LUMBAR SPONDYLOSIS, ITS RELATION

TO SACRAL ANGLE AND POSTURAL INSTABILITY

خشىنة الفقرات القطنية ، علاقتها بالزاوية

العجزية وخلل اتزان القىام

ACKNOWLEDGEMENT

THIS THESIS WOULD NOT HAVE BEEN POSSIBLEWITHOUT GOD ALMIGHTY WITH HIS BLESSINGS ANDPOWER THAT WORK WITHIN ME AND ALSO WITHOUTTHE PEOPLE BEHIND MY LIFE FOR INSPIRING, GUIDINGAND ACCOMPANYING ME THROUGHOUT MY WORK.

I AM HEARTILY THANKFUL TO PROF. DR. NAHED A. SALEM,PROFESSOR OF PHYSICAL THERAPY FOR NEUROMUSCULARDISORDERS AND ITS SURGERY, FACULTY OF PHYSICALTHERAPY, CAIRO UNIVERSITY. WITHOUT HER GUIDANCEAND SUPPORT, THIS THESIS WOULD NEVER HAVE BEENCOMPLETED.

I OWE MY SINCERE AND DEEPEST GRATITUDE TO PROF. DR.MOHAMED N. EL-BAHRAWY, PROFESSOR OF PHYSICALTHERAPY FOR NEUROMUSCULAR DISORDERS AND ITSSURGERY; FACULTY OF PHYSICAL THERAPY, CAIROUNIVERSITY, FOR HIS INSPIRATION AND ENCOURAGEMENTTHAT ALWAYS STIMULATED ME TO SEEK MOREKNOWLEDGE.

I WISH TO EXPRESS MY WARM AND SINCERE THANKSTO DR. MOHAMED E. EL-AWADY, PROFESSOR OFNEUROLOGY, FACULTY OF MEDICINE, CAIROUNIVERSITY, FOR HIS TIME AND INSIGHTFULCOMMENTS ON MY THESIS.

I COULD HAVE NEVER ACCOMPLISHED THIS WORKWITHOUT THE GUIDANCE SUPPORT AND

INSTRUCTIONS OF PROF. DR. IBTESAM KHATTAB.

WITHOUT HER, THIS WORK WOULDN’T HAVE SEENTHE LIGHT.

AND TO THE REST, WHOM I FAILED TO MENTION, THANKYOU VERY MUCH FOR YOUR PRAYERS.

INTRODUCTION

LUMBAR SPONDYLOSIS REFERS TO ANATOMICAL CHANGES TOTHE VERTEBRAL BODIES AND INTERVERTEBRAL DISK SPACESTHAT MAY BE ASSOCIATED WITH CLINICAL PAIN SYNDROMES.LOW BACK PAIN (LBP) HAS BEEN RELATED WITHANTHROPOMETRIC, POSTURAL, MUSCULAR, AND MOBILITYCHARACTERISTICS. NUMEROUS ETIOLOGIC FACTORS HAVEBEEN LINKED TO VARIOUS CONDITIONS INCLUDING OBESITY,INCREASED LUMBAR LORDOSIS, POOR ABDOMINAL MUSCLESTRENGTH, AND IMBALANCE BETWEEN FLEXOR ANDEXTENSOR TRUNK MUSCLE STRENGTH, REDUCED SPINALMOBILITY, TIGHT HAMSTRINGS, AND LEG-LENGTHDISCREPANCY (MIDDLETON AND FISH, 2009).

THE TERM ‘BALANCE’ REFERS TO A MULTI-SYSTEMFUNCTION THAT STRIVES TO KEEP THE BODY UPRIGHTDURING SITTING OR STANDING AND WHILE CHANGINGPOSTURE. BALANCE OR THE STATE OF EQUILIBRIUM HASBEEN DIVIDED INTO STATIC AND DYNAMIC BALANCE,DEPENDING ON WHETHER THE BASE IS STATIONARY ORMOVING (SPIRDUSO, 1995).

POSTURAL STABILITY IS THE ABILITY TO MAINTAIN THEBODY IN SPATIAL EQUILIBRIUM UNDER BOTH STATIC ANDDYNAMIC CONDITIONS. POSTURAL STABILITY IS ANESSENTIAL COMPONENT IN ASSESSING THE EFFICACY OFINTERVENTIONS FOR IMPROVING BALANCE.

POSTURAL CONTROL MEANS INTEGRATION OF THEPOSTURE AND VOLUNTARY MOVEMENT BASED ON THESELECTIVE AND RAPID INTEGRATION OF SENSORYINFORMATION (SOMATOSENSORY, VISUAL, ANDVESTIBULAR) FROM MULTIPLE SOURCES (NICOLETA ANDJOYCE, 2007).

THE PELVIS PLAYS A ROLE IN THE MUSCLE ACTIVITY ANDRESULTING LOADS ON THE SPINE DURING STANDING. THEBASE OF THE SACRUM IS INCLINED FORWARD ANDDOWNWARD. THE ANGLE OF INCLINATION, OR SACRALANGLE, WAS DEFINED AS AN ANGLE BETWEEN HORIZONTALLINE PARALLEL TO BOTTOM END OF THE FILM AND SUPERIORENDPLATE OF SACRUM AND IT IS ABOUT 30 DEGREES TO THETRANSVERSE PLANE DURING RELAXED STANDING (KIM ETAL., 2006).

STATEMENT OF THE PROBLEM:

WAS THERE A RELATIONSHIP BETWEEN CHANGES INSACRAL ANGLE AND POSTURAL INSTABILITY IN PATIENTSWITH LOW BACK PAIN DUE TO LUMBAR SPONDYLOSIS?

PURPOSE OF THE STUDY:

THE PURPOSES OF THIS STUDY WERE:

• TO INVESTIGATE THE BIOMECHANICAL FEATURES OF THELUMBOSACRAL REGION IN PATIENTS WITH LOW BACKPAIN SECONDARY TO LUMBAR SPONDYLOSIS.

• TO DETERMINE IF THERE IS A RELATIONSHIP BETWEENPOSTURAL INSTABILITY AND SACRAL ANGLE IN PATIENTSWITH LOW BACK PAIN AS A RESULT OF LUMBARSPONDYLOSIS.

SIGNIFICANCE OF THE STUDY:

LOW BACK PAIN (LBP) IS A HIGHLY COMMON PROBLEM ANDCAUSES MUCH MORBIDITY AND SOCIOECONOMIC LOSS INTHE COMMUNITY, WITH LIFETIME INCIDENCE RATESREPORTED BETWEEN 50%AND 90%.

THE IMPORTANCE OF MAINTENANCE OF APPROPRIATELUMBAR LORDOSIS HAS RECEIVED INCREASING ATTENTIONOVER THE LAST FEW YEARS. A DEFINITION OF INSTABILITY OFTHE LUMBAR SPINE AND ITS RELATIONSHIP TO CLINICALSYMPTOMS HAS NOT BEEN ESTABLISHED. SACRAL ANGLE IS ANIMPORTANT DETERMINANT TO LUMBAR LORDOSIS AND ISUNSTABLE BECAUSE IT IS INFLEXION POINT IN SPINALCURVATURE. IN ADDITION, BECAUSE THE SACRUM IS FIRMLYATTACHED TO THE PELVIS, THE SACRAL ANGLE ALSO IMPLIESPELVIC TILT (HO-JUN KIM ET AL., 2006).

CHANGING LUMBAR LORDOSIS SEEMS TO DEPEND ON THEABDOMINAL MUSCLES, BACK MUSCLES AND PELVIC/BACKALIGNMENT AND THIS MAY AFFECT THE DIAGNOSIS ANDTREATMENT IN PATIENTS WITH LBP AND ALSO AFFECT THEPLANNING OF A PROPER EXERCISE PROGRAM FOR THESEPATIENTS.

NULL HYPOTHESES:

IT WAS HYPOTHESIZED THAT THERE WAS NO RELATIONSHIPBETWEEN CHANGES IN SACRAL ANGLE AND POSTURALINSTABILITY IN PATIENTS WITH LOW BACK PAIN OWING TOLUMBAR SPONDYLOSIS.

DELIMITATIONS:

THIS STUDY WAS DELIMITED TO THE FOLLOWING ASPECTS:

-FORTY SUBJECTS FROM BOTH SEXES WERE RECRUITED FOR THIS STUDY.

-TWENTY PATIENT DIAGNOSED AS LUMBAR SPONDYLOSIS AND TWENTYNORMAL PERSONS MATCHED FOR AGE, SEX, WEIGHT AND HEIGHT WERERECRUITED IN THIS STUDY.

• ALL PATIENTS WERE ABLE TO FOLLOW INSTRUCTIONS AND AGREED TOPARTICIPATE IN THIS STUDY.

• THEIR AGE WAS RANGE FROM 40-60 YEARS.

• ALL OF THE SELECTED PATIENTS RECEIVED THE SAME SYMPTOMATICMEDICAL TREATMENT.

• THE DURATION OF LOW BACK PAIN WAS MORE THAN SIX MONTHS

LIMITATIONS:

-CO-OPERATION OF THE PATIENTS MAY AFFECT THE RESULTSOF THE MEASUREMENTS.

-PERSONAL AND INDIVIDUAL DIFFERENCES BETWEENPATIENTS, MAY AFFECT THEIR PERFORMANCE IN FORM OFAFFECTING THEIR UNDERSTANDING TO THE ASSESSMENTPROCEDURE.

BASIC ASSUMPTIONS:

IT WAS ASSUMED THAT:

1-PATIENTS FOLLOWED THE INVESTIGATOR`SINSTRUCTIONS DURING THE TESTING PROCEDURES.

2-ALL PATIENTS EXERTED MAXIMAL EFFORT DURINGTESTING PROCEDURES.

SUBJECT MATERIALS AND METHODS

THIS STUDY WAS CONDUCTED IN THE COMPUTERIZEDDYNAMIC POSTUROGRAPHY LAB IN KASR EL- AINI, CAIROUNIVERSITY HOSPITALS, DEPARTMENT OF NEUROLOGY,FROM THE PERIOD OF MAY 2013 TO MAY 2014. THE DATAWAS COLLECTED USING THE NEUROCOM BALANCEMASTER SYSTEM VERSION 7.

SUBJECTS SELECTION

TWENTY PATIENTS FROM BOTH SEXES DIAGNOSED AS HAVINGLUMBAR SPONDYLOSIS PARTICIPATED IN THIS STUDY, ANDWERE SELECTED FROM KASR EL-AINI HOSPITAL OUTPATIENTCLINICS (NEUROLOGY AND PHYSICAL THERAPY).THEY WEREDIAGNOSED ON THE BASIS OF A MEDICAL REVIEW AND ANOBJECTIVE EXAMINATION BY THE SAME NEUROLOGIST ANDPHYSICAL THERAPIST AND THE DIAGNOSIS WAS CONFIRMEDBY PLAIN X-RAY ON LUMBAR SPINE.

INCLUSION CRITERIA:

• ALL OF THE PATIENTS WERE ABLE TO FOLLOW INSTRUCTIONS AND AGREED TO PARTICIPATE IN THIS STUDY.

• THEIR AGE RANGED FROM 40-60 YEARS.

EXCLUSION CRITERIA:

• OTHER NEUROLOGICAL DISORDERS AFFECTING POSTURAL STABILITY (I.EATAXIA, PARKINSONISM, PERIPHERAL NEUROPATHY).

• MUSCULOSKELETAL DISORDERS INCLUDING LOWER LIMB FRACTURES ORCONTRACTURES OF FIXED DEFORMITY, ESPECIALLY AT THE ANKLE JOINT,LIMITING LOCOMOTION OR BALANCE.

• DEFICITS IN ATTENTION, COGNITION, AND SENSATION.

• PERIPHERAL VESTIBULAR DISEASES .

• HISTORY OF FREQUENT LOSS OF BALANCE OR FALLING.

• PREVIOUS HISTORY OF VERTEBROBASILAR INSUFFICIENCY (VBI).

• MARKED VISUAL IMPAIRMENTS.

INSTRUMENTATIONS AND MATERIALS

COMPUTERIZED DYNAMIC POSTUROGRAPHY:

THE BALANCE MASTER (BM) IS A REHABILITATION TOOL DESIGNED TOPROVIDE PRECISE, OBJECTIVE AND POTENTIALLY MORE SENSITIVEMEASUREMENTS OF STATIC AND DYNAMIC BALANCE PERFORMANCE. ITCOMBINES CENTRE OF PRESSURE (COP) MEASURES WITH VISUAL FEEDBACK ONCENTRE OF MASS (COM) DISPLACEMENTS DURING POSTURAL CONTROL TASKS.THE ASSESSMENT OF POSTURAL STABILITY AT THE SUBJECT'S LIMITS OFSTABILITY (LOS) IS ONE OF THESE TASKS AND ONE OF THE EVALUATION OPTIONSAVAILABLE IN THE BM ASSESSMENT MODULES. THE SYSTEM UTILIZESFORCEPLATE TECHNOLOGY TO DETERMINE THE LOCATION OF THE COG WITHINPREDEFINED (THEORETICAL) LIMITS OF STABILITY. THE SOFTWARE PROVIDESMEASURES OF POSTURAL SWAY AND THE ABILITY TO MAINTAIN THE COGWITHIN A DEFINED TARGET AREA (WOODHOUSE AND VASSELJEN, 2008).

Smart Balance Master

THE LIMITS OF STABILITY TEST (LOS):

THIS TEST QUANTIFIES SEVERAL MOVEMENTCHARACTERISTICS ASSOCIATED WITH THE PATIENT'S ABILITYTO VOLUNTARILY SWAY TO VARIOUS LOCATIONS IN SPACE,AND BRIEFLY MAINTAIN STABILITY AT THOSE POSITIONS. THEMEASURED PARAMETERS WERE REACTION TIME, SWAYVELOCITY, DIRECTIONAL CONTROL, END POINT EXCURSION,AND MAXIMUM EXCURSION.

THE LOS TEST CONSISTED OF EIGHT TRIALS, NORMALLYCONDUCTED IN THE FOLLOWING ORDER FORWARD,BACKWARD, FORWARD-RIGHT, BACKWARD-LEFT, RIGHT, LEFT,BACKWARD-RIGHT AND FORWARD-LEFT.

RHYTHMIC WEIGHT SHIFT (RWS):

• THE RHYTHMIC WEIGHT SHIFT TEST MEASURED “ON-AXISVELOCITY” AND “DIRECTIONAL CONTROL” PARAMETERS.

• THE TEST CONSISTS OF SIX TRIALS, CONDUCTED IN THEFOLLOWING ORDER LEFT/RIGHT, SLOW (THREE SECTRANSITIONS), LEFT/RIGHT, MEDIUM (TWO SECTRANSITIONS), LEFT/RIGHT, FAST (ONE SEC TRANSITIONS),FORWARD/BACKWARD, SLOW (THREE SEC TRANSITIONS,FORWARD /BACKWARD, MEDIUM (TWO SEC TRANSITIONS)AND FORWARD/BACKWARD, FAST (ONE SEC TRANSITIONS).

RESULTS

Descriptive statistics of the mean age, weight, height and BMI of the study group.

RangeMaximumMinimum X ±SD

50604044.7 ± 4.4

Age (years)

23886575.3 ± 5.75

Weight (Kg)

15175160172.75 ± 3.46

Height (cm)

6.2428.7322.4925.22 ± 1.62

BMI (Kg/m2)

X : MeanSD : Standard Deviation

RELATIONSHIP BETWEEN SACRAL ANGLE AND LIMITS OF STABILITY:

THERE WAS A MODERATE POSITIVE SIGNIFICANT CORRELATIONBETWEEN SACRAL ANGLE AND DIRECTIONAL CONTROL , AMODERATE POSITIVE SIGNIFICANT CORRELATION BETWEEN SACRALANGLE AND END POINT EXCURSION , A MODERATE POSITIVESIGNIFICANT CORRELATION BETWEEN SACRAL ANGLE ANDMAXIMUM EXCURSION , A VERY WEAK NEGATIVE NON SIGNIFICANTCORRELATION BETWEEN SACRAL ANGLE AND MOVEMENT VELOCITY, AND A MODERATE NEGATIVE SIGNIFICANT CORRELATION BETWEENSACRAL ANGLE AND REACTION TIME .

RELATIONSHIP BETWEEN SACRAL ANGLE AND RHYTHMIC WEIGHTSHIFT:

THERE WAS A MODERATE POSITIVE SIGNIFICANT CORRELATIONBETWEEN SACRAL ANGLE AND ON AXIS VELOCITY IN FRONT-BACKDIRECTION, WHILE THERE WAS A VERY WEAK NEGATIVE NONSIGNIFICANT CORRELATION BETWEEN SACRAL ANGLE AND ON AXISVELOCITY IN LEFT-RIGHT DIRECTION, A MODERATE NEGATIVESIGNIFICANT CORRELATION BETWEEN SACRAL ANGLE ANDDIRECTIONAL CONTROL IN FRONT- BACK DIRECTION, AND AMODERATE NEGATIVE SIGNIFICANT CORRELATION BETWEEN SACRALANGLE AND DIRECTIONAL CONTROL IN LEFT- RIGHT DIRECTION .

DISCUSSION

IT WAS FOUND THAT SA WAS LOWER IN MALE PATIENTSWITH LBP COMPARED TO MALE HEALTHY NORMALCONTROLS( HNCS) WITHOUT LBP.

IN ADDITION, SIA AND BMI WERE HIGHER IN FEMALEPATIENTS COMPARED TO MALE PATIENTS.

DIFFERENCES IN RESULTS MIGHT HAVE BEEN CAUSED BYDIFFERENCES IN REGIONAL ANGLE MEASUREMENT METHODS,NUMBER OF PATIENTS INVOLVED, AGE OF PATIENTS, ANDDIAGNOSTIC DIFFERENCES. PLACEBO-CONTROLLED STUDIESWITH HIGHER NUMBER OF PARTICIPANTS IN WHICHSTANDARDIZED ANGLE REGIONS AND METHODS ARE USEDARE NEEDED FOR EXACT DETERMINATION OF THE EFFECTS OFLBP ON SA . RESULTS OF SUCH STUDIES MAY GUIDE THECLINICIAN DURING EXAMINATION OF SA OF PATIENTS WITHLBP.

DYNAMIC MOVEMENTS OF THE LUMBAR REGION ARECRUCIAL TO OUR LIVES. THEREFORE, WE AIMED ATINVESTIGATING WHETHER OR NOT ANGLES OF THELUMBOSACRAL REGION IMPACTED ON DEVELOPMENT OFCHRONIC LBP.

RECOMMENDATIONS

• MORE RESEARCHES ARE NEEDED TO INVESTIGATE THE BIOMECHANICALFEATURES OF THE LUMBOSACRAL REGION IN PATIENTS WITH LOW BACKPAIN SECONDARY TO LUMBAR SPONDYLOSIS.

• FURTHER STUDIES AND RESEARCH ARE REQUIRED TO DETERMINE IF THEREIS A RELATIONSHIP BETWEEN POSTURAL STABILITY AND SACRAL ANGLE INPATIENTS WITH LOW BACK PAIN AS A RESULT OF LUMBAR SPONDYLOSIS.

• MORE RESEARCHES INCLUDING LARGER SAMPLE SIZE ARE NEEDED TODETERMINE AND CONFIRM INVESTIGATE THE BIOMECHANICAL FEATURES OFTHE LUMBOSACRAL REGION IN PATIENTS WITH LOW BACK PAIN SECONDARYTO LUMBAR SPONDYLOSIS.

• FURTHER STUDIES ARE NEEDED TO EVALUATE THE ABILITY OF OTHERCLINICAL TESTS FOR ASSESSMENT OF LUMBAR STABILITY.

THANK YOU