Exercise prescription variables predict reductions in pain intensity in adults with chronic low back pain: secondary analysis of a randomised controlled trial

Objectives

The relationship between exercise training variables and clinical outcomes in low back pain (LBP) is unclear. The current study aimed to explore the relationship between exercise training parameters and pain intensity in individuals with chronic LBP.

Methods

This study is a secondary analysis of a previously reported randomised controlled trial comparing the effects of general strength and conditioning to motor control exercises and manual therapy. This secondary analysis includes adults with chronic LBP (n=20) randomised to the general strength and conditioning programme only. Primary outcomes of this analysis were exercise training parameters (time under tension, rating of perceived exertion (RPE), session duration, session-RPE and training frequency) and pain intensity (0-100 mm visual analogue acale) measured every 2 weeks from baseline to 6 months follow-up. Linear mixed models with random effects (participants) and allowance for heterogeneity of variance (study date) were used to determine the association between pain intensity and training parameters over time.

Results

Mean (95% CI) pain intensity decreased over time from baseline to 6 months follow-up by 10.7 (2.8 to 18.7) points (p=0.008). Over the 6-month intervention, lower pain intensity was associated with higher RPE (β (95% CI) -27.168 (-44.265 to -10.071), p=0.002), greater time under tension (-0.029 (-0.056 to -0.001), p=0.040) and shorter session duration (1.938 (0.011 to 3.865), p=0.049).

Conclusion

During 6 months of general strength and conditioning, lower pain intensity was associated with higher participant-reported training intensity, greater volume and shorter session duration. To ensure positive outcomes to exercise training, these variables should be monitored on a short-term basis.

Trial registration number

ACTRN12615001270505.

The Interaction Between Psychosocial Factors and Exercise-Induced Hypoalgesia in Pain-Free Nurses

Purpose

This cross-sectional study aimed to investigate whether psychosocial factors were predictive for exercise-induced hypoalgesia (EIH) in pain-free adults.

Methods

A sample of 38 pain-free nurses with a mean (SD) age of 26 (6) years were included in this study. Participants completed psychosocial questionnaires prior to physical tests. Pressure pain threshold (PPT) was assessed bilaterally at the calves (local), lower back (semi-local) and forearm (remote) before and immediately after a maximal graded cycling exercise test. Separate linear mixed effects models were used to determine change in PPT before and after cycling exercise (EIH). Multiple linear regression for all psychosocial variables and best subset regression was used to identify predictors of EIH at all locations.

Results

The relative mean increase in PPT at the forearm, lumbar, calf, and globally (all sites pooled) was 6.0% (p<0.001), 10.1% (p<0.001), 13.9% (p<0.001), and 10.2% (p=0.013), respectively. Separate best subset multiple linear regression models at the forearm (predictors; Multidimensional Scale of Perceived Social Support (MSPSS) total), lumbar (predictors; MSPSS total, Pain Catastrophizing Scale (PCS) total, Depression Anxiety Stress Scale (DASS) depression), calf (predictors; MSPSS friends, PCS total), and global (predictors; MSPSS friends, PCS total) accounted for 7.5% (p=0.053), 13% (p=0.052), 24% (p=0.003), and 17% (p=0.015) of the variance, respectively.

Conclusion

These findings confirm that cycling exercise produced EIH in young nurses and provided preliminary evidence to support the interaction between perceived social support, pain catastrophizing and EIH. Further investigation is required to better understand psychological and social factors that mediate EIH on a larger sample of adults at high risk of developing chronic musculoskeletal pain.

Features and methods to discriminate between mechanism-based categories of pain experienced in the musculoskeletal system: a Delphi expert consensus study

ABSTRACT

Classification of musculoskeletal pain based on underlying pain mechanisms (nociceptive, neuropathic, and nociplastic pain) is challenging. In the absence of a gold standard, verification of features that could aid in discrimination between these mechanisms in clinical practice and research depends on expert consensus. This Delphi expert consensus study aimed to: (1) identify features and assessment findings that are unique to a pain mechanism category or shared between no more than 2 categories and (2) develop a ranked list of candidate features that could potentially discriminate between pain mechanisms. A group of international experts were recruited based on their expertise in the field of pain. The Delphi process involved 2 rounds: round 1 assessed expert opinion on features that are unique to a pain mechanism category or shared between 2 (based on a 40% agreement threshold); and round 2 reviewed features that failed to reach consensus, evaluated additional features, and considered wording changes. Forty-nine international experts representing a wide range of disciplines participated. Consensus was reached for 196 of 292 features presented to the panel (clinical examination-134 features, quantitative sensory testing-34, imaging and diagnostic testing-14, and pain-type questionnaires-14). From the 196 features, consensus was reached for 76 features as unique to nociceptive (17), neuropathic (37), or nociplastic (22) pain mechanisms and 120 features as shared between pairs of pain mechanism categories (78 for neuropathic and nociplastic pain). This consensus study generated a list of potential candidate features that are likely to aid in discrimination between types of musculoskeletal pain.

Exercise may impact on lumbar vertebrae marrow adipose tissue: Randomised controlled trial

BACKGROUND

Animal and human cross-sectional data suggest that bone marrow adipose tissue (MAT) may respond to mechanical loads and exercise. We conducted the first randomised controlled trial of exercise on MAT modulations in humans.

METHODS

Forty patients with chronic non-specific low back pain (NSCLBP) were enrolled in a six-month single-blinded randomised controlled trial (ACTRN12615001270505). Twenty patients loaded their spines via progressive upright aerobic and resistance exercises targeting major muscle groups (Exercise). Twenty patients performed non-weightbearing motor control training and manual therapy (Control). Testing occurred at baseline, 3-months (3mo) and 6-months (6mo). Lumbar vertebral fat fraction (VFF) was measured using magnetic resonance imaging axial mDixon sequences.

RESULTS

When compared to baseline (percent change), lumbar vertebral fat fraction (VFF; measured using magnetic resonance imaging axial mDixon sequences) was lower in Exercise at 3mo at L2 (-3.7[6.8]%, p = 0.033) and L4 (-2.6[4.1]%, p = 0.015), but not in Control. There were no between-group effects. The effects of Exercise on VFF were sex-specific, with VFF lower in men at L2, L3, L4 at 3mo and at L1, L2, L3 and L4 at 6mo (p all ≤ 0.05), but not in women. Leg and trunk lean mass were increased at 3mo in Exercise. Changes in VFF correlated significantly with changes in total fat (ρ = 0.40) and lean (ρ = -0.41) masses, but not with lumbar BMD (ρ = -0.10) or visceral adipose tissue volume (ρ = 0.23).

CONCLUSIONS

This trial provided first prospective evidence in humans that a moderate exercise intervention may modulate lumbar VFF as a surrogate measure of MAT at 3mo, yet not 6mo. The effect of exercise on MAT may be more prominent in males than females.

Understanding how individualised physiotherapy or advice altered different elements of disability for people with low back pain using network analysis

Purpose

The Oswestry Disability Index (ODI) is a common aggregate measure of disability for people with Low Back Pain (LBP). Scores on individual items and the relationship between items of the ODI may help understand the complexity of low back disorders and their response to treatment. In this study, we present a network analysis to explore how individualised physiotherapy or advice might influence individual items of the ODI, and the relationship between those items, at different time points for people with LBP.

Methods

Data from a randomised controlled trial (n = 300) comparing individualised physiotherapy versus advice for low back pain were used. A network analysis was performed at baseline, 5, 10, 26 and 52 weeks, with the 10 items of the Oswestry Disability Index modelled as continuous variables and treatment group (Individualised Physiotherapy or Advice) modelled as a dichotomous variable. A Mixed Graphical Model was used to estimate associations between variables in the network, while centrality indices (Strength, Closeness and Betweenness) were calculated to determine the importance of each variable.

Results

Individualised Physiotherapy was directly related to lower Sleep and Pain scores at all follow-up time points relative to advice, as well as a lower Standing score at 10-weeks, and higher Lifting and Travelling scores at 5-weeks. The strongest associations in the network were between Sitting and Travelling at weeks 5 and 26, between Walking and Standing at week 10, and between Sitting and Standing scores at week 52. ODI items with the highest centrality measures were consistently found to be Pain, Work and Social Life.

Conclusion

This study represents the first to understand how individualised physiotherapy or advice differentially altered disability in people with LBP. Individualised Physiotherapy directly reduced Pain and Sleep more effectively than advice, which in turn may have facilitated improvements in other disability items. Through their high centrality measures, Pain may be considered as a candidate therapeutic target for optimising LBP management, while Work and Socialising may need to be addressed via intermediary improvements in lifting, standing, walking, travelling or sleep. Slower (5-week follow-up) improvements in Lifting and Travelling as an intended element of the Individualised Physiotherapy approach did not negatively impact any longer-term outcomes.

Trials registration

ACTRN12609000834257.

Protection motivation theory screening tool for predicting chronic low back pain rehabilitation adherence: analysis of a randomised controlled trial

OBJECTIVE

To explore a protection motivation theory screening tool for predicting rehabilitation adherence.

DESIGN

Analysis of a randomised controlled trial.

SETTING

An exercise physiology and physiotherapist clinic.

PARTICIPANTS

Patients with chronic low back pain (n=40).

INTERVENTIONS

General strength and conditioning (GSC) compared with motor control and manual therapy. Primary and secondary outcome measures: predicting patient adherence to supervised sessions and dropout using the Sports Injury Rehabilitation Beliefs Scale, seven-item barriers checklist and Positive and Negative Affect Schedule and Sports Injury Rehabilitation Adherence Scale.

RESULTS

Average attendance was 77% (motor control and manual therapy) and 60% (GSC) with eight dropouts. No Sports Injury Rehabilitation Adherence Scale values other than 5 across all three components were recorded. Treatment efficacy (p=0.019), self-efficacy (p=0.001), rehabilitation value (p=0.028) and injury severity (p=0.002) positively correlated with susceptibility (the extent of vulnerability to having health problems from not taking action). Rehabilitation value positively correlated with self-efficacy (p=0.005). Injury severity positively correlated with rehabilitation value (p=0.011). The final model for number of cancellations included rehabilitation value only and accounted for approximately 12% of variance (p=0.033).

CONCLUSIONS

Perceived value of rehabilitation should be considered by clinicians in the rehabilitation setting to improve treatment adherence in patients with chronic low back pain.

TRIAL REGISTRATION NUMBER

ACTRN12615001270505.

How does individualised physiotherapy work for people with low back pain? A Bayesian Network analysis using randomised controlled trial data

PURPOSE

Individualised physiotherapy is an effective treatment for low back pain. We sought to determine how this treatment works by using randomised controlled trial data to develop a Bayesian Network model.

METHODS

300 randomised controlled trial participants (153 male, 147 female, mean age 44.1) with low back pain (of duration 6-26 weeks) received either individualised physiotherapy or advice. Variables with potential to explain how individualised physiotherapy works were included in a multivariate Bayesian Network model. Modelling incorporated the intervention period (0-10 weeks after study commencement-"early" changes) and the follow-up period (10-52 weeks after study commencement-"late" changes). Sequences of variables in the Bayesian Network showed the most common direct and indirect recovery pathways followed by participants with low back pain receiving individualised physiotherapy versus advice.

RESULTS

Individualised physiotherapy directly reduced early disability in people with low back pain. Individualised physiotherapy exerted indirect effects on pain intensity, recovery expectations, sleep, fear, anxiety, and depression via its ability to facilitate early improvement in disability. Early improvement in disability, led to an early reduction in depression both directly and via more complex pathways involving fear, recovery expectations, anxiety, and pain intensity. Individualised physiotherapy had its greatest influence on early change variables (during the intervention period).

CONCLUSION

Individualised physiotherapy for low back pain appears to work predominately by facilitating an early reduction in disability, which in turn leads to improvements in other biopsychosocial outcomes. The current study cannot rule out that unmeasured mechanisms (such as tissue healing or reduced inflammation) may mediate the relationship between individualised physiotherapy treatment and improvement in disability. Further data-driven analyses involving a broad range of plausible biopsychosocial variables are recommended to fully understand how treatments work for people with low back pain.

TRIALS REGISTRATION

ACTRN12609000834257.

Effects of specific muscle activation for low back pain on activity limitation, pain, work participation, or recurrence: A systematic review

BACKGROUND

Specific muscle activation (SMA) is a commonly used treatment for people with low back pain (LBP) however there is variability in systematic reviews to date on effectiveness. This may be because of the use of eligibility criteria incongruent with original descriptions of the SMA approach.

PURPOSE

The purpose of this study was to determine the effectiveness of SMA on improving activity limitation, pain, work participation or recurrence for people with LBP.

STUDY DESIGN

Systematic review METHODS: Computer databases were searched for randomised controlled trials (RCTs) published in English up to September 6, 2019. Eligibility criteria were chosen to ensure all clinically relevant RCTs were included and trials of poorly defined or executed SMA excluded. Outcomes for activity limitation, pain, work participation or recurrence were extracted.

RESULTS

Twenty-eight RCTs were included in this review with 18 being considered high quality. GRADE quality assessment revealed low to high quality evidence that SMA was more effective than exercise, conservative medical management, multi-modal physiotherapy, placebo, advice and minimal intervention.

CONCLUSIONS

This systematic review is the first to evaluate the effectiveness of SMA in accordance with the original clinical descriptions. We found significant evidence supporting the effectiveness of SMA for the treatment of LBP. Where significant results were demonstrated, the between-group differences were in many comparisons clinically important based on contemporary definitions and an effect size of 0.5 or more. Practitioners should consider SMA as a treatment component in their patients with LBP.

Clinical features as predictors of histologically confirmed inflammation in patients with lumbar disc herniation with associated radiculopathy

Background

An understanding of the clinical features of inflammation in low back pain with or without leg symptoms may allow targeted evaluations of anti-inflammatory treatment in randomised-controlled-trials and clinical practice.

Purpose

This study evaluated the diagnostic accuracy of clinical features to predict the presence/absence of histologically confirmed inflammation in herniated disc specimens removed at surgery in patients with lumbar disc herniation and associated radiculopathy (DHR).

Study design

Cohort Study.

Methods

Disc material from patients with DHR undergoing lumbar discectomy was sampled and underwent histological/immunohistochemistry analyses. Control discs were sampled from patients undergoing surgical correction for scoliosis. Baseline assessment comprising sociodemographic factors, subjective examination, physical examination and psychosocial screening was conducted and a range of potential clinical predictors of inflammation developed based on the existing literature. Multi-variate analysis was undertaken to determine diagnostic accuracy.

Results

Forty patients with DHR and three control patients were recruited. None of the control discs had evidence of inflammation compared to 28% of patients with DHR. Predictors of the presence of histologically confirmed inflammation included back pain < 5/10, symptoms worse the next day after injury, lumbar flexion range between 0 and 30° and a positive clinical inflammation score (at least 3 of: constant symptoms, morning pain/stiffness greater than 60-min, short walking not easing symptoms and significant night symptoms). The model achieved a sensitivity of 90.9%, a specificity of 92.9%, and a predictive accuracy of 92.3%.

Conclusion

In a sample of patients with lumbar DHR a combination of clinical features predicted the presence or absence of histologically confirmed inflammation.

Clinical relevance

These clinical features may enable targeted anti-inflammatory treatment in future RCTs and in clinical practice.

A multivariate prognostic model for pain and activity limitation in people undergoing lumbar discectomy

Purpose: The purpose of this study was to identify a multivariate predictive model for 6-month outcomes on overall pain, leg pain and activity limitation in patients undergoing lumbar discectomy. Identification of predictors of outcome for lumbar discectomy has the potential to assist identifying treatment targets, clinical decision making and disease understanding.Materials and methods: Prospective cohort design. Ninety-seven patients deemed by study surgeons to be suitable for lumbar discectomy completed a comprehensive clinical and radiological baseline assessment. At 6-months post surgery outcome measures of overall and leg pain (visual analogue scale) as well as activity limitation (Oswestry Disability Index) were completed. Univariate and multivariate analyses were conducted to determine the best multivariate predictive model of outcome.Results: In the multivariate model, presence of a compensation claim, longer duration of injury and presence of below knee pain and/or parasthesia were negative prognostic indicators for at least two of the outcomes. Peripheralization in response to mechanical loading strategies was a positive prognostic indicator for overall pain and leg pain. A range of other prognostic indicators for one outcome were also identified. The prognostic model explained up to 32% of the variance in outcome.Conclusions: An 11-factor prognostic model was identified from a range of clinically and radiologically assessed variables in accordance with a biopsychosocial model. The multivariate model has potential implications for researchers and practitioners in the field. Further high quality research is required to externally validate the prognostic model, evaluate effect of the identified prognostic factors on treatment effectiveness and explore potential mechanisms of effect.

Development of a Multivariate Prognostic Model for Pain and Activity Limitation in People With Low Back Disorders Receiving Physiotherapy

OBJECTIVE

To identify predictors for back pain, leg pain, and activity limitation in patients with early persistent low back disorders (LBDs).

DESIGN

Prospective inception cohort study.

SETTING

Primary care private physiotherapy clinics in Melbourne, Australia.

PARTICIPANTS

Individuals (N=300) aged 18-65 years with low back and/or referred leg pain of ≥6 weeks and ≤6 months duration.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Numeric rating scales for back pain and leg pain as well as the Oswestry Disability Scale.

RESULTS

Prognostic factors included sociodemographics, treatment related factors, subjective/physical examination, subgrouping factors, and standardized questionnaires. Univariate analysis followed by generalized estimating equations were used to develop a multivariate prognostic model for back pain, leg pain, and activity limitation. Fifty-eight prognostic factors progressed to the multivariate stage where 15 showed significant (P<.05) associations with at least 1 of the 3 outcomes. There were 5 indicators of positive outcome (2 types of LBD subgroups, paresthesia below waist, walking as an easing factor, and low transversus abdominis tone) and 10 indicators of negative outcome (both parents born overseas, deep leg symptoms, longer sick leave duration, high multifidus tone, clinically determined inflammation, higher back and leg pain severity, lower lifting capacity, lower work capacity, and higher pain drawing percentage coverage). The preliminary model identifying predictors of LBDs explained up to 37% of the variance in outcome.

CONCLUSIONS

This study evaluated a comprehensive range of prognostic factors reflective of both the biomedical and psychosocial domains of LBDs. The preliminary multivariate model requires further validation before being considered for clinical use.

Comparison of 2 Exercise Rehabilitation Programs for Multidirectional Instability of the Glenohumeral Joint: A Randomized Controlled Trial

BACKGROUND

The recommended initial treatment for multidirectional instability (MDI) of the shoulder is a rehabilitation program, yet there is very low-quality evidence to support this approach. Purpose/Hypothesis: The purpose was to compare the Watson MDI program and Rockwood Instability program among patients with nontraumatic, nonstructural MDI. The hypothesis was that the Watson MDI program would produce clinically and statistically superior outcomes over the Rockwood Instability program.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

Forty-one participants with MDI were randomly allocated to the Watson MDI or Rockwood Instability program. Participants attended 12 weekly physiotherapy sessions for exercise prescription. Outcomes were assessed at baseline and 6, 12, and 24 weeks after randomization. Primary outcomes were the Melbourne Instability Shoulder Score (MISS) and the Western Ontario Shoulder Index (WOSI). Secondary outcomes included the Orebro Musculoskeletal Pain Questionnaire, pain, muscle strength, scapular upward rotation, scapular coordinates, global rating of change, satisfaction scales, limiting angle in abduction range, limiting factor in abduction range, and incidence of dislocation. Primary analysis was by intention to treat based on linear mixed models.

RESULTS

Between-group differences showed significant effects favoring the Watson program for the WOSI (effect size [ES], 11.1; 95% CI, 1.9-20.2; P = .018) and for the limiting factor in abduction (ES, 0.1; 95% CI, 0.0-1.6; P = .023) at 12 weeks, and for the WOSI (ES, 12.6; 95% CI, 3.4-21.9; P =. 008), MISS (ES, 15.4; 95% CI, 5.9-24.8; P = .002), and pain (ES, -2.0; CI: -2.3 to -0.7, P = .003) at 24 weeks.

CONCLUSION

For people with MDI, 12 sessions of the Watson MDI program were more effective than the Rockwood program at 12- and 24-week follow-up. Registration: ACTRN12613001240730 (Australian New Zealand Clinical Trials Registry).

Individualized functional restoration as an adjunct to advice for lumbar disc herniation with associated radiculopathy. A preplanned subgroup analysis of a randomized controlled trial

BACKGROUND CONTEXT

Physical therapy is commonly sought by people with lumbar disc herniation and associated radiculopathy. It is unclear whether physical therapy is effective for this population.

PURPOSE

To determine the effectiveness of physical therapist-delivered individualized functional restoration as an adjunct to guideline-based advice in people with lumbar disc herniation and associated radiculopathy.

STUDY DESIGN

This is a preplanned subgroup analysis of a multicenter parallel group randomized controlled trial.

PATIENT SAMPLE

The study included 54 participants with clinical features of radiculopathy (6-week to 6-month duration) and imaging showing a lumbar disc herniation.

OUTCOME MEASURES

Primary outcomes were activity limitation (Oswestry Disability Index) and separate 0-10 numerical pain rating scales for leg pain and back pain. Measures were taken at baseline and at 5, 10, 26, and 52 weeks.

METHODS

The participants were randomly allocated to receive either individualized functional restoration incorporating advice (10 sessions) or guideline-based advice alone (2 sessions) over a 10-week period. Treatment was administered by 11 physical therapists at private clinics in Melbourne, Australia.

RESULTS

Between-group differences for activity limitation favored the addition of individualized functional restoration to advice alone at 10 weeks (7.7, 95% confidence interval [CI] 0.3-15.1) and 52 weeks (8.2, 95% CI 0.7-15.6), as well as back pain at 10 weeks (1.4, 95% CI 0.2-2.7). There were no significant differences between groups for leg pain at any follow-up. Several secondary outcomes also favored individualized functional restoration over advice.

CONCLUSIONS

In participants with lumbar disc herniation and associated radiculopathy, an individualized functional restoration program incorporating advice led to greater reduction in activity limitation at 10- and 52-week follow-ups compared with guideline-based advice alone. Although back pain was significantly reduced at 10 weeks with individualized functional restoration, this effect was not maintained at later timepoints, and there were no significant effects on leg pain, relative to guideline-based advice.

Effect of exercise-based management on multidirectional instability of the glenohumeral joint: a pilot randomised controlled trial protocol

INTRODUCTION

The most commonly recommended treatment for multidirectional instability (MDI) of the shoulder is exercise. Despite this recommendation, there is limited evidence to support the effectiveness of exercise. The aim of this paper is to describe a pilot randomised controlled trial comparing the effectiveness of 2 exercise programmes on outcomes of participants with MDI.

METHODS AND ANALYSIS

Consenting participants between 12 and 35 years, with non-traumatic MDI will be randomly allocated to participate in either the Rockwood Instability programme or the Watson MDI programme. Both programmes involve 1 consultation per week for 12 weeks with a physiotherapist to prescribe and progress a home exercise programme. Outcomes will be assessed at baseline, 6, 12, 24 and 52 weeks. Primary outcome measures include the Melbourne Instability Shoulder Score and Western Ontario Shoulder Index. Secondary outcomes include scapular coordinates, scapular upward rotation angles, muscle strength, symptomatic onset, limiting factor and angle of limiting factor in abduction range, incidence of complete glenohumeral joint dislocation, global rating of change, satisfaction scores, the Orebro Musculoskeletal Pain Questionnaire, adverse events and compliance with the home exercise programme. Data will be analysed on intention-to-treat principles and a per protocol basis.

DISCUSSION

This trial will evaluate whether there are differences in outcomes between the Rockwood and the Watson MDI programmes for participants with MDI.

ETHICS AND DISSEMINATION

Participant confidentiality will be maintained with publication of results. Ethics approval: Faculty of Health Sciences (FHEC12/201).

TRIAL REGISTRATION NUMBER

ACTRN12613001240730; Pre-results.

Effects of individualised directional preference management versus advice for reducible discogenic pain: A pre-planned secondary analysis of a randomised controlled trial

BACKGROUND

Low back disorders are prevalent and directional preference management is a common treatment with mixed evidence for effectiveness.

OBJECTIVES

To determine the effectiveness of individualised directional preference management plus guideline-based advice versus advice alone in participants with reducible discogenic pain of 6-week to 6-month duration.

DESIGN

Pre-planned secondary analysis of a multicentre, parallel group randomised controlled trial.

METHODS

Participants were randomly allocated to receive a 10-week physiotherapy program of 10-sessions of individualised directional preference management plus guideline-based advice (n = 40) or 2-sessions of advice alone (n = 38). Primary outcomes were back pain, leg pain and activity limitation. Outcomes were taken at baseline and 5, 10, 26, and 52-weeks.

RESULTS

Between-group differences significantly favoured directional preference management compared with advice for back pain at 5-weeks (1.28; 95% CI 0.34-2.23) and 10-weeks (1.45; 95% CI 0.51-2.40), and leg pain at 10-weeks (1.21; 95% CI 0.04-2.39). These short-term differences were not maintained. There were no significant differences between-groups for activity limitation. Secondary outcomes and responder analyses favoured directional preference management suggesting between-group differences were clinically important.

CONCLUSIONS

In people with reducible discogenic pain, individualised directional preference management plus guideline-based advice resulted in significant and rapid improvement in short-term back and leg pain compared with advice alone. These effects were not maintained at long-term and there were no differences in activity limitation. Individualised directional preference management could be considered for patients with reducible discogenic pain seeking rapid pain relief however further research is indicated.

Individualised physiotherapy as an adjunct to guideline-based advice for low back disorders in primary care: a randomised controlled trial

BACKGROUND

Many patients with low-back disorders persisting beyond 6 weeks do not recover. This study investigates whether individualised physiotherapy plus guideline-based advice results in superior outcomes to advice alone in participants with low-back disorders.

METHODS

This prospective parallel group multicentre randomised controlled trial was set in 16 primary care physiotherapy practices in Melbourne, Australia. Random assignment resulted in 156 participants receiving 10 sessions of physiotherapy that was individualised based on pathoanatomical, psychosocial and neurophysiological barriers to recovery combined with guideline-based advice, and 144 participants receiving 2 sessions of physiotherapist-delivered advice alone. Primary outcomes were activity limitation (Oswestry Disability Index) and numerical rating scales for back and leg pain at 5, 10, 26 and 52 weeks postbaseline. Analyses were by intention-to-treat using linear mixed models.

RESULTS

Between-group differences showed significant effects favouring individualised physiotherapy for back and leg pain at 10 weeks (back: 1.3, 95% CI 0.8 to 1.8; leg: 1.1, 95% CI 0.5 to 1.7) and 26 weeks (back: 0.9, 95% CI 0.4 to 1.4; leg: 1.0, 95% CI 0.4 to 1.6). Oswestry favoured individualised physiotherapy at 10 weeks (4.7; 95% CI 2.0 to 7.5), 26 weeks (5.4; 95% CI 2.6 to 8.2) and 52 weeks (4.3; 95% CI 1.4 to 7.1). Responder analysis at 52 weeks showed participants receiving individualised physiotherapy were more likely to improve by a clinically important amount of 50% from baseline for Oswestry (relative risk (RR=1.3) 1.5; 95% CI 1.2 to 1.8) and back pain (RR 1.3; 95% CI 1.2 to 1.8) than participants receiving advice alone.

CONCLUSIONS

10 sessions of individualised physiotherapy was more effective than 2 sessions of advice alone in participants with low-back disorders of ≥6 weeks and ≤6 months duration. Between-group changes were sustained at 12 months for activity limitation and 6 months for back and leg pain and were likely to be clinically significant.

CLINICAL TRIAL REGISTRATION

ACTRN12609000834257.

The effect of exercise-based management for multidirectional instability of the glenohumeral joint: a systematic review

BACKGROUND

The most commonly recommended treatment for multidirectional instability (MDI) of the glenohumeral joint is exercise-based management. The primary objective of this review was to evaluate the effectiveness of exercise-based management in patients with MDI. The secondary aim was to observe the types of exercise protocols and outcomes used, as well as any adverse results associated with exercise.

METHODS

The Cochrane Database of Systematic Reviews, Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PEDro, Current Contents, Allied and Complementary Medicine (AMED), Australasian Medical Index (AMI), Ausport, and Clinical Trials Registers were searched for published and unpublished studies from the inception date to June 2012 using the keywords multidirectional instability, glenohumeral, and exercise. Selection criteria included all study designs (except case reports and case series) and participants with clinically diagnosed MDI using exercise-based management. Inclusion criteria were not limited by outcomes. The authors' own risk-of-bias tool was used for quality assessment of studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to synthesize the evidence.

RESULTS

The risk of bias was high in all 7 included studies. For before-and-after comparisons of exercise-based management, GRADE assessment showed very low-quality evidence for improvements in shoulder kinematics, the Rowe score, overall status rating, and peak muscle strength.

CONCLUSIONS

The effect of exercise-based management on MDI was variable across the included studies because of study heterogeneity and a high level of bias. There is a need for high-quality intervention studies to be undertaken to validate the effect of exercise for MDI.

Preliminary evidence for the features of non-reducible discogenic low back pain: survey of an international physiotherapy expert panel with the Delphi technique

OBJECTIVES

The lumbar intervertebral disc is a known source of low back pain (LBP). Various clinical features of discogenic pain have been proposed, but none have been validated. Several subgroups of discogenic pain have been hypothesised, with non-reducible discogenic pain (NRDP) proposed as a relevant clinical subgroup. The objectives of this study were to obtain consensus from an expert panel on the features of discogenic low back pain, the existence of subgroups of discogenic LBP, particularly NRDP, and the associated features of NRDP.

DESIGN

Three-round Delphi survey.

PARTICIPANTS

Twenty-one international physiotherapists with expertise in LBP.

METHODS

Panellists listed and ranked features that they believed to be indicative of discogenic pain and NRDP. On completion of Round 3, features with ≥50% agreement between panellists were deemed to have reached consensus.

RESULTS

After three rounds, 10 features of discogenic LBP were identified. Nineteen of the panellists believed that NRDP was a subgroup of discogenic LBP, and nine features of NRDP were identified.

CONCLUSION

This study provides preliminary validation for the features associated with discogenic LBP. It also provides evidence supporting the existence and features of NRDP as a separate clinical subgroup of discogenic LBP.

The effectiveness of physiotherapy functional restoration for post-acute low back pain: a systematic review

BACKGROUND

The effectiveness of multidisciplinary treatment for post-acute (>6 weeks) low back pain (LBP) has been established. Physiotherapists have sufficient training to conduct less intensive functional restoration. The effectiveness of physiotherapy functional restoration (PFR) has not been evaluated using current systematic review methodology.

OBJECTIVES

To determine the effects of PFR for post-acute LBP.

DATA SOURCES

Electronic databases searched include: MEDLINE, EMBASE, CINAHL, PsycINFO, PEDro and Cochrane CENTRAL. TRIAL ELIGIBILITY CRITERIA: Randomised controlled trials of physiotherapy treatment for post-acute LBP combining exercise and cognitive-behavioural intervention compared with other intervention, no intervention or placebo. TRIAL APPRAISAL AND SYNTHESIS METHODS: Two authors independently extracted data. Risk of bias was assessed using the PEDro scale and overall quality of the body of evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Treatment effect sizes and 95% confidence intervals were calculated for pain, function and sick leave.

RESULTS

Sixteen trials were included. Heterogeneity prevented meta-analysis for most comparisons. Meta-analyses showed moderate to high quality evidence of significant but small effects favouring PFR compared with advice for intermediate term function and intermediate and long term pain. There was however low to moderate quality evidence that PFR was no more effective than a range of other treatment types. Heterogeneous trials frequently contributed to very low quality evidence.

CONCLUSIONS

Moderate to high quality evidence was found of small effects favouring PFR compared with advice. Preliminary evidence suggested PFR is not different to other treatment types. Further high quality research is required replicating existing trial protocols.

The effectiveness of sub-group specific manual therapy for low back pain: a systematic review

BACKGROUND

Manual therapy is frequently used to treat low back pain (LBP), but evidence of its effectiveness is limited. One explanation may be sample heterogeneity and inadequate sub-grouping of participants in randomized controlled trials (RCTs) where manual therapy has not been targeted toward those likely to respond.

OBJECTIVES

To determine the effectiveness of specific manual therapy provided to sub-groups of participants identified as likely to respond to manual therapy.

DATA SOURCES

A systematic search of electronic databases of MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled trials (CENTRAL). TRIAL ELIGIBILITY CRITERIA: RCTs on manual therapy for participants identified as belonging to a sub-group of LBP likely to respond to manual therapy were included. TRIAL APPRAISAL AND SYNTHESIS METHODS: Identified trials were assessed for eligibility. Data from included trials were extracted by two authors independently. Risk of bias in each trial was assessed using the PEDro scale and the overall quality of evidence rated according to the GRADE domains. Treatment effect sizes and 95% confidence intervals were calculated for pain and activity.

RESULTS

Seven RCTs were included in the review. Clinical and statistical heterogeneity precluded meta-analysis. Significant treatment effects were found favouring sub-group specific manual therapy over a number of comparison treatments for pain and activity at short and intermediate follow-up. However, the overall GRADE quality of evidence was very low.

CONCLUSIONS

This review found preliminary evidence supporting the effectiveness of sub-group specific manual therapy. Further high quality research on LBP sub-groups is required.

Contributions of the maternal uterine environment and piglet genotype on weaning survivability potential: I. Development of neonatal piglets after reciprocal embryo transfers between Meishan and White crossbred gilts

In commercial pigs, the greatest susceptibility for pre-weaning mortality occurs in low birth-weight piglets. Despite their overall decreased birth weight, Meishan (MS) piglets have decreased pre-weaning mortality rates compared with contemporary Western breeds. The objective of the current study was to determine the contributions of the maternal uterine environment, piglet genotype, and their interaction on the development of neonatal piglets pertaining to pre-weaning survivability using reciprocal embryo transfer between MS and White crossbred (WC) pigs. Twenty-five successful pregnancies were produced from 2 farrowing seasons, generating litters of maternal uterine environment (MUE) by piglet genotype (PigG) combinations; MS × MS (n = 4 litters), MS × WC (n = 7 litters), WC × MS (n = 7 litters), and WC × WC (n = 7 litters). At approximately 24 h of age (Day 1), piglets (n = 173) were weighed and a blood sample was taken. Hematocrit, hemoglobin, glucose, plasma urea nitrogen, albumin, NEFA, lactate, and cortisol were measured in all blood samples. Representative piglets (n = 46) from each litter were harvested and body measurements (i.e., organ weights, tissue glycogen content, and body composition) were determined. Piglet data were analyzed by ANOVA using MIXED model procedures. Both MUE (P < 0.001) and PigG (P < 0.01) affected piglet BW, illustrating that piglets gestated in WC gilts were heavier than piglets gestated in MS gilts, and WC piglets were heavier than MS piglets. Serum albumin concentrations were increased (P < 0.05) in MS piglets compared with WC piglets, indicating greater liver maturity. Significant MUE × PigG interactions were observed for hematocrit and hemoglobin, in which the greatest concentrations were observed in MS piglets gestated in MS and WC gilts, and the lowest concentrations were observed in WC piglets gestated in WC gilts, demonstrating increased oxygen-carrying capability. The percentage of fat and nitrogen, as well as the GE of the body, were greater (P < 0.05) in MS piglets, indicating greater energy stores. Liver, bicep femoris, and LM glycogen concentrations were greater (P < 0.01) in WC piglets compared with MS piglets, demonstrating increased glycogen catabolism in MS piglets. This study demonstrated limited interactions between the maternal uterine environment and piglet genotype on weaning survivability potential, suggesting that the MS piglet is a viable model for pre-weaning survivability.

Specific treatment of problems of the spine (STOPS): design of a randomised controlled trial comparing specific physiotherapy versus advice for people with subacute low back disorders

Background

Low back disorders are a common and costly cause of pain and activity limitation in adults. Few treatment options have demonstrated clinically meaningful benefits apart from advice which is recommended in all international guidelines. Clinical heterogeneity of participants in clinical trials is hypothesised as reducing the likelihood of demonstrating treatment effects, and sampling of more homogenous subgroups is recommended. We propose five subgroups that allow the delivery of specific physiotherapy treatment targeting the pathoanatomical, neurophysiological and psychosocial components of low back disorders. The aim of this article is to describe the methodology of a randomised controlled trial comparing specific physiotherapy treatment to advice for people classified into five subacute low back disorder subgroups.

Methods/Design

A multi-centre parallel group randomised controlled trial is proposed. A minimum of 250 participants with subacute (6 weeks to 6 months) low back pain and/or referred leg pain will be classified into one of five subgroups and then randomly allocated to receive either physiotherapy advice (2 sessions over 10 weeks) or specific physiotherapy treatment (10 sessions over 10 weeks) tailored according to the subgroup of the participant. Outcomes will be assessed at 5 weeks, 10 weeks, 6 months and 12 months following randomisation. Primary outcomes will be activity limitation measured with a modified Oswestry Disability Index as well as leg and back pain intensity measured on separate 0-10 Numerical Rating Scales. Secondary outcomes will include a 7-point global rating of change scale, satisfaction with physiotherapy treatment, satisfaction with treatment results, the Sciatica Frequency and Bothersomeness Scale, quality of life (EuroQol-5D), interference with work, and psychosocial risk factors (Orebro Musculoskeletal Pain Questionnaire). Adverse events and co-interventions will also be measured. Data will be analysed according to intention to treat principles, using linear mixed models for continuous outcomes, Mann Whitney U tests for ordinal outcomes, and Chi-square, risk ratios and risk differences for dichotomous outcomes.

Discussion

This trial will determine the difference in outcomes between specific physiotherapy treatment tailored to each of the five subgroups versus advice which is recommended in guidelines as a suitable treatment for most people with a low back disorder.

Trial registration

Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609000834257.

Assessment of pubertal development of boars derived from ultrasonographic determination of testicular diameter

At the onset of puberty, seminiferous tubules rapidly increase in diameter, thereby occupying a greater proportion of the testis, resulting in a rapid increase in testicular size. The objective of the current studies was to evaluate ultrasonography for assessing testicular diameter, as a basis for ranking boars relative to their extent of pubertal development. In the initial study, prior to castration at 4, 5, 6, or 7 mo of age, testicular length and diameter were assessed by ultrasonography in 160 anesthetized boars. After castration, testes were weighed. Mean diameter of seminiferous tubules and percentage of the testis occupied by tubules were determined by histological evaluations of all testes. Testicular volume was calculated from length and diameter and was correlated with testicular weight (P < 0.001; r ≧ 0.78) within each of the four age groups. At 4 and 5 mo of age, testicular diameter correlated positively (P < 0.001) with diameter of seminiferous tubules; this relationship was not significant at older ages. In two subsequent studies, testicular diameter determined ultrasonographically in conscious boars was highly correlated (r > 0.8) when assessed twice on the same day, or when diameter of the right was compared with diameter of the left testis. Similarly, testicular diameter obtained initially at 92 d of age correlated positively (P < 0.001) with the diameter observed at older ages, but the magnitude of the relationship decreased as time between evaluations increased. These findings supported ultrasonographic determination of testicular diameter during early pubertal development, as a means to rank boars of similar chronological age for extent of pubertal development.

Porcine hypothalamic aromatase cytochrome P450: isoform characterization, sex-dependent activity, regional expression, and regulation by enzyme inhibition in neonatal boars

Domestic pigs have three CYP19 genes encoding functional paralogues of the enzyme aromatase cytochrome P450 (P450arom) that are expressed in the gonads, placenta, and preimplantation blastocyst. All catalyze estrogen synthesis, but the gonadal-type enzyme is unique in also synthesizing a nonaromatizable biopotent testosterone metabolite, 1OH-testosterone (1OH-T). P450arom is expressed in the vertebrate brain, is higher in males than females, but has not been investigated in pigs, to our knowledge. Therefore, these studies defined which of the porcine CYP19 genes was expressed, and at what level, in adult male and female hypothalamus. Regional expression was examined in mature boars, and regulation of P450arom expression in neonatal boars was investigated by inhibition of P450arom with letrozole, which is known to reprogram testicular expression. Pig hypothalami expressed the gonadal form of P450arom (redesignated the "gonadal/hypothalamic" porcine CYP19 gene and paralogue) based on functional analysis confirmed by cloning and sequencing transcripts. Hypothalamic tissue synthesized 1OH-T and was sensitive to the selective P450arom inhibitor etomidate. Levels were 4-fold higher in male than female hypothalami, with expression in the medial preoptic area and lateral borders of the ventromedial hypothalamus of boars. In vivo, letrozole-treated neonates had increased aromatase activity in hypothalami but decreased activity in testes. Therefore, although the same CYP19 gene is expressed in both tissues, expression is regulated differently in the hypothalamus than testis. These investigations, the first such studies in pig brain to our knowledge, demonstrate unusual aspects of P450arom expression and regulation in the hypothalamus, offering promise of gaining better insight into roles of P450arom in reproductive function.

Testicular development of Zebu bulls after chronic treatment with a gonadotropin-releasing hormone agonist

The objective was to compare testis characteristics of Zebu bulls treated with the GnRH agonist, deslorelin, at different times and for different durations during their development. An additional objective was to determine the usefulness of a stain for the transcription factor GATA-binding protein 4 (GATA-4) as a specific marker for Sertoli cell nuclei in cattle. Bulls (54) were allocated to nine groups (n = 6) and received s.c. deslorelin implants as follows: G1 = from birth to 3 mo of age; G2 = from 3 to 6 mo; G3 = from 6 to 9 mo; G4 = from 9 to 12 mo; G5 = from birth to 15 mo; G6 = from 3 to 15 mo; G7 = from 6 to 15 mo; G8 = from 12 to 15 mo; and G9 (control) = no implant. Bulls were castrated at 19 mo of age. Paraffin sections (10 microm) were subjected to quantitative morphometry and GATA-4 immunohistochemistry. At castration, all bulls in the control group (6/6) had attained puberty (scrotal circumference > or = 28 cm), whereas a smaller proportion (P < 0.05) had reached puberty in G2 (2/5) and G6 (1/6). Bulls in G2 and G6 also had a lesser (P < 0.05) testis weight compared with the control group. Total volume of seminiferous epithelium and total daily sperm production in G2 and G6 were only half that observed in the control group. Spermatids were observed in less than 50% of seminiferous tubules in G2, G6, and G7 compared with 82% in the control group (P < 0.05). Staining for GATA-4 was specific for and abundant in the Sertoli cell nucleus in both pre- and postpubertal bulls, and no other cell nucleus inside the seminiferous tubule was positive for GATA-4. Total number of Sertoli cells was not affected by treatment (P = 0.45), but nuclear volume was smaller in G2 and G6 (P < 0.05) compared with the control group. In conclusion, treatment of Zebu bulls with deslorelin had no apparent beneficial effect on testis development and delayed puberty when treatment was initiated at 3 mo of age. Staining for GATA-4 was a useful method for identifying and quantifying Sertoli cell nuclei in both pre- and postpubertal bulls.

Growth and pubertal development of F1 bulls from Hereford, Angus, Norwegian Red, Swedish Red and White, Friesian, and Wagyu sires1,2

The objective of the study was to characterize body growth, testicular development, and puberty from 8 to 14 mo of age in bulls (n = 120) produced by mating sires from Hereford, Angus, Norwegian Red, Swedish Red and White, Friesian, and Wagyu breeds to MARC III ((1/4) Hereford, (1/4) Angus, (1/4) Red Poll, and (1/4) Pinzgauer) cows. Traits evaluated were birth weight, weaning weight (at 215 d), yearling weight, ADG from 8 to 14 mo of age, paired testicular volume growth from 8 to 14 mo of age, age at puberty (determined by production of 50 x 10(6) sperm with 10% motility), age at freezable semen (determined by production of 500 x 10(6) sperm with 50% motility), and, at 15 mo of age, paired testicular weight and daily sperm production per testis pair. There was an effect of sire breed (P = 0.03) for age at puberty; animals with Wagyu and Swedish Red and White inheritance reached puberty at a later date (302 and 302 d of age, respectively) compared with Angus-sired bulls (268 d). Age at puberty for Hereford-, Norwegian Red-, and Friesian-sired bulls was 270, 271, and 278 d, respectively. Differences in BW were observed (P = 0.03) at birth; bulls with Hereford and Friesian were heavier at birth (43 and 41 kg, respectively) compared with those with Norwegian Red, Swedish Red and White, and Wagyu inheritance (39, 38, and 38 kg, respectively). Differences in BW were also observed at 1 yr of age (P = 0.001), where the heaviest animals were those sired by Angus (450 kg), whereas the lightest animals were those sired by Wagyu (403 kg). Bulls with Wagyu inheritance had the lowest (P = 0.04) ADG (1.12 kg/d) compared with bulls with inheritance from Hereford (1.22 kg/d), Angus (1.28 kg/d), Norwegian Red (1.24 kg/d), Swedish Red and White (1.25 kg/d), and Friesian (1.27 kg/d). Differences in scrotal growth rate were not significant (P = 0.99). They ranged from 1.95 in Angus-sired to 1.66 cm3/d in Wagyu-sired bulls. There were no differences (P = 0.80) for age at freezable semen (335 +/- 10 d). At slaughter (15 mo of age), there were no differences (P = 0.62) for paired testicular weight (603 +/- 28 g) and daily sperm production (10.6 x 10(9) +/- 0.9 x 10(9) per testis pair). Growth of bulls with Wagyu inheritance was slower, and bulls with Wagyu or Scandinavian inheritance reach puberty at an older age than bulls with Angus inheritance.

Indicators of lumbar zygapophyseal joint pain: survey of an expert panel with the Delphi technique

BACKGROUND AND PURPOSE

The lumbar zygapophyseal joints (LZJs) are thought to be a source of low back pain (LBP); however, no valid or reliable indicators exist. The purpose of this study was to obtain a consensus from an expert panel on the indicators of LZJ pain.

SUBJECTS

A multidisciplinary panel of 20 experts in the field of LBP participated in this study.

METHODS

A 3-round Delphi survey designed to obtain a consensus on the indicators of LZJ pain was completed by use of accepted protocols. Subjects also were asked to justify their selection of each indicator.

RESULTS

Following the 3 rounds, consensus was achieved, and 12 indicators were identified. Those that reached the highest levels of consensus were a positive response to facet joint injection, localized unilateral LBP, positive medial branch block, pain upon unilateral palpation of the LZJ or transverse process, lack of radicular features, pain eased by flexion, and pain, if referred, located above the knee. Justifications for the experts' selection of the indicators, predominantly based on pathoanatomical mechanisms, also were described.

DISCUSSION AND CONCLUSION

This Delphi survey identified 12 indicators of LZJ pain, each with an associated pathoanatomical mechanism justifying selection. This survey provides preliminary validation for these indicators, which will be of value in further research into the classification and treatment of LZJ pain.

Exploring the contribution of patient-reported and clinician based variables for the prediction of low back work status

BACKGROUND

Successful management of workers on sick leave due to low back pain by the general physician and physiotherapist depends on reliable prognostic information on the course of low back pain and work resumption.

METHODS

Retrospective cohort study in 194 patients who were compensated because of chronic low back pain and who were treated by a physiotherapy functional restoration program. Patient-reported and clinician based prognostic indicators were assessed at baseline before patients entered the functional restoration program. We investigated the predictive value of these indicators on work status at 6 months. Relationships were studied using logistic regression analysis in a 2-step bootstrap modelling approach and a nomogram was developed. Discrimination and calibration of the nomogram was evaluated internally and the explained variation of the nomogram calculated.

RESULTS

Seventy percent of workers were back to work at 6 months. We found that including duration of complaints, functional disability, disc herniation and fear avoidance beliefs resulted in the "best" prognostic model. All these factors delayed work resumption. This model was used to construct a nomogram. The explained variation of the nomogram was 23.7%. Discrimination was estimated by the area under the receiver operating characteristic curve and was 0.76 and for calibration we used the slope estimate that was 0.91. The positive predictive values of the nomogram at different cut-off levels of predicted probability were good.

CONCLUSIONS

Knowledge of the predictive value of these indicators by physicians and physiotherapists will help to identify subgroups of patients and will thus enhance clinical decision-making.

Breed differences in clearance of porcine FSH in hypophysectomized rats

Extracts of anterior pituitary (AP) glands were infused i.v. into hypophysectomized male rats followed by sequential sampling of blood for 120 min. Determination of follicle-stimulating hormone (FSH) concentrations established that FSH from Chinese Meishan males decreased in the circulation of rats more slowly than FSH in extracts of AP from crossbred occidental pigs (P<0.003). Additionally, FSH from AP extracts of castrated males disappeared somewhat more slowly (P<0.06) than FSH from extracts of boars. Evaluation of FSH by bioassay and radioimmunoassay yielded similar concentrations in AP from Meishan and crossbred boars. Serum testosterone concentrations increased with time through 90 min after infusion of AP, but the rate of increase of testosterone was not related to amount of luteinizing hormone (LH) that was administered indicating LH receptor saturation. Unexpectedly, the rate of increase in testosterone was more rapid with AP extracts from boars than with extracts from castrated males. Observations from the current study imply structural alterations of FSH in the AP of Meishan males relative to crossbred males allowing sustained concentrations in the circulation, and this FSH possesses similar activation of the FSH receptor. The amount of LH in the AP extracts saturated the LH receptors of the hypophysectomized male rats, but some factor in extracts of boars differed from those of castrated males.

Functional restoration for a chronic lumbar disk extrusion with associated radiculopathy

BACKGROUND AND PURPOSE

The effectiveness of functional restoration (FR) for patients with lumbar disk herniation with associated radiculopathy (LDHR) is unclear. This case report describes how an FR program was used to rehabilitate a patient with such an injury.

CASE DESCRIPTION

The patient was a 26-year-old female child care worker with a 12-month history of back pain and a 4-month history of unremitting left leg symptoms. She had clinical and radiological evidence of an L5-S1 disk extrusion with associated left S1 radiculopathy. Interventions. The patient completed a 9-week FR program supervised by a physical therapist. Exercises then were continued more independently for a 2-year period at a public gymnasium.

OUTCOMES

Following 9 weeks of supervised FR, the patient demonstrated marked improvement in symptoms and functional ability, and resolution of neurological signs. Fourteen months after commencing FR, a follow-up magnetic resonance imaging scan demonstrated resolution of the L5-S1 disk extrusion and relief of S1 nerve root compression. Functional improvements continued and were maintained 2 years following the start of intervention.

DISCUSSION

A patient with chronic LDHR who underwent FR made significant improvements. Research is needed to determine the efficacy of an FR approach for treating such patients.

Genetic variation in sperm production

In boars, the primary determinant of daily sperm production is the number of Sertoli cells, which establishes testicular weight. The only breed comparison of foetal testicular development in boars contrasted two diverse breeds, White composite (WC, Landrace-Yorkshire) with Meishan, a Chinese breed that undergoes pubertal development at a young age and has small testicular size. During the prenatal period, the pattern of change in testicular development is similar in these two breeds with both having their greatest proportion of proliferating Sertoli cells at 90 days of gestation, and with WC boars possessing more Sertoli cells and greater mass of seminiferous tubules during the latter half of gestation. During the first month of life, Meishan boars accumulate Sertoli cells and mass of seminiferous tubules at a greater rate than WC boars, and Meishan boars undergo terminal differentiation of Sertoli cells at a younger age. Postpubertal boars, within each breed and crossbreds of the two breeds, with small testicular size have increased circulating concentrations of follicle-stimulating hormone. No direct breed comparisons of testicular development are apparent for postpubertal boars of other breeds. Accepting the limitations of data reported from different laboratories, Piau boars reach puberty at an older age and have a greater proportion of their testes occupied with seminiferous tubules than Meishan boars; both breeds have small testes. A gene or genes on the X chromosome code for small testicular size in Meishan crossbred boars; genetic determinants of testicular size and sperm production in other breeds remain to be identified.

Deciphering the pig genome to understand gamete production

The field of livestock genomics has made considerable advances in the past decade. In the area of pig reproduction, a number of genome scans have identified several genomic regions associated with variation in reproductive measures ranging from ovulation rate, litter size and testis size. Additionally, several candidate genes have been associated with variation in litter size. These studies primarily focused on developing genetic markers to facilitate selection decisions. To date, their results have made minor contributions to commercial pig performance and our knowledge on the inheritance of complex phenotypes. With the availability of additional resources for pig, as well as from human and mouse studies, future studies should be directed to identifying genetic variation that affects biological processes. To reach this goal, teams of diversely trained scientists need to be formed that include geneticists, physiologists, molecular biologists and bioinformaticists. A diversified team of scientists equipped with all of the available research tools (genomic sequence data, expression arrays, knowledge of gene product functions, etc.) and appropriate swine populations should be able to decode the genome's hidden secrets on how it controls reproductive processes.

Follicular development and maturation in gilts selected for an index of high ovulation rate and high prenatal survival1

Seventy-one 10th-generation gilts from White Line-1 (WL-1 = randomly selected control line) and White Line-2 (WL-2 = selected for an index of ovulation rate and prenatal survival rate) were used to compare the pattern of follicular development and atresia during the follicular phase of the estrous cycle. Gilts were treated with PGF(2alpha)on d 13 of the estrous cycle (d 0 of induced follicular development) to induce luteolysis and assigned randomly within line and sire for ovary recovery on d 0, 2, 3, 4, 5, and the day after estrus. Ovaries were evaluated for numbers of corpora albicantia and small (2 to 2.9 mm), medium (M1 = 3 to 4.9 mm; M2 = 5 to 6.9 mm), and large (>or=7 mm) follicles. The concentration of estradiol-17beta in follicular fluid was used to classify individual M2 and large follicles as estrogen-active (>or=100 ng of estradiol-17beta/mL) or inactive (<100 ng of estradiol-17beta/mL). The WL-2 gilts had a greater ovulation rate than WL-1 gilts at their pre-treatment estrus (20.4 vs. 13.8 corpora albicantia; P < 0.001). The small and M1 follicle populations decreased rapidly in both lines over time (P < 0.001). The M2 follicle population increased in both lines between d 0 to 4 and then decreased. Mean estradiol concentration of M2 follicles increased in both genetic lines over time (P < 0.02). All large follicles were estrogen-active in both lines; the number of large follicles increased with day (P < 0.001) and was similar in both lines. The number of estrogen-active M2 follicles was similar in both lines, increasing to d 3 and 4 and then decreasing (P < 0.01) thereafter. However, the total number of estrogen-active follicles (sum of estrogen-active M2 and large follicles) was greater in WL-2 than in WL-1 gilts (P < 0.04), increasing to the ovulatory potential by d 3 in WL-1 gilts, but continuing to increase through d 4 in WL-2 gilts. Selection of an additional six ovulatory follicles from the estrogen-active M2 follicle pool after d 5 was required in both lines to achieve the projected ovulation rate, and after estrus, the number of large follicles remained insufficient to attain the ovulatory potential of each line.

Lack of an association between plasma follicle-stimulating hormone concentrations and ovarian weight in prepubertal gilts1

Selection for increased number of corpora lutea in gilts is associated with increased plasma FSH concentrations during pubertal development. In the current study, 270 gilts from a control (CO) line and a line selected for increased ovulation rate (OR) were unilaterally ovariectomized at 85 d of age, and this ovarian weight was related to FSH concentrations at 65, 75, and 85 d of age. Gilts were produced during two farrowing seasons, spring and fall, and the age at first estrus was monitored from 160 to 250 d. Plasma FSH was greater in OR than in CO gilts at 65 (P < 0.01) and 75 d (difference in spring greater than in fall, P < 0.01), but FSH at these ages was not correlated with ovarian weight at 85 d. At 85 d, FSH did not differ in gilts of these lines; however, FSH was negatively correlated (r = -0.27, P < 0.01) with ovarian weight. The proportion of gilts detected in estrus was less for spring-born CO gilts than for spring-born OR or for fall-born CO and OR gilts (78 vs. 92%, season x line, P < 0.02). The age at first estrus was similar in the two lines but was earlier (P < 0.01) for spring-born than for fall-born gilts (194 vs. 204 d). Concentrations of FSH at each of the ages examined were not correlated with the age at first estrus. These observations support the conclusion that selection for a greater number of corpora lutea produces a correlated increase in plasma FSH during early pubertal development. This increase in FSH most likely reflects differences in FSH synthesis and release and not differences in the stage of pubertal development.

Stereological evaluation of Sertoli cell ontogeny during fetal and neonatal life in two diverse breeds of swine

Chinese Meishan (MS) boars have smaller testes due to fewer Sertoli cells compared with White Composite (WC) boars. The objective was to describe Sertoli cell development relative to circulating FSH concentrations in fetal and neonatal MS and WC boars. Testes and blood samples were collected on days 60, 75, 90 and 105 postcoitum (dpc) and 1, 7, 14 and 25 postpartum (dpp). One testis was immunostained for GATA4 or Ki67 antigen to evaluate total and proliferating Sertoli cell numbers respectively. Testicular size was greater (P<0.01) in WC than MS boars at all ages, associated with a greater mass of interstitial tIssue. Tubular mass (P<0.01) was greater in prenatal WC boars, but postnatally increased more rapidly (P<0.001) in MS boars, exceeding WC boars by 25 dpp. Sertoli cell numbers increased with age, was greater (P<0.001) in WC than MS boars during prenatal development but increased rapidly (P<0.01) by 1 dpp in MS and thereafter was similar in both breeds. The proportion of Ki67-positive Sertoli cells was maximal at 90 dpc, declining thereafter, did not differ between breeds through 7 dpp, but was greater (P<0.05) in WC than MS boars at 14 and 25 dpp. Plasma FSH concentrations were greater (P<0.05) in WC than MS boars at 75 dpc. FSH concentrations were elevated at 105 dpc (MS) and 1 dpp (WC) but declined thereafter with advancing postnatal age in both breeds. This study illustrates that late gestation represents the period of maximal Sertoli cell proliferation. Despite asynchronous Sertoli cell population growth between breeds during early postnatal life, differential mature Sertoli cell numbers and testicular size are probably due to differences in duration of the proliferative period after 25 dpp, potentially regulated by Sertoli cell maturation and blood-testis barrier formation. These events were not associated with fetal or early postnatal changes in FSH secretion.

Endocrine and molecular influences on testicular development in Meishan and White Composite boars

The aim of this study was to evaluate developmental changes in thyroid hormone and other key endocrine hormones/molecular markers produced by testicular cells, in relation to breed differences in proliferation and maturation of Sertoli cells and general testicular morphological development in Meishan (MS) and White Composite (WC) boars. Blood samples and testes were collected on days 60, 75, 90 and 105 post coitum (dpc) and days 1, 7, 14 and 25 post partum (dpp). Testes were immunostained for thyroid hormone receptor-beta1 (THRbeta1), GATA4, Müllerian-inhibiting substance (MIS), 17-alpha-hydroxylase (P450(c17)) and inhibin subunits (alpha, betaA, betaB). In addition, protein levels were determined by densitometry. Plasma concentrations of free triiodothyronine (T(3)) were greater in MS (hyperthyroid) compared with WC (hypothyroid) boars (P<0.01) during fetal life, but the reverse was evident postnatally. Elevated levels of free T(3) during fetal life were associated with increased levels of THRbeta1, suggesting increased thyroid responsiveness of the testis during this time, contrasting with observations during early postnatal life. Localization patterns of THRbeta1, MIS, GATA4 and the inhibin subunits were consistent with previous studies. MIS protein levels declined more rapidly (P<0.001) in MS compared with WC Sertoli cells postnatally, consistent with earlier maturation of Sertoli cells as indicated by our previous study. In this study, transient neonatal hyperthyroidism in MS boars during late gestation was associated with a decline in proliferation and early maturation of Sertoli cells, followed by early onset of puberty in this breed. These observations indicate a possible role for thyroid hormone in the modification of Sertoli cell development, thereby influencing growth and differentiation of the testis in pigs.

Biochemical assessment of limits to estrogen synthesis in porcine follicles

Limits to estrogen production by early and late preovulatory porcine follicles were assessed by comparing enzymatic capacities for androgen (17,20-lyase) and estrogen (aromatase) synthesis in theca interna and granulosa, support of enzyme activities by the redox partner proteins NADPH-cytochrome P450 oxidoreductase (reductase) and cytochrome b5, and tissue-specific expression and regulation of these proteins. Parameters included follicular fluid (FF) estradiol and progesterone levels, theca and granulosa aromatase and reductase activities, and theca 17,20-lyase activity. Expression of proteins responsible for these activities, aromatase (P450arom) and 17 alpha-hydroxylase/17,20-lyase (P450c17) cytochromes P450, reductase, and for the first time in ovarian tissues cytochrome b5, were examined by Western immunoblot and immunocytochemistry. Theca and granulosa aromatase activities were as much as 100-fold lower than theca 17,20-lyase activity, but aromatase was correlated with only the log of FF estradiol. Granulosa reductase activity was twice that of the theca, and cytochrome b5 expression was clearly identified in both the theca and granulosa layers, as was P450arom, but was not highly correlated with either 17,20-lyase or aromatase activities. Reductase expression did not change with stage of follicular development, but cytochrome b5, P450c17, and P450arom were markedly lower in post-LH tissues. These data indicate that aromatase and not 17,20-lyase must limit porcine follicular estradiol synthesis, but this limitation is not reflected acutely in FF steroid concentrations. Neither reductase nor cytochrome b5 appear to regulate P450 activities, but the expression of cytochrome b5 in granulosa and theca suggests possible alternative roles for this protein in follicular development or function.

Relationships of testicular iron and ferritin concentrations with testicular weight and sperm production in boars

The inverse relationship of testicular size and circulating follicle-stimulating hormone (FSH) concentrations has been documented, and accompanying this relationship is the change in color of the parenchymal tissue of the testes. Large testes (300 to 400 g) are pink to light red and small testes (100 g) are dark maroon with color gradations for weights in between. It was hypothesized that this color most likely represented an iron protein. Chromatographic analysis of testicular tissue indicated that the Fe was associated primarily with ferritin, and immunohistochemistry showed that Leydig cells were the primary location of ferritin storage within the testes. Concentrations of Fe and ferritin were higher in small testes and decreased as testes weight increased (P < 0.05). As testicular Fe concentrations increased, daily sperm production (DSP) and total DSP declined (P < 0.05). Genotyping six generations of Meishan x White composite boars (n = 288) for a quantitative trait locus that is indicative of elevated FSH and small testes in boars indicated that the Meishan genotype had elevated testicular iron concentrations and darker color in conjunction with reduced total DSP (P < 0.01). It is not thought the elevated iron concentrations affect testicular weights but are probably a result of elevated FSH and FSH inducement of Fe transport. The storage of Fe in Leydig cells may provide a reservoir of Fe for easy access by Sertoli and germ cells, but still provide a degree of protection to germ cells from ionic iron.

Sertoli cells in the boar testis: changes during development and compensatory hypertrophy after hemicastration at different ages

Changes in Sertoli cell numbers and testicular structure during normal development and compensatory hypertrophy were assessed in crossbred Meishan x White Composite males. Boars were assigned at birth to unilateral castration at 1, 10, 56, or 112 days or to remain as intact controls through 220 days. The first testes removed were compared to assess testicular development. At 220 days, testicular structure was evaluated in boars representing the 25% with the largest (Lg) testis and the 25% with the smallest (Sm) testis in each treatment group. The number of Sertoli cells per testis reached a maximum by Day 56 in Sm testis but not until Day 112 in Lg testis boars, indicating a longer duration of Sertoli cell proliferation in Lg testis boars. Unilateral castration of Lg testis boars on Days 1, 10, 56, and 112 caused the weight of the remaining testis to hypertrophy by 149%, 135%, 119%, and 120%, respectively, and total sperm production to increase to 127%, 128%, 97%, and 106%, respectively. However, Sertoli cell numbers changed little in hemicastrate boars. In Lg testis boars, compensatory hypertrophy primarily involved proliferation of Leydig cells and expansion of existing Sertoli cells with little increase in Sertoli cell numbers, but in Sm testis boars, it involved expansion of existing Leydig and Sertoli cells without increase in cell numbers. These results indicate that Lg and Sm testis boars display intriguing differences during both development and compensatory hypertrophy, and they identify a unique animal model for further studies of factors that program and control Sertoli cell proliferation.

Expression levels of Mullerian-inhibiting substance, GATA4 and 17alpha-hydroxylase/17,20-lyase cytochrome P450 during embryonic gonadal development in two diverse breeds of swine

Sexual differentiation and early embryonic/fetal gonad development is a tightly regulated process controlled by numerous endocrine and molecular signals. These signals ensure appropriate structural organization and subsequent development of gonads and accessory organs. Substantial differences exist in adult reproductive characteristics in Meishan (MS) and White Composite (WC) pig breeds. This study compared the timing of embryonic sexual differentiation in MS and WC pigs. Embryos/fetuses were evaluated on 26, 28, 30, 35, 40 and 50 days postcoitum (dpc). Gonadal differentiation was based on morphological criteria and on localization of GATA4, Mullerian-inhibiting substance (MIS) and 17alpha-hydroxylase/17,20-lyase cytochrome P450 (P450(c17)). The timing of testicular cord formation and functional differentiation of Sertoli and Leydig cells were similar between breeds. Levels of GATA4, MIS and P450(c17) proteins increased with advancing gestation, with greater levels of MIS and P450(c17) in testes of MS compared with WC embryos. Organization of ovarian medullary cords and formation of egg nests was evident at similar ages in both breeds; however, a greater number of MS compared with WC embryos exhibited signs of ovarian differentiation at 30 dpc. In summary, despite breed differences in MIS and P450(c17) levels in the testis, which may be related to Sertoli and Leydig cell function, the timing of testicular differentiation did not differ between breeds and is unlikely to impact reproductive performance in adult boars. In contrast, female MS embryos exhibited advanced ovarian differentiation compared with WC embryos which may be related to the earlier reproductive maturity observed in this breed.

Regulation of microsomal P450, redox partner proteins, and steroidogenesis in the developing testes of the neonatal pig

Testicular growth and plasma androgen concentrations increase markedly in the first weeks of neonatal life of pigs. The regulation of steroidogenesis through this period was examined by measuring total microsomal cytochromes P450 (P450), 17alpha-hydroxylase/17,20-lyase P450 (P450c17) and aromatase P450 (P450arom) enzyme activities, and the redox partner proteins nicotinamide adenine dinucleotide phosphate, reduced form (NADPH)-cytochrome P450 reductase (reductase) and cytochrome b(5) in testicular microsomes. Testes were collected from 1-24 d of age, and testicular development was suppressed by a GnRH antagonist in some animals from d 1-14. Both 17/20-lyase and aromatase activities increased from d 1-7 but not thereafter, and 17-20-lyase activity was always at least 200-fold higher than aromatase activity. Reductase decreased in wk 1, then increased to d 24. No changes were seen in cytochrome b(5) expression. GnRH antagonist treatment suppressed plasma LH, testosterone and testes growth to d 14. 17,20-Lyase and aromatase activities in testicular microsomes were reduced by 20% and 50%, respectively. Total microsomal P450 concentration was reduced by 50% on d 7, but there was no effect of treatment on reductase or cytochrome b(5) expression. These data support the hypothesis that the rise in neonatal testicular androgen secretion is more likely due to gonadotropin-stimulated gonadal growth, rather than specific P450c17 expression. Neither P450c17 nor P450arom can account for the decline in total microsomal P450. Reductase and cytochrome b(5) expression appears to be constitutive, but reductase levels saturate both P450c17 and P450arom.

An integrated comparative map of the porcine X chromosome

The objectives of this study were to assign both microsatellite and gene-based markers on porcine chromosome X to two radiation hybrid (RH) panels and to develop a more extensive integrated map of SSC-X. Thirty-five microsatellite and 20 gene-based markers were assigned to T43RH, and 16 previously unreported microsatellite and 15 gene-based markers were added to IMpRH map. Of these, 30 microsatellite and 12 gene-based markers were common to both RH maps. Twenty-two gene-based markers were submitted to BLASTN analysis for identification of orthologues of genes on HSA-X. Single nucleotide polymorphisms (SNPs) were detected for 12 gene-based markers, and nine of these were placed on the genetic map. A total of 92 known loci are present on at least one porcine chromosome X map. Thirty-seven loci are present on all three maps; 31 loci are found on only one map. Location of 33 gene-based markers on the comprehensive map translates into an integrated comparative map that supports conservation of gene order between SSC-X and HSA-X. This integrated map will be valuable for selection of candidate genes for porcine quantitative trait loci (QTLs) that map to SSC-X.

Interrelationships of porcine X and Y chromosomes with pituitary gonadotropins and testicular size

Endocrine and testicular responses to unilateral castration on 1, 10, 56, or 112 days of age were characterized in 132 Chinese Meishan (MS) x White composite (WC) crossbred boars in which testicular size associates with a quantitative trait locus (QTL) on X chromosome. At 220 days of age, testicles of boars unilaterally castrated on Day 1 or 10 weighed more and had greater total daily sperm production (DSP) than one testicle of bilaterally intact boars (P < 0.05); compensation did not double these two responses. Boars with MS alleles at the X chromosome QTL had smaller testicles, darker colored parenchyma, and lower total DSP than boars with WC alleles (P < 0.05). The MS alleles engendered greater (P < 0.05) plasma FSH and LH during puberty than WC alleles. Plasma FSH increased (P < 0.05) within 48 h of unilateral castration on Days 1, 10, and 56. Subsequent increases occurred earlier during puberty (P < 0.05) after unilateral castration at younger ages than after unilateral castration at older ages. Pubertal increases in plasma FSH and LH were greater (P < 0.05) in boars with MS alleles than in those with WC alleles for the X chromosome QTL. Breed of Y chromosome had no effect on testicular traits, FSH, testosterone, or estrone. For LH, boars with an MS Y chromosome had greater (P < 0.01) plasma LH across all ages than boars with a WC Y chromosome. We conclude that a gene or groups of genes that reside on the porcine X chromosome regulate testicular development and pubertal gonadotropin concentrations.