[Evaluation of a prostate cancer E­health tutorial : Development and testing of the website prostata-information.ch]. / Evaluation eines Online-Tutorials zum Prostatakarzinom : Entwicklung und Überprüfung der Seite prostata-information.ch.

BACKGROUND: Due to the multitude of therapy options, the treatment decision after diagnosis of localized prostate cancer is challenging. Compared to printed booklets, web-based information technology offers more possibilities to tailor information to patients' individual needs. OBJECTIVES: To support the decision-making process as well as the communication with patients, we developed an online tutorial in a systematic process in the German-speaking part of Switzerland and then tested it in a pilot study. The study investigated users' satisfaction, the coverage of information needs, the preparation for decision making, and the subjective quality of the decision. MATERIALS AND METHODS: Based on already existing information material, the online tutorial was developed in an iterative process using focus groups with patients and urologists. For the following evaluation in eight clinics a total of 87 patients were invited to access the platform and participate in the study. Of these patients, 56 used the tutorial and 48 answered both surveys (the first one 4 weeks after the first login and the second one 3 months after treatment decision). The surveys used the Preparation for Decision Making Scale (PDMS), the Decisional Conflict Scale (DCS), and the Decisional Regret Scale (DRS). RESULTS AND CONCLUSION: Satisfaction with the tutorial is very high among patients with newly diagnosed localized prostate cancer. Users find their information needs sufficiently covered. Three months after the decision they felt that they were well prepared for the decision making (mean PDMS 75, standard deviation [SD] 23), they had low decisional conflict (mean DCS 9.6, SD 11), and almost no decisional regret (mean DRS 6.4, SD 9.6). Based on these findings, further use of the tutorial can be recommended.

Human osseous intervertebral foramen width.

Alterations of the width of the human intervertebral foramen can play a pathophysiological role in low back pain. Osseous dimensions of the human intervertebral foramen are rarely recorded. Therefore, we present reference data obtained from skeletal samples of known lifestyle, population affinity, sex, and age at death. Cervical, thoracic, and lumbar vertebrae of functional transition zones of 71 macroscopically normal spines from early 19th century AD Swiss burial sites were selected. The intervertebral foramen widths (IFW) were analyzed with respect to possible lateralization and the impact of sex, individual age, and stature. Neither a significant side difference nor a correlation of IFW with individual age or stature could be found. Females show somewhat larger IFW than males, especially in the lumbar region. Data comparisons with earlier studies are limited due to methodological differences and possible interpopulational variations. Furthermore, the osseous intervertebral foramen only reveals a glimpse of the clinically relevant in vivo structure. Nevertheless, more focus on the osseous dimensions of the intervertebral foramen will provide baseline data of this important anatomical landmark. These data could also explore the peculiarities of the intervertebral foramen, such as its reverse sex dimorphism.

Age-dependent changes of the normal human spine during adulthood.

The impact of aging on the morphology of the osseous spine is still debated. Clinical studies usually record combined aging effects, as well as age-related degenerative changes. The aim of this study was to determine the impact of (degeneration-independent) aging on the morphology of the osseous human spine during adulthood. Various osseous dimensions of human spinal landmarks at all major vertebral levels have been assessed in macroscopically normal Swiss skeletons (N = 71), with historically known sex and age at death, as well as in larger Central European skeletal samples (N = 277) with anthropologically determined individual age and sex. All measurements were correlated with individual age (or age group) by linear regression and analyzed separately for each sex. Only few osseous spinal dimensions, and only in men, correlate significantly with individual age. Generally, the significant dimensions show an increase in size during adulthood. Similar tendencies, but with significant alterations of spinal measurements in women as well, can be found in the larger samples with anthropologically determined sex and age group. Increase of certain spinal dimensions found in this study may be a reflection of an increase in the robustness of individuals with age. Because of the absence of a significant secular alteration of stature within the well-recorded sample, we exclude secular change in body dimensions as a major bias.

[Erectile dysfunction: reasonable diagnostics and treatment in general practice]. / Rationale Abklärung und Therapie der erektilen Dysfunktion in der hausärztlichen Praxis.

The availability of efficacious oral drugs has radically changed the diagnostic and therapeutic approach to erectile dysfunction. Complicated examinations as well as invasive treatment options have been widely abandoned. Instead the management of impotent men has become much more pragmatic and focused on the symptom. Consequently only a minority of impotent men needs to be referred to an urologist, which makes the therapy of erectile dysfunction increasingly attractive for general practitioners. However, successful treatment first of all still needs time and a genuine interest in the field of erectile dysfunction. In this article a reasonable diagnostic evaluation of impotent patients in general practice is described. Furthermore indication and use of little or non-invasive therapies are discussed.

[Urolithiasis and ultrasound diagnosis. Value of ultrasound in diagnosis of urolithiasis]. / Urolithiasis und Ultraschalldiagnostik. Stellenwert der Sonographie bei der Diagnostik der Urolithiasis.

In Europe and the United States urolithiasis is a very common clinical finding. In primary diagnostic and at follow up sonography plays a central part because of its high accuracy, its easy and noninvasive use as well as its availability and low costs. Although popular, the color Doppler examination is of minor importance in the evaluation of patients with stone disease. Apart from conservative management shock-wave lithotripsy is the first procedure of choice in the treatment of urinary stones. In the follow up of both patients with conservative and patients after interventional treatment sonography is the first line examination.

Comparison of three active therapies for chronic low back pain: results of a randomized clinical trial with one-year follow-up.

OBJECTIVES: To examine the relative efficacy of three active therapies for patients with chronic low back pain. METHODS: One hundred and forty-eight subjects with chronic low back pain were randomized to receive, twice weekly for 3 months, (i) active physiotherapy, (ii) muscle reconditioning on training devices, or (ii) low-impact aerobics. Questionnaires were administered to assess pain intensity, pain frequency and disability before and after therapy and at 6 and 12 months of follow-up. RESULTS: One hundred and thirty-two of the 148 patients (89%) completed the therapy programmes and 127 of the 148 (86%) returned a questionnaire at all four time-points. The three treatments were equally efficacious in significantly reducing pain intensity and frequency for up to 1 yr after therapy. However, the groups differed with respect to the temporal changes in self-rated disability over the study period (P=0.03): all groups showed a similar reduction after therapy, but for the physiotherapy group disability increased again during the first 6 months of follow-up whilst the other two groups showed a further decline. In all groups the values then remained stable up to the 12-month follow-up. The larger group size and minimal infrastructure required for low-impact aerobics rendered it considerably less expensive to administer than the other two programmes. CONCLUSIONS: The introduction of low-impact aerobic exercise programmes for patients with chronic low back pain may reduce the enormous costs associated with its treatment.

Active therapy for chronic low back pain part 1. Effects on back muscle activation, fatigability, and strength.

DESIGN: Randomized prospective study of the effects of three types of active therapy on back muscle function in chronic low back pain patients. OBJECTIVES: To quantify the effects of 3 months active therapy on strength, endurance, activation, and fatigability of the back entensor muscles. SUMMARY OF BACKGROUND DATA: Many studies have documented an association between chronic low back pain and diminished muscular performance capacity. Few studies have quantified the changes in these measures following interventions using objective measurement techniques or related them to changes in clinical outcome. METHODS: A total of 148 individuals (57% women) with chronic low back pain (age, 45.0 +/- 10.0 years; duration of low back pain, 10.9 +/- 9.5 years) were randomized to a treatment that they attended for 3 months: active physiotherapy, muscle reconditioning on devices, or low-impact aerobics. Before and after therapy, assessments were made of the following: trunk muscle strength (in flexion, extension, lateral bending, and axial rotation), erector spinae activation (maximal, and during forward bending movements), back extensor endurance (Biering-Sørensen test), and erector spinae fatigability (determined from changes in the median frequency of the surface electromyographic signal) during isometric and dynamic tests. RESULTS: A total of 132 of 148 patients (89%) completed the therapy. Isometric strength in each movement direction increased in all groups post-therapy (P < 0.0008), most notably in the devices group. Activation of the erector spinae during the extension tests also increased significantly in all groups and showed a weak, but significant, relationship with increased maximal strength (P = 0.01). Pretherapy 55% of the subjects showed no relaxation of the back muscles at L5 when in the fully flexed position; no changes were observed in any group post-therapy. Endurance time during the Biering-Sørensen test increased significantly post-therapy in all groups (P = 0.0001), but there were no significant changes in EMG-determined fatigability. Fatigability of the lumbar muscles at L5 (EMG median frequency changes) during the dynamic test increased post-therapy (P = 0.0001) without group differences. CONCLUSION: Significant changes in muscle performance were observed in all three active therapy groups post-therapy, which appeared to be mainly due to changes in neural activation of the lumbar muscles and psychological changes concerning, for example, motivation or pain tolerance.

Active therapy for chronic low back pain: part 2. Effects on paraspinal muscle cross-sectional area, fiber type size, and distribution.

DESIGN: Randomized prospective study to compare the effects of three types of active therapy on the back muscle structure of chronic low back pain patients. OBJECTIVES: To analyze the effects of 3 months active therapy on gross back muscle size and muscle fiber type characteristics and their relationship to changes in muscle function. SUMMARY OF BACKGROUND DATA: Many studies have documented a diminished muscular performance capacity in cLBP patients, but few have supported this with evidence of alterations in either the macro- or microscopic structure of the paraspinal muscles. Investigations of the changes in muscle structure following active rehabilitation are even rarer. METHODS: Assessments of trunk muscle cross-sectional area (using MRI), erector spinae fiber size/type distribution and pathology (percutaneous biopsy), and muscle function (see Part 1) were made in a group of 59 individuals with cLBP, who were participating in a randomized trial of active therapies for cLBP (physiotherapy, muscle training on devices, aerobics). RESULTS: Fifty-three out of 59 patients (90%) completed the therapy. At baseline, significant correlations were observed between the size of the paraspinal muscles and isometric back extension strength (P=0.0001), and between the proportional area of the muscle occupied by each fiber type and the fatigability of the muscle (P=0.012). Following therapy, there were small (few percent) increases in trunk muscle size in the aerobics and physiotherapy groups and a similarly slight decrease in the devices group. Changes in erector spine size correlated only weakly and nonsignificantly with changes in back extension strength. There were no major changes in fiber type proportion or fiber size in any group following therapy. CONCLUSION: Three months active therapy is not sufficient to reverse the typical "glycolytic" profile of the muscles of cLBP patients or to effect major changes in backmuscle size. The alterations in muscle performance observed (increased strength and endurance; Part 1) werenot explainable on the basis of structural changes within the muscle.

Active therapy for chronic low back pain: part 3. Factors influencing self-rated disability and its change following therapy.

DESIGN: Cross-sectional analysis of the factors influencing self-rated disability associated with chronic low back pain and prospective study of the relationship between changes in each of these factors and in disability following active therapy. OBJECTIVES: To examine the relative influences of pain, psychological factors, and physiological factors on self-rated disability. SUMMARY OF BACKGROUND DATA: In chronic LBP, the interrelationship between physical impairment, pain, and disability is particularly complicated, due to the influence of various psychological factors and the lack of unequivocal methods for assessing impairment. Investigations using new "belief" questionnaires and "sophisticated" performance tests, which have shown promise as discriminating measures of impairment, may assist in clarifying the situation. Previous studies have rarely investigated all these factors simultaneously. METHODS: One hundred forty-eight patients with cLBP completed questionnaires and underwent tests of mobility, strength, muscle activation, and fatigability, and (in a subgroup) erector spinae size and fiber size/type distribution. All measures were repeated after 3 months active therapy. Relationships between each factor and self-rated disability (Roland and Morris questionnaire) at baseline, and between the changes in each factor and changes in disability following therapy, were examined. RESULTS: Stepwise linear regression showed that the most significant predictors of disability at baseline were, in decreasing order of importance: pain; psychological distress; fear-avoidance beliefs; muscle activation levels; lumbar range of motion; gender. Only changes in pain, psychological distress, and fear-avoidance beliefs significantly accounted for the changes in disability following therapy. CONCLUSION: A combination of pain, psychological and physiological factors was best able to predict baseline disability, although its decrease following therapy was determined only by reductions in pain and psychological variables. The active therapy program-in addition to improving physical function-appeared capable of modifying important psychological factors, possibly as a result of the positive experience of completing the prescribed exercises without undue harm.

[Increase in strength after active therapy in chronic low back pain (CLBP) patients: muscular adaptations and clinical relevance]. / Kraftzuwachs nach aktiver Therapie bei Patienten mit chronischen Rückenschmerzen (LBP) - Muskuläre Adaptationen und klinische Relevanz.

INTRODUCTION: Active treatments are advocated for the management of non-specific chronic low back pain (CLBP), although few studies have documented the relative efficacy of differing types of programme. A number of the available treatments comprise exercise routines on specially designed training machines, which are ostensibly better disposed to reverse the compromised trunk muscle function displayed by these patients than are 'free exercise' programmes. However, in using these muscle-training programmes, the physiological or anatomical adaptations that might account for the improved performance are rarely investigated, let alone identified. This is an important issue, because if the 'newly-acquired strength' is mostly specific to performance on the devices on which the patient has trained and been tested, and reflects the skill in executing these particular tasks, this will not necessarily assist the patient during performance of his/her everyday activities. The aims of the present study were (1) to quantify the changes in back muscle performance in chronic LBP patients following 3 months active therapy, and (2) to analyse the corresponding changes in activation and cross-sectional area of the paraspinal muscles. METHODS: 148 individuals (57% women) with CLBP (age 45.0+/-10.0 years; duration of LBP 10.9+/-9.5 years) were randomised to a treatment which they attended 2/week for 3 months: active physiotherapy, muscle reconditioning on training devices, or low-impact aerobics. Pre- and post-therapy, assessments were made of isometric trunk muscle strength in each plane of movement and of erector spinae activation (using surface electromyography) during back extension. In a sub-group of 56 patients, the cross-sectional area of the paravertebral muscles was determined using magnetic resonance imaging (MRI). In all patients, self-rated pain intensity, pain frequency and disability were assessed before and after therapy. RESULTS: 132/148 patients completed the therapy. Isometric strength in each movement plane increased significantly in all groups post-therapy. Apart from trunk extension, the changes were significantly greater in the devices group than in the other two groups (Fig 1). Activation of the paraspinal muscles during back extension also increased significantly in all groups (Fig 2) and was weakly, but significantly (r = 0.37; p = 0.0001) correlated with increased strength in back extension. Although, at baseline, highly significant correlations were observed between the size of the paraspinal muscles (at L3/4 and at L4/5) and isometric back extension strength (r=0.75; p< 0.0001), post-training increases in strength were not accompanied by corresponding changes in muscle size. None of the improvements in strength showed any relationship with the clinical changes in pain and disability, regardless of whether the latter were examined on an individual basis or in relation to 'outcome groups'. CONCLUSION: The superior trunk strength shown by the devices group post-therapy was considered to be attributable, in part, to a 'learning effect', of the type often seen when training and testing are carried out on the same machines. These gains are considered to be mostly 'task-specific'. However, part of the improvement in strength after active therapy (in all groups) also appeared to be due to an increased neural activation of the trunk muscles. These positive effects should be transferable to the performance of everyday activities for which the same muscles are employed, although the percentage improvement is probably not as high as the measured increase in strength might suggest. Possible roles for improved co-ordination and changes in motivation and/or pain tolerance after therapy cannot be excluded. No differences in the clinical outcome were observed between the three therapy groups, and the changes in physical performance after therapy did not correlate with the clinical outcome. It is therefore questionable whether strength measurements have any clinical significance in documenting the success of rehabilitation programmes, other than on a motivational basis. The results of the present study suggest that the value of supervised active therapy programmes does not reside in the reversal of specific muscular deficiencies, but rather in the provision of a source of confirmation/encouragement for the patient, that movement is not harmful, and a foundation upon which to further build. Whether the utilisation of specific training devices, or individual instruction, is necessary to elicit these particular effects is questionable.

Calcium ion in skeletal muscle: its crucial role for muscle function, plasticity, and disease.

Mammalian skeletal muscle shows an enormous variability in its functional features such as rate of force production, resistance to fatigue, and energy metabolism, with a wide spectrum from slow aerobic to fast anaerobic physiology. In addition, skeletal muscle exhibits high plasticity that is based on the potential of the muscle fibers to undergo changes of their cytoarchitecture and composition of specific muscle protein isoforms. Adaptive changes of the muscle fibers occur in response to a variety of stimuli such as, e.g., growth and differentition factors, hormones, nerve signals, or exercise. Additionally, the muscle fibers are arranged in compartments that often function as largely independent muscular subunits. All muscle fibers use Ca(2+) as their main regulatory and signaling molecule. Therefore, contractile properties of muscle fibers are dependent on the variable expression of proteins involved in Ca(2+) signaling and handling. Molecular diversity of the main proteins in the Ca(2+) signaling apparatus (the calcium cycle) largely determines the contraction and relaxation properties of a muscle fiber. The Ca(2+) signaling apparatus includes 1) the ryanodine receptor that is the sarcoplasmic reticulum Ca(2+) release channel, 2) the troponin protein complex that mediates the Ca(2+) effect to the myofibrillar structures leading to contraction, 3) the Ca(2+) pump responsible for Ca(2+) reuptake into the sarcoplasmic reticulum, and 4) calsequestrin, the Ca(2+) storage protein in the sarcoplasmic reticulum. In addition, a multitude of Ca(2+)-binding proteins is present in muscle tissue including parvalbumin, calmodulin, S100 proteins, annexins, sorcin, myosin light chains, beta-actinin, calcineurin, and calpain. These Ca(2+)-binding proteins may either exert an important role in Ca(2+)-triggered muscle contraction under certain conditions or modulate other muscle activities such as protein metabolism, differentiation, and growth. Recently, several Ca(2+) signaling and handling molecules have been shown to be altered in muscle diseases. Functional alterations of Ca(2+) handling seem to be responsible for the pathophysiological conditions seen in dystrophinopathies, Brody's disease, and malignant hyperthermia. These also underline the importance of the affected molecules for correct muscle performance.

Influence of age and duration of symptoms on fibre type distribution and size of the back muscles in chronic low back pain patients.

Many studies have documented an association between chronic low back pain (LBP) and deficits in back muscle strength and endurance. The sub-optimal performance is believed to be the result of alterations in the size and structure of the muscle, although the long-standing issue of whether the observed changes precede or are a consequence of the pain remains unresolved. If consequent to the problem, and predominantly related to disuse of the muscles, then it may be expected that a relationship between muscle structure and symptom duration would exist. Lumbar paraspinal muscle samples were obtained from 59 chronic LBP patients using the percutaneous biopsy technique. The samples were subject to routine histochemical analysis for the examination of muscle fibre type characteristics and cytochemical architectural changes. In 55 of the patients, the gross cross-sectional areas of magnetic resonance images of the trunk muscles were also measured. Multivariate analysis showed that symptom duration was the strongest predictor of the individual proportions of the fast-fatigable type IIX fibres; with age and gender included in the model, nearly 30% of the variance in fibre type distribution could be accounted for. Duration of pain had no influence on fibre size. Gross muscle cross-sectional area correlated directly with lean body mass and inversely with age, but showed no relationship with symptom duration. Pathological changes in the internal fibre structure were more frequently encountered in older patients, and were independent of symptom duration. The results suggest that, over the long term, fibre type transformations rather than alterations in fibre size are the predominant changes to be found in the muscles of chronic LBP patients. The direction of change supports the results of many previous studies that have demonstrated corresponding differences in the fatigability of the muscles. There is a strong case for the early implementation of active measures to attempt to offset the development of these changes in back pain patients.

Experimental changes to limb muscles elicit contralateral reactions: the problem of controls

The extensor digitorum longus muscle (EDL) or soleus muscle (SOL) in rats was mechanically overloaded on one side. The muscles were (i) untreated (normal) or (ii) self- or foreign-reinnervated (leading to persisting muscle fibres) or transplanted (leading to regenerating muscle fibres). The effects of the different procedures were studied in the treated and untreated muscles on the operated side and in the untreated muscles on the contralateral side. Overloading led to an absolute increase in mass (versus control values) in the normal muscles and to a relative increase in mass (versus the lower mass after reinnervation) in the treated muscles. The mechanism underlying this gain in mass was usually a compensatory hypertrophy. Overloading was followed by transformation of fibres from fast to slow in normal muscles. In the reinnervated muscles, the fibre distribution changed in response to the new nervous input and then remained constant. The majority of the experimental procedures elicited significant muscular changes in the contralateral muscles, including hyperplasia, fibre transformation and fibre hypertrophy or atrophy. The changes are interpreted as the consequence of a general compensatory neuromuscular activity designed to maintain a symmetrical posture during walking and running. These frequent and substantial muscular changes in the unoperated muscles clearly show that the muscles of the contralateral side cannot be used as normal controls.

A randomized clinical trial of three active therapies for chronic low back pain.

STUDY DESIGN: A randomized clinical trial. OBJECTIVES: To examine the relative efficacy of three active therapies for chronic low back pain. SUMMARY OF BACKGROUND DATA: There is much evidence documenting the efficacy of exercise in the conservative management of chronic low back pain, but many questions remain regarding its exact prescription and method of application. The most successful method must be identified to enable refinement of future rehabilitation programs to target the specific needs of the patient with chronic low back pain and the budget of the healthcare provider. METHODS: One hundred forty-eight patients with chronic low back pain were randomized to one of the following treatments, which they attended twice a week for 3 months: 1) modern active physiotherapy, 2) muscle reconditioning on training devices, or 3) low-impact aerobics. Pretherapy and posttherapy, objective measurements of lumbar mobility were performed, and questionnaires were administered inquiring about self-rated pain and disability, and psychosocial factors. Similar questionnaires were administered 6 months after therapy. The data were analyzed using the intention-to-treat principle. RESULTS: Of the 148 patients, 16 (10.8%) dropped out of the therapy. One hundred thirty-seven questionnaires (93%) were available for analysis at all three time points. After therapy, significant reductions were observed in pain intensity, frequency, and disability; Fear-Avoidance Beliefs about physical activity (FABQactivity); and "praying/hoping," "catastrophizing," and "pain behavior" coping strategies--each with no group differences in the extent of the response. These effects were maintained over the subsequent 6 months, with the exception of disability and FABQactivity for the physiotherapy group. There were small but significant posttherapy increases in lumbar mobility, with aerobics and devices showing a greater response than physiotherapy. CONCLUSION: The general lack of treatment specificity suggests that the main effects of the therapies were educed not through the reversal of physical weaknesses targeted by the corresponding exercise modality, but rather through some "central" effect, perhaps involving an adjustment of perception in relation to pain and disability. The direct costs associated with administering physiotherapy were three times as great, and devices four times as great, as those for aerobics. Administration of aerobics as an efficacious therapy for chronic low back pain has the potential to relieve some of the huge financial burden associated with the condition.

Paraspinal muscle fibre type alterations associated with scoliosis: an old problem revisited with new evidence.

To establish the extent to which the paraspinal muscles are affected in idiopathic scoliosis, samples from patients must be compared with controls of a similar gender and age. To date, insufficient control data has been available for these purposes. The aim of this study was to re-dress this tissue, in order to identify whether one side of the apex of the scoliotic curve showed greater muscular abnormalities than the other. Bilateral samples of the paraspinal muscles were obtained during surgery from 14 female scoliosis patients, at the apex of the scoliotic curve at T9-T11. Percutaneous muscle biopsy samples were obtained from nine female volunteers, on the left side of the spine at T10. Samples were prepared for routine histochemistry for the identification of muscle fibre types. Fibre size was measured using computerised image analysis. Compared with control muscle, there was a significantly lower proportion of type I (slow-twitch oxidative) fibres in the muscle on the concave side of the scoliotic curve, but no difference on the convex side. The proportion of type IIB (fast-twitch, glycolytic) fibres was higher on both sides of the curve compared with controls, with the effect being significantly more marked on the concave side. The percentage of type IIA (slow-twitch, oxidative-glycolytic) fibres did not differ between the groups, and neither did fibre size (although there was a tendency for the controls to have larger type IIA fibres than the patients). Collectively, the differences in fibre type size and distribution meant that on the concave side the relative area of the muscle occupied by type I fibres was smaller, and on both sides of the curve the relative area occupied by type IIB fibres was greater and by type IIA fibres smaller, in comparison with controls. In scoliosis, the spinal musculature is most affected on the concave side of the curve's apex. The muscle adopts a 'faster', or more 'glycolytic' profile, which would be consistent with a reduced low-level tonic activity of the muscle, perhaps consequent to a local change in activity on this side of the spine following progression of the curve. Less marked changes, in the same direction, are also evident on the convex side; these may be the result of general disuse of the paraspinal muscles associated with the spinal deformity.

Fiber transformations in multifidus muscle of young patients with idiopathic scoliosis.

STUDY DESIGN: In this study, the authors investigated the superficial multifidus muscle in patients with idiopathic scoliosis. During spinal fusion, biopsies were taken bilaterally at the apex of the curve, and at the upper and lower end vertebrae. OBJECTIVES: To analyze the muscular reactions in response to bracing in patients with idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: The extent to which intervertebral mobility is restricted by an orthosis is still controversial. In addition, the effect of bracing on the erector spinae has not been investigated. METHODS: Of a total 30 patients, 11 had been treated with a corset for a year or more before surgery. Biopsies were investigated histochemically and the muscle fibers classified as Type I, IIA, IIB, or IIC (transitional fibers). The relative distribution of the fibers was calculated and their diameter was measured. RESULTS: In unbraced patients, a shift in the fiber distribution (from "slow" to "fast") was observed exclusively at the concave side of the apex. This shift was paralleled by an increased percentage of the intermediate Type IIC fiber (indicative of fiber transformation). In patients who always wore a corset, the relative amount of Type IIC fibers was increased, without preference for a specific location. CONCLUSIONS: Corset treatment elicits muscle fiber transformation processes at different levels along the scoliosis. This general reaction of the paraspinal muscles provides strong evidence against the existence of muscular disorders that are restricted to the area of the apex and are thus causing the scoliosis. As such, it must be assumed that the muscular changes in the apical region are secondary.

Posterior surgical approach to the lumbar spine and its effect on the multifidus muscle.

STUDY DESIGN: This study investigated the changes in the lumbar muscles after posterior fusion of the lumbar spine and the potential correlation between muscular changes and the persistence of low back pain. OBJECTIVES: To evaluate prospectively the effect of the posterior approach to the spine on the lumbar erector spinae. SUMMARY OF BACKGROUND DATA: The posterior approach to the spine leads to considerable alteration of the erector spinae muscles. An eventual correlation between these changes and persisting pain or other clinical symptoms has not been investigated previously. METHODS: Seventy-five patients undergoing spondylosyndesis for different indications (43 patients) or a second operation for the removal of internal fixation (32 patients) were allotted to the study. In each patient, four biopsy specimens from the lumbar multifidus muscle were harvested; in 14 patients, biopsies were taken at both operations. Size and distribution of the fiber types (I, IIA, IIB, IIC) were determined, and pain scoring (visual analogue scale) and the presence of neurologic deficits were recorded. RESULTS: At the time of the first operation, 88% of the patients showed pathologic changes (altered internal structure, atrophy, type grouping) in one or more biopsies. Statistical analysis showed a correlation between both age and pain and type II (A + B) atrophy. After surgery, the patients showed significantly more biopsies with denervation signs than before surgery. No correlation could be made, however, between the intensity of pain before or after surgery and the relative number of biopsies with signs of denervation. CONCLUSIONS: Posterior surgery causes muscular alterations; however, no correlation with pain or other clinical symptoms could be established. Therefore, in the case of unsatisfactory results after surgery of the lumbar spine, reasons other than muscle damage caused by use of the posterior approach must be considered.

Correlation of mATPase, parvalbumin, and cytochrome c oxidase in rat skeletal muscle fibres.

Muscle fibre typing is conventionally performed on unfixed frozen sections. Within the particular classes of fibre types mATPase correlates well with the type of myosin heavy chain (MHC). However, investigation of other properties, e.g., parvalbumin (PV) level, cannot be determined on unfixed frozen sections. Determination of PV, which correlates with the relaxation time, is performed immunohistochemically on fixed tissue. By that method a comparison of mATPase activity and the amount of PV within the same muscle fibre is difficult. The present method, combining histochemistry of mATPase and cytochrome c oxidase with parvalbumin immunohistochemistry on consecutive sections, allows the distinction of six fibre types: I, IB, IIA, IIB, IIAB, IIX, and a C fibre population without division into IC and IIC fibres. The advantages and disadvantages of the present method are discussed.

Fibre type characteristics of the lumbar paraspinal muscles in normal healthy subjects and in patients with low back pain.

A knowledge of the alteration in the fibre type profile of paraspinal muscle associated with low back pain is essential for the design of successful rehabilitation programmes. In attempting to compare the muscles of patients with low back pain with those of controls, few previous studies have considered factors such as gender, age, and size of the subjects, each of which can potentially confound interpretation of the results. We obtained samples of lumbar paraspinal muscle during spinal surgery from 21 patients with low back pain and, using the percutaneous biopsy technique, from 21 control volunteers matched for gender, age, and body mass. The samples were subject to routine histochemical analysis to determine characteristics of muscle fibre type. Compared with controls, the muscle of the patients had a significantly higher proportion of type-IIB (fast-twitch glycolytic) fibres than type-I (slow oxidative) fibres. The mean size of a given fibre type did not differ between the patients and the controls. Consequently, the relative area of the muscle occupied by type-IIB fibres was higher and that by type-I fibres was lower in the patients. The patients had a greater number of muscle samples with more than 1% type-IIC fibres, and abnormalities that could be described as pathological were more marked in the patients than in the controls. In conclusion, the paraspinal muscles of patients who have low back pain display a more glycolytic (faster) profile; this can be expected to render them less resistant to fatigue.

Increase of skeletal muscle relaxation speed by direct injection of parvalbumin cDNA.

Parvalbumin (PV) is a high affinity Ca(2+)-binding protein found at high concentration in fast-contracting/relaxing skeletal muscle fibers of vertebrates. It has been proposed that PV acts in the process of muscle relaxation by facilitating Ca2+ transport from the myofibrils to the sarcoplasmic reticulum. However, on the basis of metal-binding kinetics of PV in vitro, this hypothesis has been challenged. To investigate the function of PV in skeletal muscle fibers, direct gene transfer was applied in normal and regenerating rat soleus muscles which do not synthesize detectable amounts of PV. Two weeks after in vivo transfection with PV cDNA, considerable levels of PV mRNA and protein were detected in normal muscle, and even higher amounts were detected in regenerating muscle. Twitch half-relaxation time was significantly shortened in a dose-dependent way in transfected muscles, while contraction time remained unaltered. The observed shortening of half-relaxation time is due to PV and its ability to bind Ca2+, because a mutant protein lacking Ca(2+)-binding capacity did not promote any change in physiology. These results directly demonstrate the physiological function of PV as a relaxing factor in mammalian skeletal muscle.