Introdução: Força, resistência e atividade muscular são uma área importante de pesquisa e avaliação contribuindo para um melhor entendimento de aspectos musculoesqueléticos de mecanismos de dor e lesão. No entanto, a utilização de testes que avaliem a região lombopélvica ainda é controversa, pois apesar de muitos testes clínicos estarem disponíveis na literatura, ainda não estão estabelecidos quais os mais confiáveis na prática clínica. Objetivos: Estabelecer valores de referência, determinar confiabilidade intra e interexaminador e as medidas de erro de um conjunto de testes clínicos que avaliam a região lombopélvica em indivíduos assintomáticos de diferentes gêneros, faixas etárias e níveis de atividade física. Materiais e Métodos: Para os valores de referência, 152 indivíduos (79 homens, 73 mulheres) estratificados por gênero, faixa etária e nível de atividade física realizaram um conjunto de nove testes clínicos: força isométrica máxima de abdutores, extensores, flexores e rotadores laterais de quadril, resistência nas posições de ponte lateral, ponte frontal, flexores e extensores lombares e atividade muscular da região lombopélvica. Para a confiabilidade, 33 indivíduos foram avaliados por dois examinadores em um intervalo de 3 a 7 dias, onde realizaram aleatoriamente o mesmo conjunto de testes. As medidas de confiabilidade foram avaliadas pelo Coeficiente de Correlação Interclasse (CCI2,1) e as medidas de erro definidas pelo Erro Padrão da Medida (EPM) e pela Mínima Mudança Detectável (MMD). Resultados: Foram observadas diferenças significativas (p<0.05) nos testes clínicos para as variáveis: gênero, faixa etária e nível de atividade física e estabelecidos valores de referência para cada grupo. Todos os testes apresentaram valores de confiabilidade excelente com CCI (IC 95%) maior que 0.8 para as confiabilidades intra e interexaminador; os valores da MMD foram superiores à média do EPM em todos os testes. Conclusão: Os resultados do presente estudo apontam valores de referência que contribuem com o estabelecimento de referências para auxiliar na tomada de decisões clínicas. Além disso, este conjunto de 10 testes apresentou confiabilidade intra e interexaminador bem como valores de EPM e MMD, confirmando a possibilidade de seu uso na prática clínica. / Background: The assessment of the lumbopelvic region is useful for many musculoskeletal dysfunctions. Several clinical tests are commonly used to assess this region, however, reference values for clinical assessments and results concerning method, reliability and error measurements of these tests have not been reported. Objectives: To establish reference values and to determine intra and interrater reliability, standard error of measurement (SEM) and minimum detectable change (MDC) of a set of clinical tests used for assessing the lumbopelvic region in asymptomatic volunteers of different gender, age groups and physical activity levels. Methods: For reference values, 152 subjects (79 men, 73 women) divided by gender, age group and physical activity levels, performed nine clinical tests: Maximum voluntary isometric strength of hip abductors, extensors, flexors and lateral rotators, transversus abdominis(TrA) muscle activity (using a Pressure Biofeedback Unit), prone and side bridges, trunk flexor and extensor endurance tests. To measure reliability, 33 individuals performed the same set of tests, in random order within a week period. Intrarater and interrater analysis were assessed using the Intraclass Correlation Coefficient (ICC) and the error measurements were defined by using the SEM and the MDC. Results: Reference values were established for each group and our results showed significant (p<0.05) differences concerning gender, age group and physical activity levels in clinical tests. In general, strength differences were related to gender and physical activity levels and endurance results could be related to interactions between gender, age group and physical activity levels. All tests presented good reliability indices with an ICC (95%CI) higher than 0.8 for the intrarater and interrater reliability; MDC values were greater than mean of SEM in all tests, confirming its usage for clinical practice assessments. Conclusion: Reference values are necessary to help clinicians in the evaluation of subjects and these results can contribute for clinical practice in providing clinical training targets. Also, this set of tests presented good intra and interrater reliability measures of strength, endurance and TrA muscle activity test as well as SEM and MDC values, confirming its use for assessing the lumbopelvic region.

A mielopatia espondilótica cervical (MEC) é afecção relacionada diretamente com o estreitamento do canal vertebral cervical. O objetivo deste estudo foi avaliar variações morfométricas da coluna vertebral cervical em pacientes portadores de MEC por meio da ressonância magnética dinâmica nas posições neutra, em flexão e em extensão. Este é um estudo prospectivo de pacientes portadores de MEC secundária à doença degenerativa da coluna vertebral cervical. Os parâmetros morfométricos foram avaliados pelas sequências de ressonância magnética ponderadas em T2, no plano sagital em posições neutra, flexão e extensão. Os parâmetros estudados foram o comprimento anterior da medula espinhal (CAME), o comprimento posterior da medula espinhal (CPME), o diâmetro do canal vertebral (DCV) e o diâmetro da medula espinhal (DME). O CAME e o CPME foram mais longo em flexão do que nas posições em neutro e extensão, sendo encontrada diferença estatisticamente significativa entre a posição em flexão e extensão. O DCV e o DME foram maiores em flexão do que nas posições neutra e em extensão, no entanto não foi encontrada diferença estatisticamente significativa quando comparados nas posições em neutro, flexão e extensão. Desta forma, o exame de ressonância magnética dinâmica permite avaliar as variações morfométricas do canal vertebral cervical em pacientes portadores de mielopatia cervical espondilótica. / Cervical spondylotic myelopathy is a condition directly related to the narrowing of the cervical vertebral canal. The objective of this study was to evaluate morphometric variations of the cervical spine in patients with CSM using dynamic magnetic resonance imaging (MRI) in neutral, flexion and extension positions. This is a prospective study of patients with CSM secondary to degenerative disease of the cervical spine. The morphometric parameters were evaluated using T2-weighted MRI sequences in the sagittal plane with neutral, flexion and extension position of the neck. The parameters studied were the anterior length of the spinal cord (ALSC), the posterior length of the spinal cord (PLSC), the diameter of the vertebral canal (DVC) and the diameter of the spinal cord (DSC). The ALSC and PLSC were longer in flexion than extension and neutral position, with statistically significant difference between the flexion and extension position. The DVC and the DSC were greater in flexion than in extension and neutral position, however there was no statistically significant difference when comparing the positions in neutral, flexion and extension. Therefore, dynamic MRI allowed to evaluate morphometric variations in the cervical spinal canal in patients with cervical spondylotic myelopathy.

Sweden and Norway have the worldwide highest incidence of osteoporotic fractures. As these fractures constitute a tremendous and growing problem, primary prevention is of great importance. The principal causes of an osteoporotic fracture are a fall and a fragile skeleton. The aim of the studies reported in these papers was therefore to determine the genetic and environmental influences on fractures and the genetic influence on the two main reasons to the emergence of osteoporotic fractures; bone mineral density and propensity to fall. In the present thesis, we display that the heritability of fractures is dependent on fracture site and age. With increasing age, lifestyle becomes the dominant explanatory factor. These results indicate that focus should be on lifestyle interventions for the prevention of fractures in the elderly. Although the genetic liability to impaired balance is modest, twins with self-reported impaired balance have a substantially increased risk of osteoporotic fractures compared to their co-twin without impaired balance. Asking a patient about his or her balance might be a simple tool for future risk assessment. The genetic influence on bone phenotypes is under strong genetic influence in Swedish adult twins. These findings are in agreement with the results from previous studies in other countries, with a lower incidence of osteoporotic fractures compared to Sweden. The high heritability of bone phenotypes together with the low heritability of fractures at old age, indicates that bone mineral density has a modest influence on fracture risk at old age. In summary, based on the results in this thesis, more emphasis should be targeted to the prevention of falls, by strength and balance training in order to prevent the occurrence of  low energy fractures in the elderly.

Background: The global burden of osteoporosis includes considerable numbers of fractures, morbidity, mortality and expenses, due mainly to vertebral, hip and forearm fractures. Underdiagnosis and undertreatment are common. Several studies have shown decreased health-related quality of life (HRQOL) after osteoporotic fracture, but there is a lack of data from long-term follow-up studies, particularly regarding vertebral fractures, which are often overlooked despite patients reporting symptoms. Aim: The overall aim of this thesis was to evaluate the usefulness of a recent low-energy fracture as index event in a case-finding strategy for osteoporosis and to describe and analyse long-term HRQOL in postmenopausal women with osteoporotic fracture. The specific aims were to describe bone mineral density and risk factors in women 55-75 years of age with a recent low-energy fracture (I), estimate the impact of osteoporotic fractures on HRQOL in women three months and two years after a forearm, proximal humerus, vertebral or hip fracture (II), investigate the changes and long-term impact of vertebral or hip fracture on HRQOL in women prospectively between two and seven years after the inclusion fracture (III), and describe how HRQOL and daily life had been affected in women with vertebral fracture several years after diagnosis (IV). Design and methods: Data were collected from southern Sweden between 1998 and 2008. A total of 303 women were included in Study I, and this group served as the basis for Studies II (n=303), III (n=67), and IV (n=10). A cross-sectional observational, case-control design (I), and a prospective longitudinal observational design (II-III) were used. In Study IV a qualitative inductive approach with interviews was used and data were analysed using a qualitative conventional content analysis. Results: The type of recent fracture and number of previous fractures are important information for finding the most osteoporotic women in terms of severity (I). Hip and vertebral fractures in particular have a significantly larger impact on HRQOL evaluated using the SF-36 than do humerus and forearm fractures, both during the three months after fracture and two years later, compared between the different fracture groups and the reference population (II). Women who had a vertebral fracture as inclusion fracture had remaining pronounced reduction of HRQOL at seven years. At the mean age of 75.5 years (±4.6 SD), the prevalence of vertebral fracture suggests more negative long-term impact on HRQOL, more severe osteoporosis and a poorer prognosis than a hip fracture does, and this effect may have been underestimated in the past (III). Study IV demonstrates that the women’s HRQOL and daily life have been strongly affected by the long-term impact of the vertebral fracture several years after diagnosis. The women strive to maintain their independence by trying to manage different types of symptoms and consequences in different ways. Conclusions and implications: Type and number of fractures should be taken into account in the case-finding strategy for osteoporosis in postmenopausal women between 55 and 75 years of age. The long-term reduction of HRQOL in postmenopausal women (age span 55-75 yr) with vertebral fracture emerged clearly, compared to women with other types of osteoporotic fractures and references in this thesis. The results ought to be taken into consideration when developing guidelines for more effective fracture prevention and treatment, including non-pharmacological intervention for women with osteoporotic fractures, with highest priority placed on vertebral fractures and multiple fractures, to increase or maintain HRQOL.

The research described in this thesis began with a single long-term objective: modelling of the vertebral artery during chiropractic manipulation of the cervical spine. Although chiropractic treatment has become prevalent, the possible correlation between neck manipulation and subsequent stroke in patients has been the subject of debate without resolution. Past research has been qualitative or statistical, whereas resolution demands a fundamental understanding of the associated mechanics.<p> Analysis in the thesis begins with a study of the anatomy and properties pertinent to the chiropractic problem. This indicates that the complexity of the problem will necessitate a long-term multidisciplinary effort including a nonlinear finite element formulation effective in analysing image data for soft tissue modelled as nearly incompressible. This leads to an assessment of existing finite element methods and the conclusion that new equation solving techniques are needed to ensure numerical stability.<p> Three techniques for effectively eliminating the source of numerical instability are developed and demonstrated with the aid of original finite element codes. Two of the methods are derived as modifications of matrix decomposition algorithms, while the third method constitutes a new finite element formulation. In addition, the understanding gained in developing these methods is used to produce a theorem for assessing a different but related problem: deformation of a nearly incompressible material subjected to a single concentrated force. Throughout the thesis, an interdisciplinary path from chiropractic problem to numerical algorithms is outlined, and results are in the form of mathematical proofs and derivations of both existing and new methods.

Biomaterials used for stabilization of compressed vertebraes due to osteoporosis, have mainly been based on resin materials, like PMMA (polymethyl methacrylate), but have recently expanded to consist of injectable ceramics, such as calcium-aluminate. In this in vitro study human osteoblast-like cells, MG-63, were cultured on three different injectable biomaterials based on: Ca-aluminate, Bis-GMA (bisphenol A-glycidylmethacrylate) and PMMA, to investigate the cellular response elicited by these materials. Cell proliferation was measured by the NucleoCounter® system, cell viability was investigated by LDH (lactate dehydrogenase) analysis, cell differentiation and mineralization was evaluated by mRNA gene expression of the osteoblastic markers: ALP (alkaline phosphatase), OC (osteocalcin) and COLL-I (collagen type I) by qPCR (quantitative polymerase chain reaction) analysis. Two control materials were used: TCP (tissue culture polystyrene, negative control) and PVC (polyvinyl chloride, positive control). The results showed that all the bone cement materials were non-toxic and biocompatible, i.e. they provided good cell viability and proliferation of the MG-63 cells. They are specific for bone cells, since they expressed high values of the osteoblast-specific differentiation markers, and are thus promising as injectable bone cement materials. Among the bone cements, Xeraspine appears to be the most biocompatible material for bone cells. It is followed by Cortoss and then Vertebroplastic.

The research described in this thesis began with a single long-term objective: modelling of the vertebral artery during chiropractic manipulation of the cervical spine. Although chiropractic treatment has become prevalent, the possible correlation between neck manipulation and subsequent stroke in patients has been the subject of debate without resolution. Past research has been qualitative or statistical, whereas resolution demands a fundamental understanding of the associated mechanics.<p> Analysis in the thesis begins with a study of the anatomy and properties pertinent to the chiropractic problem. This indicates that the complexity of the problem will necessitate a long-term multidisciplinary effort including a nonlinear finite element formulation effective in analysing image data for soft tissue modelled as nearly incompressible. This leads to an assessment of existing finite element methods and the conclusion that new equation solving techniques are needed to ensure numerical stability.<p> Three techniques for effectively eliminating the source of numerical instability are developed and demonstrated with the aid of original finite element codes. Two of the methods are derived as modifications of matrix decomposition algorithms, while the third method constitutes a new finite element formulation. In addition, the understanding gained in developing these methods is used to produce a theorem for assessing a different but related problem: deformation of a nearly incompressible material subjected to a single concentrated force. Throughout the thesis, an interdisciplinary path from chiropractic problem to numerical algorithms is outlined, and results are in the form of mathematical proofs and derivations of both existing and new methods.

<p>Biomaterials used for stabilization of compressed vertebraes due to osteoporosis, have mainly been based on resin materials, like PMMA (polymethyl methacrylate), but have recently expanded to consist of injectable ceramics, such as calcium-aluminate. In this in vitro study human osteoblast-like cells, MG-63, were cultured on three different injectable biomaterials based on: Ca-aluminate, Bis-GMA (bisphenol A-glycidylmethacrylate) and PMMA, to investigate the cellular response elicited by these materials. Cell proliferation was measured by the NucleoCounter® system, cell viability was investigated by LDH (lactate dehydrogenase) analysis, cell differentiation and mineralization was evaluated by mRNA gene expression of the osteoblastic markers: ALP (alkaline phosphatase), OC (osteocalcin) and COLL-I (collagen type I) by qPCR (quantitative polymerase chain reaction) analysis. Two control materials were used: TCP (tissue culture polystyrene, negative control) and PVC (polyvinyl chloride, positive control). The results showed that all the bone cement materials were non-toxic and biocompatible, i.e. they provided good cell viability and proliferation of the MG-63 cells. They are specific for bone cells, since they expressed high values of the osteoblast-specific differentiation markers, and are thus promising as injectable bone cement materials. Among the bone cements, Xeraspine appears to be the most biocompatible material for bone cells. It is followed by Cortoss and then Vertebroplastic.</p>

Replacing a diseased disc with a tissue engineered disc has the potential to restore normal spinal biomechanics. However, recreating the interface between annulus fibrosus (AF) and vertebral bone (VB) will be necessary to facilitate proper function of the implant in vivo. This study characterizes the native bovine AF-VB interface and assesses adult human discs. The AF insertion site in humans and cows is uniquely differentiated from other soft tissue-bone interfaces, as AF collagen fibers anchor into the calcified region of vertebral endplate through a zone of hyaline cartilage and have a different organization in inner and outer AF. Mineralization-associated proteins are present in this region and the chondroid tissue undergoes calcification over time. Based on these observations an in vitro AF culture system was developed and demonstrated that AF cells can induce mineralization. Understanding mechanism(s) regulating AF mineralization will help develop conditions to ensure proper integration of bioengineered AF.

Replacing a diseased disc with a tissue engineered disc has the potential to restore normal spinal biomechanics. However, recreating the interface between annulus fibrosus (AF) and vertebral bone (VB) will be necessary to facilitate proper function of the implant in vivo. This study characterizes the native bovine AF-VB interface and assesses adult human discs. The AF insertion site in humans and cows is uniquely differentiated from other soft tissue-bone interfaces, as AF collagen fibers anchor into the calcified region of vertebral endplate through a zone of hyaline cartilage and have a different organization in inner and outer AF. Mineralization-associated proteins are present in this region and the chondroid tissue undergoes calcification over time. Based on these observations an in vitro AF culture system was developed and demonstrated that AF cells can induce mineralization. Understanding mechanism(s) regulating AF mineralization will help develop conditions to ensure proper integration of bioengineered AF.