Changes in the central nervous system (CNS) pathways controlling trunk and leg muscles in patients with low back pain and radiculopathy have been observed and this study investigated whether surgery impacts upon these changes. Parameters of corticospinal control were examined on 3 occasions in 22 patients prior to, at 6 and 26 weeks following lumbar decompression surgery and in 14 control subjects at the same intervals. Electromyographic activity was recorded from tibialis anterior (TA), soleus (SOL), rectus abdominis (RA), external oblique (EO) and erector spinae (ES) muscles at the T12 & L4 levels in response to transcranial magnetic stimulation of the motor cortex.Introduction
Methods
Patients have an important role in evaluating the health-care they receive; including the treatment they receive as well as the healthcare process. This information can be invaluable in understanding patient needs and developing a more patient centred approach to health care. As part of an RCT into the post-operative management of spinal surgery we explored patient’s experience of the health care system and their perceptions of how the system worked for them. To date 201 patients have completed the trial; 60 receiving usual care, 37 an educational booklet, 48 rehabilitation and 56 received both booklet and rehabilitation after decompression surgery for stenosis or disc prolapse. The majority (82%) were referred to the consultant through their GP. 40% identified a specific event that led to their pain; of these 48% reported a longstanding pain and 33% noting a sudden injury. 30% waited less than a month for surgery, and 32% 1–3 months. 18% experienced surgical cancellations. The majority of patients felt well informed pre-operatively, had faith in their surgical team and had sufficient time to discuss their condition. Similarly during their operative stay they felt supported and in good hands. When questioned about their feelings on the health care process as a whole; positive patient comments included: the speed and quality of surgery and the pain relief experienced; whilst negative comments included: lack of information or advice, the delays between diagnosis and management, dissatisfaction with GP care, feeling abandoned, lack of respect from the surgeon, and disappointment with the outcome.
Increasing attention has focused on the spinal muscles with respect to stability and low back pain (LBP) with suggestions of a de-conditioning syndrome. What is less clear is the extent of this degeneration and whether it is a long term of short term consequence of LBP. This study sought to explore the cross section area (CSA) and muscle quality of the spinal extensor group in a subset of LBP patients. MRI scans of 100 spinal clinic patients were retrospectively reviewed; sagittal and transverse (from levels L3-5) images were annoymised and archived along with details of age, gender and presenting symptoms. An image analysis package was used to determine CSA of the extensor muscle groups, and levels of fat infiltration were calculated using a pseudocolouring technique. 46 patients had spinal stenosis (28 males, 18 females, mean age 66±14.2 years) and 54 had a disc prolapse (28 males, 26 females, mean age 50±12.9 years). CSA was significantly smaller in the stenotics at both L3/4 and L4/5. Patients presenting with leg pain and a disc herniation had a significantly smaller CSA (p<
0.01) at L3/4 and L4/5 levels. A left right CSA asymmetry was noted but this was not specific to diagnosis, or presenting symptoms. Fat infiltration was present in both groups but was significantly greater in the stenotic group (p<
0.01) and was present at a similar degree at all spinal levels. Multiple regression analysis confirmed that reduced CSA was linked to leg pain (p<
0.01) and age was linked with fat infiltration (0<
0.01).
Rowing is associated with a high incidence of low back pain (LBP) often attributed to the associated loading and large trunk rotations. Here we examine electromyographic (EMG) activity in rowers who undertake sweep rowing (asymmetrical) or sculling (symmetrical). 22 right handed elite rowers participated and written informed consent was obtained. Each had a preferred rowing side (bow side [BS, n=6]; stroke side [SS, n=7) or sculling [SC, n=9]). Testing was performed in a Cybex isokinetic dynamometer and bilateral EMG activity recorded from trunk muscles (erector spinae [ES] and rectus abdominis [RA]) synchronously. There were no differences between the groups in peak torque during isokinetic or isometric testing, although extensor torque was higher than flexor torque. Analysis of EMG activity revealed that scullers showed no left/right differences in any of the testing protocols. However, sweep rowers showed significant differences between left and right ES during extension protocols, in the isokinetic testing at 30°s−1 (in the SS rowers [LES 0.11±0.01mV vs RES 0.08±0.01mV] and at 90°s−1 in the BS rowers [LES 0.14±0.02mV vs RES 0.12±0.01mV]. In the isometric tests, the SS rowers showed higher left ES activity than the right [LES 0.11±0.01mV vs RES 0.09±0.01mV]. The flexion protocols did not reveal any left right differences in any groups in any of the protocols used. These results reveal that sweep rowing is associated with asymmetric activity of trunk extensors, but not flexors. This could be a contributing factor to the high incidence of LBP in sweep rowers.
The purpose of this study was to design a questionnaire to evaluate patients’ satisfaction with the healthcare system relating to their spinal procedure, and to gather information relating to pre and post operative management. If successful, this questionnaire will be incorporated into the FASTER (Function after spinal treatment, exercise and rehabilitation) study, with the aim of identifying common care pathways and to understand where stumbling blocks arise. The questionnaire included three sections: Care before surgery, care after surgery, plus general measures of satisfaction. Patients were randomly selected from the hospital records if they had undergone a lumbar discectomy or lateral nerve root decompression within the past year; this included both NHS and private patients. 34 pilot questionnaires were sent, to date 18 have been returned (9 NHS and 9 private patients). It was found that 79% of patients went to their GP when first experiencing pain/discomfort; however, alarmingly, an overwhelming majority of these patients felt their problem was not dealt with correctly at this stage. Fifty percent of the patients who went through the NHS “Definitely” felt left alone to deal with their problem. Only 10% of patients had physiotherapy prior to surgery and none went to pain management classes. 32% of patients received physiotherapy after leaving hospital; however, in all but one case this was after returning with symptoms. Despite this, patients in general were very pleased with the care they received during there hospital stay. This pilot data provides an insight into the issues experienced by spinal surgery patients.
Trunk flexor-extensor asymmetry has been implicated in the development of back pain; however, left-right trunk muscle asymmetry has received little attention. This study examined whether such left-right asymmetries exist and if these are related to differing sporting tasks. Thirty-five subjects were recruited and written informed consent obtained; 12 subjects participated in unilateral (UL) sports e.g. racquet sports (mean age 21.6±0.7 (SEM) years), 13 in bilateral (BL) activities e.g. rugby (mean age 21.7±0.2) and 10 controls (C) not involved in sport (mean age 21.7±0.2) years). Isokinetic and isometric trunk flexions and extensions including a fatiguing isometric hold were performed in a Cybex isokinetic dynamometer synchronised with bilateral electromyographic (EMG) recordings from trunk extensors (erector spinae at L4), and flexors (rectus abdominis at T10). A ratio of left:right EMG activity was calculated for each set of muscles, to examine asymmetry. No differences were seen in left:right extensor EMG ratios across any of the test protocols. However, the UL group had higher (P<
0.05) left:right flexor EMG ratios than the BL group during pre-fatigue (UL:1.32±0.15 vs. BL:0.84±0.07) and post-fatigue (UL:1.30±0.18 vs BL:0.84±0.07) isometric flexion. Torque data suggested that the trunk extensor-flexor ratio was larger (P<
0.05) in the BL group compared to the C in the isokinetic exercises at the 30°s−1 (BL:1.27±0.05; C:1.00±0.06) and at the 90°s−1 speeds (BL:1.28±0.05; C:0.95±0.08), but no differences were seen during isometric testing. This study suggests that training for different sports can generate significant asymmetry in the trunk muscles, particularly in the flexors, the importance of which requires further research.
The FASTER study (Function after spinal treatment, exercise and rehabilitation) aims to evaluate, via a factorial RCT, the benefits of a rehabilitation programme and an education booklet for the postoperative management of patients undergoing discectomy or lateral nerve root decompression, each compared with “usual care”. Since the scientific literature reveals little evidence in favour of any specific exercises or approach, the rehabilitation programme had a general focus on simply getting people exercising and was based on Klaber-Moffett &
Frost’s [2000] “Back to fitness” programme; classes include elements of stretching, strengthening, relaxation and an opportunity for discussion. Currently, 128 patients have been recruited into the study of which 65 have been randomised to receive rehabilitation, which is offered 6 weeks after their surgery. At the end of the 6 week period of rehabilitation classes, participants are requested to complete a questionnaire containing forced and open questions on the content, style, length, timeliness and usefulness of these classes. Feedback is very positive. In terms of class length 95% felt it was about right and easy to follow. All knew why they were doing the exercises, and 90% felt they had enough support and assistance during the classes. 95% would recommend to others. Important elements were noted to be; being with other people with the same problem, learning to exercise, gaining confidence and support and information from the staff. The average overall rating of the classes was 8.5/10. The results show that content of the rehabilitation classes appears to be pitched at the right level for post-operative patients and that the attendees are benefiting from interactions with each other and learning to exercise and be active. The impact of these classes on outcome remains to be determined.
The FASTER study (Function after spinal treatment, exercise and rehabilitation) aims to evaluate, via a factorial RCT, the benefits of a rehabilitation programme and an education booklet To date, 128 patients have been recruited into the study of which 63 have been randomised to receive the booklet. At 3 months post-surgery all of these patients are requested to complete a questionnaire on the booklet. This questionnaire contained forced-choice questions on readability etc and open questions regarding content. Finally, patients were asked their overall rating of the booklet on a scale from 1 to 10. Feedback is very positive. The average overall rating of the booklet was 8.3/10. Over 85% found it easy to read, interesting, and of appropriate length. Over 90% also stated they had learnt new and helpful information. All subjects stated that they would recommend the booklet to a friend, and the majority stated that they frequently referred to the booklet. The predominant messages received and understood by the patients were related to the safe benefits of early activation and return to normal activities. The results show that spinal surgery patients appreciate evidence-based information in booklet form, and suggest that this booklet may be an important adjunct to post-operative management of spinal patients.
To date, 80 patients have been recruited into the study of which 34 have been randomised to receive the booklet. At 6 months post-surgery all of these patients are requested to complete a questionnaire on the booklet. This questionnaire contained forced-choice questions on readability, style, information level, believability, length, content and helpfulness. Further open questions concern the booklet’s messages, giving patients the opportunity to identify anything they did not like or understand, voice any concerns that were not covered, and say if they thought the booklet would change what they did after surgery. Finally, they were asked their overall rating of the booklet on a scale from 1 to 10. Feedback is very positive. The average overall rating of the booklet was 8.6/10. Over 80% found it easy to read, interesting, and of appropriate length. Over 80% also stated they had learnt new and helpful information. All subjects stated that they would recommend the booklet to a friend, and the majority stated that they frequently referred to the booklet. The predominant messages received and understood by the patients were related to the safe benefits of early activation and return to normal activities. The results show that spinal surgery patients appreciate evidence-based information in booklet form, and suggest that this booklet may be an important adjunct to post-operative management of spinal patients.
Poor trunk extensor endurance is implicated in low back pain; less, however, is known about contributions of left and right sides and upper and lower parts to maximum torque production following fatigue. This study examines torque and electromyographic (EMG) activity in different parts of the left and right trunk extensors before and following a maximal voluntary contraction (MVC) hold. 16 student rowers participated and written informed consent was obtained. Testing was performed in a Cybex isokinetic dynamometer with synchronous bilateral EMG recordings (during brief MVCs) from the left and right the erector spinae (ES) muscles at vertebral levels T12 and L4, prior to and immediately after, and 1, 5 and 10 minutes after a 60 second MVC. A small decrease in maximum torque was observed during 60s MVC, followed by a non significant step-wise increase. The torque at 10 minutes post MVC was the highest value recorded. EMG activity rose in the right upper back 5 and 10 mins following the fatigue. Furthermore, the ratios of left:right EMG activity revealed an increase compared to pre-fatigue values in the lower back but a decrease in the upper back, suggesting the task involved differential use of left and right sides in addition to upper and lower back muscles. These results suggest that 60s MVC induces differential activation of left and right sides and upper and lower parts of the trunk extensors. The apparent potentiation in force and asymmetry of activation following the 60s MVC task requires further investigation.
Highly active anti-retroviral therapy has transformed HIV into a chronic disease with a long-term asymptomatic phase. As a result, emphasis is shifting to other effects of the virus, aside from immunosuppression and mortality. We have reviewed the current evidence for an association between HIV infection and poor fracture healing. The increased prevalence of osteoporosis and fragility fractures in HIV patients is well recognised. The suggestion that this may be purely as a result of highly active anti-retroviral therapy has been largely rejected. Apart from directly impeding cellular function in bone remodelling, HIV infection is known to cause derangement in the levels of those cytokines involved in fracture healing (particularly tumour necrosis factor-α) and appears to impair the blood supply of bone. Many other factors complicate this issue, including a reduced body mass index, suboptimal nutrition, the effects of anti-retroviral drugs and the avoidance of operative intervention because of high rates of wound infection. However, there are sound molecular and biochemical hypotheses for a direct relationship between HIV infection and impaired fracture healing, and the rewards for further knowledge in this area are extensive in terms of optimised fracture management, reduced patient morbidity and educated resource allocation. Further investigation in this area is overdue.
This study sought to determine the post-operative management of spinal patients in the UK, and to determine if uniformity exists between surgeons and if there is any published evidence for this practice. A reply-paid questionnaire was sent to members of the British Association of Spinal Surgeons and the Society for Back Pain Research. The questionnaire documented the surgeon’s experience, where they work, their operative population, the types of spinal surgery performed, and whether they have a routine for post-operative management or any written instructions for patients concerning post operative management. It also asked about the nature and duration of professionally supervised rehabilitation. Of the 89 questionnaires distributed, 63 (71%) were returned, of which 51 could be used in the analysis. The 12 not used were either completed incorrectly, had missing data or the surgeon had since retired. The replies demonstrated wide variation: only 35% of surgeons provide their patients with written post-operative instructions; there was limited referral to physiotherapy, with only 45% referring to a physiotherapist (for an average of 1.8 sessions); only a modest fraction of surgeons advocated the use of a post-operative corset (18%), others restricting sitting or encouraging bed rest; and a range of recommendations regarding return to work. There was also only a limited correlation between restrictions on sitting and recommendations about return to sedentary work or driving (Spearman r=0.08 and 0.36, respectively). In summary, although individual surgeons may be certain of their practice, the overall variation indicates ongoing uncertainty across the profession. This was further substantiated by our literature search, which revealed limited evidence for current practices, and a paucity of research into postoperative management.
The purpose of this study was to assess the technique of ultrasonographic evaluation of anterior shoulder translation from an anterior approach. Anterior translation in the right shoulders of 23 volunteers was evaluated using ultrasound with a 10 MHz, 6 cm wide linear transducer. A translatory force of 90 Newtons (N) was used to translate the humeral head in the adduction and internal rotation position (Position 1), while 60 N was used in the more clinically relevant position of 90° abduction and external rotation position (Position 2). The overall intraobserver coefficients of variation ranged from 0–13% (mean 3.8 ± 2.5%) for examiner 1 and 0.5–20.9% (mean 5.1 ± 3.9%) for examiner 2. The overall interobserver variation ranged from 0–29.8% (mean 9.3 ± 7.3%). The anterior translation in Position 1 ranged from –2.6 to 12.9 mm (mean 2.1 ± 3.1 mm) for examiner I and from −4.1 to 4.7 mm (mean 1.1 ± 2.2 mm) for examiner II. The anterior translation in Position 2 ranged from −3.3 to 3.7 mm (mean 0.3 ± 1.9 mm) for examiner I and from −8.3 mm to 4.5 mm (mean −0.7 ± 2.6 mm) for examiner II. The intraclass correlation coefficients (r) for the measured anterior translation between the 2 examiners for the 2 positions were 0.029 and −0.058 respectively. The interobserver coefficient of variation remains excessive and there was poor agreement in the measured anterior translation. The finding of negative values in the measured anterior translation despite translatory force raises further concerns about the prospective clinical use of this technique at the present moment.
Arthroscopic stabilisation of the shoulder is a technically-demanding and developing technique, and the reported results have yet to match those for open surgery. We present a consecutive initial series of 55 patients with post-traumatic recurrent anteroinferior instability managed since September 1999 using a titanium knotless suture anchor. Patients were reviewed from 12–33 months postoperatively and assessed using the Rowe, Walch-Duplay and Constant scores. Following mobilisation of the capsulolabral complex, labral reconstruction was achieved using a two-portal technique and an average of three anchors placed on the glenoid articular rim. In 13 cases, additional electrothermal shrinkage was required to reduce capsular redundancy in the anterior and inferior recesses following labral repair, although 11 of these were in the first 18 months. Incorporation of a south-to-north capsular shift has reduced the need for supplementary shrinkage. Complications have included one instance of anchor migration requiring open retrieval and two documented episodes of recurrent instability, although these occurred in patients having surgery within the first six months after the introduction of this technique. Based on our initial experience, we believe that arthroscopic labral repair is a viable alternative to open Bankart repair and have now expanded the indications to include patients with primary dislocation, those participating in gymnastic and contact/collision sports, and revision cases with failed open repairs.
Low back pain (LBP) is a common problem in rowers of all levels. Few studies have looked at the relationship between rowing technique, the forces generated during the rowing stroke and the kinematics of spinal motion. Of particular concern with respect to spinal injury and damage are the effects of fatigue during long rowing sessions. A technique has been developed using an electromagnetic motion system and strain gauge instrumented load cell to measure spinal and pelvic motion and force generated at the oar during rowing on an exercise rowing ergometer. Using this technique 13 elite national and international oarsmen (mean age 22.43 ± 0.02 years) from local top squad rowing teams were investigated. The test protocol comprised of a one hour rowing piece. During this session rowing stroke profiles were quantified in terms of lumbopelvic kinematics and stroke force profiles. These profiles were sampled at the start of the session and quarterly intervals during the hour piece. From this data we were able to quantify the motion of the lumbar spine and pelvis during rowing and relate this to the stroke force profile. The stroke profiles over the one hour piece were then compared to examine the effects of fatigue. This revealed marked changes and increases in the amount of spinal motion during the hour piece suggesting that to maintain stroke force profiles athletes were utilising greater ranges of spinal motion. The relevance of this with regard to low back pain however, requires further investigation.