published_or_final_version / Orthopaedics and Traumatology / Master / Master of Philosophy

Back pain is a massive global public health problem with multiple contributing factors including obesity. Obesity is thought to be linked to back pain through mechanical factors. However, obesity also causes a systemic low-grade inflammatory milieu. This would suggest a possible biochemical link between obesity, intervertebral disc degeneration, and back pain. Furthermore, the relationship between obesity and the clinical presentation of spine patients is unclear. This thesis aims to examine the effect of and relationship between obesity, the intervertebral discs, and back pain from biochemical, clinical, and epidemiological perspectives. In this thesis, an in vitro study assessed the effect of leptin, a fat-specific cytokine, upon the intervertebral disc. The bovine intervertebral disc was used as a model in a cell culture system. An ex vivo study examined leptin and pro-inflammatory cytokines produced by paraspinal adipose tissue taken during routine surgical procedures from spinal patients. Plasma taken from patients presenting with low back pain was analysed by mass spectrometry and multiplex immunoassay to identify possible protein biomarkers. At an epidemiological level, statistical modelling of the Genodisc patient population was conducted. This was a pan-European study of 2636 patients presenting to tertiary spinal units. Analyses were performed to examine relationships between obesity, quantified by body mass index (BMI), and pain, clinical diagnosis, and spinal degeneration identified on magnetic resonance imaging (MRI). Leptin was shown to increase the production of and expression of degradative and pain-generating molecules by disc cells. A pro-inflammatory environment, especially IL-6, potentiated this response. Leptin and pro-inflammatory cytokines produced by paraspinal fat were unrelated to clinical symptoms. However, levels of the pro-inflammatory cytokines, TNF-α and IL-6, were raised in the plasma of patients with greater pain or those with spinal stenosis. Furthermore, clusterin and complement were identified, by mass spectrometry, as potential biomarkers for spine patients. Epidemiological analyses revealed that obesity was associated with greater back pain, although the magnitude of this association was small. Similarly, obesity was associated with a diagnosis of spinal stenosis. Finally, increased BMI was found to be an independent predictor of disc degeneration, spinal stenosis, and disc herniation on MRI. In summary, this thesis has furthered the clinical understanding of lumbar spine pathology and back pain. It will provide clinicians with a better framework to assess spine patients. These results show that obesity is associated with lumbar spine degeneration and pain. Leptin could be a factor mediating this relationship. Further studies should concentrate on clarifying the mechanism of action of leptin upon the intervertebral disc and assessing the longitudinal effect of obesity upon the lumbar spine. In this thesis, an in vitro study assessed the effect of leptin, a fat-specific cytokine, upon the intervertebral disc. The bovine intervertebral disc was used as a model in a cell culture system. An ex vivo study examined leptin and pro-inflammatory cytokines produced by paraspinal adipose tissue taken during routine surgical procedures from spinal patients. Plasma taken from patients presenting with low back pain was analysed by mass spectrometry and multiplex immunoassay to identify possible protein biomarkers. At an epidemiological level, statistical modelling of the Genodisc patient population was conducted. This was a pan-European study of 2636 patients presenting to tertiary spinal units. Analyses were performed to examine relationships between obesity, quantified by body mass index (BMI), and pain, clinical diagnosis, and spinal degeneration identified on magnetic resonance imaging (MRI). Leptin was shown to increase the production of and expression of degradative and pain-generating molecules by disc cells. A pro-inflammatory environment, especially IL-6, potentiated this response. Leptin and pro-inflammatory cytokines produced by paraspinal fat were unrelated to clinical symptoms. However, levels of the pro-inflammatory cytokines, TNF-α and IL-6, were raised in the plasma of patients with greater pain or those with spinal stenosis. Furthermore, clusterin and complement were identified, by mass spectrometry, as potential biomarkers for spine patients. Epidemiological analyses revealed that obesity was associated with greater back pain, although the magnitude of this association was small. Similarly, obesity was associated with a diagnosis of spinal stenosis. Finally, increased BMI was found to be an independent predictor of disc degeneration, spinal stenosis, and disc herniation on MRI. In summary, this thesis has furthered the clinical understanding of lumbar spine pathology and back pain. It will provide clinicians with a better framework to assess spine patients. These results show that obesity is associated with lumbar spine degeneration and pain. Leptin could be a factor mediating this relationship. Further studies should concentrate on clarifying the mechanism of action of leptin upon the intervertebral disc and assessing the longitudinal effect of obesity upon the lumbar spine.

Memoria para optar al Título Profesional de Médico Veterinario / Se realizó un estudio, con la finalidad de describir los casos de perros con hernia discal toracolumbar tipo I y que fueron sometidos a cirugía descompresiva. Para alcanzar el objetivo descrito, se revisaron un total de 4.569 casos clínicos de perros, que llegaron a consulta neurológica en el período comprendido entre Enero de 2001 y Diciembre de 2010, al Instituto Neurológico y de Especialidades Veterinarias. De este número, 409 correspondieron a perros con hernia discal toracolumbar tipo I, lo que equivale a una morbilidad proporcional de un 8,95%. Un 98,53% (403 perros), del total de pacientes con hernia discal toracolumbar, fueron sometidos a hemilaminectomía, los cuales fueron considerados en el análisis del presente estudio. La población de perros con hernia discal toracolumbar tipo I, consistió mayoritariamente en perros de rango etario adulto (48,2%), raza Dachshund (38,7%), machos (55,33%) y animales enteros (93,8%), siendo el 2010, el año con mayor presentación de casos (72 casos, lo que representó un 17,37% del total). El espacio intervertebral más afectado fue T12-T13 (37,75% de los casos). Por otro lado, 392 perros (97,3% del total), contaron con información en sus registros clínicos, acerca de si volvieron o no a caminar después de la cirugía. De estos, 361 volvieron a caminar, lo que significó un éxito quirúrgico del 92,1%.

<p>Juvenile nucleus pulposus (NP) cells of the intervertebral disc (IVD) are large, vacuolated cells that form cell clusters with numerous cell-cell interactions. With maturation and aging, NP cells lose their ability to form these cell clusters, with associated changes in NP cell phenotype, morphology and proteoglycan synthesis that may contribute to IVD degeneration. Studies demonstrate healthy, juvenile NP cells exhibit potential for preservation of multi-cell clusters and NP cell phenotype when cultured upon soft, laminin-containing substrates; however, the mechanisms that regulate metabolism and phenotype of these NP cells are not understood. N-cadherin is a cell adhesion molecule that is present in juvenile NP cells, but disappears with age. The goal of this dissertation was to reveal the role of N-cadherin for NP cells in multi-cell clusters that contribute to the maintenance of the juvenile NP cell morphology and phenotype in vitro, and to evaluate the potential for laminin- functionalized poly(ethylene glycol) (PEG-LM) hydrogels to promote human NP cells towards a juvenile NP cell phenotype. </p><p>In this dissertation, juvenile porcine IVD cells were promoted to form cell clusters in vitro, and analyzed for preservation of the juvenile NP phenotype on soft, laminin-rich hydrogels. In the first part of this dissertation, preservation of the porcine juvenile NP cell phenotype and presence of N-cadherin was analyzed by culturing porcine NP cells on soft, laminin-rich or PEG-LM hydrogels. Secondly, cadherin-blocking experiments were performed to prevent cluster formation in order to study the importance of cluster formation in NP cell signaling. Finally, human IVD cells were cultured on PEG-LM hydrogels to investigate the potential to revert degenerate, human NP cells toward a juvenile NP cell phenotype and morphology. </p><p>Findings reveal soft (<500 Pa), laminin-rich substrates promote NP cell clustering, a key feature of the juvenile NP cell that is associated with N-cadherin positive expression. Additionally, N-cadherin-mediated cell-clustering regulates NP cell matrix production and gene expression of NP-specific and NP-matrix related markers. Inhibition of N-cadherin-mediated contacts resulted in decreased expression of juvenile NP cell features. Finally, juvenile human NP cells are also able to form N-cadherin positive cell clusters on soft, PEG-LM hydrogels with higher expression of juvenile NP cell features compared to culturing on stiff PEG-LM hydrogels. Some degenerate, human NP cells are also able to form N-cadherin positive cell clusters with some features of the juvenile NP cell. </p><p>The studies presented in this dissertation support the proposed hypothesis and establish the importance of soft, laminin-rich substrates in promoting NP cell clustering behaviors with associated features of a juvenile cell phenotype and morphology. Additionally, these studies establish a regulatory role for N-cadherin in juvenile NP cells and suggest that preservation of N-cadherin-mediated cell-cell contacts is important for preserving the juvenile NP cell phenotype and morphology. Furthermore, findings from this dissertation reveal the ability to promote degenerate, mature human NP cells towards a juvenile NP cell phenotype, demonstrating the potential to use PEG-LM hydrogels as a means for autologous cell delivery for the restoration of healthy IVD.</p> / Dissertation

Einleitung: Der Verdacht, dass Hunde mit einem Bandscheibenvorfall eine Prädisposition für die Entstehung einer Pankreatitis haben könnten, wurde in der Veterinärmedizin bereits in den frühen 1980er Jahren diskutiert. Trotz dieser bereits vor vielen Jahren erhobenen Vermutungen, wurde der Zusammenhang zwischen der Entstehung einer Pankreatitis und einem zeitgleich vorliegenden Bandscheibenvorfall auch im Hinblick auf mögliche Risikofaktoren wie dem Einfluss der Narkose oder dem Einsatz von Medikamenten (v. a. Glukokortikoide und nichtsteroidale Antiphlogistika) bisher nicht näher untersucht. Ziele der Untersuchungen: Im Rahmen der vorliegenden prospektiven Studie sollte untersucht werden, ob Bandscheibenvorfälle ein Risikofaktor für die Entstehung einer Pankreatitis beim Hund darstellen. Ferner sollte geklärt werden, ob die Narkose und die Gabe von Glukokortikoiden und/oder nichtsteroidalen Antiphlogistika zusätzlich das Risiko der Entstehung einer Pankreatitis bei Hunden mit einem Bandscheibenvorfall erhöhen. Material und Methoden: Insgesamt wurden 106 Hunde, bei denen aufgrund der klinischen Symptome der Verdacht einer Rückenmarksläsion bestand, an fünf aufeinander folgenden Tagen klinisch untersucht. Besonderes Augenmerk wurde hierbei auf Symptome gelegt, welche typischerweise bei Pankreatitiden zu beobachten sind (reduziertes Allgemeinbefinden, Schwäche, Anorexie, dolentes Abdomen, Vomitus, Regurgitieren, Diarrhoe, Fieber, Dehydratation). Ferner wurde am Tag 0 und Tag 4 der stationären Aufnahme die Konzentration der caninen pankreasspezifischen Lipase im Serum gemessen (Spec cPL und Snap cPL). Am Tag 0 wurde von dem Vorliegen einer Pankreatitis ausgegangen, wenn klinische Befunde im Sinne einer Pankreatitis sowie eine abnorm erhöhte Konzentration der caninen pankreasspezifischen Lipase im Serum (>400 μg/L) auffällig waren. Am Tag 4 erfolgte zudem eine sonographische Untersuchung des Abdomens. Somit basierte die Diagnosestellung einer Pankreatitis an diesem Tag auf dem Vorliegen von zwei der folgenden drei Kriterien: klinische Befunde im Sinne einer Pankreatitis, abnorm erhöhte Konzentration der caninen pankreasspezifischen Lipase im Serum, sonographische Hinweise für das Vorliegen einer Pankreatitis. Im Rahmen der statistischen Auswertung wurden zudem auch Patienten erfasst, welche in einem oder in mehreren der oben genannten Kriterien ein fragliches Ergebnis aufwiesen. Entsprechend ihrer neurologischen Ausfallserscheinungen sowie der Befunde im Rahmen der bildgebenden Diagnostik (Myelographie, Computertomographie, Kernspintomographie) wurden die Patienten in eine der folgenden drei Untersuchungsgruppen eingeteilt: 1. Hunde mit einem chirurgisch versorgten Bandscheibenvorfall (n = 71) 2. Hunde mit einem konservativ therapierten Bandscheibenvorfall (n = 20) und 3. Hunde mit einer akuten intramedullären Läsion (n = 15). Die statistische Auswerte erfolgte aufgrund der geringen Stichprobengrößen vorwiegend deskriptiv. Die Daten wurden mittels des Shapiro-Wilk-Tests auf Normalverteilung überprüft, die durchgeführten Gruppenvergleiche erfolgten unter Verwendung des Kruskal-Wallis und Mann-Whitney-U-Tests. Zudem wurden die betrachteten Merkmale mit dem Fisher Test und dem Chi-Quadrat-Test auf Unabhängigkeit überprüft. Das Signifikanzniveau wurde für alle Tests mit p < 0,05 festgelegt. Ergebnisse: Basierend auf den klinischen Symptomen und der Konzentration der caninen pankreasspezifischen Lipase im Serum konnte insgesamt am Tag 0 bei vier Hunden (3,8 %) eine Pankreatitis diagnostiziert werden. Am Tag 4 waren es, basierend auf den drei Kriterien, welche für die Diagnosestellung einer Pankreatitis herangezogen werden, insgesamt acht Patienten (7,5 %). Hunde mit einem Bandscheibenvorfall (chirurgisch beziehungsweise konservativ therapiert) wiesen am Tag 0 beziehungsweise Tag 4 in 4,3 % (n = 4) beziehungsweise 7,7 % (n = 7) der Fälle eine Pankreatitis auf. Aufgrund der geringen Häufigkeiten in den einzelnen Untersuchungsgruppen, war eine Berechnung eines signifikanten Unterschieds zwischen den Gruppen nicht möglich. Hinsichtlich einer möglichen Korrelation zwischen einer Narkose und der Entstehung einer Pankreatitis bei Hunden mit einer Rückenmarksläsion konnte kein signifikanter Zusammenhang festgestellt werden. Auch die Gabe von Glukokortikoiden und/oder nichtsteroidalen Antiphlogistika hatte hier keinen signifikanten Einfluss auf die Entstehung einer Pankreatitis. Schlussfolgerung: Vergleicht man die Ergebnisse der vorliegenden Studie mit der in der Literatur angegebenen Prävalenz für akute Pankreatitiden beim Hund (0,7-3,5 %), so kann geschlussfolgert werden, dass eine Rückenmarksläsion, insbesondere ein Bandscheibenvorfall, als Risikofaktor für die Entstehung einer akuten Pankreatitis beim Hund in Betracht gezogen werden muss. Demgegenüber erhöhen weder die Narkose noch die Gabe von Glukokortikoiden und/oder nichtsteroidalen Antiphlogistika zusätzlich das Risiko der Entstehung einer Pankreatitis bei Hunden mit einer Rückenmarksläsion. / Objective: The suspicion that dogs with intervertebral disc disease are at greater risk of developing pancreatitis is being discussed in veterinary medicine since the early 1980s. So far no study has been published examining the correlation between intervertebral disk disease and the development of pancreatitis in dogs, especially in combination with general anaesthesia and anti-inflammatory medication (glucocorticoids and/or nonsteroidal anti-inflammatory drugs). The aim of this study was therefore 1) to evaluate intervertebral disk disease as possible risk factor of pancreatitis and 2) to ascertain if general anaesthesia and the administration of glucocorticoids and/or nonsteroidal anti-inflammatory drugs further increase the risk of pancreatitis in dogs with intervertebral disk disease. Material and methods: One hundred and six dogs with symptoms associated with spinal cord injury were clinically examined over a period of five days. Special attention was payed to symptoms usually seen with pancreatitis such as anorexia, vomitus and abdominal pain. Furthermore the concentration of canine pancreatic lipase in the blood serum was measured with Spec cPL and Snap cPL at day 0 and day 4 after admission. At day 0 the diagnosis of pancreatitis was based on clinical symptoms associated with pancreatitis in combination with an increased concentration of canine pancreatic lipase in the blood serum (>400 μg/L). A sonography of the pancreas was performed at day 4 to evaluate the organ itself and the surrounding tissue for lesions associated with pancreatitis. Therefore the diagnosis of pancreatitis at day 4 was based on positive results in at least two of the three following criteria: symptoms associated with pancreatitis, elevation of the concentration of canine pancreatic lipase in the blood serum, sonographic changes of the pancreas parenchyma and the surrounding tissue associated with pancreatitis. For statistical analysis questionable results in one or more of these criteria were also documented. According to the neurologic symptoms and the findings of diagnostic imaging (myelography, computed tomography and magnetic resonance imaging), dogs were categorized in one of the following groups: 1. dogs with surgically treated intervertebral disk disease (n = 71), 2. dogs with medically treated intervertebral disk disease (n = 20), 3. dogs with an acute intramedullary lesion (n = 15). Due to the small sample size, statistics were primarily performed descriptively. Data were tested for normal distribution using the Shapiro-Wilk test. If Group comparisons were feasible, they were performed using the Kruskal-Wallis test and the Mann-Whitney-U test. Fisher test and the Chi-Square test were used to test for association between group affiliation and possible risk factors for the development of pancreatitis. A value of P < 0.5 was considered significant for all analysis. Results: Based on clinical symptoms and an elevated concentration of the canine pancreatic lipase (> 400μg/l) at day 0, four dogs (3.8 %) were diagnosed with pancreatitis. According to the clinical symptoms, the concentration of the canine pancreatic lipase and sonographic changes, a total number of eight dogs (7.5 %) were diagnosed with pancreatitis at day 4. Considering only the dogs with intervertebral disk disease (surgically and medically treated) 4.3 % (n = 4) and 7.7 % (n = 7) were diagnosed with pancreatitis at day 0 and day 4, respectively. Due to the small sample size, the calculation of significant differences between the three subgroups was not feasible. There was no significant correlation between general anaesthesia and the development of pancreatitis. Furthermore, the administration of glucocorticoids and/or nonsteroidal anti-inflammatory drugs is not significantly associated with the genesis of pancreatitis.

Chronic lower back pain is a major public health problem, with direct and indirect economic costs comparable to those of heart disease, depression and diabetes. In many cases this pain derives from degeneration of the intervertebral disc (IVD), a fibrous, avascular tissue that sits between the vertebrae in the spinal column. A novel treatment approach for this ‘discogenic’ pain is the injection of a hydrogel that hybridises in situ and restores the normal biomechanical function of the disc. While a number of promising materials are currently under development, existing approaches to removing degenerate material from the disc prior to injection are invasive and compromise the structural integrity of the disc. Mechanical fractionation of the tissue using acoustic cavitation generated by high intensity focussed ultrasound (HIFU) has the potential to be non-invasive, and to enhance the effectiveness of the procedure by preserving the outer regions of the disc. The primary goal of this thesis is to investigate the feasibility of this approach. The acoustic properties of the disc were first measured using a modified scanning acoustic microscope. The outer region of the disc, the annulus fibrosus (AF) was found to be highly attenuative compared to the central nucleus pulposus (NP). These measured properties were then used in a simplified two-dimensional model to simulate the shape of the acoustic pressure field within the disc. A configuration using two confocal spherically focussed 0.5 MHz single-element transducers was able to produce a tightly focused field suitable for use in the IVD. As preliminary experiments suggested that high pressure amplitudes were required to initiate cavitation inside the disc, the use of exogenous nuclei to lower this threshold was investigated. A novel class of solid sonosensitive nanoparticles (SNPs) suitable for use in the IVD were developed and characterised. These SNPs comprise a layer of hydrophobic silica particles deposited onto a polystyrene core, and are thought to trap small gas pockets in surface crevices. Coated particles were found to reduce the cavitation threshold significantly in both water and blood, from some 2.0 - 2.5 MPa at 1.067 MHz to below 1.0 MPa. The particles were also found to provide repeatable initiation of cavitation activity during prolonged or repeated exposures, and to exhibit good storage stability, suggesting that they they may be appropriate for use within the IVD. Finally, a combined therapy and monitoring system was designed, built and validated. The system comprised two confocal 0.5 MHz spherically focussed HIFU transducers with central openings, each co-axially aligned with either a single element passive cavitation detector or a 64-element array that could be used for both active and passive imaging. The system was found to be capable of initiating inertial cavitation in the disc at pressures as low as 2.5MPa in the presence of sonosensitive nanoparticles. Use of the array in active mode enables creation of a B-mode image that provides anatomical information on the boundaries of the IVD, whist the same array could be used for passive mapping of acoustic emissions arising fromthe HIFU focus during therapy. Two different exposure regimes were found to be capable of producing sizeable perforations within the NP without significantly damaging the AF, and preliminary investigations were carried out into themechanism of damage. The location and extent of cavitation as seen on passive maps acquired during treatment was found to coincide with the regions of NP fractionation. This confirms that passive acoustic mapping can provide the real-time treatment monitoring necessary to ensure both safety and efficacy of ultrasonic IVD fractionation. Prior to clinical application, a significant amount of further development is required to further validate non-invasive disc fractionation by HIFU and the subsequent steps for minimally invasive disc replacement using injectable hydrogels. The present work has nonetheless demonstrated for the first time that minimally invasive removal of degenerate disc tissue is feasible trough the combined use of sonosensitive nanoparticles and a relatively low-cost therapeutic ultrasound system that provides simultaneous anatomical imaging and real-time treatment monitoring by passive acoustic mapping.

No description available.

Title: Human axial system: identification of connective tissues changes Objectives: The main objective of this thesis was to compile a review of techniques and methods currently used in identification of connective tissues changes. Methods: The method used in this thesis is a critical literature review - a study of research papers from available information sources accompanied by author's comments. Foreign sources are represented mostly by research papers accessible via electronic archives such as ScienceDirect, Pubmed, Springer, Wiley. Also other foreign publications were used. The theoretical part is focused on basic anatomy and physiology of the spine and states main methods of identification of connective tissues changes involved in this area. The main part describes particulars of researches dedicated to identification of functional and morphological characteristics of different spinal components. Results: In addition to classic methods of spinal research, the thesis introduces also new developing techniques and methods. Procedures used in current research are described; their advantages and limits are explained. Key words: spine, biomechanics, loading, intervertebral disc, method

Lower back disorders due to whole-body vibration (WBV) are the most common injuries reported by professional drivers. Such injuries often have long-term complications leading to significant personal and societal costs. An improved mathematical model of the whole human body would contribute to a better understanding of the mechanisms of lower back injury and be valuable in injury prevention research. Current biodynamic human models reported in the literature lack detailed information for predicting the non-linearity due to vibration amplitude of transmission of vibration from seat to a human. Therefore, one of the primary objectives of this research has been to develop and validate a detailed threedimensional biodynamic human model, with special attention given to the incorporation of active trunk muscles with non-linear stiffness properties. These muscles have been incorporated into an existing spine and neck model of a MADYMO 50th percentile male occupant model. A detailed multi-body human model has been developed, called MODEL ONE. This thesis shows that incorporating non-linear stiffness functions and energy dissipation using hysteresis or damping into a human model is appropriate for predicting non-linear biodynamic responses in arbitrary excitation functions. A major advantage of MODEL ONE compared to other multi-body models and lumped mass models is its ability to predict nonlinear seat-to-human transmissibility. However MADYMO 50th male occupant models use simplified geometry and rigid bodies to represent the lower lumbar spine. These simplified spinal models have no ability to simulate the internal stresses and deformations of soft tissues, even if these are the apparent cause of lower back pain (LBP). Therefore a detailed finite element human lower lumbar spine model - with appropriate material properties and capable of simulating internal stresses⎯is necessary, in order to better understand spinal injuries under WBV. A three-dimensional finite element model of a lower lumbar spine motion segment - called MODEL TWO - has thus been developed for the present study. MODEL TWO comprises a detailed geometric description of vertebrae, nucleus pulposus, endplates, and intervertebral discs. The intervertebral discs lump together the annulus fibrosus, ground substance and ligaments. The vertebrae have been assumed to be rigid. The material properties of the intervertebral discs of MODEL TWO were obtained from test matrices and from various parameter data reported in the literature. MODEL TWO has been validated against cadaveric experiments reported in the literature. The mechanical behaviour and stress distribution within the MODEL TWO intervertebral disc agree reasonably well with the cadaveric experiments. MODEL TWO was integrated into MODEL ONE to form a new human model, called MODEL THREE, which was subsequently dynamically validated against volunteers� responses to WBV reported in the literature. MODEL THREE, as presented in this thesis, consists of a multi-body human model with detailed representation of a finite element (FE) lower lumbar spine. As far as the author is aware, MODEL THREE is the first model with detailed representation of a FE lower lumbar spine to successfully demonstrate that it is capable of simulating the stress profile of the entire intervertebral disc and endplate region due to WBV. The simulated results revealed abnormal stress concentrations in both the posterior and xviii the posterolateral annulus. The stresses increased most in the posterolateral intervertebral discs region during WBV, suggesting a possible mechanism for disc mechanical overload leading to fatigue fracture and degeneration. The results from MODEL THREE are promising and lead to a more comprehensive understanding of the behaviour of the intervertebral disc under WBV. MODEL THREE has also provided a good foundation for the development of a bio-fidelity human model. However, implementation of currently unavailable and/or inadequate in vitro and in vivo experimental studies is needed to further validate and develop MODEL THREE. A better understanding of injury mechanisms and the clinical significance of LBP will ultimately be arrived at using a combination of analytical models with in vitro and in vivo experimental data.

Bibliography: leaves 107-109 / 109 leaves, [26] leaves of plates : / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / Thesis (M.D.)--University of Adelaide, 1989