems. The current study compared the effectiveness of 6 weeks of NASM-based exercise training and eccentric-based exercise programs on body image and upper-quarter posture in schoolgirls with hyperkyphosis. In this randomized, controlled study, two intervention groups that received 6 weeks of NASM and eccentric-based exercise were compared with a control group that did nothing but continue their daily activities. For the purpose of conducting the experiment, 14 subjects were assigned to two groups (eccentric-based and control), and 12 subjects were assigned to the NASM group by using a simple blocked randomization method. The body esteem scale questionnaire was used to assess participants' body image in the groups. Likewise, the photogrammetric technique and Kyphometer were used to gather data from all groups before and after six weeks of targeted corrective exercises. Differences in responses to workouts across groups were investigated using analysis of variance-covariance (ANCOVA) followed by post hoc Bonferroni tests. The results from the ANCOVA analysis indicated significant differences between the experimental and control groups regarding the effects of time*group on kyphosis (P < 0.001), shoulder angle (P < 0.001), and forward head posture (P < 0.001). Nonetheless, there was no significant difference between the considered groups regarding body image (P = 0.617). Based on the Bonferroni test, we found a significant difference between the control and eccentric-based groups for postural parameters measured during the study (P < 0.001). Similarly, both the control and NASM groups demonstrated significant differences for all variables(P < 0.001), except the body image. However, we could not find any statistical difference between the NASM training group and the eccentric-based exercise group concerning the upper quarter postural variables that were mentioned before. This study demonstrates that compared with a control group, schoolgirls with hyper-kyphosis who received a six-week intervention of eccentric-based and NASM- based exercises had significantly improved postural parameters but not body image. Despite these advantages, the improved kyphosis, shoulder angle, and forward head posture did not differ significantly between the NASM-based and eccentric-based exercise groups.

ACROMORFO study: gait analysis in a cohort of acromegalic patients

PURPOSE

In acromegaly, skeletal complications resulted to be associated with low quality of life (QoL) and high risk of falls. The aim of the present study was to perform a quantitative assessment of movement through gait analysis technique in patients with acromegaly.

STUDY POPULATION

Thirty-three acromegalic patients [9 with active disease (AD), 14 with controlled disease (CD) and 10 with disease remission (RD)] and 20 healthy subjects were enrolled for the study.

MEASUREMENTS

Kinetic and kinematic data were collected with 3D-gait analysis. Kinematic data were processed to compute the Gait Profile Score (GPS), a parameter that summarizes the overall deviation of kinematic gait data relative to unaffected population.

RESULTS

The acromegalic group showed longer stance phase duration (p < 0.0001) compared to controls. The GPS and several gait variable scores resulted to be statistically higher in the acromegalic group compared to healthy controls. GPS values were significantly higher in AD compared to CD (p < 0.05) and RD groups (p = 0.001). The AD group presented significantly higher values in terms of hip rotation and ankle dorsiflexion compared to CD and RD groups and with regard to the foot progression compared to RD. Interestingly, patients with RD exhibited a more physiological gait pattern.

CONCLUSION

Acromegalic patients showed quantitative alterations of gait pattern, suggesting instability and increased risk of falls. Arthropathy, along with its associated abnormal joint loading, proprioceptive impairment and hyperkyphosis could be contributing factors. Disease control and remission appear to improve postural balance. A better knowledge on walking performance in acromegaly would help to develop specific rehabilitation programmes to reduce falls' risk and improve QoL.

[Translated article] Anatomical and biomechanical factors of osteoporotic vertebral fracture and the occurrence of cascade fractures

Osteoporosis weakens the structural strength of bone to such an extent that normal daily activity may exceed the capacity of the vertebra to bear this load. Vertebral fracture and deformity is a hallmark of osteoporosis. The detriment of trabecular bone properties alone cannot explain the occurrence of osteoporotic vertebral fracture. The ability of the spine to bear and resist loads depends on the structural capacity of the vertebrae, but also on loading conditions arising from activities of daily living or low-energy trauma. This review describes the mechanical properties of the vertebral bone, the structural load-bearing capacity of the various elements forming the spine, the neuromuscular control of the trunk, as well as the biomechanics of the loads to which the spine is subjected in relation to the presence of osteoporosis and the risk of vertebral fracture. A better understanding of biomechanical factors may help to explain both the high incidence of osteoporotic vertebral fractures and their mechanism of production. Consideration of these issues may be important in the development of prevention and management strategies.

Anatomical and biomechanical factors of osteoporotic vertebral fracture and the occurrence of cascade fractures

Osteoporosis weakens the structural strength of bone to such an extent that normal daily activity may exceed the capacity of the vertebra to bear this load. Vertebral fracture and deformity is a hallmark of osteoporosis. The detriment of trabecular bone properties alone cannot explain the occurrence of osteoporotic vertebral fracture. The ability of the spine to bear and resist loads depends on the structural capacity of the vertebrae, but also on loading conditions arising from activities of daily living or low-energy trauma. This review describes the mechanical properties of the vertebral bone, the structural load-bearing capacity of the various elements forming the spine, the neuromuscular control of the trunk, as well as the biomechanics of the loads to which the spine is subjected in relation to the presence of osteoporosis and the risk of vertebral fracture. A better understanding of biomechanical factors may help to explain both the high incidence of osteoporotic vertebral fractures and their mechanism of production. Consideration of these issues may be important in the development of prevention and management strategies.

Does Texting While Walking Affect Gait's Plantar Pressure Parameters?

BACKGROUND

This study aims to examine the possible effects of mobile phone use on plantar pressure and spatiotemporal parameters during walking.

MATERIALS AND METHODS

Thirty volunteers (18 males and 12 females) participated in the study. A 10-m walking path was prepared, and a messaging connection was established. They were asked to write three posts without word or character mistakes and participants walked on the path walk as much as they wanted on the trail to make sure they were walking at their own pace. The gait's spatiotemporal parameters and plantar pressure parameters were recorded while walking. A paired samples t-test was used to determine whether there was a difference between normal walking and walking while texting.

RESULTS

While walking and writing a message, cadence, speed, and step length decreased significantly (P < 0.05). In the plantar pressure parameters, the fore- and midfoot load and pressure were significantly increased (P < 0.05).

CONCLUSIONS

Compared to normal walking, the forces on the forefoot and midfoot and the pressure per unit area increased in walking while texting. It is thought that the pace of walking slows down, and focus and attention shift to the front of the body.

Effectiveness of mid thoracic spine mobilization on postural balance and gait ability in subacute stroke patients: A randomized clinical trial

BACKGROUND

Although mulligan sustained natural apophyseal glides (SNAG) and maitland mobilization (MM) are common interventions for musculoskeletal disease, no study has directly compared the effectiveness of mid-thoracic spine mobilization in subacute stroke patients.

OBJECTIVE

To investigate the effects of mid-thoracic spine mobilization (SNAG vs. MM) on postural balance and gait ability in subacute stroke patients.

METHODS

Fifty subacute stroke patients were randomly allocated to the SNAG (n= 17), MM (n= 16), and control (n= 17) groups, each receiving a neuro-developmental therapy program for four successive weeks. The SNAG and MM groups additionally received mid-thoracic spine mobilization (T4∼8). The primary outcome measure was postural sway, and secondary outcome measures included the five times sit-to-stand test (FTSST), functional reach test (FRT), 10-m walk test (10MWT), 6-minute walk test (6MWT) and global rating of change (GRC).

RESULTS

Participants reported no adverse events, and there was no loss to follow-up. The SNAG and MM group patients demonstrated significant improvements (p< 0.05) in postural sway, FTSST, FRT, 10MWT, and 6MWT compared with those in the control group, with no between-group differences.

CONCLUSIONS

Mid-thoracic spine mobilization allows significant improvements in postural balance and gait ability in subacute stroke patients, with no differences between the SNAG and MM techniques.

Which trunk muscle parameter is the best predictor for physical function in older adults?

Background

Despite preliminary evidence demonstrating the relevance of trunk muscle strength for physical function in older adults, it is not clear which muscle-related trunk parameter is the best predictor for physical functions. Therefore, this study aimed to compare trunk muscle morphology or strength parameters regarding their predictive ability for physical functions.

Methods

Seventy-four older adults (38 men, 36 women, mean age 76.85 years) were tested for maximum absolute and relative isokinetic trunk flexion and extension strength, trunk lean mass, and trunk muscle quality. Functional assessment included normal and fast walking speed, repeated sit-to-stand transfer, timed up and go, and postural sway during a closed-feet and a semi-tandem stance adjusted for body height. Pearson's correlations were used to compare relationship between trunk strength adjusted and unadjusted for body weight to physical functions. Linear regression analysis including sex and age as co-variables was performed between trunk muscle and functional test parameters.

Results

Relative back extension strength was the most consistent significant predictor for all physical function tests (p = 0.004-0.04) except for postural sway. Relative trunk flexion strength was related to normal walking speed (p = 0.024). Trunk lean mass was related to timed up and go performance (p = 0.024).

Conclusion

Relative back extension strength is associated with better performance in nearly all standard tests for physical function in older adults, while trunk flexion strength and lean mass seem to play a minor role. Our findings emphasize the importance of trunk muscle strength, especially the back extensor muscles, for physical function in older adults.

EMG Validation of a Subject-Specific Thoracolumbar Spine Musculoskeletal Model During Dynamic Activities in Older Adults

Musculoskeletal models can uniquely estimate in vivo demands and injury risk. In this study, we aimed to compare muscle activations from subject-specific thoracolumbar spine OpenSim models with recorded muscle activity from electromyography (EMG) during five dynamic tasks. Specifically, 11 older adults (mean = 65 years, SD = 9) lifted a crate weighted to 10% of their body mass in axial rotation, 2-handed sagittal lift, 1-handed sagittal lift, and lateral bending, and simulated a window opening task. EMG measurements of back and abdominal muscles were directly compared to equivalent model-predicted activity for temporal similarity via maximum absolute normalized cross-correlation (MANCC) coefficients and for magnitude differences via root-mean-square errors (RMSE), across all combinations of participants, dynamic tasks, and muscle groups. We found that across most of the tasks the model reasonably predicted temporal behavior of back extensor muscles (median MANCC = 0.92 ± 0.07) but moderate temporal similarity was observed for abdominal muscles (median MANCC = 0.60 ± 0.20). Activation magnitude was comparable to previous modeling studies, and median RMSE was 0.18 ± 0.08 for back extensor muscles. Overall, these results indicate that our thoracolumbar spine model can be used to estimate subject-specific in vivo muscular activations for these dynamic lifting tasks.

Smartphone Use-Influence on Posture and Gait during Standing and Walking

Prolonged gaze at a smartphone is characterized by pronounced flexion of the cervical spine and is associated with health risks. In addition, it is suspected that smartphone distraction could lead to gait changes. Therefore, the aim of this study was to detect smartphone-associated postural changes at thoracic and lumbar levels as well as gait changes. Spinal analysis was performed prospectively in 21 healthy men using the DIERS 4Dmotion®Lab in a controlled crossover design to evaluate posture-associated parameters while standing and walking. The examination sequence provided three randomized gaze directions: GN = Gaze Neutral; S1H = Smartphone one-handed; S2H = Smartphone two-handed. Results reveal a higher vertebra prominens (VP)-flexion in S1H (23.8° ± 6.9°; p ≤ 0.001) and S2H (22.4° ± 4.7°; p ≤ 0.001) compared to GN (17.6° ± 3.8°). Kyphosis angles were also different with higher values observed in S1H (58.8° ± 5.8°; p ≤ 0.001) and S2H (61.6° ± 4.9°; p ≤ 0.001) compared to GN (49.1° ± 4.6°). During walking, similar results were observed in kyphosis angles. No differences were observed in gait during smartphone use (p = 0.180-0.883). The study revealed a significantly increased inclination of the lower cervical and thoracic spine during smartphone use. However, the inclination was larger during S2H. Standing or walking conditions did not affect the measurement outcomes. Long-term smartphone use associated with a larger inclination of the cervical and thoracic spine might result in increased pressure and shear forces acting on vertebral bodies, intervertebral discs, and muscles, which potentially increases the risk of spinal pain and disease.

The Relationship between Chronic Musculoskeletal Pain and Sarcopenia Risk in Community-Dwelling Older Adults: A Cross-Sectional Study

BACKGROUND

This study aimed to better understand the relationship between chronic musculoskeletal pain and the risk of sarcopenia in older adults.

METHODS

The risk of sarcopenia was assessed in 210 older adults using the SARC-F (strength, assistance with walking, rising from a chair, ascending stairs, and falls) questionnaire. Geriatric pain measures were used to assess pain. We also recorded the pain sites (ankles/feet, wrists/hands, upper back, lower back, neck, shoulder, hips, and knees).

RESULTS

Participant mean age was 72.4±7 years, and 109 (51.9%) of the participants were female. The prevalence rates of sarcopenia and chronic musculoskeletal pain were 60% and 92.9%, respectively. Older adults at risk of sarcopenia had a higher mean age, body mass index (BMI), number of comorbidities and falls, presence of chronic pain, pain intensity, and pain sites. Sarcopenia risk was correlated with chronic pain intensity (current and last 7 days) (r=0.506, p<0.001 and r=0.584, p< 0.001, respectively), multisite pain (r=0.442, p< 0.001), and Geriatric Pain Measure score (r=0.730; p< 0.001). Age (odds ratio [OR]=1.1; 95% confidence interval [CI], 1.0-1.2), BMI (OR=1.1; 95% CI, 1.0-1.2), and geriatric pain (OR=1.1; 95% Cl, 1.0-1.1) were associated with sarcopenia risk.

CONCLUSIONS

The risk of sarcopenia is linked to chronic pain, which frequently occurs in geriatric populations. Our study results also showed that higher pain intensity was associated with a higher risk of sarcopenia. Older adults at risk for sarcopenia often experience chronic musculoskeletal pain, which must be better recognized. Moreover, its significance must be noted in the treatment process.

Association between sagittal alignment and loads at the adjacent segment in the fused spine: a combined clinical and musculoskeletal modeling study of 205 patients with adult spinal deformity

PURPOSE

Sagittal malalignment is a risk factor for mechanical complications after surgery for adult spinal deformity (ASD). Spinal loads, modulated by sagittal alignment, may explain this relationship. The aims of this study were to investigate the relationships between: (1) postoperative changes in loads at the proximal segment and realignment, and (2) absolute postoperative loads and postoperative alignment measures.

METHODS

A previously validated musculoskeletal model of the whole spine was applied to study a clinical sample of 205 patients with ASD. Based on clinical and radiographic data, pre-and postoperative patient-specific alignments were simulated to predict loads at the proximal segment adjacent to the spinal fusion.

RESULTS

Weak-to-moderate associations were found between pre-to-postop changes in lumbar lordosis, LL (r =  - 0.23, r =  - 0.43; p < 0.001), global tilt, GT (r = 0.26, r = 0.38; p < 0.001) and the Global Alignment and Proportion score, GAP (r = 0.26, r = 0.37; p < 0.001), and changes in compressive and shear forces at the proximal segment. GAP score parameters, thoracic kyphosis measurements and the slope of upper instrumented vertebra were associated with changes in shear. In patients with T10-pelvis fusion, moderate-to-strong associations were found between postoperative sagittal alignment measures and compressive and shear loads, with GT showing the strongest correlations (r = 0.75, r = 0.73, p < 0.001).

CONCLUSIONS

Spinal loads were estimated for patient-specific full spinal alignment profiles in a large cohort of patients with ASD pre-and postoperatively. Loads on the proximal segments were greater in association with sagittal malalignment and malorientation of proximal vertebra. Future work should explore whether they provide a causative mechanism explaining the associated risk of proximal junction complications.

Polg mtDNA mutator mice reveal limited involvement of vertebral bone loss in premature aging-related thoracolumbar hyperkyphosis

Background

Age-related hyperkyphosis is multifactorial and involves alterations of vertebral bone, intervertebral discs (IVD) and paraspinal muscles. The relative contribution of these tissues remains unclear. Here, we compared differences in vertebral bone microarchitecture and IVD thickness between prematurely aging mice with spinal hyperkyphosis and wild type littermates.

Methods

Thoracolumbar vertebral columns were dissected from homozygous Polg ^D257A and age-matched wild type littermates. Micro-computed tomography was performed to quantify cortical and trabecular bone parameters at anterior and posterior portions of T8-L4 vertebrae. In addition, vertebral shape, transaxial facet joint orientation and IVD thickness were quantified. Differences in anterior/posterior ratios between genotypes were compared by Student's t-test and association between vertebral bone and IVD parameters was investigated using Pearson correlation analysis.

Results

Hyperkyphotic homozygous mice displayed generalized osteopenia that was more pronounced at the posterior compared with anterior portion of thoracolumbar vertebrae. An increase in the anterior/posterior ratio of trabecular bone parameters was revealed at the thoracolumbar junction (T13-L1). Polg ^D257A displayed diffuse loss of cortical bone thickness, yet anterior/posterior ratios were unchanged. Despite generalized and regional bone loss, vertebral shape was unaffected. PolG ^D257A mice showed a 10-20 % reduction of IVD thickness at both thoracic and lumbar levels, with only minimal histopathological changes. IVD thickness was negatively correlated with anterior/posterior ratios of trabecular bone parameters, as well as with more coronally oriented facet joints, but negatively correlated with the anterior/posterior ratio of cortical bone thickness.

Conclusions

Aging-induced regional changes of vertebral trabecular and cortical bone did not lead to altered vertebral shape in Polg ^D257A mice but may indirectly cause hyperkyphosis through reduction of IVD thickness. These findings suggest a limited role for aging-induced bone loss in spinal hyperkyphosis and warrants further research on the involvement of paraspinal muscle degeneration.

Static and Dynamic Postural Characteristics in Patients with Chronic Obstructive Pulmonary Disease: The Relationship with Dyspnea and Pulmonary Functions

BACKGROUND

There is little evidence about posture influence and its relationship with pulmonary functions in chronic obstructive pulmonary diseases(COPD) patients.

OBJECTIVES

To compare spinal curvature, mobility, and postural competency in participants with and without COPD and investigate the relationship of postural characteristics with dyspnea and pulmonary functions in COPD patients.

METHODS

We included 47 COPD patients and 47 age and gender-matched controls in our cross-sectional study. Participants underwent the following evaluations: modified Medical Research Council Dyspnea Scale, respiratory function test, and postural measurements in the sagittal plane in a standing position using a non-invasive, computer-assisted electromechanical device. Postural variables were compared between groups, and the relationship between postural variables with dyspnea and pulmonary functions was analyzed by multivariate regression analysis.

RESULTS

Thoracic and lumbar curvature were higher (p<0.05), thoracic mobility and spinal inclination were lower (p=0.011, p=0.030, respectively) in patients with COPD. Thoracic angle and spinal inclination increased in COPD patients (p=0.040, p=0.011, respectively) while only spinal tilt increased in the control group (p=0.010) under spinal loading. Thoracic angle and mobility were related with dyspnea (r2=0.25, p<0.001), forced expiratory volume in the first second (r2=0.56, p<0.001), forced vital capacity (r2=0.41, p<0.001), and RV (r2 = 0.42, p<0.001).

CONCLUSION

COPD patients had greater thoracic and lumbar angles in the static upright posture and lower thoracic mobility and spinal inclination in the sagittal plane. It was observed that patients increase their thoracic angles to maintain postural stability in dynamic conditions. Thoracic angle and mobility were related to dyspnea and pulmonary functions.

Spine Posture, Mobility, and Stability of Top Mobile Esports Athletes: A Case Series

Professional esports athletes spend a long time in the same sitting posture during training and competition. Mobile esports may exacerbate potential postural problems because of the closer and unsupported arms and because athletes spend more time in a forward-/flexed-head posture. Prolonged sitting in these postures carries significant health risks and may lead to musculoskeletal problems and injuries. The objective of this retrospective study is to assess the posture, mobility, and stability of the spine for professional mobile esports athletes. We collected spine-assessment data from 48 athletes participating in a top-tier league on a real-time-strategy battle-arena online game. The spinal assessment was conducted using the SpinalMouse® under upright standing and trunk flexion in addition to the Matthiass test. Measurements were converted into Idiag Scores by the SpinalMouse® software. The Idiag Posture, Idiag Mobility, and Idiag Stability scores were 62.50 (IQR: 21), 63.50 (IQR: 19.5), and 54.50 (IQR: 14.5), respectively, and were significantly lower (p < 0.001) than the reference normative value (100). Age was found to have a weak positive correlation with the posture score (ρ = 0.29, p = 0.048). Although career duration appeared to lower the scores, the association was insignificant (p > 0.05). The scores also had no significant association with body height, body mass, body mass index, and esports team (p > 0.05). It was anticipated that mobile-based esports would attenuate the biomechanics of the spine and increase the likelihood of musculoskeletal problems, such as neck and back pain.

Lower thoracic spine extension mobility is associated with higher intensity of thoracic spine pain

Objectives

To evaluate the association of thoracic spine (TS) posture and mobility with TS pain.

Methods

Participants with TS pain reported maximum, average, and night pain in TS area, and pain summary score was calculated. Upright and sitting TS postures were evaluated by inspection. TS posture and mobility (flexion and extension) were recorded using an inclinometer and a tape measure, respectively. Correlations between posture and mobility assessments were calculated using Spearman rank correlation, the association of TS posture and mobility with TS pain by logistic regression analysis.

Results

The participants’ (n = 73, 52 females, age range 22–56) TS pain duration was 12 weeks on average. The correlations for measurements of TS posture and flexion mobility were higher than correlations of other TS measurements being between 0.53 and 0.82. Decreased extension mobility of the upper (from 1^st to 6^th TS segments; Th1–Th6) TS was associated with higher worst pain (OR 1.04, 95% CI 1.00–1.07) and whole TS with pain sum score (OR 1.05, 95% CI 1.01–1.08). Less kyphotic whole TS was associated with lower pain sum score (OR 0.96, 95% CI 0.92–1.00). Greater flexion mobility of upper and lower (Th6–Th12) TS were associated with lower pain sum score (OR 0.96, 95% CI 0.91–1.00, and OR 0.96, 95% CI 0.91–1.00, respectively).

Conclusions

Reduced thoracic extension mobility was associated with higher pain scores and the greater flexion mobility with lower pain scores. Future research is warranted to evaluate if treatments geared toward TS extension mobility improvements would result in lower TS pain.

Effect of postural alignment alteration with age on vertebral strength

EOS biplane radiographs of 117 subjects between 20 and 83 years were analyzed to compute the upper body lever arm over the L1 vertebra and its impact on vertebral strength. Postural sagittal alignment alteration was observed with age and resulted in a greater lever arm causing vertebral strength to decrease.

PURPOSE

The purpose of this study was to analyze the impact of postural alignment changes with age on vertebral strength using finite element analysis and barycentremetry.

METHODS

A total of 117 subjects from 20 to 83 years were divided in three age groups: young (20 to 40 years, 62 subjects), intermediate (40 to 60 years, 26 subjects), and elderly (60 years and over, 29 subjects). EOS biplane radiographs were acquired, allowing 3D reconstruction of the spine and body envelope as well as spinal, pelvic, and sagittal alignment parameter measurements. A barycentremetry method allowed the estimation of the mass and center of mass (CoM) position of the upper body above L1, relatively to the center of the L1 vertebra (lever arm). To investigate the effect of this lever arm, vertebral strength of a generic finite element model (with constant geometry and mechanical properties for all subjects) was successively computed applying the personalized lever arm of each subject.

RESULTS

A combination of an increase in thoracic kyphosis, cervical lordosis, and pelvic tilt with a loss of lumbar lordosis was observed between the young and the older groups. Sagittal alignment parameters indicated a more forward position as age increased. The lever arm of the CoM above L1 varied from an average of 1 mm backward for the young group, to averages of 10 and 24 mm forward, respectively, for the intermediate and elderly group. As a result, vertebral strength decreased from 2527 N for the young group to 1820 N for the elderly group.

CONCLUSION

The global sagittal alignment modifications observed with age were consistent with the literature. Posture alteration with age reduced vertebral strength significantly in this simplified loading model. Postural alignment seems essential to be considered in the evaluation of osteoporotic patients.

Intelligent Evaluation of Global Spinal Alignment by a Decentralized Convolutional Neural Network

Degenerative changes of the spine can cause spinal misalignment, with part of the spine arching beyond normal limits or moving in an incorrect direction, potentially resulting in back pain and significantly limiting a person’s mobility. The most important parameters related to spinal misalignment include pelvic incidence, pelvic tilt, lumbar lordosis, thoracic kyphosis, and cervical lordosis. As a general rule, alignment of the spine for diagnosis and surgical treatment is estimated based on geometrical parameters measured manually by experienced doctors. However, these measurements consume the time and effort of experts to perform repetitive tasks that could be automated, especially with the powerful support of current artificial intelligence techniques. This paper focuses on creation of a decentralized convolutional neural network to precisely measure 12 spinal alignment parameters. Specifically, this method is based on detecting regions of interest with its dimensions that decrease by three orders of magnitude to focus on the necessary region to provide the output as key points. Using these key points, parameters representing spinal alignment are calculated. The quality of the method’s performance, which is the consistency of the measurement results with manual measurement, is validated by 30 test cases and shows 10 of 12 parameters with a correlation coefficient > 0.8, with pelvic tilt having the smallest absolute deviation of 1.156°.

Does mobilisation of the thoracic spine using mechanical massage affect diaphragmatic excursion in individuals with thoracic hyperkyphosis?

BACKGROUND

Thoracic mobilisation improves thoracic hyperkyphosis and respiratory function. Diaphragmatic excursion is associated with respiratory function; however, limited studies have assessed the effect of thoracic mobilisation on diaphragmatic excursion.

OBJECTIVE

This study aimed to investigate the effects of thoracic mobilisation on diaphragmatic excursion and respiratory function in individuals with thoracic hyperkyphosis.

METHODS

Participants were recruited through Internet advertising and participated voluntarily. Nineteen healthy participants (age: 33.37 ± 6.56 years; height: 170.32 ± 7.92 cm; weight: 69.77 ± 14.70 kg) with thoracic hyperkyphosis underwent thoracic mobilisation for 8 weeks. Diaphragmatic excursion, thoracic kyphosis, and respiratory function were measured. Thoracic mobilisation was provided using a mechanical massage device.

RESULTS

Thoracic mobilisation for 8 weeks significantly improved diaphragmatic excursion during deep breathing (p= 0.015), forced vital capacity (p< 0.01), and thoracic hyperkyphosis (p< 0.01).

CONCLUSIONS

Thoracic mobilisation can be recommended in respiratory rehabilitation programs to increase diaphragmatic excursion and respiratory function for the management and prevention of respiratory dysfunction in individuals with thoracic hyperkyphosis.

Association of Core Muscle Endurance Times With Balance, Fatigue, Physical Activity Level, and Kyphosis Angle in Patients With Ankylosing Spondylitis

BACKGROUND/OBJECTIVE

Core muscle endurance (CME), which is the ability of sustaining the activity of trunk muscles, has been shown to be lower in patients with ankylosing spondylitis (AS). The aim was to investigate the possible relationship between CME times and balance, fatigue, physical activity (PA) level, and thoracic kyphosis angle.

METHODS

Fifty-one patients with AS with a mean age of 41.0 years (interquartile range, 25/75 years; 29.0/51.0 years) were included in the study. Core muscle endurance times were assessed by using trunk extension, trunk flexion, and side bridge tests. Overall stability index, anteroposterior stability index, mediolateral stability index, and limits of stability were evaluated with the Biodex Balance System. Fatigue and PA levels were surveyed using Fatigue Severity Scale and International Physical Activity Questionnaire, respectively. Thoracic kyphosis angle was measured by using a digital inclinometer. Additionally, CME times were compared for "high-fatigue" versus "low-fatigue" and as "low PA" versus "moderate/high PA" groups. Spearman correlation coefficients and Mann-Whitney U test were used for statistical analysis.

RESULTS

Significant correlations were detected between overall stability index, anteroposterior stability index, Fatigue Severity Scale, International Physical Activity Questionnaire, and all CME tests (p < 0.05) and between mediolateral stability index and side bridge test (p < 0.05). Limits of stability correlated only with side bridge test (p < 0.05). Core muscle endurance significantly differed between high-fatigue and low-fatigue groups (p < 0.05), except trunk flexor test (p > 0.05). No significant differences were observed between low PA and moderate/high PA groups (p > 0.05), except side bridge test (p < 0.05).

CONCLUSIONS

Core muscle endurance times seem to be related to PA level, fatigue, and balance but not with thoracic kyphosis angle. Assessing CME in patients with AS might help in planning individualized exercise programs.

Progressive enlargement of thoracic ossification of the ligamentum flavum in professional baseball pitchers: a report of two cases

Both systemic and local factors might influence the development of ossification of the ligamentum flavum (OLF); however, whether specific physical activities play a role in the development of OLF remains unclear. This report presents two cases of thoracic radiculopathy owing to progressive enlargement of thoracic OLF within a few years in Japanese professional baseball pitchers. Two left-handed, Japanese, professional baseball pitchers in their 20s experienced thoracic radiating pain. Mild hypesthesia of the lower thoracic vertebral levels was observed, and an increase in the size of the OLF within a few years was identified in the lower thoracic spine using computed tomography and magnetic resonance imaging. Neither patient exhibited myelopathy and were, therefore, treated conservatively. Both patients were able to return to playing in top condition within 4 months after onset. The findings in these cases suggest that thoracic OLF might increase in size and become exacerbated in certain individuals, such as professional pitchers, who experience repeated, localized, mechanical stress on the thoracic spine, irrespective of age.

Physical characteristics of patients with symptomatic lumbar spondylolysis who have recurrent low back pain after returning to sports

INTRODUCTION

To determine the physical characteristics of patients with symptomatic lumbar spondylolysis (LS) who have recurrent low back pain after returning to sports.

METHOD

Fifty-three adolescent patients with symptomatic LS participated in this study. Patients with symptomatic LS were assessed for flexibility, trunk muscle strength, and Functional Movement Screen (FMS) score, and then divided into two groups according to the degree of pain experienced one month after returning to sport.

RESULTS

Twenty-four patients returned to their pre-injury sports level without pain (excellent group), while the remaining 29 patients had pain and decreased activity level during sports (pain group). The excellent group had a significantly higher shoulder mobility score on the FMS than the pain group, and the effect size was larger. However, there were no significant differences in body flexibility, muscle tightness, trunk muscle strength, or other FMS items.

DISCUSSION

The most important finding of this study is that patients with LS who have recurrent low back pain after returning to sports are characterized by poor functional upper body movement.

CONCLUSIONS

Because upper body functional movement pattern may be an important factor in the management of patients with symptomatic LS, preventive rehabilitation to enhance upper body mobility and motor control should be considered for these patients.

Comparison of spinal column alignment and autonomic nervous activity using the intersegmental tenderness test in the segment above

[Purpose] The thoracolumbar supraspinous intersegmental tenderness test (ITT) in the segment above was performed to compare spinal alignment and autonomic activity in the presence or absence of pain. [Participants and Methods] Thirty young males were grouped into Th1–4 (Cardiopulmonary visceral nerves), Th5–9 (Large visceral nerve), and Th10–12 (Small visceral nerve) by ITT for the presence of pain. Measurements of the spinal alignment and autonomic function were performed. [Results] Those with ITT pain had a significantly lower range of motion in the sagittal plane at Th12, Th12–L1, and L2–3 and in the frontal plane at Th1–2, Th4–5, Th6–7, and L3–4 than those in the no pain group. On autonomic function tests, the pain group had significantly lower Total Power, LF (Low Frequency), and CVRR (Coefficient of variation of R-R interval). [Conclusion] In ITT, patients with pain at Th5–9 have a mixture of reduced sagittal tilt angle and autonomic hypofunction of the adjacent upper and lower thoracic to lumbar vertebrae.

The Influence of Kinematic Constraints on Model Performance During Inverse Kinematics Analysis of the Thoracolumbar Spine

Motion analysis is increasingly applied to spine musculoskeletal models using kinematic constraints to estimate individual intervertebral joint movements, which cannot be directly measured from the skin surface markers. Traditionally, kinematic constraints have allowed a single spinal degree of freedom (DOF) in each direction, and there has been little examination of how different kinematic constraints affect evaluations of spine motion. Thus, the objective of this study was to evaluate the performance of different kinematic constraints for inverse kinematics analysis. We collected motion analysis marker data in seven healthy participants (4F, 3M, aged 27–67) during flexion–extension, lateral bending, and axial rotation tasks. Inverse kinematics analyses were performed on subject-specific models with 17 thoracolumbar joints allowing 51 rotational DOF (51DOF) and corresponding models including seven sets of kinematic constraints that limited spine motion from 3 to 9DOF. Outcomes included: (1) root mean square (RMS) error of spine markers (measured vs. model); (2) lag-one autocorrelation coefficients to assess smoothness of angular motions; (3) maximum range of motion (ROM) of intervertebral joints in three directions of motion (FE, LB, AR) to assess whether they are physiologically reasonable; and (4) segmental spine angles in static ROM trials. We found that RMS error of spine markers was higher with constraints than without (p < 0.0001) but did not notably improve kinematic constraints above 6DOF. Compared to segmental angles calculated directly from spine markers, models with kinematic constraints had moderate to good intraclass correlation coefficients (ICCs) for flexion–extension and lateral bending, though weak to moderate ICCs for axial rotation. Adding more DOF to kinematic constraints did not improve performance in matching segmental angles. Kinematic constraints with 4–6DOF produced similar levels of smoothness across all tasks and generally improved smoothness compared to 9DOF or unconstrained (51DOF) models. Our results also revealed that the maximum joint ROMs predicted using 4–6DOF constraints were largely within physiologically acceptable ranges throughout the spine and in all directions of motions. We conclude that a kinematic constraint with 5DOF can produce smooth spine motions with physiologically reasonable joint ROMs and relatively low marker error.

Investigating women's chest size, trunk muscle co-contraction and back pain during prolonged standing

BACKGROUND

Chest size is a known factor in the development of back pain for women. However, the neuromuscular mechanisms associated with chest size and back pain are poorly understood.

OBJECTIVE

The purpose of this study was to investigate chest size and its association with back pain development and muscle activity patterns during prolonged standing.

METHODS

Twenty university-aged women were divided into two groups: small chest size (n= 10, ∼A/C cup) and large chest size (n= 10, ∼D/E cup). Participants completed a 2-hr standing protocol, where eight channels of bilateral trunk electromyography were collected. Muscle activity, specifically co-contraction, was compared between chest size groups, pain developers, and time.

RESULTS

The large chest size group reported higher amounts of pain at the upper, middle, and low back. Women in the large chest group sustained higher levels of co-contraction for muscles involving the thoracic and lumbar erector spinae compared to those in the small chest size group during prolonged standing.

CONCLUSIONS

Thoracolumbar co-contraction determined in this study may be a potential mechanism contributing to increased back pain development for women with large chest sizes during prolonged standing. This pain mechanism could be targeted and addressed in future non-invasive musculoskeletal rehabilitation to improve back pain for women.

Spinal Orthoses Prescription for Vertebral Fragility Fractures by Italian Physical and Rehabilitation Medicine Physicians: The SPIN-VER Survey

Vertebral fragility fractures (VFFs) are the most common type of osteoporotic fractures, related to pain and disability. In this scenario, physical and rehabilitative medicine (PRM) physicians prescribe a patient-tailored rehabilitation plan, including spinal orthoses. However, there is a high heterogeneity in the clinical indications of spinal orthoses. Thus, the aim of this survey was to investigate common clinical practice in terms of the prescription of spinal orthoses. This nationwide cross-sectional survey recruited Italian PRM physicians commonly involved in the management of patients with VFFs. One hundred twenty-six PRM physicians completed the survey. The results showed that most PRM physicians prescribe spinal orthoses in outpatients suffering from VFFs (n = 106; 83.9%). The most prescribed spinal orthosis for acute VFF patients was the three-point rigid orthosis (n = 64; 50.8%), followed by the semirigid thoraco-lumbar orthosis (n: 20; 15.9%). However, most PRM physicians prescribed dynamic orthoses in outpatients with chronic VFFs (n = 66; 52.4%). Albeit that a correct management of VFFs is mandatory to improve pain and reduce disability, our findings highlighted uncertainty in the type of spinal orthosis prescription in both the acute and chronic VFF phase. Therefore, high-quality research trials are warranted to provide clear recommendations for the correct clinical management of VFF.

Load Distribution in the Lumbar Spine During Modeled Compression Depends on Lordosis

Excessive or incorrect loading of lumbar spinal structures is commonly assumed as one of the factors to accelerate degenerative processes, which may lead to lower back pain. Accordingly, the mechanics of the spine under medical conditions, such as scoliosis or spondylolisthesis, is well-investigated. Treatments via both conventional therapy and surgical methods alike aim at restoring a "healthy" (or at least pain-free) load distribution. Yet, surprisingly little is known about the inter-subject variability of load bearings within a "healthy" lumbar spine. Hence, we utilized computer tomography data from 28 trauma-room patients, whose lumbar spines showed no visible sign of degeneration, to construct simplified multi-body simulation models. The subject-specific geometries, measured by the corresponding lumbar lordosis (LL) between the endplates of vertebra L1 and the sacrum, served as ceteris paribus condition in a standardized forward dynamic compression procedure. Further, the influence of stimulating muscles from the M. multifidus group was assessed. For the range of available LL from 28 to 66°, changes in compressive and shear forces, bending moments, as well as facet joint forces between adjacent vertebrae were calculated. While compressive forces tended to decrease with increasing LL, facet forces were tendentiously increasing. Shear forces decreased between more cranial vertebrae and increased between more caudal ones, while bending moments remained constant. Our results suggest that there exist significant, LL-dependent variations in the loading of "healthy" spinal structures, which should be considered when striving for individually appropriate therapeutic measures.

The characteristics, disabilities, and spinal alignment of women with double crush syndrome: a case-control study

AIMS

Double crush syndrome is a clinical condition composed of neurological dysfunction due to compressive pathology at multiple sites along a single peripheral nerve. The aims were to investigate the characteristics and disabilities of women with double crush syndrome, to compare the spinal alignment to healthy women, and to determine the cut-offs for the spinal alignment characteristics.

METHODS

Twenty women with double crush syndrome (age: 49.50 ± 8.64 years) and 21 asymptomatic healthy controls (age: 44.76 ± 7.82 years) were included in the study. The physical characteristics, pain intensity, and symptoms were questioned. Disability with Disability of Arm and Shoulder Questionnaire and Neck Disability Index and spinal alignment with Spinal Mouse^® (Idiag, Fehraltorf, Switzerland) were assessed.

RESULTS

The pain intensity at rest, night, and during activity was 3.70 ± 3.25, 6.01 ± 2.77, and 7.15 ± 2.68 cm, respectively. The most bothersome symptom was numbness (65%). The symptoms were seen in hands and/or fingers (55%), arms (15%), shoulder blade (15%), and neck (15%). The Disability of Arm and Shoulder Questionnaire and Neck Disability Index scores were 58.64 ± 15.41 and 19.55 ± 6.37, respectively. The sagittal thoracic curvature (p: .011) and lumbar curvature (p: .049) increased, and the overall spine mobility (p<.001) decreased in the double crush syndrome patients. The cut-off points were detected as 54.5° (area under the curve: 0.680, p: .049, 40% sensitivity, 99.9% specificity) for the thoracic spinal curvature, and 113.5° (area under the curve: 0.667, p<.000, 65% sensitivity, 99.9% specificity) for the overall spine mobility.

CONCLUSIONS

The double crush syndrome patients had moderate to severe pain and disability, increased thoracic and lumbar curvature, and decreased spine mobility. The cut-off values were found as 54.5° for thoracic curvature and 113.5° for spine mobility.

The influence of smartphone use on spinal posture - A laboratory study

BACKGROUND

Smartphones have become increasingly more popular and complicated tasks can be performed with these devices. However, the increasing use is associated with shoulder and neck pain, as well as with psychological addiction.

RESEARCH QUESTION

Do different smartphone tasks lead to changes in spinal posture and pelvic position? Is there a relationship between smartphone addiction and changes in posture?

METHODS

A cross-sectional study including 50 participants was performed. Test subjects completed the Smartphone Addiction Scale and the SF-36 health questionnaire. Subjects spinal posture and pelvic position during different smartphone tasks were measured through a surface topography system. The different tasks were: standing in an upright position, simulating a phone call, texting with one or two hands during standing or while walking on a treadmill. Paired T-tests and ANOVA tests were performed to evaluate differences. The Kendall rank test was used to investigate the association between clinical scores and changes in spinal posture.

RESULTS

All smartphone tasks lead to a significant increase in thoracic kyphosis and trunk inclination during standing and while walking. A significant increased lumbar lordosis was also found. Texting with one or two hands correlated with increased surface rotation. No associations between smartphone addiction and changes of the spinal posture were reported.

SIGNIFICANCE

This represents the first surface topography study that investigated the influence of different smartphone tasks on the spinal posture and pelvic position during standing and while walking. With the results of this study we demonstrated that smartphone use leads to significant changes of sagittal and frontal spine parameters. Further research should focus on the evaluation of possible detrimental effects of long-term smartphone use on the spinal posture and on the development of preventive measures.

Vertebral Fractures Associated with Spinal Sagittal Imbalance and Quality of Life in Acromegaly: A Radiographic Study with EOS 2D/3D Technology

INTRODUCTION

Acromegaly is commonly complicated by arthropathy and skeletal fragility with high risk of vertebral fractures (VFs).

OBJECTIVE

This study aimed to assess whether VFs may be associated with sagittal spine deformities, arthropathy, impaired quality of life (QoL), pain, and disability.

METHODS

Thirty-eight patients with acromegaly (median age: 55 years, 20 males) and 38 matched control subjects were evaluated by a low-dose sagittal and coronal planes, X-ray imaging system (EOS®-2D/3D) for morphometric VFs, radiological signs of spine arthropathy, and spine deformities (Cobb thoracic index ≥40°, pelvic incidence minus lumbar lordosis ≥10°, pelvic tilt >20°, and sagittal vertical axis ≥4 cm) determining sagittal spine imbalance. Acromegalic patients were also evaluated by questionnaires for QoL (Acromegaly QoL Questionnaire [AcroQoL] and Short Form-36 [SF-36]) and pain and disability (Western Ontario and McMaster University [WOMAC]).

RESULTS

Acromegalic patients showed higher prevalence of thoracic hyperkyphosis (i.e., Cobb thoracic index ≥40°; p = 0.04) and pelvic tilt >20° (p = 0.02) than control subjects. VFs were found in 34.2% of acromegalic patients (p = 0.003 vs. control subjects), in relationship with higher prevalence of hyperkyphosis (p = 0.03), pelvic tilt >20° (p = 0.04), sagittal vertical axis ≥4 cm (p = 0.03), and moderate/severe subchondral degeneration (p = 0.01). Moreover, patients with VFs had lower AcroQoL general health (p = 0.007) and SF-36 general health (p = 0.002) scores and higher WOMAC pain (p = 0.003) and global (p = 0.009) scores than patients who did not fracture.

CONCLUSIONS

In acromegaly, VFs may be associated with spine deformities and sagittal imbalance, spine arthropathy, impaired QoL, and disability.

Effects of Manual Therapy and Mechanical Massage on Spinal Alignment, Extension Range of Motion, Back Extensor Electromyographic Activity, and Thoracic Extension Strength in Individuals with Thoracic Hyperkyphosis: A Randomized Controlled Trial

BACKGROUND

Manual therapy has been recommended to reduce and prevent musculoskeletal problems related to thoracic hyperkyphosis. With recent rapid technological developments, manual techniques can now be implemented by mechanical devices; hence, mechanical massage can manipulate the back muscles and mobilize the spine.

PURPOSE

Here, we aimed to 1) determine the effects of mechanical massage and manual therapy and 2) compare their effects on spinal posture, extension range of motion, trunk extensor electromyographic activity, and thoracic extension strength in individuals with thoracic hyperkyphosis.

METHODS

Participants with thoracic hyperkyphosis were randomly assigned to the manual therapy (n = 16) or mechanical massage (n = 19) group. Each intervention was applied for 8 weeks. The participants' spinal posture, extension range of motion, trunk extensor electromyographic activity, and thoracic extension strength were measured before and after intervention.

RESULTS

Intergroup analyses revealed no significant differences in any variables. However, thoracic kyphosis angle, thoracic extension range of motion, longissimus thoracis electromyographic activity, iliocostalis lumborum pars lumborum activity, and thoracic extension strength differed significantly in intertime analyses. The results of paired t-test analysis showed that thoracic kyphosis angle, thoracic extension range of motion, longissimus thoracis electromyographic activity, and thoracic extension strength were significantly different after intervention in both groups (p < 0.05).

CONCLUSIONS

Mechanical massage and manual therapy effectively improve thoracic kyphosis angle, thoracic extension range of motion, and thoracic extension strength. Therefore, mechanical massage is an alternative intervention to manual therapy for improving thoracic kyphosis angle, thoracic extension range of motion, and thoracic extension strength in participants with hyperkyphosis. This trail is registered with KCT0004527.

The Impact of Geometrical Spinal Shape on Fresh Vertebral Fractures in Elderly Volunteers: A Longitudinal Cohort Analysis

STUDY DESIGN

Four-year, longitudinal cohort study.

OBJECTIVE

The aim of this study was to investigate the effect of original spinal shape on incidental vertebral fractures (VFs) and to identify the influence of changes in pre- and post-fracture geometrical spinal shape.

SUMMARY OF BACKGROUND DATA

Clinical evidence demonstrates that VFs cause spinal kyphosis, morbidities, and deteriorating quality of life in elderly people. However, knowledge of geometrical spinal shapes that affect incidental VFs is limited.

METHODS

Three hundred seventeen volunteers underwent whole spine radiography as part of a health screening in both 2012 and 2016. We extracted volunteers with incidental VF in 2016. Sex- and age-matched volunteers without VF were enrolled as controls. Baseline demographic variables, geometrical spinal shape, and spinopelvic parameters were compared between the two groups. In volunteers with incidental VF, we investigated the association between baseline spinal shape and post-fracture shape.

RESULTS

Twenty-seven volunteers (12 men; mean age 75.4 ± 5.4 and 15 women; mean age 71.6 ± 7.9) with VF were enrolled, and 175 volunteers (48 men, 127 women) without VF were selected as controls. In men with VF, the thoracic kyphosis apex was located significantly more posteriorly and caudally than in those without VF. In women with VF, the lordosis apex was located significantly more posteriorly and caudally than in those without VF. After fractures occurring above the inflexion vertebra, the low anterior apex spine (L5) changed its geometrical shape in that the posterior apex and the inflexion vertebra shifted significantly more posteriorly compared to the high anterior apex spine (L4/5).

CONCLUSION

Original geometrical spinal shape affected the occurrence of VF, and post-fracture spinal shape depended on the positional relationship between the inflexion vertebra and fractured vertebra. Our study helps to understand the influence of geometrical spinal shape on the risks of VF.

LEVEL OF EVIDENCE

3.

Validity of flexicurve and motion capture for measurements of thoracic kyphosis vs standing radiographic measurements

Thoracic kyphosis varies among healthy adults and typically increases with age. Excessive kyphosis (hyperkyphosis) is associated with negative health. Spinal alignment also affects spine loading, with implications for conditions such as vertebral fractures and back pain. Valid measurements of kyphosis are necessary for clinical and research assessment of age-related posture changes, and to support improved biomechanical understating of spine conditions. Independent validation of non-radiographic techniques, however, remains limited. The goal of this study was to compare standing radiographic kyphosis measurements with non-radiographic measurements and predictions of thoracic kyphosis using flexicurve and motion analysis markers, in order to determine their validity. Thirteen non-radiographic measures of thoracic kyphosis were obtained in each of 40 adult subjects who also underwent standing radiographs of the thoracic spine. Measures included estimates derived by fitting of polynomials or circles to the non-radiographic data, as well as predictions calculated using previously published methods. Intra-class correlations (ICC) and root-mean square errors (RMSEs) were calculated between radiographic and non-radiographic measures to determine validity. Most non-radiographic estimates of kyphosis show similar, weak to moderate levels of validity when compared to radiographic measurements, and RMSEs ranging from 8.0° to 20.8°. Unbiased estimates of radiographic measurements with moderate to good ICCs were identified, however, based on marker measurements, and new prediction equations were created with similar validity that also account for age and body habitus. Clinical significance: These non-radiographic measurements of thoracic kyphosis can be applied to clinical practice or to clinical studies with recognition of specific limitations.

Effect of a Spinomed orthosis on balance performance, spinal alignment, joint position sense and back muscle endurance in elderly people with hyperkyphotic posture: A randomized controlled trial

BACKGROUND

Hyperkyphosis may cause balance impairment in elderly people. Although the effectiveness of orthoses for improving balance in hyperkyphotic elderly people has received much attention, the mechanisms by which devices affect balance remain unknown.

OBJECTIVES

The objective of this study was to evaluate changes in balance performance, thoracic kyphosis angle, craniovertebral angle, back muscle endurance and joint position sense after 3 months of wearing a Spinomed orthosis. The study also included a secondary exploratory analysis to determine whether changes in any of the above-mentioned outcome measures can predict balance performance improvement in elderly people with hyperkyphosis.

STUDY DESIGN

Parallel group randomized controlled trial.

METHODS

In total, 44 hyperkyphotic elderly people were randomly allocated to an experimental group, who wore a Spinomed orthosis and a control group, who did not. No other treatment or change in physical activity was permitted during the study. A blinded assessor evaluated thoracic kyphosis angle, joint position sense, craniovertebral angle, back muscle endurance, Timed Up and Go Test time and Berg Balance Scale score at baseline and after 5, 9 and 13 weeks. All dependent variables were measured without the orthosis and analyzed separately using a 2 × 4 (time × group) mixed model analysis of variance. Based on the results of correlation analysis, thoracic kyphosis angle, back muscle endurance and joint position sense were selected as independent variables in a stepwise multiple regression model.

RESULTS

The two-way (group × time) interactions were significant in terms of Berg Balance Scale (F = 11.6, P ⩽ 0.001, ηp2=0.59), Timed Up and Go Test (F = 3.74, P = 0.013, ηp2=0.46), thoracic kyphosis angle (F = 43.39, P ⩽ 0.001, ηp2=0.96), craniovertebral angle (F = 5.245, P = 0.002, ηp2=0.59) and joint position sense (F = 4.44, P = 0.005, [Formula: see text]). The two-way interaction was not significant in terms of back muscle endurance; however, the main effect of group was significant for this variable (F = 3.85, P = 0.025). Stepwise multiple regression showed that thoracic kyphosis angle and joint position sense were significant determinants of Timed Up and Go Test time (R² = 0.155, P = 0.037 and R² = 0.292, P = 0.012, respectively).

CONCLUSION

Wearing a Spinomed orthosis for 3 months improved the posture, position sense and muscle performance of hyperkyphotic elderly people. Orthoses may improve balance performance by correcting spinal alignment and increasing proprioceptive information.

Is Breast Size Related to Prevalent Thoracic Vertebral Fracture? A Cross-Sectional Study

Large breasts may increase the likelihood of thoracic vertebral fractures by increasing the mechanical loading of the spine. We examined breast size as a factor associated with prevalent thoracic vertebral fractures, also considering its relationship with thoracic kyphosis and upper back extensor muscle endurance. Using a cross-sectional study, the design measurements collected were thoracic vertebral fractures (≥20% loss in vertebral body height on lateral radiograph), breast size (bra size converted to an ordinal breast size score), BMD (g/cm² averaged femoral neck, DXA), upper back extensor muscle endurance (isometric chest raise test), body composition (DXA), thoracic kyphosis (radiograph), and upper back pain (numerical rating scale). Correlations and multivariable logistic regression examined relationships between characteristics and their association with vertebral fracture. Participants were 117 healthy postmenopausal women. The 17 (15%) women with ≥1 thoracic vertebral fracture had larger breast size (mean difference [MD]: 2.2 sizes; 95% CI, 0.6 to 3.8 sizes), less upper back extensor muscle endurance (MD: -38.6 s; 95% CI, -62.9 to -14.3 s), and greater thoracic kyphosis (MD: 7.3°; 95% CI, 1.7° to 12.8°) than those without vertebral fracture. There were no between group differences in age, height, weight, and BMD. Breast size (r = -0.233, p = 0.012) and thoracic kyphosis (r = -0.241, p = 0.009) correlated negatively with upper back extensor muscle endurance. Breast size was unrelated to thoracic kyphosis (r = 0.057, p = 0.542). A (final) multivariable model containing breast size (OR 1.85; 95% CI, 1.10 to 3.10) and thoracic kyphosis (OR 2.04; 95%CI, 1.12 to 3.70) explained 18% of the variance in vertebral fracture. Breast size had a significant, but weak relationship with vertebral fracture (R ² = 0.10), which was independent of BMD and unrelated to thoracic kyphosis. Further work is needed to confirm larger breast size as a risk factor for vertebral fracture. © 2020 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Distribution of Prevalent and Incident Vertebral Fractures and Their Association with Bone Mineral Density in Postmenopausal Women in the Teriparatide Versus Risedronate VERO Clinical Trial

Vertebral fractures (VFx) occur most frequently in the mid-thoracic and thoraco-lumbar regions, which experience the highest mechanical loading along the spine. The prevalence and incidence of VFx by their location and severity, and their relationship with bone mineral density (BMD), are seldom reported in randomized clinical trial cohorts. The VERO trial randomized 1360 postmenopausal women with at least two moderate or one severe VFx to receive either teriparatide or risedronate for up to 24 months. In this post hoc analysis, we describe the centrally read distribution and severity of prevalent and incident VFx, and the association of their location with the baseline BMD. At baseline, 21.4% of all evaluable vertebral bodies had a prevalent VFx; most commonly at L₁, T₁₂, L₂ and T₁₁ (38.5%, 37.4%, 25.3% and 23.5% of patients, respectively). Patients with prevalent VFx only at T₁₂/L₁ showed a higher baseline BMD compared to patients with VFx at other levels. At month 24, 100 patients had 126 incident VFx (teriparatide: 35; risedronate: 91). The most frequent incident VFx occurred at T₁₂ (n = 17, 1.6% of patients), followed by L₁ and T₁₁ (n = 14, 1.3% both). The frequency of incident VFx was lower at all vertebral levels in patients given teriparatide. These results confirm prior reports that VFx occurs more frequently at mid-thoracic and thoraco-lumbar regions of the spine. Patients with these VFx locations have higher BMD than those who fracture at other sites, suggesting a role for mechanical stress in the etiology of VFx. Teriparatide is superior to risedronate in the prevention of VFx at these common fracture locations.Trial registration ClinicalTrials.gov Identifier: NCT01709110.

Clinical and radiological evaluation of thoracic spine fractures with or without sternal fracture: is there a need for ventral stabilization?

OBJECTIVE

The treatment of thoracic spine (TS) fractures with additional sternal fractures compared to TS fractures without sternal fractures is discussed controversionally, because in some studies it was stated that sternal fractures decrease the thoracic stability. We hypothesized that both types of fractures can be treated the same way by posterior stabilization alone.

METHODS

A total number of 69 patients with thoracic fractures, with or without additional sternal fractures, were examined, regarding the angle of kyphosis after fracture, postoperatively and after 6 and 12 months. We also recorded the outcome using the Odom's score and the time until patients returned to work and the activity level.

RESULTS

It was found that the angle of kyphosis was nearly physiological after stabilization in both groups and a loss of reduction after 1 year was also comparable, either in the patients suffering from the additional sternal fracture or not. In addition, the Odom's score and the time until return to work and the activity level were comparable in both groups.

CONCLUSION

We did not find any arguments to preserve additional anterior stabilization or reasons for different treatment strategies either additional sternal fractures occur in thoracic spine fractures or not.

Design, Implementation and Preliminary Testing of a Novel Orthosis for Reducing Erector Spinae Muscle Activity, and Improving Balance Control for Hyperkyphotic Elderly Subjects

BACKGROUND

Aging often results in thoracic kyphosis and adverse postural changes. This may interfere with physiologic activity of paraspinal muscles. Few styles of spinal orthosis have been already used to reduce thoracic kyphosis. This paper describes the development of a novel orthosis, which is designed based on the anatomy of the back muscles. This novel orthosis may potentiate muscle activity and balance control among older hyper kyphotic subjects.

OBJECTIVES

The object of this study was to design and preliminary testing of a new orthosis to potentiate muscle activity and balance control among older hyper kyphotic subjects.

MATERIAL AND METHODS

In this quasi-experimental study, a new postural control orthosis with a textile band structure was designed to provide an additional support for spine and muscles of the back. The functional impact of this orthosis was evaluated in six older hyper-kyphotic subjects. According to the results, the paraspinal muscles activity and balance control were significantly improved.

RESULTS

The RMS sEMG of the lumbar and thoracic erector spinae muscles reduced significantly (p<0.05), and a significant improvement (p<0.05) was observed in the balance test when patients put on the novel orthosis (p<0.05).

CONCLUSION

The new orthosis can considerably improve the paraspinal muscles activity at both the upper and lower lumbar levels. It can also recover balance control among elderly subjects.

A novel tool to provide predictable alignment data irrespective of source and image quality acquired on mobile phones: what engineers can offer clinicians

PURPOSE

Existing automated spine alignment is based on original X-rays that are not applicable for teleradiology for spinal deformities patients. We aim to provide a novel automated vertebral segmentation method enabling accurate sagittal alignment detection, with no restrictions imposed by image quality or pathology type.

METHODS

A total of 428 optical images of original sagittal X-rays taken by smartphones or screenshots for consecutive patients attending our spine clinic were prospectively collected. Of these, 300 were randomly selected and their vertebrae were labelled with Labelme. The ground truth was specialists measured sagittal alignment parameters. Pre-trained Mask R-CNN was fine-tuned and trained to predict the vertebra level(s) on the remaining 128 testing cases. The sagittal alignment parameters including the thoracic kyphosis (TK), lumbar lordosis (LL) and sacral slope (SS) were auto-detected, based on the segmented vertebra. Dice similarity coefficient (DSC) and mean intersection over union (mIoU) were calculated to evaluate the accuracy of the predicted vertebra. The detected sagittal alignments were then quantitatively compared with the ground truth.

RESULTS

The DSC was 84.6 ± 3.8% and mIoU was 72.1 ± 4.8% indicating accurate vertebra prediction. The sagittal alignments detected were all strongly correlated with the ground truth (p < 0.001). Standard errors of the estimated parameters had a small difference from the specialists' results (3.5° for TK and SS; 3.4° for LL).

CONCLUSION

This is the first study using fine-tuned Mask R-CNN to predict vertebral locations on optical images of X-rays accurately and automatically. We provide a novel alignment detection method that has a significant application on teleradiology aiding out-of-hospital consultations. These slides can be retrieved under Electronic Supplementary Material.

Risk factors of low back pain and the relationship with sagittal vertebral alignment in Tanzania

Background

LBP is a common and serious problem affecting vast populations of the world. However, only few studies on LBP in sub-Saharan Africa have been conducted. Studies report that LBP and pelvic angle are interrelated, and African residents have a high pelvic tilt. The strategy to prevent LBP should focus on activities that promote holistic health. For that purpose, it is important to grasp the state of LBP and how it affects people’s lifestyle in Tanzania to clarify the direction of implementation of physiotherapy treatment and reduce the incidences of LBP among adults. This study aimed to investigate the prevalence and presentation of low back pain (LBP) and the relationship between anthropometric measurements and LBP among people in Moshi city, Kilimanjaro region Tanzania.

Methods

Following signing consent forms, participants were given questionnaires regarding LBP and then grouped accordingly into either asymptomatic or symptomatic cohorts. Anthropometric measurements of participants’ height, weight, curvature of the spine, and pelvic angle were obtained.

Results

A Mann-Whitney U test analysis showed a significant difference in pelvic angle, body mass index (BMI), and thoracic kyphosis angle between the asymptomatic group and the symptomatic group. No significant differences in lumbar lordosis angle or abdominal muscle strength were found between the two groups.

Conclusions

A person with symptomatic LBP in Tanzania has a large anteversion of the pelvic tilt and a thoracic kyphotic posture. This study shows a relationship between sagittal spinal alignment and LBP in Tanzania, which could allow for prospective identification of subjects prone to developing LBP in the future.

Upper back pain in postmenopausal women and associated physical characteristics

The physical characteristics of postmenopausal women that are associated with upper back pain are not well-understood. The aim of this cross-sectional study was to identify the physical characteristics associated with presence and severity of upper back pain in healthy postmenopausal women. Self-reported upper back pain presence (within the previous month) and severity (numerical rating scale) were examined against the physical characteristics: height; weight; body mass index; breast size; breast ptosis; upper back extensor muscle endurance (isometric chest raise test); head, shoulder and upper back posture (photogrammetry); thoracic extension mobility (photogrammetry); bone mineral density (dual-energy x-ray absorptiometry (DXA)); body composition (DXA); and thoracic kyphosis, thoracic osteoarthritis and thoracic vertebral fracture (all radiography). A multivariable logistic regression model, adjusted for age, was built using physical characteristics with a significant univariate association with upper back pain. Censored Tobit regression, adjusted for age, was used to examine each physical characteristic against upper back pain severity. Postmenopausal women (n = 119) with a mean (SD) age of 61.4 (7.0) years participated in the study. After adjusting for age, the physical characteristics independently associated with upper back pain were: height (OR: 0.50, 95% CI: 0.31–0.79); and upper back extensor muscle endurance (OR: 0.46, 95%CI: 0.28–0.75). This model explained 31% of the variance in upper back pain (p<0.001). After adjusting for age, being taller and having better upper back extensor muscle endurance were associated with lower odds for upper back pain. After adjusting for age, differences in upper back pain severity were explained by upper back extensor muscle endurance (p = <0.001) and lean mass (p = 0.01). Conclusion: As a modifiable physical characteristic of postmenopausal women with upper back pain, upper back extensor muscle endurance is worth considering clinically.

Interaction Between Thoracic Movement and Lumbar Spine Muscle Activation Patterns in Young Adults Asymptomatic for Low Back Pain: A Cross-Sectional Study

OBJECTIVE

The purpose of this study was to investigate the interaction between thoracic movement and lumbar muscle co-contraction when the lumbar spine was held in a relatively neutral posture.

METHODS

Thirty young adults, asymptomatic for back pain, performed 10 trials of upright standing, maximum trunk range of motion, and thoracic movement tasks while lumbar muscle activation was measured. Lumbar co-contraction was calculated, compared between tasks, and correlated to thoracic angles.

RESULTS

Movement tasks typically exhibited greater co-contraction than upright standing. Co-contraction in the lumbar musculature was 67%, 45%, and 55% greater than upright standing for thoracic flex, thoracic bend, and thoracic twist, respectively. Generally, the thoracic movement task demonstrated greater co-contraction than the maximum task in the same direction. Co-contraction was also correlated to thoracic angles in each movement direction.

CONCLUSION

Tasks with thoracic movement and a neutral lumbar spine posture resulted in increases in co-contraction within the lumbar musculature compared with quiet standing and maximum trunk range-of-motion tasks. Findings indicated an interaction between the 2 spine regions, suggesting that thoracic posture should be accounted for during the investigation of lumbar spine mechanics.

Exercise for improving outcomes after osteoporotic vertebral fracture

BACKGROUND

Vertebral fractures are associated with increased morbidity (e.g. pain, reduced quality of life) and mortality. Therapeutic exercise is a non-pharmacological conservative treatment that is often recommended for patients with vertebral fractures to reduce pain and restore functional movement. This is an update of a Cochrane Review first published in 2013.

OBJECTIVES

To assess the effects (benefits and harms) of exercise intervention of four weeks or greater (alone or as part of a physical therapy intervention) versus non-exercise/non-active physical therapy intervention, no intervention or placebo among adults with a history of vertebral fractures on incident fragility fractures of the hip, vertebra or other sites. Our secondary objectives were to evaluate the effects of exercise on the following outcomes: falls, pain, physical performance, health-related quality of life (disease-specific and generic), and adverse events.

SEARCH METHODS

We searched the following databases until November 2017: the Cochrane Library (Issue 11 of 12), MEDLINE (from 2005), Embase (from 1988), CINAHL (Cumulative Index to Nursing and Allied Health Literature, from 1982), AMED (from 1985), and PEDro (Physiotherapy Evidence Database, from 1929). Ongoing/recently completed trials were identified by searching the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov. Conference proceedings were searched via ISI and SCOPUS, and targeted searches of proceedings of the American Congress of Rehabilitation Medicine and American Society for Bone and Mineral Research. Search terms or MeSH headings included terms such as vertebral fracture AND exercise OR physical therapy. For this update, the search results were limited from 2011 onward.

SELECTION CRITERIA

We included all randomized controlled trials and quasi-randomized trials comparing exercise or active physical therapy interventions with placebo/non-exercise/non-active physical therapy interventions or no intervention implemented in individuals with a history of vertebral fracture.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials and extracted data using a pre-tested data extraction form. Disagreements were resolved by consensus, or third-party adjudication. We used Cochrane's tool for assessing risk of bias to evaluate each study. Studies were grouped according to duration of follow-up (i.e. a) 4-12 weeks; b) 16-24 weeks; c) 52 weeks); a study could be represented in more than one group depending on the number of follow-up assessments. For dichotomous data, we reported risk ratios (RR) and corresponding 95% confidence intervals (95% CI). For continuous data, we reported mean differences (MD) of the change from baseline and 95% CI. Data were pooled for Timed Up and Go test, self-reported physical function measured by the QUALEFFO-41 physical function subscale score (scale of zero to 100; lower scores indicate better self-reported physical function), and disease-specific quality of life measured by the QUALEFFO-41 total score (scale of zero to 100; lower scores indicate better quality of life) at 12 weeks using a fixed-effect model.

MAIN RESULTS

Nine trials (n = 749, 68 male participants; two new trials in this review update) were included. Substantial variability across the trials prevented any meaningful pooling of data for most outcomes. Risk of bias across all studies was variable; low risk across most domains in four studies, and unclear/high risk in most domains for five studies. Performance bias and blinding of subjective outcome assessment were almost all high risk of bias.One trial reported no between-group difference in favor of the effect of exercise on incident fragility fractures after 52 weeks (RR 0.54, 95% CI 0.17 to 1.71; very low-quality evidence with control: 184 per 1000 and exercise: 100 per 1000, 95% CI 31 to 315; absolute difference: 8%, 95% CI 2 to 30). One trial reported no between-group difference in favor of the effect of exercise on incident falls after 52 weeks (RR 1.06, 95% CI 0.53 to 2.10; very low-quality evidence with control: 262 per 1000 and exercise: 277 per 1000; 95% CI 139 to 550; absolute difference: 2%, 95% CI -12 to 29). These findings should be interpreted with caution because of the very serious risk of bias in these studies and the small sample sizes resulting in imprecise estimates.We are uncertain that exercise could improve pain, self-reported physical function, and disease-specific quality of life, because certain studies showed no evidence of clinically important differences for these outcomes. Pooled analyses revealed a small between-group difference in favor of exercise for Timed Up and Go (MD -1.13 seconds, 95% CI -1.85 to -0.42; studies = 2), which did not change following a sensitivity analysis (MD -1.09 seconds, 95% CI -1.78 to -0.40; studies = 3; moderate-quality evidence). Exercise improved QUALEFFO-41 physical function score (MD -2.84 points, 95% CI -5.57 to -0.11; studies = 2; very low-quality evidence) and QUALEFFO-41 total score (MD -3.24 points, 95% CI -6.05 to -0.43; studies = 2; very low-quality evidence), yet it is unlikely that we observed any clinically important differences. Three trials reported four adverse events related to the exercise intervention (costal cartilage fracture, rib fracture, knee pain, irritation to tape, very low-quality evidence).

AUTHORS' CONCLUSIONS

In conclusion, we do not have sufficient evidence to determine the effects of exercise on incident fractures, falls or adverse events. Our updated review found moderate-quality evidence that exercise probably improves physical performance, specifically Timed Up and Go test, in individuals with vertebral fracture (downgraded due to study limitations). However, a one-second improvement in Timed Up and Go is not a clinically important improvement. Although individual trials did report benefits for some pain and disease-specific quality of life outcomes, the findings do not represent clinically meaningful improvements and should be interpreted with caution given the very low-quality evidence due to inconsistent findings, study limitations and imprecise estimates. The small number of trials and variability across trials limited our ability to pool outcomes or make conclusions. Evidence regarding the effects of exercise after vertebral fracture in men is scarce. A high-quality randomized trial is needed to inform safety and effectiveness of exercise to lower incidence of fracture and falls and to improve patient-centered outcomes (pain, function) for individuals with vertebral fractures (minimal sample size required is approximately 2500 untreated participants or 4400 participants if taking anti-osteoporosis therapy).

Back Muscle Function in Older Women With Age-Related Hyperkyphosis: A Comparative Study

OBJECTIVE

The purpose of this study was to compare static maximal back extensor muscle force, endurance, and characteristics of flexion relaxation phenomenon (FRP) in older women with and without age-related hyperkyphosis.

METHODS

Maximum back extensor force and endurance measured in a sitting position with a designed load cell setup; appearance, onset, and offset angles of FRP; and extension relaxation ratio (ERR) during a dynamic flexion-extension task were compared between 24 older women with hyperkyphosis (thoracic kyphosis angle ≥50°), mean age 65 ± 4.4 years, and 24 older women without hyperkyphosis (thoracic kyphosis angle ≪50°), mean age 63 ± 4.3 years. Variables of force, endurance, angles of FRP, and ERR were analyzed using an independent sample t test. A χ² test was used to identify differences between groups in FRP appearance.

RESULTS

Static back extensor force and endurance were significantly lower among those with versus those without hyperkyphosis (P ≪ .001). Although the 2 groups did not differ in FRP appearance and ERR in the superficial erector spinal muscles (P ≫ .05), FRP in the hyperkyphosis group started sooner and ended later than in the group without hyperkyphosis (P ≪ .05).

CONCLUSION

Our study indicates that women with age-related hyperkyphosis had decreased static maximal force and endurance of the back extensor muscles and prolonged myoelectrical silence of the superficial erector spinal muscles. Reduced endurance of the superficial erector spinal muscles may trigger early onset of FRP and prolonged relaxation of these muscles.

Twente Spine Model: A thorough investigation of the spinal loads in a complete and coherent musculoskeletal model of the human spine

Although in vivospinal loads have been previously measured, existing data are limited to certain lumbar and thoracic levels. A detailed investigation of spinal loads would assist with injury prevention and implant design but is unavailable. In this study, we developed a complete and coherent musculoskeletal model of the entire human spine and studied the intervertebral disc compression forces for physiological movements on three anatomical planes. This model incorporates the individual vertebrae at the cervical, thoracic, and lumbar regions, a flexible ribcage, and complete muscle anatomy. Intradiscal pressures were estimated from predicted compressive forces, and these were generally in close agreement with previously measured data. We found that compressive forces at the trunk discs increased during trunk lateral bending and axial rotation of the trunk. During flexion, compressive forces increased in the thoracolumbar and lumbar regions and slightly decreased at the middle thoracic discs. In extension, the forces generally decreased at the thoracolumbar and lumbar discs whereas they slightly increased at the upper and middle thoracic discs. Furthermore, similar to a previous biomechanical model of the cervical spine, our model predicted increased compression forces in neck flexion, lateral bending, and axial rotation, and decreased forces in neck extension.

Fully automated radiological analysis of spinal disorders and deformities: a deep learning approach

PURPOSE

We present an automated method for extracting anatomical parameters from biplanar radiographs of the spine, which is able to deal with a wide scenario of conditions, including sagittal and coronal deformities, degenerative phenomena as well as images acquired with different fields of view.

METHODS

The location of 78 landmarks (end plate centers, hip joint centers, and margins of the S1 end plate) was extracted from three-dimensional reconstructions of 493 spines of patients suffering from various disorders, including adolescent idiopathic scoliosis, adult deformities, and spinal stenosis. A fully convolutional neural network featuring an additional differentiable spatial to numerical (DSNT) layer was trained to predict the location of each landmark. The values of some parameters (T4-T12 kyphosis, L1-L5 lordosis, Cobb angle of scoliosis, pelvic incidence, sacral slope, and pelvic tilt) were then calculated based on the landmarks' locations. A quantitative comparison between the predicted parameters and the ground truth was performed on a set of 50 patients.

RESULTS

The spine shape predicted by the models was perceptually convincing in all cases. All predicted parameters were strongly correlated with the ground truth. However, the standard errors of the estimated parameters ranged from 2.7° (for the pelvic tilt) to 11.5° (for the L1-L5 lordosis).

CONCLUSIONS

The proposed method is able to automatically determine the spine shape in biplanar radiographs and calculate anatomical and posture parameters in a wide scenario of clinical conditions with a very good visual performance, despite limitations highlighted by the statistical analysis of the results. These slides can be retrieved under Electronic Supplementary Material.