In der Therapie orthopädischer Erkrankungen/Verletzungen gewann in den letzten Jahren das Training im Wasser als aktive Maßnahme an Bedeutung. Auf der Suche nach Möglichkeiten einer frühfunktionellen, aber schonenden Behandlung wurde das Bewegungstraining im Wasser wieder entdeckt (vgl. Froböse/ Nellessen/ Eckey 2003, 211-29). Innenmoser (2007) betonte, dass therapeutisches Aqua-Jogging geeignet bzw. notwendig ist für Menschen mit Schädigungen, chronischen Krankheiten und mit Beeinträchtigungen bzw. Gefährdungen vor allem der körperlichen Funktionen, aber auch bei Schwächen des Stütz- u. Bewegungsapparats und chronischen Erkrankungen wie Rheuma, Wirbelsäulenschäden und auch bei „Low-Back-Pain“-Patienten. Der Bewegungsraum Wasser bietet im Vergleich zu Bewegungen an Land, aufgrund seiner besonderen physikalischen Eigenschaften (vgl. hierzu alle zitiert in: Innenmoser 2001, 27: Aschoff 1971; Klauck 1977, 1998; Stegemann 1991; Stuart 2000 u.a.), eine weitestgehende Entlastung des Stütz- und Bewegungsapparates, insbesondere bei Teilnehmern mit stark verändertem Bewegungsbild. Für viele Menschen mit körperlichen Schädigungen sind bewegungstherapeutische Maßnahmen im Wasser die einzige Möglichkeit zur Erhaltung bzw. Steigerung ihrer Leistungsfähigkeit. 2 Ziele der vorliegenden Untersuchung Ziel der vorliegenden Untersuchung ist es, die möglichen Wirkungen der Aktiven Wassertherapie in Form des therapeutischen Aqua-Jogging nach dem Konzept Innenmoser (2001) bei „chronischen“ Rückenschmerz- Patienten nachzuweisen. Weil in sportwissenschaftlichen Studien die in klinischen Studien üblichen medizinischen Kontrollverfahren (Röntgendiagnostik, Oberflächen- EMG usw.) nicht zur Anwendung kommen können, wird in dieser Studie versucht, die Wirkungen der „ Bewegungstherapie im Wasser“ über den Weg eines indirekten Schließverfahrens zu ermitteln. Dieses beruht darauf, dass die Wirkungen der Aktiven Wassertherapie sich in einer verbesserten Bewegungsmöglichkeit bzw. einem höheren Bewegungsausmaß der Bewegungen des Rumpfes bzw. der unteren Wirbelsäule dann zeigen, wenn die Personen unmittelbar nach Verlassen des Wassers mit unserem ultraschallgestützten Prüfverfahren kontrolliert werden. Der Vergleich zwischen den Veränderungen der Messwerte bei ausgesuchten Bewegungsaufgaben / Tests im Bereich der Wirbelsäule vor Beginn des Aqua-Joggens und unmittelbar danach wird als Indikator für eine bessernde Wirkung der Bewegungen im Wasser angesehen. Dabei galt es nachzuweisen, dass tatsächlich die Kontrolle am Beckenrand deutlichere Zeichen einer Wirkung der Bewegungen im Wasser erbringen kann, als die zeitlich immer viel später liegenden Laboruntersuchungen. 3 Methodik und Design In einer kontrollierten prospektiven Studie wurden 11 Probanden im Alter zwischen 41 und 71 Lebensjahren mit chronischen Rückenschmerzen in der Lendenwirbelsäule (Dauer > 2 Jahre) in Rahmen einer Einzelfallstudie (ohne begleitende physiotherapeutische Behandlung) erfasst. Sie nahmen über die Dauer von 14 Wochen ein mal pro Woche an einem Aqua-Jogging-Programm von 60 min Dauer teil. Alle Probanden absolvierten das Trainingsprogramm ausschließlich im Wasser. Neben den Messungen von Mobilität und Schmerz wurden durch Prä-, Post-, Follow-up-Tests und die verlaufsdiagnostische Untersuchung mit Hilfe eines „Befindlichkeitsfragebogens“, auch die subjektiven Einschätzungen von Leistungsfähigkeit, Befinden und Schmerzempfinden ermittelt. Im Labor kamen als ergänzende Parameter die Ermittlung der statischen Körperhaltung und der anthropometrischen Date hinzu. Der alltäglich wechselnde Schmerzzustand der Probanden wurde anhand eines „Tagebuchs“ festgehalten. Die Lendenwirbelsäule-Mobilität wurde mit Hilfe der Bestimmung des „Schoberzeichens“ im Labor in die Analyse mit einbezogen. Die Schmerzvarianten der Personen wurde mit Hilfe einer Befragung (Fragebogen FSR), dem ein Schmerzregulationsmodell zugrunde liegt, am Anfang und am Ende des Aqua-Jogging-Programms und nach dessen Ende im Follow-Up Zeitraum gemessen. Wichtigste Aufgabe aber waren die Messungen der Bewegungsmöglichkeiten der Lendenwirbelsäule mit Hilfe des Ultraschallmessverfahrens System Zebris am Beckenrand vor und nach dem Aqua-Jogging und dessen Auswertung unter Berücksichtung jedes einzelnen Probanden. 4 Ergebnisse Die Auswertung der Veränderungen mit dem ultraschalltopografischen Messverfahren nach Zebris in den Verlaufsuntersuchungen ergab bei 8 Probanden eine Verbesserung der LWS Beweglichkeit. Bei 8 Probanden waren auch Verbesserungen im Follow-Up Test im Merkmal Flexion zu sehen. Diese fiel deutlich umfangreicher aus. Bei weiteren 6 Probanden ergaben sich Verbesserungen der Extension im Bereich der LWS. Ebenfalls 6 Probanden konnten die Lateralflexion nach links vergrößern. Nur bei 5 Probanden verbesserte sich die Lateralflexion nach rechts. Bei 5 Probanden war die Rotation nach links besser, während bei 8 Probanden die Rotation nach rechts besser gelang. 6 Probanden verbesserten ihre LWS Beweglichkeit in der Flexion, wenn man das Schoberzeichen als Kriterium heranzog. Nur 3 Probanden verbesserten ihre FSR- Kompetenz, während 5 Probanden eine geringere Schmerzintensität lt. FSR aufwiesen. 7 Probanden zeigten eine geringere Angst gemäß FSR und bei 7 Probanden verringerte sich die Neigung zu Depression, Die Effekte sind unabhängig von Geschlecht und Chronifizierungsausmaß. Verallgemeinernd gesehen waren mit Hilfe der ausgewählten Messkriterien eine Verbesserung der Beweglichkeit der Wirbelsäule, eine Linderung der Schmerzen und Steigerung der Lebensqualität zu beobachten. Trainingsbedingt zeigte sich teilweise eine kräftige Beschwerdereduktion (Linderung der Schmerzintensität) und eine relativ deutliche Steigerung der körperlichen Leistungsfähigkeit. Teilnehmer über 60 Jahre zeigen gegenüber jüngeren Teilnehmern einen höheren Beweglichkeitszuwachs der Flexion bei gleicher Schmerzreduktion. Es wurde eindeutig klar, dass die individuell unterschiedlichen Wirkungen des Aqua-Joggings auf Flexion, Extension, Lateralflexion links und rechts und Rotation links und rechts nur dann sicher erfasst werden können, wenn die Kontrolle tatsächlich am Beckenrand erfolgte. Diese akuten Wirkungen erklärten auch das fast stets gesteigerte Gefühl des Wohlbefindens bei den Probanden und ihre regelmäßig geäußerten Wünsche nach einer Fortsetzung der Trainingsmaßnahmen 5 Schlussfolgerungen Das Aqua-Jogging bestätigte sich als wirksame Maßnahme im Sinne einer Trainingstherapie. In der untersuchten Stichprobe wurden schon nach kurzer Zeit und im Verlauf der Studie bis zum Ende deutliche positive Veränderungen der Bewegungsmöglichkeiten der Lendenwirbelsäule festgestellt. Dass dies nicht bei allen Probanden bei allen Provokation einheitlich gleich war, lässt sich erklären durch die sehr unterschiedlichen Ausprägungen der Symptome, obwohl alle sicher zur Gruppe der „Low-Back-Pain“-Patienten zu zählen sind. Die Ergebnisse der Untersuchungen und die Durchführung des Trainings unter den festgelegten Bedingungen können weitere Erkenntnisse für effektive Therapiemaßnahmen für Rückenpatienten bringen. 6 Schlussthesen 6.1 Mit Hilfe des Ultraschall-Diagnoseverfahrens (System Zebris) am Beckenrand gelingt es, die unmittelbaren Auswirkungen des Aqua Joggings – repräsentiert durch eine verbesserte Beweglichkeit in Flexion, Extension, Lateralflexion und Rotation der LWS – nach jeder Therapieeinheit nachzuweisen. 6.2 Ein erhöhtes Niveau der Lendenwirbelsäulen–Bewegungsmöglichkeiten und eine Verbesserung der „Schmerzfaktoren“ kann durch ein spezifisches Aqua-Jogging Training erreicht werden. Eine längerfristige Wirksamkeit der Intervention in Form von geringeren Rückbildungsprozessen auf den alten Zustand vor Beginn des Programms konnte am Follow-up-Messzeitpunkt nur teilweise gezeigt werden. 6.3 Alle Teilnehmer der Studie reagierten beim Post Test im Vergleich mit dem Prä-Test – im Sinne der Schmerzreduktion – positiv auf die Teilnahme am Aqua-Jogging. Die Patienten fühlten sich nach dem Aqua Jogging wohler als vor dem Aqua-Jogging.:Abbildungsverzeichnis I Tabellenverzeichnis III Abkürzungsverzeichnis VIII Danksagung XI 1. Einleitung 1 1.1 Zur Frage der Prüfverfahren 3 1.2 Zielstellung der Arbeit 4 2. Wissenschaftlicher Sachstand 7 2.1 Medizinische Grundlagen zu „tiefen Rückenschmerzen“ („low back pain“) 7 2.1.1 Ursachen und Risikofaktoren 7 2.1.2 Therapiemöglichkeiten des chronischen unspezifischen Kreuzschmerzes 8 2.2 Bewegunsgmöglichkeiten der Lenden Wirbelsäule 10 2.2.1 Methoden zur Messung der Lendenwirbelsäulenbeweglichkeit 11 2.2.2 Die Neutral- oder Null-Methode 12 2.2.3 Schobersches Zeichen der Lendenwirbelsäule 12 2.2.4 CMS 10 -3D-Bewegungsanalyse der LWS (Ultraschall Zebris Mess System)12 2.3 Aktive Wassertherapie, therapeutisches Aqua-Jogging 14 2.3.1 Definition der Aktive Wassertherapie 14 2.3.2 Vorteile der „Aqualen Behandlung“ bei Rücken schmerzen 15 2.3.3 Bedeutung für die Situation der Wirbelsäule 15 2.3.4 Aqua jogging- Eine Form der Aktiven Wassertherapie 16 2.4 Forschungsmethodische Grundlagen 17 2.4.1 Einzelfallstudie 17 2.4.2 Qualitative versus quantitative Forschungsmethoden 18 3 Ziele und Forschungsfragen 19 3.1 Forschungsfragen 19 4. Verwendete Methoden 21 4.1 Verfahren der Datengewinnung 4.1.1 Prüfverfahren der Wirbelsäulenbeweglichkeit 23 4.1.1.1. Schoberzeichen 24 4.1.1.2. Ultraschalldiagnostische Verfahren 25 4.1.2 Messugen der Bewegungsmöglichkeiten 25 4.1.2.1 Ultraschalldiagnostik als verlaufsdiagnostisches Kontrollverfahren am Beckenrand 26 4.1.3 Überprüfung des aktuellen Schmerzempfindens 30 4.1.3.1 Der Fragebogen zur Schmerzregulation (FSR) (im Prä- Test, Post- Test und Follow up) 31 4.1.4 Erhebung der Anthropometrischen Daten 33 4.1.4.1 Körpergröße/-höhe 33 4.1.4.2 Körpergewicht 34 4.1.5 Weitere Verfahren der Verlaufsdiagnostik 34 4.1.5.1 Herzfrequenzmessung 34 4.1.5.2 Fragebogen zur körperlichen und psychosozialen subjektiven Befindlichkeit (Smylies), (modifiziert nach Innenmoser, 1998) und Borg-Skala 35 4.1.5.3 Die Kontrollverfahren zur Datengewinnung im Einzelnen Videokontrolle - Videoaufzeichnungen (Labortest, Verlaufsdiagnostik) 36 4.1.5.4 Diagnose- und Anamnesebogen (Prä-Test) aus dem Aqua-Jogging (Konzept INNENMOSER 2001) 36 4.1.5.5 Scmerztagebuch (in der Verlaufsdiagnostik und im Follow up) 37 4.2 Verfahren der Datenauswertung 38 4.2.1 Auswertung der Videoaufnahmen 38 4.2.2 Auswertung der Daten des Schmerzfragebogens(FSR) 39 4.2.3 Auswertung der Befindlichkeitsdaten 39 4.2.4 Auswertung der Daten des verlaufsdiagnostischen Verfahren (nach Innenmoser) 40 4.2.4.1 Auswertung der Verfahren der Ultraschalldiagnostik am Beckenrand und im Labor 41 4.3 Verfahren der Datendarstellung 41 4.3.1 Grafische Darstellung der „weichen Messdaten“ 41 4.3.2 Darstellung der Einzelergebnisse der Probanden Ultraschall Messdaten 41 4.4 Maßnahmen der Interventionen („therapeutisches Aqua- Jogging“) 41 4.4.1 Methodische Vorgehensweisen und Inhalte 42 4.5 Teilnehmer der Studie 44 4.5.1 tabellarische Daten im Vergleich 44 4.5.2. Ausführliche Einzeldarstellung 45 4.6. Zeitplanung 47 5. Ergebnisse 49 5.1 Labormessdaten 49 5.2 Ultraschall- Diagnostik 54 5.2.1 Labormessungen prä, post, follow- up 54 5.2.2 Messungen am Beckenrand im zeitlichen Verlauf 59 5.3 Veränderungen im Befinden 104 5.4 Zusammenfassung Für alle Probanden 110 5.5 Empfehlenswerte Inhalte/Bewegungsaufgaben des therapeutischen Aqua- Jogging 111 6 Diskussion der verwendeten Methoden und Verfahren 113 6.1 Kritische Überprüfungen der verwendeten Verfahren und Methoden 113 6.1.1 Prüfung der Bewegungsmöglichkeit der LWS mit Hilfe des Zebris-Mess- Systems 115 6.1.2 Befragung zur Erfassung des Befindens 119 6.1.3 Befragungen zur Erfassung der Schmerzintensität (FSR) 120 7. Diskussion der Ergebnisse 121 7.1 Exemplarischer Vergleich der Ergebnisse einzelner Teilnehmer im zeitlichen Verlauf 121 7.1.1 Vergleich der Ergebnisse 3D-Bewegungsfunktionsanalyse Zebris ausgewählter Teilnehmer im zeitlichen Verlauf 121 7.1.2 Ergebnisse zur körperlichen und psychischen Befindlichkeit 127 7.1.2.1 Körperliches Befinden (Mittelwerte der 5 Therapiestunden (Vor/ Nach) 127 7.1.2.2 Befragung zur Erfassung der psychischen Befindlichkeit (Vor/ Nach) in der verlaufsdiagnostischen Messreihe bei Alle Probanden 128 7.2 Vergleich der Ergebnisse der Gesamtgruppe (Prä-, Post-, Follow- up) 129 7.2.1 Vergleich der Ergebnisse der Messung des „Schoberzeichen“ der Gesamtgruppe (Prä-Post-Follow-up) 129 7.2.2 Ergebnisse der 3D-Bewegungsfunktionsanalyse der Gesamtgruppe 130 7.3 Vergleich der Messdaten am Beckenrand versus Labormessungen 133 7.3.1 Messdaten der Ultraschall-Untersuchung mit denen der klassischen Prüfverfahren 133 8. Zusammenfassende Wertungen der Wirkungen von therapeutischem Aqua- Jogging 134 8.1 Diskussionen unter Berücksichtigung der Hypothesen 140 8.2 Zusammenfassung (Hypothesen) 144 9. Literaturverzeichnis 145 10. Anhang 156 10.1 Fragebögen 156 10.1.1 Fragebögen FSR 156 10.1.2 Fragebögen Befindlichkeit 160 10.1.3 Fragebögen Diagnose- und Anamnesebogen 162 10.2. Schmerztagebuch 165 10.3 Dokumentation zur Markierung Dornfortsatz des Wirbelkörpers T12 und S1 des Patienten. Für Befestigung Zwei Signalgeber 165 10.4 Verlauf ausgewählter Übungseinheiten 166 10.5 Thesen zur Dissertationsschrift 172 10,6 Versicherung 176 10.7 Lebenslauf 177

The risk of having a disability increases with advancing age and as the life expectancy is growing worldwide, the number of people living with disability is expected to increase, as well as the number of years lived with disability. Low back pain and sarcopenia are health problems that present a higher prevalence with aging. While low back pain is a symptom, sarcopenia is considered a geriatric syndrome. However, both issues constitute a significant health burden in older adults. Although there are many research studies investigating low back pain, the participation of older adults is often missing from these studies, preventing the generalization of the findings to this population, and leaving some questions unanswered. On the other hand, sarcopenia is a new research field with gaps to fill and flaws to correct. Questions related to low back pain management in older adults, the inclusion of this population in clinical trials, the presence of association between sarcopenia and low back pain and questions pertaining the diagnosis and measurement of sarcopenia have yet to be fully addressed by researchers. The broad aim of this thesis therefore was to contribute to a better understanding concerning low back pain and sarcopenia in older adults by performing studies in these key research areas. Different interventions are presented in clinical practice guidelines for the treatment of low back pain. However, these recommendations are based on clinical trials investigating young and middle-aged adults and as a result, the recommendations do not encompass older adults. Therefore, a systematic review was performed with the objective of assessing the effectiveness of interventions for low back pain in older adults ≥ 60 years (Chapter 3). Eligible studies were identified via searches in Medline, EMBASE, CINAHL, LILACS, PEDro, and Cochrane CENTRAL. A total of 18 randomized controlled trials fulfilled the eligibility criteria and the results from eight trials were pooled in a meta-analysis to test the effectiveness of complementary health approaches (i.e., manual therapy, acupuncture, mindfulness, yoga). Evidence about interventions to manage non-specific low back pain in older adults was found to be weak. Very low to moderate quality evidence showed that complementary health approaches, percutaneous electrical nerve stimulation, education, exercise, or pharmacological agents did not produce a clinically significant reduction in pain and disability at short and intermediate terms compared to sham, usual care, or minimal intervention. Interventions were often not well described and the risk of bias was moderate (average of 6.4 on the 10-point PEDro Scale (SD = 1.44)). Evidence about interventions for non-specific low back pain in older adults is limited and new studies are highly likely to change these results. Participation of older adults in clinical trials pertaining to the management of low back pain has been limited. Usually, the exclusion of older adults from clinical trials is based solely on an arbitrary age limit. Therefore, an investigation concerning the potential increased inclusion of older adults in upcoming clinical trials was conducted (Chapter 4). Chapter four presents an analysis of the International Clinical Trial Registry Platform database from the World Health Organization performed to verify the participation of older adults in registered clinical trials. A total of 167 clinical trial protocols for low back pain with registration dates from January 2015 through November 2018 were planning to recruit participants older than 65 years. However, only five registered trials (2.99%; pooled sample = 169 participants) were designed to target this population specifically. The exclusion of older participants was not formally justified and imposed through an arbitrary upper-age limit in 93.6% of the protocols. Most studies planning to include older adults were interested in pharmacologic interventions, devices/technology, and physical rehabilitation, and were to be carried out in developed regions. However, older adults with low back pain will continue to be under-investigated in clinical trials for low back pain in the near future. Although a slight increase in the participation of older adults in clinical trials was observed, the improvement is small and some questions still need an answer. Therefore, a survey investigating whether researchers recognize the exclusion of older adults from clinical trials, its impact, and justifications to support this exclusion was realized (Chapter 5). All attendees of the 2017 International Back Forum were invited by email to answer an electronic survey about their opinions regarding participation of older adults in clinical trials for low back pain. Approximately 90% of those who answered the questionnaire were engaged with back research, with more than a half having done or doing a clinical trial for low back pain. Most of the respondents believed that older people are excluded from clinical trials for low back pain and that exclusion based solely on age is not justifiable. About two thirds of the respondents reported that the exclusion of older people from clinical trials can impose a barrier in offering evidence-based interventions to this population. More researchers are planning to include older adults in their current/future trials compared to their previous work. An increase in the investigation of older adults in clinical trials is expected in the future which may optimize the development of evidence-based interventions for this population. As early evidence suggests an association between sarcopenic markers and low back pain, the association between the diagnosis of sarcopenia and low back pain still needs to be investigated (Chapter 6). Therefore, a study investigating the association between sarcopenia using different diagnosis criteria and low back pain in older adults was performed. Data from 12,646 older adults (50.1% men, 49.9% women) ≥ 65 years of age that participated in the Canadian Longitudinal Study on Aging (CLSA) were analyzed. The prevalence of low back pain in the past 12 months as well the prevalence of sarcopenia assessed through different definitions, and the number of comorbidities and depressive symptoms were included in the analysis. Associations between sarcopenia, comorbidities and lifestyle factors with low back pain were examined using multivariate logistic regressions. Prevalence of low back pain was 16.3% and the prevalence of sarcopenia varied among sarcopenia definitions and the presence of low back pain. Participants with low back pain had higher prevalence of pre-sarcopenia and sarcopenia compared to those without low back pain based on the International Working Group on Sarcopenia (x2 = 20.25, p < 0.001) and the Foundation National Institute of Health definitions (x2 = 13.83, p < 0.001). The odds of having low back pain was higher among those with sarcopenia based on the Foundation National Institute of Health criterion (OR 1.28, 95%CI 1.0-1.64). These results suggest that sarcopenia may influence low back pain in older adults and future studies should consider to test whether the association between sarcopenia and low back pain is causal. Current clinical practice guidelines recommend to divide patients with low back pain in specific subgroups to provide a targeted intervention. However, despite older adults presenting specific age-related characteristics that could classify them as a subgroup, this population has been neglected. Sarcopenia is a muscle disease affecting older adults and is diagnosed with the presence of a reduction in muscle strength and muscle quantity/quality. Although low back pain has been shown to be associated with muscle dysfunction, the role of sarcopenia in relation to low back pain is unknown. An experiment comparing sarcopenic markers (grip strength and gait speed), muscle activity and elasticity between older adults with and without chronic low back pain was conducted (Chapter 7). The anticipatory activity of transversus abdominis muscle during the rapid arm abduction test, transversus abdominis muscle elasticity, grip strength and gait speed were collected from a group of older adults (≥ 60 years) with chronic low back pain (≥ 3 months) and the results compared with a control group of matched older adults without low back pain. Participants with chronic low back pain presented with a reduction in the sarcopenic markers compared with the controls: grip strength (mean difference (MD) = 5.3Kg, 95%CI = 1.5-9.0, p = 0.006), gait speed (MD = 0.21m/s, 95%CI = 0.10-0.31, p<0.001), as well as a delay in activation of transversus abdominis (p = 0.002). A delay in transversus abdominis muscle activation, and a reduction in muscle strength and gait speed were observed in older adults with chronic low back pain compared to subjects without back complaints. These findings show an association between muscle dysfunction and chronic low back pain in older adults. Although the definition of sarcopenia was recently updated establishing muscle strength as the key criteria surpassing the role of muscle mass, there remains confusion regarding its diagnosis and the comparison of estimates is problematic. Therefore, a systematic review assessing how sarcopenia is measured and defined in population-based studies was performed. Chapters 8 and 9 describe the protocol of a systematic review and the full systematic review respectively. The databases Medline, EMBASE, CINAHL, Web of Science (Core Collection), and Google Scholar were searched for observational population-based studies reporting prevalence of sarcopenia in community dwelling older adults. Descriptive statistics were used to present data pertaining to sarcopenia definition and measurement tools, and the quality-effects model for meta-analysis of pooled prevalence. Results found seven different operational definitions of sarcopenia and a variety of measurement tools applied to assess the sarcopenic markers: muscle mass, muscle strength and physical performance. The prevalence of sarcopenia varied between the definitions, with general estimates ranging from 5% based on the European Working Group on Sarcopenia in Older People (EWGSOP1) criterion to 17% with the International Working Group on Sarcopenia criterion. The use of different measurement tools to assess muscle mass, strength and physical performance resulted in variations within definitions ranging from 1 to 7%, 1 to 12% and 0 to 22%, respectively. The criteria used to define sarcopenia, as well as the measurement tools used to assess sarcopenic markers has an influence in the prevalence of sarcopenia. The establishment of a unique definition for sarcopenia, the use of methods that guarantee an accurate evaluation of muscle mass, and the standardization of measurement tools are necessary to allow a proper diagnosis and comparison of sarcopenia prevalence among populations.

Background:Lower back pain is one of the most common health-related complaints in the adult population. Thirty percent of Americans 65 years and older reported symptoms of lower back pain in 2004. With an aging population, the proportion of people over the age of 65 is expected to reach 20% by the year 2030. Because of this increase in older adults, lumbar spinal stenosis (LSS) associated with arthritic changes will also likely increase. In older adults, lower back pain is most often caused by degenerative lumbar spinal stenosis. Stenosis is the narrowing ofthe spinal canal, causing pressure on the nerve roots and is frequently treated surgically. Lumbar spinal stenosis is one of the most common reasons for back surgery in patients 65 years and older 2. However, risks associated with surgery increase with age 3-5 and older patients may choose non-surgical treatment for their lower back pain, including injection treatment. Injection treatment, usually consisting of anti-inflammatory medications and analgesics, has improved since the mid-1990's when fluoroscopic guidance was developed. Information about injection treatment for lower back pain is limited, especially in the older population. An extensive review of published literature regarding injection treatment revealed a paucity of information about older adults diagnosed with lumbar spinal stenosis. In this study, three aims were designed to gain more information about the effectiveness of injection treatment in older patients with lumbar spinal stenosis. In the first (retrospective) study, information about receipt of second injections and time between injections was collected to examine injection usage. In the second and third (prospective) studies, information about pain relief and functional return following injection treatment was collected to examine the effectiveness of injection treatment in patients age 60 and older diagnosed with lumbar spinal stenosis. To our knowledge, such results have not been repolted for this population in the literature. Objective:Injection treatment is a commonly used non-surgical procedure to alleviate lower back pain in older adults. However, older patients do not have enough information about how long pain relief will last after treatment or the amount of pain relief and functional return they will experience. These studies focused on three topics: 1) usage of injection treatment; 2) effectiveness of injection treatment on pain relief; 3) effectiveness of injection treatment on functional return. In addition, the variations of the effectiveness were examined by selected patient attributes. Methods:In a retrospective study, medical records of patients aged 60 years or older from a high volume dedicated spine center at the University of Massachusetts Memorial Hospital were retrospectively reviewed. This study included those diagnosed with degenerative LSS, who had not received an injection for lower back pain within six months, and whom were treated between June I, 2006 and May 31, 2007. In two prospective studies, patients scheduled for lumbar injection treatment between January 1 and June 30, 2008 were selected from the University of Massachusetts Memorial Hospital Spine Center. Selection criteria included patients age 60 and over, diagnosed with degenerative lumbar spinal stenosis and no previous lumbar injection within 6 months or lumbar surgery within 2 years. The Pain sub-score of the SF-36 questionnaire was used to measure pain at baseline and at one and three months post injection. The Physical Component Score (PCS) of the SF-36 questionnaire and the Oswestry Disability Index (ODI) were used to measure function at baseline and at one and three months post injection. Variations in longitudinal changes in scores by patient characteristics were analyzed in both unadjusted (univariate) analyses using one-way analysis of variance (ANOVA), and adjusted (multiple regression) analyses using linear mixed effects models. Results: In the retrospective cohort, the mean age of the cohort was 68, 64% were female, 59% were married, with a mean Body Mass index of 32 kg/m2. Of 92 eligible patients, 57% returned for a second injection within six months of the first. The mean number of months between injections was 4.8 for all patients, ranging from 1 to 22 months. When patient characteristics were examined, the only variable that showed a statistically significant difference was age. Patients aged 70 years and older were found to be 67% less likely to return for a second injection when compared to patients age 60-69 (OR=0.33 (0.12 - 0.94)p In the prospective cohort, information was collected on 62 patients. Mean Pain scores improved significantly from baseline to one month (14.1 points), and from baseline to three months (8.3 points). Post injection changes in Pain scores varied by Body Mass Index (BMI) and baseline emotional health. Based on a linear mixed effects model analysis, higher baseline emotional health, as measured by the SF-36 Mental Component Score (MCS>50), was associated with greater reduction in pain over three months when compared to lower emotional health (MCS Conclusion: Patients over age 70 do not return for repeat injection as frequently as patients age 60-69. In addition, each year a patient ages over age 60, they are 10% less likely to return for a repeat injection. Lower back pain in older adults with LSS is clinically significantly alleviated after injection treatment. In addition, injection treatment for LSS is associated with return of lost function needed for daily living activities in older adults. Pain relief and functional return varies by patient personal and clinical characteristics. Higher emotional health was associated with more pain relief and more functional return experienced over three months following injection treatment. Additional information is needed about why older patients do not return for second injections at the same rate as younger patients and how emotional health affects response to injection treatment in older adults.

Problem Statement: Because of the lack of evidence in support of a pathology-based approach to low back pain (LBP), many researchers advocate the use of classification systems that classify patients with LBP based on common clinical characteristics. Treatment based on direction tolerance can improve circulation, diminish pain and inflammation, restore normal motion, and reduce fear-avoidance beliefs. Treatment performed in the standing position can functionally integrate related regions of the body, can replicate normal tissue loading in standing position, replicate normal proprioceptive demands of motion performed in standing position, and address underlying movement impairments in related regions that may contribute to compensatory tissue pathology in the low back. The problem is that none of the existing functional classification systems for evaluation and treatment of LBP are designed for this purpose. The Direction Tolerance System (DTS) is a new functional classification system that is based on direction tolerance and performed entirely in the standing position. Objectives: The purpose of this research was to investigate the reliability, outcome, and prognostic ability of the DTS for evaluation and treatment of LBP. Methods: This exploratory research was a prospective cohort study with 60 patients seeking physical therapy (PT) for treatment of LBP by 5 different therapists. All patients were evaluated and treated for 8 visits using the DTS. Reliability was measured by comparing DTS scores (DTI) on visits 1 and 2. DTS treatment consisted of a scripted flexibility and strengthening exercise program based on motions that were determined to be non-aggravating during the DTS examination. Outcome was assessed using the DTI, modified Oswestry Disability Questionnaire (ODQ), Numeric Pain Rating Scale (NPRS) and Fear-Avoidance Beliefs Questionnaire Physical Activity Subscale (PABQ-PA). Baseline variables were assessed for correlation with successful outcome and ability to predict a successful outcome. Results: (1) Group intra-rater reliability between visits 1 and 2 using ICC (3,1) was good (.80, p<.001); (2) The group success rate was 62%, which exceeded the expected 50% success rate. (3) Baseline variables were not associated with a successful outcome and did not significantly predict a successful outcome. Discussion: The DTS is a simple, reliable and effective method of evaluating and treating LBP, and with proper training, can be used by clinicians.

Background: The presence of muscular deficiency seems to be a major cause of back pain that requires counteractions. Considering that the autochthonous back muscles, responsible for straightening and stabilizing the spine, cannot be activated voluntarily, they can be strengthened only through specific training. The computer-supported test and training system (CTT) Centaur (BfMC GmbH, Leipzig, SN, Germany) seems well suited for this purpose. To show its potential as a reliable diagnostic and training tool, this study aimed to evaluate the test-retest reliability of this 3D spatial rotation device. Methods: A prospective pilot study was conducted in 20 healthy volunteers of both sexes. For test-retest reliability analysis, three measurements were performed with a two-day interval between each measurement. Each measurement consisted of a one-minute endurance test performed in eight different positions (transverse plane). During the test, the subject was tilted by 90° in the sagittal plane from a neutral, upright position. Meanwhile, the subject's level of upper body stabilization along the body axis was assessed. All trunk movements (momentum values) were quantified by a multicomponent force sensor and standardized relative to the subject's upper body mass. The range of motion was assessed by 95% confidence ellipse analysis. Here, all position-specific confidence ellipses for each measurement were merged to a summarized quantity. Finally, ICC analysis using a single-rating, absolute agreement, two-way mixed-effects model and a Bland-Altman plot was performed to determine the reliability. Results: Considering all measurements (t1, t2, t3), the ICC for reliability evaluation was 0.805, and the corresponding 95% confidence interval (CI) was [0.643, 0.910]. Moreover, the Bland-Altman plots for all three pairs of time points did not show significant differences. Conclusion: This study concludes that the CTT Centaur shows good test-retest reliability, indicating it can be used in clinical practice in the future.

Bakgrund: Längdskidåkning är en sport med hög förekomst av överbelastningsskador i ländryggen. Anledningarna till besvärens uppkomst har diskuterats frekvent och flera faktorer har setts spela in. Att variera träningen har setts vara viktigt, inte minst under uppväxten, för att undvika skador längre upp i åldrarna.  Syfte: Att undersöka förekomsten av upplevda ländryggsbesvär de senaste 12 månaderna hos elever på längdskidgymnasium i Sverige. Studien undersökte även skillnader i träningsminuter och träningsvariation under åldern 10–12 år mellan elever utan ländryggsbesvär och elever med lindriga–svåra ländryggsbesvär. Metod: En deskriptiv jämförande tvärsnittsstudie gjordes där 11 av Sveriges 12 längdskidgymnasium deltog. Antalet studiedeltagare var 147, vilket motsvarade en svarsfrekvens på 46%. Könsfördelningen var 52,4% kvinnor och 47,6% män. En webbenkät besvarades angående ländryggsbesvär de senaste 12 månaderna baserat på frågeformuläret Nordic Musculoskeletal Questionnaire (NMQ). Även frågor gällande träning under åldern 10–12 och ländryggsbesvär under längdskidåkning besvarades. Utifrån svaren delades deltagarna in i grupper baserade på besvärsgrad.  Resultat: Förekomsten av ländryggsbesvär senaste 12 månaderna var 50,3%. Det fanns inga signifikanta skillnader gällande träningsminuter under uppväxten mellan grupperna “ej besvär” och “måttliga-svåra besvär” respektive “ej besvär” och “besvär”. Slutsats: Studiens resultat kunde bekräfta en hög förekomst av ländryggsbesvär hos längdskidgymnasieelever. Inga skillnader sågs i träningen under uppväxten mellan de med respektive utan besvär. Fler faktorer spelar in och vidare studier krävs för att få klarhet i varför besvären uppstår i en så hög grad. / Background: Cross-country skiing have a high prevalence of overuse injuries mainly located at the lower back. Low back pain (LBP) is frequently discussed among cross-country skiers and several factors may cause the problem. A variation in training has been seen to be important, especially during childhood, to avoid overuse injuries in higher ages.  Objective: To investigate the prevalence of LBP for the past 12 months in Swedish high school students specialized at cross-country skiing. The study also investigated the differences in training minutes and the variation in training during age 10–12 years between students without LBP and students with mild to severe LBP. Method: A descriptive comparative cross-sectional study was made, 11 of the 12 cross-country ski high schools in Sweden participated. The response rate was 46% which corresponds 147 participants, 52,4% women and 47,6% men.  The participants answered a web survey with questions regarding LBP the last 12 months and training during childhood. Groups based on the severity of LBP was formed.  Results: The prevalence of LBP the last 12 months was 50,3%. There were no significant differences regarding training in the age of 10–12 years between the groups. Conclusion: The study confirms that the prevalence of LBP is high in high school students specialized at cross-country skiing. No differences were found regarding training during childhood between the groups. More factors may affect the problem and further research is needed.

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No description available.

BACKGROUND: Chronic low back pain (CLBP) is the leading cause of disability in the United States. People suffering from CLBP often have multiple comorbidities including depression, anxiety, and substance use disorder (SUD). Although the opioid epidemic has intensified the search for new treatment options, both pharmacological and other, opioids still remain the most common treatment for chronic pain. Long-term opioid therapy (LTOT) has been shown to lead to opioid-induced hyperalgesia (OIH), an increased sensitivity to painful stimuli. It remains unclear, however, the extent to which reductions in opioid dose impact OIH. METHODS: This is a longitudinal cohort study whose primary aim is to determine how changes in opioid doses are associated with changes in psychosocial and quantitative sensory testing (QST) variables. Participants were 24 adults with CLBP being treated with LTOT and visits were conducted on a monthly basis for six months. All 24 participants were included in the analysis of demographic and psychosocial variables (disability, anxiety, depression, opioid misuse, pain severity, pain interference, and catastrophizing). A subset of 13 participants were included in the analysis of QST variables. RESULTS: We found that pressure pain thresholds at the thumb and the trapezius, and heat pain threshold significantly (p < 0.05) improved between visit 1 and visit 6. We also found that a decrease in morphine equivalent doses (MED) is correlated (coefficient > 0.2) with improvements in punctuate probe rating, pain pressure at the thumb, and maximum cold ratings. DISCUSSION: Our results show that reductions in opioid dose are associated with reduced pain sensitivity, even while the psychosocial variables studied (including subjective pain score, depression, and anxiety) remain stable.

Chronic low back pain (CLBP) is a nonspecific and persistent ailment that entails many physiological, psychological, social, and economic consequences for individuals and societies. Although there is a plethora of treatments available to treat CLBP, each treatment has varying efficacy for different patients, and it is currently unknown how to best link patients to their ideal treatment. However, it is known that biopsychosocial influences associated with CLBP affect the way that we move. It has been hypothesized that identifying phenotypes of spinal motion could facilitate an objective and repeatable method of determining the optimal treatment for each patient. The objective of this research was to develop an array of high deflection strain gauges to monitor spinal motion, and use that information to identify spinal-motion phenotypes. The high deflection strain gauges used in this endeavor exhibit highly nonlinear electrical signal due to their viscoelastic material properties. Two sub-models were developed to account for these nonlinearities: the first characterizes the relationship between quasistatic strain and resistance, and the second accounts for transient electrical phenomena due to the viscoelastic response to dynamic loads. These sub-models are superimposed to predict and interpret the electrical signal under a wide range of applications. The combined model accurately predicts sensor strain with a mean absolute error (MAE) of 1.4% strain and strain rate with an MAE of 0.036 mm/s. Additionally, a multilayered architecture was developed for the strain gauges to provide mechanical support during high strain, cyclic loads. The architecture significantly mitigates sensor creep and viscoplastic deformation, thereby reducing electrical signal drift by 74%. This research also evaluates the effects of CLBP on patient-reported outcomes. An exploratory factor analysis revealed that there are five primary components of well-being: Pain and Physical Limitations, Psychological Distress, Physical Activity, Sleep Deprivation, and Pain Catastrophizing. The presence of CLBP has adverse effects on all these components. It was also observed that different patient reported outcomes are highly correlated with each other, and the presence of CLBP is a significant moderating factor in many of these relationships. Arrays of high-deflection strain gauges were used to collect spinal kinematic data from 274 subjects. Seven phenotypes of spinal motion were identified among study participants. Statistical analyses revealed significant differences in the patient-reported outcomes of subjects who exhibited different phenotypes. This is a promising indication that the phenotypes may also provide important information to clinicians who treat patients suffering from CLBP. Future research will be conducted to develop and identify the optimal treatments for patients according to their phenotypes, which has the potential to reduce medical costs, expedite recovery, and improve the lives of millions of patients worldwide.