Objetivo: Determinar la prevalencia y factores asociados a la adherencia de los fisioterapeutas peruanos a las guías de práctica clínica del dolor lumbar. Diseño: El diseño del estudio es exploratorio de tipo observacional, utilizando el estudio de corte transversal analítico. El cual pretende asociar los factores exposición a la adhesión a las guías de prácticas clínicas de los fisioterapeutas licenciados del Perú que hayan tratado pacientes con dolor lumbar.

Solicitud de embargo por publicación en revista indexada. / Objetivo: Determinar si existe asociación entre haber padecido de esguince de tobillo y la presencia de dolor lumbar en bailarines de ballet de 18 a más años de edad, en el último año. Diseño: Diseño transversal analítico prospectivo observacional.

M.Tech. / aim of this unblinded randomized control study was to compare Chiropractic Adjustive Therapy (CAT) to Interferential Current Therapy (IFC) as treatment for Painful Minor Intervertebral Dysfunction (PMID) in the lumbar spine. The effects of CAT and IFC on lumbar spine range of motion (ROM) and pain relief from PMID were also examined. The participants of the trials were treated at the Chiropractic Day Clinic at the University of Johannesburg. Thirty participants presenting with Low Back Pain (LBP) and PMID on segmental intervertebral examination were used for this study and divided into two groups of fifteen. Group A participants were treated with CAT applied to the painful intervertebral segment. Group B participants were treated with IFC over the painful intervertebral segment. The objective data for this research was recorded by the readings obtained from the application of transverse pressure by a Pressure Algometer to the lateral aspect of a painful spinous process. Further objective readings were taken using a Digital Inclinometer to measure the participants Range of Motion (ROM). Subjective data was obtained by an Oswestry Pain and Disability Index (ODI). The subjective and the objective data were both recorded at the first, fourth and seventh visit which took place over a three week period. The results of the study showed that Group A had a statistically significant decrease in Pressure Algometer Readings and ODI scores. Group A also showed a statistically significant improvement in ROM readings for Left Lateral Flexion, Left Rotation and Right Rotation. Group B did not show any statistical significance in either the subjective or objective data. Importantly, an Inter-group comparison for the Pressure Algometer Readings also revealed an increasing statistically significant difference between Group A and Group B from the first to the fourth and seventh visit. The pain elicited by transverse pressure to a spinous process is core to the diagnosis of PMID, which can result in many pain syndromes of vertebral origin (Maigne, 2006). This research provides evidence that CAT is more beneficial than IFC for the treatment of PMID in the lumbar spine over a short and longer period of time.

published_or_final_version / Orthopaedics and Traumatology / Master / Master of Philosophy

Objective: To develop modular software to assess angular impulse and to determine the effect of a reduced dataset on the net angular impulse acting at the L5/S1 joint. Background. With the prevalence and incidence of lower back pain increasing annually, accurate assessment of physical job demands is needed. Many lab based approaches exist to measure the moments acting on the lower back, but require advanced and sensitive testing equipment. Of the methodologies currently used in industrial settings, most require significant contributions of time or money to be implemented. There is a need for cost and time effective methods to record a worker’s kinematic data over their whole shift. Methods: Twelve participants performed 12 consecutive lifts under five lifting conditions: SQ00 (squat 0kg); SQ04 (squat 4kg); SQ10 (squat 10kg); FP04 (fast squat 4kg); ST04 (stoop 4kg). Kinematic data of the upper limbs, head, and trunk was recorded with external load data and kinetic analysis was performed by implementing an extension of the Hof (1992) method called the lined-segment engine (LSE) to calculate the angular impulse (N•m•s) acting on the L5/S1 joint. Results: The LSE was sensitive to changes in load, lifting speed, and lifting posture (p < 0.05). There was no difference in dynamic, quasi-static, or static models when calculating angular impulse, but there was a difference in the L5/S1 angular impulse when the upper limbs were removed from the dynamic LSE model (p < 0.05). Conclusion: The LSE requires further refinement, but could be a generic approach to kinetic calculations. A scaled no-arms model for calculating the angular impulse acting on the low back could be used to assess field based lifting studies with 5.8% error. / Thesis (Master, Kinesiology & Health Studies) -- Queen's University, 2013-08-03 15:05:03.257

Overloading of the back can cause instability such that buttressing the instability is a primary objective of many of the leading edge therapeutic approaches. However, a challenge lies in determining the location of the instability or the least stable vertebral joint. A mathematical analysis, based on a commonly used approach in engineering for determining structural stability, has been developed for the lumbar spine. The purpose of this investigation was to determine the feasibility of a method for mathematically locating potential areas of instability within a computer-based model of the lumbar spine. To validate this method, the eigenvector from the stability analysis was compared to the output from a geometric equation that approximated individual vertebral joint rotational stiffness with the idea that the entry in the eigenvector with the largest absolute value would correspond to the vertebral joint and axis with the lowest stiffness. Validation of the eigenvector was not possible due to computational similarities between the stability analysis and the geometric rotational stiffness method. However, it has been previously demonstrated that the eigenvector can be useful for locating instability, and thus warrants future study. Determining the least stable vertebral joint and axis can be used to guide proper motor pattern training as a clinical intervention. It was also shown in this investigation that an even distribution of fascicle force and stiffness generated stability. This supports the idea that well-coordinated efforts of muscle activation are beneficial for improving stability of the lumbar spine.

BACKGROUND: The psoas major is an important muscle that is part of the iliopsoas complex, which is also known as the hip flexor and contains a major web of nerves called the lumbar plexus. The location of the lumbar plexus within the psoas muscle has been studied on cadaveric dissections previously, particularly with respect to the location of the L4 nerve root but the effect of posture on psoas morphology has not previously been studied. Hip flexion along with the potential changes in spinal alignment while in an upright sitting position may cause significant changes in the positioning and geometry of the psoas and may also change the orientation of the lumbar plexus within the muscle. Current controversy exists in determining patient suitability for Lateral Lumbar Interbody Fusion (LLIF) based on psoas morphology. Oblique and trans-psoas approaches have become a popular minimally invasive lumbar fusion technique in recent years. Lumbar plexus injury, particularly L4 nerve root injury, is a known potential complication of the oblique and trans-psoas approach and may be minimized by careful assessment of the psoas anatomy preoperatively. Quadriceps weakness as a result of L4 nerve root injury is a known potential complication of the trans-psoas approach and may be minimized by careful assessment of the psoas anatomy preoperatively. Patients may present with a sitting MRI rather than supine MRI, however, the effect of posture on the geometry of the psoas muscle, and therefore of the lumbar plexus, has not been previously reported. METHODS: We conducted a retrospective review of a single-spine surgeon practice over a 6-month period to identify patients who had undergone MRI of the lumbar spine for evaluation of degenerative spinal pathologies. Male and female patients were included if aged between 18-90 years presenting with degenerative lumbar spinal pathology between 2015-2016, and excluded if they had previous lumbar fusion, scoliosis, diagnosed with neuromuscular disease, were skeletally immature or had intrinsic abnormalities of the psoas muscles (e.g. tumor, infection or trauma). The anteroposterior (AP) dimension of the psoas muscle was measured at each disc space from L1 to L5 and compared to the AP dimension of the intervertebral disc, as measured at the inferior vertebral endplate. The AP psoas:disc ratio was then calculated and compared between patients undergoing sitting and/or supine MRIs. RESULTS: With a total of 269 patients, 113 of them were male and 157 were female. 209 patients were identified with supine-, and 60 patients with sitting- MRIs, of which 13 patients had undergone both sitting and supine MRIs (BOTH group). A propensity score match (PSM) was performed for patients undergoing either a supine or sitting MRI to match for age, BMI and gender to produce two groups of 43 patients. In the BOTH and PSM group, the sitting MRIs displayed significantly higher AP psoas:disc ratio compared with the supine MRIs at all intervertebral levels except L1-L2. The largest difference observed was a mean 32-37% increase in sitting AP psoas:disc ratio at the L4-L5 disc in sitting MRIs compared to supine MRIs in the BOTH group (range 0-137%). CONCLUSIONS: The psoas muscle and the lumbar plexus became anteriorly displace in sitting MRIs, with a greater effect noted at caudal intervertebral discs. This may have implication in selection suitability for LLIF and intra-operative patient positioning.

Objectiu:Investigar el comportament biomecànic de diversos al·loempelts (fèmur, tíbia i peroné) col·locats anteriorment en substitució del cos vertebral. Investigar la influència de la preparació del platet vertebral en un model de corporectomia per avaluar la millor configuració biomecànica.Material i mètode:S'utilitza un model no linear d'elements finits en tres dimensions del raquis lumbar (Noailly 2003) al qual s'adapten quatre cargols transpediculars (Sherpa®, Surgival® S.A.) en L3 i L5, dues barres i un connector. Aquest model va ser modificat amb l'extracció de d'ambdós disc intervertebrals i el cos de L4. Es van realitzar tomografies computeritzades d'un fragment diafisari de fèmur, un fragment diafisari de tíbia i un fragment diafisari de peroné del mateix pacient. Aquests fragments van ser reconstruïts i model·litzats, per a després ser inserits a dins del model. Es van investigar quatre configuracions dels empelts: amb un fragment de fèmur, amb un fragment de tíbia, amb tres fragments de peroné i amb sis fragments de peroné. Es van avaluar quatre configuracions del platet vertebral: amb l'empelt recolzat sobre tot el platet vertebral, amb l'empelt recolzat sobre la meitat de cartílag, amb l'empelt recolzat sobre l'os subcondral i amb l'empelt recolzat sobre l'os esponjós. Es van aplicar forces de compressió(1000N), flexió, extensió i torsió (15 Nmm), sobre el platet superior de L3, es va considerar el platet inferior de L5 fix, i es van calcular les tensions i deformacions produïdes.Resultats:Les tensions de Von Misses a dins del fixador es mantenen per sota del límit de fatiga del material i del Yield estrès quan es complementa el muntatge amb l'al·loempelt anterior, i per tant no es produeix la fallida del fixador. L'ús del fixador fa que el raquis lumbar sigui deu vegades més rígid, el que afectarà a la remodelació a llarg termini. La geometria i la configuració de l'al·loempelt te una important influència en les tensions i deformacions a dins de les vèrtebres adjacents, amb la reducció de les mateixes. La resecció del cartílag i la sustentació de l'empelt sobre el platet cortical es la configuració que canvia més les tensions del platet restant, creant àrees de tensions màximes en les zones de contacte. Per altre banda, la resecció complerta de l'os subcondral és la configuració que canvia menys la distribució de tensions en el platet vertebral. La utilització de sis peronés ha demostrat ser el muntatge més estable, però també el que modifica en major mesura les tensions en les vèrtebres adjacents. Donada la seva geometria el·lipsoidal, la tíbia dona unes deformacions més asimètriques que el fèmur. Els resultats amb al·loempelt de fèmur modifiquen en menor mesura les tensions en les vèrtebres adjacents, configurant un muntatge més fisiològic.Conclusions:La preservació del platet vertebral cortical no ofereix cap avantatge biomecànic significatiu en la reconstrucció de la columna anterior del raquis lumbar quan s'utilitza una instrumentació transpedicular rígida. Els fragments de diàfisi femoral col·locats en substitució del cos vertebral modifiquen en menor mesura la distribució de tensions i deformacions en les vèrtebres adjacents, en comparació amb tíbia i peroné, comportant-se des del punt de vista biomecànic de manera més fisiològica. / Aims.Investigate the influence of various types of allograft (from the tibia, femur, and fibula) through finite element analysis. Investigate the influence of end-plate preparation in a model of corporectomy to evaluate the best biomechanical configuration.Methods.A non-linear 3D finite element model of a lumbar spine L3-L5 was used as a physiologic model (Noailly, 2003). The model was modified with the insertion of a transpedicular instrumentation (Surgival SA, Spain) and the removal of the L4 body and two adjacent discs. CT scans of a femur, tibia and fibula from the same patient were performed. Fragments of each bone were reconstructed and inserted within the model. Four configurations of allografts were investigated: one femur fragment, one tibial fragment, three fragments of fibula, six fragments of fibula. Four configurations of endplate were investigated: with allograft supported on the entire end-plate, with allograft supported on the half of cartilage endplate wide, with allograft supported on the subcondral cortical shell and, finally, with allograft supported on the trabecular bone. Conventional types of loadings were applied on superior endplate of L3: compression (1000N), flexion, extension, and rotation (15Nm). Fixed displacements were imposed on the distal part of L5 endplate, and strain and stresses were calculated in large displacement (MARC, MSC Software).Results.Von Mises stresses within the internal fixator are well below the Yield stress and the fatigue limit and therefore no fracture of the fixator is foreseen. The use of a fixator to create fusion of the two vertebras makes the lumbar spine much stiffer. The geometry and configuration of the allografts have a large influence on the strain and stresses within the adjacent vertebrae with a reduction of strains and stresses. The resection of the cartilage and support the allograft in the cortical shell changes most the maximal principal strains in the remaining end-plate, and creates a peak stress in the contact area. On the other hand, the complete resection of cartilage and subcondral cortical end-plate is the configuration that changes least the maximal principal strains within the adjacent vertebrae. The use of fragments of fibula gives the most stable configuration, but this is also the configuration that changes most the maximal principal strains within the vertebrae. Results obtained with the femur or the tibia are very similar between each other. However, due to its ellipsoidal geometry, the allograft in tibia gives more asymmetric deformations than the femur.Conclusions.Preservation of the cortical end-plate may not offer a significant biomechanical advantage in reconstructing the anterior column of lumbar spine when rigid transpedicular instrumentation was used. Allografts harvested from the femur seems to be more reliable and change least the strain and stress distributions within the lumbar spine compared to allografts from the tibia or fibula.

Overloading of the back can cause instability such that buttressing the instability is a primary objective of many of the leading edge therapeutic approaches. However, a challenge lies in determining the location of the instability or the least stable vertebral joint. A mathematical analysis, based on a commonly used approach in engineering for determining structural stability, has been developed for the lumbar spine. The purpose of this investigation was to determine the feasibility of a method for mathematically locating potential areas of instability within a computer-based model of the lumbar spine. To validate this method, the eigenvector from the stability analysis was compared to the output from a geometric equation that approximated individual vertebral joint rotational stiffness with the idea that the entry in the eigenvector with the largest absolute value would correspond to the vertebral joint and axis with the lowest stiffness. Validation of the eigenvector was not possible due to computational similarities between the stability analysis and the geometric rotational stiffness method. However, it has been previously demonstrated that the eigenvector can be useful for locating instability, and thus warrants future study. Determining the least stable vertebral joint and axis can be used to guide proper motor pattern training as a clinical intervention. It was also shown in this investigation that an even distribution of fascicle force and stiffness generated stability. This supports the idea that well-coordinated efforts of muscle activation are beneficial for improving stability of the lumbar spine.

名古屋大学博士学位論文 学位の種類 : 博士(医学)(論文) 学位授与年月日:平成4年7月20日 新田弘幸氏の博士論文として提出された