Multivariate shoulder and spine relationship using planar range of motion assessment.

CONTEXT: Goniometry and posture are commonly used metrics in clinical assessment of the shoulder and spine. When both the shoulder and spine are assessed individually using these techniques, there are structural and functional musculoskeletal relationships between the two anatomical regions that may be overlooked. OBJECTIVE: To determine the relationships between and within the shoulder and spine as measured by active range of motion (ROM) and spine curvature. DESIGN: Cross-sectional. SETTING: Clinical assessment in university setting. PARTICIPANTS: 163 asymptomatic, right hand dominant, young adults; INTERVENTION: None. MAIN OUTCOME MEASURES: A multivariate canonical correlation was used to identify a shoulder-spine relationship using active ROM assessments. RESULTS: A shoulder-spine relationship was determined using planar assessments and multivariate analyses of these two areas. Measures contributing to this relationship included shoulder flexion, internal rotation, external rotation, and trunk flexion and lumbar lordosis. CONCLUSIONS: The findings of this study suggest that assessment of shoulder ROM should be interpreted with respect to spine region and vice versa, regardless of presenting region of concern, owing to the multivariate shoulder-spine ROM relationship when considering multiple measures of ROM and posture.

Investigating women's chest size, trunk muscle co-contraction and back pain during prolonged standing.

BACKGROUND: Chest size is a known factor in the development of back pain for women. However, the neuromuscular mechanisms associated with chest size and back pain are poorly understood. OBJECTIVE: The purpose of this study was to investigate chest size and its association with back pain development and muscle activity patterns during prolonged standing. METHODS: Twenty university-aged women were divided into two groups: small chest size (n= 10, ∼A/C cup) and large chest size (n= 10, ∼D/E cup). Participants completed a 2-hr standing protocol, where eight channels of bilateral trunk electromyography were collected. Muscle activity, specifically co-contraction, was compared between chest size groups, pain developers, and time. RESULTS: The large chest size group reported higher amounts of pain at the upper, middle, and low back. Women in the large chest group sustained higher levels of co-contraction for muscles involving the thoracic and lumbar erector spinae compared to those in the small chest size group during prolonged standing. CONCLUSIONS: Thoracolumbar co-contraction determined in this study may be a potential mechanism contributing to increased back pain development for women with large chest sizes during prolonged standing. This pain mechanism could be targeted and addressed in future non-invasive musculoskeletal rehabilitation to improve back pain for women.

Interaction Between Thoracic Movement and Lumbar Spine Muscle Activation Patterns in Young Adults Asymptomatic for Low Back Pain: A Cross-Sectional Study.

OBJECTIVE: The purpose of this study was to investigate the interaction between thoracic movement and lumbar muscle co-contraction when the lumbar spine was held in a relatively neutral posture. METHODS: Thirty young adults, asymptomatic for back pain, performed 10 trials of upright standing, maximum trunk range of motion, and thoracic movement tasks while lumbar muscle activation was measured. Lumbar co-contraction was calculated, compared between tasks, and correlated to thoracic angles. RESULTS: Movement tasks typically exhibited greater co-contraction than upright standing. Co-contraction in the lumbar musculature was 67%, 45%, and 55% greater than upright standing for thoracic flex, thoracic bend, and thoracic twist, respectively. Generally, the thoracic movement task demonstrated greater co-contraction than the maximum task in the same direction. Co-contraction was also correlated to thoracic angles in each movement direction. CONCLUSION: Tasks with thoracic movement and a neutral lumbar spine posture resulted in increases in co-contraction within the lumbar musculature compared with quiet standing and maximum trunk range-of-motion tasks. Findings indicated an interaction between the 2 spine regions, suggesting that thoracic posture should be accounted for during the investigation of lumbar spine mechanics.

Motion and Muscle Activity Are Affected by Instability Location During a Squat Exercise.

Nairn, BC, Sutherland, CA, and Drake, JDM. Motion and muscle activity are affected by instability location during a squat exercise. J Strength Cond Res 31(3): 677-685, 2017-Squat exercise training using instability devices has become increasingly popular for a multitude of reasons. Many devices generate instability at the feet and provide a bottom-up perturbation; however, the effect of a top-down instability device during a squat remains unclear. To induce instability at the upper body, a water-filled cylinder called the Attitube was used. This study analyzed the effects of instability location (top-down, bottom-up, and no instability) during a squat exercise in terms of kinematics and muscle activation. Ten male participants were instrumented with 75 reflective markers to track kinematics of the ankle, knee, hip, trunk, and the Bar/Attitube, and electromyography was recorded from 12 muscles bilaterally. Squats were performed with an Olympic bar on a stable surface, an Olympic bar on a BOSU ball (BALL, bottom-up), and the Attitube on solid ground (TUBE, top-down). The TUBE showed up to 1.5 times reduction in erector spinae activation and up to 1.5 times less trunk flexion while being performed at a slower velocity. There was also higher abdominal activation in the TUBE, with up to 2.8 times greater oblique activation compared with the stable condition. The BALL increased ankle eversion and knee flexion with higher muscle activation in gastrocnemius, biceps femoris, and quadriceps. Overall, changing the location of instability during a squat changed the motion and muscle activation patterns of the trunk and lower extremities. This provides information for future research into rehabilitation, learning proper squat technique, and for specific training scenarios.

Breast size impacts spine motion and postural muscle activation.

BACKGROUND: While it is generally accepted that large breast sizes in females contribute to back pain and poor posture, the effects of breast size on spinal motion and muscle activation characteristics are poorly understood. OBJECTIVE: This study examined the relationship between breast size, spine motion, and trunk muscle activation. METHODS: Fifteen university-aged females, free of back pain symptoms, were tested. Breast sizes were calculated, and three-dimensional spine motion and activation from five trunk muscles bilaterally were measured during standing and trunk flexion movements. Correlations between breast size and motion and muscle activation measures were assessed. RESULTS: Head and trunk angles were strongly, negatively correlated to breast size during upright standing; thoracic angles were moderately, positively correlated to breast size during thoracic flexion movements. Trunk muscles showed positive, moderate-strength relationships with breast size during upright standing and some trunk movements. CONCLUSIONS: These findings provide a preliminary indication that increasing breast sizes are associated with altered postures and increased muscle activation in a non-clinical population, and constitute a baseline for the study of females with a full range of breast sizes. Further research is required to confirm the generalizability of these findings to other sizes, in order to inform strategies for the prevention or reduction of back pain, as well as diagnosis, treatment, and rehabilitation techniques associated with breast size and back pain.

Seated maximum flexion: An alternative to standing maximum flexion for determining presence of flexion-relaxation?

BACKGROUND: The flexion-relaxation phenomenon (FRP) in standing is a specific and sensitive diagnostic tool for low back pain. Seated flexion as an alternative could be beneficial for certain populations, yet the behavior of the trunk extensors during seated maximum flexion compared to standing flexion remains unclear. OBJECTIVE: Compare FRP occurrences and spine angles between seated and standing flexion postures in three levels of the erector spinae muscles. METHODS: Thirty-one participants free of back pain performed seated and standing maximum trunk flexion. Electromyographical signals were recorded from the bilateral lumbar (L3), lower-thoracic (T9), and upper-thoracic (T4) erector spinae and assessed for the occurrence of FRP. Spine angles corresponding to FRP onset and cessation were determined, and FRP occurrences and angles were compared between posture and muscle. RESULTS: FRP occurrence was similar in standing and seated maximum flexion across all muscles, with the lumbar muscles showing the greatest consistency. Standing FRP onset and cessation angles were consistently greater than the corresponding seated FRP angles. CONCLUSION: Considering the similar number of FRP occurrences, seated maximum flexion may constitute an objective criterion for low back pain diagnosis. Future work should seek to confirm the utility of this test in individuals with low back pain.

Sequencing of superficial trunk muscle activation during range-of-motion tasks.

Altered lumbo-pelvic activation sequences have been identified in individuals with low back pain. However, an analysis of activation sequences within different levels of the trunk musculature has yet to be conducted. This study identified the activation sequences characteristic of the trunk musculature during upright standing and range-of-motion tasks. Surface electromyography was recorded for eight trunk muscles bilaterally during trunk range-of-motion movement tasks in 30 participants. Cross-correlation was performed on 48 pairings of muscles, consisting of one lower- and one mid-level muscle, or one mid-level and one upper muscle. Time lags of the maximum cross-correlation coefficient were extracted and defined as a top-down or bottom-up activation sequence, or similar activation timing. Pairings that demonstrated a specific activation sequence in 50% or more of participants were then identified. Similar activation timing was consistently identified between muscle pairings for upright standing. Top-down sequences and similar timing were identified for abdominal - mid-level pairings in maximum flexion and slumped standing, respectively, while both tasks were characterized by bottom-up sequences when considering the lumbar and lower-thoracic erector spinae. Sequences were more variable across muscle pairings for lateral bend and axial twist tasks. These results provide insight into the synergy of the trunk musculature for movements in the three planes of motion. These findings can be used for comparison to low back pain populations, as altered activation sequences in these individuals may contribute to maladaptive loading patterns and consequently the development or exacerbation of low back pain.

Location of Instability During a Bench Press Alters Movement Patterns and Electromyographical Activity.

Instability training devices with the bench press exercise are becoming increasingly popular. Typically, the instability device is placed at the trunk/upper body (e.g., lying on a Swiss ball); however, a recent product called the Attitube has been developed, which places the location of instability at the hands by users lifting a water-filled tube. Therefore, the purpose of this study was to analyze the effects of different instability devices (location of instability) on kinematic and electromyographical patterns during the bench press exercise. Ten healthy males were recruited and performed 1 set of 3 repetitions for 3 different bench press conditions: Olympic bar on a stable bench (BENCH), Olympic bar on a stability ball (BALL), and Attitube on a stable bench (TUBE). The eccentric and concentric phases were analyzed in 10% intervals while electromyography was recorded from 24 electrode sites, and motion capture was used to track elbow flexion angle and 3-dimensional movement trajectories and vertical velocity of the Bar/Attitube. The prime movers tended to show a reduction in muscle activity during the TUBE trials; however, pectoralis major initially showed increased activation during the eccentric phase of the TUBE condition. The trunk muscle activations were greatest during the TUBE and smallest during the BAR. In addition, the TUBE showed decreased range of elbow flexion and increased medial-lateral movement of the Attitube itself. The results further support the notion that instability devices may be more beneficial for trunk muscles rather than prime movers.

Repeatability of kinematic and electromyographical measures during standing and trunk motion: how many trials are sufficient?

Previous studies have recommended a minimum of five trials to produce repeatable kinematic and electromyography (EMG) measures during target postures or contraction levels. This study aimed to evaluate the repeatability and reliability of kinematic and EMG measures that are of primary interest in the investigation of trunk movement, and to determine the number of trials required to achieve repeatability and reliability for these measures. Thirty participants performed ten trials of upright standing and maximum trunk ranges-of-motion. Mean (upright standing) and maximum (movement tasks) kinematic and EMG measures were assessed using intraclass correlation coefficients and standard error of measurement, which were used to identify the minimum number of trials for each measure. The repeatability and reliability of the measures were generally high, with 64%, 77%, 85%, and 92% of measures producing repeatable and reliable values with two, three, four, and five trials, respectively. Ten trials were not sufficient for several upright standing angle measures and maximum twist lumbar angles. Further, several abdominal muscles during maximum flexion, as well as the left lower-thoracic erector spinae during maximum twist, required as many as five trials. These measures were typically those with very small amounts of motion, or muscles that did not act in the role of prime mover. These results suggest that as few as two trials may be sufficient for many of the kinematic and EMG measures of primary interest in the investigation of trunk movement, while the collection of four trials should produce repeatable and reliable values for over 80% of measures. These recommendations are intended to provide an acceptable trade-off between repeatable and reliable values and feasibility of the collection protocol.

Which motion segments are required to sufficiently characterize the kinematic behavior of the trunk?

Various kinematic definitions of the thoracic spine have been employed in past work. However, the segments necessary to sufficiently characterize the thoracic spine during trunk movements in all three planes of motion have not yet been identified. This study aimed to determine the minimum number of segments necessary to adequately characterize the kinematics of the thoracic spine. Thirty individuals, asymptomatic for back pain, performed ten trials of maximum trunk flexion, lateral bend, and axial twist; thoracic flexion, lateral bend, and axial twist; and slumped standing. Marker clusters were applied over the C(7), T(3), T(6), T(9), T(12), and L(5) vertebrae. Three-dimensional angles of each cluster were calculated, and cross-correlation (R(xy(time))) and correlation (R(xy(max))) analyses were employed to assess the relationships in the motion patterns and maximum angles of adjacent clusters, respectively. The motion patterns and maximum angles of adjacent clusters were very strongly (R(xy(time)) > 0.90 for 26 of 35 pairings) and strongly (R(xy(max)) > 0.80 for 25 of 35 pairings) correlated, respectively. A four-cluster set (C(7), T(6), T(12), and L(5)) represented thoracic movement for six of the seven movement tasks tested. These results provide insight into thoracic movement coordination, with implications for predictive spinal modeling and clinical assessment practices.

Differences in lumbopelvic control and occupational behaviours in female nurses with and without a recent history of low back pain due to back injury.

Low back pain is highly prevalent in nurses. This study aimed to determine which physical fitness, physical activity (PA) and biomechanical characteristics most clearly distinguish between nurses with [recently injured (RInj)] and without [not recently injured (NRInj)] a recent back injury. Twenty-seven (8 RInj, 19 NRInj) female nurses completed questionnaires (pain, work, PA), physical fitness, biomechanical and low back discomfort measures, and wore an accelerometer for one work shift. Relative to NRInj nurses, RInj nurses exhibited reduced lumbopelvic control (41.4% more displayed a moderate loss of frontal plane position), less active occupational behaviours (less moderate PA; less patient lifts performed alone; more sitting and less standing time) and more than two times higher low back discomfort scores. Despite no physical fitness differences, the lumbopelvic control, occupational behaviours and discomfort measures differed between nurses with and without recent back injuries. It is unclear whether poor lumbopelvic control is causal or adaptive in RInj nurses and may require further investigation. Practitioner Summary: It is unclear which personal modifiable factors are most clearly associated with low back pain in nurses. Lumbopelvic control was the only performance-based measure to distinguish between nurses with and without recent back injuries. Future research may investigate whether reduced lumbopelvic control is causal or adaptive in recently injured nurses.

Quantification of the lumbar flexion-relaxation phenomenon: comparing outcomes of lumbar erector spinae and superficial lumbar multifidus in standing full trunk flexion and slumped sitting postures.

OBJECTIVE: The purpose of this study was to identify differences in flexion-relaxation outcomes in asymptomatic participants, with respect to both flexion-relaxation phenomenon (FRP) occurrence and spinal onset angles, as a function of posture and choice of muscle being examined. METHODS: This was a cross-sectional study in a laboratory setting. Thirty asymptomatic participants performed standing full trunk flexion and slumped sitting postures while activation levels of the lumbar erector spinae and superficial lumbar multifidus were monitored. Two thresholds were used to define whether FRP was present in each muscle and, if present, at what trunk flexion angle it occurred. These outcomes were compared descriptively between muscles and between postures. RESULTS: Most participants displayed FRP in both muscles during standing full flexion; occurrences were more variable in slumped sitting. On average, FRP during standing full flexion and slumped sitting occurred at approximately 80% and 52% of participants' maximum flexion value, respectively. Variability in the slumped sitting onset angles was greater than that in standing full flexion. CONCLUSION: Outcomes for FRP during standing full flexion in asymptomatic participants appeared to be more robust and were not affected by the choice of either lumbar erector spinae or superficial lumbar multifidus. Conversely, during slumped sitting, FRP occurrence varied substantially depending on choice of muscle, although onset angles were relatively consistent between muscles. Although the choice of one muscle over the other may be warranted, it may be prudent to examine both muscles during FRP investigations in sitting postures, in order to fully characterize the behavior and activation patterns of the lumbar musculature.

Impact of lumbar spine posture on thoracic spine motion and muscle activation patterns.

Complex motion during standing is typical in daily living and requires movement of both the thoracic and lumbar spine; however, the effects of lumbar spine posture on thoracic spine motion patterns remain unclear. Thirteen males moved to six positions involving different lumbar (neutral and flexed) and thoracic (flexed and twisted) posture combinations. The thoracic spine was partitioned into three segments and the range of motion from each posture was calculated. Electromyographical data were collected from eight muscles bilaterally. Results showed that with a flexed lumbar spine, the lower-thoracic region had 14.83 ° and 15.6 1 ° more flexion than the upper- and mid-thoracic regions, respectively. A flexed lumbar spine significantly reduced the mid-thoracic axial twist angle by 5.21 ° compared to maximum twist in the mid-thoracic region. Functional differences emerged across muscles, as low back musculature was greatest in maintaining flexed lumbar postures, while thoracic erector spinae and abdominals showed bilateral differences with greater activations to the ipsilateral side. Combined postures have been previously identified as potential injury modulators and bilateral muscle patterns can have an effect on loading pathways. Overall, changes in thoracic motion were modified by lumbar spine posture, highlighting the importance of considering a multi-segmented approach when analyzing trunk motion.

Head and arm positions that elicit maximal voluntary trunk range-of-motion measures.

Relationships have been shown between spinal motion and head and arm postures, yet there has been little standardization of the head and arm positions that elicit maximal voluntary spine angles during maximal trunk flexion, lateral bend, and axial twist. This study aimed to determine the head and arm positions that facilitated maximum voluntary range of motion in various spinal regions during these movements. Twenty-four individuals performed maximal movements in each plane with different combinations of head and arm positions (flexion and lateral bend: four combinations; axial twist: six combinations). Generally, greater angles were elicited for the upper spine regions when the head was moved in the direction of trunk motion, while the angles of the lower regions were either unaffected or greater when the head was kept in a neutral position. Arm positions also affected maximum spinal angles, in that angles were greatest when the arms were hanging to the floor (flexion), abducted to 90° (axial twist), and either hanging to the floor or crossed over the chest (lateral bend). These findings provide insight into the interplay between the spine and adjacent segments and constitute an initial attempt to develop standardized positions during maximum range-of-motion trials.

Should a standing or seated reference posture be used when normalizing seated spine kinematics?

Currently in the literature there is no consensus on which procedure for normalizing seated spine kinematics is most effective. The objective of this study was to examine the changes in the range of motion (ROM) of seated posture trials when expressed as a percent of maximum standing and seated ROM. A secondary purpose was to determine whether the typical maximum planar calibration movements (flexion, lateral-bend, and axial twist) elicited the respective maximum ROM values for each spine region versus postures with specific movement instruction. Thirteen male participants completed seven different movement trials. These consisted of the maximum planar movement trials, with the remaining four postures being combinations of specific lumbar and thoracic movements. Global and relative angles for the upper-thoracic, mid-thoracic, lower-thoracic, and lumbar regions were calculated and normalized to both a seated and standing reference posture. When normalizing both global and relative angles the standing reference appears optimal for flexion, twisting and lateral bend angles in all spine regions, with the exception of relative flexion angle in the mid-thoracic region. The maximum planar movement trials captured the greatest ROM for each global angle, relative lower-thoracic angle and relative lumbar flexion angle, but did not for all other relative angles in the upper-thoracic, mid-thoracic, and lumbar regions. If future researchers can only collect one reference posture these results recommend that a standing reference posture be collected for normalizing seated spine kinematics, although a seated reference posture should be collected if examining relative flexion angles at the mid-thoracic region.

Transient pain developers show increased abdominal muscle activity during prolonged sitting.

BACKGROUND: Sitting is a commonly adopted posture during work and prolonged exposures may have detrimental effects. Little attention has been paid to the thoracic spine and/or multiple axes of motion during prolonged sitting. Accordingly, this study examined three-dimensional motion and muscle activity of the trunk during two hours of uninterrupted sitting. METHODS: Ten asymptomatic males sat during a simulated office task. Kinematics were analyzed from six segments (Neck, Upper-, Mid-, and Lower-thoracic, Lumbar, and Pelvis) and electromyography was recorded from eight muscles bilaterally. RESULTS: Four participants developed transient pain. These participants showed higher average muscle activations in the abdominal muscles. Additionally, the non-pain group showed less lateral bend positional change in the mid-thoracic region compared to the upper- and lower-thoracic regions. Weak-to-moderate positive correlations were also found between rated pain and low back muscle activation. DISCUSSION: The results provided further evidence of reduced movement in non-pain developers and altered muscle activation patterns in pain developers. Low-level, prolonged static contractions could lead to an increased risk of injury; and though the increased abdominal activity in the pain developers was not directly associated with increased rated pain scores, this could indicate a pre-disposition to, or enhancer of, transient pain development.

Evaluation of methods for the quantification of the flexion-relaxation phenomenon in the lumbar erector spinae muscles.

OBJECTIVES: There are various methods to quantify the flexion-relaxation phenomenon (FRP); however, there is little standardization. This study aimed to evaluate the performance of various quantification methods in terms of their ability to identify lumbar erector spinae flexion-relaxation during standing forward trunk flexion. METHODS: The study was a cross-sectional design in a laboratory setting. Lumbar erector spinae activation levels were measured in 12 male participants performing full trunk flexion movements. Electromyographical signals were assessed using 16 criteria within 4 quantification methods (visual, statistical, threshold, ratio), and the sensitivity of each was assessed relative to the benchmark criterion (visual inspection of raw electromyography data). RESULTS: Visual inspection and most of the threshold and ratio criteria displayed the highest sensitivity. On average (SD) across the 16 criteria, FRP was positively identified 21.6 (6.2) times of 24 data sets (12 participants, 2 muscles). The visual inspection criteria positively identified FRP in all 24 trials, whereas the statistical method did not identify FRP at all (P = .44 and P = .46 for the left and right sides, respectively). The threshold and ratio criteria positively identified FRP 23.2 (1.5) and 22.5 (3.7) times, on average, respectively. Results from criteria based on differences between upright and fully flexed muscle activation tended to be conservative in FRP identification. The methods were classified as reliable or nonreliable, based on their sensitivity when specific characteristics were evident in the electromyography signals. CONCLUSIONS: Although many of the criteria identified FRP with 100% sensitivity, others produced unrealistic results. The latter may be suitable for other experimental designs or may require reevaluation regarding their ability to identify FRP. Although visual inspection, threshold, or ratio methods performed well and may be appropriate for either biomechanical or clinical research, the threshold method provided the optimal trade-off between performance, consistency, and feasibility for these data.

What is slumped sitting? A kinematic and electromyographical evaluation.

Slumped sitting is a commonly used reference posture when comparing effects of upright sitting in both clinical and non-clinical populations alike. The exact nature of slumped sitting has not been clearly defined, including regional differences within the posture, and how the passive nature of slumped sitting compares to an active-flexion posture. Kinematic and electromyographical (EMG) data were collected from 12 males during three repeats of slumped sitting and seated maximum forward flexion. Spine angles were defined in four regions (three thoracic and lumbar) as well as for the pelvis, and EMG was collected from eight muscles bilaterally. Kinematic data were expressed as a range of motion (in degrees), and as a percent of full forward flexion while seated (%SIT-FF) and standing (%STAND-FF). EMG data were normalized to a percent maximum contraction (%MVC). Results showed that slumped sitting is characterized by 10° posterior pelvis rotation, near end-range flexion of the mid- (90%SIT-FF) and lower- (81%SIT-FF) thoracic regions, and mid-range flexion of the upper-thoracic (51%SIT-FF) and lumbar (43%SIT-FF) regions. Comparison of slumped by %STAND-FF showed the upper- and mid-thoracic regions to have high variability and large values (over 100%STAND-FF). Muscle activation showed a significant 3%MVC reduction in the lower-thoracic erector spinae muscle when moving from upright to slumped sitting. These data highlight the postural differences occurring within different spine regions, and interpretations that could be drawn, depending on which normalization (sit or stand) method is used.

Investigation of trunk muscle co-contraction and its association with low back pain development during prolonged sitting.

Previous work has shown muscle activation differences between chronic low back pain patients and healthy controls in sitting postures, and between asymptomatic individuals who do (PDs: pain developers) and do not (NPDs: non-pain developers) develop transient back pain during prolonged standing (as determined using a visual analog scale). The current study aimed to investigate differences in trunk muscle co-contraction between PD and NPD individuals over 2h of prolonged sitting. Ten healthy males sat continuously for 2h while performing tasks that simulated computer-aided-drafting; four were classified as PDs, and six as NPDs. Co-contraction indices were calculated from EMG data collected from eight trunk muscles bilaterally, and compared between pain groups and over time. PDs exhibited higher levels of co-contraction than NPDs. Additionally, co-contraction tended to increase over time, and was significantly correlated to pain development. The relationship between co-contraction and back pain development may actually be circular, in that it is both causal and adaptive: high co-contraction initially predisposes to pain development, following which co-contraction further increases in an attempt to alleviate the pain, and the cycle perpetuates. Further work will be required to elucidate the exact nature of this relationship, and to confirm the generalizability to other populations.

Intervertebral neural foramina deformation due to two types of repetitive combined loading.

BACKGROUND: Tissue compression and noxious stimuli are known to elicit pain from neural tissues in the spine. Compression of nerve roots due to decreases in the intervertebral foramina may be caused by posture, sustained loading and disc height loss, herniation, or altered mechanics. It has been established that non-neutral postures combined with repeated loading can cause disc herniations, however information regarding the effect of repetitive axial twist loading is limited. The objectives of this study were twofold; to measure the occlusion of the foramina due to two types of repetitive loading and to investigate whether repetitive combined axial twist loading can contribute to disc injury. METHODS: Sixteen porcine cervical spine segments (C5/6) were subjected to 1500 N of compression combined with either repetitive flexion-extension motions or 16.4 degrees (Standard Deviation 2.1) of static flexion with repetitive axial twist motions. The foramina pressure was measured bilaterally using plastic tubing and a custom pressure monitoring system. Specimens were loaded until 10,000 cycles were reached or disc herniation occurred. FINDINGS: Significantly larger pressure (pre-post difference) developed in the intervertebral foramina of specimens that were repetitively flexed-extended (P=0.028) compared to those that were repetitively twisted. All of the flexed-extended specimens herniated, whereas in the twisted specimens five (62.5%) had incomplete herniations, one (12.5%) sustained a facet fracture, and two (25%) had no damage. There was no difference between the loading groups for vertical height loss (P=0.994). INTERPRETATION: Repetitive loading of flexion-extension motions are a viable pain generating pathway in absence of distinguishing height loss. This information may be useful to consider for the diagnosis and treatment of nerve root compression.