Archive for year: 2015

Limke JC, Eur J Phys Rehab Med. Dec;44 2008.

This interesting study at the New England Baptist bone and joint institute in Boston investigated the efficacy of its (2) set progressive resistance (PRE) program used to reverse deconditioning vs just (1) set. They were investigating whether completing (1) vs. (2) sets of resistance exercise during an otherwise identical spine rehab program would prove additional benefits from the additional set. There were 100 subjects with a mean age of 46. The measures included back strength and progressive iso-inertial lifting evaluation (PILE) at discharge from the program. Exercises consisted of Cybex back extension, rotary torso, pull downs, various hip and leg exercises as well as lifting crates. A (4) rep max as well as the PILE measures were the outcome measures.

Results: at discharge there was NO significant difference in strength, disability or pain measures between subjects completing (1) vs. (2) sets.

Conclusions:  These findings suggest that there is NO added benefits for completing a second set for patients with cLBP.

Most lumbar disc herniations protrude posterolateral, away from the center of the body. Once lateral the disc can lie either lateral or medial to the nerve root, the terms lateral &medial refer to the relationship between the disc and the nerve root NOT the relationship to the midline.  A lateral presentation finds the patient leaning away from the side of pain, medial leaning into the pain side.

Antalgia can help differentiate these two conditions and improve clinical treatment choice. Leaning the patient in the opposite direction increases radicular irritation in both conditions. However like extension pain at the initial motions, tolerance and improvement to repetitive motions signals a potential ‘directional preference’ and a less recalcitrant presentation in some cases. Many times patients will present with antalgia in more than one position and this needs to be taken into account as well.

Though Kemps test has been used to differentiate facet involvement its indications by some authors suggests a herniation differential in the case of antalgia as well. It is often done in the seated posture to increase IDP. Antalgia noted before these tests, resistance to lateral bending into and opposing antalgia and the resultant changes in back/leg pain must be taken into account in interpretation.

In 2013, Alayat et al reported on a randomized double-blind placebo-controlled trial of laser therapy for the treatment of 48 patients with Bell’s palsy. Facial exercises and massage  were given to all patients. Patients were randomized to one of three groups: high-intensity laser therapy, low-level laser therapy or exercise only. Laser treatment was given three times per week to eight points of the affected side for six weeks. At three and six weeks after treatment, outcomes were assessed using the facial disability scale (FDI) and the House-Brackmann scale (HBS). Significant improvements in recovery were seen in both laser therapy groups over exercise alone with the most improvement seen with high-intensity laser.

Proprietary Information of Blue Cross and Blue Shield of Alabama
Medical Policy #270

“ASLR with or without ‘reinforcement’ (pelvic compression) to engage the form & force closure can be used to evaluate a patients’ ability to transfer load from the LS junction thru the pelvic girdle and hip joint to the lower extremity. A (right) supine ALR results in:

PI rotation of right innominate, anterior rotation of sacral base with nutation of right SI.

A tendency for the whole pelvis to rotate around the vertical axis toward the raised leg as well as a rotation at the LS junction in the opposite direction which decreases SI joint motion.

The overall effect is a stabilization of both LS and (in this case) right SI joint. A decreased ability to perform the ASL test while supine seems to correlate with abnormally increased mobility of the pelvic girdle. If dysfunction is found it can be assessed as to whether the problem is with the active or passive restraint systems. If contraction of the “inner core” (e.g. TrA, pelvic floor etc contraction) stabilizes and improves ROM and symmetry of leg-raise the clinician can focus there…If the anterior oblique system (tested via restraint of opposite trunk rotation) is at issue then that area  can be addressed. The Posterior oblique system can be better evaluated via the prone ALR challenge”.

The introduction of the artificial disc, producing results similar to fusion provides strong support for the hypothesis that loading is central to back pain. The artificial disc does not create a pattern of normal movement, and is not designed to do so. It does not necessarily require removal of the posterior innervated annulus, often regarded as a primary source of back pain, which continues to be moved and stressed after surgery. The one mechanical effect it has is to alter load Transmission while allowing movement.
The interface between implant and underlying vertebra is critical. It is here that load is transmitted. Bony integration must not only stop movement, but must be sufficiently extensive that the area of bone transmitting is adequate. Cages demonstrate that a small area of bony integration sufficient to stop movement, but insufficient to transfer load over a wide footprint is associated with continued pain.
With the artificial disc with a larger footprint transfer of load is thru plates resting on the vertebra…a universal feature of currently used disc replacements. This load transfer may be abnormal if the bone-plate interface is a mixture of fibrous tissue and bone, producing an irregular pattern of load.
This could be one reason the procedure is showing no better results than fusion.
The artificial disc must be focused on its role as a transmitter of load, not an enabler of movement. It seems one cause of clinical failure could be due to the failure to establish a normal loading pattern at the plate-bone interface.